General General v/sv/s Spinal – Epidural Spinal – Epidural v/sv/s Regional / Regional / LocalLocal

Dr. Prakash Ambardekar Senior Anaesthesiologist Dept of Anesthesia SL Raheja Hospital, Mumbai

Estimated population with diabetesEstimated population with diabetes mellitus in this country is about 32 million.mellitus in this country is about 32 million. 15-20 % have foot problems15-20 % have foot problems 30% have P. V. D. 30% have P. V. D. Frequent CAUSE for hospitalisationFrequent CAUSE for hospitalisation One of the expensive complication of One of the expensive complication of

D.M.D.M.

Diabetes Mellitus is not a simple endocrine disorder

PATHOLOGICAL PROCESS AFFECTING PHYSIOLOGICAL PROCESS IN TURN AFFECTING VARIOUS END-ORGANS

1] Cardio-vascular system - Angina pectoris, - silent small to massive Myocardial

Infarcts, - varying degrees of cardiomyopathies, - varying types of Conduction blocks etc - may be accompanied with Hypertension. - coronary heart disease four times more common in male and five times more common in women D M population

Significance - Detailed Pre-Op Evaluation - Intense Peri-operative Monitoring

2] Reno-vascular system - Nephropathies leading to Chronic renal failure - Pt. on DIALYSIS Significance - Identify pts. With IMPENDING RENAL FAILURE - Correction of Electrolyte

Imbalance - Correction Of Anaemia

3] Central nervous system - Secondary to Age Related - Septicaemia - Electrolyte Imbalance 4] Autonomic nervous system - Autonomic Imbalance Significance - Varying degrees of

Hypotension - Arrhythmias

5] Immunological system - suppression - prone to infections

6] Septicaemia - following infection affecting various systems

7] Fluid & Electrolyte status - Hyponatraemia - Hypokalaemia - Hyperkalaemia - Altered pH

8] Pulmonary system - altered ventilation and perfusion - obesity - A R D S

9] G. I. system - slows gastric emptying - altered tone of G-O sphincter - aspiration

10] Skeleto-muscular system - stiff joint syndrome - prayer’s sign - fusion of upper cervical vertebrae with limited neck - movement and “Palm test “ - obesity - short neck.

Thus, in Diabetes, the selection of Anesthesia becomes a tricky and highly skillful job.

 Special Problems

1] Aseptic technique is critical for all procedures in patients with DM to decrease the incidence of postoperative infection.

2] Surgical removal of infected tissue (ie amputation of gangrenous limb, incision of abscess, etc) results in dramatic reductions in Insulin requirement (and the danger of hypo-glycaemia) postoperatively.

3] Prabha Adhikari, Abraham Abey [2004] - It is well known that D M pts are at a greater risk of peri-operative mortality and morbidity after a major surgery especially with the presence of coexisting diseases.

4] 4] David Rothenberg [2006] - Mortality rates in diabetic patients Mortality rates in diabetic patients have been estimated to be up to 5 times greater than in have been estimated to be up to 5 times greater than in nondiabetic patients, often related to the end-organ damage nondiabetic patients, often related to the end-organ damage caused by the disease.caused by the disease.

5] Fortunately, intensive glycemic control has been shown 5] Fortunately, intensive glycemic control has been shown to have a profound effect on reducing the incidence of to have a profound effect on reducing the incidence of many of these complications in a variety of surgical many of these complications in a variety of surgical populations.populations.

6] O H G like sulfonylureas should be stopped pre-6] O H G like sulfonylureas should be stopped pre-operatively as operatively as

-can cause hypoglycemia -can cause hypoglycemia -being associated with interfering with ischemic -being associated with interfering with ischemic

myocardial preconditioning and may increase risk of peri-myocardial preconditioning and may increase risk of peri-operative myocardial ischemia and infarction. operative myocardial ischemia and infarction.

7] Patients taking metformin should be advised to 7] Patients taking metformin should be advised to discontinue this drug because of the risk of developing discontinue this drug because of the risk of developing lactic acidosis. lactic acidosis.

8]8] Hyperglycaemia at the time of cerebral ischaemic insults is associated with a poor outcome.

RISK FACTORS DURING ANAESTHESIA

1] MALE / FEMALE – CARDIAC AFFECTION FOR CHD

2] CARDIAC AUTONOMIC NEUROPATHY

3] RENAL INVOLVEMENT

4] GLYCEMIC CONTROL

5] ASSOCIATED MEDICAL DISEASES

6] SMOKING, OBESITY etc.

CHOICE OF ANAESTHESIACHOICE OF ANAESTHESIA

SELECTION :SELECTION :

1] General Anaesthesia1] General Anaesthesia

2] Regional Analgesia -2] Regional Analgesia - SpinalSpinal - Epidural - one shot - Epidural - one shot - continous- continous - Nerve blocks in Thigh- Nerve blocks in Thigh - sciatic- sciatic - femoral- femoral - Nerve blocks in Leg- Nerve blocks in Leg

- Ant. Tibial - Ant. Tibial - Post. Tibial - Post. Tibial

- Lat. Popliteal- Lat. Popliteal - Sural- Sural

- Field block- Field block

General Anaesthesia : Indications

1] Any Pt. on VENTILATOR

2] Any Pt. Hypersensitive to L. A. Agent

3] REFUSAL from Pt.

4] FAILURE of Regional Anaesthesia

General Anesthesia: [besides usual precautions]

a] Risk of Aspiration and PONV

b] Difficult intubations

c] Resistant hypotension which may last for longer time

d] Management of ischaemic changes and arrhythmias

e] Management of blood sugar

Spinal & Epidural Anaesthesia

a] Prevention and management of hypotension

b] Cannot be repeated frequently [ except in continuous epidural analgesia ] especially for small but painful procedures.

Why regional anaesthesia ?

1] Ideal for day-care patients

2] Safety in high risk patients

3] No intra-op regurgitation & aspiration

4] No PONV

5] Minimal alteration in drug schedule -specially in diabetics

Why regional anaesthesia ? Continued….

6] Minimal effects on vital parameters

7] Safer in emergency situations

8] Can be repeated frequently

9] Conscious & arousable patient at the end of the surgery

10] Reduction in morbidity & mortality

STRESS RELIEFSTRESS RELIEFPatients, coming to O. T., despite Good CounselingPatients, coming to O. T., despite Good Counseling

May be pretty APPREHENSIVE.May be pretty APPREHENSIVE.

This can be managed byThis can be managed by

1] REASSURANCE - Verbal1] REASSURANCE - Verbal

2] REASSURANCE – Tactile2] REASSURANCE – Tactile

3] SEDATION – mild to moderate3] SEDATION – mild to moderate

4] REASSURANCE – under Light Sedation.4] REASSURANCE – under Light Sedation.

Limitations

1] Surgical time limit is between 1-3 hrs.

2] Patient’s co-operation is must

3] Failure or partially acted block

StatisticsStatistics

Total No. of PATIENTS - 1757Total No. of PATIENTS - 1757No. RECEIVED Leg Blocks - 1400 [ 79.68% ]No. RECEIVED Leg Blocks - 1400 [ 79.68% ] - Low Leg Block - 1109 [ 79.21% ]- Low Leg Block - 1109 [ 79.21% ] - Mid Leg Block - 210 [ 15.00% ]- Mid Leg Block - 210 [ 15.00% ] - High Leg Block - 84 [ 6.00% ]- High Leg Block - 84 [ 6.00% ]Failure of the Block - 41 [ 2.93% ]Failure of the Block - 41 [ 2.93% ]{ All were given TIVA or GA }{ All were given TIVA or GA }

No. did NOT RECEIVE Blocks - 357 [ 20.31%]No. did NOT RECEIVE Blocks - 357 [ 20.31%] - Spinal - 123 [ 7.00%]- Spinal - 123 [ 7.00%] - Epidural{one shot/cont.} - 122 [ 6.94%]- Epidural{one shot/cont.} - 122 [ 6.94%] - General Anaesthesia - 112 [ 6.37%]- General Anaesthesia - 112 [ 6.37%]

Pre-block preparation Besides usual instructions….

Application of elastocrepe bandage 2-3 days prior to surgery

Advantages :-• limb becomes soft & supple • reduced oedema , improved limb circulation • pH of tissue fluid alters

Success rate improves

Pre-block preparation

Counseling the patient regarding the procedure and the expectation from the patient (compliance and accurate replies regarding paresthesia)

Lower leg block or modified ankle block

Deep peroneal nerve – can be blocked by injecting subcutaneously 3-5 mm along the lat border of the shin with 2 ml 2% xylocaine with 24 g 1.5 inch needle

Lower leg block or modified ankle block

Post. Tibial nerve – Blocked by injecting 3-5 ml 2% xylocaine at the junction of proximal 1/3rd with distal 2/3rd of medial malleolus to calcaneum, where normally pulsations of post. Tibial artery is felt.

Sural nerve

Inject 2% xylocaine between the tendoachilles and the calcaneaum on the lateral aspect

Lower leg block or modified ankle block

Ring block – 0.5 % xylocaine around theleg to block cutaneous nerves

Lower leg block or modified ankle block

Calcaneal nerve block

2 Finger breadths proximal to the medial malleolus

Inject along the direction of the nerve

Lower leg block or modified ankle block

Mid leg block

Anterior Tibial nerve

Inject 2- 4 ml 2% xylocaine subcutaneously 5-7 mm along the lateral border of the shin

Mid leg block

Posterior Tibial NerveSpinal needle no 23 G is inserted from the lateral side of the leg over the ant. border of fibula going medially downwards just to slip the interosseous border of tibia , advance 1-2 mm & deposit 8-10 ml 2% xylocaine

Mid leg block

Sural nerve

Inject 2 – 3 ml 2% xylocaine along a line extended proximallytangential to the lateral border of the tendo achilles

Ring block

0.5 % xylocaine around the leg to block cutaneous

nerves

Mid leg block

High leg block

Anterior Tibial nerve Inject 3-4 ml 2% xylocaine 5-10 mm deep lateral to theupper end of shin

High leg block

Posterior Tibial nerve

2-4cm below the neck of the fibula

Lateral approach –Spinal needle no 23 G is passed from the lateral side of the leg over the ant. border of fibula going medially downwards just to slip the interosseous border of tibia, advance 1-2 mm & deposit 8-10 ml 2% xylocaine.

Lateral Popliteal Nerve 2- 4 ml 2% xylocaine injected around the neck of fibula

High leg block

Ring block

0.5 % xylocaine around the leg to block cutaneous

nerves

High leg block

If patient has a pain-free leg, then one may give sciatic nerve

block in the lower third of thigh alongwith lat. Popliteal nerve block and ring block.

A) Posterior approachB) Lateral approach

High leg block

An alternate technique -

CONCLUSIONCONCLUSION

1] EVALUATE THE PATIENT 1] EVALUATE THE PATIENT IN TOTO. IN TOTO.

2] COUNSEL THE PATIENT & THE RELATIVES2] COUNSEL THE PATIENT & THE RELATIVES

3] PRACTICE WHAT YOU BELIEVE IS SAFE - -3] PRACTICE WHAT YOU BELIEVE IS SAFE - -

SAFE FOR YOU, YOUR PATIENT, YOUR TEAM.SAFE FOR YOU, YOUR PATIENT, YOUR TEAM.

4] ONCE YOU GET FAMILIAR WITH BLOCKS, YOU 4] ONCE YOU GET FAMILIAR WITH BLOCKS, YOU WILL FIND WIDER INDICATIONS AND GREATER WILL FIND WIDER INDICATIONS AND GREATER SATISFACTION.SATISFACTION.

Practice regularlyYour patienceThe surgeons’ patienceThe patients’ patience!

Steps to success with local blocks

Patients’ comfortThe surgeons comfortYour comfortAND SAFETY!!

In Diabetic FootIn Diabetic Foot

Blocks are the way to Blocks are the way to the goal !!the goal !!