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 2-3 yrs
blackish discolouration 10 days

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

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

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

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. 10 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 -5
th
(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
analogu
es
<0.25-
0.5
0.5-1.5 2-3
isophan
e
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*
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)
>300 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.
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 activitydelay 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

Albertis 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
Albertis 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)
Albertis 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

1
R-R intervals ratio in upright position >1.04
1.01 -1.03
<1.00
0

1

Diastolic BP increase during hand
grip test (mmhg)

>16
11-15
<10
0

1

Respiratory dysrhythmias <15
11-14
<10

0

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, 6
th
ed Churchill Livingstone
Oral Hypoglycemic Agents
Class
Sulfonylurea

Agents Duration Action Side-
effects
1
st

generation
Tolbutamide

Chlorpropami
de
6 -12 h


24 -72 h

6 -12 h
Up to 24h
Increased
pancreatic
insulin
release

Receptor
level
action



Hypoglyc
emia
2
nd

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
dysfunct
ion

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
www.anaesthesia.co.in anaesthesia.co.in@gmail.com