Challenges and Successes in the Medical and Perioperative Management of Patients With Diabetes

Hi there. I'm Dr. Lee Rogers. I am a podiatrist, and I am the Chief of Podiatry at the University of Texas Health Science Center in San Antonio. Also, I am the President of the American Board of Podiatric Medicine.

I think the biggest challenge that DPMs face in perioperative management with patients with diabetes is really one of coordination. The patients generally have multiple comorbidities. Diabetes is one, but they've got a lot of other diseases, like vascular disease and possibly a previous cardiac history. And so, it really takes a lot of coordination to get somebody ready to go to surgery.

Now, we classify the types of diabetic foot surgeries by how urgent they are, right? So, we've got either surgeries that are totally elective, that might be somebody with just a painful bunion that just happens to have diabetes. But then we've got somebody that we're doing a prophylactic surgery on, somebody with limited range of motion, they have neuropathy, we want to prevent a diabetic foot ulcer. We also have curative foot surgeries, and those are people that have an ulcer already and there's limited range of motion, and we're doing a surgery to improve the range of motion to get the ulcer to heal. And then lastly, we have emergent surgeries, and that might be somebody that has that ulcer and it's infected. And now, this is an emergency.

There's a different level of coordination with these depending on the urgency of the surgery. Obviously, an emergent surgery does not need to have cardiac clearance. They're there, they're in the emergency room. You're admitting the patient, there's an inherent risk of going to the operating room. But, somebody all the way on the other end of the spectrum that's getting an elective surgery happens to have diabetes, you're going to want to make sure that they have the right clearances, that you've adequately assessed their perfusion to get them ready for surgery to avoid any postoperative or perioperative complications or issues.

Really, I think one of the misconceptions that DPMs deal with around surgery is the fact that you need to get clearance on every patient. And so, patients that are urgent, that have to get to the operating room, don't need any clearance whatsoever. If it's an emergency, the patient goes to the operating room. If we have an infection that's causing sepsis, the patient's really at risk for life and limb seriously. No clearance is necessary. You've made that diagnosis, you've declared this emergency, and you take the patient to the operating room. I do see where a lot of people will wait for a vascular clearance with a surgical infection emergency, and you don't need that. In fact, you want to do source control first, and then have engage your vascular partner. That might be your vascular surgeon, your interventionist, engage your vascular partner after you've achieved source control.

Probably the most important thing that DPMs can do in their practice today to improve their outcomes is preparation. If you're just seeing somebody for the first time, you're not prepared on how to get them through the spectrum of the pre-operative clearance and their overall risk reduction or assessment, then you're really using a lot of time. You're probably going to cut some corners. So, creating pre-operative checklists, I think, are very important. And just preparing, thinking in advance, "What am I going to do when that serious patient comes in?" Let's say, you're in your office, come into my office. And really create a problem in your scheduling and all that. "How am I going to take care of this as quick as possible and in the best and most efficient way possible to reduce their overall risk?"