Keywords
foot diabetic
locoregional anesthesia
general anesthesia
amputation
How to Cite
Abstract
Objective: The identification of the epidemiological characteristics as well as the comparison of the anesthetic techniques of the patients presenting a gangrene of the foot diabetic (general anesthesia versus locoregional anesthesia).
Material and method: Descriptive, retrospective study spread over the year 2013 and realized in the operating block of the emergencies of the military hospital of Rabat. The criteria of inclusion were an age of more than 18 years, and an amputation at the level of the lower limb further to a gangrene evolving in a context of known or inaugural diabetes. The incomplete files were excluded. Various epidemiological, clinical, biological and therapeutic parameters were collected. The various used anesthetic techniques were compared in term of modifications perioperative hémodynamiques, speed to reduce the hyperglycemia, arisen post-operative short-term complication, appeal in the analgesia operating comment as well as the total duration of intervention.
Results: During year 2013, 118 patients were listed among which 109 only included. The average age of the patients was 58.3
± 11 years old (extremes: 25-86 years) among which 81.6% were male (40 men, 9 women). The gangrene was localized at the level of a foot (61.5%), of a toe (34.9%), by a leg (2.7%) or of a thigh (0.9%). The biological characteristics of the patients in the admission were characterized by a hyperleucocytose, hyponatremia, a light acidose and a renal insufficiency. The quantity of the perfused solution in preoperative was 250 ± 132 mL with administration of an initial bolus of 10 UI of fast insulin. The antibiotic treatment was with amoxicillin/clavulanic acid (66.7%), of cefazolin (22.8%), of amoxicilline/clavulanic acid + metronidazol (6.3%) and of metronidazol only (4.2%). The used anesthetic techniques were a plexique block (62.2%), a spinal anesthesia (24.7%), a local anesthetic (8.5%) and a general anesthesia (4.6%). These various techniques were compared in term of modifications perioperative hémodynamiques, speed to reduce the hyperglycemia, arisen post-operative short-term complication, appeal in the analgesia operating comment as well as the total duration of intervention. The quantity of the perfusd solution it peropératoire was 775
± 409 mL. The premedication was made by the midazolam. The hemodynamic variations were important in the group spinal anesthesia and local anesthetic. The reduction of hyperglycemia as well as the duration of intervention were more important in the group general anesthesia. The post-operative consequences were marked by the arisen of a hemorrhagic shock at three sick (3.3%) and with a toxic shock at a sick person (1.1%). Our study showed the advantage to realize plexique blocks compared with the other anesthetic techniques.
Conclusion: Our therapeutic protocol which consists of an adapted hydro electrolytic resuscitation e metabolic preoperative and favors plexiques blocks allowed to reduce the incidence of the hemodynamics peroperative variations and the post-operative complications but would require to have patients’ more important staff and to be compared with other similar studies.
References
Lipsky BA, Berendt AR, Cornia PB, et al. 2012 Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections. Clin Infect Dis 2012; 54:e132-e173.
Aragón-Sánchez J, Lázaro-Martínez JL, Hernández-Herrero C, et al. Does osteomyelitis in the feet of patients with diabetes really recur after surgical treatment? Natural history of a surgical series. Diabet Med 2012; 29:813-818.
L.Bernard, Lavigne JP. Prise en charge du pied diabétique infecté. Médecine et maladies infectieuses 2007; 37:26-50.
Acharya S, Soliman M, Egun A, Rajbhandari SM. Conservative management of diabetic foot osteomyelitis. Diabetes Res Clin Pract 2013; 101:e18-e20.
Lipsky BA, Berendt AR, Embil J, De Lalla F. Diagnosing and treating diabetic foot infections. Diabetes Metab Res Rev 2004; 20:S56-64.
Delamaire M, Maugendre D, Moreno M, Le Goff MC, Allanic H, Genetet B. Impaired leucocyte functions in diabetic patients. Diabet Med 1997; 14:29-34.
Muchová J, Liptáková A, Országhová Z et al. Antioxydant system in polymorphonuclear leucocytes of type 2 diabetes mellitus. Diabet Med 1999; 16:74-8.
Bakker K, Apelqvist J, Schaper NC on behalf of the International Working Group on the Diabetic Foot Editorial Board. Practical guidelines on the management and prevention of the diabetic foot 2011. Diabetes Metab Res Rev 2012; 28:225-31.
Vigilance JE, Reid HL. Glycaemic control influences peripheral blood flow and haemorheological variables in patients with diabetes mellitus. Clin Hemorheol Microcirc 2005; 33:337-46.
Falanga V. Wound healing and its impairment in the diabetic foot. Lancet 2005; 366:1736-43.
Raymakers JT, Houben AJ, Van der Heyden JJ, Tordoir JH, Kitslaar PJ, Schaper NC. The effect of diabetes and severe ischaemia on the penetration of ceftazidime into tissues of the limb. Diabet Med 2001; 18:229-34.
Brownrigg JR, Davey J, Holt et al. The association of ulceration of the foot with cardiovascular and all-cause mortality in patients with diabetes: a meta-analysis. Diabetologia 2012; 55:2906-12.
Mendes JJ, Neves J. Diabetic Foot Infections: Current Diagnosis and Treatment. J Diab Foot Complic 2012; 4:26-45.
Krishnan S, Nash F, Baker N, et al. Reduction in diabetic amputations over 11 years in a defined UK population: benefits of multidisciplinary team work and continuous prospective audit. Diabetes Care 2008; 31:99-101.
Gottrup F. Management of the diabetic foot: surgical and organisational aspects. Horm Metab Res 2005; 37:69-75.
Apelqvist J. Diagnostics and treatment of the diabetic foot. Endocrine 2012; 41:384-97.
Dris I, Game F, Jeffcoate W. Does close glycaemic control promote healing in diabetic foot ulcers? Diabet Med 2005; 22:1060-3.
Krankel N, Adams V, Linke A et al. Hyperglycemia reduces survival and impairs function of circulating blood-derived progenitor cells. Arterioscler Thromb Vasc Biol 2005; 25:698-703.
Van den Berghe G, Wouters P, Weekers F et al. Intensive insulin therapy in the critically ill patients. N Engl J Med 2001; 345:1359-67.
Lipsky BA. Treating Diabetic Foot Osteomyelitis Primarily With Surgery or Antibiotics: Have We Answered the Question? Diabet Care 2014; 37:593-5.
Rao N, Ziran BH, Lipsky BA. Treating osteomyelitis: antibiotics and surgery. Plast Reconstr Surg 2011; 127:177S-187S.
Idris I, Game F, Jeffcoate W. Does close glycaemic control promote healing in diabetic foot ulcers? Diabet Med 2005; 22:1060-3.
Can MF, Yagci G, Dag B et al. Preoperative administration of oral carbohydrate-rich solutions: Comparison of glucometabolic responses and tolerability between patients with and without insulin resistance. Nutrition 2009; 25:72-7.
Langouche L, Vanhorebeek I, Vlasselaers D et al. Intensive insulin therapy protects the endothelium of critically ill patients. J Clin Investigation 2005; 115:2277-86.
Van den Berghe G, Wilmer A, Hermans G et al. Intensive insulin therapy in the medical ICU. N Engl J Med 2006; 354:449-61.
Carles-Michel M, Raucoules-Aimé M. Anesthésie du pAtient diAbétique. Mapar 2010.
Noel GJ, Bush K, Bagchi P, Ianus J, Strauss RS. A randomized,double-blind trial comparing ceftobiprole medocaril with vancomycin plus ceftazidime for the treatment of patients with complicated skin and skin-structure infections. Clin Infect Dis 2008; 46:647-55.
Rao N, Ziran BH, Lipsky BA. Treating osteomyelitis: antibiotics and surgery. Plast Reconstr Surg 2011; 127:177S-187S.
Lázaro-Martínez JL, Aragón-Sánchez J, García-Morales E. Antibiotics versus conservative surgery for treating diabetic foot osteomyelitis: a randomized comparative trial. Diabetes Care 2014; 37:789-95.
Large M, Knowles MA, White MJ, Messersmith R, Shand JEG. Generalised tetanus following a diabetic foot ulcer. The Diabetic Foot 2002; 5:187-90.
Coudert B, Saguez-Andribet C, Rey M, Espinoza P. Prévention du tétanos des plaies. In Meaume S, Dereure O, Téot L (eds): Plaies et Cicatrisations. Paris: Masson. 2005:271-4.
Brull R, McCartney CJL, Chan VWS, El-Beheiry H. Neurological complications after regional anesthesia : contemporary estimates risk. Anesth Analg 2007; 104:965-74.
Hebl JR, Horlocker TT, Schroeder DR. Neuroaxial anesthesia and analgesia in patients with preexisting central nervous system disorders. Anesth Analg 2006; 103:223-8.
Hebl JR, Kopp SL, Schroeder DR, Horlocker TT. Neurologic complications after neuroaxial anesthesia or analgesia in patients prexisting peripheral sensorimotor neuropathy or diabetic polyneuropathy. Anesth Analg 2006; 103:1294-9.
Capdevila X, Pirat P, Bringuier S et al. Continuous Peripheral nerve blocks in hospital wards after orthopedic surgery: a multicenter prospective analysis of the quality of postoperative analgesia and complications in 1,416 patients. Anesthesiology 2005; 103:1035-45.
Crawford JS. Epidural analgesia for patients with chronic neurological disease. Anesth Analg 1983; 62:621-2.
Dellamonica J, Blay M, Raucoules-Aimé M. Le diabétique en périopératoire. Quoi de neuf ? In: Sfar, editor. Conférences d’actualisation. 45e Congrès national d’anesthésie et de réanimation. Paris. Elsevier; 2003:407-26.
Ph. Cuvillon, C. Boisson, E. Nouvellon, J. Ripart. Peut-on faire une ALR en présence d’une neuropathie périphérique ? JMARU 2007.
Vandam LD, Dripps RD. Exacerbation of pre-existing neurologic disease after spinal anesthesia. N Engl J Med 1956; 255:843-9.
Kiziltan ME, Gunduz A, Kiziltan G, Akalin MA, Uzun N. Peripheral neuropathy in patients with diabetic foot ulcers: Clinical and nerve conduction study. J Neurol Sci 2007; 30.
Krishnan AV, Kiernan C. Altered nerve excitability properties in established diabetic neuropathy. Brain 2005; 128:1178-87.
Zochodne DW, Sun H, Eyer J. Accelerated diabetic neuropathy in axons without neurofilaments. Brain 2004; 127:2193-200.
Brull R, McCartney CJL, Chan VWS, El-Beheiry H. Neurological complications after regional anaesthesia: contemporary estimates risk. Anesth Analg 2007; 104:965-74.
Recommandations pour la pratique. Les Blocs périmédullaires chez l’adulte. SFAR 2006, Texte court en ligne sur www.SFAR.org.
Krishnan AV, Kiernan C. Altered nerve excitability properties in established diabetic neuropathy. Brain 2005; 128:1178-87.