Endocrine (Altose): DMII
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What is normal fasting glucose? What is considered pre-diabetic/diabetic fasting glucose levels?
Normal: <100 mg/dL Impaired/diabetic: >126 mg/dL
What is the etiology of DMI? What is it usually caused by?
Autoimmune etiology Due to destruction of islet cells of the pancreas (functions to synthesize insulin)
How do we prepare our Type I DM patients pre-op?
Instruct them not to take short-term insulin. Instruct them to take 1/3 to 2/3 of their usual intermediate-lasting dose.
Where is insulin produced? At what rate is it made? How much do we usually secrete a day?
Beta islet cells of the pancreas 1 unit/hr at rest 40-50 U/day (Response to food, vagal stimulation, beta stim, alpha block)
What is the effect of insulin on the moieties in our body?
Increases cellular uptake of glucose and potassium Stimulates glycogen formation Inhibits lipolysis and gluconeogenesis
What does surgical stress do to our insulin levels?
It drops our insulin levels. Release of cortisol, catecholes, and glucagon all lead to hyperglycemia because of this.
Primary difference btwn DM I and DM II is.. How do their onsets differ?
DMI - no insulin production at all DMII - insulin resistant cells or decreased insulin production (or both) DMI = early onset DMII = late onset
HgbA1c is a measure of…
the average level of blood sugar (glucose) over the previous 3 months. Correlates well with rate of complications
What specific types of insulins would you withhold pre-op in diabetic patients?
Hold metformin (inhibits hepatic gluconeogenesis) Hold sulfonureas (glyburide, glipizide) bc they increase beta-cell secretion of insulin If significant interruption of caloric intake is not anticipated, many recommend no change in therapy with DMII patients.
What are some anesthetic considerations about diabetic patients?
End-organ diseases Difficult laryngoscopy due to stiff joints Autonomic dysfunction Positioning (more susceptible to ischemia) Nerve injuries more likely due to poorer perfusion (regional anesthesia) Increased risk of infection
What is the glucose level threshold at which you would delay surgery? Postpone surgery?
>270 mg/dL = delay surgery until you get a better value >400 mg/dL postpone surgery until you get pt metabolic state under control
What happens at the onset of surgery to our glucose levels? In diabetic patients, what glucose levels should we strive for intra-operatively?
Blood sugar will go up due to decreased insulin secretion from stress hormones Shoot for 150-200 mg/dL (or <180 mg/dL according to Barash) Note that blood sugar < 110 mg/dL leads to poorer outcomes.
What is DKA?
Diabetic ketoaciosis is a state of exclusive fatty acid breakdown for energy (lipolysis) that leads to ketoacidosis
What subtype of diabetics experience DKA?
Type I DM Type II DM don’t experence DKA because only small amounts of insulin is needed to block lipolyis (and they have it whereas DMI pts dont’ have any)
What are physiological effects of DKA?
Dehydration due to osmotic diuresis Electrolyte imbalances Anion-gap metabolic acidosis N/V Ileus
If a DM pt experiences mental status changes, what is the first thing you should do?
Check blood sugar to rule out hypoglycemia. THEN check ABG to rule out DKA or HNKC.
How can we treat DKA intra-op?
Treat with fluid, electrolytes, and insulin. Add some glucose when BG < 250 to prevent precipitous drop in blood glucose (which would cause hypoglycemia, the opposite end of the spectrum) Electrolytes: Correct N: add 1.5-2.0 mEq/dL every 100 mg/dL BG over 100 Give K (pt may be hyperkalemic, but total body K will be low) Maintain UOP
In a pt undergoing DKA, what is usually his/her range of blood glucose level? Does this correlate with the severity of the acidosis?
300-500 mg/dL range NO, Degree of hyperglycemia does NOT correlate with severity of acidosis
What is the relationship between glucose and potassium?
K follows Glucose
What is HNKC? What is it characterized by?
HNKC: Hyperosmolar Non-Ketotic Coma Characterized by very high BG (>600 mg/dL) with enough insulin to prevent ketosis
What subtype of DM pts can get HNKC?
DMII patients. DMI patients will get DKA instead of HNKC due to lack of any insulin.
Symptoms of HNKC include…
Significant HoTN that leads to lactic acidosis Cerebral edema –> coma, seizures Thrombosis secondary to hyovolemia, HoTN, and hyperviscosity of blood (due to extreme dehydration)
How do we treat HNKC?
Treat with a lot of fluids given at a slow rate as well as insulin infusions. Correct over 24 hours.
What is hypoglycemia?
BG of < 40-50 mg/dL Diabetis may have symptoms at higher levels due to higher threshold for BG levels