anaesthesia of the diabetic patient
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Considerations, management and a case example with anaesthetic
protocol
Anaesthesia of the Diabetic
Patient
Case details
*8 year old labrador*32kg bodyweight*Requires surgery for removal of a large
lipoma in perineal region.*Has Diabetes Mellitus and receives 10iu of
Insulin in the morning and 15iu in the afternoon.*Owner monitors the dog’s glucose at
home and feel it is under good control.
Considerations for this case*32kg = within healthy weight range for adult
labrador.*Antimicrobial protocol*Insulin medication *Monitoring of blood glucose peri-operatively*Presence of concurrent disease*Hydration status & fluid administration*Analgesia *Recovery
Diabetes Mellitus – a brief summaryType 1: Destruction of insulin-producing Beta cells in the pacreas. Most common type seen in dogs. Usually immune-mediated and may be linked with pancreatitis.Type 2: Relative insufficiency of insulin – being produced but body has become resistant. Linked to obesity and seen in older, overweight dogs. Most common type in humans and cats.
Decreased insulin relative to requirement -> blood glucose cannot enter cells -> hyperglycaemia -> energy-deficient cells -> body utilises fat stores (may lead to ketosis and hepatic lipidosis).Prone to bacterial infection and UTIs (as excess blood glucose filtered through kidneys -> glucosuria).Other clinical signs include weight loss, PU/PD, polyphagia, lethargy…
Pre-op Preparation*Withhold food for 4-6 hours *Biochemistry and haematology to assess
function of kidneys, liver and to check for signs of underlying disease.*Urinalysis (glucose, ketones, protein,
RBCs)*Take a pre-op blood glucose measurement
Measuring glycaemia
Pre, intra and post-op measurements are essential. If patient hospitalised overnight, can take several measurements and create a blood glucose or fructosamine curve to determine how well-controlled the glycaemia is. Fructosamine levels:Control Fructosamine (umol/l)Normal range 225-375Excellent 350-400Good 400-450Fair 450-550Poor >550Prolonged hypoglycaemia
<300
Glucose levels
Should aim for between 5-10 during surgery (this is average blood glucose levels for a well-controlled diabetic dog).
Control Blood glucose (mmol/l)
Hypoglycaemic <3Minimum safe range for diabetic dog
3-5
Normal target range 5-10Maximum safe range for diabetic dog
10-20
Hyperglycaemic >20
Potential Problems and what to do about them
*Hyperglycaemia – administer insulin *Hypoglycaemia – dextrose infusion (2.5% or 5%
depending on severity)* Hypotension – IV fluid bolus
- Reduce vapouriser %- +ve ionotrope eg dopamine
*Hypothermia – warm patient up!
References used* De Vries M. Diabetes mellitus and anaesthesia: dealing with its
potential problems. Veterinary Times 2011; 27 http://www.vetsonline.com/publications/veterinary-times/archives/n-41-27/diabetes-mellitus-and-anaesthesia-dealing-with-its-potential-problems.html
* Oliver JAC, Clark L, Corletto F, Gould DJ. A comparison of anesthetic complications between diabetic and nondiabetic dogs undergoing phacoemulsification cataract surgery: a retrospective study. Veterinary Ophthalmology 2010; 13
* Panti A, Bradbrook C. Clinical Conundrum. BSAVA Companion 2012* 2010 AAHA Diabetes Management Guidelines for Dogs and Cats
https://www.aaha.org/professional/resources/diabetes_management.aspx#gsc.tab=0
* http://petdiabetes.wikia.com/wiki/Blood_sugar_guidelines* http://www.caninsulin.co.uk/
Pre-medication, induction, monitoring, and recovery of a diabetic dog
Carl’s big day
Pre-op
Clinical Exam
BAR – friendly,
calm
Starved overnight
IV catheter in right
cephalic vein
Blood Glucose
Pre-anaesthetic blood work
Blood glucose
<5 mmol/l
Pre-medication – 9am
Methadone – 0.3 mg/kg IV(9.6 mg)
ACP – 0.03 mg/kg IV(0.96
mg)
Surgery
Induction drugsPropofol – 4
mg/kg IV(128 mg)
IV fluids
Hartmann’s Soln – 5
ml/kg/hr (160 ml/hr)
5% Glucose infusion - 3 ml/kg/hr (64
ml/hr)
MonitoringMonitor blood
glucose every 30-60 minutes
Goal of 8.3-14 mmol/l
Vitals
Inhaled Gas
Isoflurane – 1.5-2.5% +
oxygen
Analgesia/ Antibiosis
Augmentin – 8.75 mg/kg (280 mg) IV
every 8 hours
Meloxicam – 0.2 mg/kg
(6.4 mg) SQ
Recovery
Anaesthetic
Discontinue isoflurane. Continue
oxygen via ET tube.
Extubate normally
Blood Glucose
Monitor every 30-60 minutes until fully awake
and able to eat
Discontinue glucose infusion and give a small
meal. Continue to monitor blood glucose
Evening dinner + 15 IU insulin. Resume normal
insulin routine
Analgesia/ Antibiosis
Methadone – 0.3 mg/kg IM (9.6 mg) every 4 hours until
9am
Meloxicam – 0.1 mg/kg (3.2 mg)
PO SID for 5 days
Augmentin – 12.5 mg/kg (400 mg) PO
BID for 7 days
Any questions?
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