Q.26What special considerations in relation to analgesia and anaesthesia are appropriate for women with diabetes?

Bibliographic InformationStudy Type & Evidence LevelNumber of PatientsPatient CharacteristicsIntervention & ComparisonFollow-up & Outcome MeasuresEffect SizeStudy SummaryReviewer Comments
Lattermann,R.; Carli,F.; Wykes,L.; Schricker,T.

2002

{Lattermann, 2002 37232 /id}
Study Type: RCT

Evidence level: 1+
16 patients
  1. Intervention group (n = 8)
16 patients undergoing elective colorectal surgery for nonmetastatic carcinoma were admitted to the study.

All patients had a body mass index (BMI) of 20–27 kg/m2 and maintained their body weight during the preceding 3 months (<5% weight loss).;

Exclusion criteria were any cardiac, hepatic, renal, endocrine, or metabolic disorders, ingestion of any medication known to affect metabolism, and history of severe sciatica or back surgery that contraindicated the use of epidural catheters. Further exclusions were patients with a plasma albumin concentration less than 35 g/l, with anaemia (haemoglobin < 10 g/dl), and patients who received chemotherapy during 6 months before surgery.

Country: Canada
Intervention: A combination of epidural blockade with bupivacaine and general anaesthesia.

Comparison: General anaesthesia alone (control group).
Follow-up period:

Outcome Measures: Plasma concentrations of:
  1. Glucose
  2. Cortisol
  3. Glucagon
  4. Insulin
Epidural blockade blunted the perioperative increase in the plasma concentration of glucose, cortisol, and glucagon when compared to the control group (P < 0.05).

Plasma concentrations of lactate, free fatty acids and insulin did not change.

Intra-and postoperative glucose production was lower in patients with epidural blockade than in control subjects (intraoperative, epidural blockade 8.2 ± 1.9 vs. control 10.7 ± 1.4 μmol/kg/min, P < 0.05; postoperative, epidural blockade 8.5 ± 1.8 vs. control 10.5 ± 1.2 μmol/kg/min, P < 0.05), whereas glucose clearance decreased by a similar extent in both groups (P < 0.05).

Protein breakdown (P < 0.05), protein synthesis (P < 0.05), and amino acid oxidation (p > 0.05) decreased with both anaesthetic techniques.
Epidural blockade attenuates the hyperglycaemic response to surgery through modification of glucose production whilst perioperative suppression of protein metabolism was not influenced by epidural blockade.Patients undergoing elective colorectal surgery for nonmetastatic carcinoma, not women with diabetes.
Datta,S.; Kitzmiller,J.L.; Naulty,J.S.; Ostheimer,G.W.; Weiss,J.B.

1982

{Datta, 1982 34438 /id}
Study Type: Cohort

Evidence level: 2-
20 patientsRigidly controlled insulin-dependent women with diabetes and women without diabetes undergoing spinal anaesthesia for caesarean section.

Country: USA
Intervention: Spinal anaesthesia in women with diabetes

Comparison: Spinal anaesthesia in women without diabetes
Follow-up period:

Outcome Measures:
  1. Acid-base values
  2. Apgar scores
There were no significant differences in the acid-base values between the women with diabetes and women without diabetes and the infants of the mothers with diabetes compared to the control group.

There were no differences in the induction-delivery or uterine-incision delivery interval between the two groups

Apgar scores were also similar in the two groups.
If maternal diabetes is well controlled, dextrose-containing solutions are not used for intravascular volume expansion before delivery and hypotension is avoided, spinal anaesthesia can be used safely for women with diabetes undergoing caesarean section.The sample size is very small, and the role of chance may not be excluded. Also the study is very old, conducted 1982 over 20 years ago
Hebl,J.R.; Kopp,S.L.; Schroeder,D.R.; Horlocker,T.T.

2006

{Hebl, 2006 36652 /id}
Study Type: Cohort

Evidence level: 2+
567 patients with a preexisting peripheral sensorimotor neuropathy or diabetic polyneuropathy.
  1. Receiving anaesthesia (n = 325)
  2. Epidural anaesthesia or analgesia (n = 214)
  3. Continuous spinal anaesthesia (n = 24)
  4. Combined spinal- epidural (n= 4)
567 patients with a preexisting peripheral sensorimotor neuropathy or diabetic polyneuropathy who subsequently underwent neuraxial anaesthesia or analgesia.

Country: USA
Intervention: Neuraxial anaesthesia or analgesia.

Comparison: General population undergoing the same procedure.
Follow-up period: At least six months.

Outcome Measures:
  1. New or progressive postoperative neurological deficits.
  2. Technical complications such as unintentional elicitation of a paresthesia.
  3. Infectious complications
  4. Haematologic complications
The majority of patients had chronically stable neurological signs or symptoms at the time of block placement, with very few reporting progression of their symptoms within the last 6 months.

Overall, two (0.4%; 95% CI 0.1% to 1.3%) patients experienced new or progressive postoperative neurological deficits, in the setting of an uneventful neuraxial technique.

In these patients, the neuraxial block may have contributed to the injury secondary to direct trauma or local anaesthetic neurotoxicity around an already vulnerable nerve.

Overall the risk of severe postoperative neurological dysfunction in patients with peripheral sensorimotor neuropathy or diabetic polyneuropathy undergoing neuraxial anaesthesia or analgesia was found to be 0.4% (95% CI 0.1 to 1.3%).

Sixty-five (11.5%) technical complications occurred in 63 patients with the most common complication being unintentional elicitation of a paresthesia (7.6%), followed by traumatic (evidence of blood) needle placement (1.6%) and unplanned dural puncture (0.9%).

There were no infectious or haematologic complications.
The risk of severe postoperative neurological dysfunction in patients with peripheral sensorimotor neuropathy or diabetic polyneuropathy undergoing neuraxial anesthesia or analgesia is high. Hence clinicians should be aware of this potentially high- risk subgroup of patients when developing and implementing a regional anesthetic care plan.Study involved general population of patients with peripheral sensorimotor neuropathy or diabetic polyneuropathy, not women with diabetes undergoing analgesia or anaesthesia.
Ramanathan,S.; Khoo,P.; Arismendy,J.{Ramanathan, 1991 35590 /id}Study Type:

Cohort

Evidence level: 2+
50 women (20 with type 1 diabetes and 30 without diabetes)20 women with type 1 diabetes and 30 women without diabetes undergoing elective caesarean section under lumbar epidural anaesthesia.

All the women were selected from the population.

The three groups were similar in age, weight and height.

Country: USA
Intervention:
The usual insulin dosage plus epidural bupivacaine before caesarean section (Group 1).

Comparison:
  1. Lactated ringer's solution plus dextrose in water (Group 2)
  2. Lactated ringer's solution alone (Group 3)
Follow-up period: Not reported

Outcome Measures:
Maternal outcomes:
  1. Maternal vital statistics
  2. Acid-base balance
  3. Glucose levels
  4. Blood lactate
  5. Blood pyruvate
  6. Blood excess lactate
  7. Lactate/pyruvate ratio
Neonatal outcomes:
  1. Neonatal complications (such as hypoglycaemia and respiratory distress)
  2. Neonatal acid-base balance
  3. Neonatal glucose levels
  4. Blood lactate
  5. Blood pyruvate
  6. Blood excess lactate
  7. Lactate/pyruvate ratio
None of the women with diabetes developed hypoglycaemia before delivery.

Seven infants in Group 1 developed (mild) hypoglycaemia which was treated only with early oral feeding.

Two infants developed hypoglycaemia within 1 hour. The remaining five infants developed hypoglcaemia at 3 hours.

Two infants from group 1 developed respiratory distress and required constant airway positive pressure breathing.

No neonatal deaths occurred.

No significant differences were observed in the maternal and neonatal blood pH, PO2, PCO2, or base excess at delivery.

At delivery the mean neonatal capillary blood glucose level (46 ± 3 mg/dL) was significantly lower than both the umbilical venous (135 ± 12 mg/dL) and arterial (103 ± 8 mg/dL) blood glucose levels in Group 1 (P = 0.01).

Maternal venous blood glucose levels were greatest in the healthy women given glucose before epidural anaesthesia.

Blood lactate level was higher in mothers in Group 1 than the corresponding levels in group 2 and 3 mothers. Neonatal umbilical venous blood in group 2 contained significantly higher levels of lactate than group 1 or 3.

Blood pyruvate:
The pyruvate levels in maternal venous blood were significantly lower in group 1 mothers than in group 2. Both the umbilical venous and arterial blood pyruvate levels in group 1 were significantly lower than the corresponding levels in then other two groups. Blood pyruvate levels in both umbilical vein and artery were greatest in group 2.

Blood Excesses lactate and lactate/pyruvate ratio: In maternal venous blood, excess lactate was significantly greater in group 1 compared to that in the other two groups. Groups 1 and 2 had greater concentrations of excess lactate in the neonatal umbilical venous blood. In the maternal venous and neonatal umbilical venous and arterial blood, lactate/pyruvate ratio was significantly greater than in group 1 than in the other groups.
The data show that epidural anaesthesia for caesarean section in women with diabetes is associated with satisfactory neonatal Apgar scores and acid-base status at the time of birth. Epidural anaesthesia in women with diabetes is associated with normal acid-base status in the mother and the neonate. In women with diabetes, there is increased incidence of neonatal hypoglycaemia and altered maternal and neonatal glycolysis.
Tsen, L.C.

2003

{Tsen, 2003 34440 /id}
Study Type: Other

Evidence Level: 3
Intervention:
Anaesthetic management of women with diabetes

Comparison:
neuraxial anaesthesia and general anaesthesia
Pregnant women with cardiac disease and diabetes or gestational diabetes. For the purposes of the review, interest lies in those women with diabetes or gestational diabetes

Country: various
Umbilical cord, fetal and neonatal acidosisNo summary statistcs providedManagement should be undertaken by a multidisciplinary teamThe paper provided an important reference to a relevant study.
Rees,G.A.; Hayes,T.M.; Pearson, J.F.

1982

{Rees, 1982 34439 /id}
Study Type: Other

Evidence Level: 3
Intervention:
Anaesthesia for pregnant women with diabetes or gestational diabetes

Comparison: The authors discuss benefits and risks accompanying: general anaesthesia regional anaesthesia epidural analgesia
Women / mothers with gestational diabetes

Country: various
Type of anaesthetic metabolic issues (hyperglycaemia vs hypoglycaemia) obstetric and medical complicationsPregnant women with diabetes should be managed in specialist centres.

The care team should include an anaesthetist

Particular attention must be paid to diagnosing women who develop gestational diabetes.
The paper was useful in providing good background information

From: Evidence tables

Cover of Diabetes in Pregnancy
Diabetes in Pregnancy: Management of Diabetes and Its Complications from Preconception to the Postnatal Period.
NICE Clinical Guidelines, No. 63.
National Collaborating Centre for Women's and Children's Health (UK).
London: RCOG Press; 2008 Mar.
Copyright © 2008, National Collaborating Centre for Women’s and Children’s Health.

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