Diabetes Mellitus and Anaesthesia

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Diabetes Mellitus and Anaesthesia

• Dr R Milaszkiewicz
• August 2007

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Epidemiology

• Estimated 245 million people globally
• 20of adult population
• 5 of all deaths each year
• 80 of people with diabetes live in low and
  middle income countries

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Diabetes

• Fasting Plasma Glucose 7.0mmol/l(126mg/dl)
• OR
• 2 hour plasma glucose 11.1 mmol/l (200mg/dl)

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Impaired Fasting Glucose

• 6.1 6.9 mmol/l (110 125 mg/dl)

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Impaired Glucose tolerance

• Fasting Plasma Glucose 7mmol/l (126mg/dl)
• AND
• 2 hour glucose 7.8 11.1 (140 - 200mg/dl)

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Type 1 Diabetes

• Absolute Insulin Deficiency
• Autoimmune destruction of pancreatic ß cells
• Combination of ?viral infection superimposed on
  genetic predisposition
• Type 1A autoimmune markers found
• Type 1B no autoimmune markers

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Type 1 Diabetes

• Signs of diabetes develop when 80 of ß cells are
  destroyed
• Rate of decline less when Type 1 diabetes
  develops later in life.

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Type 2 Diabetes

• Also a combination of genetic susceptibility and
  environmental factors
• A combination of insulin resistance and relative
  insulin deficiency, as well as increased hepatic
  glucose production
• Obesity is associated with insulin resistance

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Gestational DM

• Any degree of glucose intolerance with onset
  during pregnancy
• Increased risk of pre-eclampsia
• Powerful predictor for the development of type 2
  diabetes later in life.

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Physiology

• Glucose uptake and utilisation is governed by
  complex interactions.
• Transporters insulin dependent/independent
• GLUT 4 in muscle

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Physiology

• Inhibitory effects of insulin may be as important
  as stimulatory effects
• Vascular endothelium insulin dependent,
• But exogenous insulin may be harmful
• Insulin sensitisers may improve vascular outcome

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Therapy

• Type 1 require Insulin
• Variety of long and short acting, and designer
  insulins exist
• Developments include aerosols and continuous pumps

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Therapy

• Type 2 multimodal therapy
• Diet
• Exercise
• Drugs
• Sulphonylureas
• Metformin
• Glitazones (thiazolidinediones)

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Complications of diabetes

• Cardiovascular
• Renal
• Neuropathy
• Peripheral
• Autonomic
• Musculoskeletal
• Ocular

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Stress response

• Neurohumoral response with metabolic
  consequences.
• Interleukins and histamine are released from the
  damaged tissue triggering synthesis of acute
  phase proteins
• IL1ß, IL2, IL6, tumour necrosis factor, CRP
  fibrinogen, complement and interferons

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Consequences of the stress response

• Impaired breakdown of carbohydrate, lipid and
  protein.
• Reduced peripheral utilisation of glucose
• Magnitude of response is related to surgical
  stimulus

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Anaesthetic implicationsAims

• Avoid hypoglycaemia
• Avoid hyperglycaemia
• Minimise electrolyte dysfunction
• Prevention of lipolysis and proteolysis
• ?Tight glycaemic control?

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Pre-operative Care

• Full physical assessment
• Biochemical assessment
• Discussion and plan re drug therapies
• Discussion and plan re anaesthetic

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Effects of Anaesthesia

• There is no evidence that anaesthetic technique
  affects mortality or morbidity
• Regional techniques have some advantage in
  obtunding the stress response, decreasing blood
  loss, and decreasing thrombo-embolic complications

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Peri-operative Glucose Management

• Type of diabetes
• Type of Surgery
• Local availability of resources

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General Principles

• Type 1 Diabetics
• Major and intermediate surgery
• Glucose and insulin infusions
• Minor surgery..?

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General Principles

• Type 2 diabetics
• Major surgery Insulin and glucose infusions
• Minor and intermediateProbably not Insulin and
  glucose.
• Omit hypolycaemic drugs timing of this

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Future developments?