Strategies for managing the diabetic patient

A novel glucose-insulin infusion maintains perioperative glycaemic control through multiple transitions of care

To measure the efficacy of the Glucose-Insulin Infusion--Parkland Protocol (GIPPr) compared to subcutaneous (SC) insulin, blood glucose readings were reviewed in diabetic adults admitted for surgical intervention of a soft tissue or bone infection in Dallas, Texas. Hypoglycaemia occurred in 0.69% of readings in GIPPr-treated patients compared to 4.52% in SC-treated patients. The GIPPr maintained a higher proportion of blood glucose readings between 3.89-10 mmol/L compared to SC insulin (85.40% versus 50.68%).

Perioperative care for the older outpatient undergoing ambulatory surgery

As the number of ambulatory surgery procedures continues to grow in an aging global society, the implementation of evidence-based perioperative care programs for the elderly will assume increased importance. Given the recent advances in anesthesia, surgery, and monitoring technology, the ambulatory setting offers potential advantages for elderly patients undergoing elective surgery. In this review article we summarize the physiologic and pharmacologic effects of aging and their influence on anesthetic drugs, the important considerations in the preoperative evaluation of elderly outpatients with coexisting diseases, the advantages and disadvantages of different anesthetic techniques on a procedural-specific basis, and offer recommendations regarding the management of common postoperative side effects (including delirium and cognitive dysfunction, fatigue, dizziness, pain, and gastrointestinal dysfunction) after ambulatory surgery. We conclude with a discussion of future challenges related to the growth of ambulatory surgery practice in this segment of our surgical population. When information specifically for the elderly population was not available in the peer-reviewed literature, we drew from relevant information in other ambulatory surgery populations.

A comparison of anesthetic complications between diabetic and nondiabetic dogs undergoing phacoemulsification cataract surgery: a retrospective study

OBJECTIVE

To compare the incidence of anesthetic complications in diabetic and nondiabetic dogs undergoing general anesthesia and phacoemulsification cataract surgery.

PROCEDURE

The medical and anesthetic records of all dogs undergoing phacoemulsification cataract surgery at Davies Veterinary Specialists between 2005 and 2008 were reviewed. Anesthetic records were evaluated by an ECVAA Diplomate. Dogs for which records were incomplete were excluded. The anesthetic technique, including all drugs administered in the perioperative period, was recorded. The anesthetic complications investigated included hypotension (MAP (mmHg): >or=55 none/mild; <or=54 moderate/severe), bradycardia (<60 bpm associated with hypotension) and hypothermia (esophageal temperature <36.7 degrees C). Where hypotension was present, the method of and response to treatment was recorded. The incidence of severe hyperglycemia (blood glucose >13.75 mmol/L (250 mg/dL)) in the diabetic group was also assessed.

RESULTS

66 diabetic and 64 nondiabetic dogs were included in the study. Diabetic dogs were more likely to develop moderate and severe intraoperative hypotension than nondiabetic dogs. Forty-four percent of diabetic dogs had at least one episode of severe hyperglycemia whilst anesthetized.

CONCLUSIONS

Diabetic dogs undergoing phacoemulsification are more likely to suffer the anesthetic complications of moderate and severe hypotension than nondiabetic dogs. The increased incidence and severity of hypotension in diabetic dogs may be explained by hypovolemia secondary to hyperglycemia and resultant osmotic diuresis.

Perioperative blood glucose monitoring in the general surgical population

Several studies have shown a relationship between poor outcome and uncontrolled blood glucose (BG) in cardiac, neurosurgical, critical care, and general surgical patients. A major study showed that tight glycemic control (80-110mg/dl) was related to increased mortality. Based on evidence from controlled studies, the American Diabetes Association, and the Society of Thoracic Surgeons, maintaining intraoperative BG levels in the 140-180 mg/dl range seems appropriate. Optimization of the patient's preoperative medications and the use of insulin infusions, as well as surgical and anesthetic technique, are important factors for achieving desirable perioperative BG control. Minimizing BG variability during surgery should be part of the glycemic control strategy. Advances in real-time glucose monitoring may soon benefit hospitalized diabetes and nondiabetes patients.

Diabetes mellitus and anesthesia

Diabetes mellitus is an extremely common condition with specific associated comorbidity. Its incidence is rising. Diabetic patients have more perioperative complications than nondiabetic patients. These complications may be related to the presence of organ damage secondary to the diabetes, rather than the defects in carbohydrate metabolism themselves, or to perioperative hyperglycemia. Several new drugs are available for the treatment of diabetes, and these are associated with specific and significant side effects, and varying lengths of action with which the anesthetist should be familiar. Few data are available regarding recommendations for fasting in the presence of these newer drugs. In the postoperative period and during cardiac surgery, hyperglycemia has been shown to be detrimental, and should probably be sought and managed aggressively. The incidence of intraoperative hyperglycemia in noncardiac surgery patients is not as well-defined, nor are the effects of aggressive management.

Präoperative Dauertherapie

A large number of patients undergoing elective surgical procedures already take routine medication preoperatively. The majority of these patients use drugs for therapy of preexisting cardiovascular, pulmonary or endocrinological diseases which are independent of the planned surgical procedure. The number and type of preoperative drug therapy are correlated to age, gender and co-morbidity of the patients. Furthermore, patients with higher ASA-classes usually take more drugs, as they suffer from several medical diseases. Information about the perioperative handling of routine drug therapy is important for the planning of anaesthesia and surgery. A close cooperation of all medical specialities involved is necessary, in particular when patients take anticoagulants or other substances which should be withdrawn or replaced. This review focuses on the handling of routine preoperative medication by the anaesthesiologist in the light of available literature.