Perioperative medicine and anaesthesia Flashcards
Conditions and Presentations
ASA grade 0
normal healthy patients, who are non-smokers and with no/minimal alcohol intake.
ASA grade I
- mild systemic disease
- well controlled diabetes or hypertension, current smoker, obesity (BMI 30-40), and mild lung disease.
ASA grade III
Severe systemic disease
e.g. poorly controlled diabetes or hypertension, COPD, morbid obesity (BMI >40), history of ACS/stroke/TIA >3 months ago.
ASA grade IV
*severe systemic disease
* constant threat to life
* MI/stroke/TIA within 3 months
ASA grade V is
moribund patients not expected to survive
ASA grade VI
- brain dead
- used for transplant
Simple airway manouvers
- suction
- head tilt/ chin lift
- Jaw thrust
Aiway adjuncts
- Oropharyngeal airway (OPA)
- Nasopharynx airways
Nasopharyngeal airway
Useful in patients with a sensitive gag reflex when using OPA
Contraindicated in base of skull fracture
Supraglottic airway
- Sits over the top of the larynx
- Can be used with ventilation machine
Surigcal airway managment
- Tracheostomy
- Cricothyroidotomy
Signs and symptoms of c-spine injurt
- Neck pain
- Decreased range of motion in the neck
- Focal neurological deficits, such as weakness or numbness in the arms or legs
- Signs of spinal shock, including flaccid paralysis and loss of bowel or bladder control
Nexus criteria- what is it
- criteria which suggest c-spine injury is **not likely **
- All criteria has to be met in Nexus criteria
Nexus criteria (5)
- Normal level of alertness
- No evidence of intoxication
- No painful distracting injuries
- No focal neurological deficit
- Absence of midline cervical tenderness
What to do if C-spine isnt cleared
CT C-spine
Managment of C-spine fracture
- airway managment
- appropriately sized semi-rigid collar
- block and tape use
- full body stabilisation
Signs of post-operative bleed
- mild pyrexia
- hypotension
- tachycardia
Managment of hypovolemic shock
fluid bolus of a crystalloid
Mild to moderate pain managment
- Paracetamol.
- Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen and naproxen.
- Aspirin (a salicylate NSAID).
- Weak opioids, such as codeine, dihydrocodeine, and tramadol.
cluster headaches
- Primarily unilateral and typically more severe around the eye region.
- occur in clusters,
- numerous attacks within small time frame (e.g weeks)
epidemiology of cluster headaches
more prevalent among middle-aged men
What precipitates cluster headaches
- alcohol consumption
- smoking
cause of cluster headaches
activation of the trigeminal nerve
Signs and symptoms of cluster headaches
- Unilateral, severe headache, often around the eye
- A bloodshot or teary eye on the affected side
- Vomiting
Treatment of cluster headaches
100% oxygen and sumatriptan
Prophylaxis of cluster headaches
verapamil and steroids
compartmental syndrome
increase in pressure within the muscle compartments of a limb, typically following trauma.
Signs and symptoms of compartmental syndrome
- Severe pain, particularly evident during passive flexion of the toes
- Pallor of affected limb
- Paralysis or weakness of the limb
- pulselessness
- Paraesthesia
Managment of compartmental syndrome
- Keep the limb at a neutral level with the patient
- Oxygen
- Fluid administration
- Remove all dressings/splints/casts down to the skin
- Analgesia for pain management (usually opioids)
- Fasciotomy
Malignant Hyperthermia
- life-threatening condition
- occurs due to suxamethonium
Aetiology of malignant hyperthermia
- autosomal dominant mutation in the ryanodine receptor 1 gene
- Causes hyperkalemia
- results in increased metabolic rate
Signs and symptoms of malignant hyperthermia
- Rapid increase in body temperature
- Muscle rigidity
- Metabolic acidosis
- Tachycardia
- Increased exhaled carbon dioxide
Investigation of malignant hyperthermia
- Blood tests: metabolic acidosis and** increased creatine kinase levels.**
- Core temperature monitoring to detect hyperthermia.
Managment of malignany hyperthermia
- stop drugs
- supportive measurments
- agressive cooling treatment
Managment of head trauma
- major trauma- given IV morphine (no IV access, intranasal diamorphine or ketamine)
- TBI- sit patiet 30*
Managment of ICP
- DO NOT do LP
- short-term hyperventilation
Confirm positioning of NG tube
- pH (1.5-3.5) aspiration
- Erect CXR tip should ideally be seen at least 10cm beyond the gastro-oesophageal junction
CPAP
- Type I respiratory failure, providing positive pressure
- keep the alveoli open for a longer period of time to facilitate gas exchange.
BiPAP
- type II respiratory failure
- two different levels of positive pressure on inspiration and expiration
Criteria of NIV
- Patient awake and able to protect airway
- Co-operative patient
- Consideration of quality of life of patient
Contradictions of NIV
- Facial burns
- Vomiting
- Untreated pneumothorax
- Severe co-morbidities
- Haemodynamically unstable
- Patient refusal
Steps of rapid induction sequences
- Airway
- Drug preparation
- Monitoring of vital signs
- Drug administration
- Cricoid pressure
Pre-operative anaemia managment
- Oral iron if >6 weeks until planned surgery
- IV iron if <6 weeks until planned surgery
- B12/folate replacement
- Erythropoiesis‐stimulating agent (ESA) therapy
- Transfusion if profound anaemia and surgery cannot be delayed
Post-operative anaemia managment
- Transfusion
- IV iron
- Oral iron
Causes of type 1 resp failure (6)
- Decreased atmospheric pressure
- Ventilation-perfusion mismatch
- Shunt
- Pneumonia
- ARDS
- Pulmonary embolism
Diabetic drugs and surgery
Post-operative poor urinary output
output of less than 0.5 mL/kg/hour in adults is considered low.
Post-renal causes of less urine output
- Benign prostatic hypertrophy
- Effects of drugs such as anticholinergic or alpha adrenoreceptor antagonists, often used in anaesthetics
- Pain following surgery, particularly hernia operations
- Psychological inhibition
- Opiate analgesia
Pre-renal causes of poor urine output
- Hypovolaemia
- Hypotension
- Dehydration
Renal causes of poor urine output
Acute tubular necrosis
Signs and symptoms of poor urine output
- Decreased urine frequency/volume
- Hypotension and tachycardia (pre-renal causes)
- Abdominal pain or discomfort
- Symptoms of drug side effects such as dry mouth, blurred vision, and constipation (post-renal causes due to anticholinergic drugs)
poor urine output after surgery investigations
- Urine output measuremen
- Urinalysis
- U+E
- Ultrasound of kidneys and bladder: To identify any potential obstructions in the urinary tract.
Managment of poor urine output after surgery
- Correction of any fluid or electrolyte imbalances
- manage underlying cause
- urinary catheterisation
Suxamethonium apnoea
- defect in the plasma cholinesterase enzyme
- Patients will have prolonged period of paralysis
Signs and symptoms of suxamethonium apnoea
- prolonged paralysis
- make little effort to cough or breathe spontaneously.
Investigations of Suxamethanoium apnoea
checking plasma cholinesterase levels to identify any potential defects.
Managment of Suxamethanoium apnoea
- intubated and ventilated until they are able to breathe spontaneously.
- do not use in future again
Major trauma, first line analgesia
IV Morphine
If IV cant be accessed, intranasal diamorphine or ketamine.
Suspected TBI managment
- patient at 30 degrees
- If ICP is raising, increase rate of ventilation
Systemic inflammatory response syndrome (SIRS)
SIRS
Must have one of the following to diagnose
* Temperature >38 or <36 degrees Centigrade
* Heart rate >90
* Respiratory rate >20
* White cell count >12 or <4 x10^9/L
<1 paeds signs
- RR 30-40
- HR 110-160
- SBP 70-90
1-2 vital signs
- RR 25-35
- HR 100-150
- SBP 80-95
2-5 vital signs
- RR 25-30
- HR 95-140
- SBP 80-100
5-12 vital signs
- RR 20-25
- HR 80-120
- SBP 90-110
> 12 vital signs
- RR15-20
- HR 60-100
- SBP 100-120
Peri op guidance on hypertension
Only cancel if BP persistently elevated
•Stage 1 = proceed as normal •Stage 2 = Proceed as normal
•Stage 3 = if no evidence of end-organ damage – consider proceeding with fastidious BP monitoring + A-line. If evidence of end-organ damage or patient is unwell – consider postponing surgery for 4weeks.
•Consider peri-op Beta-blockade – reduces risk of myocardial ischaemia / CVS complications
What are surgical site infections (SSI)?
Infections that occur following a breach in tissue surfaces, allowing normal commensals and pathogens to initiate infection
SSI are a major cause of morbidity and mortality, comprising up to 20% of all healthcare-associated infections.
What percentage of patients undergoing surgery will develop an SSI?
At least 5%
SSI can significantly impact recovery and hospital stay.
What are common measures that may increase the risk of SSI?
- Shaving the wound with a razor
- Using non-iodine impregnated incise drapes
- Tissue hypoxia
- Delayed administration of prophylactic antibiotics in tourniquet surgery
What is the recommended method for hair removal before surgery?
Use electrical clippers with a single-use head
Razors increase infection risk.
When should antibiotic prophylaxis be administered?
- Placement of prosthesis or valve
- Clean-contaminated surgery
- Contaminated surgery
What is the preferred method for skin preparation to reduce SSI?
Alcoholic chlorhexidine
This method has the lowest incidence of SSI.
True or False: Administration of supplementary oxygen reduces the risk of wound infection.
False
A recent meta-analysis confirmed that supplementary oxygen does not reduce the risk of wound infection.
What are the two main types of respiratory failure?
- Type 1: ↓ pO2 with normal or ↓ pCO2
- Type 2: ↑ pCO2 with normal or ↓ pO2
What causes type 1 respiratory failure?
- Pneumonia
- Pulmonary embolism
- Asthma
- Pulmonary oedema
- Acute respiratory distress syndrome
What causes type 2 respiratory failure?
- Chronic obstructive pulmonary disease
- Decompensation in other respiratory conditions
- Neuromuscular disease
- Obesity hypoventilation syndrome
- Sedative drugs (e.g., benzodiazepines, opiate overdose)
What are the key indications for non-invasive ventilation (NIV)?
- COPD with respiratory acidosis (pH 7.25-7.35)
- Type II respiratory failure due to chest wall deformity, neuromuscular disease, or obstructive sleep apnoea
- Cardiogenic pulmonary oedema unresponsive to CPAP
- Weaning from tracheal intubation
What are the recommended initial settings for bi-level pressure support in COPD?
- EPAP: 4-5 cm H2O
- IPAP: 10-15 cm H2O
- Back up rate: 15 breaths/min
- Back up inspiration:expiration ratio: 1:3
What is the mechanism of action of ADP receptor inhibitors?
Inhibition of the P2Y12 receptor, leading to reduced platelet aggregation
ADP is a key platelet activation factor.
What are the first-line and second-line treatments for acute coronary syndrome (ACS)?
- 1st line: Aspirin (lifelong) & Ticagrelor (12 months)
- 2nd line: Clopidogrel (lifelong) if aspirin is contraindicated
What notable adverse effect is associated with Ticagrelor?
Dyspnoea
This is due to impaired clearance of adenosine.
What are the contraindications for Prasugrel?
- Prior stroke or transient ischaemic attack
- High risk of bleeding
- Prasugrel hypersensitivity
What is necrotising fasciitis?
A medical emergency characterized by rapidly progressing infection of the soft tissue
It can be difficult to recognize in the early stages.
What are the features of necrotising fasciitis?
- Acute onset
- Pain, swelling, erythema
- Rapidly worsening cellulitis
- Skin necrosis and crepitus/gas gangrene as late signs
What is the average mortality rate for necrotising fasciitis?
20%
Early recognition and intervention are critical.
What is the maximum normal diameter for small bowel obstruction?
35 mm
What is the maximum normal diameter for large bowel obstruction?
55 mm
What is the most common cause of large bowel obstruction?
Tumor
Tumors account for 60% of cases of large bowel obstruction.
What are common clinical features of bowel obstruction?
- Absence of passing flatus or stool
- Symptoms suggestive of underlying causes (e.g., colorectal cancer)
What accounts for 60% of cases of large bowel obstruction?
tumour
What is the initial presenting complaint of colonic malignancy in approximately 30% of cases?
obstruction
Which types of tumors tend to obstruct earlier due to smaller lumen diameter?
distal colonic and rectal tumours
List three underlying causes of bowel obstruction.
- volvulus
- diverticular disease
- colorectal cancer
What are common clinical features of bowel obstruction?
- absence of passing flatus or stool
- abdominal pain
- abdominal distention
- nausea and vomiting
- peritonism (if perforation is present)
What imaging is still commonly used as the first-line investigation for bowel obstruction?
abdominal x-ray
What are the normal diameter limits for the caecum, ascending colon, and recto-sigmoid?
- caecum: 10-12 cm
- ascending colon: 8 cm
- recto-sigmoid: 6.5 cm
What does the presence of free intra-peritoneal gas indicate?
colonic perforation
What are the sensitivities and specificities of CT scans for identifying bowel obstruction?
> 90% each
What are the initial management steps for bowel obstruction?
- NBM
- IV fluids
- nasogastric tube with free drainage
What percentage of patients with bowel obstruction will eventually require surgery?
around 75%
When is emergency surgery necessary in bowel obstruction management?
if there is overt peritonitis or evidence of bowel perforation
What is postoperative ileus sometimes referred to as?
paralytic ileus
List common features of postoperative ileus.
- abdominal distention/bloating
- abdominal pain
- nausea/vomiting
- inability to pass flatus
- inability to tolerate an oral diet
Which electrolytes should be checked as they can contribute to postoperative ileus?
- potassium
- magnesium
- phosphate
What are the initial management steps for postoperative ileus?
- nil-by-mouth initially
- nasogastric tube if vomiting
- IV fluids to maintain normovolaemia
- additives to correct electrolyte disturbances
- total parenteral nutrition (occasionally)
What is the most common cause of small bowel obstruction?
adhesions (following previous surgery)
What are common features of small bowel obstruction?
- diffuse, central abdominal pain
- nausea and vomiting
- typically bilious vomiting
- ‘constipation’ with complete obstruction
- abdominal distension
- ‘tinkling’ bowel sounds
What imaging is generally first-line for suspected small bowel obstruction?
abdominal x-ray
What diameter is the small bowel considered dilated?
> 3 cm
What is the definitive investigation for small bowel obstruction?
CT scan
What initial steps should be taken for the management of small bowel obstruction?
- NBM
- IV fluids
- nasogastric tube with free drainage
What are the genetic causes of learning difficulties?
Fragile X, Down’s syndrome
These are chromosomal abnormalities that can impact cognitive development.
Which congenital infections can lead to learning difficulties?
Cytomegalovirus, toxoplasmosis, rubella
These infections can affect fetal development and result in cognitive impairments.
What birth-related factors can cause learning difficulties?
Hypoxia, rhesus haemolytic disease, intraventricular haemorrhage
These conditions can affect brain development during or shortly after birth.
Name three metabolic disorders associated with learning difficulties.
PKU, maple syrup urine disease, homocystinuria
These disorders affect metabolism and can lead to cognitive impairments if untreated.
What is an extradural haematoma?
Bleeding into the space between the dura mater and the skull
Often results from trauma and most commonly occurs in the temporal region.
What are the features of an extradural haematoma?
Raised intracranial pressure, lucid interval
A lucid interval may occur before symptoms worsen.
What distinguishes a subdural haematoma from an extradural haematoma?
Bleeding into the outermost meningeal layer
Subdural haematomas often have a slower onset of symptoms.
What are common risk factors for subdural haematomas?
Old age, alcoholism
These factors can increase the likelihood of developing subdural haematomas.
What is subarachnoid haemorrhage typically associated with?
Ruptured cerebral aneurysm
It may also occur with other injuries in traumatic brain injury cases.
What is diffuse axonal injury?
Injury from mechanical shearing following deceleration
It results in disruption and tearing of axons.
What is the minimum cerebral perfusion pressure in adults?
70 mmHg
This is crucial for adequate brain perfusion.
What does the Cushing’s reflex indicate?
Hypertension and bradycardia
It often occurs late and is usually a pre-terminal event.
What is the recommended management for life-threatening rising ICP?
Use of IV mannitol/frusemide
This may be required while preparing for surgery or transfer.
How are pupils interpreted in head injuries?
Unilaterally dilated, sluggish or fixed indicates 3rd nerve compression
Different pupil responses can indicate various types of brain injury.
What are the GCS criteria for immediate CT head scan?
GCS < 13, GCS < 15 at 2 hours, suspected open or depressed skull fracture
These criteria help determine the need for urgent imaging.
What is the management for iron overdose?
Whole bowel irrigation, desferrioxamine if serum iron levels are high
Activated charcoal is ineffective in iron poisoning.
What is lithium toxicity often precipitated by? (3)
Dehydration, renal failure, certain medications
Monitoring is essential in patients on lithium due to its narrow therapeutic range.
What is the treatment for paracetamol overdose?
Acetylcysteine if plasma concentration is above treatment line
Treatment guidelines have changed to treat all patients similarly regardless of risk factors.
What are the common symptoms of superior vena cava obstruction?
Dyspnoea, swelling of the face, neck, and arms, headache
These symptoms can indicate serious underlying malignancies.
What is the first-line treatment for hiccups in terminal patients?
Chlorpromazine
Other options include haloperidol and gabapentin.
What is the recommended dosage of paracetamol for patients presenting with overdose symptoms?
150 mg/kg of paracetamol
What laboratory findings indicate the need to continue acetylcysteine treatment?
Paracetamol concentration or ALT remains elevated
What is the current infusion duration for acetylcysteine to reduce adverse effects?
1 hour
What type of reaction is commonly caused by acetylcysteine?
Anaphylactoid reaction
What are the King’s College Hospital criteria for liver transplantation in paracetamol liver failure?
Arterial pH < 7.3, or prothrombin time > 100 seconds, creatinine > 300 µmol/l, grade III or IV encephalopathy
What defines a staggered overdose of paracetamol?
All tablets were not taken within 1 hour
What is the therapeutic range for lithium?
0.4-1.0 mmol/L
What are common precipitating factors for lithium toxicity? (6)
- Dehydration
- Renal failure
- Diuretics
- ACE inhibitors/angiotensin II receptor blockers
- NSAIDs
- Metronidazole
What are the features of lithium toxicity?
- Coarse tremor
- Hyperreflexia
- Acute confusion
- Polyuria
- Seizure
- Coma
What is the recommended management for mild-moderate lithium toxicity?
Volume resuscitation with normal saline
What are the typical symptoms of diabetic ketoacidosis (DKA)?
- Abdominal pain
- Polyuria
- Polydipsia
- Dehydration
- Kussmaul respiration
- Acetone-smelling breath
What is the C-peptide level typically seen in patients with type 1 diabetes mellitus (T1DM)?
Low
What are the diagnostic criteria for type 1 diabetes mellitus if the patient is symptomatic?
- Fasting glucose ≥ 7.0 mmol/l
- Random glucose ≥ 11.1 mmol/l
How can type 1 diabetes mellitus be distinguished from type 2 diabetes mellitus?
By features such as age of onset, speed of onset, weight of patient, and presence of ketonuria
What should be considered for further investigation in adults suspected of type 1 diabetes?
Measurement of C-peptide and/or diabetes-specific autoantibody titres
What is the diagnostic HbA1c level for diabetes mellitus?
≥ 48 mmol/mol (6.5%)
What are conditions where HbA1c may not be used for diagnosis? (8)
- Haemoglobinopathies
- Haemolytic anaemia
- Untreated iron deficiency anaemia
- Suspected gestational diabetes
- Children
- HIV
- Chronic kidney disease
- Medications causing hyperglycaemia
What defines impaired fasting glucose (IFG)?
Fasting glucose ≥ 6.1 but < 7.0 mmol/l
What is diabetes mellitus?
A chronic condition characterised by abnormally raised levels of blood glucose
Why is the management of diabetes mellitus important?
To reduce the incidence of macrovascular and microvascular complications
What is type 1 diabetes mellitus (T1DM)?
An autoimmune disorder resulting in absolute deficiency of insulin
What characterizes type 2 diabetes mellitus (T2DM)?
Relative deficiency of insulin due to excess adipose tissue
What is prediabetes?
A condition where patients do not yet meet criteria for T2DM but are likely to develop it
What are the main symptoms of type 1 diabetes mellitus?
- Weight loss
- Polydipsia
- Polyuria
- May present with diabetic ketoacidosis
What are the four main ways to check blood glucose?
- Finger-prick bedside glucose monitor
- One-off blood glucose
- HbA1c
- Glucose tolerance test
What is the first-line medication for managing type 2 diabetes?
Metformin
What are the main side effects of insulin therapy?
- Hypoglycaemia
- Weight gain
- Lipodystrophy
What is the mechanism of action of metformin?
Increases insulin sensitivity and decreases hepatic gluconeogenesis
What is the role of thiazolidinediones in diabetes management?
Activate PPAR-gamma receptor to promote adipogenesis and fatty acid uptake
What is an example of a DPP-4 inhibitor?
Gliptins
What is the mechanism of action of SGLT-2 inhibitors?
Inhibit reabsorption of glucose in the kidneys
What is hyponatraemia?
A condition characterized by low sodium levels in the blood
Examples include gliclazide and glimepiride
What is the effect of thiazolidinediones on adipocytes?
Activate PPAR-gamma receptor to promote adipogenesis and fatty acid uptake
Only currently available thiazolidinedione is pioglitazone
What is a common adverse effect of thiazolidinediones?
Weight gain and fluid retention
What do DPP-4 inhibitors do?
Increase incretin levels which inhibit glucagon secretion
Examples include vildagliptin and sitagliptin
How are DPP-4 inhibitors generally tolerated?
Relatively well tolerated but increased risk of pancreatitis
What do SGLT-2 inhibitors inhibit?
Reabsorption of glucose in the kidney
What is the primary route of administration for GLP-1 agonists?
Subcutaneous injection
What is a common side effect of GLP-1 agonists?
Nausea and vomiting
What is the target HbA1c reduction for ongoing prescription of GLP-1 mimetics?
> 11 mmol/mol (1%) reduction in HbA1c and 3% weight loss after 6 months
What is the target blood pressure for type 2 diabetics according to NICE?
< 140/90 mmHg
What is the recommended first-line antihypertensive for diabetic patients?
ACE inhibitors or angiotensin-II receptor antagonists (A2RBs)
What are the recommended HbA1c monitoring intervals for adults with type 1 diabetes?
Every 3-6 months
What is the target HbA1c level for adults with type 1 diabetes?
48 mmol/mol (6.5%) or lower
What type of insulin regimen is preferred for adults with type 1 diabetes?
Multiple daily injection basal-bolus insulin regimens
What dietary advice is recommended for diabetes management?
High fibre, low glycaemic index carbohydrates, low-fat dairy, oily fish, control saturated fats
What is the initial target weight loss for an overweight person with diabetes?
5-10%
What should be done if a patient’s HbA1c rises to 58 mmol/mol (7.5%)?
Further treatment is indicated
What are the options for second-line therapy if HbA1c targets are not met?
Add one of the following:
* Metformin + DPP-4 inhibitor
* Metformin + pioglitazone
* Metformin + sulfonylurea
* Metformin + SGLT-2 inhibitor (if NICE criteria met)
What is the preferred statin for patients with a 10-year cardiovascular risk > 10%?
Atorvastatin 20mg
What is a significant concern when using beta-blockers in uncomplicated hypertension?
They may cause insulin resistance and impair insulin secretion
What should be considered when advising Muslim patients about fasting during Ramadan?
Chronic conditions may exempt them from fasting or allow for delayed fasting to shorter days
Fill in the blank: The incretin effect is largely mediated by _______.
GLP-1
True or False: GLP-1 mimetics result in weight gain.
False
What is the primary consideration for Muslim patients regarding fasting during Ramadan?
Patients with chronic conditions are exempt from fasting or may delay fasting to shorter days.
What percentage of Muslim patients with type 2 diabetes mellitus fast during Ramadan?
Around 79%.
What meal should patients with type 2 diabetes mellitus eat before sunrise?
A meal containing long-acting carbohydrates (Suhoor).
What is the recommended adjustment for metformin dosing for patients fasting during Ramadan?
Split the dose: one-third before sunrise (Suhoor) and two-thirds after sunset (Iftar).
For patients on insulin therapy during Ramadan, what must they not do?
They must not stop insulin therapy due to the risk of diabetic ketoacidosis.
What is a key recommendation for patients with type 1 diabetes fasting during Ramadan?
Check blood glucose more frequently, every 1-2 hours.
What are the two main factors leading to diabetic foot disease?
- Neuropathy
- Peripheral arterial disease
What should all patients with diabetes be screened for annually?
Diabetic foot disease.
What tool is used to screen for neuropathy in diabetic patients?
A 10 g monofilament.
What is the mechanism of action of metformin? (4)
- Activation of AMP-activated protein kinase (AMPK)
- Increases insulin sensitivity
- Decreases hepatic gluconeogenesis
- Reduces gastrointestinal absorption of carbohydrates
What are common adverse effects of metformin?
- Gastrointestinal upsets (nausea, anorexia, diarrhoea)
- Reduced vitamin B12 absorption
- Lactic acidosis in severe renal disease
What is the prevalence of prediabetes among adults in the UK according to Diabetes UK?
Around 1 in 7 adults.
What are the two types of impaired glucose regulation (IGR)?
- Impaired fasting glucose (IFG)
- Impaired glucose tolerance (IGT)
What is the definition of impaired fasting glucose (IFG)?
A fasting glucose greater than or equal to 6.1 but less than 7.0 mmol/l.
What are the important adverse effects of SGLT-2 inhibitors? (3)
- Urinary and genital infections
- Normoglycaemic ketoacidosis
- Increased risk of lower-limb amputation
What is the first-line treatment for type 2 diabetes mellitus?
Metformin.
What should be done if a patient on metformin develops unacceptable side effects?
Consider modified-release metformin.
True or False: Patients with impaired glucose tolerance (IGT) are more likely to develop T2DM than those with impaired fasting glucose (IFG).
True.
What is the recommended follow-up for patients identified at high risk for type 2 diabetes?
At least yearly follow-up with blood tests.
What should be done if a patient with type 2 diabetes is acutely ill?
Temporarily stop some oral hypoglycaemics.
What is the risk stratification for diabetic foot disease?
- Low risk: no risk factors except callus alone
- Moderate risk: deformity or neuropathy or non-critical limb ischaemia
- High risk: previous ulceration or amputation, renal replacement therapy, or combinations of risk factors.
What is the action of SGLT-2 inhibitors?
Reversibly inhibit sodium-glucose co-transporter 2 (SGLT-2) to reduce glucose reabsorption.
What should be monitored for patients taking SGLT-2 inhibitors?
Feet should be closely monitored for signs of infection or amputation risk.
What should be done with Metformin the day prior to admission?
Take as normal
What is the instruction for Metformin if taken three times per day on the day of surgery (morning operation)?
Omit lunchtime dose
What should be done with Sulfonylureas if taken once daily in the morning on the day of surgery (afternoon operation)?
Omit the dose that day
What is the instruction for DPP IV inhibitors (-gliptins) on the day of surgery?
Take as normal
What should be done with SGLT-2 inhibitors (-flozins) on the day of surgery?
Omit on the day of surgery
What is the recommended dose change for once daily insulins (e.g. Lantus, Levemir) on the day of surgery?
Reduce dose by 20%
What should be done with twice daily Biphasic or ultra-long acting insulins (e.g. Novomix 30, Humulin M3) on the day of surgery (morning operation)?
Halve the usual morning dose. Leave evening dose unchanged
Fill in the blank: If Sulfonylureas are taken twice daily, on the day of surgery (afternoon operation), _______.
omit both doses that day
What should be done with GLP-1 analogues (-tides) the day of surgery?
Take as normal
Fill in the blank: On the day of surgery, if Metformin is taken once or twice a day, the patient should _______.
take as normal
True or False: DPP IV inhibitors can be adjusted on the day of surgery.
False
