Diabetic Autonomic

Neuropathy

(DAN)
 Why recognise DAN?
• High Mortality - 25- 50 % with in 5-10 yrs of Diagnosis

• Quite common but unrecognised

• Marker of adverse cardiovascular, renal and

cerebrovascular outcomes

• Implications in various clinical situations

• Peri-operative complication

• Commonly misdiagnosed in OPD

 DAN
• CARDIAC AUTONOMIC NEUROPATHY - CAN
( MOST COMMONLY AFFECTED)

• G I TRACT - GIAN

• GENITOURINAY SYSTEM - GUAN

• OTHERS - Respiratory , Skin , Pupils etc

 Common Symptoms
• Dizziness

• Palpitation

• Poor exercise tolerance

• Epigastric discomfort and bloating

• Diarrhoea
 IDENTIFYING- DAN
• CLINICAL - “Symptoms have poor specificity”

• MAINTAIN HIGH CLINICAL SUSPICION

• OBJECTIVE TEST -

• TO IDENTIFY - CAN

• OTHER SYSTEMS- GIAN , GUAN ETC -

• TEST NOT STANDARDISED.

 CAN

• Heart rate variability- earliest change -

(subclinical)

• Resting Tachycardia ( 90 -100 bpm) and fixed

HR - Late finding of vagal impairment

• Orthostatic Hypotension - Sympathetic

dysfunction - advanced autonomic dysfunction
 Clinical manifestations

• Heart Rate changes

– Impaired Heart rate variability
– Resting tachycardia and fixed HR
• BP changes
– Nocturnal hypertension
– Orthostatic hypotension
– postprandial hypotension
• Limited exercise tolerance
 Evaluation

• For parasympathetic HR responses to

– Breathing
– Standing
– Valsalva
• For sympathetic BP responses to
– Standing
– Isometric exercise
Parasympathetic tests :-
HR response to deep breathing :-
The patient breathes deeply for 3 cycles .Greatest HR difference during each cycle is
measured & the differences are averaged .
Normal : ≥ 15 BPM
Borderline : 11-14 BPM
Abnormal : ≤ 10 BPM

HR response to Valsalva :-
- Subject breathes into disposable mouthpiece attached to sphygmomanometer to keep
pressure at 40 mmHg for 15 sec .
- Ratio of longest R-R within 20 beats of ending manouvre to shortest R-R during manouvre .
- Test is done 3 times & the average ratio is measured .
Normal : ≥ 1.21
Abnormal : ≤ 1.20

HR response to standing :- 30 : 15 ratio

Longest R-R at 30th beat & Shortest R-R at 15th beat
Normal : ≥ 1.04
Borderline : 1.01-1.04
Abnormal : ≤ 1.00
Sympathetic tests :-

BP response to standing :- systolic BP

Normal : ≤ 10 mmHg
Borderline : 11-20 mmHg
Abnormal : ≥ 30 mmHg

BP response to sustained handgrip :-

- Maintaining handgrip at 30% of max voluntary pressure for up to 5 min .
- Systolic BP is recorded every min .
- Stop if rise reaches normal level . If not , record just before handgrip release at 5 min .

Normal : ≥ 16 mmHg
Borderline : 11-15 mmHg
Abnormal : ≤ 10 mmHg
 Screening for DAN

• American Neurological Society

• Type 2 Diabetes - At Diagnosis

• Type 1 Diabetes - Within 5 yrs of Diagnosis

 GIAN
• Oesophageal dysfunction - Vagal neuropathy ( common , seen in
40% ) - Heartburn and dysphagia for solids

• Gastric neuropathy - Delayed emptying - early satiety , anorexia ,

nausea and vomiting, epigastric discomfort and bloating.

• Small Intestine - (poor peristalsis) Bacterial overgrowth . Diabetic

diarrhoea - Profuse , watery , typically nocturnal diarrhoea lasting
for days , may often alternate with periods of constipation

• Gall bladder atony and enlargement - may facilitate cholelithiasis

• Anal and rectal neuropathy - disturbed anal sphincter tone - Faecal

incontinence.
 Other system involvement
• Respiratory system :central dysregulation of breathing -
reduced bronchial reactivity

• Neurovascular system - sweating abnormalities (anhidrosis,

hyperhidrosis, gustatory sweating) ,changes in skin blood
flow (warm skin, Varicose veins, peripheral edema)

• Pupillomotor - pupil dysfunction

• Genitourinary system - bladder dysfunction , sexual

dysfunction .
 DD
• Medications ( beta blockers , TCA’s etc )

• Other Peripheral autonomic neuropathies ex

Amyloid neuropathy , Alcohol related neuropathy

• Hypothyroidism , Addison’s disease

• Pure Autonomic Failure

• Multisystem Atrophy ( MSA -A)

 Anaesthetic and Surgical Implications

• Anaesthesia can result in deleterious hypotension not

responding to vasopressors and inotropes

• These patients are more prone to hypothermia

• Insulin can further decrease the arterial blood pressure

• Poor ventilatory drive - post-op respiratory depression

• High risk of aspiration due to poor gastric emptying

• High likelihood of post operative paralytic ileus

THANKS