presented by lori richwine, d.o., fapwhc medical director ... · glycemic control. vs . amputation....
TRANSCRIPT
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Presented by Lori Richwine, D.O., FAPWHc
Medical DirectorAtlantiCare Wound Healing Center
Healogics Specialty Physician
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Disclosure to Participants• Notice of Requirements for Successful Completion:
For successful completion, participants are required to be in attendance in the full activity, complete and submit the program evaluation at the conclusion of the educational event.
• Presenter Conflicts Of Interest and Financial Relationships Disclosures • None
• Non-Endorsement Of Products: Accredited status does not imply endorsement by AADE, ANCC, or ACPE of any commercial products displayed in conjunction with this educational activity.
• Off-Label Use: Participants will be notified by speakers to any product used for a purpose other than that for which it was approved by the Food and Drug Administration.
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1. Discuss the pathophysiology of Diabetic Foot Wounds
2. Evaluate various etiologies of the Diabetic Foot Wound on physical examination
3. Recognize advanced therapeutic modalities in the treatment of Diabetic Foot Wounds
Objectives
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DIABETES:ANY GIVEN DAY…
Prevalence : 8-10% of diabetics have a DFU right now
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Providers/Hospitals/Payers are Challenged by Treating Wounds• By having an outpatient Wound Healing Center, the problems of treating difficult
and expensive wounds can be helped
• The Advisory Board estimated that inpatient woundswere costing hospitals on average:
• Four additional days per discharge• 7.2% increase in mortality discharges• $5,423 additional costs per discharge
• Often, a transfer to an outpatient wound healing center may lead to reduced lengths of stay and costs • Care will be regular on a weekly basis for visits to reducecomplications and readmissions • Care is coordinated with all providers on an outpatient basis
including Home Health Nurses , dressing companies, PCP’s
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By the Numbers…Co
st
Chronic wounds affect 6.5 million Americans per year at a treatment cost of $25 billion per year
Cost
Additional $39 billion in lost wages per year
Cost
$15.3 billion estimated expense on wound care products in 2010
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If Diabetes Mellitus was a Country…
0 0.2 0.4 0.6 0.8 1 1.2 1.4
China
India
Diabetica
US
Indonesia
Brazil
1.36
1.26
0.347
0.319
0.237
0.203
Population Density (B), 2014
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Prevalence of diagnosed diabetes in America
0
10
20
30
40
1960
1965
1968
1972
1977
1982
1987
1992
1997
2002
2020
2040
2050
People(Millions)
Diabetes-related complications, including amputations, lower-extremity neuropathies and premature cardiovascular disease are a major cause of chronic wounds.
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DFUs increase the risk of lower extremity amputation: 15-46%
Consequences…
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The Potential Impact Of A Diabetic Foot Ulcer
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LOSE A LIMB…LOSE A LIFE
• There are nearly 2 million people living with limb loss in the US– most commonly due to PAD and DM
• 5 year mortality after amputation ~ 50% • 3 x > breast cancer• 6 x > prostate cancer • 55% of diabetic amputees will require amputation
of the second leg within 3 years
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AMPUTATIONS’ MORTALITY RATES COMPARE TO CANCER
Patients with amputations and diseases related to diabetes die at a rate as high as many
cancers.
45
47
55
64
18
18
23
48
86
97
Protstate Cancer
Breast Cancer
Hodgkins…
Neuropatic…
Amputation
Colon Cancer
Ishemic Ulcer
PAD
Lung Cancer
Pancreatic…
Five-Year Mortality Rates
Cancer Diabetic related amputations
Sadly, 30% of chronic wounds left untreated result in amputation; over 47% of amputees die within five years.
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This Is Not Okay
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We Know the Causes…DFU Pathophysiology
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Glycemic Control vs Amputation
Aubert, Ronald. “Chapter 18.” Diabetes in America, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, 1995, p. 418.
Twofold increase risk of leg ulcers including gangrene in Diabetic individuals with higher blood glucose levels vs lower blood glucose levels
Statistically significant increased amputation risk in these Diabetic individuals with higher blood glucose levels vs lower blood glucose levels
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What is a Chronic Wound? • “An insult or injury that has failed to proceed through an
orderly and timely repair process to produce anatomic and functional integrity”
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Chemotactic Migration Mitosis
AngiogenesisSynthesis of ECM
Proteolytic Turnover of ECM
Proliferation
Inflammation
Remodeling
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Chronic Wound Delayed Healing
Degrades ECM• impaired cell migration• impaired connective tissue depositionDegrades Growth Factors
Repeated TraumaLocal Tissue Ischemia
Necrotic TissueHeavy Bacterial Burden
Tissue Breakdown
↑ Production MMPs and ↓ TIMPs
TNFα and IL-1β
Prolonged Inflammation Stimulation of macrophage and
neutrophils to wound bed
Activation of macrophages with release of cytokines
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Location: typically, plantar aspect of the foot beneath a bony prominence
Appearance: ill-defined borders, prominent callus, and palpable pulses
DIABETIC ULCER
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“Seven Elements of Standard Wound Care”:
Assessment of patient’s vascular status and documentation of correction of any vascular problems in affected limb, if possible
Optimization of nutritional status
Optimization of glucose control
Debridement by any means to remove devitalized tissue
Maintenance of a clean, moist wound bed of granulation tissue with moist dressings
Appropriate off-loading
Necessary treatment to resolve any infection that might be present
Wagner Scale
Grade 3 – Lesion has penetrated deeper than grade 2 and there is abscess, osteo, pyarthrosis, plantar space abscess, or infection of the tendon and tendon sheaths
Grade 4 – Wet or dry gangrene in the toes or forefoot
Grade 5 – Gangrene involves the whole foot or such a percentage that no local procedures are possible and amputation (at least at the BKA level) is indicated
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Loss of peripheral sensation
Typically seen in Diabetic patients
Lack of sensation over pressure points
Microtrauma
Tissue breakdown
Ulceration
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Compromised blood flow
Deprived oxygen to tissues
Discoloration and Necrotic tissue formation
“Punched out” appearance –well defined even Wound margins
Delayed capillary return
Hair loss
Atrophic skin /nail changes
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ARTERIAL ULCER
Location: distal lower extremity
Appearance: distinct margin (cookie cutter), with central necrosis in setting of PAD:
• Cool extremity
• Diminished /absent pulses
• Shiny skin /hair loss
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ChronicWound
PressureSoft Tissue Infection
Systemic Illness
Osteomyelitis
Nutrition
Wound Environment
EdemaComplianceSystemic Healing Ability
Perfusion
Oxygen
FACTORS AFFECTING WOUND HEALING
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Glycemic Control in Wound Healing
Collins, Nancy, and Ruth Toiba. “Nutrition 411: The Importance of Glycemic Control in Wound Healing.” Wound Management & Prevention, www.o-wm.com/content/importance-glycemic-control-wound-healing.
12 week randomized study from Boston Medical:
• Stressed importance of sustained blood glucose with Diabetic Wound Healing
• Elevated blood glucose (Hgb A1c) 15 % decreased incidence of healing with every 1% increase with HgbA1c
• Importance of HgbA1c monitoring• Diet control is not just “controlling sugar”• Goal is to control the entire metabolic syndrome including obesity,
dyslipidemia and hypertension• Multidisciplinary approach reinforced the importance of controlling blood
glucose during wound healing• Dietary recommendations i.e Protein dietary consumption 1.5-2 g/kg per
day -may vary depending of wound type and renal status
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CAUSES OF HYPOXIA IN WOUND HEALING
Key components of wound healing are all dependent on oxygen to function
Arterial InsufficiencyDiabetes – impaired microcirculationABI/TCOM/Vascular StudiesSmoking
InfectionBacteria promote an oxygen
DumpEdemaCompression required
Radiation tissue damageDecrease in the quantity of blood vessels
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• The administration of 100% oxygen at greater than 1 atmosphere pressure absolute (ATA)
• Achieved in a chamber in which the whole body is instilled
• Only method of HBOT that is approved by CMS (Center of Medicare Service)
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USING HBO THERAPY AS PART OF THE APPROACH
Hyperbaric Oxygen Therapy (HBOT) is a powerful adjunctive therapy, reimbursed by Medicare and most payers, that is indicated for 10-15% of patients with chronic wounds.
Medicare-Approved Non-Emergent Indications:
Acute peripheral arterial insufficiency
Acute traumatic peripheral
ischemia
Chronic refractory osteomyelitis
Crush injures and suturing of
severed limbs
Diabetic wounds of the lower extremities
Osteoradionecrosis
Compromisedskin grafts
Progressive necrotizing
infection
Soft-tissueradionecrosis
94% of diabetic foot ulcer patients treated with HBOT maintained an intact limb at 55 months post-treatment1
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HYPOXIC TISSUE BENEFITS
• Restoration of microcirculation• Decreased local edema• Improved cellular energy metabolism• Improved local tissue oxygenation• Improved leukocyte-killing ability• Improved effectiveness of antibiotics
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Diabetic wounds of the lower extremity
Acute peripheral arterial insufficiency
Treatment of compromised skin grafts or flaps
Chronic refractory Osteomyelitis
Osteoradionecrosis
Soft tissue radionecrosis
Acute traumatic peripheral ischemia
Crush injuries and suturing of severed limbs
Progressive necrotizing infections
Gas gangrene
INDICATIONS -WOUND CARE
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ADDITIONAL ADVANCED THERAPIES
• Debridement• Advanced Dressing Selection• Topical Growth Factors• Compression• Bioengineered Skin Substitutes• Topical Antimicrobials
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• Faster healing and a shorter recovery period
• Limb salvage
• Restoration of health and mobility
• Improved quality of life
• Wound Care education to help patients understand their condition and prevent complications
BENEFITS TO PATIENTS AS PART OF THE WOUND CARE CONTINUUM
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What Can You Do?• Recognize who is at RISK for chronic wounds• Perform an accurate assessment of the WOUND and the
PATIENT• Implement PREVENTATIVE measures• Nutritional support• Surface offloading/ Skin protection• Choose appropriate DRESSINGS• Make prompt REFERRALS for wound care and HBOT
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GUIDELINES FOR REFERRAL
• Full thickness wounds that fail to show significant improvement in 2 weeks or complete healing in 4 weeks
• All full thickness ulcers that involve tendon, ligament, bone and/or joint and/or are significantly infected
• Neuropathic ulcers in diabetic patients, especially those with accompanying foot deformity
• Any wound in a diabetic patient due to the compromised healing ability
• Ulcers in compromised patients• Venous ulcers, especially those with arterial component or chronic
lower extremity swelling• Ulcers with significant ischemia
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Dr. Lori Richwine 609-407-2205