CASE PRESENTATION DIABETIC FOOT

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CASE PRESENTATIONDIABETIC FOOT

• MODERATOR Dr. Rani
• PRESENTER Dr. Priyanka Jain

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HISTORY

• 63 yrs old female
• Presenting complaint
• swelling of right lower limb ?2-3 yrs
• blackish discolouration ? 10 days

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• 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

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

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• 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

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• 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.

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• 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

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• 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

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• 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

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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

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• 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

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

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• 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

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• 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.

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• 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 .

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• 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 .

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Provisional Diagnosis

• Type2 DM with wet gangrene of RT lower limb.

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• 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

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

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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

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• 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

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• Diabetic neuropathy
• peripheral
• autonomic
• proximal
• Focal

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(No Transcript)
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Autonomic function tests

• Autonomic neuropathy
• Gastroparesis
• Intrapoand postop cardiorespiratory arrest
• Painless myocardial ischemia
• Increased depressant effects of drugs
• Paradoxical cvs effects of insulin

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

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•  
•  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

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

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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

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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
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RISKS

• CVS disorders 2-3 times
• CVS mortality 3 times
• Intermediate clinical predictors of risk

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

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

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

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• Goals
• Treatment before surgery

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

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• 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

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• 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

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• 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

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• 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.

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

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• Complications
• Microvascular and macrovascular
• acute and chronic

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• 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

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• 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

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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

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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

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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

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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

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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

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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

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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

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Albertis regimen

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

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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

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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

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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
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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
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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
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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
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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
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