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 Type 2 Diabetes Mellitus Medication: Antidiabetics, Biguanides, Antidiabetics, Sulfonylureas, Antidiabetics, Meglitinide Derivatives, Antidiabetics, Alpha-Glucosidase Inhibitors, Antidiabetics, Thiazolidinediones, Antidiabetics, Glucagonlike Peptide-1 Agonists, Antidiabetics, Dipeptidyl Peptidase IV Inhibitors, Antidiabetics, Amylinomimetics, Selective Sodium-Glucose Transporter-2 Inhibitors, Bile Acid Sequestrants, Antidiabetics, Rapid-Acting Insulins, Antidiabetics, Short-Acting Insulins, Antidiabetics, Intermediate-Acting Insulins, Antidiabetics, Long-Acting Insulins, Dopamine Agonists Updated: Dec 24, 2020 Share Feedback Medication Summary Pharmacologic therapy of type 2 diabetes has changed dramatically in the last 10 years, with new drugs and drug classes becoming available. These drugs allow for the use of combination oral therapy, often with improvement in glycemic control that was previously beyond the reach of medical therapy. Agents used in diabetic therapy include the foll

 Laryngeal Mask Airway (LMA) The LMA designed by Archie Brain in 1988 is becoming increasing! y popular and is replacing the EIT for anaesthesia and maintaining the airway in many situations. It allows attachment to circuit, end-tidal monitoring, and acts as a route for EIT. ADVANTAGES OVER ETI • Simpler to insert and check placement (safer airway tool for non-anaesthetists) • Can be inserted without muscle relaxation and even with local anaesthesia • Well tolerated till awake and does not cause a sympathetic response • Can be used for IPPV without entering or traumatising the larynx and trachea • Protects the larynx from secretions and bleeding from above DISADVANTAGES • Contraindicated in "full stomach" as aspiration may occur • Contraindicated if ventilation requires high airway pressures e.g. obesity • Relative contraindication if access for adjustments is limited during surgery • High seal pressure on mucosa may cause posterior pharyngeal wall damage Selection of patient

 Extubation "The only real mistake is the one from which we learn nothing". John Powell Extubation can be as hazardous as intubation. Withdrawal of ventilatory support and extubation are not synonymous. Indication for intubation is important in deciding on conditions for extubation. 1. Surgical access : extubate deep when ventilation is adequate. 2. Full stomach : extubate awake when bucking on EIT, in the left lateral position. 3. Difficult airway : extubate when awake, responding to commands, and able to maintain the airway. Leave a catheter in the trachea in cases where re-intubation maybe required. 4. Suspicion of laryngeal oedema: deflate cuff and listen for air leak before extubation. 5. Obese patient : head up or sitting position to facilitate breathing Extubation procedure 1. Suction the naso-gastric tube, oral cavity, and nose as appropriate. 2. Assist ventilation with 100% oxygen for at least 5 breaths prior to extubation to maintain oxygenation during apnoea which

 Airway Management Tracheal Intubation Tracheal intubation is required for airway maintenance and ventilation when the use of a face mask or laryngeal mask is difficult, unsatisfactory, or unsafe. INDICATIONS l. Prevent aspiration e.g. full stomach 2. Provide surgical access e.g. oral surgery 3. Maintain a difficult airway e.g. obesity 4. Provide IPPV 5. Facilitate removal of secretions EQUIPMENT • Two laryngoscopes with 3 sizes of blades (check batteries, contact, bulb, light) • Endotracheal tubes (ETT) estimated size, and smaller and larger sizes • Magill's forceps • Stylet, bougie, LMA • Suction apparatus within easy reach • Pillows for the head and shoulders • Wee's detector I ETC02 for confirmation of tracheal placement Endotracheal Tube Tracheal tube sizes are marked according to the internal diameter (ID) in mm. Children : (age/ 4) + 4 mm, a size less if small for age. Adult size at > 14 years. Adult female: oral 7.0-7.Smm, nasal 7.0mm. Male: oral 8.0-9.Smm, nasal 7.5

 The Airway "An opening must be attempted in the trunk of the trachea, into which a tube of reed or cane should be put; you will then blow into this, so that the lung may rise again and the heart becomes strong." Vesalius 1555 The anaesthetist is responsible for maintenance of the airway and gas exchange. 28% of deaths due to anaesthesia are due to inability to intubate or ventilate (ASA). Normal airway patency is maintained by tension in the muscles connecting the larynx to the sternum, skull and mandible. Contraction of the pharyngeal dilator and tongue muscles opens the airway in a phasic manner during inspiration. Loss of muscle tension due to deep sleep, alcohol, sedation or disease may lead to pharyngeal obstruction, specially in the presence of anatomical abnormalities. The oropharynx is most prone to obstruction (posterior border of the tongue). As it is also part of the gastro-intestinal tract the protective airway reflexes are essential to prevent aspiration. Manage

 "Primum non nocere" (first of all do no harm). Hippocrates 400BC Surgeon and anaesthetist are jointly responsible for positioning the patient. Patient positioning depends on the following factors : 1. Patient : CVS and RS compromised, obesity 2. Surgical : Provide surgical access and minimize bleeding 3. Anaesthetic : Prevent aspiration and optimize respiration and venous return PROBLEMS 1. Cardiovascular Postural hypotension occurs as venous return is greatly influenced by gravity in the anaesthetized patient, being more marked with sympathetic block. e.g. spinal blockade, vasodilators, prolonged immobilization. Blood pressure should be measured within 5 minutes of changing position. Air embolism may occur when the site of surgery is above the level of the heart. 2. Respiratory Difficulty in maintaining the airway Limited access to the airway (e.g. prone position) Endobronchial intubation should be excluded after change of position. Embarrassment of ventilation by upward di

 General Anaesthesia Morton successfully demonstrated ether general anaesthesia on 16.10.1846 at Boston, Massachusetts and his epitaph by the surgeon Henry Bigelow reads : "Thomas Green Morton : By whom pain in surgery was annulled, Before whom, in all time surgery was agony, Since whom, science has control over pain " Stages of Anaesthesia Guedel's classic description of the four stages of anaesthesia in 1937, in un-pre-medicated patients breathing diethyl ether in air was based on : • Progressive reduction of catecholamine induced autonomic responses • Progressive muscle paralysis (eye muscles first and intercostals and diaphragm last) • Progressive abolition of reflexes (eyelash, conjunctiva), corneal, cough, carinal) Stage I : Stage of analgesia (conscious and pain free as in Entonox for labour) Stage II : Stage of excitement due to catecholamines (increased BP, pulse, restless) Deep, irregular respiration, eye movements, divergent and dilated pupils, Lacrimation, vom

 INTRODUCTION CHAPTER  23  Non–Laryngeal  Mask  Airway  Supraglottic  Airway  Devices   467 Nothing  is  more  fundamental  to  the  practice  of  general anesthesia  than  the  maintenance  of  a  clear  upper  airway. The  choice  of  device  depends  on  several  factors,  including  access  to  the  airway,  duration  of  surgery,  and  risk factors  for  aspiration.  After  placement,  the  cuffed  ETT provides  a  secure  airway  and  protects  against  aspiration, but  placement  and  removal  of  an  ETT  require  training and  judgment. Although  ETTs  typically  are  used  without incident,  complications  ranging  from  trivial  to  lifethreatening  can  occur.1 Advanced  airway  management  depends  on  many airway  devices,  several  of  which  have  been  included  in the  American  Society  of  Anesthesiologists  (ASA)  difficult  airway  algorithm.2  The  Classic  laryngeal  mask  airway (LMA  Classic,  LMA  North  America,  San  Diego,  CA)  was introduced  into  clini

 Pre-operative Modification of Patient's Drug Therapy Aim To obtain best optimisation and stability peri-operatively To ensure reversibility and quick control, change to drugs with shorter half lives To minimize withdrawal, side effects, and drug interactions To modify drug, dose, route and anaesthetic for best outcome • Oestrogens (DVT risk) for 4 weeks pre and post surgery (may continue if ambulatory, minor operations, or low dose) ACE inhibitors and angiotensin receptor inhibitors for 24 hours • Clopidogrel for 7 days Change • MAOI : pargyline, phenelzine, tranylcypromine, isocarboxacid Danger with pethidine, ephedrine (hypertension, fits, coma) • Tri -cyclic anti-depressants block reuptake, cause tachyarrhythmias Danger with ephedrine, halothane, ketamine, and pancuronium • Potassium sparing diuretics cause hyperkalaemia Danger with muscle injury, bums, renal disease, suxamethonium • Warfarin : stop for 3 days, convert to heparin, if needed • Aspirin : stop for 7 days, but weig

 Premedication "That which cannot be easily treated had better be prevented." Alfred Lee. Medication should be individualized to the patient and risk factors. 1. Anxiolytic Building a rapport with the patient is the best anxiolytic. Drugs needed specially for cardiac, hypertensive, asthmatic patients. Caution in extremes of age, renal and hepatic failure. c.g. diazepam or midazolam. Use lorazepam in the elderly. 2. Amnesic To avoid 'awareness' specially with minimal anaesthesia e.g. midazolam, lorazepam in trauma, cardio pulmonary by pass surgery etc. 3. Anti sialogogue To reduce secretions in oral surgery, in the mentally handicapped e.g. atropine, glycopyrrolate 4. Autonomic suppression Vagolytic (atropine) for dilatations, squint and retinal surgery, children Beta blocker for hypertension, IHD, and hypotensive anaesthesia 5. Analgesic Paracetamol, NSAIDs, tramadol (unless regional analgesia is planned) EMLA patch (1 hr before) or ametop (20 min before) 6. Antiemeti

 General Anesthesia: General Considerations, Preoperative Period, Intraoperative Period General anesthesia (GA) is the state produced when a patient receives medications to produce amnesia and analgesia with or without reversible muscle paralysis. An anesthetized patient can be thought of as being in a controlled, reversible state of unconsciousness. Anesthesia enables a patient to tolerate surgical procedures that would otherwise inflict unbearable pain, potentiate extreme physiologic exacerbations, and result in unpleasant memories. The combination of anesthetic agents used for general anesthesia often leaves a patient with the following clinical constellation: [1] Unarousable to painful stimuli Unable to remember what happened (amnesia) Unable to maintain adequate airway protection and/or spontaneous ventilation as a result of muscle paralysis Cardiovascular changes secondary to stimulant/depressant effects of anesthetic agents General anesthesia General anesthesia is induced and ma