Stress Response to Surgery Under General Anesthesia in ... · Stress Response to Surgery Under...
Transcript of Stress Response to Surgery Under General Anesthesia in ... · Stress Response to Surgery Under...
![Page 1: Stress Response to Surgery Under General Anesthesia in ... · Stress Response to Surgery Under General Anesthesia in Type 2 Diabetic Patient Dr Kawsar Sardar, MD Associate professor](https://reader034.fdocuments.us/reader034/viewer/2022042919/5f62412520fcd6758051efd8/html5/thumbnails/1.jpg)
Stress Response to Surgery Under General Anesthesia in
Type 2 Diabetic Patient
Dr Kawsar Sardar, MD
Associate professor Department of Anesthesiology, BIRDEM, Bangladesh Joint secretary, Bangladesh Society of Anesthesiologists
![Page 2: Stress Response to Surgery Under General Anesthesia in ... · Stress Response to Surgery Under General Anesthesia in Type 2 Diabetic Patient Dr Kawsar Sardar, MD Associate professor](https://reader034.fdocuments.us/reader034/viewer/2022042919/5f62412520fcd6758051efd8/html5/thumbnails/2.jpg)
BANGLADESH
![Page 3: Stress Response to Surgery Under General Anesthesia in ... · Stress Response to Surgery Under General Anesthesia in Type 2 Diabetic Patient Dr Kawsar Sardar, MD Associate professor](https://reader034.fdocuments.us/reader034/viewer/2022042919/5f62412520fcd6758051efd8/html5/thumbnails/3.jpg)
• Central Location • 700-bed multidisciplinary hospital • Very large OPD (4500 patients /day) • 60-70 diabetic patients under went operative
procedure everyday • WHO Collaborating Centre for Research on
Diabetes and its complications (Till 2014)
![Page 4: Stress Response to Surgery Under General Anesthesia in ... · Stress Response to Surgery Under General Anesthesia in Type 2 Diabetic Patient Dr Kawsar Sardar, MD Associate professor](https://reader034.fdocuments.us/reader034/viewer/2022042919/5f62412520fcd6758051efd8/html5/thumbnails/4.jpg)
– One of Largest diabetes care provider in the world
– One of Largest non-profit health care network outside Govt. in the world
– Provide healthcare through a network of hospitals & educational institutions of its own
![Page 5: Stress Response to Surgery Under General Anesthesia in ... · Stress Response to Surgery Under General Anesthesia in Type 2 Diabetic Patient Dr Kawsar Sardar, MD Associate professor](https://reader034.fdocuments.us/reader034/viewer/2022042919/5f62412520fcd6758051efd8/html5/thumbnails/5.jpg)
Our network all over the country
![Page 6: Stress Response to Surgery Under General Anesthesia in ... · Stress Response to Surgery Under General Anesthesia in Type 2 Diabetic Patient Dr Kawsar Sardar, MD Associate professor](https://reader034.fdocuments.us/reader034/viewer/2022042919/5f62412520fcd6758051efd8/html5/thumbnails/6.jpg)
Diabetes Mellitus
• One of the major chronic diseases
affecting mankind all over the world
• It has been declared as an epidemic in
developing countries by both the World
Health Organization and International
Diabetes Federation
![Page 7: Stress Response to Surgery Under General Anesthesia in ... · Stress Response to Surgery Under General Anesthesia in Type 2 Diabetic Patient Dr Kawsar Sardar, MD Associate professor](https://reader034.fdocuments.us/reader034/viewer/2022042919/5f62412520fcd6758051efd8/html5/thumbnails/7.jpg)
HIGHEST ABSOLUTE NUMBERS
CHINA 90 million ●
INDIA 61 million ●
HIGHEST PREVALENCES RATE
● MIDDLE EAST 1 in 5 adults HIGHEST REGIONAL INCREASE BETWEEN 2011 - 2030
● AFRICA – 90% increase
Killer Facts:
• More than 382 million (8.3%) people live with diabetes – by 2035 will be 592 (9.9%) million
• 80% live in low- and middle-income countries (LMCs)
• 4.6 million deaths each year
• Every 8 seconds, someone in the world dies from diabetes
Diabetes Atlas
![Page 8: Stress Response to Surgery Under General Anesthesia in ... · Stress Response to Surgery Under General Anesthesia in Type 2 Diabetic Patient Dr Kawsar Sardar, MD Associate professor](https://reader034.fdocuments.us/reader034/viewer/2022042919/5f62412520fcd6758051efd8/html5/thumbnails/8.jpg)
Diabetes in Bangladesh
• The estimated prevalence of diabetes in
Bangladesh is around 6.8%
• Mostly Type 2 diabetes (99%)
![Page 9: Stress Response to Surgery Under General Anesthesia in ... · Stress Response to Surgery Under General Anesthesia in Type 2 Diabetic Patient Dr Kawsar Sardar, MD Associate professor](https://reader034.fdocuments.us/reader034/viewer/2022042919/5f62412520fcd6758051efd8/html5/thumbnails/9.jpg)
Fifty percent of all diabetic patients present
for surgery during their life time
![Page 10: Stress Response to Surgery Under General Anesthesia in ... · Stress Response to Surgery Under General Anesthesia in Type 2 Diabetic Patient Dr Kawsar Sardar, MD Associate professor](https://reader034.fdocuments.us/reader034/viewer/2022042919/5f62412520fcd6758051efd8/html5/thumbnails/10.jpg)
Inevitably, diabetic patients presenting for incidental surgery, or surgery related to their disease, will place an increasing burden on
anesthetic services
![Page 11: Stress Response to Surgery Under General Anesthesia in ... · Stress Response to Surgery Under General Anesthesia in Type 2 Diabetic Patient Dr Kawsar Sardar, MD Associate professor](https://reader034.fdocuments.us/reader034/viewer/2022042919/5f62412520fcd6758051efd8/html5/thumbnails/11.jpg)
Perioperative morbidity and mortality are greater in diabetic than in nondiabetic patients
![Page 12: Stress Response to Surgery Under General Anesthesia in ... · Stress Response to Surgery Under General Anesthesia in Type 2 Diabetic Patient Dr Kawsar Sardar, MD Associate professor](https://reader034.fdocuments.us/reader034/viewer/2022042919/5f62412520fcd6758051efd8/html5/thumbnails/12.jpg)
In response to stress during surgery and anesthesia- the biochemical parameters like
stress hormone being altered
![Page 13: Stress Response to Surgery Under General Anesthesia in ... · Stress Response to Surgery Under General Anesthesia in Type 2 Diabetic Patient Dr Kawsar Sardar, MD Associate professor](https://reader034.fdocuments.us/reader034/viewer/2022042919/5f62412520fcd6758051efd8/html5/thumbnails/13.jpg)
The neuroendocrine system comes into play to maintain fuel requirements by glycogenolysis
and gluconeogenesis through stress hormones catecholamines, glucagon, cortisol, and growth
hormone
![Page 14: Stress Response to Surgery Under General Anesthesia in ... · Stress Response to Surgery Under General Anesthesia in Type 2 Diabetic Patient Dr Kawsar Sardar, MD Associate professor](https://reader034.fdocuments.us/reader034/viewer/2022042919/5f62412520fcd6758051efd8/html5/thumbnails/14.jpg)
The endocrine hormones like cortisol, thyroxin, glucagon, and growth hormone are released
due to surgical stress under hypothalamopituitary control
![Page 15: Stress Response to Surgery Under General Anesthesia in ... · Stress Response to Surgery Under General Anesthesia in Type 2 Diabetic Patient Dr Kawsar Sardar, MD Associate professor](https://reader034.fdocuments.us/reader034/viewer/2022042919/5f62412520fcd6758051efd8/html5/thumbnails/15.jpg)
Surgery elicits a stress response that is directly proportional to the degree of tissue trauma
![Page 16: Stress Response to Surgery Under General Anesthesia in ... · Stress Response to Surgery Under General Anesthesia in Type 2 Diabetic Patient Dr Kawsar Sardar, MD Associate professor](https://reader034.fdocuments.us/reader034/viewer/2022042919/5f62412520fcd6758051efd8/html5/thumbnails/16.jpg)
Why Stress response to surgery
under anesthesia is complicated in diabetic patients?
• Insulin deficiency
• Counter regulatory hormones activity
• Autonomic neuropathy
• Electrolytes transport
• Preoperative fasting states
• Dehydration
![Page 17: Stress Response to Surgery Under General Anesthesia in ... · Stress Response to Surgery Under General Anesthesia in Type 2 Diabetic Patient Dr Kawsar Sardar, MD Associate professor](https://reader034.fdocuments.us/reader034/viewer/2022042919/5f62412520fcd6758051efd8/html5/thumbnails/17.jpg)
These lead to abnormal metabolism of carbohydrate, protein and fat as well as electrolyte imbalance
![Page 18: Stress Response to Surgery Under General Anesthesia in ... · Stress Response to Surgery Under General Anesthesia in Type 2 Diabetic Patient Dr Kawsar Sardar, MD Associate professor](https://reader034.fdocuments.us/reader034/viewer/2022042919/5f62412520fcd6758051efd8/html5/thumbnails/18.jpg)
Anesthesia also principally affects glucose metabolism through the modulation of sympathetic tone
![Page 19: Stress Response to Surgery Under General Anesthesia in ... · Stress Response to Surgery Under General Anesthesia in Type 2 Diabetic Patient Dr Kawsar Sardar, MD Associate professor](https://reader034.fdocuments.us/reader034/viewer/2022042919/5f62412520fcd6758051efd8/html5/thumbnails/19.jpg)
Our study
• It was designed to explore the metabolic and stress response to lower abdominal surgery under general anesthesia in type 2 diabetic subjects with particular focus on
– Serum glucose – C-peptide – Cortisol – Electrolytes
• It also investigated the stress response in different
treatment variability
![Page 20: Stress Response to Surgery Under General Anesthesia in ... · Stress Response to Surgery Under General Anesthesia in Type 2 Diabetic Patient Dr Kawsar Sardar, MD Associate professor](https://reader034.fdocuments.us/reader034/viewer/2022042919/5f62412520fcd6758051efd8/html5/thumbnails/20.jpg)
OBJECTIVES
• To investigate the glycemic response to surgery in type 2 diabetic subjects under general anesthesia.
• To investigate the serum cortisol response to surgery in type 2 diabetic subjects under general anesthesia.
![Page 21: Stress Response to Surgery Under General Anesthesia in ... · Stress Response to Surgery Under General Anesthesia in Type 2 Diabetic Patient Dr Kawsar Sardar, MD Associate professor](https://reader034.fdocuments.us/reader034/viewer/2022042919/5f62412520fcd6758051efd8/html5/thumbnails/21.jpg)
OBJECTIVES
• To investigate the stress response in insulin and combined insulin-OHA treated type 2 diabetic subjects during surgery under general anesthesia.
• To investigate the stress response in hypertensive and normotensive type 2 diabetic subjects during surgery under general anesthesia.
![Page 22: Stress Response to Surgery Under General Anesthesia in ... · Stress Response to Surgery Under General Anesthesia in Type 2 Diabetic Patient Dr Kawsar Sardar, MD Associate professor](https://reader034.fdocuments.us/reader034/viewer/2022042919/5f62412520fcd6758051efd8/html5/thumbnails/22.jpg)
Study design
The study was a cross sectional prospective study
![Page 23: Stress Response to Surgery Under General Anesthesia in ... · Stress Response to Surgery Under General Anesthesia in Type 2 Diabetic Patient Dr Kawsar Sardar, MD Associate professor](https://reader034.fdocuments.us/reader034/viewer/2022042919/5f62412520fcd6758051efd8/html5/thumbnails/23.jpg)
Study subjects
100 subjects who were admitted in BIRDEM hospital in fit physical condition (ASA Class II) were received total abdominal hysterectomy under general anesthesia
![Page 24: Stress Response to Surgery Under General Anesthesia in ... · Stress Response to Surgery Under General Anesthesia in Type 2 Diabetic Patient Dr Kawsar Sardar, MD Associate professor](https://reader034.fdocuments.us/reader034/viewer/2022042919/5f62412520fcd6758051efd8/html5/thumbnails/24.jpg)
Exclusion criteria
• Influencing variable like patients taking steroid or analgesics
• Pre operative plasma glucose <5 mmol/l and >10 mmol /l
• Patients of ASA Class III, IV, V and E
• Obese and malnourish
![Page 25: Stress Response to Surgery Under General Anesthesia in ... · Stress Response to Surgery Under General Anesthesia in Type 2 Diabetic Patient Dr Kawsar Sardar, MD Associate professor](https://reader034.fdocuments.us/reader034/viewer/2022042919/5f62412520fcd6758051efd8/html5/thumbnails/25.jpg)
Design of general anesthesia
• Induction: Thiopental, fentanyl, vecuronium
• Maintenance: Halothane, nitrous oxide with oxygen
![Page 26: Stress Response to Surgery Under General Anesthesia in ... · Stress Response to Surgery Under General Anesthesia in Type 2 Diabetic Patient Dr Kawsar Sardar, MD Associate professor](https://reader034.fdocuments.us/reader034/viewer/2022042919/5f62412520fcd6758051efd8/html5/thumbnails/26.jpg)
Sample collection
Three samples (8-10 ml) were collected
– The first sample- just before anesthesia
– 2nd sample- 10 minutes after incision
– 3rd sample- 10 minutes after extubation
![Page 27: Stress Response to Surgery Under General Anesthesia in ... · Stress Response to Surgery Under General Anesthesia in Type 2 Diabetic Patient Dr Kawsar Sardar, MD Associate professor](https://reader034.fdocuments.us/reader034/viewer/2022042919/5f62412520fcd6758051efd8/html5/thumbnails/27.jpg)
Control
First sample of each subject were served as a control
![Page 28: Stress Response to Surgery Under General Anesthesia in ... · Stress Response to Surgery Under General Anesthesia in Type 2 Diabetic Patient Dr Kawsar Sardar, MD Associate professor](https://reader034.fdocuments.us/reader034/viewer/2022042919/5f62412520fcd6758051efd8/html5/thumbnails/28.jpg)
ANALYTICAL METHODS
• Plasma glucose was measured by glucose oxidase method (Randox, UK).
• Serum electrolytes were measured by Dry Chemistry method (DT-60, USA).
• Serum C-peptide was measured by chemiluminescent immunoassay (Immulite, USA).
• Serum cortisol was measured by chemiluminescent immunoassay (Immulite, USA).
![Page 29: Stress Response to Surgery Under General Anesthesia in ... · Stress Response to Surgery Under General Anesthesia in Type 2 Diabetic Patient Dr Kawsar Sardar, MD Associate professor](https://reader034.fdocuments.us/reader034/viewer/2022042919/5f62412520fcd6758051efd8/html5/thumbnails/29.jpg)
STATISTICAL ANALYSIS
Statistical analysis was performed using SPSS (Statistical Package for Social Science) software for Windows version 17 (SPSS Inc., Chicago, Illinois, USA).
![Page 30: Stress Response to Surgery Under General Anesthesia in ... · Stress Response to Surgery Under General Anesthesia in Type 2 Diabetic Patient Dr Kawsar Sardar, MD Associate professor](https://reader034.fdocuments.us/reader034/viewer/2022042919/5f62412520fcd6758051efd8/html5/thumbnails/30.jpg)
RESULTS AND OBSERVATIONS
![Page 31: Stress Response to Surgery Under General Anesthesia in ... · Stress Response to Surgery Under General Anesthesia in Type 2 Diabetic Patient Dr Kawsar Sardar, MD Associate professor](https://reader034.fdocuments.us/reader034/viewer/2022042919/5f62412520fcd6758051efd8/html5/thumbnails/31.jpg)
0
2
4
6
8
10
12
14
PTo PT1 PT2
Plasma Glucose (mmol/l)
0
0.5
1
1.5
2
2.5
3
3.5
PTo PT1 PT2
C-peptide (ng/ml)
Figure: Perioperative glycemic and insulinemic status of the study subjects
*
![Page 32: Stress Response to Surgery Under General Anesthesia in ... · Stress Response to Surgery Under General Anesthesia in Type 2 Diabetic Patient Dr Kawsar Sardar, MD Associate professor](https://reader034.fdocuments.us/reader034/viewer/2022042919/5f62412520fcd6758051efd8/html5/thumbnails/32.jpg)
0
5
10
15
20
25
30
35
40
45
PTo PT1 PT2
Cortisol (ng/ml)
Figure: Perioperative serum cortisol status of the study subjects
*
![Page 33: Stress Response to Surgery Under General Anesthesia in ... · Stress Response to Surgery Under General Anesthesia in Type 2 Diabetic Patient Dr Kawsar Sardar, MD Associate professor](https://reader034.fdocuments.us/reader034/viewer/2022042919/5f62412520fcd6758051efd8/html5/thumbnails/33.jpg)
120
125
130
135
140
145
PTo PT1 PT2
S Sodium (mmol/l)
2
2.5
3
3.5
4
PTo PT1 PT2
S Potassium (mmol/l)
Figure: Perioperative serum electrolytes level of the study subjects
![Page 34: Stress Response to Surgery Under General Anesthesia in ... · Stress Response to Surgery Under General Anesthesia in Type 2 Diabetic Patient Dr Kawsar Sardar, MD Associate professor](https://reader034.fdocuments.us/reader034/viewer/2022042919/5f62412520fcd6758051efd8/html5/thumbnails/34.jpg)
Seru
m G
luco
se (mmol/L
)
C-Pe
ptid
e (ng
/ml)
Figure: Perioperative glycemic and insulinemic status of insulin and insulin-OHA treated subjects
* *
*
![Page 35: Stress Response to Surgery Under General Anesthesia in ... · Stress Response to Surgery Under General Anesthesia in Type 2 Diabetic Patient Dr Kawsar Sardar, MD Associate professor](https://reader034.fdocuments.us/reader034/viewer/2022042919/5f62412520fcd6758051efd8/html5/thumbnails/35.jpg)
Figure: Perioperative serum cortisol status of insulin and insulin-OHA treated subjects
Seru
m C
ortiso
l (n
g/ml)
*
*
![Page 36: Stress Response to Surgery Under General Anesthesia in ... · Stress Response to Surgery Under General Anesthesia in Type 2 Diabetic Patient Dr Kawsar Sardar, MD Associate professor](https://reader034.fdocuments.us/reader034/viewer/2022042919/5f62412520fcd6758051efd8/html5/thumbnails/36.jpg)
Seru
m N
a+ (mmol/l)
Seru
m K
+ (mmol/l)
Figure: Perioperative serum electrolytes status of insulin and insulin-OHA treated subjects
![Page 37: Stress Response to Surgery Under General Anesthesia in ... · Stress Response to Surgery Under General Anesthesia in Type 2 Diabetic Patient Dr Kawsar Sardar, MD Associate professor](https://reader034.fdocuments.us/reader034/viewer/2022042919/5f62412520fcd6758051efd8/html5/thumbnails/37.jpg)
Seru
m G
luco
se (mmol/l)
Seru
m C
-Pe
ptid
e (ng
/ml)
Figure: Perioperative glycemic and insulinemic status of hypertensive and normotensive study subjects
* *
![Page 38: Stress Response to Surgery Under General Anesthesia in ... · Stress Response to Surgery Under General Anesthesia in Type 2 Diabetic Patient Dr Kawsar Sardar, MD Associate professor](https://reader034.fdocuments.us/reader034/viewer/2022042919/5f62412520fcd6758051efd8/html5/thumbnails/38.jpg)
Seru
m C
ortiso
l (n
g/ml)
Figure: Perioperative serum cortisol status of hypertensive and normotensive study subjects
*
*
*
![Page 39: Stress Response to Surgery Under General Anesthesia in ... · Stress Response to Surgery Under General Anesthesia in Type 2 Diabetic Patient Dr Kawsar Sardar, MD Associate professor](https://reader034.fdocuments.us/reader034/viewer/2022042919/5f62412520fcd6758051efd8/html5/thumbnails/39.jpg)
Figure: Perioperative serum electrolytes status of hypertensive and normotensive study subjects
Seru
m N
a+ (mmol/l)
Seru
m K
+ (mmol/l)
![Page 40: Stress Response to Surgery Under General Anesthesia in ... · Stress Response to Surgery Under General Anesthesia in Type 2 Diabetic Patient Dr Kawsar Sardar, MD Associate professor](https://reader034.fdocuments.us/reader034/viewer/2022042919/5f62412520fcd6758051efd8/html5/thumbnails/40.jpg)
The data lead to following conclusions
1. Lower abdominal surgery under general anesthesia in well controlled type 2 diabetic subjects is accompanied by a hyperglycemic response which results from rise of insulin antagonists like cortisol rather than fall of insulin secretion.
![Page 41: Stress Response to Surgery Under General Anesthesia in ... · Stress Response to Surgery Under General Anesthesia in Type 2 Diabetic Patient Dr Kawsar Sardar, MD Associate professor](https://reader034.fdocuments.us/reader034/viewer/2022042919/5f62412520fcd6758051efd8/html5/thumbnails/41.jpg)
The data lead to following conclusions
2. Insulin treatment alone is more effective than insulin-OHA combination to control blood glucose in type 2 diabetic subjects undergoing surgery under general anesthesia; but the two treatment modalities lead to similar cortisol response.
3. Coexisting hypertension is associated with insulin hyposecretion leading to hyperglycemia in type 2 diabetic patients undergoing surgery under general anesthesia.
![Page 42: Stress Response to Surgery Under General Anesthesia in ... · Stress Response to Surgery Under General Anesthesia in Type 2 Diabetic Patient Dr Kawsar Sardar, MD Associate professor](https://reader034.fdocuments.us/reader034/viewer/2022042919/5f62412520fcd6758051efd8/html5/thumbnails/42.jpg)
RECOMMENDATIONS
1. Insulin rather than insulin-OHA may be a good choice of treatment for preoperative glycemic control.
2. Special attention should be given regarding perioperative glycemic control in type 2 diabetic coexisting hypertensive patients.
![Page 43: Stress Response to Surgery Under General Anesthesia in ... · Stress Response to Surgery Under General Anesthesia in Type 2 Diabetic Patient Dr Kawsar Sardar, MD Associate professor](https://reader034.fdocuments.us/reader034/viewer/2022042919/5f62412520fcd6758051efd8/html5/thumbnails/43.jpg)
RECOMMENDATIONS
3. Other stress hormones like glucagon, catecholamines, growth hormone and heat shock proteins may be measured for better quantification of the surgical stress.
4.To reduce the stress response- premedication and other anesthetic drugs, by increasing the dose of same anesthetic agents or anesthetic procedure may be applied for better management of type 2 diabetic subjects.
![Page 44: Stress Response to Surgery Under General Anesthesia in ... · Stress Response to Surgery Under General Anesthesia in Type 2 Diabetic Patient Dr Kawsar Sardar, MD Associate professor](https://reader034.fdocuments.us/reader034/viewer/2022042919/5f62412520fcd6758051efd8/html5/thumbnails/44.jpg)
T H A N K Y O
U