ANESTESIA DENGAN DM

PERIODE 25 MARET – 27 APRIL 2019

Maharani Sekar Ningrum
Rosy Osiana
Zafira Pringgoutami

KEPANITERAAN KLINIK BAGIAN ANESTHESIOLOGI

Perceptor:
DAN TERAPI INTENSIF RUMAH SAKIT UMUM dr Wirawan Anggorotomo,
DAERAH ABDUL MOELOEK Sp. An
2019
TINJAUAN PUSTAKA
ANATOMY
 ANATOMY

Sel endokrin pankreas yang terbanyak adalah sel β, tempat sintesis dan sekresi insulin, dan sel α
yang menghasilkan glukagon. Sel D, yang lebih jarang adalah tampat sintesis somatostein
(Sherwood, 2009).
PHYSIOLOGY
Adults normally secrete approximately 50
units of insulin each day from the ß cells of
the islets of Langerhans in the pancreas

The rate of insulin secretion is primarily

determined by the plasma glucose
concentration
 Effects of insulin

Effects on liver Anabolic

• Promotes glycogenesis
• Increases synthesis of triglycerides, cholesterol, and VLDL
• Increases protein synthesis
• Promotes glycolysis
Anticatabolic
• Inhibits glycogenolysis
• Inhibits ketogenesis
• Inhibits gluconeogenesis

Effects on muscle Anabolic

• Increases aminoacid transport
• Increases protein synthesis
Anticatabolic
• Increases glucose transport
• Enhances activity of glycogen synthetase
• Inhibits activity of glycogen phosphorylase

Effects on fat Promotes triglyceride storage

• Induces lipoprotein lipase, making fatty acids available for absorption into fat cells
• Increases glucose transport in to fat cells, thus increasing availability of a
glycerolphosphate for triglyceride synthesis
• Inhibits intracellular lipolysis
 Diagnosis and classification of
DIABETES MELLITUS diabetes mellitus
Diagnosis (based on blood glucose level)
Fasting 126 mg/dL (7.0 mmol/L)
Glucose tolerance test 200 mg/dL (11.1
Diabetes mellitus is characterized mmol/L)
by hyperglycemia and glycosuria Classification
arising from impairment of Type 1 (juvenile) Absolute insullin
carbohydrate metabolism deficiency secondary to
immune-mediated or
idiopathic causes
The diagnosis is based on an Type 2 Onset in childhood or
adulthood secondary to
elevated fasting plasma glucose insulin resistance (reative
greater than 126mg/dL or insulin insensitivity)
glycated hemoglobin (HbA1c) of Gestasional Onset of disease during
6.5% or greater. pregnancy; may or may
not persist postpartum
Three life-threatening acute
complications of diabetes
• Diabetic ketoacidosis (DKA),
• Hyperosmolar nonketotic coma,
• Hypoglycemia
ANESTHETIC CONSIDERATIONS

Preoperative Postoperative

Intraoperative
PREOPERATIVE
Abnormally elevated • Poor control of blood glucose over time.
• Greater risk for perioperative hyperglycemia, perioperative
hemoglobin A 1c complications, and adverse outcomes.

• uncover cardiac enlargement, pulmonary vascular congestion, or

Chest radiograph pleural effusion, but is not routinely indicated.

• increased incidence of ST-segment and T-wave-segment

abnormalities
ECG • Myocardial ischemia or old infarction may be evident on an ECG
despite a negative history.
Diabetic patients with hypertension have a 50%
likelihood of coexisting diabetic autonomic
Neuropathy. Reflex dysfunction of the autonomic
nervous system may be increased by old age,
diabetes of longer than 10 years’ duration, coronary
artery disease, or β-adrenergic blockade.

Diabetic autonomic neuropathy may limit the patient’s

ability to compensate (with tachycardia and increased
peripheral resistance) for intravascular volume
changes and may predispose the patient to
cardiovascular instability (eg, postinduction
hypotension) and even sudden cardiac death.

The incidence of perioperative cardiovascular Autonomic dysfunction contributes to delayed gastric

instability appears increased by the concomitant use
emptying (diabetic gastroparesis).
of ACE-inhibitors or ARB.
Premedication with a nonparticulate antacid and
metoclopramide is often used in an obese diabetic
patient with signs of cardiac autonomic dysfunction.
 • manifested first by proteinuria and later by
Diabetic renal elevated serum creatinine
dysfunction • most patients with type 1 diabetes have
evidence of kidney disease by 30 years of age.

• should be assessed preoperatively in diabetic

Temporomandibular patients to reduce the likelihood of
joint and cervical unanticipated difficult intubations.
spine mobility • Chronic hyperglycemia can lead to glycosylation
of tissue proteins and limited mobility of joints.
INTRAOPERATIVE The goal of intraoperative blood glucose management is to avoid
hypoglycemia while maintaining blood glucose below 180 mg/dL.

Attempting to maintain strict euglycemia is imprudent; “loose” blood glucose control (>180 mg/dL)
also carries risk.

Severe hyperglycemia may worsen neurological outcome following an episode of cerebral

ischemia and may compromise outcome following cardiac surgery or after an acute myocardial
infarction.

A benefit of true “tight” control (<150 mg/dL) during surgery or critical illness has not yet been
demonstrated convincingly and in some studies has been associated with worse outcome than
“looser” control (<180 mg/dL).

Lack of consensus regarding the appropriate target for blood glucose has not prevented
perioperative glucose management from becoming yet another indicator of so-called “quality”
anesthetic care.
Management regimens for insulin-dependent diabetic patients.

the patient receives a usually half of the total morning insulin dose in the form
of intermediate-acting insulin before surgery along with an infusion of 5%
dextrose solution (1.5 mL/kg/h).

Absorption of subcutaneous or intramuscular insulin depends on tissue blood

flow, and can be unpredictable during surgery.

Dedication of a small-gauge intravenous line for the dextrose infusion prevents

interference with other intraoperative fluids and drugs.

Supplemental dextrose can be administeredif the patient becomes

hypoglycemic (<100 mg/dL).

An alternative method is to administer regular insulin as a continuous infusion.

The advantage of this technique is more precise control of insulin delivery than
can be achieved with a subcutaneous or intramuscular injection of NPH insulin,
particularly in conditions associated with poor skin and muscle perfusion.
1 U = lowers plasma glucose by 25-30 mg/dl.
 If the patient is taking an oral hypoglycemic agent preoperatively rather than
Oral Hypoglicemic Agents? insulin, the drug can be continued until the day of surgery. However,
sulfonylureas and metformin have long halflives and many clinicians will
discontinue them 24–48 h before surgery.

They can be started postoperatively when the patient resumes oral intake.
Metformin is restarted if renal and hepatic function remain adequate. The
Many patients maintained on oral antidiabetic effects of oral hypoglycemic drugs with a short duration of action can be
agents will require insulin treatment during the prolonged in the presence of kidney failure.
intraoperative and postoperative periods.

which increases insulin

requirements.

Each of these contributes

to stress hyperglycemia,

The stress of surgery

causes elevations in
counterregulatory
hormones (eg,
catecholamines,
glucocorticoids, growth
hormone) and infl
ammatory mediators such
TNF and interleukins.
Monitor plasma glucose levels frequently!

Patients receiving insulin infusions intraoperatively

may need to have their glucose measured hourly.

Bedside glucose meters are capable of determining

the glucose concentration in a drop of blood
obtained from a fi nger stick (or withdrawn from a
central or arterial line) within a minute.
POSTOPERATIVE
Close monitoring of blood
glucose must continue
postoperatively, especially
the progression of stress
hyperglycemia in the
recovery period.

There is considerable
patient-topatient variation
in onset and duration of
action of insulin
preparations
ANALISA KASUS
KEPANITERAAN KLINIK BAGIAN ANESTHESIOLOGI
DAN TERAPI INTENSIF RUMAH SAKIT UMUM PERIODE 25 MARET-
DAERAH ABDUL MOELOEK 27 APRIL 2019
2019