1362396561 glycemic control skke

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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 ulcersApparent / unapparent deep seated abscessesWide-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 resistanceNutritional support difficultCritical care setting

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Glycemic control anddiabetic foot

The infected foot: 4 On the horns of dilemma:Glycemic control haywire, difficult to achieveCause of uncontrolled diabetes is in foot infectionFoot cannot be tackled as control is poorBalance – golden mean necessary

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Glycemic control anddiabetic foot

The aggressive approach: 1Medical assessment

Hydration / NutritionAntibiotics

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 anemiaUrine – ketones – as a baseline and guide of managementAlbumin for nephropathy

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Glycemic control anddiabetic foot

The aggressive approach – 3Renal 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– 5Baseline electrocardiogram for normal variant patterns – LBBB, IRBB, RBBB, bigeminyBaseline 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 monitoringTiming and type of insulin therapy coinciding with monitoringBedside rapid assay - reliable meters proper technique and daily calibration - mandatory

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Glycemic control anddiabetic foot

The aggressive approach – 7Assessing hydration: 1Central 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 – 8Types of central venous access -The best: Sub-clavian - costly, needs expertiseVery occasionally pneumothoraxAdvantages:Most reliable for assessing hydration statusCan be maintained for long

Contd.

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Glycemic control anddiabetic foot

The aggressive approach – 8 Multiple infusions through 3 ways possibleTPN – easy. Low infectivity. Ambulation possible Frees legs and armsJugular messy, inconvenient, difficult to maintain, administer drugs, specially on respirators

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Glycemic control anddiabetic foot

The aggressive approach – 9 Next best: AnticubitalEasy, less costlyReliable for hydration assessmentLow infective potentialTPN not difficult

Contd.

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Glycemic control anddiabetic foot

The aggressive approach – 9Anticubital 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 mandatoryHigher insulin dosing mandatoryTPN: If intake is poor, if serum albumin lowBegin as early as felt required200 gm of glucose mandatory per dayLipids / albumin infusion / whole bloodReady tube feeding mixtures, costly but have balanced elements, vitamins.

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Glycemic control anddiabetic foot

The aggressive approach – 11Antibiotics:Infections often mixedCephalosporinsQuinolonesAminoglycosides – Amikacin, MetronidazoleGuided by: Blood Culture, wound swabs

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Glycemic control anddiabetic foot

The aggressive approach – 12Blood culture:10 – 15 ml blood to be drawnBefore antibiotics orJust prior to next dosePus culture from wounds

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Glycemic control anddiabetic foot

Insulin regimens: 1In the worst cases:Food intake poor,Dependence on iv insulin therapyNo 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 weightRapid acting insulin – bolus ½ IV, ½ IM (if no hypotension)N / ½ N Saline with 5 – 7 u/hrThe rate or the insulin concentrationcan be varied

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Glycemic control anddiabetic foot

Insulin regimens: 3 Hourly monitoring if BG > 400 mg/dlInfuse dextrose with insulin – once glucose is lowered to about 200 mg/dlStart dextrose saline 5 – 7 u/hrMonitor, adjustK+ 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 insulin100 – 200 mg/dl 1 – 2 u/hr200 – 300 mg/dl 2 – 3 u/hr300 – 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 cmsRespiratory rate , Pulse rate Blood pressure stabilizesBlood gas – pH 7.3, HCO3 15 mmol/L

Blood glucose 150-200 mg/dl ketones may persistPatient ready for surgery

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Glycemic control anddiabetic foot

In less severe cases:Patient not acidoticIs able to eat, drinkInfection spread arrestedNeeds surgical interventionI.V. dependence not heavyOther 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 glucosePre lunch (decides fasting as well as prelunch dose)Post lunch – can modulate 5 p.m. dosePre dinner – Rapid control possible

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Glycemic control anddiabetic foot

MSII Cascading doses:Relatively higher pre breakfast Insulin – 12 – 16 or more unitsPre lunch 2 – 4 units less5 p.m. – further 2 – 4 units lessPre dinner – adjustedIntermediate 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 50:50Recent trial – equal ratingPre – dinner and pre breakfastCould be supplemented by a short acting pre lunch small dose 6 – 10 unitsMonitoring – 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 hypertriglyceridemaLipids – insulin required for metabolism

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Glycemic control anddiabetic foot

Distinctions - 2 Protein intake – renal status must be the guideSodium – important for neurological function / SIADHPotassium – severe hypokalemia – dangerous arrhythemiaHyperkalemia – indication for correction - dialysis

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Glycemic control anddiabetic foot

Distinctions - 3 Hyperkalemia – cardiac standstillRemove all possible potassium administration100 mg hydrocortisone – SOS repeatI.V. frusemide 40 – 80 mg/dlNa bicarbonate I.V.Dialyse