Endocrine (Altose): DMII

Question 1

What is normal fasting glucose? What is considered pre-diabetic/diabetic fasting glucose levels?

Answer 1

Normal: <100 mg/dL

Impaired/diabetic: >126 mg/dL

Question 2

What is the etiology of DMI? What is it usually caused by?

Answer 2

Autoimmune etiology

Due to destruction of islet cells of the pancreas (functions to synthesize insulin)

Question 3

How do we prepare our Type I DM patients pre-op?

Answer 3

Instruct them not to take short-term insulin.

Instruct them to take 1/3 to 2/3 of their usual intermediate-lasting dose.

Question 4

Where is insulin produced? At what rate is it made?

How much do we usually secrete a day?

Answer 4

Beta islet cells of the pancreas

1 unit/hr at rest

40-50 U/day (Response to food, vagal stimulation, beta stim, alpha block)

Question 5

What is the effect of insulin on the moieties in our body?

Answer 5

Increases cellular uptake of glucose and potassium

Stimulates glycogen formation

Inhibits lipolysis and gluconeogenesis

Question 6

What does surgical stress do to our insulin levels?

Answer 6

It drops our insulin levels.

Release of cortisol, catecholes, and glucagon all lead to hyperglycemia because of this.

Question 7

Primary difference btwn DM I and DM II is..

How do their onsets differ?

Answer 7

DMI - no insulin production at all

DMII - insulin resistant cells or decreased insulin production (or both)

DMI = early onset

DMII = late onset

Question 8

HgbA1c is a measure of…

Answer 8

the average level of blood sugar (glucose) over the previous 3 months.

Correlates well with rate of complications

Question 9

What specific types of insulins would you withhold pre-op in diabetic patients?

Answer 9

Hold metformin (inhibits hepatic gluconeogenesis)

Hold sulfonureas (glyburide, glipizide) bc they increase beta-cell secretion of insulin

If significant interruption of caloric intake is not anticipated, many recommend no change in therapy with DMII patients.

Question 10

What are some anesthetic considerations about diabetic patients?

Answer 10

End-organ diseases

Difficult laryngoscopy due to stiff joints

Autonomic dysfunction

Positioning (more susceptible to ischemia)

Nerve injuries more likely due to poorer perfusion (regional anesthesia)

Increased risk of infection

Question 11

What is the glucose level threshold at which you would delay surgery? Postpone surgery?

Answer 11

>270 mg/dL = delay surgery until you get a better value

>400 mg/dL postpone surgery until you get pt metabolic state under control

Question 12

What happens at the onset of surgery to our glucose levels?

In diabetic patients, what glucose levels should we strive for intra-operatively?

Answer 12

Blood sugar will go up due to decreased insulin secretion from stress hormones

Shoot for 150-200 mg/dL (or <180 mg/dL according to Barash)

Note that blood sugar < 110 mg/dL leads to poorer outcomes.

Question 13

What is DKA?

Answer 13

Diabetic ketoaciosis is a state of exclusive fatty acid breakdown for energy (lipolysis) that leads to ketoacidosis

Question 14

What subtype of diabetics experience DKA?

Answer 14

Type I DM

Type II DM don’t experence DKA because only small amounts of insulin is needed to block lipolyis (and they have it whereas DMI pts dont’ have any)

Question 15

What are physiological effects of DKA?

Answer 15

Dehydration due to osmotic diuresis

Electrolyte imbalances

Anion-gap metabolic acidosis

N/V

Ileus

Question 16

If a DM pt experiences mental status changes, what is the first thing you should do?

Answer 16

Check blood sugar to rule out hypoglycemia.

THEN check ABG to rule out DKA or HNKC.

Question 17

How can we treat DKA intra-op?

Answer 17

Treat with fluid, electrolytes, and insulin.

Add some glucose when BG < 250 to prevent precipitous drop in blood glucose (which would cause hypoglycemia, the opposite end of the spectrum)

Electrolytes:

Correct N: add 1.5-2.0 mEq/dL every 100 mg/dL BG over 100

Give K (pt may be hyperkalemic, but total body K will be low)

Maintain UOP

Question 18

In a pt undergoing DKA, what is usually his/her range of blood glucose level?

Does this correlate with the severity of the acidosis?

Answer 18

300-500 mg/dL range

NO, Degree of hyperglycemia does NOT correlate with severity of acidosis

Question 19

What is the relationship between glucose and potassium?

Answer 19

K follows Glucose

Question 20

What is HNKC?

What is it characterized by?

Answer 20

HNKC: Hyperosmolar Non-Ketotic Coma

Characterized by very high BG (>600 mg/dL) with enough insulin to prevent ketosis

Question 21

What subtype of DM pts can get HNKC?

Answer 21

DMII patients.

DMI patients will get DKA instead of HNKC due to lack of any insulin.

Question 22

Symptoms of HNKC include…

Answer 22

Significant HoTN that leads to lactic acidosis

Cerebral edema –> coma, seizures

Thrombosis secondary to hyovolemia, HoTN, and hyperviscosity of blood (due to extreme dehydration)

Question 23

How do we treat HNKC?

Answer 23

Treat with a lot of fluids given at a slow rate as well as insulin infusions.

Correct over 24 hours.

Question 24

What is hypoglycemia?

Answer 24

BG of < 40-50 mg/dL

Diabetis may have symptoms at higher levels due to higher threshold for BG levels

Question 25

Symptoms of hypoglycemia include..

Answer 25

Seizures Brady HoTN Respiratory failure \*\*Almost impossible to diagnose in unconscious pt

Question 26

How can we treat hypoglycemia?

Answer 26

25g IV dextrose 1 mg IM glucagon

Question 27

Why do renal patients often have high blood glucose levels?

Answer 27

Insulin is excreted through your kidneys so renal pts have slow release of insulin into the bloodstream

Question 28

When you are administering insulin through plastic tubing, what do you need to remember?

Answer 28

It gets stuck to the plastic! Waste **20 cc's!**

Question 29

What are carcinoids?

Answer 29

Slow growing tumors that are often asymptomatic for a long period of time.

Question 30

The majority of all carcinoid tumors are found in the _______ , \_\_\_\_\_\_\_,and \_\_\_\_\_\_\_.

Answer 30

bronchus, jejunum, colon

Question 31

Carcinoid syndrome occurs in X% of carcinoid tumors.

Answer 31

X = 20

Question 32

What are the signs of Carcinoid Syndrome?

Answer 32

Acute onset of: Flushing Bronchospasm Diarrhea HTN/HoTN Arrhythmias

Question 33

What is Carcinoid Crisis? What are the signs of it?

Answer 33

A more severe condition of Carcinoid Syndrome that can be fatal if left untreated. Signs of Carcinoid Syndrome but more severe in addition to: Tachycardia Abd pain

Question 34

What causes Carcinoid Syndrome?

Answer 34

Carcinoid tumor causes release of serotonin, histamine, bradykinin, epi, NE, kallikrein

Question 35

How can we treat Carconid Synrome/Crisis?

Answer 35

Administer **somatostatin/octreotide** to reduce release of vasoactive products.

Question 36

Drugs to avoid in pts with Carcinoid Syndrome:

Answer 36

HA releasing drugs SCh Atracurium Epi Norepi Dopamine Thiopentol Isoproterenol