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1362396561 glycemic control skke

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glycemic control skke

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1362396561 glycemic control skke

  1. 1. 1 Glycemic control and highly infected diabetic foot Dr. Sanjeev Kelkar M.D. Medical Director Novo Nordisk Education Foundation, Bangalore, INDIA
  2. 2. 2 Glycemic control and infected diabetic foot - The infective catabolic insulin resistant state - Aggressive approach - Methods of control - Limitations - Nutritional considerations - General management
  3. 3. 3 Glycemic control and diabetic foot The infected foot: 1 Infected large ulcers Apparent / unapparent deep seated abscesses Wide-spread infection and subsequent inflammation
  4. 4. 4 Glycemic control and diabetic foot The infected foot:2 Failure of body to localize the infection* Endotoxemia Septicaemia Necrotising fascitis Multiorgan failure
  5. 5. 5 Glycemic control and diabetic 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. 6. 6 Glycemic control and diabetic 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. 7. 7 Glycemic control and diabetic foot The aggressive approach: 1 Medical assessment Hydration / Nutrition Antibiotics Surgical treatment - Operative / Conservative Insulin administration
  8. 8. 8 Glycemic control and diabetic 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. 9. 9 Glycemic control and diabetic 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. 10. 10 Glycemic control and diabetic 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. 11. 11 Glycemic control and diabetic 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. 12. 12 Glycemic control and diabetic 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. 13. 13 Glycemic control and diabetic 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. 14. 14 Glycemic control and diabetic 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. 15. 15 Glycemic control and diabetic 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. 16. 16 Glycemic control and diabetic foot The aggressive approach – 9 Next best: Anticubital Easy, less costly Reliable for hydration assessment Low infective potential TPN not difficult Contd.
  17. 17. 17 Glycemic control and diabetic 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. 18. 18 Glycemic control and diabetic 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. 19. 19 Glycemic control and diabetic foot The aggressive approach – 11 Antibiotics: Infections often mixed Cephalosporins Quinolones Aminoglycosides – Amikacin, Metronidazole Guided by: Blood Culture, wound swabs
  20. 20. 20 Glycemic control and diabetic 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. 21. 21 Glycemic control and diabetic 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. 22. 22 Glycemic control and diabetic 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. 23. 23 Glycemic control and diabetic 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. 24. 24 Glycemic control and diabetic 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. 25. 25 Glycemic control and diabetic 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. 26. 26 Glycemic control and diabetic 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. 27. 27 Glycemic control and diabetic 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. 28. 28 Glycemic control and diabetic 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. 29. 29 Glycemic control and diabetic 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. 30. 30 Glycemic control and diabetic 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. 31. 31 Glycemic control and diabetic foot Post 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. 32. 32 Glycemic control and diabetic 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. 33. 33 Glycemic control and diabetic 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. 34. 34 Glycemic control and diabetic 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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