Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / @xirurgi_2025 / @xirurgi_2025 - 344 - файл
.pdf
7 The Science andUtility ofOoading theDiabetic Foot
83
altered in a way that gives advantage to the
Achilles, such as a transmetatarsal amputation. The tendoachilles lengthening or TAL is
the surgical gold standard in these clinical scenarios. In a study by Mueller etal., they looked
at 30 patients with forefoot ulcerations with
which a TAL was performed and all patients
healed the ulceration [30]. The author’s preferred technique is the percutaneous triple
hemisection as described by Hoke. The smaller
incisions afford less complications in the
comorbid patient.
Tendon Transfers
Tendon transfers are utilized to improve motor
function when weakness and imbalance exist in
the diabetic foot, particularly after an amputation of different parts of the foot. Key tendon
insertion sites are amputated and soft tissue
imbalance can lead to deforming forces on different areas of the foot.
In the authors opinion, there are key clinical
principles that are crucial when deciding to perform a tendon transfer: (1) Tendon transfers
cannot overcome a xed deformity; therefore,
these are only of functional use in a exible
deformity, (2) the tendon being harvested
should be a minimum strength grade of 4+ as
the tendon loses one grade of strength following transfer, (3) the ideal tendon to transfer is
one that functions in the same phase of gait,
although this is not an absolute contraindication of transplantation, (4) perhaps most importantly, muscle-tendon tension should be
adequately xated to give optimal function
postoperatively.
Understanding agonist and antagonist actions
of the different muscles of the lower extremity is
imperative when deciding when to do a tendon
transfer. One of the most common muscle imbalances in the foot is after amputation of the fth
ray and losing the peroneus brevis tendon attachment. The direct antagonist to the peroneus brevis is the posterior tibial tendon, which over time
will lead to an equinovarus deformity of the foot.
One method to correct this is utilizing a posterior
tibial tendon transfer to the lateral aspect of the
foot (typically the lateral cuneiform) through the
interosseous membrane to create a more plantigrade foot.
Bone Procedures
Modied Keller Resection Arthroplasty
forFirst MPJ Ulcers Under Hallux
The Keller arthroplasty is typically reserved for
the elderly population with moderate to severe
osteoarthritis for the rst metatarsophalangeal
joint and associated osteoporotic bone. However,
this procedure can be useful in the case of a
recurring plantar hallux ulceration. In a study by
Tamir et al., the authors looked at 28 keller
arthroplasties with a plantar hallux wound. 78%
of the ulcerations recovered in a mean of 3.1
weeks and had no recurrence at a mean follow-up
of 26 months [31]. The procedure essentially acts
to decompress the hallux and allow for more
extension of the metatarsophalangeal joint. This
acts to decrease the pressure associated with the
formation of the wound.
MIS Invasive Floating Metatarsal
Osteotomy forPressure Under
Metatarsal Heads
There are several operations that can be utilized
for plantar metatarsal head ulcerations such as
the Weil osteotomy, plantar condylectomy, or
dorsal closing wedge osteotomy. These are great
procedures to ofoad the plantar aspect of the
foot; however with these open procedures in the
diabetic population, there is an increase in postoperative complications such as wound dehiscence or infection [32].
This procedure is done by making a small
3mm incision over the affected metatarsal. Next,
utilize a mosquito or curved hemostat for blunt
dissection down to bone. Using a Shannon burr,
make a perpendicular or short oblique osteotomy
in the metatarsal to dorsally displace the metatarsal head. In a study by Tamir etal., they looked at
20 cases of this osteotomy in patients with plantar metatarsal head ulcerations. In 17 of the 20
cases, the ulcer fully healed at 6 weeks. The
84
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
C. S. Zarick et al.
remaining 3 showed clinical improvement but
not full healing of the ulcer [32].
As minimally invasive procedures are gaining
traction in foot and ankle surgery, this is an attractive procedure for numerous reasons. First, there
is no hardware needed which is ideal in a patient
with a wound. Additionally, there is a minimal
chance of wound complications and these patients
are able to be full weight-bearing immediately
post-op in a surgical shoe further decreasing
post-op recovery.
Utility ofExternal Fixation
forOoading
Surgical ofoading via the use of external xation (Fig.7.7) is a unique and valuable tool for
any foot and ankle surgeon, particularly when
conservative ofoading methods fail due to
excess drainage from the wound or patient compliance issues. It is used for the stabilization,
protection, and immobilization of the soft tissue
and osseous structures and is particularly helpful with limb salvage plastic surgery techniques
[33]. Soft tissue reconstruction can easily be
disrupted postoperatively from weight-bearing
or premature joint motion. The external xator
helps to avoid these complications as well as
gives you access to wounds and/or free aps.
As we stated earlier, total contact casts are
the gold standard for diabetic foot ofoading.
The only pitfall to this cast is that the patient,
physician, or home nurse cannot examine a
wound regularly which can lead to advancement of the ulcer, infection, or even new
ulcerations.
The benets of utilizing an external xator
for ofoading purposes is that you remove
absolutely all weight from the foot and eliminate all tension on the plantar aspect of the foot.
Additionally as stated above, wound care can
be done at any time and any skin graft or free
ap used can be protected from areas of
pressure.
On the other hand, there are downsides to the
use of external xation. First, the surgeon must
be skilled and condent in applying these
frames. Perhaps the largest downside to external
xation is the high possibility of pin tract infection which occurs at the skin-pin interface. One
systematic review reported that the cumulative
pin tract infection rate throughout the literature
was 27% [34] which every surgeon should be
aware of and diligent wound care should be
done daily.
In the author’s opinion the times to use an
external xation for ofoading are: ulcerations
not responding to total contact cast treatment or
other typical methods of ofoading, large plantar
Fig. 7.7 Circular external xation device
7 The Science andUtility ofOoading theDiabetic Foot
Table 7.2 This table demonstrates different methods for ofoading based on wound location
Location Common pathology Conservative Surgical
Hallux – Hallux limitus/rigidus – Diabetic shoe/
insert
– Custom orthotics – Exostectomy
Digits – Mallet, claw, hammertoe – Diabetic shoe – Flexor tenotomy
Forefoot – Distal fat pad displacement – Diabetic shoe/
insert
– Transfer pressure from elongated or shorten
ray
– Equinus – CAM walker – Tendon transfers
Midfoot – Rigid atfoot – Diabetic shoe/
– Charcot neuroarthropathy – Total contact cast – External xator
Hindfoot – Calcaneal gait – Diabetic shoe/
– Charcot neuroarthropathy – Total contact cast – Achilles repair
– Pressure – CAM walker – Ankle fusion
Listed are both conservative and surgical methods of ofoading
– Felt metatarsal pad – Gastroc recession
insert
– CAM walker – Surgical reconstruction
– CROW boot – Tendon transfers
insert
– CROW boot – Tibio-Talo-Calcaneal arthrodesis
– Keller arthroplasty
– Arthroplasty
– Tendoachilles lengthening
– Floating metatarsal head
osteotomy
– Exostectomy
– External xator
85
ulcerations, ulcers in patients that have extreme
difculty being non-weight-bearing perhaps due
to obesity, ulcerations that require skin grafting
or aps, and for reconstructive surgeries when
internal xation is contraindicated.
Ooading Options Categorized by
Wound Location
Conservative and surgical ofoading of the diabetic foot is paramount in both the treatment and
the prevention of ulcerations. One must take into
account many factors when selecting both shortterm and long-term ofoading options. Each
ulceration and each patient is unique and thus a
plan, whether conservative or surgical, must be
developed based on each unique situation. Please
see Table7.2 for a summary of different methods
of ofoading both surgical and conservative
based on wound location.
Every diabetic patient should be evaluated
periodically for proper ofoading mechanisms.
If conservative ofoading devices are not work-
ing and a patient continues to develop an ulceration, then a surgical ofoading mechanism
may be necessary. The treatment of diabetic foot
ulcers begins with prevention and begins with
the basic knowledge and understanding of
ofoading.
References
1. International Diabetes Federation. IDF diabetes atlas.
9th edn. 2019. p.14–25.
2. Jodheea-Jutton A, Hindocha S, Bhaw-Luximon A.
Health economics of diabetic foot ulcer and recent
trends to accelerate treatment. Foot. 2022;52:101909.
https://doi.org/10.1016/j.foot.2022.101909.
3. Blume P, Stephanie W.Updating the diabetic foot treatment algorithm: recommendations on treatment using
advanced medicine and therapies. 2017;30(2):29–35.
4. Cavanagh P, Bus S.Off-loading the diabetic foot for
ulcer prevention and healing. 2010;52(3):37–43.
5. Baker N, Osman I.The principles and practicalities
of ofoading diabetic foot ulcers. 2016;19(4):172–81.
6. Kim P.Biomechanics of the diabetic foot: consideration in limb salvage. 2013;2(3):107–11.
7. Pham H, Armstrong DG, Harvey C, Harkless LB,
Giurini JM, Veves A.Screening techniques to identify
86
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
C. S. Zarick et al.
people at high risk for diabetic foot ulceration: a prospective multicenter trial. 2000;23:606.
8. Dardari D.An overview of Charcot’s neuroarthropathy. J Clin Transl Endocrinol. 2020;22:100239.
9. Potter J, Potter MJ.Effect of callus removal on peak
plantar pressures. Foot. 2000;10(1):23–6.
10. Veves A, Murray HJ, Young MJ, Boulton AJ. The
risk of foot ulceration in diabetic patients with high
foot pressure: a prospective study. Diabetologia.
1992;35:660.
11. Mrdjenovich D. Off-loading practices for the
wounded foot: concepts and choices. J Am Col Certif
Wound Spec. 2010;2(4):73–8.
12. Armstrong DG, Athanasiou KA.The edge effect: how
and why wounds grow in size and depth. Clin Podiatr
Med Surg. 1998;15(1):105–8.
13. McCartan BL, Rosenblum BI. Ofoading of the
diabetic foot: orthotic and pedorthic strategies. Clin
Podiatr Med Surg. 2014;31:71–88.
14. Albert S, Rinouie C. Effect of custom orthotics on
pressure distribution in the pronated diabetic foot. J
Foot Ankle Surg. 1994;33:598–604.
15. Lanez-Sharma R.Diabetic shoes: why you need them.
https://www.ankle- footspecialist.com/blog/diabeticshoes- why- you- need- them. Accessed 21 March 2022.
16. Tejada A. The difference between diabetic shoes
and regular shoes. 2019. https://www.orthofeet.com/
blogs/news/the- difference- between- diabetic- shoesand- regular- shoes. Accessed 22 March 2022.
17. Gutekunst DJ, Hastings MK, Bohnert KL, Strube
MJ, Sinacore DR.Removable cast walker boots yield
greater forefoot off-loading than total contact casts.
Clin Biomech. 2011;26(6):649–54.
18. Pollo FE, Brodsky JW, Crenshaw SJ, Kirksey
C. Plantar pressures in berglass total contact casts
vs a new diabetic walking boot. Foot Ankle Int.
2003;24(1):1–5.
19. Ababneh A, Finlayson K, Edwards H, Lazzarini
PA. Factors associated with adherence to using
removable cast walker treatment among patients with
diabetes-related foot ulcers. BMJ Open Diabetes Res
Care. 2022;10:e002640.
20. Armstrong DG, Nguyen HC, Lavery LA, van Schie
CH, Boulton AJ, Haarkless LB.Off-loading the diabetic foot wound: a randomized clinical trial. Diabetes
Care. 2001;24(6):1019–22.
21. Rogers LC, Hanft J. Point-counterpoint: is total
contact casting better than the CAM Walker Boot
for plantar diabetic wounds? 2019. https://www.
hmpgloballearningnetwork.com/site/podiatry/
point- counterpoint- total- contact- casting- better- cam-
walker- boot- plantar- diabetic- wounds. Accessed 22
March 2022.
22. Messenger G, Masoetsa R, Hussain I. A narrative
review of the benets and risks of total contact casts
in the management of diabetic foot ulcers. J Am Coll
Clin Wound Spec. 2017;9(1–3):19–23.
23. Grifths DA, Kaminski MR.Duration of total contact casting for resolution of acute Charcot foot:
a retrospective cohort study. J Foot Ankle Res.
2021;14(1):44.
24. Elattar O, Smith T, Ferguson A, Farber D, Wapner
K. Uses of braces and orthotics for conservative
management of foot and ankle disorders. Foot Ankle
Orthop. 2018;3(3).
25. Sarmiento A.A functional below-the-knee cast for tibial fractures. J Bone Joint Surg Am. 1967;49:855–75.
26. Alimerzaloo F, Kashani RV, Saeedi H, Farzi M,
Fallahian N.Patellar tendon bearing brace: combined
effect of heel clearance and ankle status on foot plantar pressure. Prosthet Orthot Int. 2014;38(1):34–8.
27. Tanaka H, Goto NT, Inoue A.The effect of the patellar
tendon-bracing cast on loading. J Bone Joint Surg Br.
2000;82(2):228–32.
28. Armstrong DG, Frykberg RG. Classifying diabetic
foot surgery: toward a rational denition. Diabet Med.
2003;20:329–31.
29. Armstrong DG, Stacpoole-Shea S, Nguyen H,
Harkless LB.Lengthening of the Achilles tendon in
diabetic patients who are at high risk for ulceration of
the foot. J Bone Joint Surg Am. 1999;81:535–8.
30. Mueller M, Sinacore DR, Hastings MK, Strube MJ,
Johnson JE. Effect of Achilles tendon lengthening
on neuropathic plantar ulcers. A randomized clinical
trial. J Bone Joint Surg Am. 2003;85(8):1436–45.
31. Tamir E, Tamir J, Beer Y, Kosashvili Y, Finestone
AS.Resection arthroplasty for resistant ulcers underlying the Hallux in insensate diabetics. Foot Ankle
Int. 2015;36(8):969–75.
32. Tamir E, Finestone AS, Avisar E, Agar G. Miniinvasive oating metatarsal osteotomy for resistant or
recurrent neuropathic plantar metatarsal head ulcers. J
Orthop Surg Res. 2016;11:78.
33. Ramanujam CL, Facaros Z, Zgonis T. Surgical offloading external xation and plastic reconstruction
of the foot and ankle. 2016. https://musculoskel-
etalkey.com/surgical- off- loading- external- fixationand- plastic- reconstruction- of- the- foot- and- ankle/.
Accessed 26 March 2022.
34. Lobst CA, Liu RW.A systematic review of incidence
of pin track infections associated with external xation. J limb lengthening reconstr. 2016;2(1):6–16.
Medical Management oftheLimb
Salvage Inpatient
MarieM.Alternburg, JenniferM.Haydek,
SaraKiparizoska, NinaK.Weaver,
andMargotG.Wheeler
8
Section 1: Perioperative
Management ofCardiac Risk
Factors andDisease
Noncardiac surgeries, including limb salvage
procedures, are a robust part of a functioning
healthcare system, with 1in every 30–40 adults
undertaking such procedures at some point in
their lives. In a large-scale WHO-funded inquiry,
among the 200 million adults worldwide who
undergo noncardiac surgery each year, more than
ten million will suffer from a major vascular
event—myocardial infarction, cardiac arrest, cardiac death—within 30 days from surgery [1].
Effective, evidence-based perioperative cardiac
management can improve mortality, avoid subsequent morbidities, decrease length of hospitalization, and minimize the cost burden on the
healthcare system.
Estimate Risk
It is crucial to begin any preoperative management with an assessment of the patient’s cardiac
risk as well as the risk inherent in the planned
surgery. This assessment can and should inform a
range of clinical decisions regarding testing,
monitoring, and medical management leading up
to the surgery as well as perioperatively.
Risk ofProcedure
The rst step in any perioperative evaluation is to
risk stratify the procedure itself. The American
guidelines consider noncardiac surgeries with
<1% risk of major adverse cardiac event (MACE)
low risk, whereas high risk are procedures with
higher rates of adverse events including vascular
(7.7%), thoracic (6.5%), transplant (6.2%), general surgeries (3.9%) [2]. While most limb salvage procedures t in the low-risk category, more
complex surgeries such as ap procedures are
high-risk surgeries due to prolonged surgical
time.
M. M. Alternburg · J. M. Haydek · S. Kiparizoska ·
N. K. Weaver · M. G. Wheeler (*)
Department of Internal Medicine, Medstar
Georgetown University Hospital,
Washington, DC, USA
e-mail: Marie.M.Altenburg@medstar.net;
Jennifer.M.Haydek@medstar.net;
Sara.Kiparizoska@medstar.net;
Nina.K.Weaver@medstar.net;
Margot.G.Wheeler@gunet.georgetown.edu
© Springer Nature Switzerland AG 2023
C. E. Attinger, J. S. Steinberg (eds.), Functional Limb Salvage,
https://doi.org/10.1007/978-3-031-27725-2_8
Conditions That Confer Risk
It has been established that pre-existing cardiac
conditions like CAD, cardiac stents, CHF,
arrhythmias including atrial brillation and valvular pathologies including aortic stenosis can
increase the risk of perioperative morbidity and
mortality.
87
88
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
M. M. Alternburg et al.
Tools
The Revised Cardiac Risk Index (RCRI) is the most
used risk assessment tool given its relative simplicity, taking into account the risk of the surgery, a history of ischemic heart disease, congestive heart
failure, cerebrovascular disease, preoperative insulin dependence, and a preoperative creatinine
greater than 2mg/dL.More recent prospective studies suggest higher risk estimates for major adverse
cardiac events than originally established; up to a
sixfold increase in events vs. the rate predicted by
the RCRI.The NSQIP has been found to have superior ability to discriminate for adverse cardiac
events vs. the RCRI [3, 4], though these studies did
not routinely monitor perioperative troponins and
likely missed a signicant number of cardiac events,
which are often silent [5]. The major American and
Canadian guidelines recommend using the RCRI
over the NSQIP.Patients with 0 points on the RCRI
score have a 3.9% risk of MACE; 1 point confers a
6.0% risk; 2 points confer a 10.1% risk; 3 or more
points convey a 15% risk.
Functional Capacity
The next crucial step in any preoperative evaluation is to assess functional capacity. The inability
to perform more than four metabolic equivalents
(METS), which is equivalent to walking up two
ights of stairs or undertaking heavy housework
has been associated with double the perioperative
cardiac complications [6].
Myocardial Injury After Noncardiac
Surgery (MINS)
The MINS protocol helps identify patients who
are at high risk for developing myocardial injury
after noncardiac surgery. Patients >age 65 with
known coronary artery disease should have troponin measurements on day 1, 2, and 3 after surgery.
An elevation in the troponin allows physicians to
identify MINS and start secondary measures [7].
EKG
American guidelines recommend a preoperative
EKG when there is a history of coronary artery
disease (CAD), arrhythmia, CVA, or structural
cardiac disease and prior to a higher risk procedure [8]. Multiple studies have found little benet
to a preoperative EKG in low-risk surgeries, and
while bundle blocks were associated with
increased risk, no more so than when history
identied risk [9–11].
Transthoracic Echocardiography
American guidelines do not support preoperative
transthoracic echocardiography (TTE) unless the
patient has a history of moderate or severe valvular disease without a TTE in past 12months or in
those with symptoms of severe valvular disease
such as syncope, dyspnea, angina, dyspnea, or
edema [8]. Overall, routine TTE is not recommended if there are no history of symptoms indicating active heart failure or structural disease.
These recommendations are based on studies that
have found an increased risk of perioperative cardiac events in patients with congestive heart failure and structural disease. Aortic stenosis with a
gradient >40mmHg, left ventricular hypertrophy,
and left ventricular systolic dysfunction associated were associated with increased cardiac
events, including myocardial infarction, pulmonary edema, ventricular brillation or arrest, and
complete heart block [12]. A preoperative TTE w/
any degree of systolic dysfunction, moderate to
severe LVH, moderate to severe mitral regurgitation, or AS w/ gradient >20mmHg was 80% sensitive for perioperative cardiac events w/ negative
predictive value of 97% [12]. AS on preoperative
TTE was associated with increased risk of perioperative death or MI (14% vs. 2% w/out aortic stenosis) [13]. Left ventricular ejection fraction
(LVEF) <30% was associated with greater risk of
perioperative death, MI, or heart failure decompensation (53.5% vs. 26% w/ LVEF >30%) [14].
Preoperative Cardiac Testing
Cardiac Stress Testing
The current American guidelines suggest preopBased upon the risk of the procedure being undertaken and the patient’s risk assessment, various preoperative diagnostic testing might be appropriate.
erative stress test only when a patient cannot
perform >4 METS and if the outcome would
change perioperative management [8].
8 Medical Management oftheLimb Salvage Inpatient
89
These guidelines are based on studies associating poor functional capacity with worse perioperative outcomes. The inability to perform four
METS was associated with a twofold increase in
perioperative MACE [6]. In an assessment using
the Duke Activity Score Index, which is validated
to access functional capacity, lower scores were
associated with death or MI in 2% of patients
within 30days of surgery [15]. In small, prospective studies myocardial ischemia at low workload
(<60% of maximum predicted heart rate) was
associated with increased event rates (23% risk
of death/MI vs. 5% in those without ischemia)
[16]. A negative dobutamine stress echo and no
wall motion abnormalities had excellent negative
predictive value for perioperative MACE [17].
Cardiac Catheterization/CTA
The current American and Canadian guidelines
recommend invasive angiography only if a preceding stress test indicates myocardial ischemia
and when results would change perioperative
care. A randomized controlled study assigning
510 patients with CAD about to have vascular
surgery to either revascularization or conservative management found that revascularization did
not signicantly impact long-term outcomes,
though the study was not adequately powered to
assess differences in short-term outcomes [18].
There is no current guideline for coronary CT
scans [19]. It is an area of active inquiry whether
noninvasive preoperative coronary CT scans
might help predict perioperative MACE and
potentially inform management. In a study of 239
patient getting pre-op CT coronary angiography,
a higher RCRI, a high CACS (113), the presence
of signicant coronary artery stenosis (diameter
stenosis 50%), and multivessel coronary artery
disease were signicantly associated with postoperative cardiovascular events. CTCA was more
sensitive than RCRI alone in patients with RCRI
<2. This suggests CTCA might be a good option
for patients who cannot tolerate exercise or
chemical stress test [20]. A 2019 meta-analysis
found incremental risk of MACE with CAD by
coronary CT and that multivessel CAD on coronary CT conferred eightfold increased risk of
perioperative MACE [21]. A prospective cohort
study of 955 patients found that while pre-op
coronary CT can improve estimated risk, it can
also overestimate the risk by vefold in patients
who will not have these outcomes [22].
Cardiac Biomarkers
N-terminal-pro-BNP (NT-ProBNP) is a polypeptide released by cardiac cells in response to
stretch. It is an area of active investigation to see
if serum NT-ProBNP levels might be associated
with perioperative cardiac risk. The current
AHA/ACC guidelines do not endorse preoperative BNP measurement as there has been no data
showing that this practice might reduce cardiovascular risk [8]. The Canadian guidelines, however, recommend checking pro-bnp prior to
surgery for patients who have cardiovascular
disease and RCRI >1, or for anyone >65years
old [5].
Optimizing Medical Therapies
Preoperatively
Beta-Blocker
Beta-blockers are known to decrease myocardial
wall stretch, prolong coronary artery diastolic
lling time, and reduce myocardial oxygen supply and demand mismatch. As such, they were
previously prescribed perioperatively with abandon, including starting new beta-blockers on the
day of surgery. Current ACC/AHA guidelines
support continuing previously prescribed betablockers and starting them for patients with
appropriate BB indications if >7 days prior to
surgery, but do not support initiating betablockers in the immediate pre-op period [19],
which is in line with European guidelines. In a
retrospective cohort analysis of 136,745 patients
exposed to beta-blockers on the day of or following surgery, perioperative beta-blocker exposure
was associated with lower rates of 30-day allcause mortality in patients with 2 or more Revised
Cardiac Risk Index factors [23].
A 2014 metanalysis including 16 RCTs
showed that while beta-blockers were associated
with a trend toward reduced all-cause mortality
rate in the DECREASE trials (RR: 0.42; 95% CI:
90
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
M. M. Alternburg et al.
0.15–1.22), they were associated with increased
all-cause mortality rate in other trials (RR: 1.30;
95% CI: 1.03–1.64). Additionally, this study
found that while perioperative beta-blockers
started within 1 day or less before noncardiac
surgery prevents nonfatal MI, these patients had
increased risks of stroke, death, hypotension, and
bradycardia. As such, putting aside the
DECREASE studies, there are insufcient data
on beta blockade started 2 or more days prior to
surgery [24].
An international, multicenter RCT of 8351
patients with cardiovascular disease or at risk for
cardiac disease randomized to receive 100 mg
metoprolol succinate on day of surgery and then
continued for 30days found that fewer patients in
the metoprolol group than in the placebo group
had a myocardial infarction. However, there were
more deaths in the metoprolol group than in the
placebo group, as well as more strokes [25].
In a 2010 prospective study of 940 vascular
surgery patients given beta-blockers 0–1, 1–4,
and 4 weeks before surgery, beta-blocker treatment initiated >1week before surgery is associated with lower preoperative heart rate and
improved outcome, compared with treatment initiated <1week preoperatively [26].
Aspirin
Aspirin is an irreversible cox-1 inhibitor and as
such reduces the aggregation of platelets and is
associated with increased bleeding risks. The
current American guidelines recommend to hold
aspirin prior to noncardiac surgery unless the
ischemic risks outweigh the chances of bleeding
[19]. However, more recent data supports continuing aspirin in patients who have had a history
of PCI [27]. In practice, many of the limb salvage
patients do have a history of PCI or lower extremity stenting and aspirin is continued throughout
the perioperative period.
Statin/Lipid-Lowering
Statin therapy might have a role in minimizing
perioperative cardiac risk, as they have been
found to have anti-inammatory and stabilizing
effects on cardiac lesions more generally.
European guidelines support continuing statins
and initiating them at least 2weeks in advance
for patients with indications not currently on
statin therapy [28]. Canadian guidelines support continuing but not initiating statin therapy
preoperatively. ACC/AHA guidelines support
initiating statin therapy prior to a vascular surgery in patients with indications for lipid lowering therapy. While there have been observational
studies, there are no major RCT data to support
this. In practice, many limb salvage patients
have pre- existing coronary artery and peripheral vascular disease and are already on a moderate to high dose statin. If not, the internist
should consider the addition of a statin during
the hospitalization.
Ace-I/Arb
Angiotensin converting enzyme inhibitors and
angiotensin II receptor blockers have a neurohormonal effect by reducing activation of the
renin- angiotensin- aldosterone axis, resulting in
downstream vasodilation and decreased circulating blood volume. They are part of the backbone of heart failure with reduced ejection
fraction treatment. Canadian guidelines suggest
stopping ACE-I/ARBs 24h prior to surgery and
restarting on postoperative day 2 [5]; European
guidelines suggest a temporary hiatus if they are
prescribed for blood pressure control but continuing them if prescribed for heart failure with
decreased left ventricular systolic function [28];
American guidelines suggest that continuing
Ace/Arb medications “is reasonable” in all
cases and suggests restarting them as soon as
possible if they are held [8]. Debate about best
practices remains as there is yet to be a welldesigned RCT comparing administration vs.
holding of these medications.
The recommendations are based upon prospective and observational studies. A prospective
randomized trial analyzing hemodynamics during anesthesia induction showed an increased
incidence of severe hypotension during induction for people who continued their chronic ARB
on day of surgery [29]. An international prospective cohort study of 14,687 patients found that
when compared to patients who continued their
angiotensin- converting enzyme inhibitors/angio-
8 Medical Management oftheLimb Salvage Inpatient
91
tensin II receptor blockers, the 1245 (26%)
angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker users who withheld
their angiotensin-converting enzyme inhibitors/
angiotensin II receptor blockers in the 24 h
before surgery were less likely to suffer the primary composite outcome of all-cause death,
stroke, or myocardial injury and intraoperative
hypotension [30].
Summary ofCardiovascular
Assessment
The preoperative history and physical examination are used to assess the patient’s cardiovascular risk factors and medication management. A
risk assessment utilizing the RCRI is performed
in order to quantify the patient’s risk of cardiac
complications. Next, consideration of further cardiac testing is made and only pursued if the
results will affect the patient’s management. A
careful review of medications is performed prior
to surgical intervention. The internists’ role is to
perform a risk assessment, communicate that risk
to the patient and surgical team, and to guide further testing and treatment for known or suspected
heart disease. A clear analysis of the patient’s risk
and management options is essential in surgical
planning.
Section 2: Diabetes Management
Glucose Management
ing glucose management, medication management, insulin initiation and titration, and
discharge planning—is crucial for many hospitalized limb salvage patients.
A diabetic patient’s glucose should be checked
regularly while admitted and kept within a goal
range, avoiding both hypoglycemia and
hyperglycemia.
Hypoglycemia
Hypoglycemia, dened by the American Diabetes
Association (ADA) and the Endocrine Society as
glucose <70 mg/dL, is a serious adverse event
that can complicate antidiabetic therapy in the
hospital [33]. In many cases, hypoglycemia is a
side effect of the antidiabetic therapy itself.
Overtreatment with insulin or the continuation of
an insulin secretagogue like a sulfonylurea can
result in hypoglycemia, particularly when a
patient is hospitalized and might be suffering
from a severe illness or not eating their normal
diet. Many patients recognize the symptoms of
hypoglycemia, but hospitalized patients may
have impaired awareness and be unable to detect
these symptoms [34]. Hypoglycemia triggers the
autonomic nervous system, producing symptoms
including tremulousness, anxiety, diaphoresis,
and palpitations. Hypoglycemia also deprives
neurons of glucose, producing fatigue, weakness,
and confusion. When severe or prolonged, acute
hypoglycemia can cause seizures, neuronal damage, or even death [35]. Even after symptom resolution, episodes of hypoglycemia have been
associated with long-term increased morbidity
and mortality.
Inpatient care for limb salvage patients often
requires diabetes management. Diabetes mellitus
puts patients at greater risk for atherosclerotic
disease, including peripheral arterial disease
(PAD). A disproportionate share of diabetic
patients has PAD, and 20–30% of patients with
PAD have diabetes [31]. Diabetic neuropathy, a
complication of long-standing diabetes, and PAD
put patients at increased risk for limb salvage
procedures, as patients with both PAD and diabetes are ve times as likely to need amputation
[32]. Therefore, inpatient diabetes care—includ-
Hyperglycemia
Hyperglycemia presents a more visible and
common conundrum for the inpatient provider.
Many patients, diabetic or not, experience
hyperglycemia while hospitalized due to glucocorticoid use or acute illness. Hyperglycemia
has been associated with increased morbidity
and mortality during hospitalizations [36]. In
surgical patients specically, preoperative
hyperglycemia has been linked in some studies
to elevated infection rates and worse overall
outcomes [37, 38].
92
decrease insulin dose by 25%.
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
M. M. Alternburg et al.
Goal Glucose Range
Providers should aim to keep a diabetic patient’s
glucose between 140 and 180 mg/dL, in accordance with the 2020 ADA Standards of Care and
Endocrine Society guidelines [39]. Titrating therapy to this goal generally protects against hyperand hypoglycemia. A patient who is eating should
have their blood glucose checked at bedside fasting in the morning and before every meal. A
patient who is NPO or on continuous tube feeds
should have blood glucose checked every 4–6h.
The optimal range of 140–180 mg/dL has
been studied in perioperative patients. A Cochrane
review of perioperative glycemic control in diabetic patients noted that lower targets were associated with no improved outcomes but with more
episodes of hypoglycemia [40]. A subsequent
meta-analysis of perioperative outcomes noted
that a liberal glucose target of >200 mg/dL
resulted in higher mortality and stroke than a target of <200mg/dL. However, a very strict glucose goal of <140mg/dL showed no additional
benets but higher rates of hypoglycemia [41].
The 2009 NICE-SUGAR trial demonstrated
the risk of strict glucose control in critically ill
patients. Those patients maintained at a blood
glucose of <108mg/dL had a signicantly higher
mortality rate than those maintained at <180mg/
dL. Patients receiving tighter control also had
more episodes of hypoglycemia and no better
outcomes in length of stay or mechanical ventilation [42]. Per the Endocrine Society guidelines, a
patient’s antidiabetic therapy should be reevaluated and potentially lessened if a patient’s glucose falls below 100mg/dL.
not yet have safety data supporting use for hospitalized patients [39]. Oral and injectable medications also tend to act slowly, limiting easy
titration. Particularly for patients scheduled for
surgery, the Endocrine Society recommends discontinuing oral and non-insulin injectable antidiabetic agents and typically transitioning to
insulin [44].
Insulin
In most cases, insulin should be the primary therapy used to manage hyperglycemia during a hospital stay [44]. If a patient is not already on
insulin, they should be started when they have a
persistent glucose >180 mg/dL. Insulin dosing
should be calculated using the patient’s weight
and diet. If a patient is NPO or has poor oral
intake, insulin should be provided as a basal dose
with a correctional sliding scale. A patient on
continuous tube feeds or TPN should receive
subcutaneous rapid-acting insulin every 4–6h. A
patient eating a normal diet should receive basal
insulin, prandial insulin, and a mealtime correctional sliding scale [44]. Figure8.1 shows standard dosing of insulin in patients with diabetes
and hyperglycemia depending on type and
amount of intake [43].
Some clinicians may be concerned about
causing hypoglycemia when starting a patient on
a weight-based insulin regimen. A retrospective
Diabetes with glucose > 140 mg/dL (7.7 mmol/L)
Nothing by mouth
Uncertain oral intake
Poor oral intake
Adequate
oral intake
Antidiabetic Medications
Non-insulin Medications
Many patients will be taking oral or injectable
antidiabetic medications when admitted to the
hospital. In general, these antidiabetic agents
should be withheld on admission [43]. An admitted patient may develop acute abnormalities,
Basal insulin Basal-bolus
• Start at 0.2–0.25 U/kg/day
• Correction doses with
rapid-acting insulin
before meals
• Adjust basal as needed
a
Reduce total daily dose to 0.15 U/kg in patients ≥
age 70 or with serum creatinine ≥ 2.0 mg/dL.
b
In patients already on basal-bolus at home,
such as kidney injury or critical illness, which are
contraindications to use of these medications.
Some medications, like SGLT-2 inhibitors, do
Fig. 8.1 Insulin dosing in a patient with diabetes and
hyperglycemia depending on type and amount of intake
a
Total daily dose:
0.4–0.5 U/kg/day
• 1/2 basal, 1/2 bolus
• Adjust as needed
b
Соседние файлы в папке @xirurgi_2025