pre-operative evaluation for diabetic cardiac autonomic neuropathy and their behaviour during...
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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
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Guide: Dr.P.S. SHANMUGAM, M.D., D.A PROFESSOR & H.O.D ANESTHESIOLOGY, KILPAUK MEDICAL COLLEGE
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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
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Study design
Randomized prospective comparative study
Pre-study assessment done
consent obtained from all patient
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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
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Exclusion criteria
1.age < 40& > 60 years
2.PS II & III
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GROUPSGroup 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
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EQUIPMENT REQUIRED
CANS 504 – cardiac neuropathy system analyser
ECG moniter
Spyghmomanometer
Pulse oxymeter
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CANS 504
tool to measure and diagnose autonomic dysfunction using ECG R-R interval and automatic BP measurement
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Normal and abnormal values in tests of
autonomic function TEST Normal
Grade 0
Borderline Grade 1
Abnormal Grade 2
1.parasympathetic: valsalva deep breathing [max:min HR] standing
1.2 15 BPM 1.04
1.1 – 1.2 11 –14 BPM 1.01 – 1.03
1.1 10 BPM 1.00
2.sympathetic [B.P response] standing(systolic) exercise(diastolic)
10 mmHg 16 mmHg
11- 29 mmHg 11- 15 mmHg
30mmHg 10mmHg
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METHODOLOGY50 patient were randomized into three groupsPatients evaluated for cardiac autonomic dysfunction using CANS 504 - preoperativelySubarachonoid block given at the level of L2- L3 ,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.
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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
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INJ. EPHEDRINE * Group Crosstabulation
Group
1 2 3 Total
INJ. EPHEDRINE 0 dose Count 4 2 12 18
% within Group 20.0% 20.0% 60.0% 36.0%
1 dose Count 3 4 8 15
% within Group 15.0% 40.0% 40.0% 30.0%
2 dose Count 5 4 0 9
% within Group 25.0% 40.0% .0% 18.0%
3 dose Count 6 0 0 6
% within Group 30.0% .0% .0% 12.0%
4 dose Count 2 0 0 2
% within Group 10.0% .0% .0% 4.0%
Total Count 20 10 20 50
% within Group 100.0% 100.0% 100.0% 100.0%
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INJ. ATROP * Group Crosstabulation
Group
1 2 3 Total
INJ. ATROP
0 dose Count 3 5 19 27
% within Group 15.0% 50.0% 95.0% 54.0%
0dose Count 0 3 0 3
% within Group .0% 30.0% .0% 6.0%
1 dose Count 9 2 1 12
% within Group 45.0% 20.0% 5.0% 24.0%
2 dose Count 1 0 0 1
% within Group 5.0% .0% .0% 2.0%
nil Count 7 0 0 7
% within Group 35.0% .0% .0% 14.0%
Total Count 20 10 20 50
% within Group 100.0% 100.0% 100.0% 100.0%
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RESULTSDuring 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%)
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conclusionWe found a significant correlation between degree of autonomic dysfunction and largest drop in B.P & variability in H.R & cardiac rhythmThese results prove the atypical hemodynamic behaviour and extreme instability in B.P in diabetic autonomic neuropathy under spinal anesthesia
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Conclusion….,Therefore we consider it to be very helpful to check the cardiovascular reflectory status of diabetics preoperatively.
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