Should sulodexide be initiated in a 61-year-old woman with insulin‑dependent type II diabetes, postoperative day 2 after extensive debridement and incision‑and‑drainage of a deep neck‑space infection, who is receiving ceftriaxone, omeprazole, rapid‑acting and basal insulin, fenofibrate, rosuvastatin, vitamin B complex, paracetamol and nalbuphine?

Sulodexide Should Not Be Initiated in This Patient

Sulodexide is not indicated for this patient's clinical scenario and should not be started. The current evidence-based priorities for this 61-year-old diabetic woman on postoperative day 2 following debridement of a deep neck space infection are aggressive glycemic control, appropriate antibiotic coverage, and wound management—none of which involve sulodexide.

Why Sulodexide Is Not Appropriate

Lack of Indication for Current Clinical Context

• Sulodexide is primarily indicated for peripheral arterial disease and venous thromboembolic prophylaxis, not for acute postoperative wound healing in infected diabetic patients 1.

• The patient's nonhealing wound is related to deep neck space infection in the setting of poorly controlled diabetes, not peripheral vascular insufficiency or chronic venous disease where sulodexide has demonstrated efficacy 1.

• There is no guideline or high-quality evidence supporting sulodexide use for infected surgical wounds or deep neck space infections 2.

Current Management Priorities Take Precedence

Aggressive glycemic control is the cornerstone of management for this diabetic patient with deep neck space infection, as diabetic patients with DNSI have significantly worse outcomes 3, 4.

• Target blood glucose of 100-180 mg/dL (5.6-10.0 mmol/L) should be maintained with frequent monitoring every 2-4 hours during the acute postoperative period 2.

• The patient's current insulin regimen (glulisine 8 U TID, glargine 10 U daily, plus sliding scale) should be optimized using a basal-bolus approach, which has proven efficacy in non-critically ill surgical diabetic patients 2.

Antibiotic Coverage Must Address Diabetic-Specific Pathogens

• Klebsiella pneumoniae is the most common organism (56-64%) in diabetic patients with deep neck space infections, not Streptococcus viridans as in non-diabetics 3, 4.

• The current ceftriaxone 2 g IV daily provides appropriate empirical coverage for Klebsiella, which should be continued and adjusted based on culture results 3, 4.

• Diabetic patients with DNSI have significantly higher rates of abscess formation (89.3% vs 71.3%), longer hospital stays (19.7 vs 10.2 days), and more complications (33.9% vs 8.5%) compared to non-diabetics 4.

What Should Be Done Instead

Optimize Glycemic Control

• Continue frequent capillary glucose monitoring and adjust insulin doses to maintain target range of 100-180 mg/dL 2.

• Monitor for hypoglycemia (blood glucose <3.3 mmol/L or 60 mg/dL), which requires immediate IV glucose administration given the patient's NPO status and insulin therapy 2, 5.

• Check for ketosis if blood glucose exceeds 16.5 mmol/L (300 mg/dL), as diabetic patients on insulin are at risk for ketoacidosis in the postoperative setting 2.

Ensure Adequate Wound Management

• Surgical drainage remains the primary treatment for deep neck space infections in diabetic patients, which has already been performed 3, 4.

• Continue appropriate antibiotic therapy targeting Klebsiella and adjust based on culture and sensitivity results 3, 4.

• Monitor for complications including airway compromise, mediastinitis, and sepsis, which occur more frequently in diabetic patients with DNSI 6, 3, 4.

Address Medication Interactions and Optimization

• The current fenofibrate and rosuvastatin regimen should be continued as lipid management is important in diabetic patients, but these do not interact with the acute infection management 2.

• Omeprazole 40 mg IV daily is appropriate for stress ulcer prophylaxis in this postoperative patient 2.

Critical Pitfalls to Avoid

• Do not add medications without clear indication, especially in the acute postoperative period when drug interactions and adverse effects can complicate recovery 2.

• Do not assume all diabetic wound healing problems require vascular medications—this patient's wound is infected and requires infection control and glycemic optimization, not peripheral vascular disease treatment 3, 4.

• Do not neglect the higher complication risk in diabetic patients with DNSI—maintain heightened vigilance for airway compromise, mediastinitis, and sepsis 3, 4.