Surgical Management Of Hypertension And Diabetes

HAROON MALIK 502

HYPERTENSION
In adults, a sustained systolic blood pressure of 140 mm Hg or greater and/or a sustained diastolic blood pressure of 90 mm Hg or greater is defined as hypertension.

CLASSIFICATION
BP
NORMAL
PREHYPERT ENSION STAGE 1

SYSTOLI C
<120 120 - 139 140-159 160

DIASTOLI C
<80 80-89 90-99

STAGE 2

ETIOLOGY

PRIMARY HYPERTENSI ON

SECONDARY HYPERTENSI ON

SECONDARY HYPERTENSION CAUSES

Chronic kidney disease Coarctation of the aorta Cushing syndrome and other glucocorticoid excess states Drug induced or drug related Obstructive uropathy Pheochromocytoma

Primary aldosteronism
Renovascular hypertension Sleep apnea Thyroid and para thyroid disease

Signs and symptoms

EARLY
Elevated blood pressure readings
Narrowing and sclerosis of retinal arterioles Headache

Dizziness
Tinnitus

ADVANCED
Rupture and hemorrhage of retinal arterioles Papilledema Left ventricular hypertrophy Proteinuria Congestive heart failure Angina pectoris Renal failure Dementia Encephalopathy

MEDICAL MANAGMENT
LIFE STYLE MODIFICATION FOR PREVENTION & REDUCTION OF HIGH BP

Weight loss
DASH (Dietary Approaches to Stop Hypertension) Diet Fruits Vegetables Low-fat dairy products Reduce cholesterol Reduce saturated and total fat

Reduce sodium to <2.4 g/day

Regular aerobic physical activity on most days (30 minutes of brisk walking) Limited alcohol intake to no more than 1oz/day (2 drinks for men and 1 drink for women)

SEVERITY

TREATMENT
Diuretics(+/- potassium supplements) Diuretics and a second-order drugs such as

MILD MODERATE

methyldopa (aldomet) clonidine (catapres) propranolol (inderal) metoprolol ( lopressor) hydralazine

(apresoline)
prazosin (minipress) reserpin (serposil)

severe

Diretics plus combination of strong second order drug

DENTISTS EVALUATION OF HYPERTENSION

HISTORY -The first task of the dentist is to identify patients with hypertension, both diagnosed and
undiagnosed . QUESTIONS????
1)

How it is being treated?

2)
3) 4) 5)

identification of antihypertensive drugs ?

compliance of the pt ? the presence of symptoms associated with hypertension ? Level of stability of disease ? QUESTIONS ABOUT COMPLICATION

Patients also may be receiving treatment for complications of hypertensive disease, such as congestive heart failure, cerebrovascular disease, MI, renal disease, peripheral vascular disease, and diabetes mellitus. These problems should be identified as well because they may necessitate modification of the dental management plan.

DENTISTS EVALUATION OF HYPERTENSION

EXAMINATION(RECORDING THE BLOOD PRESSURE)

1) BP at initial exam and yearly for all patients . 2) BP at each visit for patients with initial reading of

14090 or higher. all patients

3) BP prior to all type of open surgical procedures for 4) BP during lengthy dental procedures in the

diagnosed or suspected hypertensive patient

Dental Management and Follow-up Recommendations Based on Blood Pressure BLOOD DENTAL TREATMENT REFFERAL TO
RECOMMENDATION Any required Any required PHYSICIAN NO Encourage patient to see physician

PRESSURE

120/80
120/80 but <140/90

140/90 but <160/100

Any required

Encourage patient to see physician Refer patient to physician promptly (within 1 month)

160/100 but <180/110

Any required; consider intraoperative monitoring of blood pressure for upper level stage 2

180/110

Defer elective treatment

Refer to physician as soon as possible; if patient is symptomatic, refer immediately

Dental Management Recommendations for Patients With Hypertension

Stress/anxiety reduction Establishment of good rapport

Short, morning appointments

Consider premedication with sedative/anxiolytic Consider intraoperative use of nitrous oxide/oxygen Obtain excellent local anesthesia; OK to use epinephrine in modest amounts

Cautious use of epinephrine in local anesthetic in patients taking non-selective b-beta blockers or peripheral adrenergic antagonists

Avoid the use of epinephrine-impregnated gingival retraction cord

Consider periodic intraoperative BP monitoring for patients with upper level stage 2 hypertension; terminate appointment if BP rises above 179/109 Slow position changes to prevent orthostatic hypotension

Hypertension and use of vasoconstrictor

Drug interactions between vasoconstrictors and antihypertensive drugs

DIABETES MELLITUS
Is a clinical syndrome characterized by chronic hyperglycemia and disturbances in carbohydrate, lipid and protein metabolism. the disease may result from defects in insulin secretion insulin resistance both

TYPES
PRIMARY DIABETES MELLITUS SECONDARY DIABETES MELLITUS

TYPE 1 :INSULIN DEPENDENT DIABETES MELLITUS (IDDM)

1)Pancreatic diseases 2) Endocrine diseases

3) Drug induced
TYPE 2 : NON ISULIN DEPENDENT DIABETES MELLITUS (NIDDM) 4)due to genetic syndrome 5) gestational diabetes

ETIOLOGY OF PRIMARY DIABETES MELLITUS

TYPE 1(IDDM) 1) genetic 2)inheritance 3) viral infection A) genetic TYPE 2(NIDDM) Exact cause unknown

4) pancreatic pathology
5)immunological factors

B) environmental factors
C) pancreatic pathology

Clincial features
Hyperglycemia Polyurea Thirst Weight loss Polyphagia Blurred vision Pruritus Ketoacidosis

INVESTIGATIONS
1) FASTING BLOOD SUGER 2) RANDOM BLOOD SUGER 3)GLUCOSE TOLERANCE TEST 4) GLYCOSYLATED HEMOGLOBIN

5) URINALYSIS
6) OTHER INVESTIGATION

Diabetes and Surgery

Surgery is a form of physical trauma It results in catabolism, increased metabolic rate, increased fat and protein breakdown, glucose intolerance and starvation. In a diabetic patient, the pre existing metabolic disturbances are exacerbated by surgery The type of diabetes, amount of insulin dose, diet or oral hypoglycaemic agents must be considered as this will change the overall management plan The risk of significant end-organ damage increases with the duration of diabetes, although the quality of glucose control is more important than the absolute time

Factors Adversely Affecting Diabetic Control Perioperatively

Anxiety Starvation Anaesthetic drugs Infection

Metabolic response to trauma

Diseases underlying need for surgery Other drugs e.g. steroids

Metabolic Responses to Surgery

Hormonal
Secretion of stress hormones
Cortisol Catecholamines Glucagon Growth Hormone Cytokines

Metabolic
Increased gluconeogenesis and glycogenolysis Hyperglycaemia Lipolysis Protein breakdown

Relative decrease in insulin secretion Peripheral insulin resistance

Metabolic Response to Surgery and Diabetes

Hypoglycaemia
May develop perioperatively due to the residual effects of preoperative long acting oral hypoglycaemic agents or insulin.
Exacerbated by preoperative fast or insufficient glucose administration Counter-regulatory mechanisms may be defective because of autonomic dysfunction Can lead to irreversible neurological deficits Dangerous in anaesthetised or neuropathic patient as the warning signs may be absent

Management
Give i.v dextrose and monitor glucose levels

Metabolic Response to Surgery and Diabetes

Hyperglycaemia
Glucagon, cortisol and adrenaline secretion as part of the neuroendocrine response to trauma, combined with iatrogenic insulin deficiency or glucose overadministration may result in hyperglycaemia Causes osmotic diuresis, making volume status difficult to determine and risking profound dehydration and organ hypoperfusion, and increased risk of UTI osmotic diuresis, delayed wound healing, exacerbation of brain, spinal cord and renal damage by ischaemia Results in hyperosmolality with hyperviscocity, thrombogenesis and cerebral oedema

Management
Frequently measure blood glucose and administer insulin

Metabolic Response to Surgery and Diabetes

Ketoacidosis Any patient who is in a severe catabolic state and has an insulin deficiency (absolute or relative) can decompensate into keto-acidosis Most common in type 1 patients Increased risk postoperatively, often precipitated by the stress response, infection, MI, failure to continue insulin therapy. characterised by hyperglycaemia, hyperosmolarity, dehydration (may lead to shock and hypotension) and excess ketone body production resulting in an anion gap metabolic acidosis.

Metabolic Response to Surgery and Diabetes

Management restore intravascular volume

eliminate ketonaemia
control blood glucose replace electrolytes monitor glucose and ketone levels Mortality from DKA 5-10% Electrolyte abnormalities Anticipate imbalances in potassium, magnesium and phosphate

Underlying Cardiac Complications of Diabetes and Surgery

Cardiovascular problems frequently present in long standing diabetics

Ischaemic Heart Disease - Often silent ischaemia

Coronary artery disease Hypertension Diabetic patients must be considered as being at high risk of MI Silent MI in autonomic neuropathy as Cardiac Autonomic Neuropathy may abolish the hearts response to stress Induction of anaesthesia and tracheal intubation can lead to a reduction in cardiac output

Underlying Cardiac Complications of Diabetes and Surgery

Management
Most cardiac and antihypertensive drugs should be continued throughout the perioperative period except, aspirin, diuretics and anticoagulants

History to determine effort tolerance, clinical examination for cardiac failure and an electrocardiogram in all patients.

Underlying Renal Complications of Diabetes and Surgery

Renal Renal dysfunction
Intrinsic renal disease including glomerulosclerosis and renal papillary necrosis enhance the risk of acute renal failure perioperatively
Proteinuria is an early manifestation Dialysis should optimally be done the day before surgery.

Urinary infection Management Urea and electrolyte determination. Dipstix urinalysis for proteinuria

Underlying Nervous System Complications of Diabetes and Surgery

Nervous System Counter-regulatory response to hypoglycaemia Peripheral glove and stocking neuropathy with an increased susceptibility to iatrogenic nerve injuries Cardiac Autonomic Neuropathy Management History of postural dizziness, post gustatory sweating, nocturnal diarrhoea and impotence. Careful documentation of peripheral sensation

Underlying Orthopaedic Complications of Diabetes and Surgery

Small Joint Disease Non-enzymatic glycosylation causing abnormal crosslinking of collagen may lead to joint rigidity At the atlanto-occipital joint, it may result in difficult intubation The small joints of the fingers and hands are also affected Management Clinical assessment of neck extension, examination of the small joints of the hand and a good evaluation of the ease of intubation

Underlying Immune Complications of Diabetes and Surgery

Immune and infectious risk Diabetics are susceptible to infection and have delayed wound healing Hyperglycaemia facilitates proliferation of bacteria and fungi depresses the immune system management Proteolysis and decreased amino acid transport retards wound healing. Loss of phagocytic function increases the risks of post-operative infection Management Need very strict sterile techniques and need to assess risk/benefit ratio for procedures e.g catheterisation

Underlying Gastrointestinal and Opthamological Complications of Diabetes and Surgery

Gastrointestinal Gastroparesis

Management
History of early satiety and reflux H2 blocker and metoclopramide

Ophthalmology

Cataracts, glaucoma and retinopathy decrease visual acuity and increase the unpleasantness of the perioperative period
Management Increase the amount of explanation and reassurance to the patient.

DENTAL EVALUATION OF THE PATIENT WITH DIABETES MELLITUS

Detection of Patient with Diabetes

KNOWN DIABETIC PERSON

1)DETECTION BY HISTORY a) are you diabetic?

b) what medications are you taking?

c)are you being treated by a physician? 2)ESTABLISHMENT OF SEVERITY OF DISEASE AND DEGREE OF CONTROL a) When were you first diagnosed as diabetic?

b) What was the level of the last measurement of your blood glucose?

C) What is the usual level of blood glucose for you? D)How are you being treated for your diabetes? E) How often do you have insulin reactions? F) How much insulin do you take with each injection, and how often do you receive injections?

G) Do you test your urine for glucose?

H) When did you last visit your physician? i) Do you have any symptoms of diabetes at the present time?

UNDIAGNOSED DIABETIC PERSON 1)History of signs or symptoms of diabetes or its complications 2)High risk for developing diabetes Parents who are diabetic Gave birth to one or more large babies History of spontaneous abortions or stillbirths Obesee. Over 40 years of age

Dental Management of the Patient With Diabetes

1. Noninsulin-dependent patient:
if diabetes is well-controlled, all dental procedures can be performed without special precautions.

2) Insulin-controlled patient:
If diabetes is well-controlled, all dental procedures can be performed without special precautions. Morning appointments are usually best. Patient advised to take usual insulin dosage and normal meals on day of dental appointment; information confirmed when patient comes for appointment. Advise patient to inform dentist or staff if symptoms of insulin reaction occur during dental visit. Glucose source (orange juice, soda, Glucola) should be available and given to the patient if symptoms of insulin reaction occur.

3. If extensive surgery is needed:

Consult with patient's physician concerning dietary needs during postoperative period. Antibiotic prophylaxis can be considered for patients with brittle diabetes and those taking high doses of insulin who also have chronic states of oral infection. If not well-controlled Provide appropriate emergency care only. Request referral for medical evaluation, management, and risk factor modification

If symptomatic, seek IMMEDIATE referral If asymptomatic, request routine referral

Dental Management of the Patient With Diabetes and Acute Oral Infection
1)Noninsulin-controlled patients may require insulin; consultation with physician required 2)Insulin-controlled patients usually require increased dosage of insulin; consultation with physician required 3)Patient with brittle diabetes or receiving high insulin dosage should have culture(s) taken from the infected area for antibiotic sensitivity testing
a) Culture sent for testing b) Antibiotic therapy initiated c) In cases of poor clinical responses to the first antibiotic, a more effective antibiotic is selected

Dental Management of the Patient With Diabetes and Acute Oral Infection
4)Infection should be treated with the use of standard methods a) Warm intraoral rinses b) Incision and drainage c) Pulpotomy, pulpectomy, extractions, etc. d) Antibiotics

Anesthesia and Diabetes

Pharmacological effect of epinephrine oppsite to that of insulin