Total Intravenous and Balanced Anesthesia in Diabetic Patients Undergoing Video-Assisted Thoracoscopy

The aim of the study is to assess the impact of total intravenous anesthesia and balanced anesthesia as anesthesia maintenance approach on blood glucose level and postoperative complications in diabetic patients undergoing video-assisted thoracoscopy All patients will be kept fasting for 2 hours for clear fluids and 6 hours for meals preoperatively . Oral antidiabetic medications were continued in diabetic patients on the day before surgery, and were discontinued on the day of surgery. The doses of long-acting insulin administered should be reduced by 50-75% on the night before surgery to avoid hypoglycemia during a prolonged fast. Half doses of basal insulin were administered the morning of surgery. Blood glucose level is measured, if hyperglycemia occurred, control of hyperglycemia is done by giving regular insulin. A detailed history, thorough general and physical examination and routine investigations will be done. Patients fulfilling inclusion criteria will be randomly divided into two groups using computer generated random numbers with (30) patients in each group. Group A will receive Total intravenous anesthesia (TIVA). Group B will receive Balanced anesthesia.

Upon arrival to the operating room, standard monitoring including pulse oximetry (spo2), continuous electrocardiogram (ECG) and noninvasive blood pressure (BP) measurement and capnography will be started. Blood glucose level will be measured then a proper sized intravenous access will be inserted under complete aseptic conditions and secured. Blood sample for cortisol will be taken. Midazolam 0.02-0.07 mg/ kg will be given for sedation before induction of anesthesia. An intravenous drip of Ringer lactate will be initiated at a rate of 1-2 ml/kg/h as maintenance fluid and replacement fluid will also be given for fasting which is half of the deficit in the first hour of surgery then quarter of the deficit for the rest of surgery. Fluid deficit is the maintenance rate multiplied by the hours of fasting. Glucocorticoid drugs and nonsteroidal analgesics will not be allowed during the surgery. After proper pre-oxygenation general anesthesia will be induced intravenously by propofol 1.5-2.5 mg /kg, fentanyl1-2 mic / kg and atracurium 0.4-0.5 mg / kg in both groups. Endotracheal tube will be placed and secured. Blood glucose level will be measured.

For patients receiving TIVA (Group A) anesthesia will be maintained with propofol infusion (4-12 mg/kg/h), Fentanyl infusion (1-2 mic /kg/h) and atracurium 0.1 - 0.2 mg / kg every 20-30 minutes.

For patients receiving balanced anesthesia (Group B) anesthesia will be maintained with isoflurane 1.5% and atracurium 0.1 - 0.2 mg / kg every 20-30 minutes.

The maintenance of anesthesia in both groups will be performed using volume controlled ventilation with oxygen (100%), tidal volume 5-7 ml /kg for ideal body weight, rate is adjusted to maintain normocapnia.

Inclusion criteria

• Patient for both sex scheduled for VATS.
• Age group 18-70 years.
• Diagnosed diabetes mellitus (Type 1 or 2) HbA1c 6-8 % within 3 months.
• ASA II and III.

Exclusion criteria

• HbA1c > 8 % or < 6 or preoperative insulin infusion or DKA within 3 months
• Emergency surgery.
• Drug allergy.
• Chronic high-dose steroids.
• Severe hepatic/ renal impairment, significant arrhythmia or severe LV dysfunction.
• Patient refusal.
• Psychiatric illness.