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Glycemic control neonates post cardiac surgery.

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GLYCEMIC CONTROL IN POST CONGENITAL CARDIAC SURGERY IN NEONATES

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Glycemic control neonates post cardiac surgery.

  1. 1. GLYCEMIC CONTROL IN POST CONGENITAL CARDIAC SURGERIES IN NEONATES PRESENTED BY PRASANTH.K NURSING OFFICER, CTVS ICU , AIIMS, NEWDELHI MSC IN CARDIOVASCULAR AND THORACIC SCIENCE NURSING (Narayana Hrudayalaya College of Nursing Bangalore)
  2. 2. 1. BACK GROUND AND EPIDEMIOLOGY • Hyperglycemia is common in nondiabetic critically ill patients admitted to adult and pediatric intensive care units (ICUs).
  3. 3. FACTORS AFFECTING INTRA OPERATIVE GLUCOSE CONTROL
  4. 4. • Cardiopulmonary pump (CPB) prime fluid composition • Temperature while on CPB • Medications such as catecholamines and glucocorticoids.
  5. 5. • Glucose withdrawal during pediatric cardiac surgery induces threatening hypoglycemia during the prebypass period, and moderate intraoperative glucose administration (2.5 mg/kg/min) is not responsible for major hyperglycemia.
  6. 6. • Intraoperative glucose control has a significant impact on postoperative outcomes. • No optimal intraoperative or immediate postoperative insulin regimen has been identified.
  7. 7. PREDISPOSING FACTORS
  8. 8. PREDISPOSING FACTORS • Stress hyperglycemia is mainly caused by six events: • Severe trauma • Bleeding • Hypothermia • Septicemia • Severe burns • Great-magnitude surgeries
  9. 9. PHYSIOLOGY BEHIND HYPERGLYCEMIA POST CARDIAC SURGERY IN PEDIATRIC POPULATION
  10. 10. • In cardiac surgery, hyperglycemia is a common occurrence in patients with and without diabetes. • For many years, stress-induced hyperglycemia was considered an adaptive and beneficial response of the organism.
  11. 11. • Stress hyperglycemia is defined as an elevation of plasma glucose levels (above 126 mg/dl in fasting condition or 200 mg/dl at any time) in critically ill or hospitalized patients, with or without history of diabetes.
  12. 12. • Stress hyperglycemia is caused mainly by the effects of counter-regulatory hormones (catecholamines, growth hormone, and cortisol) and by depletion of the functional reserve of the beta-cells in the Langerhans islets of the pancreas.
  13. 13. • Previously diagnosed with Diabetes Mellitus
  14. 14. Acute pain Which inhibits the suppression of endogenous glucose by insulin; in addition, it releases diverse acute-stress hormones that contribute hyperglycemia, such as cortisol, glucagon, growth hormone, etc.
  15. 15. Exogenous factors Hypothermia, especially present in coronary bypass surgery due to cardioplegic solutions, provokes hyperglycemia by inhibiting the negative-feedback of the insulin response Desaturation and arterial hypoxemia, increase a sympathetic autonomous response that favors glucagon release by an alpha-receptor action.
  16. 16. • Many drugs commonly used with inpatient care might modify glucose metabolism. Some of them are well known as ‘diabetogenic’ medications such as glucocorticoids and opiates.
  17. 17. • Every synthetic catecholamine or catecholamine-agonist or blocker (such as epinephrine, norepinephrine, salbutamol, metoprolol, propanolol) and tricyclic antidepressants, might elevate glucose levels
  18. 18. • In children undergoing complex congenital heart surgery, the optimal postoperative glucose range may be 110 to 126 mg/dL
  19. 19. • An intravenous infusion of regular human insulin at the lowest dose necessary to achieve normoglycemia (defined as a blood glucose level of 80 to 110 mg per deciliter [4.4 to 6.1 mmol per liter]).
  20. 20. CGM – continuous glucose monitoring • CGM is a way to measure glucose levels in real-time throughout the day and night. • Microdialysis system
  21. 21. LEVEL OF HYPOGLYCEMIA BLOOD GLUCOSE LEVEL SERIOUSNESS 1. SEVERE HYPOGLYCEMIA <40 MG PER DECILITER SERIOUS 2. MILD HYPOGLYCEMIA 50 TO 59 MG PER DECILITER / 2.8 TO 3.3 MMOL PER LITER MODERATELY SERIOUS 3. MODERATE HYPOGLYCEMIA 40 TO 49 MG PER DECILITER /2.2 TO 2.7 MMOL PER LITER NO SERIOUS
  22. 22. • 1. Babies on continuous insulin therapy • Monitor for hypoglycemic signs and symptoms • Intermittent glucose monitoring/continuous with the help of a CGM device • Care of monitoring devise – check and change the position of probe on skin • Preserve sterile field under and around (use of drape) on the devise connected on central lines.
  23. 23. HYPOGLYCEMIA • Neonatal hypoglycemia, defined as a plasma glucose level of less than 30 mg/dL (1.65 mmol/L) in the first 24 hours of life and less than 45 mg/dL (2.5 mmol/L)
  24. 24. EARLY RECOGNITION Signs and symptoms • Infants in the first or second day of life may be asymptomatic or may have life-threatening central nervous system (CNS) and cardiopulmonary disturbances. Symptoms can include the following: • Hypotonia • Lethargy, apathy • Poor feeding • Jitteriness, seizures • Congestive heart failure • Cyanosis • Apnea • Hypothermia
  25. 25. Clinical manifestations of hypoglycorrhachia or neuroglycopenia • Headache • Mental confusion, staring, behavioral changes, difficulty concentrating • Visual disturbances (eg, decreased acuity, diplopia) • Dysarthria • Seizures • Ataxia, somnolence, coma • Stroke (hemiplegia, aphasia), paresthesias, dizziness, amnesia, decerebrate or decorticate posturing
  26. 26. MANAGEMENT PREVENTIVE MANAGEMENT • Early feeding :EBM, substitutes • Other natural fruit juices
  27. 27. MEDICAL MANAGEMENT • Oral • RT • IV • Drugs – Dextrose – glucagon
  28. 28. Post cardiac surgery • Babies on continuous insulin therapy • Monitor for hypoglycemic signs and symptoms • Intermittent glucose monitoring/continuous with the help of a CGM device • Care of monitoring devise – check and change the position of probe on skin • Preserve sterile field under and around (use of drape) on the devise connected on central lines.
  29. 29. CONCLUSION • Prevention better than managing • Assess in totality • Monitor regularly • Cautious use of drugs • Optimization of catecholamines. • Patient tailored treatment
  • EslamRashid1

    Aug. 18, 2018

GLYCEMIC CONTROL IN POST CONGENITAL CARDIAC SURGERY IN NEONATES

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