Post on 27-Dec-2015
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Glycemic control and highly infected diabetic foot
Dr. Sanjeev Kelkar M.D.
Medical Director
Novo Nordisk Education Foundation,
Bangalore, INDIA
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Glycemic control and infected diabetic foot
- The infective catabolic insulin resistant state
- Aggressive approach
- Methods of control
- Limitations
- Nutritional considerations
- General management
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Glycemic control anddiabetic foot
The infected foot: 1
Infected large ulcers
Apparent / unapparent deep seated abscesses
Wide-spread infection and subsequent inflammation
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Glycemic control anddiabetic foot
The infected foot:2
Failure of body to localize the infection*
Endotoxemia
Septicaemia
Necrotising fascitis
Multiorgan failure
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Glycemic control anddiabetic foot
The infected foot: 3
Febrile, toxic, catabolic state,
Tissue breakdown high,
Negative nitrogen balance,
High degree of insulin resistance
Nutritional support difficult
Critical care setting
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Glycemic control anddiabetic foot
The infected foot: 4
On the horns of dilemma:
Glycemic control haywire, difficult to achieve
Cause of uncontrolled diabetes is
in foot infection
Foot cannot be tackled as control is poor
Balance – golden mean necessary
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Glycemic control anddiabetic foot
The aggressive approach: 1
Medical assessment
Hydration / Nutrition
Antibiotics
Surgical treatment - Operative /
Conservative
Insulin administration
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Glycemic control anddiabetic foot
The aggressive approach - 2
Establishing investigative parameters:
Hemogram – baseline counts, peripheral smear picture, status of anemia
Urine – ketones – as a baseline and guide of management
Albumin for nephropathy
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Glycemic control anddiabetic foot
The aggressive approach – 3
Renal parameters: baseline creatinine
Patient likely to go in ARF
For monitoring recovery if so
Electrolytes: Sodium for functional importance, K+ a dangerous cation in ARF
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Glycemic control anddiabetic foot
The aggressive approach – 4 Renal parameters – daily onceElectrolytes – even multiple monitoring in a day may be essential.Blood gases: To distinguish metabolic / respiratory acidosis – mixed pictures -Important monitoring aid for acid /base status* To assess hypoxic status
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Glycemic control anddiabetic foot
The aggressive approach– 5
Baseline electrocardiogram for normal variant patterns – LBBB, IRBB, RBBB, bigeminy
Baseline chest x-ray:
For comparing newer shadows – ARDS, PTE, collapse, consolidation, effusion,
Pneumothrorax
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Glycemic control anddiabetic foot
The aggressive approach – 6
Glucose monitoring:
Multiple blood glucose monitoring
Timing and type of insulin therapy coinciding with monitoring
Bedside rapid assay - reliable meters
proper technique and daily calibration - mandatory
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Glycemic control anddiabetic foot
The aggressive approach – 7
Assessing hydration: 1
Central venous access - brachial
Reliable, often mandatory
Facilitates rapid hydration
Multiple IV access possible,
Dehydration – invitation to ARF, thrombosis
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Glycemic control anddiabetic foot
The aggressive approach – 8
Types of central venous access -
The best: Sub-clavian - costly, needs expertise
Very occasionally pneumothorax
Advantages:
Most reliable for assessing hydration status
Can be maintained for longContd.
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Glycemic control anddiabetic foot
The aggressive approach – 8
Multiple infusions through 3 ways possible
TPN – easy. Low infectivity.
Ambulation possible
Frees legs and arms
Jugular messy, inconvenient, difficult to maintain, administer drugs, specially on respirators
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Glycemic control anddiabetic foot
The aggressive approach – 9
Next best: Anticubital
Easy, less costly
Reliable for hydration assessment
Low infective potential
TPN not difficultContd.
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Glycemic control anddiabetic foot
The aggressive approach – 9
Anticubital maintained 7 –10 days
Femoral – avoided far as possible
Central venous pressure monitoring –
A must, 1/2/3/day
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Glycemic control anddiabetic foot
The aggressive approach – 10
Nutrition: Higher calorie intake mandatory
Higher insulin dosing mandatory
TPN: If intake is poor, if serum albumin low
Begin as early as felt required
200 gm of glucose mandatory per day
Lipids / albumin infusion / whole blood
Ready tube feeding mixtures, costly but have balanced elements, vitamins.
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Glycemic control anddiabetic foot
The aggressive approach – 11
Antibiotics:
Infections often mixed
Cephalosporins
Quinolones
Aminoglycosides – Amikacin, Metronidazole
Guided by: Blood Culture, wound swabs
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Glycemic control anddiabetic foot
The aggressive approach – 12
Blood culture:
10 – 15 ml blood to be drawn
Before antibiotics or
Just prior to next dose
Pus culture from wounds
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Glycemic control anddiabetic foot
Insulin regimens: 1
In the worst cases:
Food intake poor,
Dependence on iv insulin therapy
No glucose infusions if blood glucose
> 400 mg,
Normal saline preferred
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Glycemic control anddiabetic foot
Insulin regimens: 2
DKA - .4 units x kg body weight
Rapid acting insulin – bolus ½ IV,
½ IM (if no hypotension)
N / ½ N Saline with 5 – 7 u/hr
The rate or the insulin concentration
can be varied
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Glycemic control anddiabetic foot
Insulin regimens: 3
Hourly monitoring if BG > 400 mg/dl
Infuse dextrose with insulin – once glucose is lowered to about 200 mg/dl
Start dextrose saline 5 – 7 u/hr
Monitor, adjust
K+ supplements – freely if kidneys are intact, urine output is good, hydration established
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Glycemic control anddiabetic foot
Insulin regimens: 4 - Thumb rules:
Blood glucose < 100 mg/dl No insulin
100 – 200 mg/dl 1 – 2 u/hr
200 – 300 mg/dl 2 – 3 u/hr
300 – 400 mg/dl 3 – 4 u/hr
>400 mg N Saline + 5 – 7 u/hr (100 ml/hr)
Scales need upward shifting 1.5 to 3 – 4 times
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Glycemic control anddiabetic foot
Insulin regimens: 5 K+ supplementation: Calculations:
Needs – in DKA at baseline 250 mmol / d .3 (4 - K+ in serum) x kg body weight Readjustments depending on monitoring Na replacements: .6 x (140 – Na+) x body weight, Bicarbs better avoided
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Glycemic control anddiabetic foot
Results:
Hydration, CVP 10-12 cms
Respiratory rate , Pulse rate
Blood pressure stabilizes
Blood gas – pH 7.3, HCO3 15 mmol/L
Blood glucose 150-200 mg/dl ketones may persist
Patient ready for surgery
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Glycemic control anddiabetic foot
In less severe cases:
Patient not acidotic
Is able to eat, drink
Infection spread arrested
Needs surgical intervention
I.V. dependence not heavy
Other insulin regimens
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Glycemic control anddiabetic foot
In hospital insulin regimens:
MSII –
Rapid acting insulin before breakfast, before lunch and around 5 p.m.
Before dinner –
Rapid + intermediate acting insulin, sc
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Glycemic control anddiabetic foot
Monitoring MSII
Fasting blood glucose
Pre lunch (decides fasting as well as pre
lunch dose)
Post lunch – can modulate 5 p.m. dose
Pre dinner –
Rapid control possible
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Glycemic control anddiabetic foot
MSII Cascading doses:
Relatively higher pre breakfast
Insulin – 12 – 16 or more units
Pre lunch 2 – 4 units less
5 p.m. – further 2 – 4 units less
Pre dinner – adjusted
Intermediate acting controls Dawn phenomenon
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Glycemic control and diabetic footPost operatively or in a more stable patient
Split mix – 30:70 or 50:50
Recent trial – equal rating
Pre – dinner and pre breakfast
Could be supplemented by a short acting
pre lunch small dose 6 – 10 units
Monitoring – fasting, post lunch
Post dinner or pre dinner
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Glycemic control anddiabetic foot
Distinctions - 1
Hydrating fluids (mainly saline) separate from insulin infusions.
Rate of infusion may vary.
Blood adds to glucose levels marginally.
I.V. fructose may lead to hypertriglyceridema
Lipids – insulin required for metabolism
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Glycemic control anddiabetic foot
Distinctions - 2
Protein intake – renal status must be the guide
Sodium – important for neurological function / SIADH
Potassium – severe hypokalemia – dangerous arrhythemia
Hyperkalemia – indication for correction - dialysis
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Glycemic control anddiabetic foot
Distinctions - 3
Hyperkalemia – cardiac standstill
Remove all possible potassium administration
100 mg hydrocortisone – SOS repeat
I.V. frusemide 40 – 80 mg/dl
Na bicarbonate I.V.
Dialyse