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Coexisting conditions > Diabetes > Flashcards

Diabetes Flashcards

1
Q

What is a predictor of risk in a diabet pt?

A
  • Degree of end organ dysfunction
  • degree of glucose control
  • Impact seen on microvascular and macrovascular levels
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2
Q

How is diabetes diagnosed?

normal?

pre-diabetic?

A
  • Fasting plasma glucose (FPG) > 126 mg/dl
    • normal <100
    • Prediabetic 100-125
  • A1C- measures average blood glucose for the past 2-3 months
    • normal <5.7%
    • Prediabetes 5.7-6.4%
    • diabetes >6.5%
  • Oral glucose tolerance test- drink glucose, check bs 2 hrs after
    • normal <140
    • prediabetic 140-199
    • diabetic >200
  • Random glucose >200
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3
Q

What are treatments for type 2 diabetes?

A
  • Dietary adjustments
  • weight loss
  • exercise
  • 4 classes of oral anti-diabetic drugs
    • Secretagogues
    • Biguanides
    • Glitazones
    • A-Glucosidase inhibitors
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4
Q

Who uses insulin?

What are the different types?

A
  • All type 1 diabetics and 30% of type 2
  • Long acting (Ultra-lente, glargine, detemir)
  • Intermediate acting (NPH, Lente)
  • Short acting (regular)- what we use in OR
  • Ultra short acting (Lispro, aspart)
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5
Q

What is considered hypoglycemia?

symptoms?

Treatment?

A
  • Plasma glucose <50 mg/dl
  • Symptoms: (may be masked by anesthesia)
    • sweating
    • tachycardia
    • restelss
    • pallor
    • fatigue
    • confusion
  • Treatment- glucose
    • If unconscious:
      • glucose 0.5 g/kg IV or
      • glucagon 0.5-1 mg IV or IM
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6
Q

Ketoacidosis:

Plasma glucose > _____

volume status?

What will you see on ABG?

A
  • Plasma glucose >250 mg/dl
  • High glucose osmotic diuresis, causing hypovolemia
  • Ketoacids produced by breakdown of fat and proteins
  • ABG:
    • anion gap develops
    • acidosis: pH<7.3, bicarb <18, K normal or elevated
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7
Q

How is Ketoacidosis treated?

A
  • Restore volume
  • Insulin:
    • 0.1 unit/kg loading dose then 0.1 unit/kg/hour infusion
    • Sodium bicarb if pH <7.1
  • *Cancel case and stabilize patient first
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8
Q

What are some complications you would expect to see in a pt with diabetes?

A
  • renal disease
  • peripheral neuropathy
  • gastroparesis
  • autonomic neuropathy
  • infections
  • HTN
  • cardiac disease
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9
Q

What should you include in your assessment of a pt with diabetes?

A
  • Type of diabetes and duration of disease
  • Daily therapy- type of insulin/medications, diet, normal blood sugar range for them
  • Pre-op EKG
  • electrolytes
  • HgbA1C
  • Check bs in pre-op, cancel case if >300
  • target range 80-180
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10
Q

What is stiff joing syndrome?

How do you check for it

what should you be concerned about?

A
  • Increase glucose levels over time cause fibrosis of joints and sclerodermic skin
    • Glycosylation of tissue proteins leads to limited atlanto-occipital mobility and laryngeal rigidity
    • check by having pt put hands in prayer pose, if palms cant touch, this correlates to difficult intubation (31%)
  • 30-40% of pts with IDDM show evidence of limited joint mobility
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11
Q

What else should you assess in the physical assessment of a diabetic patient?

Why?

A
  • Thyroid gland size
  • Pts with type 1 dm have a 15% association of other autoimmune diseases, such as:
    • hashimoto thyroiditis
    • graves disease
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12
Q

Autonomic neuropathy:

prevalence?

What does it affect?

Anesthetic considerations?

A
  • Autonomic nervous dysfunction results from diabetes
  • present in 20-40% of all diabetics
  • mostly affects the cardiovascular and GI system
  • Anesthetic considerations:
    • orthostatic hypotension
    • resting tachycardia
    • loss of HR variability- if brady, atropine will not work, go straight to epi
    • cardiac dysrhythmias
    • altered regulation of breathing
    • sudden death
    • peripheral neuropathy
    • gastroparesis
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13
Q

How do you manage insulin pre-operatively?

A
  • Depends on type and dose
    • NPH: 2/3 dose night before and 1/2 am dose
    • Regular: 2/3 dose night before and no am dose
    • Insulin pump: overnight cut to 30%, d/c in am
  • ***Double and triple check that the insulin pump is turned OFF
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14
Q

Oral hypoglycemics should be discontinued ______ hours preop

A

24-48 hours

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15
Q

What fluid should you avoid administering to a diabetic pt?

What should you consider for fluid status?

A

lactate because it converts to glucose

  • Pt may be hypovolemic if they are diaresing d/t high osmolarity from excess glucose in plasma
    • look for fluid deficit and electrolyte abnormalities
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16
Q

What do you need to consider regarding the anesthetic management of a diabetic pt?

A
  • Schedule early in the day
  • monitors depend of condition and surgical procedure
  • possibility of difficult intubation
  • consider aspiration precautions for gastroparesis (RSI)
  • Oxygenation (50-100%) b/c they probably have cardiac disease
  • check frequent bs
  • avoid nephrotoxic agents
  • may be more sensitive to cardiorespiratory depressants
  • aggressively treat bradycardia with epi if you suspect autonomic neuropathy
  • Position carefully to avoid ulcers d/t decreased tissue perfusion
17
Q

General vs regional in the diabetic patient

A
  • Both can be safe to use
  • GA
    • induces hormonal changes causing glycogenolysis and gluconeogenesis
  • Regional
    • concern with neuropathy/compensatory mechanisms to vasodilation may be impaired
    • be prepared to use vasoactive drugs for BP control
    • Local will not be effective if injected into an infective site, inject above
18
Q

What questions do you need to have answered to decide how to manage the blood sugar in the OR?

A
  • Need to determine how “tight” control needs to be
    • Did the pt take insulin or oral hypoglycemic on day of surgery?
    • How often should the blood glucose be monitored?
    • Will the pt require an insulin drig?
    • Will pt require a glucose containing solution?
    • How should they be managed postoperatively?
19
Q

What are the benefits of tight control?

A
  • Tight control reduces risk of chronic complications in type 1
  • may affect surgical outcome!
    • increased wound healing
    • decreased infection
    • decreased osmotic diuresis
    • decreased incidence of DKA
    • decreased risk of neurologic insult
20
Q

What are the goals of anesthetic management?

A
  • AVOID hypoglycemia!!
    • frequent bs checks!!!
  • minimize metabolic derangements
  • There are different protocols
21
Q

How much does 1 unit of insulin lower blood glucose?

A

20-40 mg/dl

22
Q

How do we like a diabetic pts bs to be during anesthesia?

What do you do if hypoglycemia occurs?

A
  • mild transient hyperglycemia to avoid hypoglycemia
  • If hypoglycemia occurs:
    • 50 ml of 50% dextrose in water will increase 100 mg/dl
23
Q

What is an example of a non-tight method?

A
  • check BS before surgery
  • IV 5% dextrose 100-150 ml/hr
  • administer 1/2 normal insulin dose SQ
  • Have 2nd IV for fluid and anesthetic drug administration
  • check bs q 1 hour
  • BS>180 administer Regular insulin on sliding scale
24
Q

What are the disadvantages of non-tight method?

A
  • SQ absorption unpredictable- depends on BP, blood flow, and temp changes
  • Onset and peak subq insulin may not correspond with surgical stress and length
  • 1/2 life of Regular insulin is short, causing rollercoaster glucose profile
25
Q

How can tight management be done?

A
  • Insulin infusion- mix 100 units regular insulin in 100 ml NS
  • check fasting BS
  • IV with D5W 100 ml/hour and 2nd IV for fluids
  • Insulin infusion started- to determine rate: BS/150 = units/hour
    • run insulin gtt on a pump!
  • check bs q 1 hour and monitor K
  • administer 20 mEq KCl added to D5W if K is low
26
Q

What are the risks and advantages to tight control?

A
  • risk: hypoglycemia
  • advantage: can continue into post-op care to maintain BS 140-180 mg/dl

Coexisting conditions (34 decks)

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