Comparison of the Patients With Diabetes Mellitus Using Either Insulin or Oral Antidiabetic Drug In Terms Of Difficult Laryngoscopy
Condition: Diabetes Mellitus
MeSH terms: Diabetes Mellitus
Study type: Interventional

Summary: 
      Diabetes Mellitus is known to be a risk factor for difficult laryngoscopy. Several studies
      showed that diabetes mellitus is responsible for 30% of difficult laryngoscopy.Insulin and
      oral antidiabetic drugs are two main current medication prescribed for diabetes
      patients.Insulin is responsible for muscle hypertrophy and weigh gain.Oral antidiabetic drugs
      induces muscle atrophy. The aim of this study is to evaluate the differences in the difficult
      laryngoscopy as a general anesthetic component in patients with Diabetes Mellitus (DM) using
      either insulin or oral antidiabetic drug (OAD).
    

Detailed description: 
      DM is accepted as a risk factor for difficult intubation.OAD and insulin are two main
      pharmacological treatment component of DM.Insulin induces respiratory smooth muscle
      contraction.Otherwise, OAD drugs ca affect muscle atrophy in patients with type II DM
      patients.The use of these drugs may affect laryngoscopy during endotracheal intubation,which
      is a component of general anesthesia.Metformin causes muscle atrophy and weight loss.Some in
      vitro studies have shown an induction of cell apoptosis with therapeutic doses of
      sulfonylureas which can lead to atrophy.Glinides can cause atrophy in experimental
      animals.Hypoglycemia and weight gain are two important side effects of intensive insulin
      therapy.İnsulin is the major anabolic hormone in the body. Insulin binds to receptors on
      adipose tissues and potentiate inhibition of lypolysis and storage of triglycerids.And this
      cause obesity.This is one of the reasons that suggest the relationship between insulin and
      difficult airway.The effect of insulin on airway smooth muscle leads to increased airway
      contraction,cell proliferation,and the thicker,stiffer and more hypercontractile airway.In
      some studies,type II DM patients with duration of more than 5 years switched to insulin
      therapy and airway hypersensitivity was observed in the first three months.Insulin plays an
      anabolic role in skeletal muscle by enhancing amino acids transport in skeletal muscle and by
      increasing the rate of protein synthesis.İnsulin induces air way smooth muscle contraction
      through the production of contractile prostaglandins, which in turn are dependent on
      Rho-kinase for their contractile effects.Prostaglandins also stimulate IL-6 and MuRF-1
      transcription in human skeletal muscles.Prostaglandin regulates skeletal muscle mass and
      function.Therefore,insulin may cause airway skeletal muscle contraction and may be the reason
      of difficult laryngoscopy.

      The aim of this study is to evaluate the differences in the difficult laryngoscopy as a
      general anesthetic component in patients with Diabetes Mellitus (DM) using either insulin or
      oral antidiabetic drug (OAD).

      METHODS After the approval of the local ethics committee of our hospital, a study was planned
      for a total of 230 patients including Type I and Type II DM patients and non-DM patients as a
      control group who would undergo elective surgery between 25.01.2020-30.04.2020.Age, gender,
      body mass index (BMI), Mallampati scores, thyromental distance (TMD), sternomental distance
      (SMD), inter-incisor distance (ID) and neck extension measurements were taken.Preoperative
      HbA1C levels, DM type, diagnosis time and duration of insulin or OAD use were
      recorded.Patients without DM, patients using insulin and patients using OAD were grouped as
      group C, group I and group D, respectively.DM patients were planned to be operated as first
      patient in the morning.50 mg of ranitidine,10 mg of metoclopramide and 1 gr of cefazolin for
      surgical prophylaxis were administered intravenously 30 minutes before anthesia
      induction.Patients were preoxygenated with 100% O2 for 3 minutes.As diabetes mellitus
      patients are under high risk of aspiration due to gastroparesis,we applied rapid sequence
      induction technique.1 mcg/kg fentanyl citrate,2 mg/kg propofol,1mg/kg rocuronium bromide were
      given intravenously according to patient's adjusted body weight.After low tidal volume
      ventilation with face mask,the trachea was intubated by using DL (Macintosh
      laryngoscope).During intubation, the following data were documented:Cormack-Lehane grade,
      number of laryngoscopic attempts, intubation time, intubation success at the first attempt,
      performance of backward-upward-rightward pressure (BURP) maneuver and requirement of use of
      different airway equipments were compared between the groups. Adverse events related to
      tracheal intubation were evaluated: desaturation (SPO2<94), hypercabia (ETCO2>35),
      hypertension (mean arterial pressure >20% above baseline values), tachycardia (heart rate
      >20% above baseline values), new onset arrhythmia, laryngospasm, bronchospasm, airway trauma
      and sore throat in PACU). The primary outcome measures are mallampati score,thyromental
      distance,Cormack-Lehane grade and the time to intubation,secondary outcome measures are
      first-attempt intubation success,number of laryngoscopic attempts,performance of
      backward-upward-rightward pressure (BURP) maneuver and requirement of use of different airway
      equipments.
    

Intervention name(s): difficult laryngoscopy
Intervention type(s): Device
Intervention description(s): Patients will be intubated with the direct laryngoscope.
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: Prospective randomised
Masking: Single (Participant)
Primary purpose: Treatment
Keywords: Diabetes mellitus, difficult laryngoscopy, insulin