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Chapter

47

Anesthesia in Diabetic Patients

G Vijayakumar

The prevalence of diabetes mellitus is steadily increasing throughout


the world and in India; the prevalence of diabetes varies from 15%
to 20% of the adult population. The age of onset of diabetes is also
coming down in India. Inevitably, more and more number of diabetic
patients require surgery and hence anesthesia. Perioperative
glycemic control and end-organ effects of diabetes influence
the surgical outcome and prognosis of the patient. By proper
pre-anesthetic evaluation and risk assessment, good anesthetic
techniques, meticulous glycemic control and efficient postoperative
management, anesthesia can be made safe in diabetic patients.
Perioperative management of diabetic patients can be classified in to
pre, intra and postoperative management.

PREOPERATIVE MANAGEMENT
Preoperative management includes detailed evaluation of the endorgan damage, airway and the level of glycemic control, and decision
should be made on the type of surgery and choice of anesthesia.
The major risk factors for diabetic patients undergoing surgery are
cardiovascular dysfunction, renal insufficiency, joint collagen tissue
abnormalities, neuropathies, poor wound healing, postoperative
infection, decreased lung volume, decreased lung diffusing capacity,
etc.

Preoperative Evaluation
The aim of preoperative assessment is to determine the extent of the
end-organ damage due to diabetes and to optimize the physiological
status of the patient. The type of the disease and the antihypoglycemic
agents and other medications for associated diseases should be
assessed in detail. Investigations should include blood glucose
levels (fasting and postprandial), HbA1c (for long-term control),
urine proteins and ketones, serum electrolytes, renal function tests,
electrocardiogram (ECG), chest roentgenogram, etc. Complications
associated with diabetes should be assessed as mentioned below.

Cardiovascular Dysfunction
Diabetic men are four times more prone to and women are five times
more prone to develop coronary artery disease. It is not only coronary
artery disease but they are also more prone to develop hypertension,
cardiomyopathy, heart failure and cerebrovascular accident. Some
patients may suffer from myocardial infarction without typical
symptoms, i.e. silent ischemia resulting from autonomic neuropathy.
In patients with myocardial ischemia, surgical outcome is poor even
if the procedure is coronary artery bypass graft or angioplasty, with
an unacceptable risk benefit ratio. In case of surgeries like renal
transplantation for end-stage diabetic nephropathies or any other

elective surgeries, preoperative screening and appropriate coronary


revascularization improves surgical outcome.
Cardiovascular function assessment is most important in
preoperative examination of diabetic patients. The examiner should
ask about any history of breathlessness on exertion, palpitations, pedal
edema, chest pain, syncope, paroxysmal nocturnal dyspnea, etc. The
treatment history is very important as the patient might be taking
antiplatelet or anticoagulant drugs, which should be stopped at least
1 week before surgery. Also, patient might have undergone
thrombolysis or other revascularization procedures recently. The
clinical examination should include jugular venous pulse, liver
enlargement, apex shift, crepitations or any other relevant auscultatory
findings. This clinical assessment should be complimented with
relevant investigations like ECG, echocardiogram, etc. In ECG, we
should look for ischemic changes or previous myocardial infarction.
Echocardiogram and treadmill test should be done only if required.
Heart failure should be improved before surgery.

Autonomic Neuropathy
Diabetic patients will develop distal symmetrical sensory or sensory
motor polyneuropathy with variable degree of autonomic involvement.
Patients with diabetic autonomic neuropathy are at increased risk of:
Gastroparesis and consequent aspiration during induction and
postoperative period
Intraoperative and postoperative cardiorespiratory arrest
Exaggerated pressor response to tracheal intubation
Profound hypotension at induction
Bradycardia, hypotension, cardiopulmonary arrest during
anesthesia
Predisposes to intraoperative hypothermia
Impaired response to hypercapnia or hypoxemia
Increased risk of postoperative urinary retention and hypoxic
episodes.
Autonomic neuropathy undermines the ability of the heart
to compensate for the stress during surgery. Diabetic autonomic
neuropathy develops eventually in up to 50% of the patients and
it mainly affects cardiovascular and gastrointestinal system. The
clinical signs include orthostatic hypotension, painless myocardial
ischemia, lack of heart rate variability, reduced heart rate response
to atropine and propanolol, resting tachycardia, early satiety,
neurogenic bladder, lack of sweating and impotence.
Autonomic neuropathy can be assessed by
Heart rate response to deep breathing, standing and Valsalva
maneuver: In case of heart rate response to deep breathing at a
rate of 16 breaths/minute, the difference greater than or equal

Diabetology
to 15 breaths/minute is considered as normal, 1115 breaths/
minute is borderline and less than 10 beats/min is abnormal.
Blood pressure response to standing and handgrip: A fall in
systolic blood pressure less than 10 mm Hg is normal, 1029 mm
Hg is borderline and greater than 30 mm Hg is abnormal.
Quantitative sudomotor axon reflex test distribution, and
Thermoregulatory sweat test.
There may be partial degeneration or segmental demyelination
of nerve fibers and loss of motor units in diabetic patients. Muscular
infarction and muscle atrophy has also been reported in diabetic
patients. In such patients, the response to non-depolarizing neuro
muscular blocking drugs is exaggerated. Therefore, the onset and
recovery from neuromuscular block will differ in diabetic patients.
Poor patient positioning for surgery may lead to pressure sores that
heal poorly. Also, it is important to document existing neuropathy
especially when regional anesthesia is considered.

Diabetic Nephropathy
Angiotensin converting enzyme inhibitors have a renal protective
effect in Type I diabetic patients. But, during perioperative period,
no agent has been proved to have renal protective effect. Risk of
postoperative acute renal failure, hyperkalemia and hyponatremia
are more with diabetic renal insufficiency.
Albuminuria is the first sign and urinary protein should be
screened preoperatively. Blood urea and serum creatinine should
be checked. Fundus examination is relevant as early microvascular
changes will point toward early diabetic nephropathy as well.
Adequate hydration should be ensured to prevent postoperative
renal dysfunction and nephrotoxic drugs should be avoided.

Joint Collagen Tissue Abnormality


Diabetic stiff joint syndrome is characterized by joint rigidity
and tight waxy skin. High glycemic level promotes nonenzymatic
glycosylation of collagen and formation of abnormal proteins.
These may get deposited in joints, weaken endothelial junction
and decrease elasticity leading to stiff joint syndrome. Due to the
involvement of atlanto-occipital joint and temperomandibular joint,
affected patient will have difficult laryngoscopy and intubation.
Difficult intubation can be anticipated by positive prayer sign. Ask
the patient to bring the hands together as if praying, simultaneously
hyperextending the wrist joint to 90. If the little fingers do not
oppose, anticipate difficulty in intubation.
These glycosylated collagen and other abnormal proteins
interfere with wound healing and decrease tensile strength of healed
wound. Microvascular angiopathies and decreased oxygenation
of the tissues also contribute to poor wound healing. Thus, it is
important to normalize glycated hemoglobin level before elective
surgery. If HbA1c is normal, it indicates long-term control in blood
sugar values and hence glycosylation is not happening.

Postoperative Infection
Diabetic patient experiences more infections in clean wounds than
nondiabetic patients (rate of wound infection in clean wounds in
diabetic patients was 10.7% while in nondiabetic patients was 1.8%).
Infections account for two-thirds of postoperative complications
and 20% of perioperative death. Factors contributing to increased
infection rate in diabetic patients are:
Altered leukocyte function including inadequate granulocyte
production, decreased chemotaxis and impaired adherence to
vascular endothelium
Impaired phagocytic activity of granulocytes because NADPH is
diverted from superoxide production to polyol pathway
Vascular insufficiency resulting in local tissue ischemia, enhancing the growth of microaerophilic and anaerobic organisms

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Section 5
Reduced intracellular killing of pneumococci and staphylococci.
Tight glycemic control and judicious use of antibiotics reduce the
rate of postoperative wound infection.

Metabolic Decompensation
Many of the diabetic patients requiring emergency surgery may
have significant metabolic decompensation including ketoacidosis.
There would not be enough time for stabilizing patients, but even few
golden hours may be sufficient for the correction of life-threatening
metabolic abnormalities. The chances of intraoperative cardiac
arrhythmias and hypotension can be avoided if intravascular volume
depletion and hypokalemia are at least partially treated.
The metabolic challenges during surgery are as follows:
Stress response with catabolic hormone production: Stress
response leads to the secretion of catecholamines, cortisol,
growth hormone and glucagon. These hormones have got a
hyperglycemic effect and hence require increased dose of insulin
during perioperative period.
Starvation: Both preoperative and postoperative
Altered consciousness: Mask the symptoms of hypoglycemia and
ketoacidosis. Hence, close blood sugar monitoring and testing for
ketones in urine is required.
Circulatory disturbances associated with surgery may alter the
absorption of subcutaneous insulin.
Immobilization
Electrolyte imbalance: Plasma sodium concentration decreases
by about 1.6 MEq/L for every 100 mg/dL increase in plasma
glucose above normal. Hypokalemia especially in case of
diabetic ketoacidosis requires aggressive replacement therapy.
Hypophosphatemia due to tissue catabolism, impaired cellular
uptake and increased urinary loss may lead to significant
muscular weakness and organ dysfunction.

Type of Surgery and Choice of Anesthesia


In case of a minor surgery, patients are not expected to starve for
long duration. Therefore, blood sugar homeostasis is not affected
much. But in case of a major surgery, starvation may be required
for prolonged period depending upon the procedure and hence
aggressive blood sugar monitoring and management is required.

General Anesthesia or Regional Anesthesia


There are no specific guidelines for type of anesthesia, but is
decided by the type of surgery and the patients preference.
Regional anesthesia is preferred for some procedures in diabetic
patients especially cataract surgery. But it should be kept in mind
that anesthetic requirements are lower and the risk of nerve injury
is higher in diabetic patients. Adding adrenaline to anesthetic
solution increases risk of ischemia and edematous nerve injury.
Regional anesthesia avoids starvation (before and after surgery),
avoids hormonal and metabolic changes that occur during general
anesthesia and facilitates early mobilization. Thus, regional
anesthesia facilitates minimal interruption of the normal daily
routine of diet and treatment for diabetic patients. But there is risk
of profound hypotension, infection and vascular damage, epidural
abscess, etc.

Perioperative Blood Sugar Management


All diabetic medications should be continued until the night before
surgery except chlorpropamide and long-acting insulin. Longacting insulin should be substituted with short/intermediate-acting
insulin. Tight control of blood sugar should be established before
surgery. The main concern is to avoid harmful hypoglycemia.

Chapter 47 Anesthesia in Diabetic Patients

Section 5
But with the availability of more accurate and easy to use glucose
monitors, permissive hyperglycemia is not acceptable nowadays.
Tight glycemic control has been found to reduce the mortality and
also decreases the incidence of multiorgan failure, septicemia, acute
renal failure and polyneuropathy.
It is important to give carbohydrate source such as IV glucose
solution throughout the period of perioperative starvation. It can be
given as glucose and insulin infusion running separately or infusion
of glucose mixed with insulin. Combined glucose-insulin-potassium
solutions (GIK system or the Alberti-Thomas regimen or WATTS
regimen) have the advantage of inherent safety. Fifty percent glucose
solution with 0.25 or 0.5 units/mL of insulin can deliver glucose
and insulin equivalent to conventional systems using 10% glucose.
This can avoid the administration of large volume of free water. The
disadvantage is hypertonic glucose solution need to be given into
central vein, which may not be practical always.
Separate infusion of glucose and insulin may provide better
glycemic control and found to be more convenient for nursing staff.
But if the nursing staffs are not vigilant enough, one infusion may
be inadvertently stopped while the other infusion continued, which
may lead to disastrous consequences.

INTRAOPERATIVE MANAGEMENT
The aim of intraoperative management is to provide adequate
anesthesia, proper positioning and to avoid hypoglycemia,
hyperglycemia, ketoacidosis and electrolyte disturbances. It is
important to time diabetic patients as first in the operating list,
thus shortening the starvation period. Positioning of the patient is
also very important to avoid pressure sores and it should be done
gradually to avoid sudden drop in blood pressure. Careful titration
of inducing agents should be done with adequate preloading to
avoid hypotension due to autonomic neuropathy. There are no
contraindications to standard anesthetic induction or inhalational
agents. Rapid induction with cricoid pressure should be done if
gastroparesis is suspected. A nasogastric tube can be positioned
and aspiration should be done if required. Anticipate difficulty in
intubation and back up of laryngeal mask airway, proper blades and
endotracheal tubes, tracheostomy facility and expert help should
be ensured. Intravenous induction agents may cause hypotension,
which is worsened in diabetic patients with autonomic neuropathy.
Adequate preloading, reducing the dose of induction agents and
slow injection will reduce hypotension.
Dehydration should be avoided; normal saline can be used as
maintenance fluid. Dextrose containing fluids and ringer lactate
are better avoided. Blood sugar should be maintained with insulinglucose infusion as explained above. Blood sugar should be
monitored every hour, also as in any other case SpO2, blood pressure,
ECG, end tidal carbon dioxide, urine output and temperature
should be monitored. Continuous arterial blood pressure should be
monitored if the patient is hemodynamically unstable or large fluid

shifts are anticipated. Five lead ECG is indicated if the patient has
evidence of myocardial ischemia.

POSTOPERATIVE MANAGEMENT
During postoperative period, insulin-glucose infusion should
be continued till at least 2 hours after the first meal. Blood sugar
should be monitored every 2 hourly and normal insulin regime
or oral hypoglycemic agents can be started with the first meal. It
is also important to monitor the sodium and potassium levels.
Postoperative hyponatremia is a common electrolyte abnormality
and hypokalemia if not answered at the right time may lead to
cardiac arrhythmias. Nausea and vomiting should be prevented, and
if present, should be treated vigorously. Good analgesia decreases
catabolic hormone secretion. Nonsteroidal anti-inflammatory drugs
should be used with caution in patients with renal dysfunction.
Judicious use of antibiotics and better wound care and postoperative
glycemic control can prevent postoperative infection.
Diabetic patients may require surgery as a consequence of their
disease process or otherwise. Giving anesthesia to diabetic patients
is usually not associated with any additional risk if proper care is
taken during pre-anesthetic check-up. Meticulous glycemic control
prior to surgery is required; if possible, HbA1c should be brought to
normal before any planned surgery. Assessment of comorbidities
and complications will help to prevent complications during and
after surgery.

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