Dr.s.sivakumar m.d anesthesiology(III year) Kilpauk medical college 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: 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

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 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.

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 2 3 Total INJ. EPHEDRINE 0 dose Count 4 12 18 % within Group 20.0% 60.0% 36.0% 1 dose 8 15 15.0% 40.0% 30.0% 2 dose 5 9 25.0% .0% 18.0% 3 dose 6 12.0% 4 dose 10.0% 4.0% 20 10 50 100.0%

INJ. ATROP * Group Crosstabulation   Group 1 2 3 Total INJ. ATROP 0 dose Count 5 19 27 % within Group 15.0% 50.0% 95.0% 54.0% 0dose .0% 30.0% 6.0% 1 dose 9 12 45.0% 20.0% 5.0% 24.0% 2 dose 2.0% nil 7 35.0% 14.0% 20 10 50 100.0%

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.