diabetes mellitus in anaesthesia scrib

7/29/2019 Diabetes Mellitus in Anaesthesia Scrib

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ABSTRAK

Anaesthesiologists sering menghadapi pasien dengan penyakit sistem endokrin, khususnya

diabetes mellitus. Faktor resiko mayor bagi orang dengan diabetes yang menjalani operasi adalah

terkait end-organ: neuropati otonom kardiovaskular, jaringan kolagen pada persendian, dan

defisiensi imun. Karena kenyataannya bahwa penyakit endokrin dapat berhubungan dengan peri-operative morbiditas dan kematian yang signifikan, hal ini penting untuk anaesthesiologists

mengerti gangguan ini ketika adanya indikasi yang sesuai investigasi.


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Diabetes Mellitus in Anaesthesia

Jadelis Giquel; Yiliam F Rodriguez- Blanco; Christina Matadial; Keith Candiotti

Posted: 05/24/2012; British Journal of Diabetes and Vascular Disease. 2012;12(2):60-

64. 2012 Sage Publications, Inc.

Abstract and Introduction

Abstract

Anaesthesiologists frequently encounter patients with diseases of the endocrine system, in

particular diabetes mellitus. The major risk factors for people with diabetes undergoing surgeryare the associated end-organ diseases: cardiovascular autonomic neuropathy, joint collagen

tissue, and immune deficiency. Due to the fact that endocrine diseases can be associated with

significant peri-operative morbidity and mortality, it is critical that anaesthesiologists understandthese disorders and when indicated request the appropriate investigations.

Abbreviations and acronyms

American College of Cardiology ACC

angiotensin-converting enzyme ACE

adreno corticotrophic hormone ACTH

American Heart Association AHA

coronary artery disease CAD

central nervous system CNS

Diabetes Mellitus, Insulin-Glucose Infusion in Acute Myocardial Infarction DIGAMI

Detection of Ischemia in Asymptomatic Diabetics DIAD

glomerular filtration rate GFR

gastrointestinal GI

heart rate variability HRV


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Introduction

Diabetes mellitus affects patients of all ages and due to its increasing prevalence,[14] virtually all

physicians will inevitably be confronted with diabetic patients requiring anaesthesia and surgery.Patients with diabetes have a significantly increased risk of premature mortality and an increased

risk of microvascular and cardiovascular complications[5,6] and are often sicker than most non-

diabetic patients and therefore place a proportionally larger burden on anaesthetic services.

Some reports have suggested that diabetic patients undergoing elective surgery are at a greaterrisk of morbidity from myocardial ischaemia, wound infection, renal ischaemia and

cerebrovascular infarction.[7] A 50% increase in early mortality following coronary artery bypass

grafting has been described in diabetic patients. This increased mortality is consequent toimpaired myocardial function, a higher incidence of sternal wound infections and an increased

likelihood of delayed stroke, all of which result in a longer hospital stay.[8,9]

End-organ damage from diabetes may be a more important indicator of peri-operative outcome

than the presence of diabetes itself. The major risk factors affecting diabetic patients undergoingsurgery include cardiovascular dysfunction, renal insufficiency, joint collagen tissue

abnormalities (e.g. cervical joint stiffness) and neuropathies (cardiovascular and GI effects), all

of which may influence the effects of anaesthetics.[6]Therefore, a major focus foranaesthesiologists should be the pre-operative and pre-procedural evaluation and treatment of the

potentially complicating factors of diabetes.

Diabetes-related Complications

Cardiovascular Disease

Cardiovascular pathology is a major cause of death in 80% of diabetic patients and diabetes is a

major risk factor for cardiovascular disease, along with smoking, hypertension andhyperlipidaemia.[10] In the USA, heart disease was noted on 68% of diabetes-related death

certificates among people aged 65 years or older. Adults with diabetes have heart disease death

rates about two to four times higher than adults without diabetes.[11]

Compared with the general population, diabetic men have more than a four fold greaterprobability of having CAD, while women have a five fold greater likelihood. Making a diagnosis

is difficult as some diabetic patients may suffer from CAD but not experience its typical

symptoms. This reduced appreciation of ischaemic pain may impair timely recognition ofmyocardial ischaemia, delaying therapy. One study demonstrated that the rate of unrecognised

myocardial infarction was 39% in diabetic patients and 22% in non-diabetic patients. [12] The

mechanism of painless myocardial ischaemia is not fully understood but may be related toautonomic neuropathy or CAD itself.[13,14]

The presence of orthostatic symptoms (e.g. >15 beats/min increase in heart rate or >20 mmHg

decrease in systolic arterial pressure 510 min after changing from a supine to upright position)


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is a sign of autonomic neuropathy and indicates potential operative haemodynamic instability. In

the DIAD study, cardiac autonomic dysfunction was a strong predictor of ischaemia.[15]

Peri-operative management of diabetic patients with other risk factors, such as advanced age,smoking, hypertension and hyperlipidaemia, should be modified if there is a likelihood of

myocardial ischaemia. Asymptomatic type I diabetic patients with severe nephropathy who arescheduled for renal transplantation have been shown to benefit from pre-operative screening and

appropriate coronary revascularisation.[16]Questions regarding exercise tolerance and shortnessof breath with exertion may provide important information regarding any underlying heart

disease or the degree of compensation. Diabetic patients may also be prone to specific

cardiomyopathies that are due to secondary microvascular changes. These heart defects canprogress from impaired ventricular relaxation to diastolic dysfunction with high left-ventricular

filling pressures and heart failure. This type of dysfunction may respond well to -blockers and

calcium channel blockers, which act by decreasing heart rate and increasing diastolic relaxation.[17]

Diabetic Autonomic Neuropathy

Autonomic neuropathy develops in approximately one third of people with diabetes and affects

many organ systems. Only a small proportion of these patients display symptoms such as

orthostatic hypotension, syncopal episodes, reduced HRV, baseline tachycardia and a prolongedQT interval. Patients with these symptoms may be at an increased risk of ventricular arrhythmias

and sudden perioperative death.[18]The diagnosis of diabetic autonomic neuropathy is based on a

battery of autonomic function tests; RR variation, Valsalva manoeuvre and postural bloodpressure tests may be useful in determining the presence of cardiovascular autonomic

dysfunction.[13,14]

The most common diabetic neuropathy is a distal symmetrical sensory or sensory-motorpolyneuropathy. Diabetic neuropathy can also affect the thermoregulatory response tohypothermia; the pathogenesis of this effect may be related to inappropriate regulation of

peripheral vasoconstriction, a process that normally conserves body heat. One study reported that

the core temperature of diabetic patients with autonomic dysfunction was lower 2 hours intosurgery compared with non-diabetic participants and diabetic patients without autonomic

dysfunction.[19]

The cardiovascular effect of insulin is paradoxical in autonomic neuropathy patients.

Observations have suggested that insulin has a dual effect in patients without autonomicneuropathy: a vasoconstricting effect mediated by the sympathetic nervous system at therapeutic

dose of insulin and a vasodilator effect mediated by nitric oxide at supratherapeutic dose; in

patients with autonomic neuropathy, insulin causes a decrease in supine blood pressure andexacerbates postural hypotension, primarily by decreasing arterial vascular resistance and plasma

volume.[20]

Diabetic Nephropathy


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Diabetic nephropathy is the leading cause of end-stage renal failure in developed countries.

According to the US Centers for Disease Control and Prevention > 35% of people aged 20

years with diabetes have chronic kidney disease. Long-term, uncontrolled hyperglycaemia is animportant risk factor in the development of end-stage renal disease. [21] ACE inhibitors may slow

the decline of renal function; however, because of an increased risk of deteriorating renal

function, the use of ACE inhibitors should be avoided in patients with a creatinine concentrationof 3.0 mg/dL or a creatinine clearance of 30 ml/min.[22]

Due to the risk of accumulation of the biguanide metformin in patients with compromised renal

function (serum creatinine > 130 mmol/L or creatinine clearance < 60 ml/min or eGFR

diabetes mellitus in anaesthesia scrib

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