Medical and Surgical Management of the Diabetic Foot and Ankle, An Issue of Clinics in Podiatric Medicine and Surgery (eBook)

Peter A. Blume (Autor)

eBook Download: PDF | EPUB

2014 | 1. Auflage
100 Seiten
Elsevier Health Sciences (Verlag)
978-0-323-26409-9 (ISBN)

Infos

This issue of Clinics in Podiatric Medicine and Surgery is edited by Dr. Peter Blume and Perioperative Management of the Patient with Diabetes Mellitus, Diabetes Mellitus and Peripheral Vascular Disease, Imaging of the Diabetic Foot And Ankle, Current Therapies for Diabetic Foot Infections and Osteomyelitis, Offloading of the Diabetic Foot: Orthotic and Pedorthic Strategies, Prosthetic Management For the Diabetic Amputee, and more.

Textauszug

Perioperative Management of the Patient with Diabetes Mellitus

Update and Overview

Stephen M. Schroeder, [e-mail],     Sports Medicine Oregon, 7300 Southwest Childs Road, Suite B, Tigard, OR 97224, USA

Perioperative management of diabetic patients involves optimizing glycemic control and negotiating comorbidities to help reduce complications and obtain results on par with nondiabetics. These goals are usually achievable in the elective surgical setting, but they can be more difficult to control in urgent or emergent situations. Understanding and recognizing the comorbidities associated with diabetes is imperative for optimizing outcomes. Regulating hyperglycemia can reduce morbidity, mortality, and postoperative infections. Understanding the effects of cardiac and renal disease is also important. Taking a team approach in managing these complex patients leads to improved outcomes and is now considered the standard of care.

Keywords

Diabetes mellitus

Management

Glycemic control

Comorbidities

Key points

• Some of the primary factors that put diabetic patients at higher risk are poor glycemic control, the existence of comorbidities, and failure to recognize the condition.

• Poor long-term and short-term blood sugar control has been shown to delay healing and increase the risk of postoperative infections throughout multiple specialties.

• Diabetic patients are often elderly with comorbidities including cardiovascular disease, impaired renal function, respiratory disease, and peripheral vascular disease. Diabetic surgical patients often present with one or more of these conditions and need to be properly addressed in order to proceed safely with the planned procedure.

• Proper perioperative management of diabetic patients starts by identifying those with the disease state. Of the estimated 25 million Americans with diabetes, 7 million (28%) do not know they have it and only become aware when a complication arises. It has been established by the American Diabetes Association that controlling perioperative blood sugars for orthopedic surgical patients can decrease mortality, reduce infection rates, and lead to shorter lengths of stay in the hospital.

• Perioperative management of diabetic patients centers on optimizing glycemic control and negotiating comorbidities to help reduce complications and obtain results on par with nondiabetics.

• Taking a team approach in managing these complex patients leads to improved outcomes and is now considered the standard of care.

Introduction

The incidence of diabetes continues to escalate in the United States and throughout the world. Diabetes has deleterious affects on multiple body systems and is the leading cause of blindness, end-stage renal disease, and nontraumatic amputations.1 Peripheral neuropathy and vascular disease lead to lower extremity complications that correlate directly with higher morbidity and mortality. In addition, the sequelae of diabetes create complex scenarios that make treatment challenging. The disease is directly related to increased morbidity and length of stay in hospitals.2 It is estimated that up to 25% of hospitalized Americans have diabetes. Surgical patients are estimated to stay in house 45% longer and have 5 times higher mortality than nondiabetic patients.3

Some of the primary factors that put diabetic patients at higher risk are poor glycemic control, the existence of comorbidities, and failure to recognize the condition. Poor long-term and short-term blood sugar control has been shown to delay healing and increase the risk of postoperative infections throughout multiple specialties.4

Diabetic patients are often elderly with comorbidities including cardiovascular disease, impaired renal function, respiratory disease, and peripheral vascular disease.5 There is a 2-fold to 4-fold increase of cardiovascular disease in diabetic patients that may include hypertension, coronary artery disease, or stroke.6 Diabetic surgical patients often present with one or more of these conditions and need to be properly addressed in order to proceed safely with the planned procedure.

There is a common misconception that surgery should not be performed on diabetic patients for fear of complications and poor outcomes. Although certain aspects of diabetes can predispose patients to potential perioperative complications, improved understanding of the disease process combined with newer technology, a team-oriented approach, and better anesthesia techniques makes surgery a less harrowing proposition. This article focuses on perioperative management of diabetic patients. It gives advice on ways to prepare patients during this time in order to optimize outcomes for elective and nonelective procedures.

Perioperative assessment

Proper perioperative management of diabetic patients starts by identifying those with the disease state. Patients who have established medical care with a primary care physician (PCP) are typically identified. However, there is an increasing number of people in the United States without medical insurance, who do not have proper access to a PCP, and who may have unrecognized and untreated diabetes. Of the estimated 25 million Americans with diabetes, 7 million (28%) do not know they have it and only become aware when a complication arises,7 which is particularly problematic for patients requiring emergency surgery because hyperglycemia and other comorbidities cannot be properly managed before surgery, which may lead to increased complications.8 Patients with undocumented but suspected diabetes should be worked up by checking serum glucose and glycosylated hemoglobin A1c (HbA1c) levels before surgery.

Identification of these patients is done with a thorough history and physical examination. The history should detail symptoms of cardiac, neurologic, peripheral vascular (peripheral vascular disease [PVD]), retinal, and renal disease. It is important that patients with cardiac disease, PVD, or renal disease get proper preoperative clearance from their PCP or particular specialist before undergoing elective surgery. Proper referrals should be made before moving forward if they are not established with a PCP or specialist. Box 1 and Tables 1 and 2 detail elements that should be included in the preoperative work-up.

Box 1   Elements that should be included in a preoperative physical examination

Physical Examination

• Blood pressure

• Thyroid palpation

• Cardiac evaluation

• Pulmonary evaluation

• Abdominal palpation

• Evaluation of peripheral pulses

• Foot examination

• Skin examination

• Neurologic examination

Table 1

Elements that should be included in a preoperative history

History Questionnaire

Examples

Systemic symptoms of diabetes

Polyuria Polydipsia Blurred vision

Family history

Diabetes Cardiac disease Anesthesia complications

Social history

Dietary habits History of malnutrition Tobacco use Alcohol use Controlled substance use

Current diabetes management

Medications Diet Exercise Glucose monitoring results

History of acute diabetic complications

Ketoacidosis Hypoglycemia Acute renal failure

History of infections

Skin Feet Dentition Genitourinary system

History of vascular complications

Deep vein thrombosis Pulmonary Embolism (PE) Cerebrovascular events

History of cardiac disease complications

Severe hypertension Atrial fibrillation Unstable angina Aortic stenosis Congestive heart failure Myocardial infarction Stroke

Current medications

Corticosteroids Hypertensive medications Cholesterol-reducing medications Diuretics Diabetic medications Insulin

Risk factors for atherosclerosis

Smoking Hypertension Obesity Dyslipidemia Family history of atherosclerosis

Table 2

Additional testing that should be considered during the work-up

Perioperative management

Cardiac Disease

The risk for cardiac events in foot and ankle surgery is typically considered to be low (<1%).9 However, the mortality from heart disease in diabetic patients...

Produkt-Details

• Erscheint lt. Verlag: 9.2.2014
• Sprache: englisch
• Themenwelt: Medizinische Fachgebiete ► Chirurgie ► Unfallchirurgie / Orthopädie
• Themenwelt: Medizin / Pharmazie ► Medizinische Fachgebiete ► Orthopädie
• ISBN-10: 0-323-26409-3 / 0323264093
• ISBN-13: 978-0-323-26409-9 / 9780323264099