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CASE PRESENTATION DIABETIC FOOT

CASE PRESENTATION DIABETIC FOOT . MODERATOR Dr. Rani PRESENTER Dr. Priyanka Jain . www.anaesthesia.co.in anaesthesia.co.in@gmail.com. HISTORY . 63 yrs old female Presenting complaint : swelling of right lower limb Χ 2-3 yrs blackish discolouration Χ 10 days .

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CASE PRESENTATION DIABETIC FOOT

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  1. CASE PRESENTATIONDIABETIC FOOT MODERATOR Dr. Rani PRESENTER Dr. Priyanka Jain www.anaesthesia.co.inanaesthesia.co.in@gmail.com

  2. HISTORY • 63 yrs old female • Presenting complaint : swelling of right lower limb Χ2-3 yrs blackish discolouration Χ 10 days

  3. History of Present Illness Swelling in rt. Lower limb Χ2-3 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 Χ 1-2 yrs

  5. Medical History: DM Χ 10-12 yrs Was on OHA Χ 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 (>4 mets ) • No past h/o TB or any other significant illness in the past

  8. k/c/o HTN. Χ10 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 >=200 mg/dl (11.1mmol/l) 2) A fasting (>8hr)plasma glucose of >=126 mg/dl (7 mmol/l). 3)A glucose conc . Of >=200 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. Autonomic function tests : • Autonomic neuropathy : • Gastroparesis • Intrapoand postop cardiorespiratory arrest • Painless myocardial ischemia • Increased depressant effects of drugs • Paradoxical cvs effects of insulin

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

  25.  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

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

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

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

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

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

  31. Goals: • Treatment before surgery :

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

  33. 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

  34. 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

  35. 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

  36. 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 • <80 Check glucose after 15 min* • 80–140 Decrease infusion by 0.4 unit/h (4 ml/h) • 141–180 No change • 181–220 Increase infusion by 0.4 unit/h (4 ml/h) • 221–250 Increase infusion by 0.6 unit/h (6 ml/h) • 251–300 Increase infusion by 0.8 unit/h (8 ml/h) • >300 Increase infusion by 1 unit/h (10 ml/h) • *Regimen assumes separate infusion of glucose at ~5–10 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. • Diabetes spectrum 2002.2

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

  38. Complications ; • Microvascular and macrovascular • acute and chronic

  39. 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 2006;103:1294-1299

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

  41. 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

  42. 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

  43. “Non tight control” regimen Aim : Prevent hypoglycemia, ketoacidosis, hyperosmolar states Day before surgery : NPO > midnight Day of surgery : iv 5%D @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

  44. “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

  45. Tight control regimen I • Aim : 79-120 mg/dl • Protocol • Evening before, do preprandial bld glucose • Begin iv 5%D @ 50 ml/hr/70 kg • Piggyback to 5%D, 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

  46. Alberti’s regimen • 1979- Alberti & Thomas IV GIK solution [500ml 10% glucose + 10 units soluble insulin + 10mmol KCl @ 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 • < 90mg/dl or > 180 mg/dl replace bag with 5U or 15U respectively

  47. Alberti’s regimen-Recent version • 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 < 90 mg/dl

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