Wednesday, June 17, 2015
Saturday, June 13, 2015
Diabetes a nightmàre for anaesthesiologists
Type II DM is quite common in patients undergoing surgical procedure. Some times in quite a sizable no of patients it is detected at the time of screeing for operation. However insignificant it may be , it can cause havoc even death . Here are some case reports.
CASE 1
In earlier years of my anaesthesia practice, A relative young man of 35 yrs old was posted for Laparotomy and proceed for suspected peptic perforation. An emergency proicedure. There was no History of Diabetes from clinical examination. He was induced with Thiopentone , Scholine sequence of intubation followed by N2O+ O2 and ether anaesthesia with spontaneous respiratiobn with a boyles machine and Maggils semi open circuit was used.Additional Intra operative relaxation was provided with small doses of scholine and a deeper levels of ether anaesthesia.The intra operative monitors were BP, Pulse,Resp, Pupil and reflexes. At the end of surgery patient was extubated and sent to ward to recover slowly .The patient had gradually deeper levels of Comma and died finally. A blood sample taken and sent while comatose for blood sugar. The report received after death showed to be more than 600 mg%.
CASE 2.
A 62 yr old man underwent TURP under Spinal anaesthesia. He was mildly diabetic and received 6-4-6 units of insulin pre operatively. At the end of surgery it was observed on the table that there was still bleeding from the prostatic fossa. Surgeon wanted to inspect it again. As the effect of anaesthesia was still there , the surgeon proceeded and started to look for the bleed. And tried to remove some more prostatic t8ssue. As it took some time the pt started to be restless, So a GA was instituted with thio-Pentazocin-Midazolam and Vecuronium combination. After about 1 hr of GA there was delay in return of resp activity and fluctuations of BP, tachycardia . The patient was put on ionotropic support and ventilator. There was no facility to do bed side blood sugar estimation but with each dextrose containing solution 5 units of insulin was given. By next 4 hours pts condition detoriated , unresponsive , hypotensive and died. A blood sample collected before death for blood sugar showed the value to be 368.
CASE 3.
A 58 yr old lady relative of a doctor was posted for Lap Cholecystectomy. During preop screening she was found to be diabetic witha a random blood sugar of 230mg.
She was put on an insulin subcutaneoußly at a titrating doses of insulin by evening her blood sugar was 98. As planned she underwent Lap Chol with pre op blood sugar of 135. The operation was uneventful so also recovery. Normal protocol for fluid therapy analgesic was followed. Post op blood sugar control was not veŕy rigid. 8 hrs post operative the patient became restless then tachycardia and hypotension. All support was given by the doctor relative . By next 6 hrs the pt became unresponsive , slowly collapsed and died at mid night.
CASE 4.
A 42 yr old man suffer3d from pelcic fracture. He was type II mildly diabetic . Was converted to insulin before surgery with a dose of 8-8-10 units. The surgery 2as supposed to last for 6 to 8 hrs. An combined spi al epidural was planned and adminstered. During the course of surgery bedside blood sugar was monitored and insulin was being given into the i v drip which varied from 6 to 10 units. The patient was sedàt2d with Midazolam of 5 mg1Inspite of insulin the blood sugar remained above 200mg. It was also observed the patient is developing tachycardia and mild hypotension around 90~100 mmHg. There was no significant blood loss. A combination of RL, DNS , Ns was being aďminstered. It was a matter of concern when the heart rate increased beyond 160. At this point an ABG (arterial blood gas) analysis was done It showed metabolic acidosis with a pH of 7.24 and a blood sugar of 285 and K 3.1. Now the patient was tretaed in line with diabetic keto acidosis. With 1.5 litres of NS. 40 mEq K and 50 ml of Sodi bicarbonate and 30 u its of insulin over the nexþ hour brought things under contŕol. The patient slowly revovered with reďuced heart rate and stable CVStatus IN NEXT 8 HRS TIME.
CASE 5
A 50 yeaŕ old man was undergoing lumber disecþomy/ root decompression for radicular pain in left limb. He was hefty with a body wt of 95 kg . Had a slightly raised blood sugar which is detected during screeing. He was converted to insulin therapy before opn and received 8-6-10 units of insulin regular and mixtard combination. Pre op blood sugar on the morning od surgery was 112 mg. The patient was induced with Midazolam 5mg Propofol 130 mg Pentazocin 30 mg and intubated with scholine and veron 6 mg aded to continue ventilation. Pt was positioned prone and operation started. Abour 20 mins through operation pt started sweating. There was no apparent reason. No hypoxia, Sodalime canister was warn. There was not much tachycardia. Hypoglycemia was thought of and a 5% DNS started . A blood sample for HGT showed to be 168. The blood was taken when the Glucose containing solution was on. There fore the next bottle was added with 8 units of soluble insulin . An injecgtion of atropine was given I/v. In next 20 mins or so the sweating decreased slowly and the patient was continued to be given NS 1000 ml to compensate for profuse sweating estimated to be not less than 1.5 lit.
The procedure was completed with release of pr on root and the patient was repositioned and reversed with prostigmine and atropine. The pt recovered completely.
CASE 6
A 68 YR OLD MAN WAS POSTED FOR cabg FOR DIFFUSE CORONARY ARTERY DISEASE .
He was diabetic but mild with daily insulin requirement of 16 units on;y
Immidiate post op period was stormy with diabetic keto acidosis and was treated accordingly. The cardio vascular instability during that period was finally diagnosed when an ABG was done and metabolic acidosis detected , which was treated accordingly wirth 1500 ml of NS, Sodi bicarb, Pottasium.and insulin infusion.
CASE 1
In earlier years of my anaesthesia practice, A relative young man of 35 yrs old was posted for Laparotomy and proceed for suspected peptic perforation. An emergency proicedure. There was no History of Diabetes from clinical examination. He was induced with Thiopentone , Scholine sequence of intubation followed by N2O+ O2 and ether anaesthesia with spontaneous respiratiobn with a boyles machine and Maggils semi open circuit was used.Additional Intra operative relaxation was provided with small doses of scholine and a deeper levels of ether anaesthesia.The intra operative monitors were BP, Pulse,Resp, Pupil and reflexes. At the end of surgery patient was extubated and sent to ward to recover slowly .The patient had gradually deeper levels of Comma and died finally. A blood sample taken and sent while comatose for blood sugar. The report received after death showed to be more than 600 mg%.
CASE 2.
A 62 yr old man underwent TURP under Spinal anaesthesia. He was mildly diabetic and received 6-4-6 units of insulin pre operatively. At the end of surgery it was observed on the table that there was still bleeding from the prostatic fossa. Surgeon wanted to inspect it again. As the effect of anaesthesia was still there , the surgeon proceeded and started to look for the bleed. And tried to remove some more prostatic t8ssue. As it took some time the pt started to be restless, So a GA was instituted with thio-Pentazocin-Midazolam and Vecuronium combination. After about 1 hr of GA there was delay in return of resp activity and fluctuations of BP, tachycardia . The patient was put on ionotropic support and ventilator. There was no facility to do bed side blood sugar estimation but with each dextrose containing solution 5 units of insulin was given. By next 4 hours pts condition detoriated , unresponsive , hypotensive and died. A blood sample collected before death for blood sugar showed the value to be 368.
CASE 3.
A 58 yr old lady relative of a doctor was posted for Lap Cholecystectomy. During preop screening she was found to be diabetic witha a random blood sugar of 230mg.
She was put on an insulin subcutaneoußly at a titrating doses of insulin by evening her blood sugar was 98. As planned she underwent Lap Chol with pre op blood sugar of 135. The operation was uneventful so also recovery. Normal protocol for fluid therapy analgesic was followed. Post op blood sugar control was not veŕy rigid. 8 hrs post operative the patient became restless then tachycardia and hypotension. All support was given by the doctor relative . By next 6 hrs the pt became unresponsive , slowly collapsed and died at mid night.
CASE 4.
A 42 yr old man suffer3d from pelcic fracture. He was type II mildly diabetic . Was converted to insulin before surgery with a dose of 8-8-10 units. The surgery 2as supposed to last for 6 to 8 hrs. An combined spi al epidural was planned and adminstered. During the course of surgery bedside blood sugar was monitored and insulin was being given into the i v drip which varied from 6 to 10 units. The patient was sedàt2d with Midazolam of 5 mg1Inspite of insulin the blood sugar remained above 200mg. It was also observed the patient is developing tachycardia and mild hypotension around 90~100 mmHg. There was no significant blood loss. A combination of RL, DNS , Ns was being aďminstered. It was a matter of concern when the heart rate increased beyond 160. At this point an ABG (arterial blood gas) analysis was done It showed metabolic acidosis with a pH of 7.24 and a blood sugar of 285 and K 3.1. Now the patient was tretaed in line with diabetic keto acidosis. With 1.5 litres of NS. 40 mEq K and 50 ml of Sodi bicarbonate and 30 u its of insulin over the nexþ hour brought things under contŕol. The patient slowly revovered with reďuced heart rate and stable CVStatus IN NEXT 8 HRS TIME.
CASE 5
A 50 yeaŕ old man was undergoing lumber disecþomy/ root decompression for radicular pain in left limb. He was hefty with a body wt of 95 kg . Had a slightly raised blood sugar which is detected during screeing. He was converted to insulin therapy before opn and received 8-6-10 units of insulin regular and mixtard combination. Pre op blood sugar on the morning od surgery was 112 mg. The patient was induced with Midazolam 5mg Propofol 130 mg Pentazocin 30 mg and intubated with scholine and veron 6 mg aded to continue ventilation. Pt was positioned prone and operation started. Abour 20 mins through operation pt started sweating. There was no apparent reason. No hypoxia, Sodalime canister was warn. There was not much tachycardia. Hypoglycemia was thought of and a 5% DNS started . A blood sample for HGT showed to be 168. The blood was taken when the Glucose containing solution was on. There fore the next bottle was added with 8 units of soluble insulin . An injecgtion of atropine was given I/v. In next 20 mins or so the sweating decreased slowly and the patient was continued to be given NS 1000 ml to compensate for profuse sweating estimated to be not less than 1.5 lit.
The procedure was completed with release of pr on root and the patient was repositioned and reversed with prostigmine and atropine. The pt recovered completely.
CASE 6
A 68 YR OLD MAN WAS POSTED FOR cabg FOR DIFFUSE CORONARY ARTERY DISEASE .
He was diabetic but mild with daily insulin requirement of 16 units on;y
Immidiate post op period was stormy with diabetic keto acidosis and was treated accordingly. The cardio vascular instability during that period was finally diagnosed when an ABG was done and metabolic acidosis detected , which was treated accordingly wirth 1500 ml of NS, Sodi bicarb, Pottasium.and insulin infusion.
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