Modrator : Dr. Maya Presented by : Bikash ranjan ray

Modrator : Dr. MayaPresented by : Bikash ranjan ray Case presentation Diabetes Mellituswww.anaesthesia.co.in anaesthesia.co.in@gmail.com1HISTORYGajender kumar

55 yr , male

Bulandahar, UP

Presenting complaint:Nonhealing ulcer bilateral foot - 2 monthPus discharge from left foot ulcer 2 monthBlackish discolouration of left foot - 10 days

2History of present illness :

Apparently alright 2 month back h/o injury to b/l foot 2 month back

Developed ulcer at trauma site No associated pain at the site of ulcer

Purulent discharge from left foot ulcer : treated with antibiotics and dressing

Blackish discoloration of left foot 10 days No h/o change in colour with change in temprature

No H/o fever, swelling of lower limb

3Past history :K/c/o DM 6 yrPreviously was on OHA for 4yrsChanged to insulin since last 2 yrsH/o poor compliance to treatment and poor control of blood sugars

Presently on insulinHuman actrapid 12 IU BBF,BL & BDInsulatard 25 IU after dinnerOn this regimen blood sugars were controlled H/o similar discoloration in Lt toe 1yr back, amputation done RA, U/E

4H/o syptoms suggestive of hypoglycemic episodes

H/o tingling and numbness in both lower limbs since 2 yrs

No history s/o any other medical illness ( HTN , TB , CAD, Asthma ,etc )

5No H/o:Chest pain, palpitations, breathlessness, orthopnea/ PND, edema feet, syncope, cough urine output, generalized edemaGiddiness on change of posture

No h/o decreased vision

Limited mobility since last 1 month due to b/l foot ulcer

Initially could climb 3 flights of stairs No history of any drug allergy

6Treatment history:Inj. Levoflox 500 mg i.v. odInj. Metrogyl 500mg 8th hrly

Personal history :Bowel and bladder habits: normalAlcohol intake : occasionalCigarette smoker: smoked for 15 yrs, 4-5/day, stopped since last 3yrs

Family history :Insignificant 7General ExaminationAwake ,Conscious, Oriented, sitting comfortably in bed Wt: 55 kg, ht: 164 cm

Afebrile

No pallor, icterus, cyanosis, clubbing, jaundice, lymphadenopathy

JVP: not raised

Good i.v. access

8Pulse: 80/min, regular, adequate volume, no radioradial or radiofemoral delay

BP in right arm: 138/ 84 mm of Hg supine position, 130/ 80 mm of Hg sitting position

RR: 20/ min, regular

HR response to deep breathing: > 15bpm

9Local examinationLeft foot: heel ulcer

8x12 cm, blackish discoloration till ankle, no line of demarcation, purulent discharge, foul smelling

Surrounding skin: swollen, erythematous, tender

Right foot:

24 cm ulcer , no discharge10Systemic Examination:CVS: Apex beat in 5th intercoastal space, midclavicular line S1, S2 normal No murmurs

Respiratory system: B/L air entry present No crepitations or rhonchi

Abdomen: soft, no organomegaly

Spine: normal

11CNS:Higher functions normalCranial nerves : normalSensory examination: B/L lower limb Pain, touch and temperature sensation were decreased in the distal parts

Pressure , position sense and vibration sense intact & normal in both the limbs Motor examination: Power and tone: normal in both the limbs Reflexes: Ankle jerk: B/L absent all other reflex present

12Airway examinationMouth opening: 5 cm

MMP class: 2

Neck movements: WNL

TMD: 6 cm

Teeth: intact

Prayers sign: negative

13Provisional Diagnosis DM with b/l foot ulcer ,with gangrene of left lower limb

Surgical plan :

Below knee amputation of left leg14Investigations:Hb = 10.0 g/dlTLC =14500Platelet count =3,21,000Na+/K+ =150/4.8Urea = 58mg/dT. bil = 0.7Pt = 12/ 13CXR = WNLECG= WNLBlood sugar :Fasting 156 mg/dlUrine sugar and ketones ve

15Anaesthesia 16Diagnosis and Classification1)Symptoms ( polyuria, polydipsia,wt loss )plus random plasma glucose >=200 mg/dl (11.1mmol/l) or2) A fasting (>8hr)plasma glucose of >=126 mg/dl (7 mmol/l). or3)A glucose conc . Of >=200 mg/dl (11.1mmol/l)2 hrs after oral ingestion of 75 g glucose

2004 ADA , reduces normal fasting glucose thresold from 110mg/dl to 100 mg/dl (normal FBG = 70 100 )Impaired fasting glucose = 101 125 mg/dl

17Metabolic syndrome x

At least 3 of the following:FPG 110 mg/dlAbdominal obesity (waist grith >40 in men and >35 in women )Sr. triglycerides 150 mg/dlSr. HDL midnight

Day of surgery : iv 5%D @1.5 ml/kg/hr (Preop + intraop)

Subcut one half usual daily intermediate acting insulin on

morning of surgery, increased by 0.5U for each unit of regular

insulin dose of insulin subcut

Postop : Monitor blood glu & treat on sliding scale

Limitations:Insulin requirements vary in periop periodOnset & peak effect may not correlate with glucose admn or start of surgeryHypoglycemia esp in afternoonLowest therapeutic ratio

28Tight control regimen IAim : 79-120 mg/dl

Protocol : Evening before, do pre-prandial bld glucoseBegin iv 5%D @ 50 ml/hr/70 kgPiggyback to 5%D, infusion of regular insulin (50 U in 250 ml 0.9% NS)Insulin infusion rate (U/hr) = plasma glu (mg/dl) / 150 or /100 if on steroids or severe infectionRepeat bld glu every 4 hoursDay of surgery : Non dextrose containing solutions,Monitor blood glu at start & every 1-2 hours29Tight control regimen IIAim : Same as TC regimen I

Protocol : Obtain a feedback mechanical pancreas & set controls for desired plasma glucose.

Institute 2 iv drips for insulin & fluids

30Albertis regimen1979- Alberti & Thomas IV GIK solution [500ml 10% glucose + 10 units soluble insulin + 1 gm KCl @ 100 ml/hr]

Before surgery - stabilize on soluble insulin regimen, omit morning dose of insulin

Commence infusion early on morning & monitor glu at 2-3 hours

< 90mg/dl or > 180 mg/dl replace bag with 5U or 15U respectively

31Albertis regimen-Recent versionInitial solution : 500ml 10% glu + 10 mmol KCl + 15 U Insulin, infuse at 100 ml/hr

Check Blood glu every 2 hours

Adjust in 5 U steps

Discontinue if bld glu < 90 mg/dl

Blood glu (mg/dl)Action20020 U insulin(4U/h)32Advantages : simple, Inherent safety factor, balance appropriate

Criticism : hypoglycemia, water load & hyponatremia, cautious : poor renal function

20% or 50% D

33Hirsh regimenAim : Normoglycemia

Infuse glucose 5 g/hr with pot 2-4 mmol/hr

Start insulin infusion @.5-1U/hr

Measure blood glucose hourly

Blood glu (mg/dl)Action (insulin infusion)< 80Turn off for 30 min, give 25 ml 50% D80-120 by .3 U/h120-180No change in infusion rate180-220 by .3 U/hr> 220 by 0.5 U/hr34Regular Insulin Sliding ScaleRECOMMENDATIONS

Supplement usual diabetes medications to treat uncontrolled high blood sugars

Short term use (24-48 h) in a patient admitted with unknown insulin requirement

Should not be used as a sole substitute, risk of DKA Periop changes in regional blood flow unpredictable absorption

35

36Split-mixed insulin regimenCombining multiple daily injections of intermediate or long acting insulin (NPH, lente, or ultralente) rapid or short acting insulins (Regular, insulin lispro, or insulin aspart)

1500 Rule : (ICF) 1500/total insulin dose = how much 1 unit of regular insulin will decrease blood glucose.

37Hypoglycemia

BG < 50 mg/dl in adults and < 40 mg/dl in children whipples triad : low plasma glucose hypoglycemic symptoms resolution of symptoms with correction of blood sugar Sympathoadrenal : Weakness, sweating, HR, palpitations, tremor, nervousness, irritability, tingling, hungerNeuroglycopenia :Headache, temp, visual disturbances, mental confusion, amnesia, seizures, coma

38 Treatment :Discontinue insulin dripGive D 50 w iv patient conscious 25 ml patient unconscious 50 mlRecheck BG every 20 min & repeat 25 ml of D50 w if < 60 mg/dlRestart drip once BG is > 70 mg/dl39Diabetic autonomic neuropathy :

PupillaryDecreased diameter of darkadapted pupilArgyll-Robertson type pupilMetabolicHypoglycemia unawarenessHypoglycemia unresponsivenessCardiovascularTachycardia, exercise intoleranceCardiac denervationOrthostatic hypotensionHeat intoleranceNeurovascularAreas of symmetrical anhydrosisGustatory sweatingHyperhidrosisAlterations in skin blood flowGastrointestinalConstipationGastroparesis diabeticorumDiarrhea and fecal incontinenceEsophageal dysfunctionGenitourinaryErectile dysfunctionRetrograde ejaculationCystopathyNeurogenic bladderDefective vaginal lubrication40Diagnostic tests for cardiovascular autonomic neuropathy :

Resting heart rate> 100 beats/minute is abnormal

Beat-to-beat heart rate variationThe patient should abstain from drinking coffee overnightTest should not be performed after overnight hypoglycemic episodesWhen the patient lies supine and breathes 6 times per minute, a difference in heart rate of lessthan 10 beats/minute is abnormalAn expiration:inspiration R-R ratio > 1.17 is abnormal

Heart rate response to standingThe R-R interval is measured at beats 15 and 30 after the patient standsA 30:15 ratio of less than 1.03 is abnormal

Heart rate response to Valsalva maneuverThe patient forcibly exhales into the mouthpiece of a manometer, exerting a pressure of 40 mm Hg, for 15 secondsA ratio of longest to shortest R-R interval of less than 1.2 is abnormal41Systolic blood pressure response to standing

Systolic blood pressure is measured when the patient is lying down and 2 minutes after the patient standsA fall of more than 30 mm Hg is abnormalA fall of 10 to 29 mm Hg is borderline

Diastolic blood pressure response to isometric exercise

The patient squeezes a handgrip dynamometer to establish his or her maximumThe patient then squeezes the grip at 30% maximum for 5 minutesA rise of less than 16 mm Hg in the contralateral arm is abnormal

Electrocardiography

A QTc of more than 440 ms is abnormalDepressed very-low frequency peak or low-frequency peak indicate sympathetic dysfunctionDepressed high-frequency peak indicates parasympathetic dysfunctionLowered low-frequency/high-frequency ratio indicates sympathetic imbalance

Neurovascular flowNoninvasive laser Doppler measures of peripheral sympathetic responses to nociception

42X ray cervical spine :

43Prayer sign :

44Finger print test :

45Differential diagnosis of DKA :

46Diagnostic criteria and deficits in DKA and HHS :

47Pathogenesis of DKA and HHS :

48Diabetes and anesthesia :

Diabetes49 THANK YOU

The Greek word Diabetes = to Siphon /pass through ...and the Latin word mellitus = sweet as honeywww.anaesthesia.co.in anaesthesia.co.in@gmail.com50