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ANAESTHETICS & PERI-OPERATIVE MEDICINE > 5: Diabetes & Steroids Management > Flashcards

5: Diabetes & Steroids Management Flashcards

1
Q

which diabetes medications cause a fall in blood glucose

A
  • insulins
  • sulphonylureas
  • meglitinides
  • SGLT-2 inhibitors
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2
Q

which diabetes medications cause a glucose dependent fall in blood glucose

A
  • pioglitazone
  • DPP-4 inhibitors
  • GLP-1 analogues
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3
Q

which diabetes medications prevent a rise in blood glucose

A
  • metformin
  • acarbose
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4
Q

what are the onsets and lengths of action of insulins

A
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5
Q

basal bolus regime

A
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6
Q

twice daily pre-mixed regime

A
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7
Q

what are the risks of surgery in patients with diabetes

A
  • ↑ risk of morbidity and mortality
  • infections, wounds
  • underlying diabetic compliactions mainly CVS, AMI, stroke, ARF
  • errors of blood glucose management
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8
Q

what are the benefits of good glucose control prior to surgery

A
  • fewer complications
  • fewer patients need an insulin infusion
  • more patients have day surgery
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9
Q

what should you aim for the HbA1c to be prior to surgery

A

~ 69mmol/mol^-1

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10
Q

what happens if the Hba1c is >69 mmol/mol before surgery

A
  • if urgent: plan peri-op VRIII
  • otherwise consider delay and optimise
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11
Q

what happens if the Hba1c is <69 mmol/mol before surgery

A
  • proceed to admission
  • adjust insulin/non-insulin meds
  • plan VRIII if necessaey
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12
Q

how is diabetes managed intra-operatively

A
  • check CBG at induction and then hourly
  • aim for CBG 6-12 mmol/L
  • do not stop VRIII
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13
Q

how is diabetes managed post-operatively

A

continue hourly CBG
- aim CBG 4-12mmol/L - if usual treatment can cause hypoglycaemia e.g. insulin, sulphonylurea
- aim CBG 3.5-12 mmol/l - if usual treatment cannot cause hypoglycaemia e.g. metformin
- maintain glycaemic control, fluid & electrolytes
- facilitate early eating & drinking
- avoid iatrogenic injury

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14
Q

when do you treat hypoglycaemia

A
  • CBG <4 mmol/L: 50-100ml 20% glucose
  • CBG 4-6 if symptomatic: 50-100ml 10% glucose
  • recheck CBG at 10 mins, if persistent hypoglycaemia then contact diabetes team
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15
Q

what is the ideal range for normoglycaemia

A

6-10 mmol/L
- continue hourly CBG monitoring

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16
Q

what is the range of hyperglycaemia and how is this managed

A

> 12 mmol/L, blood ketones < 3 or urine ketones < +++
- give s/c rapid analogue insulin and reassess
- may need VRIII
- check for DKA

17
Q

what is VRIII

A

variable rate intravenous insulin infusions (sliding scale insulin)

18
Q

what are risks/cautions of VRIII

A
  • do not infuse insulin without substrate unless in ITU/HDU/CCU
  • measure CBG hourly
  • ensure administration of long acting basal insulin to prevent hyperglycaemia & ketosis on cessation
  • do not take down VRIII in T1 diabetics until alternative s/c insulin has been given in previous 30 mins
  • RDA of sodium to prevent hypoNa+
19
Q

what are the parameters of diagnosis of DKA

A
  • ketonaemia >= 3.0 mmol or significant ketonuria (more than 2+ on standard urine stick)
  • blood glucose > 11.0 mmol or known DM
  • bicarb < 15.0 mmol and/or venous pH < 7.3
20
Q

what is the management of DKA

A
  • measure blood ketones, venous pH and bicarb to use as treatment markers
  • monitor ketones and glucose
  • use weight based FRIII
  • use venous not arterial blood sample
  • monitor electrolytes using blood gas analyser
  • give long acting, basal insulin
  • give 10% glucose IV once CBG <14 - do not reduce insulin infusion till blood ketones controlled
21
Q

what are the actions of cortisol

A
  • increase availability of glcuose to facilitate fight or flight
  • suppresses immune functions and inflammation
22
Q

what is normal cortisol production and how does this change with surgery

A
  • normal: 15-30mg/day pulsatile with circadian rhythm
  • 50mg/day minor procedures
  • 75-150mg/day moderate/major operations (up to 72 hours post cardiac surgery)
23
Q

what is Cushings syndrome vs disease

A

excess cortisol production/glucocorticoid medications over a long period of time
- syndrome: exogenous glucocorticoids e.g. pred or adrenal/other tumour
- disease: secondary to pituitary tumour

24
Q

what are features of Cushings disease

A
  • moon face
  • central obesity
  • buffalo hump
  • thin, easily bruised skin
  • purple striae on abdomen and thighs
  • prox muscle wasting
  • HT, LVH, T2DM, hypoK
25
Q

what increases the risk of HPA suppression

A
  • <5mg/day prednisolone - minimal risk HPA
  • > 5mg/day prednisolone for > 1 month - higher risk of HPA
26
Q

how can HPA suppression be measured

A
  • short synacthen test
  • 250mcg synacthen
  • measure cortisol at 0,30,60 mins
  • peak at 420-700 nmol/L normal
27
Q

how does adrenal/addisonian crisis present

A
  • orthostatic hypotension
  • headache, confusion, coma
  • dehydration, dizziness
  • abdo/flank pain
  • fatigue, weakness, fever, N&V, loss of appetite
  • tachycardia, high RR, CVS collapse
28
Q

how is adrenal/addisonian crisis treated

A

hydrocortisone 100mg IV

29
Q

what is ‘steroid cover’ and why is it needed

A

surgery creates extra physiological stress which requires a ‘stress response’
- ‘steroid cover’ replaces the natural stress response surge in cortisol production

30
Q

what are the components of ‘steroid cover’

A
  • double usual steroid for 24-48 hours
  • hydrocortisone 100mg IV on induction followed by IV infusion 200mg/24 hr (or 50mg IM 6 hourly)
  • or for adrenal suppression patients only dexamethasone 6-8mg IV will last 24 hrs
31
Q

how is metformin intake (biguanide) modified for surgery

A
  • day prior: take as normal
  • morning operation: if taken TDS, omit lunchtime dose
  • afternoon operation: ‘’ ‘’
32
Q

generally, how are diabetic patients medications managed pre-surgery (3)

A
  • pt w good glycaemic control can be managed by adjusting their usual insulin regimen
  • surgery requiring fasting or more than one missed meal, poorly controlled –> VRIII
  • oral drugs are manipulated on the day
33
Q

how is sulphonylurea medication intake modified for surgery

A
  • day prior: as normal
  • morning op: if OD omit, if BD omit morning
  • afternoon: if OD omit, if BD omit both
34
Q

how are once daily insulin medications modified for surgery e.g. Lantus, Levemir

A

reduce dose by 20% at all stages

35
Q

how are twice daily insulin medications modified for surgery e.g. Novomix 30, Humulin

A
  • day prior: no change
  • morning/afternoon: 1/2 usual morning dose and leave evening dose unchanged

ANAESTHETICS & PERI-OPERATIVE MEDICINE (5 decks)

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