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Diabetes and Orthopedics



Abstract

Orthopedics refers to the medical field focusing on diseases/ailments and injuries affecting a human musculoskeletal system. As such, this system is composed of skeletal joints, bones, tendons, ligaments, nerves, and muscles critical for daily bodily functions. Initial procedural measures were primarily focused on children, who, unfortunately, were victims of limb or spine deformities. However, with time, the field encompassed the general care of patients of all age groups, from newborns to the old. Newborns could suffer from clubfeet requiring surgery (arthroscopic) as a result of injury, while the elderly could be suffering from arthritis. The above move was based on the fact that often, people break or fracture a bone during daily routines, especially as a result of physical activities. Patients with diabetes pose problems to orthopedic treatment due to complications arising from problems emanating from muscular and other joints problems experienced by diabetes patients.

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Consequently, orthopedic surgery is the management of special problems affecting one’s musculoskeletal system, with orthopedic surgeons following procedural measures in the overall treatment of such problems. As such, the initial step is the proper diagnosis of one’s disorder or injury, with this being followed up by requisite treatment procedures, i.e. exercise, surgery, medication, or other forms of treatment. It is followed by rehabilitation phase, when recommended physical therapy or exercises are conducted with the aim of restoring not only movement, but also one’s overall bodily strength and functionality. Apart from the aforementioned procedural measures, the aspect of prevention is critical. Pertinent treatment plans as well as expert information aid in the overall prevention of injury, or slows down progressive ailments (AAOS 2013). Patients suffering from diabetes mellitus are highly likely to develop orthopedic related complications. It makes it necessary for orthopedic practitioners to examine their patients when they report for treatment to ensure that they are not suffering from diabetes as this may complicate their treatment.

Diabetes and Orthopedics Attention

Therefore, orthopedic surgeons treat a majority of such musculoskeletal conditions without necessarily relying on surgery, with the help of various medications, specific exercises, as a well as other rehabilitative procedures being utilized as alternative therapies. The increase in the rates of diabetes makes it paramount to screen patient to determine whether they are suffering from diabetes before treating their orthopedic related problems. In addition, there are numerous treatment procedures for majority of such cases, with only certain critical injuries requiring specific treatment procedure. Diabetes mellitus is one of the most common chronic medical conditions, especially nowadays, as a result of current lifestyles as well as hereditary genetic passage. Globally, the spread of disease is increasing, and it will continue to increase if the measures are not taken.

In addition, health practitioners dealing with diabetic patients suffering from orthopedic problems have to identify the effect diabetes may have on their treatment. Consequently, health care providers are able to offer counseling to these patients to increase their physical activities and improve on their health so that they are able to handle health issues they are likely to face often. According to statistical figures, approximately 1 of 7 USD is spent on the treatment of diabetes in general, despite the high expenses on health care. Thus, the development of research-based, cost-effective, as well as efficient practices will go a long way in alleviating the aforementioned increase, while also reducing unnecessary expenditure on healthcare costs. The general awareness of not only the probable preoperative complications, but also the overall economic burden implications linked to increased diabetes cases, by orthopedic surgeons should be considered while taking necessary measures towards improving the quality of healthcare and reducing associated costs (Kadakia & Tsahakis 2012).

Consequently, studies have indeed identified diabetes mellitus as well as preoperative glucose imbalances as the main predisposing risk factors, which may result in increased hospital stays as well as a number of postoperative complications. Majorly, the surgical site infection (SSI) with various published rates is indicative of the above resulting in great burden to already strained medical system. Accordingly, the overall procedural measures taken in the treatment of diabetes cases, especially those related to orthopedic practice, should be clearly researched, formulated, and implemented, as founded on existent research-based best practices. Diabetes mellitus, similarly to other ailments, necessitates procedures from inpatient management to outpatient consultation.

The Central Adelaide Local Health Network – RAH: Diabetes Centre, as any other medical institution, takes various procedural measures when treating diabetes as well as related ailments. Treatment procedures are based on the level of infection, with diabetes either being the primary cause of admission or a co-morbidity symptom after various medical procedures. Majorly, these procedures are divided into two: those eating (enteral or parenteral nutrition) and those not eating, as medicines react differently on patients with empty or full stomachs. It should be noted that those admitted primarily as a result of unstable diabetes, i.e. diabetes ketoacidosis (DKA), are engaged in individualized and separate treatment plans common in the endocrine unit (American Diabetes Association 2005). The information contained in the website fails to provide the connection between diabetes and orthopedic treatment which is important to practitioners. This information is important in treating these patients as most of them do not respond to treatment the same way diabetes free patients respond. There are also health problems such as muscular problems, wounds and joints aches that are experienced by diabetics. Knowing how to deal with these kind of patients and the importance of screening for diabetes before treating a patient is of immense importance, and should be highlighted in RAH (Wyatt & Ferrance 2006).

There are special circumstances, when overall medical procedures depend on whether the patients are under parenteral or enteral nutrition, especially for those out of surgery, the ICU or the HDU. Hence, treatment of diabetes should be timed accordingly, with pertinent procedures and doses being monitored for a more effective outcome. By targeting blood glucose levels (GCL) of 5.0-10.0mmol/L in various patients, one is able to decrease not only in-hospital morbidity, but also mortality rates due to other disease states. The sliding scale insulin procedure is largely blamed for the destabilization of diabetes in most of the cases; hence, it should be utilized in specific circumstances. Proper lifestyle that considers the health conditions of a patient regulates the effects of diabetes and enables patients reduce the occurrence of musculoskeletal complications that usually affect these patients (Wyatt & Ferrance 2006).

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Care for Diabetics

As such, insulin regiments, which are critical to overall diabetes treatment, should target anticipated (prospective) blood glucose levels as opposed to reacting retrospectively to previously recorded levels. Routine monitoring should be done at least 4 times every day, with recommendations being either pre-meal (30 minutes) time or afterwards (2 hours later), usually, before bed-rest. Treatment should be adjusted daily to meet required BGL targets, with routine check of urinary ketones if patient is critically ill, or whose BGL has been persistently recorded above the recommended 15mmol/L level. In cases of suspected urinary ketone levels of 3+, or the suspicion of ketoacidosis, the endocrine unit should be immediately concerned, so that necessary medical procedures may be performed (American Diabetes Association 2006).

Continued use of insulin or oral hypo-glycemic agents (OHA) should be performed with medical officers regularly adjusting doses, according to the potential occurrence of hypoglycemia. Two protocols, medical procedures, provide measures requisite in diabetes treatment with their basis being either on patients who are not eating (fasting), or those who eat normally (3 meals a day). In both case scenarios, patients are treated according to whether they are on insulin or oral hypoglycemic agents. Treatment of hypoglycemia is vital; and accompanying documentation of both events as well as treatment is requisite. Medical officers/doctors need to be notified if either the blood pressure or pulse increases.

Post glucagon (vomiting) is a usual side effect of treatment and thus, should be expected. Overall, the medical officer in charge should constantly review diabetes management in order to determine the changes, if any are required, especially in the prevention of further hypoglycemia. Carbotest, usually given orally, should not be done in cases of drowsiness or dysphagic difficulty of swallowing. As pertaining to an orthopedic patient, treatment procedures should be preceded by at least 6 hours of fasting or non-parenteral/enteral nutrition. In addition, there is the need for withholding any medical treatment some hours prior to necessary medical procedures in order to avoid an interaction of various medicines, which may prove disastrous and even fatal (Klingensmith & Alexandria 2003).

Due to the necessity of insulin towards maintaining the required range of BGL, supplementary insulin, vial basal bolus insulin regimen, and/or oral hypoglycemic agents (OHA) may be used. It should be taken into consideration that when one eats, the ingested food provides a lot of insulin and hence, treatment procedures for people who still are able to eat should be different from those not able to eat. As such, their insulin doses should be adjusted properly to achieve the required dosage levels. Thus, before discharge, it is critical to make sure that a patient who had been on a bolus/basal intensive insulin regimen does not require it for improved control of BGL. The best recommended practices signify the importance of both oral hypoglycemic agents (OHA) as well as supplementary insulin for effective treatment of diabetes.

Under no circumstances should the aforementioned two procedural measures be carried out concurrently on a single patient, as adverse effects may occur. While they may be performed either on patients fasting or those eating regular meals, it should be noted that similarly to current research-based best practice for those eating, there is a general increase of dozes to reach the required BGL. As such, the various oral hypoglycemic agents, as per the aforementioned Central Adelaide Local Health Network – RAH: Diabetes Centre, i.e. metformin, metformin XR, glibenclamide, gliclazide, gliclazide MR, glimepiride, and glipizide are in strict adherence to the best practices all over the world. Supplementary insulin, though effective in better treatment of diabetes, should be rarely used with either regular insulin or OHA, except for special cases (Boulton 2004).

The above-mentioned information is especially critical in cases when BGL is high and the control of patients is poorly managed. In addition, there is the need for upward adjustment of supplementary insulin dose to counter the aforementioned high rates of BGL with intensive treatment via bolus/basal insulin being the most preferred form of treatment. Continued use of supplementary insulin dose will necessitate upward increment of regular insulin to prevent another rise in levels of blood glucose. Such supplementation should be recorded in its insulin subcutaneous order, subcutaneous supplementary insulin order, and the blood glucose record. It should be noted that the supplementary doses should not be given on a daily basis.

It is because it is only a reactive measure, with doses being adjusted daily on a prospective basis to prevent a rise in BGL. Insulin provision should be, consequently, stopped when treatment is over, and when necessary, to be adjusted upward by 10% of current doses. Blood glucose levels/profile when reviewed on a continued basis aid in provision of treatment procedures. As pertaining to bolus/basal intensive insulin regimen, they are conducted 4 times a day, with the short acting insulin being given with every meal. The longer acting dose should be given at bedtime, as a result of the longer duration between this and the next day’s dosage. As mentioned earlier, in treatment of those eating to the dosage of either OHA or insulin should be increased (Pittas, Siegel, & Lau 2004).

However, for patients who are fasting or are unable to consume food due to various stages of ailment, the reverse is true as there is a need to either withhold or outright cease provision of insulin or OHA, especially before the medical procedure/operation on the patient. There is a need for commencement of insulin/glucose infusion if BGL is higher than 10.0mml/L to stabilize a patient before embarking on any medical procedure. As such, a patient’s BGL should, at least, be checked within 1 hour, both after and before the procedure. It is necessary for ascertaining that the patient is stable during and after such procedures. On the aspect of insulin and glucose infusion, the entity’s (aforementioned) procedure is at par with the best practices recommended by various medical associations.

Thus, insulin infusion should never be administered alone, as concurrent administering of glucose infusion is requisite. It is delivered through a syringe driver, with the recommended concentration being one unit of insulin per ml. This specification (one unit: 1 ml) is constant. Due to the delicate nature of insulin fusion, its management plays a critical role in the nursing fraternity, as the orthopedic patient needs constant monitoring. Hence, the patient’s BGL should be closely monitored on an hourly basis, with the maximum duration being at two hourly monitoring shifts. When changing the insulin infusion rates, there is a need for documentation with hourly documentation. It should be done on the Medication Chart & Record – Actrapid Insulin & Glucose Infusion (Mealey 2006).

Two nurses, one of them being registered, are required to countercheck the prescribed insulin fusion rate, as well as the cannula insertion site and extension tubing. Every day, the nurses should embark on a cleansing routine, which should entail changing of both syringes as well as extension lines. In addition, there is the need for daily check of electrolyte levels if insulin infusion is ongoing over the 24 hours period. In cases when expected results are not forthcoming, i.e. constant elevation of BGL, even when insulin infusion is running at 12 units per hour etc., there is a need for consideration of system malfunction. It may occur as a result of the insertion site patency, the blood glucose meter malfunction, or the infusion pump patency unit; thus, further analysis of the patient’s venous specimen in terms of glucose levels is required.

Drawing from research-based best practices, a medical doctor is required to review a patient if his/her BGL exceeds the capped limit of 20mmol/L, and remains such for three consecutive hours. If the rate is more than 15mmol/L for six consecutive hours, with the patient being on insulin fusion, there is also a need to review the patient. According to the best practices, ceasing insulin infusion should be reduced only in case of subcutaneous insulin regimen or OHA dosages. Once either of the two is already administered, the IV insulin fusion can be stopped half an hour later. Consequently, if a patient is able to take his/her meal at least once, the insulin infusion regimen should be stopped. When recommencing subcutaneous insulin, this should go hand in hand with either basal/bolus insulin regimen or the pre-infusion regiment (Williams, Rotich, & Tierney 2004).

From the above-mentioned information, it is clear that insulin or OHA regimen should be recommenced only when a patient is able to regularly or adequately take food and/or medication orally. It is in tandem with the best practices in the treatment of diabetes. Critically though is the special treatment provided to those patients being transferred out of the intensive care unit (ICU). Patients who require insulin after such transfer are those with known cases of diabetes, or have required more than 24 units of insulin during the last 24 hours. However, those who do not require it are monitored as well, with their BGL being thoroughly analyzed before discharge. However, for those with known diabetes, the eventual nutrition requires the procedural measures to be undertaken with the aim of stemming rising BGL rates.

The management of diabetes, especially in terms of orthopedic patient care, is critical, as various procedures are influenced by the patient’s overall BGL. As such, this is an aspect that requires critical decision making in tandem with the requisite procedural measures to enhance the success rates of patient’s recovery from various procedural measures necessary in the field of orthopedic care. Care should also be taken when administering diabetes treatment drugs, as these are strong and hence, can counter-react negatively with other drugs currently being administered. Hence, the patient should be ‘cleansed’ of all drug effects before being administered with the aforementioned treatments. The above procedure, treatment of diabetes, as provided by the RAH: Diabetes Centre (Central Adelaide) relates to diabetes treatment (Singh, Armstrong, & Lipsky 2005).

Conclusion

In conclusion, the necessary measures entailed in diabetes treatment go a long way in ensuring little or no complications, as well as faster recovery and hence, earlier hospital discharge. It, consequently, has fundamental impact on a region’s hospital/medical system as well as national coffers in terms of cost implications and expenditure. The close relationship between occurrences of musculoskeletal complications and diabetes makes it a necessary precaution for every orthopedic practitioner to screen their patients to determine whether they are suffering from diabetes. It is due to the number of muscular and joints problems that usually face diabetic. These conditions require special attention due to the effects the disease has on the treatment used. Proper management of the disease by chiropractors through proper identification of musculoskeletal effects and complications related to diabetes reduces the number of health problems experienced by diabetics.

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