MEDICAL TREATMENT OF DIABETES MELLITUS FOOT SYNDROME

DR DIYAOLU F.P.SNR REGISTRAR, EDM DIVISION, DEPT OF MEDICINE, LUTH.

FINE OR UGLY……LOVE THEM LIKE THAT

OUTLINE:• Introduction•Principles of management:

• Glycemic control• Infection control

• Wound Care• Off Loading

• Ancillary medical treatment• Prevention & identification of precipitating

factors•Multidisciplinary management.

INTRODUCTION• Early and regular diabetes foot education and

foot evaluation by the physician is key

• Early Multidisciplinary care= better results-Ortho, Vascular, Plastic surgeons, Medical &Social workers, Psychologist/Psychiatrists, Podiatrists, Physiotherapists, Microbiologists.

• Prevention is far better a choice than treatment/cure for DMFS.

• Early presentation is important for limb salvage

PRINCIPLE OF TREATMENT

•Good glycaemic control •Treatment of infections•Wound care•Offloading to take pressure off the wound•Early surgical intervention

/multidisciplinary approach•Early diabetic foot education

FREQUENTLY ASKED QUESTIONS IN DMFS CARE:

•Who to admit? •How long on antibiotics?•Oral or systemic antibiotics?•When to invite other disciplines?•Oral antidiabetic agents or insulin?•How long is the treatment?

GOOD GLYCEMIC CONTROL • Insulin therapy for moderate to severe infections,

presence of other co-morbid states:

• Premeal boluses ±Basal insulin

• Perioperatively, Glucose-Potassium-Insulin (GKI) infusion

• Premixed insulin as part of preparation for discharge

• Target blood sugar for DMFS patients individualized

INFECTION CONTROL•Cultures must be taken prior to antibiotics

usage: wound biopsy, scrapings or aspirate-•NOT WOUND SWABS!

•Empirical antibiotics commenced till culture results are available

•Antibiotic therapy is necessary for all infected wounds but not without appropriate wound care.

INFECTION CONTROL•ANTIBIOTICS FOR ALL INFECTED

WOUNDS.• 1-2 wks for Mild infections,

• 2-3wks For Moderate To Severe infections.• >4wks if bone involvement

•Broad Spectrum till culture and sensitivity results arrive

•Gram positive cocci-Staph aureus•Cloxacillin group•Penicillins: Co- amoxiclav /Ampicillin

Sulbactam

INFECTION CONTROL•Methicillin Resistant Staph Aureus:

Doxycycline, Cotrimoxazole trimethoprim, Vancomycin, Rifampicin, Linezolid ?Gentamycin

•Antipseudomonals: Piperacillin Tazobactam

•Gram negatives: •Fluoroquinolones-Levofloxacin, Moxifloxacin•3rd generation cephalosporin- Ceftriaxone,

Ceftazidime, Cefpodoxime

Infection control

•Presence of gas forming organisms, Peripheral arterial disease, growth of anaerobes:

•Metronidazole /Clindamycin

•IV Antibiotics continues till infection subsides not necessarily till wound heals

ANTICOAGULATION & TETANUS PROPHYLAXIS•Tetanus Prophylaxis: both active and

passive immunization

•Anticoagulation: required due to increased risk of thromboembolism

ADJUVANT MEDICAL THERAPY

•Use of hyperbaric oxygen

•Use of Larvae in the care of ulcers aka biosurgery, therapeutic myiasis.

•Use of Growth factors-Platelet derived growth factor, Epidermal growth factors, Granulocyte-Colony Stimulating Factors.

USE OF HYPERBARIC OXYGEN THERAPY CHAMBERS.

BIOLOGICAL METHOD (USE OF LARVA) IN DMFS WOUND CARE•Use of laboratory cultured sterile

maggots: Lucilia sericata maggot and its fly (Blowfly)

WOUND CARE:CLEANING AGENTS• Depending on wound cleanlinessCLEAN WOUNDS•Normal saline

DIRTY WOUNDS: Chemical or BiologicalCHEMICAL•EUSOL: Edinburgh University Solution Of

Lime•Honey

PROPERTIES OF REAL, UNADULTERATED HONEYQualities of honey Properties of unadulterated

honey

1. Hygroscopic 1. Allows combustion

2. Deodorizes 2. Rolls into a ball if dropped on the soil

3. Antimicrobial activity 3. Does not attract ants

4. Acidic pH to prevent microbial activity

4. Does not soak a paper if dropped on it

5. Cheap and readily available 5. Can find fine particles of the sieved bees.

WOUND CARE:DRESSING AGENTS•Continuously moistened saline gauze: for

dry or necrotic wounds

•Hydrogels: for dry and or necrotic wounds and to facilitate autolysis

•Films: occlusive or semi-occlusive, for moistening dry wounds

WOUND CARE:DRESSING AGENTS•Hydrocolloids: for absorbing exudate and

to facilitate autolysis

•Alginates: for drying exudative wounds

•Foams: for exudative wounds

DRESSING AGENTS

DRESSING AGENTS

TREATMENT OF OSTEOMYELITIS

•Initiation with intravenous antibiotics

•Oral antibiotics based on result of bone culture, microscopy and sensitivity for 3-4 weeks

•If necrotic bones ,start parenteral antibiotics and change to oral ,duration usually up 6months

OFFLOADING TECHNIQUES•Offloading :Redistribution of pressure off the

wound to the entire weight-bearing surface of the foot

•Gold standard off loading technique : Total contact cast- reduces pressure off wound by about 84-92%

•Other offloading devices include removable cast walkers, half shoes, healing sandals, and lightweight, custom-built braces.

TOTAL CONTACT CASTS

TOAD ANTI-GRAVITY WALKING BRACE

HEALING SANDALS

TOTAL CONTACT CAST(NON REMOVABLE VS OTHER OPTIONS)

OFFLOADING DEVICES:IN-SOLES (Therapeutic foot wears-better for preventing ulcers than pressure offload on ulcers)

CRUTCHES,WALKERS AND WHEELCHAIR

PREVENTION:DIABETIC FOOT EDUCATION

•Foot education on inspection , use of appropriate foot wear, care for the nails.

•Early treatment of fissures, cracks, Tinea pedis infection.

•Every patient with DM to have at least once a year detailed foot examination for neuropathy, peripheral arterial disease –ADA guidelines.

PREVENTION

•Prevention is key- early, regular and practical guide on foot care to all patients with diabetes

•Early medical opinion on any wound noticed

•Limit or address other risk factors

•Advocacy through the mass media as there is a growing population of patients living with DM.

RECOMMENDATION•Support from the private and public health

providers in areas of podiatry training and provision of materials to work

•Routine general screening for all cases of lower limb ulcerations to identify at risk group before onset of complications

•OUR AMPUTATION RATES CAN BE LOWER!

SUMMARY..

Principles of Management with focus on:•glycaemic control• infection control•care of the wound•Offloading techniques•Prevention•FAQs in DMFS

REFERENCES• Lipsky BA, Deery HG, Berendt AR, Embil JM,

Cornia PE, Joseph WS et al. 2012 Infectious Diseases Society of America (IDSA) Clinical Practice Guideline for the Diagnosis and Treatment of Diabetic Foot Infections. CID 2012:54

• International Best Practice Guidelines: Wound Management in Diabetic Foot Ulcers. Wounds International, 2013. www.woundsinternational.com

REFERENCES

•Ikeh EI, Puepet F, Nwadiaro C. Studies on diabetic foot ulcers in patients at Jos University Teaching Hospital, Nigeria. African Journal of Clinical and Experimental Microbiology. http://dx.doi.org/10.4314/ajcem.v4i2.7308

•Ogbera AO. Improving Diabetes Foot Care in Lagos WDF13-806 sponsored by IDF 2014-2016

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