Case Presentation: Diabetes Mellitus

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Case PresentationDiabetes Mellitus

• Moderator Dr. RENU
• Presenter Dr. DIPAL

www.anaesthesia.co.in anaesthesia.co.in_at_gmail.co
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History

• Din dayal 52y/M, 60 kg
• Chief Complaints
• Pain in the Rt Lower Limb since 1 wk
• Bluish black discoloration of Rt foot since 2
  days

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History

• K/C/O DM
• Apparently alright 1 wk back
• H/O trivial trauma to the Rt toe
• Pain and ulceration at site of injury
• Purulent foul smelling discharge
• Noticed bluish black discoloration of the great
  toe since two days progressed to involve entire
  Rt foot
• No H/o fever, swelling of lower limb

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History

• DM since 15 years on irregular treatment with OHA
  
• Since 2 days insulin sliding scale
• poorly controlled
• H/o dizziness with sweating episode , weakness 10
  days back, relieved on taking food
• H/o tingling and numbness in both lower limbs
  since 2 yrs
• H/o frequent change of spectacles

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History

• H/o similar discoloration in Lt great toe 2 yrs
  back, amputation done ? RA, U/E
• No H/o
• Chest pain, palpitations, breathlessness,
  orthopnea/ PND, edema feet, syncope, cough
• ? urine output, generalized edema
• Giddiness on change of posture
• Effort tolerance limited due to pain ,
• Initially could climb 3 flights of stairs

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History

• Htn since 16 yrs on treatment with T. Amlodipine
  5 mg od
• No H/O Asthma, convulsions, TB, any other major
  medical illness
• No H/O Drug allergy

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Personal history

• Bowel and bladder habits no complaints
• Alcoholic occasional
• Cigarette smoker smoked for 30 yrs, left since 2
  yrs, 15 pack years.

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Treatment history

• Inj. Piperacillin and Tazobactum 4.5g i.v. 8th
  hrly
• Inj. Levoflox 500 mg i.v. od
• Inj. Metrogyl 500mg 8th hrly
• T. Amlodipine 5 mg od
• T. Hydroclorthiazide 50 mg od
• T. Atorvastatin 10 mg od
• T. Aspirin 150 mg od
• Inj. Insulin Sliding Scale

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General Examination

• Wt 60 kg, ht 164 cm
• Conscious, Oriented
• Pulse 80/min, Rt radial, regular, adequate
  volume, Rt dorsalis pedis not felt, all other
  peripheral pulses well felt
• Bp 110/ 70 mm of Hg supine position,
• 108/ 70 mm of Hg sitting position.
• RR 22/ min, regular
• HR response to deep breathing gt 15bpm

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General Examination

• Afebrile
• No pallor, icterus, cyanosis, clubbing, jaundice,
  lymphadenopathy
• JVP not raised
• Good i.v. access

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Systemic Examination

• CVS
• apex beat in 5th intercoastal space ant
  axillary line
• S1, S2 heard, no murmurs
• RS
• B/L air entry present
• No crepitations or rhonchi
• PA soft, no organomegaly
• Spine spaces well felt

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Systemic Examination

• CNS higher functions normal
• Sensory examination B/L
• Superficial pain, touch and temperature
  sensation were decreased in the distal parts
• Deep pressure , position sense and vibration
  sense intact and normal in both the limbs .
• Motor examination B /L
• Power and tone normal in both the limbs
• Reflexes Ankle jerk B/L absent .
• all other reflex present
  

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Airway examination

• Mouth opening 5 cm
• MMP class 2
• Neck movements WNL
• TMD 6 cm
• Teeth intact
• Prayers sign negative

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Local examination

• Rt lower limb
• 4x6 cm ulcer, on great toe, blackish
  discoloration till ankle, no line of demarcation,
  purulent discharge, foul smelling
• Surrounding skin tender, swollen, erythematous
• Dorsalis pedis absent, all other pulses well felt
• Thinning of skin, sparseness of hair till knee
• Lt lower limb WNL

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Investigations

• Hb 9.8
• Hct 30.7
• Plt ct 3 lakh
• Tlc 16100
• Dlc 88/ 10/ 02
• Urea 51
• Creatinie 1.2
• Na/ K 137/ 5.1
• T. Bili 0.6
• TP/ A/G 7.5/ 3.3/ 4.2
• SGOT/SGPT 49/ 72
• Alk Po4 244

FBS 145 mg/dl Urine sugar -ve Urine ketones
-ve ECG normal sinus rhythm No ST- T wave
changes X-ray chest Cardiomegaly Rest NAD
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Investigations

• ABG
• pH 7.314
• pO2 92.0
• pCO2 37.8
• HCO3 26.5
• BE -3.0

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Provisional Diagnosis

• Gangrene of Rt foot with diabetes mellitus with
  hypertension

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Surgery planned

• Rt below knee amputation

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Anesthesia

• Preoperative
• NPO
• Consent
• Medications insulin, GIK, others
• Procedure
• Investigations BS

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Anesthesia

• Plan SAB
• OT preparation
• Drugs
• Monitoring
• Fluids
• SAB

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Revised diagnostic criteria for diabetes
mellitus
Diabetic range mmol / l (mg) Diabetic range mmol / l (mg) IFG Further test
FPG RPG FPG Further test
ADA 1997 gt 7 (126) gt 11.1 ( 180) 6.1 7 (110 - lt126 ) Rpt in a different day
WHO 1998 gt 7 (126) gt 11.1 (180) 6.1 7 (110 - lt126 ) 2nd FPG (or) OGT
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Diabetic dysautonomic neuropathy scoring
Tests Results Scores
Sys BP decrease in upright position (mmhg) lt10 11 29 gt30 0 ½ 1
R-R intervals ratio in upright position gt1.04 1.01 -1.03 lt1.00 0 ½ 1
Diastolic BP increase during hand grip test (mmhg) gt16 11-15 lt10 0 ½ 1
Respiratory dysrhythmias gt15 11-14 lt10 0 ½ 1
Valsalva quotient gt1.21 lt1.10 0 1
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Diabetic dysautonomic neuropathy scoring
Autonomic nervous system Scoring
Normal 0 - 0.5 Early change 1 - 1.5 Definitive modification 2 - 3.5 Severe impairment 4 - 5
Miller s Anesthesia, 6th ed Churchill Livingstone
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Insulin preparations and guidelines
Rapid- acting Insulin lispro (Humalog) Insulin apart (Novolog) Onset 5 -15 min Peak 60 -120min Duration 4 5 h
Short acting Regular insulin Onset 30 - 60 min Peak 2 - 4 h Duration 6 - 8 h
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Insulin preparations and guidelines
Intermediate acting NPH (neutral protamine Hagedorn) Lente Onset 1 -3 h Peak 4 - 6 h Duration 12 - 14 h Onset 1 -3 h Peak 4 - 8 h Duration 12 - 20h
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Insulin preparations and guidelines
Long acting Ultralente Glargine Onset 2 -4 h Peak 14 - 18 h Duration 18 - 24h Onset 1 -2 h Peak less Duration 20 - 24h
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Insulin preparations and guidelines
Premixed/combination insulin 70/3070NPH/30reg 50/5050NPH/50reg 75/25NPL/25lispro BBF BD Intermediate acting twice a day
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Oral Hypoglycemic Agents
Class Sulfonylurea Agents Duration Action Side-effects
1st generation Tolbutamide Chlorpropamide 6 -12 h 24 -72 h 6 -12 h Up to 24h Increased pancreatic insulin release Receptor level action Hypoglycemia
2nd generation Glipizide Giburaide Glimepride 6 -12 h 24 -72 h 6 -12 h Up to 24h Increased pancreatic insulin release Receptor level action Hypoglycemia
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Oral Hypoglycemic Agents
Class Agents Duration Action Side-effects
Biguanides Metformin 7 -12 h Up to 24h Improve receptor sensitivity ? Reduction in resistance Pancreatic insulin release Lactic acidosis Liver dysfunction
Glitizones Tro Rosi Pio Dar 7 -12 h Up to 24h Improve receptor sensitivity ? Reduction in resistance Pancreatic insulin release Lactic acidosis Liver dysfunction
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Oral Hypoglycemic Agents
Class Agents Duration Action Side-effects
Glinides Repaglinide Nateglinide 3 h 4 h Rapid insulin secretion Reduced carbohydrate absorption Liver dysfn Diarrhea Abd pain
Alpha glucosidase inhibitor acarbose 3 h 4 h Rapid insulin secretion Reduced carbohydrate absorption Liver dysfn Diarrhea Abd pain
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Traditional Regimens

• ? No glucose, no insulin
• Limitations
• 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

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Non tight control regimen

• Aim Prevent hypoglycemia, ketoacidosis,
  hyperosmolar states
• Day before surgery NPO gt midnight
• Day of surgery iv 5D _at_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

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Non tight control regimen

• 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

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Tight control regimen I

• Aim 79-120 mg/dl
• Protocol
• Evening before, do pre-prandial bld glucose
• Begin iv 5D _at_ 50 ml/hr/70 kg
• Piggyback to 5D, 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

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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

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Albertis regimen

• 1979- Alberti Thomas IV GIK solution 500ml 10
  glucose 10 units soluble insulin 1 gm KCl _at_
  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
• lt 90mg/dl or gt 180 mg/dl replace bag with 5U or
  15U respectively

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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 lt 90 mg/dl

Blood glu (mg/dl) Action
lt120 10 U insulin (2U/h)
120-200 15 U insulin (3U/h)
gt200 20 U insulin (4U/h)
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Albertis regimen

• Advantages simple, Inherent safety factor,
  balance appropriate
• Criticism hypoglycemia, water load
  hyponatremia, cautious poor renal function
• 20 or 50 D

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Hirsh regimen
Blood glu (mg/dl) Action (insulin infusion)
lt 80 Turn off for 30 min, give 25 ml 50 D
80-120 ? by .3 U/h
120-180 No change in infusion rate
180-220 ? by .3 U/hr
gt 220 ? by 0.5 U/hr

• Aim Normoglycemia
• Infuse glucose 5 g/hr with pot 2-4 mmol/hr
• Start insulin infusion _at_.5-1U/hr
• Measure blood glucose hourly

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Regular Insulin Sliding Scale

• RECOMMENDATIONS
• 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

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Regular Insulin Sliding Scale
Blood sugar (mg/dl) Low dose scale Mod dose scale High dose scale
lt70 Initiate hypoglycemia protocol Initiate hypoglycemia protocol Initiate hypoglycemia protocol
70-130 0 0 0
131-180 2 4 8
181-240 4 8 12
241-300 6 10 16
301-50 8 12 20
351-400 10 16 24
gt400 12 20 28
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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
  equals how much 1 unit of regular insulin will
  decrease blood glucose.

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Patient on diet control or OHA
Type of procedure Glucose monitoring requirement Periop glycemic treatment Postop management
Short, simple procedure only before after surgery Diet None OHA Witheld Resume preop diet or drug regimen
Long, complex procedure Before, after surgery intraop Diet None, BSgt 200, GKI OHA Shift to reg insulin preop Continue GKI Same as above
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Periop management Type II Diabetics

• Poorly controlled preop (gt200 mg) or even if
  well controlled on OHA undergoing major surgery
  Shift to plain insulin preoperatively
• Well controlled Type II taking insulin Treat as
  type I

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Type I DM or Type II DM on insulin
Type of procedure Glucose monitoring requirement Periop glycemic treatment Postop management
Short, simple procedure Before, after surgery intraop SC insulin regimen Resume preop regimen after pt resumes eating
Long, complex procedure Continuous every 1-2 hours 5D IV insulin regimen Continue iv insulin glu till preop regimen resumed
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