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 Χ2-3 yrs blackish discolouration Χ 10 days

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

erosion on site of trauma , painless Developed progressive blackish

discolouration h/o numbness and tingling in b/l feet Χ

1-2 yrs

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

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.

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

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

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

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

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

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

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

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.

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 .

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 .

Provisional Diagnosis Type2 DM with wet gangrene of RT

lower limb.

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

Blood sugar : Fasting 156 mg/dl Urine sugar and ketones –ve

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

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

Diabetic neuropathy peripheral autonomic proximal Focal

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

Signs and symptoms : Tests : Sympathetic ; BP response to standing and sustained

grip HR response to Valsalva ,standing and

deep breathing

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

Mechanisms for diabetic autonomic neuropathy

local ischaemia tissue accumulation of sorbitol altered function of neuronal Na+/K+-

ATPase pump activity immunologically mediated damage. BJA2000

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

Onset (hr)

Peak(hr) Duration(hr)

Soluble regular

0.5-1 2-3 4-6

analogues

<0.25-0.5

0.5-1.5 2-3

isophane

2-4 4-8 10-15

Insulin zinc sus.

2-4 7-15 15-24

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

GIK infusion Alberti and Thomas (500ml

10%dextrose 10 U short acting insulin and 10 mmol KCl … 100 ml / hr )

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

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

Goals: Treatment before surgery :

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

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

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

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

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

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

Complications ; Microvascular and macrovascular acute and chronic

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

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

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

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

“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

“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

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

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

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

Blood glu (mg/dl)

Action

<120 10 U insulin) (2U/h)

120-200 15 U insulin (3U/h)

>200 20 U insulin (4U/h)

Alberti’s regimen Advantages : simple, Inherent safety

factor, balance appropriate Criticism : hypoglycemia, water load &

hyponatremia, cautious : poor renal function

20% or 50% D

Hirsh regimen

Aim : Normoglycemia

Infuse glucose 5 g/hr with pot 2-4 mmol/hr

Start insulin infusion @.5-1U/hr

Measure blood glucose hourly

Blood glu (mg/dl)

insulin

< 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

> 220 ↑ by 0.5 U/hr

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

Diabetic dysautonomic neuropathy scoring Tests Results Scores

Sys BP decrease in upright position (mmhg)

<10 11 – 29

>30

0 ½ 1

R-R intervals ratio in upright position >1.04 1.01 -1.03

<1.00

0 ½ 1

Diastolic BP increase during hand grip test (mmhg)

>16 11-15 <10

0 ½ 1

Respiratory dysrhythmias <15 11-14 <10

0 ½ 1

Valsalva quotient >1.21 <1.10

0 1

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

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

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

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

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