View
1
Download
0
Category
Preview:
Citation preview
Anesthetic Management of
Diabetic Child
Essay
Submitted for Fulfillment of Master Degree in Anesthesiology
By
Mohammed Gomaa Sobhy M.B.B.CH
Faculty of Medicine, Benha University
Under Supervision Of
Prof.Dr.Hamdy Hassan Eliwa Professor of Anesthesiology and Intensive Care
Faculty of Medicine
Benha University
Dr.Dina Hosny Abd El Hamid Lecturer of Anesthesiology and Intensive Care
Faculty of Medicine
Benha University
Faculty of Medicine
Benha University
6103
I
Abstract
n addition to recognizing the relevant differences among diabetes
treatment regimens, pediatric anesthesiologists must also consider
a child‘s metabolic control, age, size, pubertal development, the
intended surgical procedure, and its length when devising a
perioperative plan.As diabetes treatment options for children
continue to change, such algorithms will need to be updated. Formal
assessment of the impact of such algorithms on clinical outcomes,
satisfaction with care, and cost of care would provide additional
insight into their revision.
Key word
DIABETIC CHILD- GAD65-IDDM- Subcutaneous -MODY
AAcckknnoowwlleeddggmmeenntt
At First, thanks to ALLAH to whom I relate any success in my life.
I wish to express my deepest thanks, gratitude and
appreciation to Prof. Dr. Hamdy Hassan Eliwa,
Professor of Anesthesiology and Intensive Care for his
meticulous supervision, kind guidance, valuable instructions
and generous help.
Special thanks are due to Dr. Dina Hosny,
Lecturer of Anesthesiology and Intensive Care for her help,
encouragement, active participation and support.
MMoohhaammmmeedd GGoommaaaa
List of Contents
Title Page No.
Introduction ................................................................................................ 1
Aim of the Work .......................................................................................... 4
Classification and Diagnosis of Diabetes Mellitus in Children .................. 5
Pathophysiology of Diabetes Mellitus ....................................................... 11
Management of Diabetes Mellitus in Children ......................................... 35
Anesthetic Management ........................................................................... 33
Summary ................................................................................................ 121
References ............................................................................................... 123
Li
st
o
f
Tabl
es
Table No. Title Page No.
Table (1): Etiologic classification of diabetes mellitus ............................. 6
Table (2): Criteria for the diagnosis of diabetes mellitus ...................... 11
Table (3): Effects of Primary Glucoregulatory Hormones ..................... 23 Table (4): Oral hypoglycemic drugs ………………………………...……. ... 36
Table (5): Guidelines for insulin dose and target blood glucose
ranges ..................................................................................... 39
Table (6): Management of hypoglycemia ............................................... 42
Table (7): Sick day management ............................................................ 43 Table (8): Factors associated with an increased risk of cerebral
oedema .................................................................................... 52
Table (9): Proposed criteria for the diagnosis of cerebral oedema ........ 54
Table (11): Factors affecting insulin absorption. ..................................... 61
Table (11): Insulin Preparations Classified According to Their
Pharmacodynamic Profiles .................................................... 78
Table (12): Broad management goals across the perioperative timeline
…………………………………..……….………………………..…85
Li
st
o
f
Figur
es
Fig. No. Title Page No.
Fig. (1): Anatomy of the pancreas ....................................................... 19
Fig. (2): Biphasic insulin response to a constant glucose
stimulus 24
Fig. (3): Postprandial glucose flux in nondiabetic controls ................. 26
Fig. (4): Pathogenesis of Type 1 Diabetes ........................................... 31
Fig. (5): Pathogenesis of type 2 Diabetes ............................................ 32
Fig. (6): Algorithm for the management of DKA in children and
adolescents ............................................................................. 46
Fig. (7): A selection of the available insulin injection devices.
These are the most commonly used injection devices,
although others are also available. Most are available
on prescription. ....................................................................... 58
Fig. (8): Appropriate insulin injection sites. ........................................ 61
Fig. (9): Lipohypertrophy. .................................................................... 61
Fig. (11): Schematic representation of the attempt to mimic
physiologic insulin release following three main meals
using a basal bolus regimen. .................................................. 73
Fig. (11): Diabetes mellitus perioperative management clinical
practice guideline ................................................................... 94
Fig. (12): Preoperative management for split-mixed insulin
regimen ................ 112
Fig. (13): Preoperative management for insulin glargine
(Lantus®) regimen .................. 113
Fig. (14): Insulin pump ........................................................................ 114
Fig. (15): Preoperative management for insulin pump ....................... 115
Fig. (16): Preoperative management for patients on oral drugs
and/or insulin. ...................................................................... 117
Fig. (17): Preoperative management for patients who require
insulin infusion during surgery ........................................... 111
Fig. (18): Intraoperative management ................................................ 115
Fig. (19): Postoperative management. ................................................. 117
Li
st
o
f
Abbreviat
ions
Abb. Full term
ADA America diabetes association
CGMS Continuous glucose monitoring system
DKA Diabetic ketoacidosis
DM Diabetes mellitus
DPP-4 Dipeptidyl peptidase-4
FPG Fasting plasma glucose
GA General anesthesia
GAD65 Glutamic acid decarboxylase
GIP Glucose-dependent insulin tropic peptide
GLP Glucagon-like peptide
GWB2 Glucowatch biographer
HBGM Home blood glucose monitoring
HgbA1c Glycosylated hemoglobin
HLA Human leucocyte antigen
IAA Insulin autoantibodies
ICA Islet cell autoantibodies
IDDM Insulin-dependent diabetes mellitus
IFG Impaired fasting glycemia
IGT Impaired glucose tolerance
MODY Maturity onset diabetes of youth
NPH Neutral protamine Hagedorn
OGTT Oral glucose tolerance test
SC Subcutaneous
T1DM Type one diabetes mellitus
TDD Total daily dose
Introduction
1
S
INTRODUCTION
urgical operations needing general anesthesia carry a greater
risk to the child with diabetes than to the child without diabetes.
Every such surgical procedure and anesthesia should be taken
seriously and meticulously to prevent preoperative hypoglycemia,
hyperglycemia, or electrolyte disturbance (Rhodes;et al.,6112).
The demographics describing the dramatic increase in the
number of patients with diabetes are well known. Patients with
diabetes require surgical procedures more frequently and have
longer hospital stays than those without the condition . The presence
of diabetes or hyperglycaemia in surgical patients has been shown to
lead to increased morbidity and mortality, with perioperative
mortality rates up to 505 greater than the non-diabetic population
(Dhatariya;et al.,6106).
The reasons for these adverse outcomes are multifactorial, but
include : failure to identify patients with diabetes or hyperglycaemia,
multiple co-morbidities including microvascular and macrovascular
complications, complex polypharmacy and insulin prescribing
errors, increased peri-operative and postoperative infections,
associated hypoglycaemia and hyperglycaemia, a lack of, or
inadequate, institutional guidelines for management of inpatient
diabetes or hyperglycaemia and inadequate knowledge of diabetes
Introduction
2
and hyperglycaemia management amongst staff delivering care
(Rayman G,6102).
Management of glycemic levels in diabetic patients is critical,
as persistent hyperglycemia may lead itself to a number of
complications including cardiovascular disease, nephropathy,
retinopathy, neuropathy, and various foot pathologies (Diabetes
Care,6101).
Diabetes leads to increased morbidity and length of stay of the
surgical patient. The perioperative mortality rate is reported to be up
to 505 higher than that of the population without diabete (Frisch;et
al.,6101).
Surgical procedures may result in a number of metabolic
perturbations that can alter normal glucose homeostasis. The
resulting hyperglycemia due to abnormal glucose balance is a risk
factor for postoperative sepsis, endothelial dysfunction, cerebral
ischemia, and impairedwound healing. In addition, the stress
response may also cause other diabetic pathologies including
diabetic ketoacidosis (DKA) or hyperglycemic hyperosmolar
syndrome (HHS) during surgery or postoperatively (Lee;et
al.,6101).
In 2002, the total child population of the world (1-14
years) was estimated to be 1.1 billion, of whom 0.02% have
diabetes. This means that approximately 4404000 children around
the world have
Introduction
3
diabetes with 204000 new cases diagnosed each year (Diabetes
Atlas,6113).
Recent estimates indicate there were 121 million people in the
world with diabetes in the year 2000 and this is projected to
increase to 366 million by 2030 (Wild;et al.,6111).
The American Diabetes Association (ADA) estimated the
national costs of diabetes in the USA for 2002 to be $US 132
billion, increasing to $US 192 billion in 2020 (Diabetes care,6110).
Goals of anesthetic management of diabetic child are to
minimize physiological stress, to maintain euglycemia, to avoid
ketoacidosis and to minimize the risk of postoperative infection
(Can J Diab,6110).
Anesthesiologist must carefully consider not only the
pathophysiology of the disease, but also each child's specific
diabetes treatment regimen, glycemic control, child metabolic state,
age, pubertal development, intended surgery and its length, and
anticipated postoperative care when devising an appropriate peri-
operative management (Glister and Vigersky,6110).
Optimal management should maintain adequate hydration and
near to normal glycemic control, while minimizing the risk of
hypoglycemia. The stress of surgery may cause acute
hyperglycemia, which increases the risk of postoperative infection
(Van den berghe;et al.,6110).
4
Aim of the Work
T
AIM OF THE WORK
he aim of our study is to discuss the proper anesthetic
management of a diabetic child to maintain euglycemia and
minimize the physiological stress of surgery, thus avoiding the
possible complication in the form of hyperglycemia, hypoglycemia
and ketoacidosis.
5
Chapter (1) Classification and Diagnosis of Diabetes Mellitus in Children
D
CLASSIFICATION AND DIAGNOSIS
OF DIABETES MELLITUS IN CHILDREN
Definition
iabetes is a multisystem disorder caused by a relative or
absolute lack of insulin. The prevalence of diabetes is
approximately 2%. The majority (15%) have type 2 diabetes.
With increasing obesity, reduced exercise and alterations in dietary
habits, the prevalence of diabetes is increasing. For every case of
diagnosed type 2 diabetes, there is another undiagnosed individual
(Sivakumar
and Salim,6102).
Diabetes is diagnosed in the presence of either a blood glucose
concentration of 11.1mmol/L [200 mg/dL] or a fasting glucose
concentration of 2mmol/L [126mg/dL]. The diagnosis of diabetes
when symptoms are present is usually straightforward and a glucose
tolerance test is rarely needed. Glucose tolerance testing may be
indicated following the identification of a borderline blood glucose
concentration (e.g. in the sibling of a child with diabetes, or in children
with disorders such as cystic fibrosis predisposing to diabetes which, in
the early stages, may be asymptomatic) (Lowes and Gregory,6111).
Diabetes is a heterogeneous condition which may be classified
on the basis of pathogenesis. Type 1 diabetes is the most common
form of diabetes in children (Lowes and Gregory,6111).
6
Chapter (1) Classification and Diagnosis of Diabetes Mellitus in Children
Classification
Recent advances in knowledge of the etiology and pathogenesis
of DM has led to revised classifications. The changes have been made
in an attempt to describe diabetes on the basis of the pathogenic
process that leads to hyperglycemia, as opposed to the criteria such as
age of onset or type of therapy (Powers,6110).
Table 1 presents a recent classification of the pediatric
population (Green,6116).
Table (0): Etiologic classification of diabetes mellitus (Alberti;et
al.,0999).
Type 0 diabetes (β-cell destruction, usually leading to absolute insulin
deficiency) 1. Immune mediated
2. Idiopathic
Type 6 diabetes (may range from predominantly insulin resistance
with relative insulin deficiency to a predominantly secretory defect
with insulin resistance) Other specific types
0. Genetic defects of β-cell function 1. Chromosome 12, HNF-1α (MODY3) 2. Chromosome 2, glucokinase (MODY2)
3. Chromosome 20, HNF-4α (MODY1)
4. Chromosome 13, insulin promoter factor-1 (IPF-1; MODY4)
5. Chromosome 12, HNF-1β (MODY5)
6. Chromosome 2, NeuroD1 (MODY6)
2. Mitochondrial DNA 1. Others
6. Genetic defects in insulin action
1. Type A insulin resistance
2. Leprechaunism
7
Chapter (1) Classification and Diagnosis of Diabetes Mellitus in Children
3. Rabson-Mendenhall syndrome
4. Lipoatrophic diabetes
5. Others
0. Diseases of the exocrine pancreas
1. Pancreatitis
2. Trauma/pancreatectomy
3. Neoplasia
4. Cystic fibrosis
5. Hemochromatosis
6. Fibrocalculous pancreatopathy 2. Others
1. Endocrinopathies 1. Acromegaly
2. Cushing's syndrome
3. Glucagonoma
4. Pheochromocytoma
5. Hyperthyroidism 6. Somatostatinoma
2. Aldosteronoma
1. Others
2. Drug or chemical induced 1. Vacor
2. Pentamidine
3. Nicotinic acid 4. Glucocorticoids
5. Thyroid hormone
6. Diazoxide
2. β-adrenergic agonists
1. Thiazides
9. Dilantin
10.γ-
Interferon
11.Others
3. Infections
1. Congenital rubella
2. Cytomegalovirus
3. Others
7. Uncommon forms of immune-mediated diabetes 1. ―Stiff-man‖ syndrome
2. Anti-insulin receptor antibodies
3. Others
8
Chapter (1) Classification and Diagnosis of Diabetes Mellitus in Children
8. Other genetic syndromes sometimes associated with diabetes
1. Down syndrome
2. Klinefelter syndrome
3. Turner syndrome 4. Wolfram syndrome
5. Friedreich ataxia
6. Huntington chorea
2. Laurence-Moon-Biedl syndrome
1. Myotonic dystrophy
9. Porphyria 10. Prader-Willi syndrome
11.Others
9. Gestational diabetes mellitus
Type 1 diabetes (insulin-dependent diabetes mellitus, IDDM)
accounts for 905 of cases in children. It is by far the most common
metabolic abnormality in young people and its onset is usually seen
in late childhood and early adolescence. Patients present with
hyperglycemia, ketoacidosis and are reliant on insulin. Early onset of
type 2 diabetes (noninsulin-dependent diabetes mellitus) is very rare
in childhood and has previously been reported to account for 2–35
of cases (Pinhas-Hamiel;et al.,0993).
However, recent studies have shown the prevalence of this
disorder to be increasing. This may be related to the increasing
prevalence of obesity in children (Glaser,0997).
Down‘s, Turner‘s and Kleinfelter‘s syndromes are associated
with the premature development of diabetes. Diseases affecting the
exocrine pancreas can also eventually result in glucose intolerance.
In children with cystic fibrosis, there is a 2.65 incidence of diabetes
under 11 years of age. Congenital infections such as rubella greatly
9
Chapter (1) Classification and Diagnosis of Diabetes Mellitus in Children
increase the risk of DM and endocrinopathies. Other causes of
pediatric hyperglycemia include genetic defects in beta cell function
and in insulin action, growth hormone secreting tumors and
Cushing‘s syndrome, all of which are rare but essentially produce a
hyperglycemic picture (Kosch;et al.,6110).
Incidence
The incidence of type 1 diabetes varies within the UK. In
England and Wales, 12 per 100 000 children under 16 years
develop diabetes each year and, in Scotland 25 per 100 000 per
year (Green,6116).
There are approximately 29.1 million people with diabetes in
the United States (roughly 9.35 of the total population). Of these
29.1 million cases, around 225 or 1.1 million cases are
undiagnosed. Furthermore, a study funded by the World Health
Organization (WHO) found that estimated 342 million people
worldwide have diabetes. Between 2010 and 2030, a 695 increase
in the number of adults with diabetes in developing countries and a
205 increase in developed countries are predicted (Danaei;et
al.,6100).
Diagnostic criteria for diabetes in childhood
Diabetes in children usually presents with the characteristic
symptoms of polyuria, polydipsia and weight loss, in association
with glycosuria and ketonuria. In its most severe form ketoacidosis
Chapter (1) Classification and Diagnosis of Diabetes Mellitus in Children
11
or, rarely, a non-ketotic hyperosmolar state may develop and lead to
stupor, coma and, without treatment, death. The diagnosis is usually
confirmed quickly by measurement of a markedly elevated blood
glucose level. If ketones are also present in blood or urine, treatment
is urgent. Waiting another day to confirm the hyperglycaemia is
dangerous as ketoacidosis can evolve rapidly (Albert;et al.,0999).
In the presence of mild symptoms, the diagnosis of diabetes
should never be made on the basis of a single abnormal blood
glucose value. Diagnosis may require continued observation with
fasting and/or 2-hour postprandial blood glucose levels and/or an
oral glucose tolerance test (OGTT) (Table 6). In the absence of
symptoms of diabetes, hyperglycaemia detected incidentally or
under conditions of acute infection, trauma, circulation or other
stress may be transitory and should not in itself be regarded as
diagnostic of diabetes (Diabetes Care,6117).
Table (6): Criteria for the diagnosis of diabetes mellitus
(Diabetes Care,6117).
- Symptoms of diabetes plus casual plasma glucose concentration ≥11.1
mmol/L (200 mg/dL) (Casual is defined as any time of day without
regard to time since last meal.)
or
- Fasting plasma glucose ≥2.0 mmol/L (≥126 mg/dL) (Fasting is
defined as no caloric intake for at least 1 h.)
or
- Two-hour post-load glucose ≥11.1 mmol/L (≥200 mg/dL) during an
OGTT
Chapter (1) Classification and Diagnosis of Diabetes Mellitus in Children
11
The test should be performed as described by WHO [1], using a
glucose load containing the equivalent of 25 g anhydrous glucose
dissolved in water or 1.25 g/kg of body weight to a maximum of 25 g.
An OGTT should not be performed if diabetes can be
diagnosed using fasting and random or postprandial criteria, as
excessive hyperglycaemia can result. It is rarely indicated in making
the diagnosis of type 1 diabetes mellitus in childhood and
adolescence. If doubt remains, periodic retesting should be
undertaken until the diagnosis is established. In the absence of
unequivocal hyperglycaemia with acute metabolic decompensation,
these criteria should be confirmed by repeat testing on a different
day (Alberti;et al.,0999).
Impaired glucose tolerance and impaired fasting glycaemia
Impaired glucose tolerance (IGT) and impaired fasting
glycaemia (IFG) are intermediate stages in the natural history of
disordered carbohydrate metabolism between normal glucose
homeostasis and diabetes. IFG and IGT are not interchangeable and
represent different abnormalities of glucose regulation; IFG is a
measure of disturbed carbohydrate metabolism in the basal state,
whilst the IGT is a dynamic measure of carbohydrate intolerance
after a standardized glucose load (Diabetes Care,6117).
Patients with IFG and/or IGT are now referred to as having
‗pre-diabetes‘, indicating their relatively high risk for development
of diabetes (Hoerger;et al.,6111).
Chapter (1) Classification and Diagnosis of Diabetes Mellitus in Children
12
Pre-diabetes can be observed as an intermediate stage in any of
the disease processes. IFG and IGT may be associated with the
metabolic syndrome, which includes obesity (especially abdominal
or visceral obesity), dyslipidaemia of the high-triglyceride and/or
low-high-density lipoprotein type and hypertension (Alberti;et
al.,6112).
Individuals who meet criteria for IGT or IFG may be
euglycaemic in their daily lives as shown by normal or near-normal
glycated haemoglobin levels, and those with IGT may manifest
hyperglycaemia only when challenged with an OGTT. Recently, the
European Diabetes Epidemiology Group has recommended revising
the lower cut-off for IFG back to 6.1 mmol/L from the current value
of 5.6 mmol/L due to the two- to fivefold increase in prevalence of
IFG across the world (60)
but the American Diabetes Association
(ADA) continues to recommend 5.6 mmol/L as the cut-off point for
normal FPG (Forouhi;et al.,6113).
Categories of fasting plasma glucose (FPG) are defined as
follows (Diabetes Care,6117):
- FPG <5.6 mmol/L (100 mg/dL) = normal fasting glucose
- FPG 5.6–6.9 mmol/L (100–125 mg/dL) = IFG
- FPG≥2.0 mmol/L (126 mg/dL)=provisional diagnosis of
diabetes.
Chapter (1) Classification and Diagnosis of Diabetes Mellitus in Children
13
The corresponding categories for stimulated plasma glucose
when the OGTT is used are as follows:
- 2-hour post-load glucose <2.1 mmol/L (140 mg/dL) =
normal glucose tolerance
- 2-hour post-load glucose 2.1–11.1 mmol/L (140–199 mg/dL)
= IGT
- 2-hour post-load glucose ≥11.1 mmol/L (200 mg/dL)
=provisional diagnosis of diabetes (The diagnosis must be
confirmed, as described above).
Epidemiology of T1DM
Approximately 50–605 of individuals with T1DM are
diagnosed before the age of 15 years. In most Western countries,
T1DM accounts for over 905 of childhood and adolescent diabetes.
However, T2DM is becoming more common and it accounts for a
significant proportion of youth-onset diabetes in certain at-risk
populations (Pinhas-Hamiel and Zeitler,6112).
T1DM incidence varies greatly between different countries,
within countries, and between different ethnic populations.
Epidemiological incidence studies define the ‗onset of T1DM‘ by
the date of the first insulin injection because of the variable time
between the onset of symptoms and diagnosis. Annual incidence
rates for childhood T1DM (0–14 yr age group) comparing different
countries of the world (0.1–43.911004000). Gender differences
in
Chapter (1) Classification and Diagnosis of Diabetes Mellitus in Children
14
incidence are found in some, but not all, populations (Diabetes
Med,6113).
Incidence rates show a close correlation with the frequency of
human leucocyte antigen (HLA) susceptibility genes in the general
population of white Caucasian ancestry; this locus confers
approximately 505 of the genetic susceptibility to T1DM
(Barker,6113).
In countries where the incidence of T1DM is extremely low,
HLA associations are different from those in white Caucasians. In
addition, a unique, slowly progressive form of T1DM is found in
Japan (Forouhi;et al.,6113).
Migrating populations may exhibit diabetes incidence rates
closer to those of their new country compared with their country of
origin, although this is not universally the case, suggesting that the
interplay between genetics and environmental factors is variable
(Neu;et al.,6110).
From 1995 to 1999, the average annual increase was 3.45. In
Europe the average increase was 3.25 (955 CI 2.2–3.2) from 1919
to 1999, in keeping with the increases reported in other parts of
the world (Diabetes Med,6113).
In some reports there has been a disproportionately greater
increase in those under the age of 5 years. The rising incidence is
unlikely to have a strong genetic basis, as it has occurred over too
Chapter (1) Classification and Diagnosis of Diabetes Mellitus in Children
15
short a time period. Possible explanations include increased
exposure to infections and wealth-related factors, such as lifestyle
and nutrition (Betts;et al.,6112).
A seasonal variation in the presentation of new cases is well
described, with the peak being in the autumn and winter months.
Seasonality of birth has also been described in some countries,
suggesting a perinatal environmental trigger. Higher incidence rates
have been found in countries with colder climates and in colder areas
of large nations, such as China (Laron;et al.,6112).
Despite familial aggregation, there is no recognisable pattern
of Mendelian inheritance. The risk of diabetes to an identical twin of
a patient with T1DM is about 365 and for a sibling the risk is
approximately 45 by age 20 years and 9.65 by age 60 years,
compared with 0.55 for the general population. The risk is higher in
siblings of probands diagnosed at younger age. T1DM is two to
three times more common in the offspring of diabetic men (3.6–
1.55) compared with diabetic women (1.3–3.65) (Harjustalo;et
al.,6112).
The age of onset of T1DM has decreased in many countries.
This has been accompanied by increased weight and linear growth
prior to the onset of diabetes and the observation that children with
T1DM are heavier and taller than their peers. These epidemiological
findings suggest that insulin resistance is responsible for overloading
the beta cell (the accelerator hypothesis), although this hypothesis
Chapter (1) Classification and Diagnosis of Diabetes Mellitus in Children
16
remains to be proven and is not universally accepted (Clarke;et
al.,6113).
When the clinical presentation is typical of T1DM (often
associated with diabetic ketoacidosis) but antibodies are absent, then
the diabetes is classified as type 1B (idiopathic). This represents
approximately 55 of T1DM in white populations but is more
common in other parts of the world, such as Japan (Diabetes
Care,6117).
Recommended