1. Modrator : Dr. Maya Presented by : Bikash ranjan ray
Case presentation
Diabetes Mellitus
Modrator : Dr. Maya Presented by : Bikash ranjan ray

2. HISTORY Gajender kumar 55 yr , male Bulandahar, UP
Presenting complaint:
Nonhealing ulcer bilateral foot - 2 month
Pus discharge from left foot ulcer – 2 month
Blackish discolouration of left foot - 10 days

3. History of present illness :
Apparently alright 2 month back
h/o injury to b/l foot – 2 month back
Developed ulcer at trauma site
No associated pain at the site of ulcer
Purulent discharge from left foot ulcer : treated with antibiotics and dressing
Blackish discoloration of left foot – 10 days
No h/o change in colour with change in temprature
No H/o fever, swelling of lower limb

4. Past history : K/c/o DM – 6 yr Previously was on OHA for 4yrs
Changed to insulin since last 2 yrs
H/o poor compliance to treatment and poor control of blood sugars
Presently on insulin
Human actrapid 12 IU BBF,BL & BD
Insulatard 25 IU after dinner
On this regimen blood sugars were controlled
H/o similar discoloration in Lt toe 1yr back, amputation done ↓ RA, U/E

5. H/o syptoms suggestive of hypoglycemic episodes
H/o tingling and numbness in both lower limbs since 2 yrs
No history s/o any other medical illness
( HTN , TB , CAD, Asthma ,etc )

6. No h/o decreased vision
Chest pain, palpitations, breathlessness, orthopnea/ PND, edema feet, syncope, cough
↓ urine output, generalized edema
Giddiness on change of posture
No h/o decreased vision
Limited mobility since last 1 month due to b/l foot ulcer
Initially could climb 3 flights of stairs
No history of any drug allergy

7. Treatment history:
Inj. Levoflox 500 mg i.v. od
Inj. Metrogyl 500mg 8th hrly
Personal history :
Bowel and bladder habits: normal
Alcohol intake : occasional
Cigarette smoker: smoked for 15 yrs, 4-5/day, stopped since last 3yrs
Family history :
Insignificant

8. General Examination
Awake ,Conscious, Oriented, sitting comfortably in bed
Wt: 55 kg, ht: 164 cm
Afebrile
No pallor, icterus, cyanosis, clubbing, jaundice, lymphadenopathy
JVP: not raised
Good i.v. access

9. Pulse: 80/min, regular, adequate volume,
no radioradial or radiofemoral delay
BP in right arm:
138/ 84 mm of Hg supine position,
130/ 80 mm of Hg sitting position
RR: 20/ min, regular
HR response to deep breathing: > 15bpm

10. Local examination Left foot: heel ulcer
8x12 cm, blackish discoloration till ankle, no line of demarcation, purulent discharge, foul smelling
Surrounding skin: swollen, erythematous, tender
Right foot:
2×4 cm ulcer , no discharge

11. Systemic Examination:
CVS:
Apex beat in 5th intercoastal space, midclavicular line
S1, S2 normal
No murmurs
Respiratory system:
B/L air entry present
No crepitations or rhonchi
Abdomen: soft, no organomegaly
Spine: normal

12. CNS:
Higher functions normal
Cranial nerves : normal
Sensory examination:
B/L lower limb
Pain, touch and temperature
sensation were decreased in the distal parts
Pressure , position sense and vibration
sense intact & normal in both the limbs
Motor examination:
Power and tone: normal in both the limbs
Reflexes: Ankle jerk: B/L absent
all other reflex present

13. Airway examination Mouth opening: 5 cm MMP class: 2
Neck movements: WNL
TMD: 6 cm
Teeth: intact
Prayers sign: negative

14. Provisional Diagnosis
DM with b/l foot ulcer ,with gangrene of left lower limb
Surgical plan :
Below knee amputation of left leg

15. Investigations: Hb = 10.0 g/dl TLC =14500 Platelet count =3,21,000
Na+/K+ =150/4.8
Urea = 58mg/d
T. bil = 0.7
Pt = 12/ 13
CXR = WNL
ECG= WNL
Blood sugar :
Fasting 156 mg/dl
Urine sugar and ketones –ve

16. Anaesthesia

17. Diagnosis and Classification
1)Symptoms ( polyuria, polydipsia,wt loss )plus random plasma glucose >=200 mg/dl (11.1mmol/l) or
2) A fasting (>8hr)plasma glucose of >=126 mg/dl (7 mmol/l).
3)A glucose conc . Of >=200 mg/dl (11.1mmol/l)2 hrs after oral ingestion of 75 g glucose
2004 ADA , reduces normal fasting glucose thresold from 110mg/dl to 100 mg/dl (normal FBG = 70 – 100 )
Impaired fasting glucose = 101 – 125 mg/dl

18. Metabolic syndrome x At least 3 of the following: FPG ≥ 110 mg/dl
Abdominal obesity (waist grith >40 in men and >35 in women )
Sr. triglycerides ≥ 150 mg/dl
Sr. HDL <40 mg/dl in men and < 50 mg/dl in women
Blood pressure ≥ 130/85 mmhg

19. Classification Class Pathogenesis Incidence
Type 1 (Formerly juvenile or IDDM)
Immune mediated
idiopathic forms of β cell function
absolute insulin deficiency
0.4%
male =female
usually young
Type 2 (Formerly NIDDM)
Insulin resistance
relative insulin deficiency or secretory defect
6.6%
adult onset
Type 3
Specific types of DM
genetic defect / disease of exocrine pancreas
Type 4
Gestational DM
4% of pegnanrcies

20. Preoperative evaluation &risk assessment
Classical diabetic complications Macroangiopathy - arteriosclerosis Microangiopathy - heart, kidney &retina Autonomic neuropathy - heart, GI &urinary tracts Peripheral neuropathy Collagen anomalies - respiratory tract & joints Unifying hypothesis - impaired glycosylation of proteins Systematic search of diabetic complications – key step

21. Perioperative complications with Hyperglycemia
Dehydration, electrolyte & metabolic disturbances
Predisposes to DKA
Delayed wound healing
Bacterial infection & postop wound infection
Median glycemic threshold for neutrophil dysfunction 200 mg/dl
Independent risk factor for increase in short & long term mortality after cardiovascular surgery
Worsens clinical outcome in stroke, traumatic brain injury, global & focal cerebral ischaemia
Haemorrhagic extension of ischaemic stroke

22. Benefits of normal blood glucose
Maintenance of normal white blood cell & macrophage function
Positive trophic & anabolic effects of insulin
Improved erythropoiesis
Decreased hemolysis
Reduced cholestasis
Less axonal dysfunction

23. Oral Hypoglycemic Agents
Class Sulfonylurea
Agents
Duration
Action
Side-effects
1st generation
Tolbutamide
Chlorpropamide
6 -12 h h
Up to 24h
Increased pancreatic insulin release
Receptor level action
Hypoglycemia
2nd generation
Glipizide
Giburaide
Glimepride

24. Class
Agents
Duration
Action
Side-effects
Biguanides
Metformin
7 -12 h
Up to 24h
Improve receptor sensitivity ?
Reduction in resistance
Pancreatic insulin release
Lactic acidosis
Liver dysfunction
Glitizones
Tro
Rosi
Pio
Dar

25. Class
Agents
Duration
Action
Side-effects
Glinides
Repaglinide
Nateglinide
3 h
4 h
Rapid insulin
secretion
Reduced carbohydrate absorption
Liver dysfn
Diarrhea
Abd pain
Alpha –glucosidase inhibitor
acarbose

26. Insulin preparations and guidelines

27. Traditional Regimens Χ “No glucose, no insulin” Limitations :
Not suitable for insulin dependent diabetics
Pt’s stores of glucose used to meet increased metabolic demands
Patients taking long acting OHAs predisposed to hypoglycemia
Acceptable for non-insulin dependent diabetics & minor surgical procedures
Frequent blood sugar monitoring.
May require insulin therapy

28. Non tight control” regimen
Aim : Prevent hypoglycemia, ketoacidosis, hyperosmolar states
Day before surgery : NPO > midnight
Day of surgery : iv 5%D @1.5 ml/kg/hr (Preop + intraop)
Subcut one half usual daily intermediate acting insulin on
morning of surgery, increased by 0.5U for each unit of regular
insulin dose of insulin subcut
Postop : Monitor blood glu & treat on sliding scale
Limitations:
Insulin requirements vary in periop period
Onset & peak effect may not correlate with glucose admn or start of surgery
Hypoglycemia esp in afternoon
Lowest therapeutic ratio

29. Tight control regimen I
Aim : mg/dl
Protocol :
Evening before, do pre-prandial bld glucose
Begin iv 50 ml/hr/70 kg
Piggyback to 5%D, infusion of regular insulin (50 U in 250 ml 0.9% NS)
Insulin infusion rate (U/hr) = plasma glu (mg/dl) / 150 or /100 if on steroids or severe infection
Repeat bld glu every 4 hours
Day of surgery : Non dextrose containing solutions,
Monitor blood glu at start & every 1-2 hours

30. Tight control regimen II
Aim : Same as TC regimen I
Protocol : Obtain a feedback mechanical pancreas & set controls for desired plasma glucose.
Institute 2 iv drips for insulin & fluids

31. Alberti’s regimen
1979- Alberti & Thomas IV GIK solution [500ml 10% glucose + 10 units soluble insulin + 1 gm 100 ml/hr]
Before surgery - stabilize on soluble insulin regimen, omit morning dose of insulin
Commence infusion early on morning & monitor glu at 2-3 hours
< 90mg/dl or > 180 mg/dl replace bag with 5U or 15U respectively

32. Alberti’s regimen-Recent version
Initial solution : 500ml 10% glu + 10 mmol KCl + 15 U Insulin, infuse at 100 ml/hr
Check Blood glu every 2 hours
Adjust in 5 U steps
Discontinue if bld glu < 90 mg/dl
Blood glu (mg/dl)
Action
<120
10 U insulin
(2U/h)
15 U insulin
(3U/h)
>200
20 U insulin
(4U/h)

33. Advantages : simple, Inherent safety factor, balance appropriate
Criticism : hypoglycemia, water load & hyponatremia, cautious : poor renal function
20% or 50% D

34. Hirsh regimen Aim : Normoglycemia
Infuse glucose 5 g/hr with pot 2-4 mmol/hr
Start insulin
Measure blood glucose hourly
Blood glu (mg/dl)
Action (insulin infusion)
< 80
Turn off for 30 min, give 25 ml 50% D
80-120
↓ by .3 U/h
No change in infusion rate
↑ by .3 U/hr
> 220
↑ by 0.5 U/hr

35. Regular Insulin Sliding Scale
RECOMMENDATIONS
Supplement usual diabetes medications to treat uncontrolled high blood sugars
Short term use (24-48 h) in a patient admitted with unknown insulin requirement
Should not be used as a sole substitute, risk of DKA
Periop changes in regional blood flow – unpredictable absorption

37. Split-mixed insulin regimen
Combining multiple daily injections of intermediate or long acting insulin (NPH, lente, or ultralente) rapid or short acting insulins (Regular, insulin lispro, or insulin aspart)
“1500 Rule” : (ICF) 1500/total insulin dose = how much 1 unit of regular insulin will decrease blood glucose.

38. Hypoglycemia BG < 50 mg/dl in adults and < 40 mg/dl in children
whipple’s triad : low plasma glucose
hypoglycemic symptoms
resolution of symptoms with correction
of blood sugar
Sympathoadrenal :
Weakness, sweating, ↑ HR, palpitations, tremor, nervousness, irritability, tingling, hunger
Neuroglycopenia :
Headache, ↓ temp, visual disturbances, mental confusion, amnesia, seizures, coma

39. Treatment : Discontinue insulin drip Give D 50 w iv
patient conscious – 25 ml
patient unconscious – 50 ml
Recheck BG every 20 min & repeat 25 ml of D50 w if < 60 mg/dl
Restart drip once BG is > 70 mg/dl

40. Diabetic autonomic neuropathy :
Pupillary
Decreased diameter of darkadapted pupil
Argyll-Robertson type pupil
Metabolic
Hypoglycemia unawareness
Hypoglycemia unresponsiveness
Cardiovascular
Tachycardia, exercise intolerance
Cardiac denervation
Orthostatic hypotension
Heat intolerance
Neurovascular
Areas of symmetrical anhydrosis
Gustatory sweating
Hyperhidrosis
Alterations in skin blood flow
Gastrointestinal
Constipation
Gastroparesis diabeticorum
Diarrhea and fecal incontinence
Esophageal dysfunction
Genitourinary
Erectile dysfunction
Retrograde ejaculation
Cystopathy
Neurogenic bladder
Defective vaginal lubrication

41. Diagnostic tests for cardiovascular autonomic neuropathy :
Resting heart rate
> 100 beats/minute is abnormal
Beat-to-beat heart rate variation
The patient should abstain from drinking coffee overnight
Test should not be performed after overnight hypoglycemic episodes
When the patient lies supine and breathes 6 times per minute, a difference in heart rate of less
than 10 beats/minute is abnormal
An expiration:inspiration R-R ratio > 1.17 is abnormal
Heart rate response to standing
The R-R interval is measured at beats 15 and 30 after the patient stands
A 30:15 ratio of less than 1.03 is abnormal
Heart rate response to Valsalva maneuver
The patient forcibly exhales into the mouthpiece of a manometer, exerting a pressure of 40 mm Hg, for 15 seconds
A ratio of longest to shortest R-R interval of less than 1.2 is abnormal

42. Systolic blood pressure response to standing
Systolic blood pressure is measured when the patient is lying down and 2
minutes after the patient stands
A fall of more than 30 mm Hg is abnormal
A fall of 10 to 29 mm Hg is borderline
Diastolic blood pressure response to isometric exercise
The patient squeezes a handgrip dynamometer to establish his or her maximum
The patient then squeezes the grip at 30% maximum for 5 minutes
A rise of less than 16 mm Hg in the contralateral arm is abnormal
Electrocardiography
A QTc of more than 440 ms is abnormal
Depressed very-low frequency peak or low-frequency peak indicate sympathetic
dysfunction
Depressed high-frequency peak indicates parasympathetic dysfunction
Lowered low-frequency/high-frequency ratio indicates sympathetic imbalance
Neurovascular flow
Noninvasive laser Doppler measures of peripheral sympathetic responses to nociception

43. X – ray cervical spine :

44. Prayer sign :

45. Finger print test :

46. Differential diagnosis of DKA :

47. Diagnostic criteria and deficits in DKA and HHS :

48. Pathogenesis of DKA and HHS :

49. Diabetes and anesthesia :

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The Greek word Diabetes = to Siphon /pass through …
...and the Latin word mellitus = sweet as honey