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Glycemic control and highly infected diabetic foot

Glycemic control and highly infected diabetic foot. Dr. Sanjeev Kelkar M.D. Medical Director Novo Nordisk Education Foundation, Bangalore, INDIA. Glycemic control and infected diabetic foot. - The infective catabolic insulin resistant state - Aggressive approach - Methods of control

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Glycemic control and highly infected diabetic foot

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  1. Glycemic control and highly infected diabetic foot • Dr. Sanjeev Kelkar M.D. • Medical Director • Novo Nordisk Education Foundation, • Bangalore, INDIA

  2. Glycemic control and infected diabetic foot • - The infective catabolic insulin resistant state • - Aggressive approach • - Methods of control • - Limitations • - Nutritional considerations • - General management

  3. Glycemic control anddiabetic foot • The infected foot: 1 • Infected large ulcers • Apparent / unapparent deep seated abscesses • Wide-spread infection and subsequent inflammation

  4. Glycemic control anddiabetic foot • The infected foot:2 • Failure of body to localize the infection* • Endotoxemia • Septicaemia • Necrotising fascitis • Multiorgan failure

  5. 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

  6. 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

  7. Glycemic control anddiabetic foot • The aggressive approach: 1 • Medical assessment • Hydration / Nutrition • Antibiotics • Surgical treatment - Operative / • Conservative • Insulin administration

  8. 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

  9. 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

  10. Glycemic control anddiabetic foot • The aggressive approach – 4 • Renal parameters – daily once • Electrolytes – 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

  11. 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

  12. 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

  13. 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

  14. 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 long • Contd.

  15. 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

  16. Glycemic control anddiabetic foot • The aggressive approach – 9 • Next best: Anticubital • Easy, less costly • Reliable for hydration assessment • Low infective potential • TPN not difficult • Contd.

  17. 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

  18. 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.

  19. Glycemic control anddiabetic foot • The aggressive approach – 11 • Antibiotics: • Infections often mixed • Cephalosporins • Quinolones • Aminoglycosides – Amikacin, Metronidazole • Guided by: Blood Culture, wound swabs

  20. 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

  21. 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

  22. 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

  23. 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

  24. 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

  25. 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

  26. 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

  27. 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

  28. 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

  29. 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

  30. 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

  31. 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

  32. 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

  33. 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

  34. 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

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