Please enable JavaScript.
Coggle requires JavaScript to display documents.
Hypertension & Diabetes mellitus in surgery (Anaethesiology),…
Hypertension & Diabetes mellitus in surgery (Anaethesiology)
HYPERTENSION
Types
Primary/Essential HPT
condtion assoc.
increase SNS activity
insulin resistance
hyperCHOLESTROLemia
obesity
Na & H2O retenion
obstructive sleep apnea
left ventricular hypertrophy
peripheral vascular disease
renal insufficiency
Secondary HPT
renovascular disease
Cushing's syndrome
ARTERIAL STENOSIS
hyperaldosteronism
renal parenchymal disease
how to measure BP
sphygmomanometer
electric BP sets
a significant factor of
IHD
CHF
stroke
arterial aneurysm
end stage renal disease
Management of HPT
Life modifications
Exercise 150mins/week
Alcohol limit
21units/week man
14 units/week women
Diet, sodium intake, one quarter teaspoon
Stop smoking
Pharmacological/Meds
Prehypertension
when systolic BP is 120-139mmHg and diastolic is 80-89mmHg
Definition
hypertension is high blood pressure when systemic BP is higher than 140/90 mmHg
Basic abt BP
systolic-1st number represent
P in blood vessels when heart contract/beats
diatolic- 2nd number represent
P in blood vessels when heart rest between beats
Normal BP- < 180/90mmHg
Perioperative hypertension
hypertension occur during major surgery
perioperative cause of HPT
hypoxia
hypercarbia
light anaethesia
exaggerated response to anesthesia
(hypotension)
implications of hypertensive disease in surgical pt
intraoperative instability are assoc. with peri & postoperative CV events
fluid overload
pain
vasopressors
surgical effects
manipulations from laryngoscopy & surgery
(hypertension)
malignant hyperthermia
Diabetes Mellitus
definition
chronic
, metabolic disorder characterized by
elevated blood glucose level
resulting from insulin deficiency or intolerance
how to diagnosed?
by random plasma glucose .>11.1mmol/l AND
fasting glucose >7.0mmol/l
Types
DM Type 1/Insulin dependent
destruction of beta cells in the islets of Langerhan of pancreas with insulin deficiency
Mx
intraop
anesthesia determined by pt physiology & surgical requirements
2 hourly potassium monitoring-keep btwn 3.5-4.5 mmol/L
setup additioonal IV for resuscitaion fluids
hourly glucose monitoring- keep btwn 5-10mmol/L
postop
continue glucose/potassium/insulin regime until pt can take orally
oral medictaion with first meal
allow for pain resulting in increase insulin requirements
Pre-op
anti aspiration prohylaxis
initiate glucos/potassium/insulin regime after commencing NBM
NBM for 6hrs prior to sugery
measure capillary glucose hourly until operation
aim to keep blood glucose level at 5-10mmol/L
young onset
autoimmune
DM Type 2/Non-insulin dependent
reduced inslulin secretion and insulin resistance
older onset assoc. with obesity
surgical management
restart oral hypoglycemic with first meal
hourly glucose monitoring
aim to keep within 5-10mmol/L
beta cells of Islets of Langerhans produced insulin,
insulin convert glucose => glycogen
NORMAL BLOOD GLUCOSE LEVEL: 5mmol/l
Factors Adversely Affecting Diabetic
Control Perioperatively
anaesthetic drugs
infection
starvation
metabolic response to trauma
secretion of hormones stress
glucagon
GH
cathecolamines
cytokines
cortisol
decrease insulin secretion
peripheral insulin resistance
increase metabolism
hyperglycemia
lipolysis
gluconeogenesis, glycogenolysis
protein breakdown
anxiety
disease underlying need for surgery
other drugs; steroids
metabolic response to surgery and diabetes
hypoglycemia
develop perioperatively due to
residual effects
of preoperative long acting oral hypoglycemic agent/insulin
exacerbated by
preoperative fast
or insufficient insulin administration
counter regulatory mechanism, maybe defective due to autonomic dysfx
dangerous in anaesthetized or neuropathic pt sebab sign maybe absent
Mx: dextrose and monitor glucose level
hyperglycemia
secretion of glucagon, cortisol & adrenaline
neuroendocrine respond to trauma
cause osmotic diuresis -> difficult to determine volume status -> dehydration & organ hypoperfusion -> increased risk of UTI -. increase infection rate
results in hyperosmolality with hyperviscocity, thrombogenesis & cerebral edema
Mx: frequent blood glucose measurement & administer insulin
ketoacidosis
in pt with severe catabolic state & insulin deficiency
most common in type 1 pt
characterised by hyperglycemia, hyperosmolarity, dehydration, excess ketine body production
underlying complications of diabetes & surgery
cardiac complications
CAD
HOT
IHD
must be considered as being at high risk for MI
renal complications
renal dysfunction
Urinary infetcion
nervous system
orthopedic
Small Joint Disease
immune complications
principles of managing diabetics during surgery
why must manage hyperglycemia?
increase risk of ischemic myocardial injury by decreasing coronary collateral blood flow
increase glucose cause reduce vessels elasticity, reduce blood flow & O2, increase BP (hypertension), damage to vessels
**HOW TO MANAGE? tight blood glucose control during perioperative period
PREOPERATIVE ASSESSMENT
thorough history & physical exam.
Lab investigation
blood glucose
BUN
HbA1c
K+
proteinuria
creatinine
ketones
PREOPERATIVE MANAGEMENT
admit ASAP prior to surgery
avoid long acting glucose lowering agents
glibenclamide
chlorpropamide
ultralente insulins
avoid metformin
closely monitor blood glucose levels
test urine evry 8hrs for ketones
aim for blood glucose of 5-10mmol/L
place first on morning operating list if possible
anaethesia management for pt with hypertensive
perioperative
review drug being used
evaluate evidence of end organ damage
Lab investigations
Pre-operative assessment
for hpt
acceptibility for surgery
CVS; 12 lead ECG, CXR
Renal: serum urea, crweatinint, electrolyte
determine adequacy of blood control
blood pressure control assessment
history of HPT; ONSET, AGE, investigation to rule out secondary cause
BP record/trend-postrual hypotension
medication history;type, pt's compliance
continue drugs
postoperative
maintain monitoring of hemodynamic
intraoperative
anticipate exaggerate BP response to anesthetic drug
limit duration of direct laryngoscopy
administer drugs to reduce SNS response
lignocaine
esmolol
fentanyl
consider invasive blood pressure monitoring (arterial cannulation)
monitor myocardial ischemia
review drug records
to determine whether there any difficulties with intubation or anesthetics