Diabetic Stiff Joint Syndrome

S

Stiff Joint Syndrome in Diabetes: a Potential for

Difficult AirwayKeara Laffey, SRNA

Case Western Reserve University/Cleveland Clinic

OSANA Fall MeetingSeptember 13, 2015

Objectives

State the incidence and pathology of Stiff Joint Syndrome

Discuss the incidence of difficult laryngoscopy in patients with long standing DM as it relates to Stiff Joint Syndrome

Describe two screening tools to assess for difficult laryngoscopy in the diabetic patient and understand how to interpret the results

Diabetes Statistics

International Diabetes Federation Worldwide 387 million living with diabetes worldwide,

8.3% 1/12 people with diabetes worldwide

American Diabetes Association 29.1 million Americans, 9.3% of population 86 million Americans have pre-diabetes By 2050 1 in 3 Americans will have diabetes if the current

trend continues

Diabetes in Surgery

25%-50% require surgery Most common endocrine

abnormality in surgical population Higher morbidity and mortality Often undiagnosed

Complications of Diabetes

Atherosclerosis Nephropathy Neuropathy Stiff Joint Syndrome

Stiff Joint Syndrome

First described by Dr. Arlan Rosenbloom in 1974 Also referred to as Diabetic Cheiroarthropathy or

Limited Joint Mobility Most common, earliest occurring complication of

Type 1 DM, also frequent occurrence in Type 2 DM Linked to duration and control of diabetes


Patient Characteristics Joint contractures Begins in fifth finger and progresses radially Thick, tight, waxy skin Short stature Microvascular complications Symmetrical Painless, non-disabling


Prevalence Up to 50% of Type 1 DM As high as 75% of Type II DM

Causes Chronic hyperglycemia glycosylation increased

protein-protein cross-linkage clinical stiffness Microvascular disease hypoxia cellular

hyperplasia


Diagnosis Goniometry Prayer Sign Palm Print Test

Grade 0 Grade 1

Grade 2 Grade 3

Research

Diabetes and difficult laryngoscopy Hogan et al., 1988; Reisssel et al., 1990; Erden, 2003

Difference between Type I DM and Type II DMArkkila et al., 1997

Predictive value of Palm Print Test vs Mallampati, thyromental distance, and head extensionVani, Kamath, and Naik, 2000; George and Jacob, 2003

Sensitivity of Palm Print Test and Prayer Sign Sachdeva, 2013; Mahmoodpoor et al., 2013; Hashim and Thomas, 2014

Airway Assessment

Palm Print Test Highly Sensitive 75%-98%

Highly Specific 73%-96%

Prayer Sign Less sensitive 29.6%-54%

Moderate-highly specific 55%-

96%

Significance

Problems in Anesthesia

Unexpected difficult

intubation

Altered nerve monitoring

Decreased lung elasticity

Summary

Future research guiding practice

Addition of tests to pre-operative assessment

Inclusion of new knowledge into practice

References

Arkkila, P., Kantola, I., & Viikari, J. (1997). Limited Joint Mobility in NonñInsulin Dependent Diabetic (NIDDM) Patients: Correlation to Control of Diabetes, Atherosclerotic Vascular Disease, and Other Diabetic Complications. Journal of Diabetes and Its Complications, 11.4, 208-217. Retrieved August 11, 2015, from PubMed.

Barash, P.G., Cullen, B.F., Stoelting, R.K., Cahalan, M.K., Stock, M.C., and Ortega, R. (2013). Clinical Anesthesia (7th ed.). Philadelphia, PA: Lippincott, Williams & Wilkins and Wolters Kluwer Health.

Erden, V. (2003). Relationship of difficult laryngoscopy to long-term non-insulin-dependent diabetes and hand abnormality detected using the 'prayer sign' British Journal of Anaesthesia, 159-160. doi:10.1093/bja/aeg583

Fast Facts: Data and Statistics About Diabetes. American Diabetes Association, Mar. 2015. Web. 13 Aug. 2015.

George, S.P., and Jacob, R. "Predictability of Airway Evaluation Indices in Diabetic Patients." Indian Journal of Anesthesia 47.6 (2003): 476-78. PubMed. Web. 11 Aug. 2015

Hines, R.L., and Marschall, K.E. (2012). Stoeltings Anesthesia and Co-Existing Disease (6th ed.). Philadelphia, PA: Elsevier.

Hogan, K., Rusy, D., & Springman, S. (1988). Difficult Laryngoscopy and Diabetes Mellitus. Anesthesia & Analgesia, 67, 1162-1165. Retrieved July 12, 2015, from PubMed.gov

Infante, J., Rosenbloom, A., Silverstein, J., Garzarella, L., & Pollock, B. (2001). Changes in frequency and severity of limited joint mobility in children with type 1 diabetes mellitus between 1976-78 and 1998. The Journal of Pediatrics, 138(1), 33-37. doi:10.1067/mpd.2001.109710

Kadoi, Y. (2010). Anesthetic considerations in diabetic patients. Part I: Preoperative considerations of patients with diabetes mellitus. Journal of Anesthesia. Japanese Society of Anesthesiologists, 24, 739-747. doi:10.1007/s00540-010-0987-1

Larkin, M.E., Barnie, A., Braffett, B.H., Cleary, P.A., Diminick, L., Harth, J.,...(2014). Musculoskeletal Complications in Type 1 Diabetes. Diabetes Care 37.7, 1863-869. Retrieved August 11, 2015 from PubMed.

Mahmoodpoor, Ata, Hassan Soleimanpour, Kavous Shahsavari Nia, Jafar Rahimi Panahi, Mohammadreza Afhami, Samad EJ Golzari, and Karim Majani. "Sensitivity of Palm Print, Modified Mallampati Score and 3-3-2 Rule in Prediction of Difficult Intubation." International Journal of Preventive Medicine 4.9 (2013): 1063-1069. PubMed. Web. 11 Aug. 2015

Nagelhout, J.J., and Plaus, K.L. (2014). Nurse Anesthesia (5th ed.). Philadelphia, PA: Elsevier.

Reissell, E., R. Orko, E-L. Maunuksela, and Lindgren, L. "Predictability of Difficult Laryngoscopy in Patients with Long-term Diabetes Mellitus." Anaesthesia 45.12 (1990): 1024-027. PubMed. Web. 11 Aug. 2015.

Sachdeva, K., Singh, A., Kathuria, S., Kaul, T., Rupinder, M., Bajwa, N., & Singh, P. (2005). Prediction of Difficult Laryngoscopy in Diabetics by Palm Print and Interphalangeal Gap. Journal of Anesthesiology Clinical Pharmacology, 21(3), 261-264. Retrieved August 14, 2015, from PubMed.gov

Salzarulo, H., & Taylor, L. (1986). Diabetic ìStiff Joint Syndromeî as a Cause of Difficult Endotracheal Intubation. Anesthesiology, 64, 366-367. Retrieved July 20, 2015, from PubMed.gov

Silverstein, J., Gordon, G., Pollock, B., & Rosenbloom, A. (1998). Long-term glycemic control influences the onset of limited joint mobility in type 1 diabetes. The Journal of Pediatrics, 132(6), 944-947. Retrieved July 16, 2015, from PubMed.gov

Thomas, M., and Hashim, K.Y. "Sensitivity of Palm Print Sign in Prediction of Difficult Laryngoscopy in Diabetes: A Comparison with Other Airway Indices." Indian Journal of Anaesthesia Indian J Anaesth 58.3 (2014): 298-302. PubMed. Web. 11 Aug. 2015.

Vani V V, Kamath S K, Naik L D. The palm print as a sensitive predictor of difficult laryngoscopy in diabetics: a comparison with other airway evaluation indices. J Postgrad Med 2000;46:75

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Diabetic Stiff Joint Syndrome