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BJA 2024 > Perioperative Management of DM > Flashcards

Perioperative Management of DM Flashcards

1
Q

What risks are associated with patients with DM undergoing surgery?

A
  1. Increased risk of perioperative complications
  2. Prolonged hospital stay
  3. Higher rates of morbidity and mortality

Poor glycaemic control exacerbates these risks, with a higher incidence of:
1. SSI
2. Delayed wound healing
3. Cardiovascular events
4. Respiratory complications

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2
Q

Describe the pathophysiology of glucose metabolism

A

Glucose metabolism plays a vital role in energy production and maintenance of blood glucose concentrations within a narrow range.

In healthy individuals, sodium-glucose transporter 1 (SGLT1) and glucose transporter (GLUT) enzymes facilitate glucose uptake in response to oral intake.

Furthermore, glucagon-like-peptide-1 (GLP-1) is secreted by the intestinal L-cells in response to eating.
Binding of GLP-1 to its receptors stimulates insulin secretion from the pancreas.

Insulin allows glucose to be transported into the cells, where it undergoes a series of enzymatic reactions, (glycolysis) to produce energy such ATP.

Excess glucose is stored in the liver and skeletal muscle as glycogen (glycogenesis).

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3
Q

Name the different types of diabetes

A

T1DM
T2DM
LADA
MODY
Pancreatic diabetes
Endocrinopathy-related DM
Medication related DM
GDM

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4
Q

Describe the pathophysiology of T1DM

What are the perioperative concerns?

A

Autoimmune destruction of pancreatic beta cells leading to absolute insulin deficiency.

Peri Op Concerns:
1. Hypoglycaemia
2. Consider referral to DM team
3. Always need exogenous insulin source (Basal insulin, pump or IV infusion)

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5
Q

Describe the pathophysiology of T2DM

What are the perioperative concerns

A

Combination of insulin resistance and deficiency caused by diet, lifestyle and genetics.

Periop concerns depend on severity and associated comorbidities

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6
Q

What is LADA

A

Latent Autoimmune Diabetes in Adults

AI diabetes which does not manifest until adulthood. On the continuum between T1DM and T2DM

Periop concerns
Do not omit basal insulin especially if anti-GADi titre is high

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7
Q

What is MODY?

A

Mature Onset Diabetes of the Young

Monogenetic diabetes
Rare forms of diabetes, typically as a result of genetic defects in beta cell function causing impaired insulin secretion.

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8
Q

How does pancreatitis lead to DM?

A

Pancreatitis leads to islet tissue fibrosis and destruction resulting in insulin and glucagon deficiency

Periop concerns
Marked glycaemic variability and possibly unpredictable response to exogenous insulin

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9
Q

What medications can cause DM?

A

Systemic Corticosteroid treatment causes insulin resistance, increased gluconeogenesis and abnormal insulin secretion

Post transplant DM is caused by diabetogenic properties of immunosuppressant agents.

Periop Concerns:
Corticosteroid stress doses cause hyperglycemia

Hyperglycemia in post-transplant is associated with risk of transplant rejection

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10
Q

What are implications of GDM?

A

GDM - diabetes first diagnosed during pregnancy
Associated with increased risk of developing T2DM in later life.

Periop Concerns:
Glucose >8mmol/L may cause transient neonatal hyperinsulinism and neonatal hyperglycaemia

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11
Q

What are the 2022 ESC recommendations regarding diabetes and HbA1C

A

‘In patients at high surgical risk, clinicians should
consider screening for increased HbA1c before major
surgery and improving preoperative glucose control.’
(recommendation class: IIa)

‘In patients with diabetes or disturbed glucose metabolism,
a preoperative HbA1c test is recommended if this
measurement has not been performed in the previous
three months. In case of HbA1c 8.5% (69 mmol mol1),
elective NCS should be postponed if safe and practical.’
(recommendation class: I)

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12
Q

What is the MOA of and perioperative management of Metformin?

A

MOA:
Decreases hepatic glucose production and increases muscle glucose absorption

Periop concerns - Lactic Acidosis

Periop Management:
Omit on day of surgery until oral intake resumed

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13
Q

What is the MOA of and perioperative management of Sulfonylureas? (Glibenclamide, Glimepiride, Tolbutamide)

A

MOA:
Stimulated Beta cell insulin secretion

Periop concerns (hypoglycaemia)

Periop Management:
Withhold on day of surgery until oral intake resumed

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14
Q

What is the MOA of and perioperative management of Thiazolidinediones? (Glitazones)

A

MOA:
Decreases insulin resistance

Periop concerns:
Fluid retention, Hypoglycaemia

Perioperative management:
Withhold on day of surgery until oral intake resumed

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15
Q

What is the MOA of and perioperative management of GLP-1 agonists? (-natides, -glutides)

A

Endogenous GLP-1 is a gut-derived incretin hormone that:

  1. Reduces glycaemia by stimulating insulin production
  2. Stimulating secretion from pancreatic Beta cells
  3. Reducing glucagon secretion from alpha cells

MOA:
Stimulates insulin secretion and inhibits glucagon secretion, glucose-dependent

GLP-1 inhibits gastric emptying and reduces appetite

Periop concerns:
Delayed Gastric emptying

Perioperative management:
Withhold on day of surgery until oral intake resumed

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16
Q

What is the MOA of and perioperative management of DPP4-i?

A

MOA:
Increased GLP-1 concentrations

Periop Management:
Withhold on day of surgery until oral intake resumed

17
Q

What is the MOA of and perioperative management of SGLT2-i? (-glifozins)

A

MOA:
Increases renal glucose excretion

Periop concerns:
Euglycaemic ketoacidosis
Diuresis
Hypoglycaemia with insulin

Periop Management:
Withhold 72-96 hours before surgery

18
Q

How do continuous subcutaneous insulin pumps work?

A

A SC insulin pump attempts to mimic physiological insulin secretion with a continuous (ultra) short-acting insulin infusion and boluses at mealtimes.

Both basal rate and boluses are easily adjustable, allowing more flexibility in insulin dosing.

Adv:
1. Significantly improves glycaemic control
2. Improves patient satisfaction and QOL

19
Q

What is the perioperative management of insulin SC pumps?

A

Both adult and paediatric guidelines agree than an insulin pump may be used perioperatively unless there is an absolute indication (MRI, anticipated significant fluid shifts).

Switching a patient to an IV insulin infusion or multiple daily injections increases the risk of ketoacidosis and hypoglycaemia from potential miscalculations or delays in the initiation of an IV infusion.

20
Q

What issues may arise with continuous glucose monitors (CGM) intraoperatively

A
  1. During surgery and anaesthesia, physiological derangements such as hypotension and hypothermia may diminish perfusion of the subcut tissue
  2. Pressure on the CGM device and the underlying tissue could influence readings
  3. Medications (e.g. IV Paracetamol) can cause false high readings of the CGM sensor.
  4. Accuracy of CGM in periop period is unreliable.

Advise performing regular blood glucose checks to guide periop management

21
Q

Would you use Dexamethasone for a patient with DM?

A

As a potent glucocorticoid, it causes dose-dependent hyperglycaemia, with peak effect 8-16 hours after dosing.

But PADDI (Peroperative Administration of Dexamethasone and Infection) showed there was no difference in surgical site infections for dexamethasone vs. placebo.

Therefore, although Dex increases periop hyperglycaemia, it doesn’t increase risk of SSI.

PADDI trial confirmed effectiveness of Dexamethasone for PONV

22
Q

How does Magnesium affect blood glucose control?

A

It is hypothesized that magnesium enhances blood glucose control via several mechanisms:

  1. Increasing affinity of insulin to its receptors
  2. Increasing pancreatic insulin secretion
  3. Potentiating insulin mediated glucose uptake
  4. Regulating glycogenolysis and glucose output in the liver
  5. Release of catabolic hormones and glucose translocation into the cell wall
23
Q

What is the pathogenesis of Diabetic Neuropathy?

A
  1. Inflammation and oxidative stress causing changes in small blood vessels
  2. Reduced blood supply to specific areas (local ischaemia)
  3. Decreased speed of nerve signal transmission (axonal conduction velocity)
24
Q

What considerations should be made when performing RA with a patient with diabetic Neuropathy?

A
  1. Affected nerves are more sensitive to LA agents, resulting in longer duration of nerve block
  2. Caution with performing block with electrical stimulation only, as threshold of affected nerves for electrical stimulation is significantly increased, increasing risk of needle trauma
  3. When peripheral nerve catheters are used, increased risk of catheter-related infections
25
Q

What are the advantages of preoperative carbohydrate loading?

A

Objective of CHL is to prevent fasting state, thereby inhibiting catabolic pathways.

  1. CHL reduces cortisol, IL-6 and insulin resistance, attenuating the surgical inflammatory response
  2. CHL enhances patient comfort by alleviating hunger, thirst, malaise, anxiety and nausea
  3. Some studies show improved glycaemic control after CHL in patients with T2DM
26
Q

What is your post operative management for a patient with DM?

A

ADA recommend after surgery, a basal-bolus insulin regimen is preferable to a sliding scale (short acting, bolus only) insulin protocol

27
Q

How does DKA occur?

A

DKA develops because of insulin deficiency, leading to hyperglycaemia, increased lipolysis and ketone production.

The lack of insulin causes a shift in metabolism, with the body relying of fat breakdown for energy.

Ketones accumulate in the blood leading to metabolic acidosis

28
Q

What are the signs of DKA?

A

Classic signs of DM - polyuria, polydipsia, weight loss)

But can mimic URTI - tachypnoea or gastroenteritis - abdo pain, nausea and vomiting

29
Q

How does hyperglycaemic hyperosmolar syndrome (HHS) occur?

A

HHS arises from severe hyperglycaemia and extreme dehydration.

Unlike DKA, insulin still circulates in HHS, preventing ketone production. However insulin is insufficient for adequate glycaemic control, leading to a more pronounced hypoerglycaemia
(DKA > 13mmol/L vs. > 33mmol/L for HHS)

HHS also causes hyperosmolality (from increased solute concentration), a relative lack of ketones, acidosis (pH < 7.3) and mental changes.

30
Q

What is the treatment for DKA and HHS?

A
  1. Correction of dehydration with 0.9% Saline
  2. Moderate glycaemic control (target blood glucose 10-15 mmol/L)
  3. Supplementation of potassium
  4. Frequent monitoring of osmolality, glycaemia and potassium
31
Q

What are other benefits do SGLT2-i ?

A

Reduced hospitalization rates for heart failure and the progression of chronic kidney disease.

32
Q

What are other benefits of GLP-1agonists?

A

Lower rates of MI, stroke and revascularisation procedures

BJA 2024 (9 decks)

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