MetroHealthAnesthesiaAnesthesia and Diabetes Mellitus

Clinical Manifestations of Diabetes Mellitus (DM)

Insulin deficiency leads to hyperglycemia and glycosuria.
    Fasting blood glucose > 126 mg%
    GTT: blood glucose > 200 mg%
Classification: Types of DM
    Type I Immune-mediated or idiopathic absolute insulin deficiency
      onset < 16 years old
      15% have other autoimmune disease
        hypothyroidism
        Graves' disease
        Addison's disease
        myasthenia gravis
    Type II Adult onset secondary to resistance/relative deficiency
    Type III Secondary to specific genetic defects
    Type IV Gestational
      2.4% of U.S. pregnancies
Long-term complications
    Hypertension
    Myocardial infarction
    • risk of MI 2-10 X greater than in nondiabetic
    Peripheral and cerebral vascular disease
    • risk of peripheral vascular disease 5-10 X greater than in nondiabetic
    • risk of stroke twice that in nondiabetic
    Autonomic neuropathy
    • >15% of diabetics
    • increases perioperative morbidity
    Renal failure
Life-threatening acute complications
  1. Diabetic ketoacidosis (DKA)
    usually Type I
  2. Hyperosmolar nonketotic coma
  3. Hypoglycemia
DKA
    Dyspnea, abdominal pain, nausea and vomiting, dehydration, coma
    Anion-gap metabolic acidosis, elevated plasma and urine ketones (acetoacetate, beta-hyroxybutyrate), hyperglycemia
    Rx
      Insulin (regular) 0.1 U/kg/hour and increase
      NS
      Potassium when urine output
      Add D5W when plasma glucose 250 mg%
Hyperosmolar nonketotic coma
    Hyperglycemic diuresis -> severe dehydration
    Renal failure
    Lactic acidosis
    Risk of intravascular thromboses
    Hyperosmolality with coma seizures
    Rx
      Fluid resuscitation
      Insulin (relatively small doses)
      Potassium when urine output
Hypoglycemia
    Diaphoresis, tachycardia, nervousness
    Plasma glucose < 50 mg%
    Rx: D50W
Anesthetic Considerations
Preoperative
    Evaluate end-organ damage (cardiovascular, pulmonary, renal)
    Beware silent myocardial ischemia/infarction
    Diabetic autonomic neuropathy
      Hypertension
      Painless myocardial ischemia
      Orthostatic hypotension
      Lack of heart rate variability
      Reduced heart rate response to atropine or propranolol
      Resting tachycardia
      Early satiety
      Neurogenic, atonic bladder
      Lack of sweating
      Impotence
      Asymptomatic hypoglygemia
      Sudden death syndrome
      Mortality 50% over 5 years
    Gastroparesis with delayed emptying
      Consider H-2 blocker or metoclopramide premed
    Limited-mobility joint syndrome (stiff-joint sydrome) prayer sign
    • 30-40% of Type I diabetics
    • positive "prayer sign" (image at right:)
    • TJ joint and C-spine (e.g. atlanto-occipital joint) may be involved

    Direct laryngoscopy may be difficult in 30% of Type I diabetics
    Glycohemoglobin, hemoglobin A1c
    • good measure of overall blood glucose control
    • normal 5-7%
    • up to 20% in marked hypergylcemia
Intraoperative
    Insulin/glucose regimens (after starting IV and checking blood glucose)
      Start IV and check blood glucose
      Begin D5W 1 - 1.5 ml/kg/hr (IV 'piggy-back')
      Administer insulin: either
      1. 1/2 of total daily dose as intermediate form (NPH) + intraop "sliding scale," or
      2. Continuous infusion of regular insulin
          U/hr = (plasma glucose)/150 +
    Monitor blood glucose
    Avoid hypoglycemia
    Hyperglycemia:
      Hyperosmolarity
      Infection
      Poor wound healing
      Worsens neurologic outcome after cerebral ischemia
    Beware protamine sulfate anaphylaxis in patients taking NPH or protamine zinc insulin
Postoperative
    Monitor blood glucose



Send Comments to Greg Gordon MD, gjg@po.cwru.edu
Department of Anesthesiology
The MetroHealth System
2500 MetroHealth Drive
Cleveland, Ohio 44109-1998
Phone: (216) 778-4801
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