Diabetes and Endocrinology

Statement of the Problem: Diabetic foot ulcers are hard to manage because of persistent infection and concomitant defects in the local micro-vasculature. Despite the availability of best of the resources in management of diabetes and diabetes foot ulcers, amputations are still performed quite often.

 

Case report:

Case 1: In the first case, a 50 year old chronic uncontrolled type-2 diabetic presented with non-healing ulcer in the left foot (Grade 3-Wagner grading system). Patient had undergone debridement 4 times in the past. He was advised amputation. Glycated hemoglobin (A1c) at presentation was 11 and random blood sugar was 256 mg/dl. She was initiated on intensive insulin therapy and broad spectrum antibiotics. Patient was put on Continuous Glucose Monitoring (CGM). Her between day and within day variations in blood glucose were tightly controlled. She was managed in clinic on an outpatient basis. Services of trained nurse were sought. The ulcer healed in 30 days.

 

Case 2: 50 year old long standing diabetic presented to the clinic with non-healing diabetic foot ulcer on the left foot. He too was advised amputation similar to the previous case. On presentation, his fasting blood sugar was 364 mg/dl, postprandial blood sugar was 480 mg/dl and A1c was 14.8%. He was initiated on continuous subcutaneous insulin infusion. He was put on CGM. Within day and between days glucose was strictly controlled. Average glucose levels on CGM were 130 mg/dl and estimated A1c was 7%. Patient was managed on outpatient basis. Diabetic foot ulcer healed over a period of a month.

 

Conclusion: Tight glycemic control, intraday and interday using continuous glucose monitoring, trained dressing and intensive insulin therapy resulted in healing of two complicated diabetic foot ulcer. It was cost effective as the patients were managed on out-patient basis.