Anaesthetic management of diabetes

Diabetes is a complex metabolic disorder that is increasing in incidence globally. It is the most common non-communicable disease worldwide. Diabetic patients pose a challenge to anaesthesia and surgery due to the organs and systems affected by the disease. Good glycaemic control perioperatively is essential to minimize complications. There is an increasing number of therapies to control diabetes, and this is rapidly evolving, so a multidisciplinary approach to the management of these patients is recommended, and increasingly the patients themselves should be participating in managing their diabetes as long as possible.     

Anaesthetic management of diabetes

Diabetes is a complex, chronic metabolic disorder affecting approximately 8.5% of the adult population with the number of people living with diabetes worldwide having almost quadrupled since 1980. This increase has largely been attributed to global urbanization and lifestyle changes. Diabetes affects 10–15% of the surgical population. These patients are now frequently elderly, have complex medical co-morbidities and present for both high-risk elective and emergency surgery. This multisystem disease poses a significant challenge to both anaesthesia and surgery with diabetic patients demonstrating higher morbidity and mortality rates compared to their non-diabetic counterparts. As the management of diabetes becomes more complex, it is vital that the anaesthetist, as a member of the multidisciplinary team, remains up-to-date and plays a key role in patient optimization and perioperative glycaemic control. It is crucial that good glycaemic control is maintained throughout the perioperative period as this has been shown to correlate with positive patient outcomes. Patients themselves are well experienced in managing their own diabetes and should be involved in doing so whenever possible.     

记录糖尿病日历对妊娠期糖尿病患者自我管理行为及血糖的影响

目的探讨记录"糖尿病日历"对妊娠期糖尿病患者自我管理行为及血糖的影响。方法将159例门诊妊娠期糖尿病患者按诊断先后顺序分为对照组78例,干预组81例,对照组接受常规自我管理教育,干预组接受自我管理教育后指导患者记录"糖尿病日历"。干预1个月后比较两组自我管理行为评分和血糖水平。结果 1个月后,干预组自我管理行为中饮食依从性、运动、自我血糖监测问题得分显著优于对照组(P0.05,P0.01),餐后2h血糖显著低于对照组(P0.01)。结论记录"糖尿病日历"可提高妊娠期糖尿病患者的自我管理行为,降低其血糖水平。     

Monitoring of neuromuscular block after administration of vecuronium in patients with diabetes mellitus

Background. We studied the supramaximal current for ulnar nervestimulation during electromyographic monitoring of onset andrecovery of neuromuscular block using a neuromuscular transmissionmodule (M-NMT Module, Datex-Ohmeda) in patients with Type 2diabetes undergoing anaesthesia with nitrous oxide, oxygen,isoflurane and fentanyl. Methods. Thirty-six diabetic patients were randomly assignedto a post-tetanic count (PTC) group (n=17) or train-of-four(TOF) group (n=19). In addition, 30 non-diabetic patients weredivided into control PTC (n=15) and TOF groups (n=15). Results. In the diabetic patients (diabetes PTC and diabetesTOF groups), the mean supramaximal stimulating current was significantlyhigher than in the non-diabetic patients (control PTC and TOFgroups) (50.5 (SD 14.1) vs 33.4 (6.1) mA, P<0.01). Onsetof neuromuscular block (time to disappearance of T1) after vecuronium0.1 mg kg^–1 in the diabetic patients did not differ significantlyfrom that in the non-diabetic patients (276 (77) vs 244 (44)s, P=0.055). Time to return of PTC1 did not differ significantlybetween the diabetes and control PTC groups (21.0 (12.1) vs15.7 (5.0) min, P=0.126). Times to return of T1 and T4 in thediabetes TOF group were significantly longer than in the controlTOF group (T1: 37.5 (15.2) vs 25.7 (7.6) min, P=0.01; T4: 61.4(23.7) vs 43.5 (11.4) min, P=0.01). During recovery, PTC andT4/T1 in the diabetes PTC and TOF groups were similar to thosein the control PTC and TOF groups, respectively. T1/T0 in thediabetes TOF group was significantly less than in the controlTOF group, 80–120 min after vecuronium (P<0.05). Conclusions. In diabetic patients, supramaximal current is higherthan in non-diabetic patients. After vecuronium, onset of neuromuscularblock and recovery of PTC or T4/T1 are not altered, but timeto return of T1 or T4, and recovery of T1/T0 are delayed indiabetic patients. Br J Anaesth 2003; 90: 480–6     

2型糖尿病患者有效持续运动时间的研究

目的探讨在明确糖尿病患者个体运动强度下,确定有效持续运动时间及运动方案对2型糖尿病患者糖、脂代谢的影响。方法将70例2型糖尿病患者按入院时间分为观察组和对照组各35例。观察组根据最少运动时间制定有效运动方案,对照组患者采用常规运动方法。比较两组患者空腹血糖、血脂、平均运动时间变化。结果经过4周、5周、6周锻炼后,两组空腹血糖及血脂均呈好转趋势,但两组比较,差异无统计学意义(均P0.05);观察组平均每次运动时间明显短于对照组(P0.01)。结论以最少持续运动时间的运动处方进行运动能获得与长时间锻炼同样的运动效果,有效控制2型糖尿病患者血糖水平,维持血脂稳定。     

Blood glucose concentration profile after 10 mg dexamethasone in non-diabetic and type 2 diabetic patients undergoing abdominal surgery

Background. Dexamethasone prevents postoperative nausea andvomiting but may increase blood glucose. We compared blood glucoseconcentrations after dexamethasone in non-diabetic and type2 diabetic patients undergoing surgery and looked for any associationwith preoperative glycosylated haemoglobin [HbA (1c)] and BMI. Methods. Sixty three patients were enrolled: 32 were non-diabetic(Group ND) and 31 type 2 diabetic (Group D) without insulintreatment. Anaesthesia was induced using i.v. anaesthetic agentsand maintained with sevoflurane. All patients received 10 mgdexamethasone at induction. Blood glucose concentrations weremeasured at induction and then every 60 min for 240 min. Datawere analysed using ANOVA. Effects of HbA (1c) and BMI wereinvestigated using linear correlation and logistic regression. Results. Blood glucose concentrations increased significantlyover time and peaked at 120 min after 10 mg dexamethasone inboth groups. The magnitude of increase was comparable betweenthe groups [mean (SD) 29 (19) and 35 (19)% of baseline in GroupD and Group ND, respectively]. Maximum concentrations were higherin Group D [8.97 (1.51) mmol litre^–1, range 6.67–12.94mmol litre^–1] than in Group ND [7.86 (1.00) mmol litre^–1,range 5.78–10.00 mmol litre^–1]. There was a significantcorrelation between the maximum concentrations and BMI (R²=0.21)or HbA (1c) (R²=0.26). Logistic regression analysis revealedthat the higher the BMI, the lower the HbA (1c) threshold associatedwith an increased probability (>0.5) of observing blood glucoselevels higher than 8.33 mmol litre^–1 during 240 min afterdexamethasone administration. Similarly, the higher the HbA(1c), the lower the BMI threshold associated with the same probability. Conclusions. After 10 mg dexamethasone, blood glucose levelsincrease in non-diabetic and type 2 diabetic patients undergoingabdominal surgery. Poorly controlled diabetes and severe obesitycan influence the development of hyperglycaemia.     

普外科患者并存糖尿病的围手术期处理

目的明确糖尿病患者围手术期血糖控制的安全方法。方法对87例普外科患者并存糖尿病时围手术期诊断与治疗进行回顾性分析,其中62例采用静脉给药方式,15例应用胰岛素泵。结果术后因高渗性非酮症昏迷死亡1例,切口感染4例,肺部感染2例,无一例发生低血糖昏迷。结论静脉应用普通胰岛素及应用胰岛素泵是围手术期糖尿病患者血糖控制的安全有效的方法。     

Anaesthetic management of a neonate with nesidioblastosis

Nesidioblastosis is a disorder which is characterized by autonomous insulin secretion that is not affected by decreases in blood glucose. Patients usually present during the neonatal or infantile period with hypoglycaemia associated with hyperinsulinaemia. Most cases of nesidioblastosis are sporadic; however, familial forms appear to be inherited in an autosomal recessive manner. We discuss the anaesthetic management of a patient with nesidioblastosis who presented for near total pancreatectomy and review the literature pertinent to the anaesthesiologist.     

Strategies for managing the diabetic patient

Diabetes mellitus is now classified as either ‘type 1’ (failure of endogenous insulin production) or ‘type 2’ (‘insulin resistance’) and can be diagnosed if fasting blood glucose is >6.1 mmol/l (110 mg/dl) on two separate occasions or there is unequivocal hyperglycaemia with acute metabolic decompensation or obvious symptoms. The prevalence of the disease is rising and may be as great as 12–14% in western populations aged over 40 years. Diabetes is complicated by micro- and macrovascular consequences of chronically elevated blood glucose concentrations, and diabetic patients are over-represented in hospital populations, particularly among patients requiring surgical interventions. It is associated with increased perioperative mortality and morbidity. Evidence is now accumulating that intensive glycaemic monitoring and the administration of insulin infusions to achieve tight glycaemic control are associated with an improvement of both perioperative mortality and morbidity.     

Anaesthetic management of the patient with diabetes

Diabetes is a metabolic disorder characterized by chronic hyperglycaemia with disturbances of carbohydrate, fat and protein metabolism. This results from defects in insulin secretion, insulin action, or both. The effects of diabetes include long-term damage, dysfunction and failure of key organ systems.The prevalence of diabetes is increasing in the UK, standing at 4.3% in 2005, compared to 2.8% in 1996. While the incidence of type 1 diabetes is static, the incidence of type 2 diabetes is rising rapidly. This trend is expected to continue, with some models predicting a prevalence of 9% (range 6.3–13.3%) by 2025.The burdens diabetes places on healthcare are great, both financially and on an individual patient's quality of life. Excellent anaesthetic management of the diabetic patient throughout the operative journey is key to a successful outcome and efficient use of resources.     

同伴教育对妊娠期糖尿病患者自护行为的影响

目的探讨同伴教育对妊娠期糖尿病患者自护行为的影响。方法将参加医院孕妇学校学习的64例妊娠期糖尿病患者随机分为两组各32例。对照组给予妊娠期糖尿病知识的常规健康教育,观察组在此基础上接受4周的同伴教育,包括成立同伴教育小组、选择和培训同伴教育者、实施小组活动等。干预结束后对两组患者的自护行为和血糖进行比较。结果干预后,除运动维度外,观察组自护行为总分和维度得分显著高于对照组,餐前及餐后2h血糖显著低于对照组(均P<0.05)。结论同伴教育能有效改善妊娠期糖尿病患者的自护行为,降低血糖水平。     

儿童糖尿病患者围手术期的处理

近年来，儿童1型和2型糖尿病的发病率逐渐上升。由于其发病年龄及病情程度的特殊性和复杂性，因此围手术期的处理至关重要。现从术前、术中和术后各阶段综述了以美国波士顿大学儿童医院各学科众多权威学者牵头制定的一项相对比较完整的处理准则，希望能够进一步指导和增强麻醉科医师的处理能力。     

妊娠期糖尿病患者俱乐部式健康教育研究

目的探讨对妊娠期糖尿病患者开展俱乐部式健康教育的效果。方法将孕24～26周、单胎、确诊为妊娠期糖尿病的孕妇64例按时间顺序分为对照组与研究组各32例。对照组按常规行健康教育,研究组以"糖妈妈俱乐部"形式进行健康教育。干预3个月后,比较两组血糖控制情况及自我护理行为。结果干预后研究组空腹血糖、餐后2 h血糖、糖化血红蛋白显著低于对照组(均P 0. 01);研究组自我管理效能、饮食依从性评分显著高于对照组,而运动问题得分显著低于对照组(P 0. 05,P 0. 01)。结论对于妊娠期糖尿病患者采用"糖妈妈俱乐部"式健康教育,可有效控制血糖,提高孕妇的疾病自我管理能力。     

Perioperative management of diabetes

Diabetes is a complex, chronic metabolic disorder affecting approximately 9.3% of the adult population with the estimated number of adults with diabetes worldwide having more than tripled since 2000. This increase has largely been attributed to global urbanization and lifestyle changes. Diabetes affects 10–15% of the surgical population. These patients are frequently elderly, have complex medical co-morbidities and present for both high-risk elective and emergency surgery. This multisystem disease poses a significant challenge to both anaesthesia and surgery with patients with diabetes demonstrating higher morbidity and mortality rates compared to their non-diabetic counterparts. It is crucial that good glycaemic control is maintained throughout the perioperative period as this has been shown to correlate with positive patient outcomes. It is well-recognized that a co-ordinated, multidisciplinary approach aimed at optimizing every point in the patient pathway from GP referral to post-discharge care is required to obtain the best outcomes for the surgical patient with diabetes. The anaesthetist has a key role in the perioperative diabetes multidisciplinary team. Patients themselves are well experienced in manging their own diabetes and should be involved in doing so whenever possible.     

100g口服葡萄糖耐量试验与妊娠糖尿病

目的探讨妊娠糖尿病(GDM)孕妇100g口服糖耐量试验(OGTT)的血糖水平并评价能否将抽血4次减为3次。方法回顾性分析2003年1月至2004年12月本院妇产科出院的、经50g OGTT阳性(服糖后1h血糖≥7.8mmol/L)后行100g OGTT、按照美国国家糖尿病数据组(NDDG)标准诊断的115例GDM患者的100 g OGTT血糖水平。结果如果不取空腹血糖值,将有2例(1.7%)GDM孕妇被漏诊;分别略去餐后1、2和3h的血糖值,依次有42例(36.5%)、63例(54.8%)和36例(31.3%)孕妇被漏诊。结论省略餐后1、2或3h任何一个时点的血糖值都将出现较高的GDM漏诊率。目前资料显示,不论采用75 g或100g OGTT,尚不能将试验时间由3h简化为2h;而诊断标准是沿用NDDG还是采用美国糖尿病学会(ADA)的标准,有待进一步行大规模的前瞻性研究。     

Outcomes of pancreas transplants for patients with type 2 diabetes mellitus

BACKGROUND: The objective of this study was to examine how effectively pancreas transplants provide long-term glucose control in patients with type 2 diabetes mellitus (DM). We used guidelines from the American Diabetes Association (ADA) and the World Health Organization (WHO) to appropriately classify recipients with type 2 DM (vs. type 1 DM). RESULTS: From 1994 through 2002, a total of 17 patients with type 2 DM underwent a pancreas transplant at our center. Mean recipient age was 52.5 yr. The mean age at diabetes onset was 35.7 yr; mean duration, 16.8 yr. Most recipients had one or more secondary complications related to their diabetes: retinopathy (94%), neuropathy (76%), or nephropathy (65%). At the time of their transplant, three (18%) were on oral hypoglycemic agents alone and 14 (82%) were on insulin therapy. Of the 17 transplants, seven (41%) were a simultaneous pancreas-kidney transplant (SPK); four (24%), pancreas after kidney transplant (PAK); and six (35%), pancreas transplant alone (PTA). One recipient died during the perioperative period because of aspiration. The other 16 recipients became euglycemic post-transplant and had a functional graft at 1 yr post-transplant (patient and graft survival rates, 94%). Now, with a mean follow-up of 4.3 yr post-transplant, the patient survival rate is 71%. The four additional deaths were because of sepsis (n = 2), suicide (n = 1), and unknown cause (n = 1). All four of these recipients were insulin-independent at the time of death, although one was on an oral hypoglycemic agent. Of the 12 recipients currently alive, 11 remain euglycemic without requiring insulin therapy or oral hypoglycemic agents; one began insulin therapy 1.2 yr post-transplant (current daily dose, 60 units). CONCLUSION: These findings suggest that pancreas transplants can provide excellent glucose control in recipients with type 2 DM. All 16 (94%) of our recipients whose transplant was technically successful were rendered euglycemic. Long-term results were comparable with those seen in transplant recipients with type 1 DM.     

ADOPT模式护理干预在妊娠期糖尿病患者中的应用

目的 探讨ADOPT模式护理干预在妊娠期糖尿病患者中的应用效果。方法 选取妇产科门诊就诊的120例妊娠期糖尿病患者,按随机数字表法分为对照组和观察组各60例。对照组实施常规护理干预及健康指导,观察组在对照组基础上实施ADOPT模式护理干预,持续8周。对比两组干预前后糖尿病自我管理行为得分、血糖控制水平及妊娠结局。结果 干预后观察组糖尿病自我管理行为得分显著高于对照组（P＜0.01）,空腹血糖、餐后2 h血糖及糖化血红蛋白显著低于对照组（均P＜0.01）;观察组妊娠高血压、羊水过多、巨大儿发生率显著低于对照组（均P＜0.05）。结论 对妊娠期糖尿病患者实施ADOPT模式护理干预,能够提高自我管理行为水平,有效控制血糖水平,并改善患者妊娠结局。