The Anesthesia Of The Treatment Of Diabetic Foot In Transplantation Of Autologous Peripheral Blood Stem Cells

IntroductionDF is a serious complication of diabetes and is always disabling and even cause death. For tens of years , many treatments for DF are not satisfactory. Transplantation of autologous peripheral blood stem cells for the treatment of diabetic foot is a popular subject aroud the world recently and can get satisfactory effect. It was reported that this operation was usually been done under intraspi-nal anesthesia such as combined spinal - epidural anesthesia or epidural anesthesia in clinic. But there are many difficulties such as difficulty to puncture, when epidural anesthesia is applied in this kind of patients. Therefore, monitored anesthesia care( MAC) was applied in transplantation of autologous peripheral blood stem cells for the treatment of diabetic foot by us and obtained satisfactory effect. To observe patients' haemodynamics variation and reflect during operation through enforcing monitored anesthesia care for autologous peripheral blood stem cells transplantation in patients with diabetic foot. To investigate suitable compatibility of medicine and the predictive performance of monitored anesthesia care for autologous peripheral blood stem cells transplantation in patients with diabetic foot.Materials and methodsMaterialsInstrument;North American Drager 2B anesthesia machine( USA);Mini-mon 7137 plus ( British);Graseby intravenous infusion pump ( British );Sure Step blood glucose monitoring systerm(USA gohnson company).Medicine: ketamine hydrochloride injection ( ShangHai );Fentany Citrate Injection(YiChang,RenFu);Diazepam Injection (ShangHai);Propofol Injection (Italian) .MethodsPatient: We studied 60 patients (47 males, 13 females)with DF,ASAH -IV, undergoing autologous peripheral blood stem cells transplantation. The patients ranged in age from 58 - 86 years old and in body weight 44 -78Kg . All cases have a history of diabetes for more than 7 years, 56 cases with hypertension, 38 cases with coronary heart disease,26 cases with cerebral thrombosis,7 cases with old heart infarction. All patients were treated with routine insulin. The patients with hypertension were treated with hypotensive drug.Group: The sixty patients with DF undergoing autologous peripheral blood stem cells transplantation were randomly divided into four groups with 15 patients each group: epidural anesthesia(group E);diazepam + ketamine(group Ml);propofol + fentanyl (group M2);ketamine + propofol (group M3) .Anesthesia method;All patients were premedicated with intramuscular At-ropine 0. 5mg or Scopolamine 0. 3mg, 30 minutes before surgery. Break venous channel in operating room. Group E -.Patients were undergoing epidural anesthesia at L2 -3 or L3 -4 and put tube cephalad. An initial bolus of lidocaine 1.5% 3 -5ml was injected slowly to epidural cavity, followed by another 5 - 10ml bolus after the anesthesia plane emerged. Group Ml: diazepam 0.06mg kg'1 was injected ( >30seconds) intravenously before cleanse, ketamine 0. 8 - lmg ? kg"1 was injected slowly ( >30seconds) before operation. Group M2;Induced by fentanyl 0. 05mg and propofol 1-1. 5mg ? kg'1 ( >60seconds) before operation and inject propofol 200 - 300jxg ? kg" according to patients' responds. Group M3 : ketamine 0. 6mg ? kg - 1 was injected slowly ( >30seconds) before operation, anesthesia was maintained with a continuous intravenous infusion of propofol 50 - 100|xg ? kg" ? min~ (10mg ? ml" )with Graseby pump and adjusting infusion velocity by pations' responds. Stop induction 5 minutes before operation termination. Givening oxygen snuff with face guard or assisted respiration once SpO2 < 90% or breath pause > 10 seconds. Blood pressure (BP) , heart rate(HR) , saturation of blood oxygen ( SpO2 ) and electrocardiogram werecontinuously monitored with Minimon 7137 plus monitoring device. Blood glucose was monitored before anesthesia, during operation and the next day. Evaluate sedation depth with Ramsay scores before anesthesia, during operation and operation termination . Follow up postoperation to find if there are any side effect and if they have ever known during operation .PBSC transplantationAll patients' both lower extremities were given stem cell suspl. im. by 3cm x3cm spacing. To avoidance eocylosis and acute arterial thrombosis or cerebral accident from hypercoagulabale state, patients were given low molecular heparin 5000U/day, hypodrmical injetion for 5days. Statistical analysisStatistical analysis was performed with SPSS 11. 0 statistical software. Measurement data were expressed with mean standard deviation ( x ± s ). Student' s t test (two - tailed ) was used to compare the data of intraclass and in-terclass. x2analysis was used to compare numeration data.RESULTSThere are no significant difference in the patient' s gender, age, body weight and operating time.Post anesthesia BP and HR in group E and group M2 decreased significantly than that before anesthesia, Bp and HR in group Ml were no marked changes. After anesthesia BP in group M3 decreased significantly. When the operation completed there was no difference in BP to that before anesthesia in group M3. These explain that the hemodynamic of group M3 changed transiently.The blood glucose in both EA group and MAC groups was no marked changes preanesthesia and postanesthesia.Ramsay conscious - sedation score of MAC group was much better than that of EA groups. Ramsay conscious - sedation score was no marked difference a-mong three MAC groups.Hypotension in group E were more than group Ml and group M3 significantly. Hypotension, respiratory depression and body response of group M2 were more than other groups significantly.Follow — up : all patients in MAC groups were fastly come back who have no memory about what happened intraoperation.DiscussionMany patients with DF are elders and have several kinds of complications, for example, coronary heart disease or cerebral thrombosis . These factors increase danger of anesthesia. Transplantation of autologous PBSC for the treatment of DF is different from other operations for diabetes. The operative site is in the lower limbs . It takes a short time about 7 - 15min. The skeleton relaxation is not required. A good analgesia is required and the patients must be awaken immediately in order to transport and give postoperative care. It was reported that this operation was usually done under intraspinal anesthesia in clinic. Group E chose epidural anesthesia, the adverse reactions in EA group were significantly less than those in MAC group. And the blood glucose was similar before anesthesia and after anesthesia, which explain good analgesia of EA and available degrading stress reaction during operation. In clinic we found some difficulties during EA for the treatment of diabetic foot with PBSC: But these old patients have ligaments calcify because of the long - term bed and compulsive position because of ache for gangrene in legs which result in difficulties to put body position and anaesthesia puncture. Six patients in group E are difficult to puncture and change puncture another level or lateral puncture . After anesthesia BP and HR significantly decreased in group E than that before anesthesia. It increased risk of EA puncture that apply Low Molecular Heparin or Heparin Calcium during PBSC mobilization.In a word, there were many shortcomings of EA for transplantation of autologous PBSC for the treatment of DF, such as the difficulties in anaesthesia puncture and long waiting time, we suggest that other anesthesia methods should be chosen which can be simply performed and have little interfere to physiology, for these old patients.The anesthesia of this operation with MAC was fit for the treatment of diabetic foot in transplantation of autologous PBSC and obtained the satisfactoryeffect. All MAC groups can satisfy requirement of operation, oversimplify manipulation and shorten the time of anesthesia. In group M2 the compatibility of propofol + fentanyl can decrease BP temporarily and depress respiration evidently. Therefore, it should be applied much caution for old patients with low compensation of heart and pulmonary. In group Ml the compatibility of diaze-pam + ketamine influence little to circulation and respiration. There were bucking and psychiatric symptom in group Ml. It explained that a chance couldnt be excluded ,that diazepam couldnt completely prevent the psychiatric symptom of ketamine. In group M3 the compatibility of ketamine + propofol diminished psychiatric symptom and boosting — pressure role of ketamine, taken well analgesia and had low respiratory depression. Therefore, the compatibility of ketamine + propofol is a good anesthesia method.Conclusion1. Monitored anesthesia care applying in transplantation of autologous PBSC for the treatment of diabetic foot is a simply and feasible anesthesia method , especially for the old patients who are difficult to puncture.2. I considerd that the compatibility of ketamine + propofol influenced the hemodynamic little, had less adverse reactions . Therefore, the compatibility of ketamine + propofol was more equitable.