6.14
Endocrine Disease
Diabetes Mellitus (DM) Type II
- DM Type I covered in pediatrics on page 232
- Etiology/Risk Factors
- Genetics
- Lifestyle/diet
- Pathophysiology
- Hyperglycemia
- ↓ Insulin synthesis relative to increased tissue resistance (Figure 6.34)
- Frequent comorbidities = metabolic syndrome
- HTN
- Dyslipidemia
- Central obesity
- Peripheral neuropathy
- Distal
- Symmetric
- Often in stocking‐glove distribution
- Autonomic neuropathy
- Hypotension
- Orthostatic hypotension
- Impaired vasoconstriction
- Exercise intolerance
- Resting tachycardia
- Silent myocardial ischemia
- Intraoperative cardiovascular instability
- ↓ Immune function
- Polyuria
- ↑ Risk of coronary artery disease
- ↑ Risk of cerebrovascular disease
- Nephropathy
- Retinopathy
- Treatment
- Lifestyle/diet modifications
- Hypoglycemic agents
- Biguanides (metformin)
- Sulfonylureas
- Meglitinides
- TZDs
- GLP‐1s
- DPP‐4s
- α‐Glucosidase inhibitors
- SGLT2
- Insulin
- Bariatric surgery
- Primary Concerns
- Perioperative glucose levels
- Difficult airway
- Glycosylation of cervical vertebrae and/or body habitus may limit neck extension
- Atherosclerosis
- ↑ Risk of coronary artery disease
- ↑ Risk of CVA
- Nephropathy
- Autonomic neuropathy
- Gastroparesis
- ↑ Heart rate
- Evaluation
- Consult endocrinologist
- Blood glucose
- HbA1c
- Generally A1C ≤ 7% is target of glycemic control
- History
- Hypoglycemic episodes
- Frequency
- Whether patient is aware
- At what blood glucose level
- Hypoglycemic episodes
- Medications
- Exogenous insulin usage
- Consider BMP
- Evaluate for any sensory defects
- Evaluate autonomic neuropathy
- Check heart rate variability with deep breathing
- Presence of postural hypotension
- Evaluate for prayer sign
- If present, increased risk of difficult airway due to decreased joint mobility [110]
- Anesthesia Management
- Oral medications to continue and discontinue covered on pages 99–102
- GLP‐1 agonists markedly suppress gastric emptying and increase risk of aspiration
- Preoperative blood glucose
- Adjust if needed
- No contraindications to certain anesthetic induction or maintenance agents
- Relative contraindication to dexamethasone as may increase blood glucose postoperatively [111, 112]
- Consider rapid sequence induction if intubating
- Check blood glucose levels at least hourly
- Ideal to maintain blood glucose between 140 and 180 mg/dl [113]
- 1800 rule to calculate approximate blood glucose drop from rapid‐acting insulin
- Example: If they take 45 units of regular/fast acting a day, one unit should drop BG by ~40 mg/dl
- 1800/45 = 40
- Example: If they take 45 units of regular/fast acting a day, one unit should drop BG by ~40 mg/dl
- 1 g dextrose raises BG by ~4 mg/dl
- Stress of surgery will increase blood glucose
- Check blood glucose prior to discharge
Hyperthyroidism
- Etiology/Risk Factors
- Graves’ disease (Figure 6.35
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