Case presentation

Diabetes Mellitus

Modrator : Dr. Maya

Presented by : Bikash ranjan ray

www.anaesthesia.co.in

anaesthesia.co.in@gmail.com

HISTORY
Gajender
55

kumar

yr , male

Bulandahar,
Presenting

UP

complaint:

Nonhealing ulcer bilateral foot - 2 month

Pus discharge from left foot ulcer 2 month
Blackish discolouration of left foot - 10 days

History 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

Past history :

K/c/o DM 6 yr
Previously was on OHA for 4yrs
Changed to insulin since last 2 yrs
H/o poor compliance to treatment and poor control of blood
sugars
Presently on insulin
Human actrapid 12 IU BBF,BL & BD
Insulatard 25 IU after dinner

On this regimen blood sugars were controlled

H/o similar discoloration in Lt toe 1yr back, amputation

done RA, U/E

H/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 )

No H/o:
Chest pain, palpitations, breathlessness, orthopnea/ PND, edema

feet, syncope, cough

urine output, generalized edema
Giddiness 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

Treatment history:
Inj. Levoflox 500 mg i.v. od
Inj. Metrogyl 500mg 8th hrly
Personal history :
Bowel and bladder habits: normal
Alcohol intake : occasional
Cigarette smoker: smoked for 15 yrs, 4-5/day, stopped
since last 3yrs
Family history :
Insignificant

General Examination

Awake ,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

Pulse: 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

Local examination

Left 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 discharge

Systemic 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

CNS:
Higher functions normal
Cranial nerves : normal
Sensory 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

Airway examination

Mouth opening: 5 cm

MMP class: 2

Neck movements: WNL

TMD: 6 cm

Teeth: intact

Prayers sign: negative

Provisional Diagnosis

DM with b/l foot ulcer ,with gangrene

left lower limb

Surgical plan :
Below knee amputation of left leg

of

Investigations:

Hb = 10.0 g/dl
TLC =14500
Platelet count =3,21,000
Na+/K+ =150/4.8
Urea = 58mg/d
T. bil = 0.7
Pt = 12/ 13
CXR = WNL
ECG= WNL
Blood sugar :
Fasting 156 mg/dl
Urine sugar and ketones ve

Anaesthesia

Diagnosis and Classification

1)Symptoms ( polyuria, polydipsia,wt loss )plus random
plasma glucose >=200 mg/dl (11.1mmol/l)
or
2) A fasting (>8hr)plasma glucose of >=126 mg/dl (7
mmol/l).
or
3)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

 Metabolic

syndrome x

At least 3 of the following:

FPG 110 mg/dl
Abdominal obesity (waist grith >40 in men and >35 in
women )
Sr. triglycerides 150 mg/dl
Sr. HDL <40 mg/dl in men and < 50 mg/dl in women
Blood pressure 130/85 mmhg

Classification
Class

Pathogenesis

Incidence

Type 1
(Formerly
juvenile or
IDDM)

Immune mediated
idiopathic forms of cell function
absolute insulin deficiency

0.4%
male =female
usually young

Type 2
(Formerly
NIDDM)

Insulin resistance
relative insulin deficiency or secretory defect

6.6%
adult onset

Type 3

Specific types of DM
genetic defect / disease of exocrine pancreas

Type 4

Gestational DM

4% of pegnanrcies

Preoperative evaluation &risk

assessment
Classical diabetic complications
Macroangiopathy
- arteriosclerosis
Microangiopathy
- heart, kidney &retina
Autonomic neuropathy - heart, GI &urinary tracts
Peripheral neuropathy
Collagen anomalies - respiratory tract & joints
Unifying hypothesis - impaired glycosylation of proteins
Systematic search of diabetic complications key step

Perioperative complications with

Hyperglycemia
Dehydration, electrolyte & metabolic disturbances
Predisposes to DKA
Delayed wound healing
Bacterial infection & postop wound infection
Median glycemic threshold for neutrophil
dysfunction 200 mg/dl
Independent risk factor for increase in short &
long term mortality after cardiovascular surgery
Worsens clinical outcome in stroke, traumatic
brain injury, global & focal cerebral ischaemia
Haemorrhagic extension of ischaemic stroke

Benefits of normal blood

glucose

Maintenance of normal white blood cell & macrophage

function

Positive trophic & anabolic effects of insulin

Improved erythropoiesis

Decreased hemolysis

Reduced cholestasis

Less axonal dysfunction

Oral Hypoglycemic Agents

Class
Sulfonylurea

Agents

1st generation Tolbutamide

2nd
generation

Duration

Action

6 -12 h

Increase
d
pancreati
c insulin
Hypoglyc
release
emia

Chlorpropa
mide

24 -72 h

Glipizide
Giburaide
Glimepride

6 -12 h
Receptor
Up to 24h level
action

Sideeffects

Class

Agents

Duration

Action

Sideeffects

Biguanides

Metformin

7 -12 h

Improve
receptor
sensitivity ?

Lactic
acidosis

Glitizones

Tro
Rosi
Pio
Dar

Reduction in
resistance
Pancreatic
insulin
release

Liver
dysfuncti
on

Up to
24h

Class

Agents

Duration

Action

Glinides

Repaglinide
Nateglinide

3h

Rapid insulin Liver

dysfn
secretion

4h

Diarrhea
Reduced
carbohydrate
absorption
Abd pain

Alpha
glucosidase acarbose
inhibitor

Sideeffects

Insulin preparations and

guidelines

Traditional Regimens

No glucose, no insulin
Limitations :

1.
2.
3.

Not suitable for insulin dependent diabetics

Pts stores of glucose used to meet increased metabolic
demands
Patients taking long acting OHAs predisposed to
hypoglycemia

Acceptable for non-insulin dependent diabetics & minor

surgical procedures
Frequent blood sugar monitoring.
May require insulin therapy

Non tight control regimen

Aim : Prevent hypoglycemia, ketoacidosis, hyperosmolar states

Day before surgery : NPO > 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 period
Onset & peak effect may not correlate with glucose admn or start of surgery
Hypoglycemia esp in afternoon
Lowest therapeutic ratio

Tight control regimen I

Aim : 79-120 mg/dl

Protocol :

Evening before, do pre-prandial bld glucose

Begin iv 5%D @ 50 ml/hr/70 kg
Piggyback 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 infection
Repeat bld glu every 4 hours
Day of surgery : Non dextrose containing solutions,
Monitor blood glu at start & every 1-2 hours

Tight control regimen II

Aim : Same as TC regimen I

Protocol : Obtain a feedback mechanical

pancreas & set controls for desired
plasma glucose.

Institute 2 iv drips for insulin & fluids

Albertis regimen

1979- 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

Albertis regimen-Recent version

Initial 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)

Action

<120

10 U insulin
(2U/h)

120-200

15 U insulin
(3U/h)

>200

20 U insulin
(4U/h)

Advantages : simple, Inherent safety factor, balance

appropriate

Criticism : hypoglycemia, water load & hyponatremia,

cautious : poor renal function

20% or 50% D

Hirsh regimen
Blood glu
(mg/dl)

Aim : Normoglycemia

Infuse glucose 5 g/hr

with pot 2-4 mmol/hr

< 80

Start insulin infusion

@.5-1U/hr

80-120

Measure blood
glucose hourly

120-180

Action
(insulin
infusion)
Turn off for
30 min, give
25 ml 50% D
by .3 U/h

180-220

No change in
infusion rate
by .3 U/hr

> 220

by 0.5 U/hr

Regular Insulin Sliding Scale

RECOMMENDATIONS

1.

Supplement usual diabetes medications to treat

uncontrolled high blood sugars

2.

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

unknown insulin requirement

3.

Should not be used as a sole substitute, risk of DKA

Periop changes in regional blood flow unpredictable
absorption

Split-mixed insulin regimen

Combining 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.

Hypoglycemia

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, hunger

Neuroglycopenia :
Headache, temp, visual disturbances, mental confusion,

amnesia, seizures, coma

 Treatment

Discontinue insulin drip

Give D 50 w iv

patient conscious 25 ml
patient unconscious 50 ml
Recheck BG every 20 min & repeat 25 ml of
D50 w if < 60 mg/dl
Restart drip once BG is > 70 mg/dl

Diabetic
autonomic
neuropathy :
Pupillary
Decreased diameter of darkadapted pupil
Argyll-Robertson type pupil
Metabolic
Hypoglycemia unawareness
Hypoglycemia unresponsiveness
Cardiovascular
Tachycardia, exercise intolerance
Cardiac denervation
Orthostatic hypotension
Heat intolerance
Neurovascular
Areas of symmetrical anhydrosis
Gustatory sweating
Hyperhidrosis
Alterations in skin blood flow
Gastrointestinal
Constipation
Gastroparesis diabeticorum
Diarrhea and fecal incontinence
Esophageal dysfunction
Genitourinary
Erectile dysfunction
Retrograde ejaculation
Cystopathy
Neurogenic bladder
Defective vaginal lubrication

Diagnostic tests for cardiovascular autonomic

neuropathy :

Resting heart rate

> 100 beats/minute is abnormal

Beat-to-beat heart rate variation

The patient should abstain from drinking coffee overnight
Test should not be performed after overnight hypoglycemic episodes
When the patient lies supine and breathes 6 times per minute, a difference in
heart rate of less
than 10 beats/minute is abnormal
An expiration:inspiration R-R ratio > 1.17 is abnormal

Heart rate response to standing

The R-R interval is measured at beats 15 and 30 after the patient stands
A 30:15 ratio of less than 1.03 is abnormal

Heart rate response to Valsalva maneuver

The patient forcibly exhales into the mouthpiece of a manometer, exerting a
pressure of 40 mm Hg, for 15 seconds
A ratio of longest to shortest R-R interval of less than 1.2 is abnormal

 Systolic

blood pressure response to standing

Systolic blood pressure is measured when the patient is lying down and 2

minutes after the patient stands

A fall of more than 30 mm Hg is abnormal
A 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 maximum

The patient then squeezes the grip at 30% maximum for 5 minutes
A rise of less than 16 mm Hg in the contralateral arm is abnormal
Electrocardiography

A QTc of more than 440 ms is abnormal

Depressed very-low frequency peak or low-frequency peak indicate sympathetic

dysfunction
Depressed high-frequency peak indicates parasympathetic dysfunction
Lowered low-frequency/high-frequency ratio indicates sympathetic imbalance
Neurovascular flow
Noninvasive laser Doppler measures of peripheral sympathetic responses to nociception

X ray cervical spine :

Prayer sign :

Finger print test :

Differential diagnosis of DKA :

Diagnostic criteria and deficits in

DKA and HHS :

Pathogenesis of DKA and HHS :

Diabetes and anesthesia :

Diabetes

www.anaesthesia.co.in

anaesthesia.co.in@gmail.com

THANK YOU
The Greek word Diabetes = to Siphon /pass through

...and the Latin word mellitus = sweet as honey