Preoperative preparation for neuropathic and neuroischaemic patients needing surgical debridement

On admission, these patients should be regarded as medical and surgical emergencies.

Preparation for surgery

The following investigations should be carried out:

• Full blood count and typing

• Serum electrolytes and creatinine

• Blood glucose

Preoperative Preparation For Surgery

Fig. 5.23 (a) Small ulcer on 5th toe with associated blistering. (Photograph by Mark O'Brien.) (b) Extensive debridement. (Photograph by Mark O'Brien.) (c) The patient is wearing a patellar-tendon bearing weight-relieving orthosis.

Table 5.5 Insulin sliding scale. Adjust volume of fluids according to clinical state of patient

50 units soluble human insulin in 50 mL 0.9% sodium chloride Blood glucose (mmol/L) Infusion rate (units/h)

> 20 Review and call doctor

Fluids

If blood glucose >15 mmol/L give sodium chloride 0.9% If blood glucose <15 mmol/L give glucose 5%

• Liver function tests

• Electrocardiogram (ECG)

Patients should be medically stable prior to surgery.

Hyperglycaemia is usually present and patients with both type 1 and type 2 diabetes should be treated with an insulin sliding scale (Table 5.5).

An insulin sliding scale and intravenous fluids should be started. If patients have nephropathy there may be abnormal fluid retention and electrolyte disturbances which should be considered when prescribing the intravenous therapy. Basic cardiovascular risk should be assessed from the history, physical examination and simple investigations such as ECG and chest X-ray. Enquiry for myocardial infarction, angina, coronary artery bypass and congestive cardiac failure should be made. The high-risk patient will need close cardiovascular monitoring, and the anaesthetic technique can also be varied according to the risk of the patient.

For high-risk patients, perioperative use of p-blockers is now established, and this is discussed further in Chapter 6 where vascular surgery is covered. The anaesthetist must be aware that virtually all of these patients will have autonomic as well as peripheral neuropathy, and respiratory reflexes may be diminished. Postoperative respiratory arrests have been reported. Careful anaesthetic attention, particularly in the recovery room, is necessary.

Rarely type 1 diabetic patients may present with diabetic ketoacidosis complicating their diabetic foot infection. This should be treated before the patient goes to the operating theatre.

Emergency surgery to the foot usually consists of debridement or minor amputation. It is often difficult to assess how much debridement will be necessary and in

Fig. 5.23 (a) Small ulcer on 5th toe with associated blistering. (Photograph by Mark O'Brien.) (b) Extensive debridement. (Photograph by Mark O'Brien.) (c) The patient is wearing a patellar-tendon bearing weight-relieving orthosis.

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