Der Orthopäde

, Volume 38, Issue 9, pp 818–827

Perioperative Einstellung und Behandlung des Diabetes mellitus

Leitthema

Zusammenfassung

In allen operativen Fachgebieten nimmt die Zahl der Patienten, die an einem Diabetes mellitus erkrankt sind, in den letzten Jahren dramatisch zu; Grund ist, dass mittlerweile bei fast 10% der Bevölkerung diese Erkrankung vorliegt. Bei diesen Patienten muss der Diabetes und seine Folgeerkrankungen unbedingt mit therapiert werden, damit es nicht perioperativ zu Komplikationen kommt. Besonders problematisch ist, dass ein großer Teil der Patienten nicht weiß, dass sie an einer Form des Diabetes leiden. Schon präoperativ und im gesamten weiteren klinischen Verlauf ist das Zusammenwirken von Operateur, Anästhesist und Diabetologen erforderlich, um einen optimalen Verlauf zu erreichen. Außerdem müssen in allen Abteilungen der Krankenhäuser feste Algorithmen vorliegen, nach denen diese Patienten behandelt werden.

Schlüsselwörter

Diabetes mellitus Perioperative Therapie Perioperative Komplikationen Anästhesie 

Peri-operative adjustment and treatment of diabetes mellitus

Abstract

In all disciplines of operative medicine the number of patients who suffer from diabetes mellitus is increasing dramatically. The reason is that nowadays up to 10% of the population is suffering from this disease. These patients must be treated with respect to the diabetes and also subsequent related conditions to prevent peri-operative complications. A special problem is that many patients do not know that they are suffering from diabetes. Pre-operatively and during the peri-operative course the coordinated efforts of surgeons, anaesthesiologists and diabetes specialists are essential to reach an optimal result. In all hospitals obligatory algorithms must be established for the treatment of these patients.

Keywords

Diabetes mellitus Peri-operative treatment Peri-operative complications Anaesthesia 

Literatur

  1. 1.
    Kerner W, Brückel J, Böhm BO (2004) Evidenzbasierte Leitlinien der Deutschen Diabetes-Gesellschaft: Definition, Klassifikation und Diagnostik des Diabetes mellitus. Diabetes Stoffwechsel 13(Suppl 2). http://www.deutsche-diabetes-gesellschaft.deGoogle Scholar
  2. 2.
    Müller-Wieland D, Gallwitz B, Haak T (2008) Deutschland = Diabetesland: Deutscher Gesundheitsbericht Diabetes 2008. Diabetologie 3:39–40CrossRefGoogle Scholar
  3. 3.
    Sachverständigenrat zur Begutachtung der Entwicklung im Gesundheitswesen, Koordination und Integration - Gesundheitsversorgung in einer Gesellschaft des längeren Lebens. Sondergutachten 2009. 2009. Ministerium für Gesundheit, BonnGoogle Scholar
  4. 4.
    Fowkes FG, Farrow SC, Lunn JN, Robertson IB (1982) Epidemiology in anaesthesia. III. Mortality risk in patients with coexisting physical disease. Br J Anaesth 54:819–825PubMedCrossRefGoogle Scholar
  5. 5.
    Hjortrup A, Rasmussen BF, Kehlet H (1983) Morbidity in diabetic and nondiabetic patients after major vascular surgery. BMJ 287:1107PubMedCrossRefGoogle Scholar
  6. 6.
    Finney SJ, Zekveld C, Elia A, Evans TW (2003) Glucose control and mortality in critically ill patients. JAMA 290:2041–2047PubMedCrossRefGoogle Scholar
  7. 7.
    Harati Y (2007) Diabetic neuropathies: unanswered questions. Neurol Clin 25:303–317PubMedCrossRefGoogle Scholar
  8. 8.
    Burgos LG, Ebert TJ, Asiddao C et al (1989) Increased intraoperative carciovascular morbidity in diabetics with autonomic neuropathy. Anesthesiology 70:591–597PubMedCrossRefGoogle Scholar
  9. 9.
    Roizen MF, Fleisher LA (2005) Anesthetic implications of concurrent diseases. In: Miller RD (ed) Miller‘s Anesthesia. Elsevier Livingstone, Philadelphia, pp 1017Google Scholar
  10. 10.
    Ryan CM (2005) Diabetes, aging, and cognitive decline. Neurobiol Aging 26:21–25PubMedCrossRefGoogle Scholar
  11. 11.
    He Z, King GL (2004) Microvascular complications of diabetes. Endocrinol Metab Clin North Am 33:215–238PubMedCrossRefGoogle Scholar
  12. 12.
    Jauch KW (2003) Hunger und Postaggressions-/Stressstoffwechsel. In: Stein J, Jauch KW (Hrsg) Praxishandbuch klinische Ernährung und Infusionstherapie. Springer, Berlin Heidelberg New York, S 215–229Google Scholar
  13. 13.
    Van den Berghe G (2004) How does blood glucose control with insulin save lives in intensive care? J Clin Invest 114:1187–1195Google Scholar
  14. 14.
    Sakurai Y, Aarsland A, Herndon DN et al (1995) Stimulation of muscle protein synthesis by longterm insulin infusion in severely burned patients. Ann Surg 222:283–294PubMedCrossRefGoogle Scholar
  15. 15.
    Kriegstein EV, Schatz H (2004) Insulin. In: Schatz H (Hrsg) Diabetologie kompakt. Thieme, Stuttgart, S 76Google Scholar
  16. 16.
    Duncan AI, Gorman-Koch C, Xu M et al (2007) Recent metformin ingestion does not increase in-hospital morbidity and mortality after cardiac surgery. Anesth Analg 10(1):42–50CrossRefGoogle Scholar
  17. 17.
    Misbin RI, Green L,Stadel BV et al (1998) Lactic acidosis in patients with diabetes treated with metformin. N Engl J Med 338:265–266PubMedCrossRefGoogle Scholar
  18. 18.
    Lalau JD, Race JM (1999) Lactic acidosis in metformin-treated patients. Prognostic value of arterial lactate levels and plasma metformin concentrations. Drug Saf 20:377–384PubMedCrossRefGoogle Scholar
  19. 19.
    Scherbaum WA (2001) Metformin und Anästhesie - Wie hoch ist das Risiko einer Laktatazidose. Dtsch Med Wschr 126:607–608PubMedGoogle Scholar
  20. 20.
    Kersten JR, Warltier DC, Pagel PS (2005) Aggressive control of intraoperative blood glucose concentration: A shifting paradigm? Anesthesiology 103(4):677–678PubMedCrossRefGoogle Scholar
  21. 21.
    Lipshutz AKM, Gropper MA (2009) Perioeprative glycemic control – an evidence-based review. Anesthesiology 110(2):408–421PubMedGoogle Scholar
  22. 22.
    Lazar HL, Chipkin SR, Fitzgerald CA et al (2004) Tight glycemic control in diabetic coronary artery bypass graft patients improves perioperative outcomes and decreases current ischemic events. Circulation 109:1497–1502PubMedCrossRefGoogle Scholar
  23. 23.
    Oddo M, Schmidt JM, Mayer SA et al (2008) Glucose control after severe brain injury. Curr Opin Clin Nutr Metab Care 11:134–139PubMedCrossRefGoogle Scholar
  24. 24.
    Kannel W, McGee D (1979) Diabetes and cardiovascular risk factors: The Framingham Study. Circulation 59:8PubMedGoogle Scholar
  25. 25.
    Haußleiter S, Tegenthoff M (2006) Peipher-neurogene Läsionen bei Diabetes mellitus. Akt Neurol 33:543–352CrossRefGoogle Scholar
  26. 26.
    Tsueda K, Huang KC, Dumont SW et al (1991) Cardiac sympathetic tone in anesthetized diabetics. Can J Anaesth 38:20–23PubMedCrossRefGoogle Scholar
  27. 27.
    Ewing DJ, Martyn CN, Young RJ (1985) The value of cardiovascular autonomic function tests: 10 years experience in diabetes. Diabetes Care 8:491PubMedCrossRefGoogle Scholar
  28. 28.
    Lee TH, Marcantonio ER, Mangione CM et al (1999) Derivation and prospective validation of a simple index for prediction of cardic risk of major noncardiac surgery. Circulation 100:1043–1049PubMedGoogle Scholar
  29. 29.
    Wolf AR, Doyle E, Thomas E (1998) Modyfying infant stress responses to major surgery: spinal vs. extradural vs. opioid analgesia. Paediatr Anaesth 8:305–311PubMedCrossRefGoogle Scholar
  30. 30.
    Eberhart L, Schricker T (2006) Strategien zur Prophylaxe und Therapie der katabolen Stressantwort. Anästh Intensivmed 47:68–75Google Scholar
  31. 31.
    Echeverria M (2008) Spinal anaesthesia with 0,5% isobaric bupivacaine in patients with diabetes mellitus: the influence of CSF composition on sensory and motor block. Eur J Anaesthesiol 25(12):101–1019Google Scholar
  32. 32.
    Garg R (2009) Spinal anaesthesia in a diabetic patient: effect of CSF composition and physiological changes due to hyperglycaemia. Eur J Anaesthesiol 26(3):266–267PubMedCrossRefGoogle Scholar
  33. 33.
    Suto T, Takazawa T, Nishikawa K, Goto F (2007) Effects of spinal anesthesia on the peripheral and deep core temperature in elderly diabetic patients undergoing urological surgery. J Anesth 21:336–339PubMedCrossRefGoogle Scholar
  34. 34.
    Lattermann R, SchrickerT, Georgieff M et al (2001) Low dose clonidine premedication accentuates the hyperglycemic response to surgery. Can J Anaesth 48:755–759PubMedCrossRefGoogle Scholar
  35. 35.
    Mertes N, Goeters C, Kuhmann M, Zander ZF (1996) Postoperative alpha-2-adrenergic stimulation attenuates protein catabolism. Anesth Analg 82:258–263PubMedCrossRefGoogle Scholar
  36. 36.
    Kadoi Y, Saito S, Goto F, Fujita N (2003) Diabetic patients have an impaired cerebral vasodilatory response to hypercapnia under propofol anesthesia. Stroke 34:2399–2403PubMedCrossRefGoogle Scholar
  37. 37.
    Weiß G, Jacob M (2008) Präoperative Nüchternheit 2008. Anästhesist 57(9):857–872CrossRefGoogle Scholar
  38. 38.
    Coutinho M, Gerstein HC, Wang Y, Yusuf S (1999) The relationship between glucose and incident cardiovascular events: a metaregression analysis of published data from 20 studies of 95,783 individuals followed 12,4 years. Diabetes Care 22:233–240PubMedCrossRefGoogle Scholar
  39. 39.
    Ley SC, Preckel B, Schlack W (2008) Datenlage zur perioperativen Diabetesbetreuung in einem Universitätsklinikum Ergebnisse der DiTor- („diabetes therapy in the operating room“) Studie. Diabetologe 4:13–19CrossRefGoogle Scholar
  40. 40.
    Ley SC, Preckel B, Schlack W (2005) Perioperative Behandlung von Patienten mit Diabetes mellitus. AINS 40:230–249PubMedGoogle Scholar
  41. 41.
    Magee MF (2007) Hospital protocols for targeted glycemic control: Development, implementation and models for cost justification. Am J Health Syst Pharm 64(10 Suppl 6):15–20CrossRefGoogle Scholar
  42. 42.
    Nayak PP (2009) Lack of agreement between arterial and central venous blood glucose measurement in critically ill children. Intensive Care Med 35:762–763PubMedCrossRefGoogle Scholar
  43. 43.
    Abdelmalak B (2008) Intensive glucose control in major non-cardiac surgery is safe and feasible. ASA Annual Meeting, Orlando, FLGoogle Scholar
  44. 44.
    Desachy A (2008) Accuracy of bedsinde glucometry in critically ill patients: Influence of clinical characteristics and perfusion index. Mayo Clin Proc 83(4):400–405PubMedCrossRefGoogle Scholar
  45. 45.
    Siegel E (2008) Diabetes mellitus XXS pocket. Börm Bruckmer, MünchenGoogle Scholar
  46. 46.
    Wagner A (1997) Therapie der schweren diabetischen Ketoazidose – Null-Mortalität am Allgemeinkrankenhaus. Intensivmed Notfallmed 34(Suppl 1):11Google Scholar
  47. 47.
    Hensen J, Thomas T, Müller-Ziehm J (2006) Diabetische Ketoazidose und nicht-ketoazidotisches hyperosmolares diabetisches Koma - Therapiemöglichkeiten. Arnzeimitteltherapie 2(12):432–443Google Scholar
  48. 48.
    Rockemann MG (2001) Schwere perioperative Ketoazidose bei einer Patientin mit einem Dickdarmeingriff. Anästh Intensivmed 42:214–216Google Scholar
  49. 49.
    Lustik SJ, Vogt A, Chibber AK (1998) Postoperative lactic acidosis in patients receiving meetformin. Anesthesiology 89:266–267PubMedCrossRefGoogle Scholar
  50. 50.
    Scherpereel PA, Tavernier B (2001) Perioperative care of diabetic patients. Eur J Anaesthesiol 18(5):277–294PubMedGoogle Scholar
  51. 51.
    Lanier WL (1994) Glucose management during cardiopulmonary bypass: cardiovascular and neurologic implications. Anesth Analg 72:423Google Scholar
  52. 52.
    Van den Berghe G, Bouillon R, Mesotten D et al (2001) Intensive insulin therapy in the critically ill patients. N Engl J Med 345:1359–1367CrossRefGoogle Scholar
  53. 53.
    The NICE-SUGAR Study Investigators (2009) NICE-SUGAR Study Investigators, Intensive versus conventional glucose control in critically ill patients. N Engl J Med 360:1283–1297CrossRefGoogle Scholar
  54. 54.
    Bellomo R, Egi M (2009) What Is a NICE-SUGAR for Patients in the Intensive Care Unit? Mayo Clin Proc 84(5):400–402PubMedCrossRefGoogle Scholar
  55. 55.
    Van den Berghe G, Mesotten D, Vanhorebeek I (2009) Intensive insulin therapie in the intensive care unit. CMAJ 180(8):799–800Google Scholar
  56. 56.
    Schatz H (2003) Hypoglykämie – eine wichtige Differentialdiagnose bei jedem bewusstlosen Patienten. Notfallmedizin 29:115CrossRefGoogle Scholar
  57. 57.
    Hohenstein C (2006) Hypoglykämie mit Hemiparese – Intuition versus Technik. Notarzt 22:12–14CrossRefGoogle Scholar
  58. 58.
    McNay EC (2005) The impact of recurrent hypoglycemia on cognitive function in aging. Neurobiol Aging 26:76–79PubMedCrossRefGoogle Scholar
  59. 59.
    Whitmer RA, Karter AJ, Yaffe K et al (2009) Hypoglycemic episodes and risk of dementia in older patients with type 2 diabetes mellitus. JAMA 301(15):1565–1572PubMedCrossRefGoogle Scholar
  60. 60.
    Salzarulo HH, Taylor LA (1986) Diabetic „stiff joint syndrome“ as a cause of difficult endotracheal intubation. Anesthesiology 64:366–368PubMedCrossRefGoogle Scholar
  61. 61.
    Reissel E, Orko R, Maunuksela EL et al (1990) Predictability of difficult laryngoscopy in patients with long-term diabetes mellitus. Anaesthesia 45:1024CrossRefGoogle Scholar
  62. 62.
    Horowitz M, Edelbroek M, Fraser RJ et al (1991) Disordered gastric motor function in diabetes mellitus. Scand J Gastroenterol 26:673–684PubMedCrossRefGoogle Scholar
  63. 63.
    Lydon A, Murray C, Cooke T et al (2000) Evaluation of standard haemodynamic tests of autonomic function and HbA1c as predictors of delayed gastric emptying in patients with type 1 diabetes mellitus. Eur J Anaesthesiol 17:99–104PubMedCrossRefGoogle Scholar
  64. 64.
    Ishihara H, Singh A, Giesecke AH (1994) Relationship between diabetic autonomic neuropathy and gastric contents. Anesth Analg 78:943–947PubMedCrossRefGoogle Scholar
  65. 65.
    Jellish WS, Kartha V, Fluder E et al (2005) Effect of metoclopramide on gastric fluid volumes in diabetic patients who have fasted before elective surgery. Anesthesiology 102:904–909PubMedCrossRefGoogle Scholar
  66. 66.
    Zerr KJ, Grunkemeier GL, Starr A et al (1997) Glucose control lowers the risk of wound infection in diabetics after open heart operations. Ann Thorac Surg 63:356–361PubMedCrossRefGoogle Scholar
  67. 67.
    Van den Berghe G, Wouters P, Weekers F et al (2003) Outcome benefit of intensive insulin therapy in the critically ill: insulin dose versus glycemic control. Crit Care Med 31:359–366CrossRefGoogle Scholar
  68. 68.
    Bagdade JD (1976) Phagocytic and microbiological function in diabetes mellitus. Acta Endocrinol (Copenh) 83(Suppl 205):27Google Scholar
  69. 69.
    Nolan CM, Beaty HN, Bagdade JD (1978) Further characterization of the impaired bactericidal function of granulocytes in patients with poorly controlled diabetes. Diabetes 27:889PubMedGoogle Scholar
  70. 70.
    Jackson LA (2005) Evaluating diabetes mellitus as a risk factor for community-acquired infections. Clin Infect Dis 41:289–290PubMedCrossRefGoogle Scholar
  71. 71.
    Koirala GS, Khardori R, Khardori N (2007) Infections in diabetes mellitus and hyperglycemia. Infect Dis Clin North Am 21(3):617–638PubMedCrossRefGoogle Scholar
  72. 72.
    Shilling AM, Raphael J (2008) Diabetes, hyperglycemia, and infections. Best Pract Res Clin Anaesthesiol 22(3):519–535PubMedCrossRefGoogle Scholar
  73. 73.
    Kleinwächter R (2008) Influence of intraoperative blood glucose on monocyte function and postoperative infection rate. ASA Conference, Orlando, FL, pp 233Google Scholar
  74. 74.
    Rassias AJ, Givan AL, Marrin CAS et al (1999) Insulin infusion improves neutrophil function in diabetic cardiac surgery patients. Anesth Analg 88:1011–1016PubMedCrossRefGoogle Scholar
  75. 75.
    Rassias AJ (2002) Insulin increases neutrophil count and phagocytic capacity after cardiac surgery. Anesth Analg 94:1112–1129CrossRefGoogle Scholar
  76. 76.
    Woolfson AM, Heatley RV, Allison SP (1979) Insulin to inhibit protein catabolism after injury. N Engl J Med 300:14–17PubMedCrossRefGoogle Scholar
  77. 77.
    Hans P, Vanthuyne A, Dewandre PY et al (2006) Blood glucose concentration profile after 10 mg dexamethasone in nondiabetic and type 2 diabetic patients undergoing abdominal surgery. Br J Anaesth 97:164–170PubMedCrossRefGoogle Scholar
  78. 78.
    Nazar C (2009) Dexamethasone for postoperative nausea and vomiting prophylaxis: effect on glycaemia in obese patients with impaired glucose tolerance. Eur J Anaesthesiol 26:318–321PubMedCrossRefGoogle Scholar
  79. 79.
    Riegler N (2007) Die vitalbedrohliche Hyperkaliämie des Diabetikers – ein unterschätztes Risiko? Notarzt 23:123–129CrossRefGoogle Scholar
  80. 80.
    Klutmann M, Tillmans C, Gulba DC (2006) Postoperative antithrombotische Therapie bei diabetischen Patienten. Clin Res Cardiol 95(Suppl 1):74–77CrossRefGoogle Scholar

Copyright information

© Springer Medizin Verlag 2009

Authors and Affiliations

  1. 1.Abteilung für Anästhesie, operative Intensivmedizin und SchmerztherapieKlinikum Dortmund gGmbHDortmundDeutschland
  2. 2.Diabeteszentrum, Medizinische Klinik NordKlinikum Dortmund gGmbHDortmundDeutschland

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