This document discusses glycemic control in patients with highly infected diabetic foot ulcers. It outlines an aggressive treatment approach involving medical assessment, hydration, nutrition via IV lines or feeding tubes, broad-spectrum antibiotics, insulin administration, and surgical debridement as needed. Close monitoring of blood glucose, electrolytes, renal function, and other lab values is emphasized. The challenges of achieving glycemic control in this catabolic, insulin resistant state are also discussed.

1. 1
Glycemic control and highly
infected diabetic foot
Dr. Sanjeev Kelkar M.D.
Medical Director
Novo Nordisk Education Foundation,
Bangalore, INDIA

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
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
Glycemic control and
diabetic foot
The infected foot:2
Failure of body to localize the infection*
Endotoxemia
Septicaemia
Necrotising fascitis
Multiorgan failure

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
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
Glycemic control and
diabetic foot
The aggressive approach: 1
Medical assessment
Hydration / Nutrition
Antibiotics
Surgical treatment - Operative /
Conservative
Insulin administration

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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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