Transcript Pre-operative evaluation for diabetic autonomic neuropathy

Pre-operative evaluation for
diabetic cardiac autonomic
neuropathy and their
behaviour during regional
anesthesia
- Dr.s.sivakumar
m.d anesthesiology(III year)
Kilpauk medical college
Guide:
Dr.P.S. SHANMUGAM, M.D., D.A
PROFESSOR & H.O.D
ANESTHESIOLOGY,
KILPAUK MEDICAL COLLEGE
Aim of the study
preoperative evaluation for diabetic
cardiac autonomic neuropathy using
cardiac autonomic neuropathy system
analyser and evaluating their
hemodynamic stability during regional
anesthesia
Study design
Randomized prospective comparative
study
Pre-study assessment done
consent obtained from all patient
Patient selection
inclusion criteria
case:
age:40-60 years
sex :both male& female
DM > 3 years
PS I
Control:
age:40-60 years
sex:both male &female
not a known diabetic
PS I
Exclusion criteria
1.age < 40& > 60 years
2.PS II & III
GROUPS
Group I : 20 diabetic patient with
autonomic neuropathy
Group II : 10 diabetic patient without
autonomic neuropathy
Group III: 20 control pt , non- diabetic
patient without autonomic neuropathy
EQUIPMENT REQUIRED
CANS 504 – cardiac neuropathy system
analyser
ECG moniter
Spyghmomanometer
Pulse oxymeter
CANS 504
tool to measure and diagnose
autonomic dysfunction using ECG R-R
interval and automatic BP measurement
Normal and abnormal values
in tests of autonomic function
TEST
1.parasympathetic:
valsalva
deep breathing
[max:min HR]
standing
2.sympathetic
[B.P response]
standing(systolic)
exercise(diastolic)
Normal
Grade 0
Borderline
Grade 1
Abnormal
Grade 2
1.2
15 BPM
1.1 – 1.2
11 –14 BPM
1.1
10 BPM
1.04
1.01 – 1.03
1.00
10 mmHg
16 mmHg
11- 29 mmHg
11- 15 mmHg
30mmHg
10mmHg
METHODOLOGY
50 patient were randomized into three groups
Patients evaluated for cardiac autonomic
dysfunction using CANS 504 - preoperatively
Subarachonoid block given at the level of L2L3 ,volume 3 ml of 0.5% bupivacine ,level T4
–T5.
Intraoperative recording of B.P, pulse rate
,ECG rate and rhythm were done for each 5
min in first 30 min. and then for each 15 min
till the end of surgery.
METHODOLGY….
i.v Fluids and inj.ephedrine 6mg given if
systolic B.P falls below 90 mmHg
Inj. Atropine 0.6 mg given if P.R falls
below 60
INJ. EPHEDRINE * Group Crosstabulation
Group
1
INJ. EPHEDRINE
0 dose
Count
% within Group
1 dose
Count
% within Group
2 dose
Count
% within Group
3 dose
Count
% within Group
4 dose
Count
% within Group
Total
Count
% within Group
2
3
Total
4
2
12
18
20.0%
20.0%
60.0%
36.0%
3
4
8
15
15.0%
40.0%
40.0%
30.0%
5
4
0
9
25.0%
40.0%
.0%
18.0%
6
0
0
6
30.0%
.0%
.0%
12.0%
2
0
0
2
10.0%
.0%
.0%
4.0%
20
10
20
50
100.0%
100.0%
100.0%
100.0%
INJ. ATROP * Group Crosstabulation
Group
1
INJ.
ATR
OP
0 dose
Count
% within Group
0dose
Count
% within Group
1 dose
Count
% within Group
2 dose
Count
% within Group
nil
Count
% within Group
Total
Count
% within Group
2
3
Total
3
5
19
27
15.0%
50.0%
95.0%
54.0%
0
3
0
3
.0%
30.0%
.0%
6.0%
9
2
1
12
45.0%
20.0%
5.0%
24.0%
1
0
0
1
5.0%
.0%
.0%
2.0%
7
0
0
7
35.0%
.0%
.0%
14.0%
20
10
20
50
100.0%
100.0%
100.0%
100.0%
RESULTS
During spinal anesthesia patients in group 1
experienced hypotensive reactions &
bradycardia significantly more often(72%)
than patients in group II (35%) and groupIII
(15%)
In order to achieve stability in B.P the
patients of group I had to be given vasoactive
drugs much more often (55%) than patients
of groupII(30%) and those of groupIII(15%)
conclusion
We found a significant correlation
between degree of autonomic
dysfunction and largest drop in B.P &
variability in H.R & cardiac rhythm
These results prove the atypical
hemodynamic behaviour and extreme
instability in B.P in diabetic autonomic
neuropathy under spinal anesthesia
Conclusion….,
Therefore we consider it to be very
helpful to check the cardiovascular
reflectory status of diabetics
preoperatively.