Gestational diabetes is any degree of glucose intolerance with onset or first recognition during pregnancy.
Low Hb (6–8 g/dL), high reticulocyte count (10–20%), elevated bilirubin, presence of target cells, sickled cells, and Howell–Jolly bodies on blood film.
Untreated hypertensive patients are at significantly increased risk of stroke, myocardial infarction, heart failure, renal failure, and hypertensive retinopathy.
RA is a multi-system disease causing symmetrical deforming inflammatory polyarthropathy.
They should continue only metformin and pioglitazone as normal on the day of surgery and omit all others.
Pre-oxygenate well and maintain oxygenation with an appropriate FiO2.
Pleural effusions.
Lung function testing.
To prevent endocarditis.
They should be considered for critical care post-operatively.
Until the patient is eating and drinking.
The axis is the second cervical vertebra (C2) that forms a pivot on which C1 can rotate, allowing head movement.
The atlas is the first cervical vertebra (C1) that holds up the skull and is unique because it has no body and is fused to C2 below it.
A multimodal approach, including local anesthetic infiltration, wound catheters, regional anesthetic techniques, and the WHO analgesic ladder.
Almost 50% of people over the age of 65 have hypertension.
Topical local anaesthetic agents applied to potential venipuncture sites.
Lifestyle changes may include weight reduction, increased exercise, and dietary changes such as reducing salt intake.
Diabetes mellitus (DM) is a group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin secretion, insulin action, or both.
Type 1 diabetes is characterized by the loss of insulin-producing beta cells of the islets of Langerhans in the pancreas, usually via an immune or idiopathic mechanism. It typically presents in childhood and requires exogenous insulin administration to prevent ketosis.
Cautiously and with dose adjustments, especially in patients with renal impairment, respiratory compromise, or cognitive impairment.
They may need steroid supplementation.
Because the dose of anaesthetic agents required to induce and maintain anaesthesia decreases with age, but the deleterious cardiovascular effects increase.
To avoid precipitating a crisis.
Pulmonary hypertension.
IGT and IFG are intermediate conditions where glucose levels do not meet the criteria for diabetes but are too high to be considered normal. They indicate a high risk of developing diabetes later.
Fasting plasma glucose levels between 5.6–6.9 mmol/L.
Up to 50%.
They improve patient satisfaction but should be individualized based on factors like previous chronic pain status and renal function.
Due to the risk of gastric bleeding and nephrotoxicity. They should be used at the lowest dose and for the shortest duration, with proton pump inhibitors prescribed and U&Es monitored.
ICDs need to be turned off prior to surgery.
Primary (essential) hypertension accounts for 90% of cases.
Reduced doses should be used due to increased sensitivity and prolonged effects.
Pericardial effusions are uncommon and usually asymptomatic, but can rarely cause tamponade. Valvular or myocardial involvement is rare.
Carpal tunnel syndrome, polyneuropathy, and compression of nerves at the cord or root.
Hypertension is defined as a systolic blood pressure (SBP) >140 mmHg or a diastolic blood pressure (DBP) >90 mmHg.
It contributes to post-operative morbidity including delirium, cardiorespiratory complications, and failure to mobilize.
Atrial septal defect (ASD), ventricular septal defect (VSD), patent ductus arteriosus (PDA), and tetralogy of Fallot (TOF).
Tetralogy of Fallot (TOF).
The Sickledex test induces sickling by adding sodium metabisulfite to the sample, confirming the presence of HbS but cannot differentiate between HbAS and HbSS.
Obesity and/or learning difficulties.
Because their benefits may outweigh their risks, despite causing immunosuppression which may delay wound healing and increase the risk of infection.
Continue rheumatoid medication if possible, keep patients well hydrated and monitor renal function, give early and regular physiotherapy, and provide DVT prophylaxis while immobile.
Pressure areas must be closely monitored.
It may limit mouth opening.
Use fluid warmers and body warmers routinely and undertake intra-operative temperature monitoring.
ECG, FBC, U&Es, and blood sugar.
Sickle cell anaemia is a haemoglobinopathy with autosomal recessive inheritance caused by a point mutation on the gene coding for normal haemoglobin (HbA) on chromosome 11, resulting in the formation of an abnormal β-haemoglobin chain referred to as 'HbS'.
The lifespan of red blood cells carrying HbS is reduced, preventing the malaria parasite from completing its life cycle within the red blood cells.
Using a multimodal approach and involving the pain team.
Pain should be assessed regularly, with pain levels and sedation scores documented. Non-verbal cues should also be used due to potential cognitive impairment.
A protrusion from the upper anterior surface of C2 that sticks up through where the body of C1 should be to articulate with the anterior arch of C1.
Degeneration of the bursa next to the transverse ligament of the atlas, causing the ligament to weaken and allowing the odontoid peg to move and potentially impinge on the spinal cord.
Because large blood loss or fluid shifts are expected and/or an underlying cardiovascular disease is suspected.
Diabetic patients should be prioritized to minimize starvation time.
POCD resembles dementia and can present weeks or months after surgery, with features including changes in mood and behavior, and impairments in memory, learning, language, and motor function.
They should be administered slowly and at a reduced dose due to increased arm–brain circulation time.
They can cause circulatory stasis, leading to venous sludging and sickling.
VRIII is indicated if starvation time is expected to be more than one meal or if diabetes is decompensated.
Sickled cells obstruct blood flow to an organ or tissue, causing pain and potential organ damage.
No, homozygotes are not suitable candidates for day surgery.
Supplemental oxygen.
Hypothermia.
Amyloidosis, which can lead to renal failure.
Patients must be investigated and optimized by a cardiologist.
Because the vertebrae of C1 and C2 can move out of their correct positions and impinge on the spinal cord, leading to cord compression at a high level.
Acute confusion, disorientation, restlessness, agitation, fear, disturbed sleep, and hallucinations, often worse at night.
Other specific types include genetic defects of beta-cell function, genetic defects in insulin action, diseases of the exocrine pancreas, endocrinopathies, drug- or chemical-induced diabetes, infections, uncommon forms of immune-mediated diabetes, and other genetic syndromes sometimes associated with diabetes.
Secondary causes of hypertension include renal disease (e.g., renal artery stenosis), endocrine disease (e.g., Conn’s syndrome/phaeochromocytoma), and pregnancy-related disease (e.g., pre-eclampsia).
Steroid therapy causes thinning of the skin, making it fragile and prone to tearing.
Proteinuria and elevated serum creatinine.
It helps in discharge planning.
Good analgesia reduces catecholamine surges and minimizes oxygen consumption; these patients may be opioid tolerant and benefit from early pain management review.
Silent myocardial infarction (MI), stroke, pressure sores, infections, and ketogenesis.
It can cause hoarseness and limit airflow, potentially causing stridor in severe cases.
A pre-operative nasendoscopic assessment of the larynx by ENT surgeons.
Micrognathia, small mouth, macroglossia, and short neck can contribute to difficulties during intubation. A difficult airway trolley with appropriate emergency drugs should be ready and available.
Insulin should be prescribed according to National Patient Safety Agency (NPSA) recommendations for safe use of insulin.
Adeno-tonsillar hypertrophy and oro-pharyngeal hypotonia may lead to obstructive sleep apnoea. Features of this condition should be elicited during pre-operative assessment, and upper airway obstruction can worsen after anaesthesia and opioids, necessitating extended recovery or HDU environment post-operatively.
Partial or incomplete dislocation of the joint between the first cervical vertebra (C1, atlas) and the second cervical vertebra (C2, axis).
Type 2 diabetes is characterized by insulin resistance, which may be combined with relatively reduced insulin secretion. Main risk factors include central obesity, increasing age, and family history.
Keratoconjunctivitis sicca (dry eyes).
Electrophoresis, as it determines the type and proportion of HbS present.
Type 1 diabetes.
Re-enablement involves early mobilization, rehabilitation, physiotherapy, and occupational therapy to return a patient to their pre-operative functional level, requiring a multidisciplinary team approach.
All patients should receive a Variable Rate Intravenous Insulin Infusion (VRIII).
Blood glucose should be measured hourly.
Atlanto-axial subluxation is a condition where the first and second cervical vertebrae become misaligned, occurring in up to 25% of RA patients.
Multimodal analgesia and anti-emetics should be used.
Baseline blood pressure, as patients are prone to intra-operative hypotension.
Stroke and meningitis.
Hypoxia, acidosis, dehydration, and hypothermia.
10–20 days for sickled red blood cells compared to the normal lifespan of 120 days.
From 6 months of age, as adult haemoglobin begins to replace fetal haemoglobin, which has no β chains.
Anaemia of chronic disease and anaemia secondary to gastrointestinal blood loss caused by NSAID use.
To determine if the fall was due to a mechanical issue or a secondary cause like syncope.
Glucose levels between 7.8–11.1 mmol/L (2 hours post glucose load).
Approximately 2% of the population worldwide.
Because their autonomic responses are blunted.
Because prolonged venous stasis would result in sickling through the limb.
Stiff joint syndrome due to collagen glycosylation.
Down's syndrome is one of the most common chromosomal abnormalities, occurring in approximately 1 in 700 live births. It is due to the presence of either a whole or part of an extra 21st chromosome, termed trisomy 21.
The principles of the Enhanced Recovery Programme should be implemented.
Key considerations include atlanto-axial and atlanto-occipital instability, micrognathia, small mouth, macroglossia, short neck, excessive salivation, adeno-tonsillar hypertrophy, oro-pharyngeal hypotonia, and subglottic and tracheal stenosis.
Blood glucose levels rise.
Revert back to their regular medication, with possible dose adjustments and a period of overlap between VRIII and subcutaneous insulin administration.
A point mutation on the gene coding for normal haemoglobin (HbA) on chromosome 11, causing the substitution of valine for glutamic acid at position 6 on the β-haemoglobin chain.
Proliferative retinopathy.
In homozygotes, HbS polymerises at PaO2 between 5 and 6 kPa, while in heterozygotes, sickling occurs at much lower PaO2 of 2–3 kPa.
Sickled blood cells increase blood viscosity, reduce flow, and occlude smaller capillaries, causing venous thrombosis and distal organ infarcts. They also have a reduced lifespan of 10–20 days, leading to anaemia and jaundice.
Periods where the disease worsens in homozygotes with sickle cell disease.
It is a thick, strap-like ligament attached to each side of the anterior arch of the atlas, looping behind the odontoid peg to hold it snugly against the arch.
Diabetic ketoacidosis (DKA), hyperosmolar non-ketotic state (Honk), and hypoglycaemia.
Drugs, infection, metabolic imbalances, hypoperfusion, hypoxia/hypercarbia, and pain.
Gastro-oesophageal reflux, duodenal atresia, and gastric paresis.
Use fluid warmers and warming blankets, and minimize shivering to reduce oxygen consumption.
Veins are more mobile, cannulas are more prone to tissuing, and skin is more prone to damage on removal of cannula dressings.
Good nutrition facilitates healing and recovery.
Most patients have infarcted their spleens by an early age, increasing their risk of infections.
Hypertension and left ventricular hypertrophy.
Haematuria, renal failure secondary to acute papillary necrosis, and priapism.
Symptoms are actually rare, even though atlanto-axial subluxation is reasonably common on X-ray.
Women are more commonly affected than men.
Type 2 diabetes.
They should continue intermediate or long-acting insulins and either halve or omit short-acting insulins, depending on the type of insulin regimen.
Because age causes a gradual increase in closing capacity, increasing the risk of desaturation.
To identify early onset dementia and memory impairment.
Use manual in-line stabilisation when manipulating the airway and consider awake fibre-optic intubation.
Reduce VRIII to 0.5 mL/h and administer 10% dextrose. Stop the infusion only if a long-acting insulin has been continued.
Painful splenic enlargement results in anaemia and abdominal distension, managed supportively.
Infection with parvovirus B19, which arrests red cell production for 2-3 days.
Deformity of skull and long bones secondary to compensatory hyperplasia, bone pain, osteomyelitis commonly caused by Salmonella, and avascular necrosis, most commonly affecting the hip joint.
Pacemakers should have been checked within the last 6 months.
GORD can increase the risk of aspiration during surgery.
Stage 1 (mild): 140–159/90–99 mmHg, Stage 2 (moderate): 160–179/100–109 mmHg, Stage 3 (severe): 180–209/110–119 mmHg, Stage 4: >210/>120 mmHg, Isolated systolic hypertension: >150/<90 mmHg.
Postural hypotension and impaired gastric motility.
Increased risk of tissue damage and ulceration.
Reduced homeostatic compensation for blood and/or fluid loss, and patients may be prone to both dehydration and fluid overload.
Maintain blood glucose during fasting, correct metabolic derangements, ensure good glycaemic control, and manage post-operative fluid/nutrition intake.
Excessive salivation can obscure the view during laryngoscopy and pose an aspiration risk. Pre-medicating with an anti-sialogogue should be considered.
Involve the haematology team, assess disease severity, aim for HbS <40% and Hb 10–12 g/dL for major surgery, cross-match blood early, ensure vaccinations and regular penicillin and folic acid, keep nil by mouth duration minimal, and avoid sedatives.
Joint replacements can affect the placement of the diathermy pad and patient positioning for surgery.
Polypharmacy is common and there is an increased risk of drug interactions.
Check blood and urinary ketones. If <3+, administer subcutaneous insulin and reassess; if >3+, cancel surgery and treat as diabetic ketoacidosis (DKA).
Edentulous patients are more difficult to face-mask ventilate, and neck stiffness, cervical spondylosis, or arthritis may limit neck extension, making airway maintenance and intubation more difficult.
Assess the patient's range of neck movement and consider cervical spine X-rays if there is any doubt about neck stability.
A gap of >3 mm between the odontoid peg and the arch of the atlas in lateral flexion.
Poor pre-operative glycaemic control is associated with greater post-operative mortality and morbidity.
0.45% sodium chloride with 5% glucose and either 0.15% potassium chloride (KCl) or 0.3% KCl.
Subglottic and tracheal stenosis in patients with Down's syndrome may necessitate the use of a smaller than predicted endotracheal tube.
Acute sequestration syndrome of red blood cells in the liver or spleen, haemosiderosis secondary to repeated transfusions, and gallstones secondary to chronic haemolysis.
Consider early nasogastric tube (NGT) placement, pre-medicating with prokinetic agents and antacids, and/or using a rapid sequence induction technique.
Obesity, increased incidence of hypothyroidism, impaired immunity, increased incidence of leukaemia, and increased incidence of hepatitis B.
It provides an indication of cardiopulmonary reserve.
Give intravenous fluids to maintain hydration and prevent venous sludging.
The primary cause of Down's syndrome is non-disjunction of the chromosomes (95%), but it can also be due to translocation.
The technique used must be administered responsively, taking into account the patient’s physiological status.
Great care must be taken when positioning the head during intubation due to atlanto-axial and atlanto-occipital instability. Pre-operative symptoms of spinal cord compression should be assessed, and flexion-extension views of the C-spine may be considered.
Splenic infarction increases the risk, necessitating vaccination and daily oral penicillin.
Accelerated atherosclerosis, cerebrovascular disease, coronary artery disease, hypertension, and peripheral vascular disease.
Due to stiffness, deformity, joint pain, and lack of fine motor control.
To protect pressure points with adequate padding as the risk of neuropraxia and pressure sores is increased.
Determine the severity of systemic complications, assess blood glucose control, and exclude ketoacidosis.
Short-acting agents like desflurane and sevoflurane, as MAC is reduced in the elderly.
Glycosylated haemoglobin (HbA1c) levels.
The rate of red cell breakdown increases, usually seen in those with co-existing G6PD deficiency.
At low partial pressures of oxygen, deoxygenated HbS polymerises, becomes insoluble, and precipitates to form elongated crystals or 'tactoids', causing red blood cells to become rigid and form a 'sickle' shape.
Classes of antihypertensive medication include diuretics (e.g., bendroflumethiazide), β-adrenoceptor antagonists (e.g., atenolol), angiotensin-converting enzyme inhibitors (e.g., ramipril), angiotensin II inhibitors (e.g., losartan), calcium channel antagonists (e.g., amlodipine), α-adrenoceptor antagonists (e.g., doxazosin), and potassium channel activators (e.g., nicorandil).
The target blood glucose should be 6–10 mmol/L, with an acceptable range of 4–12 mmol/L.
Patients with Down's syndrome may have learning difficulties, leading to anxiety and uncooperativeness. Establishing rapport, tailoring explanations to their level of understanding, and considering pre-medication with an anxiolytic or sedative agent can help.
Homozygotes (HbSS) have only abnormal haemoglobin, while heterozygotes (HbAS) have both abnormal and normal haemoglobin and are said to have 'sickle cell trait'.
25% of West Africans, 10% of African Americans, and those of East Indian, Middle Eastern, and Mediterranean origin.
Acute chest syndrome, which manifests as pleuritic pain, cough, dyspnoea, haemoptysis, and fever. Recurrent episodes can lead to pulmonary hypertension and chronic respiratory failure.
Ulceration.
Opioid tolerance and pain management issues.
