Surgical Challenges in Diabetic Patients - MShapiro

Surgical Challenges in Diabetic Patients - MShapiro -...

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SURGICAL CHALLENGES IN DIABETIC PATIENTS Mark Shapiro, MD Mount Sinai Medical Center July 22, 2005
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Classification Type 1 Type 1A: Immune-mediated Type 1B: Idiopathic Type 2 Other causes Diseases of exocrine pancreas (cystic fibrosis, neoplasia) Endocrinopathies (glucagonoma, acromegaly, pheochromocytoma, Cushing’s, etc.) Drug induced
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Criteria for Diabetes Mellitus
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Epidemiology Sixth most common cause of death Diabetics have increased incidence of cardiac complications (leading cause of death) cerebrovascular pathology (third leading cause of death)
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Diabetics Undergo various procedures and surgeries more commonly than their nondiabetic counterparts Have increased morbidity and mortality rates when acutely compromised or ill At least a third of perioperative diabetics are unrecognized or untreated before surgery the physician must be vigilant in the identification of diabetes
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Cardiac Consequences Cardiac compromise must be identified before major surgery and during critical illness High prevalence of silent ischemia warrants cardiac testing preoperatively Acute glycemic control results in marked improvement in cardiac survival in diabetics with ACS, MI, and after recent cardiac surgery
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Renal Consequences Diabetes is the leading cause of end-stage renal disease Leads to hypertension, dyslipidemias, and anemia Developing acute renal failure after CABG increases mortality rate from 1-2% to 20% with moderate acute renal failure and 60% for patients who require dialysis Mangano CM, et al. Renal dysfunction after myocardial revascularization: Risk factors, adverse outcomes, and hospital resource utilization. Ann Inter Med 1998; 128:194-203
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Goals of Critical Care To avoid acute renal failure, leading to dialysis Limiting hypovolemia Avoiding nephrotoxins Judicious use of contrast-based radiographic procedures To decrease significant risk of aspiration (from autonomic neuropathy, gastroparesis) Appropriate patient positioning Use of gastric acid secretion suppressants
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Glycemic Control Multiple recent studies suggest that aggressive glucose control may benefit diabetic pts who are critically ill Insulin infusions are recommended as a way of glycemic control
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Surgical Challenges in Diabetic Patients - MShapiro -...

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