1 Glycemic control and highly infected diabetic foot Dr. Sanjeev Kelkar M.D. Medical Director Novo...

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


The infected foot:2

Failure of body to localize the infection*

Endotoxemia

Septicaemia

Necrotising fascitis

Multiorgan failure

5



Febrile, toxic, catabolic state,

Tissue breakdown high,

Negative nitrogen balance,

High degree of insulin resistance

Nutritional support difficult

Critical care setting

6



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


The aggressive approach: 1

Medical assessment

Hydration / Nutrition

Antibiotics

Surgical treatment - Operative /

Conservative

Insulin administration

8


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


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


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

11


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



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



Assessing hydration: 1

Central venous access - brachial

Reliable, often mandatory

Facilitates rapid hydration

Multiple IV access possible,

Dehydration – invitation to ARF, thrombosis

14



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.

15



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



Next best: Anticubital

Easy, less costly

Reliable for hydration assessment

Low infective potential

TPN not difficultContd.

17



Anticubital maintained 7 –10 days

Femoral – avoided far as possible

Central venous pressure monitoring –

A must, 1/2/3/day

18



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



Antibiotics:

Infections often mixed

Cephalosporins

Quinolones

Aminoglycosides – Amikacin, Metronidazole

Guided by: Blood Culture, wound swabs

20



Blood culture:

10 – 15 ml blood to be drawn

Before antibiotics or

Just prior to next dose

Pus culture from wounds

21


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


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


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


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


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


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


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


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


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


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


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


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


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

1 Glycemic control and highly infected diabetic foot Dr. Sanjeev Kelkar M.D. Medical Director Novo...

Documents

Transcript of 1 Glycemic control and highly infected diabetic foot Dr. Sanjeev Kelkar M.D. Medical Director Novo...