Diabetic Foot - Case Presentation 4y2t3o

CASE PRESENTATION OF

DIABETIC FOOT By: Sharma

Dr. Siddhartha Under the guidance of

Dr. P.S. Lamba

History Pt. Abdul Sattar S/o Abdul Karim, 50 yrs. Muslim,. R/o Karoli itted on 22/10/11

Chief complaints# Pins and needle sensation × 1 year # Ulcer left foot × 1 month # Discharge from ulcer × 15 days

History HOPI Pins & needle sensation Left foot both feet ( Associated heaviness)  Ulcer following trauma Papule pustule ulcer  Discharge: yellow, foul smelling, blood stained  No cough / coryza / burning micturition / Diarrhea / fainting episodes

Past history 

K/c of NIDDM Diagnosed 6 yrs back

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Taking treatment for past 4 years OHG drugs than switched to insulin and has stopped insulin from last 7-8 months

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No H/o HT, TB

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No H/o Surgery/ drug allergy

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Nonsmoker, nonalcoholic

Examination 

Awake, conscious, oriented, restless & anxious

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Pallor++, Icterus -, clubbing -,cyanosis - , edema +

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Left inguinal lymph nodes - 3×2 cm in size discrete, firm, mobile, tender, erythematous

Examination 

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PR - 100/min Regular Normal volume, character All peripheral pulses palpable including dorsalis pedis on affected side, No radio-femoral delay

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BP – 130/70 mm Hg

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Temperature afebrile

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RR – 18/min

Local examination-Ulcer 

Inspection- Single irregular ulcer,4-5 cm in size, extending from base of 2 nd metatarsal to 5 th metatarsal, inflamed, edematous, sloping edge, red floor with granulation tissue

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Palpation- Tender, sloping edges with irregular margins, indurated base, depth 3mm, not bleeding on touch, mobile, warm surrounding skin , peripheral pulses palpable

Investigations Hb- 8.1mg/dl FBS- 142mg/dl,

PP BS- 220 mg/dl

Blood urea- 97 mg/dl

S creatinine- 3.1 mg/dl

Na+ : 130 meq/l

K+ : 3.7meq/l

ECG-TWNL X-ray Chest- NAD Xray cervical spine- NAD Fundus examination -

Cl- : 104meq/l

Provisional diagnosis

DIABETIC FOOT WITH

NEPHROPATHY

www.plymouthdiabetes.org.uk/

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Changes in the vasonervorum with resulting ischemia ? cause Increased sorbitol in feeding vessels block flow and causes nerve ischemia  Intraneural acculmulation of advanced products of glycosylation 

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Abnormalities of all three neurologic systems contribute to ulceration

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Autonomic system regulates sweating and perfusion to the limb

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Loss of autonomic control inhibits thermoregulatory function and sweating

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Result is dry, scaly and stiff skin that is prone to cracking and allows a portal of entry for bacteria leading to ulcer.

www.plymouthdiabetes.org.uk/

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Wagner’s Classification 0 – Intact skin (impending ulcer) 1 – Superficial 2 – Deep to tendon, bone or ligament 3- Osteomyelitis 4 – Gangrene of toes or forefoot 5 – Gangrene of entire foot

Control of diabetes  Education 

Ambulation Shoe ware Skin and nail care Avoiding injury with F.B’s and Hot water

Local padding and dressing  Antibiotics if infected  Excision of infected bone  Amputation 

Diabetes 

Clinical syndrome characterized by deficiency of insulin accompanied by hyperglycemia due to absolute or relative excess of glucagon.

DM in India 

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INDIA : Diabetic CAPITAL of the world 4 crore diabetics in India (19% of world’s diabetic population)

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2.5% of India’s urban population is diabetic DIABETIC FOOT is most devastating with > 50,000 leg amputations/ every yr. due to D.M. in India

Diagnosis Plasma glucose Random

Fasting*

>11.1 mmol/l (200 mg/dl) >7.0 mmol/l (126 mg/dl)

Fasting*

6.1-7.0 mmol/l

(110- 126 mg/dl)

Blood glucose

Diagnosis

>10.0 mmol/l (180 mg/dl)

DM

>6.1 mmol/l

DM

(110 mg/dl) 5.6- 6.1 mmol/l

(101-110 mg/dl)

Impaired fasting glycemia -IFG

Fasting* no calorie intake for last 8 hours

Relation between whole blood and plasma glucose 

Blood glucose + 15 % = Plasma glucose

1 m mol = 18.0 mg glucose 1 m mol/l = 18.0 mg glucose/dl

Oral glucose tolerance test 75 gms of oral glucose after adequate fasting B. sugar levels after 2 hrs of ingestion

Normal

mmol/l

mg/dl)

7.8 mmol/l

(140 mg/dl)

IFG 7.8-11.1 mmol/l

(140-200 mg/dl)

DM >11.1

(200

Glycated Haemoglobin (HbA1c) 

Standard. method for assessment of long term glycemic control

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When B glucose consistently

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Reflects glycemic history over previous 2 to 3 months

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Performed by HPLC

non-enzymatic glycation of Hb

Interpretation 

<6.2% - normal

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< 7 % - effectively normal

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>9% - things begin to go wrong, development of osmotic diuresis & water & electrolyte loss

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12-15% - verge of DKA

Problems due to disease Cardiovascular system 

Premature atheroma formation

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Chances of CAD (Male-double risk ; female-triple)

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Incidence of silent MI

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HT and its sequelae

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Threshhold for arrhythmias

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Cardiac dysautonomia may present with :  

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Sudden hypotension on induction Absence of tachy. and HT with intubation

Diabetic cardiomyopathy Sudden death

Problems due to disease

Renal system 

More chances of ARF in perioperative period, due to - Intrinsic renal disease. - Hemodynamic impairment -Urosepsis

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UTI-most common post op complication in diabetics undergoing surgery

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Renal failure- incidence 7%, most common major complication

Problems due to disease CNS and PNS   

Chances of CVA Peripheral Neuropathy - incidence of N. Injury & N ischemia ANS Dysfunction -Postural hypotension -Gastroparesis -Loss of signs of Hypoglycemia -Blunted Response to atropine & beta-blockers -Urinary stasis-

Problems due to disease Respiratory system 1 Ventilatory response to PaCo2

& PaO2

2 More chances of Respiratory tract infections 3 susceptibility to ventilatory depressant drugs 4

FVC and FEV( Due to glycosylation of tissue proteins in connective tissues)

5

2,3 DPG



release of O2 to tissues

Airway 

Stiff t syndrome- restricted neck movements

Scleroderma of diabetes 

Firm, woody, nonpitting edema of posterior neck and upper back

The prayer sign 

Patient is unable to approximate the palmar surfaces of the phalangeal ts despite maximal effort

Palm print test Degree of interphalangeal t involvement can also be assessed by the ink impression made by the palm of dominant hand

Problems due to disease Other 

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Proliferative retinopathy- Vitreous H’mge on laryngoscopy and intubation Infection – poor wound healing – trophic ulcers – More chances of aspiration

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Associated acute complications -DKA -NKHS -Hypoglycemia

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Increased risk for intra-operative HYPOTHERMIA

Anaesthetic considerations

Anaesthetic management goals 1 To maintain glycaemic control 2 To avoid further deterioration of pre-existing end organ damage 3 To shift patient soon on pre op glycaemic control - drugs

Preoperative assessment -Aims   

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23% of diabetics diagnosed prior to surgery Type of DM & its duration Pre op evaluation and treatment of end organ damage which is responsible for 5-fold increase in perioperative mortality associated with D.M. Assessment of B. sugar control and to obtain a reasonable control with change to short acting drugs Limit hospital stay and decrease cost Quantification of risk

PAC To assess

Investigations

1 B sugar Control

BS- F &PP Hb1 A C

2 Nephropathy

Urine R/M, albumin microalbuminuria Kidney function tests

PAC To assess Investigations 3

Cardiac status

4

PVD

5 Retinopathy

ECG Chest X ray ECHO H/o intermittent claudication Blanching of feet Non healing ulcers Fundus exam

PAC To assess Investigations

Stiff t syndrome 6

7 Metabolic & electrolyte

X ray Cervical spine (lateral)

ABG S electrolytes Ketones-urine Postural changes in BP

PAC orders 

Consent

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NPO orders

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Anxiolytic

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Aspiration prophylaxis

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Stop long acting insulin night before surgery

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Monitoring IV fluids

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Morning sample of blood sugar, serum electrolytes to be test

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No insulin on morning of surgery

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To arrange for dextrostix, insulin, glucometer etc.

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Gentle transfer of patient

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To be taken up as 1 st case

Problems due to surgery and anesthesia

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Greater concern for aseptic precautions

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Prevention of acute complications

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Estimation of end organ damage

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More chances of sepsis

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Appropriate fluid and electrolyte maintenance

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Intensive monitoring

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Stress response due to surgery

Regional anaesthesia

Regional anaesthesia 

No absolute indication for spinal or epidural anesthesia

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May improve outcome in selected situations

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Decrease M&M in high risk patients

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Extend analgesia into postoperative period

Advantages of regional anaesthesia in diabetics 

Awake pt, intraop hypoglycemia (early recognition of hypoglycemia) can be noticed

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Risk of aspiration, PONV chances

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Blunt stress response to surgical stimulation

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Avoidance of endotracheal intubation { stiff t syndrome & Gastroparesis}

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Metabolic effects of anaesthetic agents avoided

Advantages of regional anaesthesia in diabetics 

Lower the incidence of postoperative thromboembolic events

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Decrease intraoperative blood loss

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Epidural anaesthesia block catecholamine release irrespective of the segmental level

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Rapid return to diet and insulin/ OHA

Disadvantages of Regional Anaesthesia in Diabetic patients 

Risk of nerve injuries, higher adrenaline use increases risk of ischemic injury

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LA requirement is low - sensitivity

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Risk of infection

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Epidural abscess

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Contraindicated in presence of peripheral neuropathy

General Anaesthesia 

Should be considered in -Presence of cardiovascular or renal disease -Prevension of intraoperative hypoglycemia and hypotension -Autonomic neuropathy( as it can mask hypoglycemia and may exacerbate respiratory depression with opioids) -Protection of pressure sores

General Anaesthesia 

Anaesthesia - if gastric stasis a rapid sequence induction should be used. A nasogastric tube can be used to empty the stomach and allow a safer awakening..

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Treat hypotension promptly. Hartmanns solution (Ringers lactate) should not be used in diabetic patients as the lactate it contains may be converted to glucose by the liver and cause hyperglycaemia.

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Sudden bradycardias should respond to atropine 0.3mg iv, repeated as necessary (maximum 2 mg). Tachycardias, if not due to light anaesthesia or pain, may respond to gentle massage on one side of the neck over the carotid artery. If not then consider a beta-blocker (propanolol 1mg increments: max 10mg total or labetalol 5mg increments: max 200mg in total).

General Anaesthesia 

IV induction agents normally cause hypotension on injection due to vasodilatation. If a patient has a damaged autonomic nervous system (and many diabetics do), then they cannot compensate by vasoconstricting, and the hypotension is worsened. Reducing the dose of drug and giving it slowly helps to minimise this effect.

Stress response and glucose metabolism   

Glucagon, epinephrine, GH, steroids, Insulin Insulin resistance in post operative period Consequences - Osmolar diuresis-dehydration -disrupts autoregulation of vascular beds -impaired wound healing -decreased chemotaxis and impaired phagocytosis -more acute complications

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Etomidate : Inhibitory effect on adrenal steroid genesis & glycaemic response to surgery

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Midazolam : ACTH & cortisol secretion symapthoadrenal activity; but stimulates GH secretion

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Net effect is ed glycaemic response to surgery

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α-2 adrenergic agonists (Clonidine & Dexmedetomidine )sympathetic outflow from hypothalamus, inhibits release of ACTH with stimulation of GH release

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Glycaemic control improved as a result of ed sympathoadrenal activity

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-ing plasma C peptide concentarion indicating in endogenous insulin secretion

Propofol infusion in diabetic patients 

“Lipid load resulting from propofol infusion may further lead to impairment of metabolism in diabetic patients.

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Unlikely to be relevant during short anaesthesia / induction

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Important if prolonged ICU sedation

Diabetes & Emergency Surgery 

Usually infected

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Usually uncontrolled

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Dehydration

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Metabolic decompensation

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Resistance to insulin

Check blood glucose 1. <250 mg / dl, iv insulin – glucose, delay surgery till hydrated and electrolytes corrected 2. >250 mg /dl, check ketones, arterial blood gas, anion gap. If DKA present  Large volume of normal saline iv  Regular insulin 0.1U/ Kg/h after initial bolus of 0.15 U/Kg. Blood glucose monitoring 1 hourly  Potassium, magnesium and phosphate monitored 2 hourly and replaced accordingly  Blood glucose < 250 g/dl start 5% dextrose with insulin.  Once acidosis corrected, blood glucose < 200 mg/dl, patient may be taken for surgery

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Postoperative Complications 

Hypoglycemia

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Hyperglycemia – DKA, NKHC

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Infections

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Delayed wound healing

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Periop MI risk

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Problems due to autonomic neuropathy, postural

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hypotension, atonic bleeding, urinary retention

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PONV

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Pain

watch till 72 hrs

Hypoglycemia Most frequent and dangerous complication of Insulin therapy Exacerbated by simultaneous istration of alcohol, OHA, ACE inhibitors, MAO inhibitors, and nonselective beta blockers Plasma glucose level less than 50 mg/dL If unconscious: 50 ml of 50% dextrose (D50) which increases glucose 100 mg/dLor 2 mg/dL/mL Insulin

Thanks