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Anesthesia and Diabetes MellitusClinical Manifestations of
Diabetes Mellitus (DM)
Insulin deficiency leads to hyperglycemia and glycosuria.Fasting
blood glucose > 126 mg%
GTT: blood glucose > 200 mg%Classification: Types of DM
Type I Immune-mediated or idiopathic absolute insulin
deficiencyonset < 16 years old
15% have other autoimmune diseasehypothyroidism
Graves' disease
Addison's disease
myasthenia gravisType II Adult onset secondary to
resistance/relative deficiency
Type III Secondary to specific genetic defects
Type IV Gestational2.4% of U.S. pregnancies
Long-term complicationsHypertension
Myocardial infarctiono risk of MI 2-10 X greater than in
nondiabetic
Peripheral and cerebral vascular diseaseo risk of peripheral
vascular disease 5-10 X greater than in nondiabetico risk of stroke
twice that in nondiabetic
Autonomic neuropathyo >15% of diabeticso increases
perioperative morbidity
Renal failureLife-threatening acute complications
1. Diabetic ketoacidosis (DKA)
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usually Type I
2. Hyperosmolar nonketotic coma3. Hypoglycemia
DKA
Dyspnea, abdominal pain, nausea and vomiting, dehydration,
coma
Anion-gap metabolic acidosis, elevated plasma and urine ketones
(acetoacetate,
beta-hyroxybutyrate), hyperglycemia
RxInsulin (regular) 0.1 U/kg/hour and increase
NS
Potassium when urine output
Add D5W when plasma glucose 250 mg%Hyperosmolar nonketotic
coma
Hyperglycemic diuresis -> severe dehydration
Renal failure
Lactic acidosis
Risk of intravascular thromboses
Hyperosmolality with coma seizures
RxFluid resuscitation
Insulin (relatively small doses)
Potassium when urine outputHypoglycemia
Diaphoresis, tachycardia, nervousness
Plasma glucose < 50 mg%
Rx: D50WAnesthetic Considerations
PreoperativeEvaluate end-organ damage (cardiovascular,
pulmonary, renal)
Beware silent myocardial ischemia/infarction
Diabetic autonomic neuropathyHypertensionPainless myocardial
ischemia
Orthostatic hypotension
Lack of heart rate variability
Reduced heart rate response to atropine or propranolol
Resting tachycardia
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Early satiety
Neurogenic, atonic bladder
Lack of sweatingImpotence
Asymptomatic hypoglygemiaSudden death syndrome
Mortality 50% over 5 yearsGastroparesis with delayed
emptying
Consider H-2 blocker or metoclopramide
premedLimited-mobility joint syndrome (stiff-joint
sydrome)
o 30-40% of Type I diabeticso positive "prayer sign" (image at
right:)o TJ joint and C-spine (e.g. atlanto-occipital
joint) may be involved
Direct laryngoscopy may be difficult in 30% of Type I
diabetics
Glycohemoglobin, hemoglobin A1c
o good measure of overall blood glucose controlo normal 5-7%o up
to 20% in marked hypergylcemia
IntraoperativeInsulin/glucose regimens (after starting IV and
checking blood glucose)
Start IV and check blood glucose
Begin D5W 1 - 1.5 ml/kg/hr (IV 'piggy-back')
Administer insulin: either
1. 1/2 of total daily dose as intermediate form (NPH) +
intraop"sliding scale," or
2. Continuous infusion of regular insulinU/hr = (plasma
glucose)/150 +
Monitor blood glucose
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Avoid hypoglycemia
Hyperglycemia:
HyperosmolarityInfection
Poor wound healingWorsens neurologic outcome after cerebral
ischemiaBeware protamine sulfate anaphylaxis in patients taking NPH
or protamine zinc
insulinPostoperative
Monitor blood glucoseFront PageResidency ProgramTop
Send Comments to Greg Gordon MD, [email protected]
Department of AnesthesiologyThe MetroHealth System
2500 MetroHealth DriveCleveland, Ohio 44109-1998
Phone: (216) 778-4801
Last updated: 28 July 2004
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