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Pre Operative Evaluation of Diabetic Patients

Sep 28 | 1:30 PM

The basics of a preoperative evaluation is a detailed history and physical examination to assess the possible complications the patient may have post-operatively, especially the cardiac, pulmonary and infectious complications. These risk factors automatically increase if the patient is a diabetic. Let’s find out what extra measures need to be added to the preoperative evaluation of a diabetic patient to avoid these postoperative risks.

[Music] uh good evening everyone i am dr nivedita from netflix and on behalf of team netflix i welcome you all uh this evening for today's talk on um pre-operative evaluation of diabetic patients by doctor left and colonel ashitosh is currently a professor at um kj samaya um college mumbai he has over a decade of teaching experience and along with that he also has multiple publications in both national as well as international uh journals thank you very much madam it is always pleasure to interact with as many students and the classroom is a small well well the today's uh the world has expanded where we can interact more and more often yes i am lucky that i have been chosen to give the 50th talk i never knew it will be the 50th but it is always pleasure before that i make this disclaimer and disclosure this is purely an academic exercise to help resident doctors and students as i am a teacher internist and defense pensioner for my living there is no grant gift on errarium is received from any source and the whole thing is voluntary up to date to my best knowledge and belief and i encourage you to check the facts and further as well this is my disclaimer and disclosure i will be talking only evidence based medicine nothing more than that because today's world we are totally evidence based and our delivery of health care is questioned at multiple angles first thing we must understand the diabetes is a worldwide disclosure it has got huge growth in the therapy growth in the understanding and nevertheless what is the problem that in spite of adequate control there are minor metabolic abnormalities which keep occurring and that is why the patients of diabetes have got more surgical complications more surgical requirement compared to the normal population if you take the figures from the u.s data what they have come out that we have certain seven times more chances to have the surgical requirement and surgical procedures in a diabetic patient rather than non-hazard so we will have to address this population and which is within our domain and as i go ahead i will make it simple so that you can definitely get better first we understand two very important concept first is the stress hyperglycemia and then two diabetes the his surgical procedure has got inherent metabolic effect particularly there is surgery of catecholamines the research of the fear factor the research of the other degrees of the healing endorphins and lastly alteration in the metabolic medial due to the fasting sometime due to the zealous overzealous administration of the iv fluid and so on so what i want to understand here that the stress hyperglycemia the severity of stress hyperglycemia depends on the severity of surgery and in the stiffness of the procedure duration and high prevalence is found in the cases of cardiac surgery so other is factors what we know as even the steroids are introduced sometime in the therapy so this all has to be the boning mind the every hyperglycemia you find may not be diabetes that is why ada defines it it is a transient hyperglycemia in a previously non-diabetic patient during acute illness or invasive procedure so in this condition long-term therapy and long-term complications are far less compared to diabetes second issue is undiagnosed pre-existing diabetes there are lot many studies that are done but i have taken this european union study what they have said said that in a 48 hospital patient 19 with known diabetes and 47 percent underweight surgery skinny and found to be having diabetes and for that also more stressful means that more than 10 millimole per day deciliter of the milliliters of the blood sugar means at least 180 milligram of sugar and hyperglycemia was noted in 40 of the diabetes and then after six percent of non-diabetes so what i want to emphasize that don't take it as a stress hyperglycemia don't take it as at the diabetes first identify what is what and for that one of the important things is hba1c if you have got hba1c at your hand you basically try to understand that the three-month hyperglycemia is therefore based on the hb a1c more than 6.5 you can easily understand these are you are dealing with the diabetes rather than only high stress hyperglycemia this test is available off hand and it is a very safe not related to food and meals which can be done with that interestingly all of the european countries where the surgery has been done so that is why we have to do it and it solves our one of the major problem when you evaluate a person you have to know what is the true glycemic control and for that reason you have to do hb a1c that is the chronic control it gives you idea how much the tissue glycation has occurred how delayed healing is expected and how much surgical complication are expected including the effective complications how in group glucose monitoring real-time glucose monitoring has got tremendous effect there are substantial presentations available and reported in which what they are saying that the acute control is adequately done definitely can prevent mobility there is in between also the patient for three months you are assessing with the hba1c for uh acute care you are assessing with the sugar values but if there is in between that is the protrusion levels and for prostamine levels serum glucosamine levels now which can give you idea what was the level of control in three weeks so what you know that hba1c is decent uh i mean is bad and sugars are bad you understand you are not dealing with a very high glucose load but a intermediate problem a week or 10 days or like that if you know how much wrong then accordingly you can put your effort to kill that patient with your wisdom and continuous here here so once you know the status what you have to do hb1c how dangerous it is this is very interesting study what have they there is in which what it is conveyed that is the british journal of anesthesiology what they have said that higher the hba1c more is the morbidity mortality increased risk of infarction and postpartum infections post of operating infections this goes without saying that hyperglycemia is a inhibitor to the neutrophils and it impedes the dietary disease it causes more of the problem of the care in the most of the cases so that is why this study which has been published what they have talked to that five one percent increase of hba1c increases the risk by more than 40 percent above the 7.1 degrees thing what is this important if it is more than 7.8 means that and more than 250 of the sugar abg average blood glucose there is five times complication expected compared to the adequately controlled okay after assessing how much is the problem you come to how what is the recent blood glucose levels for that you have to do the easiest and most uh available thing is continuous glucose monitoring devices in which you can get a real-time 24-hour request and it is available now within the country with the reader in which you can know that second issue is with the cgn you can also find out the glucose excursions if glucose is questions also you are noting and you are noting then you can easily identify the brittle diabetes you can easily identify the diabetes which is low sugar levels and like that so for that region you have to do cgf but ccm is not available across the country it is available in the metropolis and few of the large centers for in this condition at least three four readings if it is there it will give you idea how to go about that this study i have quoted it was published american foreign society in 1999 more than 10 000 people this is very valuable and they have come to the conclusion if better control is far superior to the sub-optimal control and too tight control also has got associated increased mortality so based on that they have come to the conclusion coming to that the glycemic history is very very important the glycemic history that is the hyperglycemic history as well as higher hypoglycemia because they are the ones who these acute events will not be reflected in the hba1 series because it is a transient reading and we say someday the patient has got 600 of sugar and he required additional insulin for a short period of time or the patient who had got hypoglycemia three days back he has come for surgery if you are not attending to it you are further causing the hypoglycemia and which can be detrimental to the patient as well as the surgical outcome so that is why we have to take the history of hyperglycemia and hypoglycemic episodes if any or if they are none at least you ask the two three relatives about the different things which are there in the house such as he is asking of the food or he has come sweating he has got certain ethanol or some erratic believer these all are the hypoglycemic episodes neuroglycopenic symptoms sometimes noticed by the relatives compared to the patient next important aspect is the for the surgical safety you require adequate propulsion and particularly there are chances of aspiration so gastroparesis is associated with 30 to 50 percent of the cases of type 1 or type 2 and that is why the gastroparesis history should be taken and if you there is it should be adequately treated the pro kinetics the host of pro kinetics are is nearly safe they prevent aspiration they prevent the surgical complication and if you have got the patient giving history of abdominal pain abdominal bloating early satiety a slowing organization or a diarrheal episode in between with obstetrician these are the ones in which there is the associated gi autonomic dysfunctions and that is why you have to be careful while evaluating these patients and particularly if certain things are so obvious the association with the election erectile dysfunction and gastroparesis is so strong that if you get the history you should anticipate this complication and if you address definitely you are heading to a better surgical outcome cardiovascular risk in diabetes is far far higher there are multiple first is the cardiovascular history particularly the silent hemi is far far more common that is 30 times more common in the diabetic of population compared even the asymptomatic a symptomatic cardiovascular illnesses are perfectly common rhythm disturbances are again 13 times more common than the normal population the gradient episodes are again nine times more common than the other population so that is why it is always wise to take the cardiovascular history and history it may not be coming as our patients in india are not so prudent to give this history that is why the simplest one albuminuria association and what we find if there is the micro albumin area the severe risk is far far higher okay next the heart disease particularly the risk factors if there are the silent myocardial infarction or overt myocardial infarction or there is the asymptomatic cardiovascular illness these are the ones who have got more catastrophic event related to invasive surgery or anesthesia episodes in this study which was published what they have come to the conclusion that the diabetic cardiovascular morbidity and mortality are more than 30 times to the normal population and this has been published and it is well recognized based on that the rigid evaluation guideline which has come up previously only ecg was accepted screening investigation on the top eco serum bmp level and in selected group of cases uh coronary angiography the stress-related studies nuclear cardiac studies and ct and you are helping us out it goes without saying that our patient which was only evaluated with the uh history and clinical examination exactly clearing this patient for the surgery in the background of diabetes is far far difficult the bnp is the brain nitric peptide which is used as the marker for the heart failure so that is why we have to evaluate this patient on those lines the diabetic nephropathy is far far common and that is why the association of diabetic nephropathy and serious illnesses are very common and in these conditions we have to look after them on those lines the first and foremost thing you have to look after in this group of patients is doing routine urine examination and routine urine examination you the easiest one to find is the protein [Music] and even over protein urea that is the milky urine or partial milky urine what you know is very rare or even removed so what is the call of the day we have to take it with the micro albumin area and adp treatment can go with that what is the association of the macro microwave and related tubular dysfunction due to persistent ischemia is well elucidated we what do you know that the even microbiologic patients have got more vulnerability if there is even little bit of the hypotension they go in atn and there is the associated complication so these are the small tests which can give you the wealth of information when you have got the urine examination the urine examination must be along with that you should do the serum creatinine and with this serum creatinine weight and the volumes you can easily calculate easy effort and then you have can understand the renal physiological reserve of that patient and based on that you can offer the series of therapy particularly the fluid management the antibiotic management and other things the other test you should do is the hemoglobin you should do ultrasound kidneys in which you find that the increased particularly permanently different differentiation and with the normal size or increase side kidney albumin creatinine ratio it is easily available even with the point of care test or there is the uh point of clear test or there is available so that is a very small effort test which can give you volume of information in the treating the station cultures are important often ignored the history of if there is the obstruction that you are taking for a major surgery the history of dysuria or even increased frequency we should not sigh of the culture many of the centers what they have done very catheterization cultural studies they have noted many of these patients were harboring infection and they were not sought for and then after this infection was missed so that is why we must understand the value of culture because the diabetic kidney and diabetic person has got 15 times more chances of uti lifetime compared to non-diabetes lastly the growth of this alt2 inhibitors has also increased the chances of the uti and in this scenario it is advocated that the cultures must be done when you are treating this patient you are evaluating you are evaluating the major organs particularly with the b peoples or and you are taking the important aspect which is particularly very very important is the management of treatment fasting and anesthesia these are the three things around which our suggestion has got the paramount but unfortunately the the other consideration overtakes and then the catastrophes are expected management of treatment one thing we must understand the insulin is the most physiological treatment for diabetes and it has got anabolic action it has got the it decreases the catabolic levels it decreases the oxidative stress it helps in healing and over and above it improves the glycemic control with the expected lines compared to other drugs so if you are having a patient which is on other drugs or therapies and he is affordable observable and available to you it is wise to put him on insulin for a small period of time till the surgery and the things are over coming to the fasting all the surgery major surgery involving the anesthesia general anesthesia or the extended anesthesia they prefer fasting because they don't want aspiration the challenge of glycemic control and fasting is something like walking on the type if you are not adequately controlling the sugar you are making him vulnerable to the morbidities and associated mortalities the problem is if you are causing the very good control with your effort what you are making him even minor fasting can lead to hypoglycemia and associated with the catecholamine surge and so what is the crux line the fasting should be minimized it should be planned the surgery patients in with diabetes should be the first in the morning and as the surgery completes and adequate safety is ensured means they are galloping and they are you know in full sensorium maybe they should be offered something to eat and that can help you gastroparetic issues it helps in the metabolic complications and what now the call of the day in the anesthesia they are also coming and they are now more sensitive to the targeted therapy and now the general anesthesia is underplayed and regional anesthesia with minimum complications are followed by in these conditions particularly the diabetes where you are knowing that the disorder particularly cardiac disorder with associated five times increased arrhythmia and nine times the radiation features or there is the greater diabetes with the hypoglycemic history these 100 complications are there if anesthesia can become this painful it can become the targeted definitely the patient pairs so that is why it is something that it is desired and their efforts this anaesthetist friends have definitely can say valuable lives okay this is the chart again taken from the european guidelines french association guideline i will request you to zoom in and zoom out so that you can understand it better the pre transient period hba1c should be better hba1c related complications uh hb1c measurement must be done capillary sugar should be done at arrival of the unit fasting rule should be applied the normal normal dinner the day before and if there is a gastroparetic patient a gastroparesis patient you can again go with the other guideline second is the liberal fluid particularly in the day of surgery and what it is important that the there should not be the my miser approach towards the fluidity because what happens that they're in this autonomy the perfusion is impaired and in decreased perfusion again is a glycemic rays which is a challenge the usual dose of insulin in the evening should be offered and that is why it should be given to the patient there is no personal correction or protocol if there is something like that particularly if you are taking somebody on long acting incident to the short acting incident the chart should be very laid down and that should be decided and thought of at least 10 millimeters of sugars are there means that the 180 and above sugars are there then only you fiddle with it otherwise you go with the old one or the second issue is you go with the shorter acting insulin because the longer acting insulin has got the longer complication and more unexpected control than the shorter acting this chart it is again taken from the european french collaborative study this is very very handy we have been using it in our hospital and with very nice results now you come to the second aspect that is pre-operative prescription what you know that the metformin should be avoided a day before the rest sulfuramide to be avoided before rest everything should be given except on the day of surgery okay so that is you have to understand and what is the two things again which is uh avoided that is the metformin and long-acting sulfonamides sulfur sulphur drugs so but these are the two ones which we have to avoid a debris and if we know that the duration of the surgery associated complication we can plan the switch of the patient on these drugs to the short acting insulin where we can have better control and greater understanding and go with that so what are the two drugs glp analogues insulins and second is the metformin and sulfonamides insulin analog particularly the long-acting analogues because you cannot afford to be on the drug which is having very long effect when you have got this fasting rule supply normal dinner then after the usual doses of sensory and capillary glucose level you have to do and this is the pre-operative pda protocols when you have the patient needs to be left with the empty stomach but it is recommended that the glucose infusion should be offered to the people who are taking sulfonylureas early nights before the emergency circuit or many of them may require in the long run so that is why we should be prepared with this insulin and we should be prepared with the fasting management which is often ignored in some of the cases i invite you to kindly zoom out this thing uh chart again from the european diabetes association and french collaborative study what is the target the target is very liberal and the target is that less than 180 diabetes is not contraindication of any of the ambulatory research it is only require the caution there is no contraindication it can be offered for that secondly when you are doing a major plant surgery don't try heroics because if you decrease the sugar very fast the associated metabolic problem and the physical problem is still an unaddressed and then after due to this unattended problems what happens that the metabolic complications are far higher so whenever you have got the these type of patient you have to have the protocol right and the right protocol is adhere to the energy assess and optimize or de-escalate based on the patient's condition requirement of safety and your wisdom when in pre-operative period ah you have to again this is i have broken into parts so that it is easy to do it when you are taking the patient for the surgery what is the most advisable thing the most advisable thing put it in the inside and incident should be ultra rapid one you will start with the concentration of very one international unit for every 50 the moment it is less than 150 of the sugar you have to go with the dextrose line so that you have what the control of the glycemia simultaneously you you have got at hand with opportunity to uh prevent hypoglycemia so that is the way you have to go around and that can help you a lot in achieving the desired goal second issue is whenever you are having the hyperglycemia with ketosis and in that condition in those condition the boulders and then is the infusion is mandated but unfortunately i am not covering that because the acute care is quite different and planned surgery where the outcome desired is we require as safe at an airline means 100 everybody should be controlled these guidelines and that is why we have to go slow ultra lengthy and low flow and at hand the dextrose line to check us when we are offline this is the important one to understand when you are having the research it is dangerous but maniest person so that is why when the patient is taking over the patient is given what you have to do you have to be careful about the insulin takeover insulin handover and going with that when first day when the patient comes back please feel free to calculate the sugars as sugars and if the moment sugars are the sugars are being controlled sugar and that is how the very operative control can be done and if we are liberal enough we can and with the insulin we have to have bedside monitoring otherwise it will be a bad situation when you are giving the patient gdm is again a very complex situation but i will come to very small three tips the first tip is that the sugar very high sugar is associated with very quantum complication that is why anytime above 200 you have to control the fast acting faster and slowly with that second issue is use whatever the patient was on the insulin you change your work to that that is the ultra limiting because you cannot the moment the fetus is out these people behave like and many times we miss this hypoglycemic episode and many times associated metabolic insults in this patient so what is the gdm is you have a something burning fireball which is after that it is going to cool down how much cooldown cooling down period we are aware that it will be very less and that is why more conditioning more look after that is important and don't fight to stop immediately if there are the conditions don't be because sister will say it is that so don't forget to do that you understand what is happening and the best advice is the capillary capillary and then that is the very important point and how to go about that that you treat the patient and he must you go with that with the modification it is not that you change all the therapy all again for a surgical cause and it should be continued so what is the conclusion i have given you the very practically most of them are from the french american french collaborative guidelines which came into 2018 so competency very nice the first thing is that it should be simple it should not be complex the very operative thing should be simple we must understand life and limb are more important than the important pressing mobility and that is why don't be under special to do the things heroics rather than differ the things which can be optimized is the one if you can optimize control of sugar optimize control of protein ingredients optimize control of that pressure or you can plan the antibacterials you can plan the robotic events it is far far better than going with heroic short-term measures the patient can come to you after a much safer condition much better condition and you can offer monitoring is the key the more you monitor the less complication you miss and that is why it is very very important liberal antibody in antibiotics is a debatable issue the diabetics are not all time requiring lot of antibiotics they should be on the event based need based and even very operating flu shots are good enough compared to the other support is important the patient has to be supported throughout he has to be monitored he has to be explained and then after he should treat adequately if he has come with the fresh diabetes he has to be evaluated on all the target objective treat the all the diseases if he has got the capital thank you so that was an amazing presentation i'm sure our audience really learned a lot from that i'll stop the slide now and we can start with the questions uh so we have uh okay so how frequently should a sugar reading be taken this is very pertinent question and really practical question you have to take the readings at least you first and foremost is that you evaluate the pre-operative levels the three things i have advocated is the hba1c then after so that you are aware what is happening when you are sending somebody to the ot they will always take morning sugar fasting and then after pre-operatively [Music] [Music] on the cooperative day and at least three to four times on subsequent weekly most of the days then only the optimum can be possible but mostly the high five hospitals there is cgm system in which you were getting the readings as quickly as five minutes or ten minutes later and in those condition definitely they are all better to my advocacy on the day at least five times on next after at least three times two days and then after you you know optimize the therapy and even once the patient is taking food adequately you can go under a fixed rate [Music] the other question is what is the difference between capillary glucose and blood glucose it is almost same don't worry about that it is one and the same so that is don't worry there is difference of at least 10 milligrams per deciliter particularly in severe hypoglycemia this matters because blood glucose is little higher than the capillary one but in routine practice it is then we have uh please put some light on hemoglobin levels and nephropathy correlation the nephropathy and hemoglobin [Music] so that is why you when you have got the stage two or even stage three you have to assess these patients with the hemoglobin epo and don't get psy away if you keep your patient at 11 grand this is the advocacy of the european union association as well as indian society of neurology the real uh that deterioration of property speaking is quite simple but in clinical practice you will get the ckd patient six to nine most of them if you [Music] uh then we have a question a pre-operative and post-operative diabetic treatment for cataract operation okay surgery it is a basically local anesthesia but the problem with the diabetes important is this oculop the microvascular complication and as well as the anterior sampler increased pressure so when you are giving fitness for somebody for the cataract surgery and diabetes you must explain to them that you want a great link you want a good real support which should be adequate and also you get him or her assessed for the intraocular pressure so these are the three things you should be careful about was going about with the optimal control of the sugar it remains one and the same it should be less than 180 all the time so that is the way you should go in cataract surgery you must ask intraocular pressure because if you are not asking many of your patients may not be doing so that is another advocacy associated with that uh difference between dawn phenomenon phenomena very nice is defined in early morning hypoglycemia what is happening that is the if there is hypoglycemia there is a reflex hyperplasia so that is why three o'clock sugar should be done what is happening low very operatively if you find the sugars are high then these must be tested and in today's world nobody is speaking a patient at p o block to do this what it is that we have to adhere to the hba1c tables and levels which can give us fairly good idea to what we are doing uh so there's one of our doctors who wants a book suggestion on perioperative medicine so if you have any uh suggestions for a book on theory operative medicine actually really operative medicine books are many available and uh chapters valuable four chapters in harrison also there is a very operative management is given but i specific book i don't know but i will suggest one book which is quite good and we are very vigilant and in spite of making losses we are updating the book like anything that is the practical management of diabetes by um and i also did a few chapters in that but this is a very good book we are very vigilant and it has got in that 20 years it has got eight edition you can understand how we are so this is the one book i will recommend it is very small and it covers almost most part of that and if you want to only diabetes you want to concentrate even the rsbi textbook of medicine also has got the three very valuable chapters which is useful then we have uh someone who wants a little bit of highlight on post covert 19 diabetes in young there are three things three categorical statement and scientific statement i want to make first and foremost that the rna virus are diabetogenic their infections are going to happen and is one second issue is the long-term steroid induced the problem and third is weed has worsened the diabetes so what in today's scenario the people who are on sitting with the leaf half covered have become over gravity the people who have gone sub optimally managed have become a complicated who have been non-diabetic they have become diabetic and people who have been given a steroid for some uh sub-optimal reasons they have become bad habits so that is the how the kuvid has played but many of you may not agree with me that in making a statement that itself again i also not agreeing to exist but rna viruses are known to precipitate that [Music] uh then what are the cardiac complex complications that we should be prepared for the cardiac complication we have already talked about is the failures are more common we the completed failures particularly the there are the rhythm is known with the diabetics quite often for that we are doing ecg some of them may require halter also and if you have got history of silent ischemia or the uh inappropriate dyspnea or like pictures it is always advocated you go for the ngos this is the way it is the evaluation should be thorough even if you will know the depth of the water that is where it is the issue is the one thing which we in india hardly we are very emphatic on is the cardiac autonomic neuropathy and that is one of the thing which is gone it is advocated in india also we do it heart rate variable study and it will predict the outcome in view of the arrhythmias associated with the diabetes so that is also an advocacy so there is the if you take it as in total the diabetes causes everything it is causes the bone failure it causes the vascular issues such as the myocardial infarction it causes the arrhythmias and it is also causes the failure so that is the way you should evaluate you should evaluate on all three angles and then after you will be justified in optimizing the correctly and outcome uh then there's another question um how to manage your patient with higher h1 or be uh higher hb a1c uh that is about 9.9 okay don't worry on that if you have got very high how high that have to think of so if you have what nine point nine or nine point eight like that you go with the proportion if the process is also very high and sugars are high and go with the higher and if there is optimal control is not received in a bee then you pop up so that is the way you should go with that and this is the advocacy of ada we all follow that the adequate bible nights adequate sulfonylureas and topping off of the insulin and the formal therapy is one third part of it and the diet therapy and the exercise are equally important they are also 33 percent so you have to sensitize the person about the exercise you have to sensitize the person about the diet part and then after the optimization occurs okay so uh then we have another question a role of a glucose positive and ketone positive in a urine routine it's the ketone positivity only positivity does not mean you much because if you do high sensitive ketone detectors particularly available on the stick test also you will find positive but if there is a positive and you find lot of the sugars also you just think that you are dealing with ketosis the ketosis part requires adequate volume replacement that is normal saline then the putting on the insulin and then find what is the aggregator if it is the only uh fasting the liquid that will help it out if it is the only fatty meals or something like that that people are going in diabetic diabolicity clinics that is also maybe the cause or if it is optimally controlled diabetes then insulin should be offered to this patient so these are the ways you have to see individualize the therapy what is the problem with my this patient and then you have to go so my suggestion is you won't don't get upset with only ketones it was with very high sugar means you may be having then [Music] um and we have in our cases of uh hypopotissimia uh potash cemia in acute renal failure what is the role of dextrose with insulin infusion okay the dextrose infusion is [Music] space to come inside the sex it is not the answer what is it is doing something like the nebulizer again what it is doing it is making the potassium to come inside the rule is that for a timeline you should understand why this hyperkalemia has occurred and you know that hyperkalemia can lead to radiation the first and foremost is the calcium that is the calcium 10 calcium vascular in 10 minutes that is 10 10 10 mnemonic we keep reaching so this you have to do then you know what is the cause of this hyperfeeling it is so that is i myself i'm having um post covered first time diagnosed or diabetes mellitus um no uses of steroid and no family history my hba1c level was 10.9 before six months which after which started metformin 500 gradually hba1c reduced and my recent reading is 6.7 so should i have to continue with oha or something that i have to investigate no i feel personally that you have got the enough reasons to stop 6.5 is very good and high-end performing is very good [Music] and you can safely come to the that directory because you are requiring so less and the control is so optimal i feel you can come to the stop limit forming and you can safely be controlled okay um and what extra things in mind in case of cardiorenal syndrome patient the cardiological syndrome is a medical emergency you in this condition the very operative management is there for it because you if the surgery is very very essential something like that being [Music] because it is a difficult situation and elective surgery you get for as much as possible till you get it adequately control the cardiac symptoms and if the renal symptoms also improve and then you can think of it otherwise you differ because risk is far more than the reward of the so what would be the drug of choice to manage ni dbms then sulfonylureas you can top up with the ppp4 inhibitors and if it is you go with the gmp one analog these are the ways if it is sub-optimal follow this protocol we go with the uh metformin you go with the sulfonylureas the p24 inhibitors or the methamine dpp for inhibitors and sulfonylureas by any chance missed any of the questions we'll get back in touch with sir and try answering your questions uh thanks a lot sir for a wonderful amazing talk and we hope to have you on our platform again soon

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dr. Lt Col Ojha

Dr. Lt Col Ojha

Professor, Internal Medicine | K J Somaiya Medical College, Mumbai

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dr. Lt Col Ojha

Dr. Lt Col Ojha

Professor, Internal Medicine | K J Somaiya Me...

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