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CASE PRESENTATION DIABETIC FOOT

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CASE PRESENTATION DIABETIC FOOT MODERATOR Dr. Rani PRESENTER Dr. Priyanka Jain www.anaesthesia.co.in anaesthesia.co.in_at_gmail.com Goals: Treatment before surgery ... – PowerPoint PPT presentation

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Title: CASE PRESENTATION DIABETIC FOOT


1
CASE PRESENTATIONDIABETIC FOOT
  • MODERATOR Dr. Rani
  • PRESENTER Dr. Priyanka Jain

www.anaesthesia.co.in anaesthesia.co.in_at_gmail.c
om
2
HISTORY
  • 63 yrs old female
  • Presenting complaint
  • swelling of right lower limb ?2-3 yrs
  • blackish discolouration ? 10 days

3
  • History of Present Illness
  • Swelling in rt. Lower limb ?2-3 yrs
  • painful initially but painless now
  • did not subside on raising the limb
  • gradually progressive
  • often associated with pus discharging lesions
    treated twice with antibiotics and drainage
  • h/o mild trauma to rt feet 10 days back

4
  • erosion on site of trauma , painless
  • Developed progressive blackish discolouration
  • h/o numbness and tingling in b/l feet ? 1-2 yrs

5
  • Medical History
  • DM ? 10-12 yrs
  • Was on OHA ? 8-9 yrs .(details not available)
  • Since 1-2 yrs on insulin
  • Currently on insulin Huminsulin(30/70)30 units
    neutral insulin and 70 units isophane insulin 40
    U BBF and 20 U BD

6
  • On this insulin regimen blood sugars were
    controlled .
  • h/o symptoms and signs sugg. Of hypoglycemic
    episodes (nervousness , palpitations ,tremors
    ,sweating )present
  • No h/o syncope ,giddiness on standing .
  • No h/o orthopnea ,PND, chestpain.

7
  • No h/o decreased urine output ,gen body edema
  • No h/o decreased vision
  • Bowel bladder habits were normal
  • No h/o prev. hosp. for diabetes
  • Could climb 2 flight of stairs (gt4 mets )
  • No past h/o TB or any other significant illness
    in the past

8
  • k/c/o HTN. ?10 yrs
  • drugs
  • Ramipril 5 mg od
  • Losartan 50mg od
  • Amlodipine 5 mg od
  • Atenolol 50 mg od
  • Atorvas 10 mg od

9
  • Personal history
  • No h/o any addictions ,drug allergy ,sedentary
    habit ,married with three children
  • Family history
  • Insignificant
  • Past surgical history
  • h/o cholecystectomy in 1980 ?GA u/e

10
EXAMINATION
  • 80 KG
  • 150 cm ?BMI 35 kg/m2
  • Conscious ,oriented
  • No pallor ,icterus cyanosis ,jaundice clubbing.
  • Vitals
  • PR ?78 /min rt radial ,regular , normal volume
    and character, dorsalis pedis (rt) not palpable

11
  • BP 160/90 mmHg rt upper arm supine
  • 150/84 mmHg rt upper arm standing
  • Temp afebrile
  • Respiratory system
  • RR14/min
  • b/l vesicular breath sounds.equal on both
    sides.
  • ? CVS
  • Apex -5th (lt)ICS, on the MCL .
  • Heart sounds normal with no murmurs

12
  • Airway assessment
  • MO 5 cm
  • MMP class II
  • TMD 6 cm
  • NM wnl
  • Prayer sign positive
  • Teeth intact

13
  • Autonomic function tests
  • BP response to standing
  • 160/90 mm Hg (supine)?156/84 mmHg
    (standing)
  • HR response to deep breathing
  • maximum- minimum HR 10/min

14
  • Lower limb Examination
  • Inspection
  • edematous tough waxy skin (b/l limbs)
  • Blackish spots till midshin level
  • rt lower limb had multiple pustules around the
    ankle not demarcated
  • Foul smelling discharge
  • Palpation
  • b/l non pitting edema with induration
  • Rt LL warm to touch.

15
  • Sensory examination of lower limbs
  • Superficial
  • pain,touch and temperature sensation were
    decreased in the distal parts
  • Deep
  • pressure , position sense and vibration sense
    intact and normal in both the limbs .

16
  • Motor examination of lower limbs
  • power and tone normal in both the limbs
  • Joint movements were normal in bot h the limbs.
  • Reflexes
  • Knee jerk b/l present.
  • ankle jerk b/labsent .

17
Provisional Diagnosis
  • Type2 DM with wet gangrene of RT lower limb.

18
  • Lab investigations
  • Hb 10.0 g/dl
  • TLC 15000
  • Platelet count 1,50,000
  • Na/K 150/4.8
  • Urea 58mg/d
  • CXR wnl
  • ECG WNL

19
  • Blood sugar
  • Fasting 156 mg/dl
  • Urine sugar and ketones ve

20
Diagnosis and Classification
  • 1)Symptoms plus random plasma glucose gt200 mg/dl
    (11.1mmol/l)
  • 2) A fasting (gt8hr)plasma glucose of gt126 mg/dl
    (7 mmol/l).
  • 3)A glucose conc . Of gt200 mg/dl (11.1mmol/l)2
    hrs after oral ingestion of 75 g glucose

21
  • Impaired fasting glucose 100mg/dl
    (5.6mmol/l) - 125mg/dl (7mmol/l)
  • Impaired glucose tolerance 140mg/dl (7.8)
    199mg/dl (11.1) 2hrs after a glucose tolerance
    test
  • Syndrome X hyperglycemia , htn. , obesity and
    dyslipidemia

22
  • Diabetic neuropathy
  • peripheral
  • autonomic
  • proximal
  • Focal

23
(No Transcript)
24
Autonomic function tests
  • Autonomic neuropathy
  • Gastroparesis
  • Intrapoand postop cardiorespiratory arrest
  • Painless myocardial ischemia
  • Increased depressant effects of drugs
  • Paradoxical cvs effects of insulin

25
  • Signs and symptoms
  • Tests
  • Sympathetic
  • BP response to standing and sustained grip
  • HR response to Valsalva ,standing and deep
    breathing

26
  •  
  •  Orthostatic Hypotension
  • Resting Tachycardia
  • Absent of beat to beat variation with deep breath
    or valsava maneuver
  • Cardiac dysrhythymias
  • Altered regulation of breathing
  • History suggested gastroparesis
  •      Vomiting
  •       Diarrhea
  •       Abdominal distension
  • Bladder atony
  • Impotence
  • Asymptomatic hypoglycemia
  • Sudden death syndrome

27
  • Mechanisms for diabetic autonomic neuropathy
  • local ischaemia
  • tissue accumulation of sorbitol
  • altered function of neuronal Na/K-ATPase pump
    activity
  • immunologically mediated damage.
  • BJA2000

28
stimulation Inhibition
Glucose uptake in muscle (GLUT4)and fat gluconeogenesis
Aa uptake and protein synthesis in muscle proteolysis
Lipogenesis Lipolysisand ketogenesis
Glycogenesis glycogenolysis
Renal sodium absorption Glucagon secretion
NO synthesis

29
Onset (hr) Peak(hr) Duration(hr)
Soluble regular 0.5-1 2-3 4-6
analogues lt0.25-0.5 0.5-1.5 2-3
isophane 2-4 4-8 10-15
Insulin zinc sus. 2-4 7-15 15-24
30
RISKS
  • CVS disorders 2-3 times
  • CVS mortality 3 times
  • Intermediate clinical predictors of risk

31
  • GIK infusion
  • Alberti and Thomas (500ml 10dextrose 10 U short
    acting insulin and 10 mmol KCl 100 ml / hr )

32
  • Approach to diabetes management
  • Type 1 DM
  • Type 2 DM
  • diet
  • Oral hypoglycemics
  • insulin

33
  • Patient with DKA for emergency surgery
  • signs and symptoms
  • precipitating events
  • emergency inv.

34
  • Goals
  • Treatment before surgery

35
  • Anesthetic technique
  • RA vs GA
  • RA
  • Central Neuraxial Block.
  • Peripheral Nerve Block.

36
  • RA
  • less airway manipulation
  • awake patient, less metabolic disruption
  • decreased risk of DVT
  • LA doses
  • stiff noncompliant epidural space .
  • preexisting peripheral neuropathy .
  • Epinephrine
  • Infection
  • Vascular damage
  • Incresed risks with autonomic neuropathy

37
  • At present, there is no evidence that regional
    anaesthesia alone, or in combination with general
    anaesthesia, confers any benefit in the diabetic
    surgical patient, in terms of mortality and major
    complications.
  • BJA 2000

38
  • Improved postoperative glycemic control (plasma
    glucose levels of 4.5 to 6 mmol/l)using a
    continuous iv infusion(IV) along with continuous
    feeding significantly decreases mortality and
    morbidity in patients who require postoperative
    intensive care and mechanical ventilation after
    major surgery.
  • NEJM 2001

39
  • Prepare a 0.1 unit/ml solution by adding 25
    units regular insulin to 250 ml normal
  • saline.
  • Flush 50 ml of insulin solution through
    infusion tubing to saturate nonspecific
  • binding sites.
  • Set initial infusion rate (generally, 0.5
    unit/h 5 ml/h for thin women 1.0 unit/h
  • 10 ml/h for others)
  • Adjust infusion rate according to bedside blood
    glucose measurement as follows
  • Blood Glucose (mg/dl) Insulin Infusion Rate
  • lt80 Check glucose after 15 min
  • 80140 Decrease infusion by 0.4 unit/h (4 ml/h)
  • 141180 No change
  • 181220 Increase infusion by 0.4 unit/h (4 ml/h)
  • 221250 Increase infusion by 0.6 unit/h (6 ml/h)
  • 251300 Increase infusion by 0.8 unit/h (8 ml/h)
  • gt300 Increase infusion by 1 unit/h (10 ml/h)
  • Regimen assumes separate infusion of glucose at
    510 g/h and hourly blood glucose monitoring.
  • Extremely high or low glucose values should be
    confirmed with an immediate repeat
  • measurement. Intravenous boluses of dextrose
    (50) or supplemental regular insulin can be
  • used for rapid correction but are rarely
    necessary.

40
  • Approach to diabetes management
  • Type 1 DM
  • Type 2 DM
  • diet
  • Oral hypoglycemics
  • insulin

41
  • Complications
  • Microvascular and macrovascular
  • acute and chronic

42
  • Neurologic Complications After Neuraxial
    Anesthesia or Analgesia in Patients with
    Preexisting Peripheral Sensorimotor Neuropathy or
    Diabetic Polyneuropathy
  • the risk of severe postoperative neurologic
    dysfunction in patients with peripheral
    sensorimotor neuropathy or diabetic
    polyneuropathy undergoing neuraxial anesthesia or
    analgesia was found to be 0.4
  • Anesth Analg
    20061031294-1299

43
  • Tight control of blood sugar and BP with physical
    activitydelay in microvascular complications
  • tight control
  • Pregnant ,CPB, global cns ischemia,postop icu
    care
  • U.K Prospective Diabetes study

44
Perioperative complications with Hyperglycemia
  • Dehydration, electrolyte metabolic disturbances
  • Predisposes to DKA
  • Delayed wound healing
  • Bacterial infection postop wound infection
  • Median glycemic threshold for neutrophil
    dysfunction 200 mg/dl

45
Immediate periop problems in a diabetic
  • Surgical induction of stress response
  • Interruption of food intake
  • Altered consciousness masks symptoms of
    hypoglycemia necessiate frequent BG estimations
  • Circulatory disturbances associated anaesthesia
    Sx

46
Non tight control regimen
  • Aim Prevent hypoglycemia, ketoacidosis,
    hyperosmolar states
  • Day before surgery NPO gt midnight
  • Day of surgery iv 5D _at_1.5 ml/kg/hr(Preop
    intraop)
  • Subcut one half usual daily intermediate acting
    insulin on morning of surgery, increased by 0.5U
    for each unit of regular insulin dose of insulin
    subcut
  • Postop Monitor blood glu treat on sliding
    scale

47
Non tight control regimen
  • Limitations
  • Insulin requirements vary in periop period
  • Onset peak effect may not corelate with glu
    cose admn or start of surgery
  • Hypoglycemia esp in afternoon
  • Lowest therapeutic ratio

48
Tight control regimen I
  • Aim 79-120 mg/dl
  • Protocol
  • Evening before, do preprandial bld glucose
  • Begin iv 5D _at_ 50 ml/hr/70 kg
  • Piggyback to 5D, infusion of regular insulin (50
    U in 250 ml 0.9 NS)
  • Insulin infusion rate (U/hr) plasma glu (mg/dl) /
    150 or /100 if on steroids or severe infection
  • Repeat bld glu every 4 hours
  • Day of surgery Non dextrose containing
    solutions,
  • Monitor blood glu at start every 1-2 hours

49
Albertis regimen
  • 1979- Alberti Thomas IV GIK solution 500ml 10
    glucose 10 units soluble insulin 10mmol KCl _at_
    100 ml/hr
  • Before surgery - stablize on soluble insulin
    regimen, omit morning dose of insulin
  • Commence infusion early on morning monitor glu
    at 2-3 hours
  • lt 90mg/dl or gt 180 mg/dl replace bag with 5U or
    15U respectively

50
Albertis regimen-Recent version
Blood glu (mg/dl) Action
lt120 10 U insulin) (2U/h)
120-200 15 U insulin (3U/h)
gt200 20 U insulin (4U/h)
  • Initial solution 500ml 10 glu 10 mmol KCl
    15 U Insulin, infuse at 100 ml/hr
  • Check Blood glu every 2 hours
  • Adjust in 5 U steps
  • Discontinue if bld glu lt 90 mg/dl

51
Albertis regimen
  • Advantages simple, Inherent safety factor,
    balance appropriate
  • Criticism hypoglycemia, water load
    hyponatremia, cautious poor renal function
  • 20 or 50 D

52
Hirsh regimen
Blood glu (mg/dl) insulin
lt 80 Turn off for 30 min, give 25 ml 50 D
80-120 ? by .3 U/h
120-180 No change in infusion rate
180-220 ? by .3 U/hr
gt 220 ? by 0.5 U/hr
  • Aim Normoglycemia
  • Infuse glucose 5 g/hr with pot 2-4 mmol/hr
  • Start insulin infusion _at_.5-1U/hr
  • Measure blood glucose hourly

53
Potential benefits of regional anaesthesia in
diabetics
  • Avoidance of tracheal intubation (stiff joint
    snndrome, gastroparesis)
  • Decreasing venous thromboembolism
  • Ophthalmic Sx More rapid recovery, earlier
    mobilization, better pain relief, less NV
    earlier oral intake
  • Abolishes catabolic hormonal response to surgery
  • Preferable to use specific nerve blocks over CNB
  • Can report symptoms of hypoglycemia

54
Diabetic dysautonomic neuropathy scoring
Tests Results Scores
Sys BP decrease in upright position (mmhg) lt10 11 29 gt30 0 ½ 1
R-R intervals ratio in upright position gt1.04 1.01 -1.03 lt1.00 0 ½ 1
Diastolic BP increase during hand grip test (mmhg) gt16 11-15 lt10 0 ½ 1
Respiratory dysrhythmias lt15 11-14 lt10 0 ½ 1
Valsalva quotient gt1.21 lt1.10 0 1
55
Diabetic dysautonomic neuropathy scoring
Autonomic nervous system Scoring
Normal 0 - 0.5 Early change 1 - 1.5 Definitive modification 2 - 3.5 Severe impairment 4 - 5
Miller s Anesthesia, 6th ed Churchill Livingstone
56
Oral Hypoglycemic Agents
Class Sulfonylurea Agents Duration Action Side-effects
1st generation Tolbutamide Chlorpropamide 6 -12 h 24 -72 h 6 -12 h Up to 24h Increased pancreatic insulin release Receptor level action Hypoglycemia
2nd generation Glipizide Giburaide Glimepride 6 -12 h 24 -72 h 6 -12 h Up to 24h Increased pancreatic insulin release Receptor level action Hypoglycemia
57
Oral Hypoglycemic Agents
Class Agents Duration Action Side-effects
Biguanides Metformin 7 -12 h Up to 24h Improve receptor sensitivity ? Reduction in resistance Pancreatic insulin release Lactic acidosis Liver dysfunction
Glitizones Tro Rosi Pio Dar 7 -12 h Up to 24h Improve receptor sensitivity ? Reduction in resistance Pancreatic insulin release Lactic acidosis Liver dysfunction
58
Oral Hypoglycemic Agents
Class Agents Duration Action Side-effects
Glinides Repaglinide Nateglinide 3 h 4 h Rapid insulin secretion Reduced carbohydrate absorption Liver dysfn Diarrhea Abd pain
Alpha glucosidase inhibitor acarbose 3 h 4 h Rapid insulin secretion Reduced carbohydrate absorption Liver dysfn Diarrhea Abd pain
www.anaesthesia.co.in anaesthesia.co.in_at_gmail.c
om
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