CASE

PRESENTATION
OF

DIABETIC FOOT
By: Dr. Siddhartha
Sharma
Under the guidance of
Dr. P.S. Lamba
 History
Pt. Abdul Sattar S/o Abdul Karim, 50 yrs. Muslim,. R/o
Karoli admitted on 22/10/11
Chief complaints-
# Pins and needle sensation 1 year
# Ulcer left foot 1 month
# Discharge from ulcer 15 days
 History
HOPI-
Pins & needle sensation Left foot
both feet ( Associated heaviness)
Ulcer following trauma Papule pustule
ulcer
Discharge: yellow, foul smelling, blood
stained
No cough / coryza / burning micturition /
Diarrhea / fainting episodes
Past history
K/c of NIDDM Diagnosed 6 yrs back
Taking treatment for past 4 years OHG drugs than
switched to insulin and has stopped insulin from last
7-8 months
No H/o HT, TB
No H/o Surgery/ drug allergy
Nonsmoker, nonalcoholic
 Examination
Awake, conscious, oriented, restless &

anxious

Pallor++, Icterus -, clubbing -,cyanosis - ,

edema +

Left inguinal lymph nodes - 32 cm in size

discrete, firm, mobile, tender, erythematous

 Examination

PR - 100/min Regular Normal volume, character

All peripheral pulses palpable including dorsalis

pedis on affected side, No radio-femoral delay

BP 130/70 mm Hg

Temperature afebrile

RR 18/min
Local examination-Ulcer
Inspection- Single irregular ulcer,4-5 cm in size,
extending from base of 2 nd metatarsal to 5 th metatarsal,

inflamed, edematous, sloping edge, red floor with

granulation tissue

Palpation- Tender, sloping edges with irregular margins,

indurated base, depth 3mm, not bleeding on touch,

mobile, warm surrounding skin , peripheral pulses

palpable
 Investigations
Hb- 8.1mg/dl

FBS- 142mg/dl, PP BS- 220 mg/dl

Blood urea- 97 mg/dl S creatinine- 3.1 mg/dl

Na+ : 130 meq/l K+ : 3.7meq/l Cl- : 104meq/l

ECG-TWNL

X-ray Chest- NAD

Xray cervical spine- NAD

Fundus examination -
Provisional diagnosis

DIABETIC FOOT
WITH NEPHROPATHY
www.plymouthdiabetes.org.uk/
 Changes in the vasonervorum with
resulting ischemia ? cause
Increased sorbitol in feeding vessels
block flow and causes nerve ischemia
Intraneural acculmulation of advanced
products of glycosylation
Abnormalities of all three neurologic
systems contribute to ulceration
 Autonomic system regulates sweating and
perfusion to the limb
Loss of autonomic control inhibits
thermoregulatory function and sweating
Result is dry, scaly and stiff skin that is prone
to cracking and allows a portal of entry for
bacteria leading to ulcer.
www.plymouthdiabetes.org.uk/
 Wagners Classification
0 Intact skin (impending ulcer)
1 Superficial
2 Deep to tendon, bone or ligament
3- Osteomyelitis
4 Gangrene of toes or forefoot
5 Gangrene of entire foot
 Control of diabetes
Education

Ambulation
Shoe ware
Skin and nail care
Avoiding injury with F.Bs and Hot water
Local padding and dressing
Antibiotics if infected

Excision of infected bone

Amputation
Diabetes
Clinical syndrome characterized by
deficiency of insulin accompanied by
hyperglycemia due to absolute or relative
excess of glucagon.
 DM in India
INDIA : Diabetic CAPITAL of the world
4 crore diabetics in India (19% of worlds diabetic
population)
2.5% of Indias urban population is diabetic
DIABETIC FOOT is most devastating with > 50,000
leg amputations/ every yr. due to D.M. in India
 Diagnosis
Plasma glucose Blood glucose Diagnosis

Random >11.1 mmol/l >10.0 mmol/l DM

(200 mg/dl) (180 mg/dl)

Fasting* >7.0 mmol/l >6.1 mmol/l DM

(126 mg/dl) (110 mg/dl)

Fasting* 6.1-7.0 mmol/l 5.6- 6.1 mmol/l Impaired

(110- 126 mg/dl) (101-110 mg/dl) fasting
glycemia -IFG
Fasting* no calorie intake for last 8 hours
Relation between whole blood
and plasma glucose
Blood glucose + 15 % = Plasma glucose

1 m mol = 18.0 mg glucose

1 m mol/l = 18.0 mg glucose/dl

 Oral glucose tolerance
test
75 gms of oral glucose after adequate fasting

B. sugar levels after 2 hrs of ingestion

Normal IFG DM

7.8 mmol/l 7.8-11.1 mmol/l >11.1

mmol/l

(140 mg/dl) (140-200 mg/dl) (200

mg/dl)
 Glycated Haemoglobin
(HbA1c)
Standard. method for assessment of long term glycemic control
When B glucose consistently non-enzymatic glycation of Hb
Reflects glycemic history over previous 2 to 3 months
Performed by HPLC

Interpretation
<6.2% - normal
< 7 % - effectively normal
>9% - things begin to go wrong, development of osmotic diuresis
& water & electrolyte loss
12-15% - verge of DKA
 Problems due to disease
Cardiovascular system
Premature atheroma formation

Chances of CAD (Male-double risk ; female-triple)

Incidence of silent MI

HT and its sequelae

Threshhold for arrhythmias

Cardiac dysautonomia may present with :

Sudden hypotension on induction
Absence of tachy. and HT with intubation

Diabetic cardiomyopathy
Sudden death
 Problems due to disease
Renal system
More chances of ARF in perioperative period, due to

- Intrinsic renal disease.

- Hemodynamic impairment

-Urosepsis

UTI-most common post op complication in diabetics undergoing surgery

Renal failure- incidence 7%, most common major complication

Problems due to disease
CNS and PNS
Chances of CVA
Peripheral Neuropathy - incidence of N. Injury & N
ischemia
ANS Dysfunction
-Postural hypotension
-Gastroparesis
-Loss of signs of Hypoglycemia
-Blunted Response to atropine & beta-blockers
-Urinary stasis-
Problems due to disease
Respiratory system

1 Ventilatory response to PaCo2 & PaO2

2 More chances of Respiratory tract infections

3 susceptibility to ventilatory depressant drugs

4 FVC and FEV( Due to glycosylation of tissue proteins in connective tissues)

5 2,3 DPG release of O2 to tissues

Airway
Stiff joint syndrome- restricted neck movements

Scleroderma of diabetes
Firm, woody, nonpitting edema of posterior neck and

upper back
The prayer sign
Patient is unable to approximate the palmar
surfaces of the phalangeal joints despite
maximal effort

Palm print test

Degree of interphalangeal joint
involvement can also be assessed
by the ink impression made by the
palm of dominant hand
 Problems due to disease
Other
Proliferative retinopathy- Vitreous Hmge on laryngoscopy and intubation
Infection poor wound healing
trophic ulcers
More chances of aspiration
Associated acute complications
-DKA
-NKHS
-Hypoglycemia

Increased risk for intra-operative HYPOTHERMIA

Anaesthetic
considerations
 Anaesthetic
management goals
1 To maintain glycaemic control

2 To avoid further deterioration of

pre-existing end organ damage

3 To shift patient soon on pre op

glycaemic control - drugs
Preoperative assessment
-Aims
23% of diabetics diagnosed prior to surgery
Type of DM & its duration
Pre op evaluation and treatment of end organ
damage which is responsible for 5-fold increase
in perioperative mortality associated with D.M.
Assessment of B. sugar control and to obtain a
reasonable control with change to short acting
drugs
Limit hospital stay and decrease cost
Quantification of risk
 PAC

To assess Investigations
1 B sugar BS- F &PP
Control Hb1 A C

2 Nephropathy Urine R/M, albumin

microalbuminuria
Kidney function tests
 PAC
To assess
Investigations
3 Cardiac ECG
status Chest X ray
ECHO
4 PVD H/o intermittent claudication
Blanching of feet
Non healing ulcers

5 Retinopathy Fundus exam

 PAC
To assess
Investigations
6 Stiff joint X ray Cervical spine
syndrome (lateral)

7 Metabolic & ABG

electrolyte S electrolytes
Ketones-urine

Postural changes in BP
 PAC orders
Consent

NPO orders

Anxiolytic

Aspiration prophylaxis

Stop long acting insulin night before surgery

 Monitoring IV fluids

Morning sample of blood sugar, serum electrolytes to be test

No insulin on morning of surgery

To arrange for dextrostix, insulin, glucometer etc.

Gentle transfer of patient

To be taken up as 1 st case
 Problems due to surgery
and
anesthesia
Greater concern for aseptic precautions
Prevention of acute complications
Estimation of end organ damage
More chances of sepsis
Appropriate fluid and electrolyte maintenance
Intensive monitoring
Stress response due to surgery
Regional anaesthesia
 Regional anaesthesia
No absolute indication for spinal or epidural
anesthesia
May improve outcome in selected situations
Decrease M&M in high risk patients
Extend analgesia into postoperative period
 Advantages of regional
anaesthesia in diabetics
Awake pt, intraop hypoglycemia (early recognition of

hypoglycemia) can be noticed

Risk of aspiration, PONV chances

Blunt stress response to surgical stimulation

Avoidance of endotracheal intubation { stiff joint syndrome &

Gastroparesis}

Metabolic effects of anaesthetic agents avoided

Advantages of regional
anaesthesia in
diabetics
Lower the incidence of postoperative thromboembolic events

Decrease intraoperative blood loss

Epidural anaesthesia block catecholamine release irrespective

of the segmental level

Rapid return to diet and insulin/ OHA

Disadvantages of Regional
Anaesthesia in Diabetic patients
Risk of nerve injuries, higher adrenaline use increases risk of

ischemic injury

LA requirement is low - sensitivity

Risk of infection

Epidural abscess

Contraindicated in presence of peripheral neuropathy

General Anaesthesia
Should be considered in
-Presence of cardiovascular or renal disease
-Prevension of intraoperative hypoglycemia and
hypotension
-Autonomic neuropathy( as it can mask hypoglycemia
and may exacerbate respiratory depression with opioids)
-Protection of pressure sores
 General Anaesthesia
Anaesthesia - if gastric stasis a rapid sequence induction should be
used. A nasogastric tube can be used to empty the stomach and allow a
safer awakening..
Treat hypotension promptly. Hartmanns solution (Ringers lactate)
should not be used in diabetic patients as the lactate it contains may
be converted to glucose by the liver and cause hyperglycaemia.
Sudden bradycardias should respond to atropine 0.3mg iv, repeated as
necessary (maximum 2 mg). Tachycardias, if not due to light
anaesthesia or pain, may respond to gentle massage on one side of the
neck over the carotid artery. If not then consider a beta-blocker
(propanolol 1mg increments: max 10mg total or labetalol 5mg
increments: max 200mg in total).
 General Anaesthesia
IV induction agents normally cause
hypotension on injection due to
vasodilatation. If a patient has a
damaged autonomic nervous system
(and many diabetics do), then they
cannot compensate by vasoconstricting,
and the hypotension is worsened.
Reducing the dose of drug and giving it
slowly helps to minimise this effect.
 Stress response and
glucose metabolism
Glucagon, epinephrine, GH, steroids, Insulin
Insulin resistance in post operative period
Consequences
- Osmolar diuresis-dehydration
-disrupts autoregulation of vascular beds
-impaired wound healing
-decreased chemotaxis and impaired
phagocytosis
-more acute complications
 Etomidate : Inhibitory effect on adrenal steroid genesis &

glycaemic response to surgery

Midazolam : ACTH & cortisol secretion symapthoadrenal

activity; but stimulates GH secretion

Net effect is ed glycaemic response to surgery

 -2 adrenergic agonists (Clonidine & Dexmedetomidine )-
sympathetic outflow from hypothalamus, inhibits release of
ACTH with stimulation of GH release
Glycaemic control improved as a result of ed
sympathoadrenal activity
-ing plasma C peptide concentarion indicating in endogenous
insulin secretion
 Propofol infusion in
diabetic patients
Lipid load resulting from propofol
infusion may further lead to impairment of
metabolism in diabetic patients.
Unlikely to be relevant during short
anaesthesia / induction
Important if prolonged ICU sedation
 Diabetes & Emergency
Surgery
Usually infected
Usually uncontrolled
Dehydration
Metabolic decompensation
Resistance to insulin
Check blood glucose
1. <250 mg / dl, iv insulin glucose, delay surgery till
hydrated and electrolytes corrected
2. >250 mg /dl, check ketones, arterial blood gas, anion
gap. If DKA present
Large volume of normal saline iv
Regular insulin 0.1U/ Kg/h after initial bolus of 0.15
U/Kg. Blood glucose monitoring 1 hourly
Potassium, magnesium and phosphate monitored 2
hourly and replaced accordingly
Blood glucose < 250 g/dl start 5% dextrose with insulin.
Once acidosis corrected, blood glucose < 200 mg/dl,
patient may be taken for surgery

51
 Postoperative
Complications
Hypoglycemia
Hyperglycemia DKA, NKHC
Infections
Delayed wound healing
Periop MI risk watch till 72 hrs
Problems due to autonomic neuropathy, postural
hypotension, atonic bleeding, urinary retention
PONV
Pain
 Hypoglycemia
Most frequent and dangerous complication
of Insulin therapy
Exacerbated by simultaneous
administration of alcohol, OHA, ACE
inhibitors, MAO inhibitors, and
nonselective beta blockers
Plasma glucose level less than 50 mg/dL
If unconscious: 50 ml of 50% dextrose (D50)
which increases glucose 100 mg/dLor 2
mg/dL/mL Insulin
Thanks