Case 1:

Seorang wanita, 54 tahun, dengan DM tipe II, direncanakan operasi total hip replacement. Psn punya riwayat Rheumatoid Arthritis dan mendapat terapi steroid sejak beberapa tahun yang lalu. Pernah dioperasi sebelumnya dinyatakan sulit intubasi.

Anamnesa:
Difokuskan pada masalah utama yg berhubungan dengan tindakan anestesi dan pembedahan.
DM tipe 2 RA Penggunaan Steroid Sulit intubasi

DM tipe 2
Lama penyakit Riwayat terapi Adekuat kontrol gula darah Komplikasi

Rheumatoid Arthritis
Lama Penyakit Sendi2 yang terkena Terapi Komplikasi: CV & Respirasi?

Perioperative Care of the Diabetic Patient

Erwin Pradian Bagian Anestesiologi dan Reanimasi Fakultas Kedokteran Universitas Padjadjaran RS. Dr. Hasan Sadikin Bandung

Perioperative care of diabetic patient

Focus
Preoperative history Physical examination : asses end-organ disease Appropriate intervention

Potential disorder
Coronary artery dis., cardiomyopathy, hypertention, renal insufficiency, peripheral vascular dis., infection, stiff joint syndrom, peripheral and autonomic neuropathy, large territory stroke, small vessel ischemic dis., retinopathy

Life-threatening metabolic derangement

Severe hypoglycemia, diabetic ketoacidosis, nonketotic hyperosmolar state

Coronary Artery Disease

Longer history of diabetes More coronary artery dis. Peak incidence of myocardial ischemia 48 to 72 hours after operation High risk hypotension, arrhythmias, hypoxemia, ECG change Monitor for MI : until third or fourth postoperative days Preoperative beta-blockade in high risk for MI Decrease in death Thrombolytic therapy Consideration : severity of cardiac event time elapsed since surgery Increased tissue plasminogen activator inhibitor Less responsive to thrombolytic therapy

Cardiomyopathy
Prolonged ACE inhibitor Reduce stroked, MI, death in diabetes patient By reduced afterload Diabetic cardiomyopathy Patient without hypertension and coronary dis. Related to microvascular change secondary to diabetes Beta-blocker or calcium channel blocker Decrease heart rate, suppress myocardial function, enhance diastolic relaxation

Hypertension - CVA
Severe hypertension(>180/105 mmHg) Increase risk of MI or stroke If untreated BP : labile in perioperative period Maintained within 20% of baseline value Inadequately treated hypertension Higher mean arterial pressure provide adequate organ perfusion Cardiac and antihypertensive drug Be continued throughout perioperative period Exception : aspirin, diuretics, anticoagulants

Renal disease ( I )
Hypergylcemia control
Avoid osmotic diuresis, prerenal azotemia, long-term progression of glomerular injury

Nephrotoxic drug and dyes is avoided

Metformin : potential for lactic acidosis Glyburide : only sulfonylurea excreted partially in bile

Low-dose dopamine, mannitol, diuretics

Administration during perioperative period renal protection? But effectiveness is debatable

Renal disease ( II )
Desmopressin acetate and cryoprecipitate
Improve coagulopathy associated with renal failure

ACE inhibitor
Creatinine concentration >3.0 mg/dl or creatinine clearance <30 ml/min high risk for deterioration of renal function

Peripheral Vascular Disease

Type I diabetes
Predominate microvascular complication
Retinopathy, neuropathy, nephropathy

Type II diabetes
Predominate macrovascular complication
Large vessel such as coronary or cerebral vessel

Complication
Foot ulcer amputation Prevention
maintainance of adequate hydration limitation of vasoconstriction attention to patient position evaluation for arterial catheter

Infection
Elevated glucose
Decrease leukocyte chemotaxis and function

Avoid delayed wound healing and wound infection

Blood glucose concentration : not exceed 250 mg/dl Strict sterile technique

Asymptomatic despite significant infection

Stiff Joint Syndrome

Long-standing type I diabetes
Joint rigidity : temporomandibular atlanto-occipital cervical spine

Short stature Tight, waxy skin

Limited neck mobility

Result in difficult intubation Identified before airway manipulation

Prayer sign
Denote stiff joint syndrome indicate difficult intubation

Peripheral Neuropathy
Increased susceptibility to soft tissue ischemia
Secondary to microvascular disease and peripheral nerve injury Pressure point : padded extensively Local anesthetics
injected into area of marginal blood supply epinephrine is avoided

Autonomic Neuropathy
Diabetic patient with hypertension
Greater incidence than normotensive diabetic patient

Myocardial ischemia
Not experience pain

High Pulmonary aspiration risk

Delayed gastric emptying

Orthostasis
Heart rate increase >15bpm or systolic BP decrease >20 mmHg from supine to upright Common sign of autonomic neuropathy Hemodynamic instability after acute volume loss

Laboratory Evaluation
Preoperative assessment
Blood glucose, blood urea nitrogen, creatinine, ECG

Renal insufficiency
Electrolyte is evaluated
Elevated potassium amd magnesium arrhythmias

DKA
ABGA and beta-hydroxy butyrate concentration indicate level of acidosis and ketosis

Hg A1C
Less than 8% indicate good glucose control Increase indicate poor control and difficult intraoperative normoglycemia

Anesthetic Management
First operative case of the day Metabolic abnormality Corrected before entering OR Oral hypoglycemic agent, regular insulin be held the day of surgery Long-acting insulin Administered in half usual dose Stress hormone Stimulate glycogenolysis and hyperglycemia Glucose monitoring Every 1 to 2 hours intraoperatively Immediate postoperative period

Hypoglycemia
Serum blood glucose concentration
Less than 50 mg/dl

Manifestation
Confusion, irritability, fatigue, headache, somnolence Adrenergic response
restlessness, diaphoresis, tachycardia, hypertension, arrhythmias, angina

Prolonged severe hypoglycemia

Seizure, focal neurological damage, coma

Initial therapy
Administration of 50 ml 50% dextrose Blood glucose change is impossible to predict

Hyperglycemia
Maximal glucose reabsorption threshold of kindey
180 mg/dl of serum blood glucose If exceed, glycosuria

Elevated blood glucose

Hyperosmolarity hyperviscosity and thrombogenesis Treatment
Initially lispro or regular insulin IV Insulin infusion gradual decrease serum glucose

Regular insulin 1 unit

Decrease blood glucose 30 mg/dl in 70-kg patient

Diabetic Ketoacidosis ( I )
Predisposing factor
Infection, trauma, MI, inappropriate insulin therapy, hypovolemia, stress response to surgery

Signs and symptoms

Dehydration( osmotic diuresis ), decreased oral intake, altered mental status, Kussmauls breathing( deep, rapid repiration ), fruity acetone odor, nausea, vomiting, abdominal pain, generalized weakness, hypothermia( acidosis-related vasodilation )

Volume deficit
Result in prerenal azotemia, acute tubular necrosis, hypotension

Total body deficit of potasssium, sodium, phosphate, magnesium

Diabetic Ketoacidosis ( II )
Arterial and large-bore IV catheter
Allow evaluation of electrolyte, hemodynamic monitoring, volume resuscitation

1 liter NS given as bolus dose and 250 to 500 ml/h is continued Potassium, magnesium, phosphorus
Be replaced as needed

Bicarbonate
Not be given routinely as acidosis

Initially 5 to 10 unit insulin : IV bolus and then insulin infusion : NS Serum glucose decrease : no faster than 50 mg/dl/h After blood glucose 250 mg/dl
Insulin infusion and other fluid : contain dextrose ( prevent cerebral edema )

Nonketotic Hyperosmolar State

Predisposing factor
Similar to DKA Secondary to postoperative dialysis IV hyperalimentation Type 2 diabetes rather than type 1

Not acidotic and not display Kussmaul breathing Electrlyte deficit : less Hyperglycemia, hyperosmolarity, dehydration
more profound

Neurologic symptoms
more prominent with confusion, seizure, coma, focal deficits

Most important goal

aggressive fluid resuscitation Insulin infusion : usually not needed

Conclusion
Most common endocrinopathy Despite advances in diagnosis and therapy
Increased risk for complication related primary to vascular disease

Tighter glycemic control

Blunt development of microvascular disease

Safe perioperative period for all diabetic patient

Attention to glycemic control Correction of metabolic derangement Anticipation of potential complications