management of the diabetic foot - nosm vascular resource · 2017-06-10 · infected diabetic foot...
TRANSCRIPT
Front linemanagement of the Diabetic Foot
Sam Fratesi MD
Diabetes + Smoking = Amputatio
n
Smoking + diabetes = amputation
Almost 2 million Canadians have diabetes
In amputated diabetics…50% ulcer developcontralateral limb <2 years
50% contralateral amputation within 5 years
3 year mortality after 1st amputation..50%
•15% of diabetics will develop a foot ulcer in theirlifetime
• amputation in the diabetic is 15- 20 times higherthan the non-diabetic
• every year 1 in every 250 diabetics will undergoamputation
Multifactorial etiology of diabetic foot ulcer
diabetic foot ulcer
trauma
infection
Non-complianceneuropathy
impaired cell immunity
Arterial insufficiency
Diabetic ulcers
A N G I O P A T H Y N E U R O P A T H Y I N F E C T I O N
E t i o l o g y o f s k i n b r e a k d o w n
• 85% of leg amputations in the diabeticpreceded by a foot ulcer
•Major cause of a diabetic related hospitaladmission is a foot related problem
•60 % of diabetics with foot ulceration haveneuropathy without clinically significantarterial disease
•20% have ulcers primarily due to arterialdisease
• 20 % have ulcers secondary to acombination of both neuropathy andarterial disease
Diabetic neuropathy
a u t o n o m i c s e n s o r y m o t o r
P a t h o p h y s i o l o g y
Skinabnormality
,immune deficiencypoor circulation
Continuous/repetitivetrauma Foot
deformity/abnormalpressure points
METARSAL HEAD PROMINENCE AND ULCERATION
ulceration is over the plantar surface of themetatarsal heads.
HAMMER-TOE DEFORMITY
Claw-toedeformity withloss of functionof intrinsicmuscles of foot
CHARCOT'S FOOT
Progressive neuropathy +Repetitive trauma + osteoporosis
ISCHEMIC FOOT ULCER
Diabetic ulcer risk
Peripheral neuropathy
Foot deformity
Limited joint movement
Elevated plantar pressure
Prior ulcer/amputation
Peripheral vascular disease
Susceptibility to infection
Structuraldeformity
Autonomic neuropathy
Sensory neuropathy
Insensate foot
Motorneuropathy
Combined motor/sensory neuropathy
Tissue loss in the diabetic foot
Diabetic foot
Callus/trauma
ulceration
Failure to heal
infection
amputation
High foot pressure
Factors that may affect healing in the diabetic patient:
• Metabolic control• Infection• Ischemia• Continuing trauma• Patient education and compliance• Concurrent medical problems/medication• Wound environment• Multidisciplinary foot care program
Atherosclerosis of the lower limb in the diabetic:
Diabetes>20 years ……> 50% lose peripheral pulse
Diabetics have small vessel disease plus moretrifurcation disease than non-diabetics
Distal revascularization has saved many diabetic limbs
Smoking + diabetes = amputation
Wagner’s classification of foot ulcers
Grade 0……..the “ at risk foot ”
Grade 1…….superficial ulcer
Grade 2…….penetrating ulcer
Grade 3……complicated by infection
Grade 4…….gangrene not requiring total foot amputation
Grade 5……gangrene requiring leg amputation
Above classification assessed in context of sufficient bloodsupply to heal
Wounds by stage
Stage 1…redness of skin that does notturn white with pressure
Stage2…abrasion,blister,ulcer..partialthickness ..involves epidermis/dermis
Stage3…full thickness skin loss intosubcut. tissue…necrosis present
Stage 4…extensive..through fascia intosupporting structures (muscle/bone )
SAH Topical Wound Overview
RED
YELLOW
BLACK
assessment after proper cleansing
Where is the infection/ulcer?
How bad is it ?
How did it get there?
What can be done to make it better?
What can be done to make sure it does not recur?
What are the co-morbid conditions?
6 simple questions
Neurological assessment of diabetic
• ankle reflexes
•vibration sensation
•pain sensation
• Diminished protective sensation tomonofilament testing (10 gram /5.07 mm Semmes-Weinstein) ?
USE OF 10-GRAM MONOFILAMENT
Factors to enhance wound environment indiabetic patients with foot ulceration:
• Aggressive debridement to remove necrotictissue and slough
• Control of infection
• Optimize oxygenation
• Avoidance of further trauma
• Ulcer dressings and topical wound therapy
Infections in diabetic foot ulcers:
• Foot infection is a common cause for diabetichospitalization
• An altered immune responses may mask the clinicalseverity of infections.
• Less than 50 % with limb threatening infections have asignificant fever or elevated WBC count.
• “ice –berg” effect quite common
Wound culture techniques:
• surface cultures from diabetic wounds may notcorrelate well with deeper culture techniques
• Deep needle aspiration via non-infected area usually correlates with deep infections
• The most reliable cultures taken from biopsy or swab after the surface exudate has been removed.
•Important to distinguish contamination from infection
•Organisms usually poymicrobial
Infected diabetic foot ulcers:
The importance of aerobic/anaerobic culture
The more serious the infection , the higher theprobability of multiple organisms particularly if adeep infectionMilder infections tend to have fewer organismsparticularly if superficial
Gm(+) cocci is the most common but is the” loneranger” in<50%
Osteomyelitis in the diabetic foot
•Initially plain X Ray may be normal
• Technetium bone scans 70% reliable with lowerspecificity
• Addition of Gallium improves the sensitivity andspecificity
• Indium WBC scanning is best scanning method butmore expensive and less readily available.
• MRI probably best test of bone infection.
Wound Assessment
All wounds should be probed for extent andhidden sepsis
Why a moist wound environment?
Proven reduction in infection rate
Allows natural enzymes to dissolve debris
Promotes wound healing (growth factors)
Helps mould wound
Prevents re-injury of a dry dressing
The role of foot soaks in diabetic foot care
Should NOT be done …a definite NO... NO
• Macerates tissues
•Increases infection
• Tendency to thermal injury/damage normal healthytissue
A foot soak gone bad
maceration
Diabetic foot ulcers:newer therapies
• Recombinant human growth factor therapy (Regranex*)
• Bio-engineered human skin replacements(Dermagraft*)
•VAC therapy (KCI)
•These do not replace nor are they first line strategies
Assessment of the diabetic foot
General / specific assessment of the patient
Documentation & exploration of wound
Assess the circulation
Debride as necessary
Xray as necessary
C& S of wound
Formulate treatment plan/wound care protocol
Follow-up/referral as necessary
Initial AssessmentInitial Assessment
Total Care Considerations
Wound Evaluation
General Health Assessment
Pressure Relief Assessment
Psychosocial/Environment
Expectations/Goals Defined
Comfort/Pain
Knowledge/Education
Prevention
Diabetic foot assessment
The importance of structuraldeformity (Charcot, hammer or clawtoe) ,limited joint mobility, neuropathyand impaired circulation
The physical examination mustinclude a thorough inspection,vascular assessment neuro assessmentand…… check out the footwear
Management of the ulcer Debride..gets rid of the necrotic
tissue/callus….allows properassessment….increases cytokines inthe wound(platelets)
Off-Load the pressure….reducefriction and shear forces…prescription footwear, orthotics,orthowedge boots ,silicone socks……
Total contact casts and removablecasts
Ulcer management
Use of antimicrobials..the importance ofrecognizing and treating the infectedulcer….in pt vs out patient therapy…oral vs IV therapy
Wound care Avoid abuse of antibiotic topical Tx
Extremely important…education and followup
Wound care protocols
standard wound care managementprotocols
Bioengineered tissue
Growth factors
Diabetic wound dressings
Promote debridement,repair and growth Reduce the pain Absorb any exudate Maintain humidity but not mascerate Keep out the bacteria
improves function and quality of life infection control maintain health status reduce costs
Early treatment of the diabetic foot
Steps in Saving the Diabetic Foot
• Patient Education• Identification of Risk Factors• Recognition and Treatment of etiology• Wound Management• Augmentative Interventions
Patient Education
• Goal Oriented• Problem Centred• Offers Feedback• Group Discussion• Varied Presentation
Identification of Risk Factors
prior diabetic ulcer
advancing age
peripheral vascular disease
diabetic neuropathy
Identification of Risk Factors
Peripheral Vascular Disease
Identification of Risk Factors
Peripheral Neuropathy - motor
- autonomic- sensory
Identification of Risk Factors
Autonomic Peripheral Neuropathy
Identification of Risk Factors
Peripheral Sensory Neuropathy
Identification of Risk Factors
Structural Deformity
Structural Deformities
Biomechanical Deficiencies- pes cavus- pes planus
Underlying Etiology
Trauma Foreign Body Improper Footwear Poor Pressure Relief
Surfaces
Limited Joint Mobility Foot Deformity Foot Mechanics Neoplasm Infection Ischemia
Extrinsic Intrinsic
Recognition and Treatment ofUnderlying Etiology
Intrinsic Cause
Limited joint mobility
Foot deformity
Recognition and Treatment ofUnderlying Etiology
Intrinsic Cause
Foot Mechanics
Principles of Wound Management
Debridement
Pressure Reduction
Removal of Bacterial Burden
Promote Healing
Wound Management
Pressure Reduction
Wound Management
Remove BacterialBurden
Augmentative Interventions
Deflective PaddingPlastazote, PPT, Silipos
gelToe muffs, crests pads,
MTP cookies, toeseparators
Crest Pad
Augmentative Interventions
Therapeutic Off-LoadingDevices
Orthowedge boots,
IPOS heel boots, air cast boots,
contact casting, circular Poseys
Augmentative Interventions
Off-Loading Devices
IPOS Heel Boot
Augmentative Interventions
Off-Loading Devices
High-Top Ambulatory Boots
Insoles and Orthotics
Soft Density
Full Length
Cost Effective
Regular Monitoring andMaintenance
Augmentative Interventions
FootwearExtra-depth and
Extra-width P.W. Minor New Balance SAS Soft Spot Clark Birkenstock NAOT
Augmentative Interventions
Off-the-Shelf Footwear
Augmentative Interventions
Custom Footwear
Diabetic Foot Ulcers arePredictable and Preventable
Foot Disease is the Most Common Complicationof Diabetes Leading to Hospitalization
Reiber and Kosak
8 commandments of foot care
Thou shalt….1) Wash daily
2) Inspect and lubricate daily
3) Diligent nail care
4) Proper fitting footwear
5) Regular activity and diet
6) Avoid common mistakes and be careful
7 ) Regular medical visits
8) DO NOT SMOKE
Smoking + diabetes = amputation