Diabetic Foot Ulcers (DFUs) Mehr Ali Rahimi Endocrinologist Associate Proffessor of Kermansha University of Medical Scinces

Transcription

1 بسم الله الرحمن الرحیم Diabetic Foot Ulcers (DFUs) Mehr Ali Rahimi Endocrinologist Associate Proffessor of Kermansha University of Medical Scinces ١

2 Case ۵۶ year old woman with DM٢ admitted with a diabetesrelated foot infection which may require surgical debridement in the near future, eating regular meals. - Weight: ٨٠ kg - Home medical regimen: Glibenchamide ١٠ mg po bid, Metformin ١٠٠٠ mg po bid, Control: - A recent HbA١c is ١٠%, POC glucose in ED ٢۴٠ mg/dl What are your initial orders?

3 Stop orals Initial Orders Basal Insulin: ٢٠-٣٠ units Nutritional Insulin: ٢١-٣٠ units (٧-١٠ units each meal) Moderate dose correction scale Monitor for ٢۴ hours and begin adjusting

4 INTRODUCTION The lifetime risk of a foot ulcer for patients with diabetes (type ١ or ٢) may be as high as ٢۵ percent ١۵% of diabetic patients will develop a diabetic foot ulcer. ٢٠% of diabetic admissions to hospital due to foot problems. Foot ulcerations are the commonest cause of hospital admission in diabetics

5 Epidemiology- amputations Diabetic foot ulcers precede >٨٠% of amputations in Diabetic patients amputation rate ١۵ fold higher than non diabetics Greater than ۵٠% of all non-traumatic amputations are diabetics

6 Epidemiology Individuals who develop a DFU are at greater risk of; premature death, MI stroke than those without a history of DFU.

7 Epidemiology- Mortality DFU patients have ٢.۴ times the mortality rate of non-ulcerated diabetic patients.

8 Epidemiology Cellulitis occurs ٩ times more frequently in diabetics than non-diabetics Osteomyelitis of the foot ١٢ times more frequently in diabetics than non-diabetics

9 Key epidemiologic points about diabetic foot ulcer can be summarized by the Rule of ١۵ : Rule of ١۵ ١۵% of diabetes patients Foot ulcer in lifetime ١۵% of foot ulcers Osteomyelitis ١۵% of foot ulcers Amputation ٢٠٠۶. American Colleg of Physicians. All Rights Reserved. ٩

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11 Pathophysiology Factors leading to development of diabetic foot: Diabetic macroangiopathy PVD Diabetic microangiopathy thickening of basement membranes Diabetic polyneuropathy Diabetic osteoathropathy abnormal foot biomechanics Reduced resistance to infection Delayed wound healing Reduced rate of collateral vessel formation

12 Pathophysiology of DFUs In most patients, peripheral neuropathy and peripheral arterial disease (PAD) (or both) play a central role and DFUs are therefore commonly classified as : Neuropathic Ischaemic Neuroischaemic (Figures).

13 Neuropathic DFU Ischaemic DFU Neuroischaemic DFU

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15 Important factors for development of diabetic foot infections include Hyperglycemia PVD Neuropathy ١۵

16 Neuropathy Neuropathy is present in over ٨٠ percent of patients with foot ulcers Sensory neuropathy Motor Neuropathy (can lead to foot deformities) Autonomic Neuropathy - Anhidrosis Dry, cracked skin, (thereby allowing infection to penetrate below the skin.) -Arterial to venous shunting -Temperature regulation disorders

17 Anhidrosis Autonomic Neuropathy Dry, cracked skin, (thereby allowing infection to penetrate below the skin.) Arterial to venous shunting Temperature regulation disorders Lack of autonomic tone in the capillary circulation causes shunting of blood from arteries directly into veins, bypassing the tissues that need nutrition. This results in a foot that feels warm and has distended veins and bounding pulses vasodilation and absent sweating thus foot is warm, dry, scaly which predisposes to fissure formation

18 Peripheral arterial disease Can Lead to impaired blood supply needed for healing of ulcers and infections. People with diabetes are twice as likely to have PAD as those without diabetes.it is also a key risk factor for lower extremity amputation ONLINE ١۶.٣ ١٨

19 Poor Immune Function Poor PMN functions Migration, phagocytosis, intracellular killing, chemotaxis Ketosis impairs leukocyte function Monocyte mediated immune function diminished Hyperglycemia impairs complement fixation Hyperglycemia impairs neutrophil function and reduces host defenses

20 Clinical manifestations The cardinal manifestations of inflammation (erythema, warmth, swelling, and tenderness) and/or the presence of pus in an ulcer or sinus tract

21 DIAGNOSIS The diagnosis of a diabetic foot infection is primarily based on suggestive clinical manifestations. The presence of two or more features of inflammation (erythema, warmth, tenderness, swelling, induration and purulent secretions) can establish the diagnosis.

22 Evaluation of a Diabetic foot

23 Evaluation The evaluation of a patient with a diabetic foot infection involves three key steps: ١) determining the extent and severity of infection, ٢) identifying underlying factors that predispose to and promote infection ٣) assessing the microbial etiology.

24 Evaluation Of The Diabetic Foot Risk factors Risk classification Wound classification Laboratory evaluation Imaging

25 Risk factors Male sex DM > ١٠ years duration Peripheral neuropathy Abnormal foot structure PVD Smoking previous ulceration / amputation Poor glycemic control (HbA١c > ٧%) presence of micro- or macrovascular disease presence of claudication

26 Early recognition and management of risk factors is important for reducing morbidity of foot ulceration Risk of PVD and Peripheral neuropathy to increase with the duration of type ٢ diabetes

27 Predictors of amputation were foot ulceration R.F+ Visual impairment Diabetic nephropathy (especially patients on dialysis) ankle brachial index <٠.٩ ADA٢٠١۴

28 Risk classification International Working Group on the Diabetic Foot can be used to design preventive and monitoring strategies Group ٠ no evidence of neuropathy Group ١ neuropathy present but no evidence of foot deformity or PVD Group ٢ neuropathy with evidence of deformity or PVD Group ٣ history of foot ulceration or lower extremity amputation ulcers occurred in ۵, ١۴, ١٣, and ۶۵ percent of patients in groups ٠, ١, ٢, and ٣, respectively. Only patients in groups ٢ and ٣ had amputations (٢ and ٢۶ percent, respectively)

29 Risk categories High risk previous ulcer/amputation At risk - neuropathy and or vascular impairment with foot deformity Low risk no neuropathy, no vascular problems or foot deformities

30 Classification of Foot Ulcers Many different classification systems have been reported in the literature. The one developed by Wagner for grading diabetic foot ulcers has been widely used and accepted. More recently, the University of Texas (UT) group has developed an alternative classification system that, in addition to ulcer depth (as in the Wagner system), takes into account the presence or absence of infection and ischemia A prospective study from ٢٠٠١ assessed and compared these two wound classification systems and concluded that the UT scheme is a better predictor of outcome than the older Wagner system. ١٣TH EDITION WILLIAMS textbook of ENDOCRINOLOGY

31 Classification (Wagner ) Grade ٠ No ulcer in a high risk foot. Grade ١ Superficial ulcer involving the full skin thickness but not underlying tissues. ONLINE ١۶.٣ ٣١

32 CLASSIFICATION (Wagner ) Grade ٢ Deep ulcer, penetrating down to ligaments and muscle, but no bone involvement or abscess formation. ONLINE ١۶.٣ ٣٢

33 CLASSIFICATION (Wagner ) Grade ٣ Deep ulcer with cellulitis or abscess formation, often with osteomyelitis. Grade ۴ Localized gangrene. Grade ۵ Extensive gangrene involving the whole foot. ONLINE ١۶.٣ ٣٣

34 This classification was based upon clinical evaluation (depth of ulcer and presence of necrosis) alone and did not account for variability in the vascular status of the foot

35 University of Texas system An update to th e Wagner system.while similar to Wagner in its first three categories, this later system eliminated grades ۴ and ۵ and added stages A to D for each of the grades

36 Grade UT system Grade ٠: Pre- or postulcerative (Stages A to D) Grade ١: superficial ulcer not involving tendon, capsule, or bone (Stages A to D) Grade ٢: Tendon or capsular involvement without bone palpable (Stages A to D) Grade ٣: Probes to bone (Stages A to D) Stage: A : Noninfected B : Infected C : Ischemic D : Infected and ischemic

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38 Laboratory evaluation ١. CBC ٢. BS & HbA١C ٣. Electrolytes ۴. renal function &Urinalysis ۵. ESR ۶. CRP can be useful for monitoring response to therapy ٧. procalcitonin (PCT), a novel inflammatory marker, may also be useful if laboratory facilities that test this

39 Laboratory evaluation Organisms cultured from superficial swabs are not reliable for predicting the pathogens responsible for deeper infection. Deep tissue cultures are required; for evaluation of osteomyelitis, bone biopsy is needed. Aerobic and anaerobic cultures of deep tissue or bone biopsies should be obtained at the time of debridement if deep tissue infection or osteomyelitis is suspected ONLINE ١۶.٣ ٣٩

40 Laboratory Evaluation Risk For Osteomyelitis Evaluation for osteomyelitis is an important consideration in the management of diabetic foot infections. ۴٠

41 Factors increase the likelihood of osteomyelitis Grossly visible bone or ability to probe to bone Ulcer size larger than ٢ X ٢ cm Ulcer depth >٣ mm Ulcer duration longer than ١ to ٢ weeks ESR >٧٠ mm/h ۴١

42 Imaging ١. Initial evaluation should include conventional radiographs to evaluate for bony deformity, foreign bodies, and gas in the soft tissu eand may be able to detect osteomyelitis ٢. In select cases, (MRI) can be performed to better evaluate for soft tissue abnormalities and osteomyelitis ٣. Other imaging techniques that have been used include radionuclide bone imaging, and imaging with indium-labeled leukocyte

43 Imaging If bone is grossly visible, supportive radiographic findings may not be necessary to make A diagnosis of osteomyelitis.

44 Evaluation for osteomyelitis Patients with diabetic foot infections should have initial evaluation with conventional radiographs. Those with one or more of the above factors whose radiographs are indeterminate for osteomyelitis should undergo magnetic resonance imaging (MRI). ONLINE ١۶.٣ ۴۴

45 Osteomyelitis Evidence of osteomyelitis by these imaging modalities should prompt a bone biopsy to confirm the diagnosis and to guide antimicrobial therapy. In the absence of osteomyelitis by these alternative imaging modalities, osteomyelitis is unlikely. ۴۵

46 Laboratory evaluation MICROBIOLOGY Most diabetic foot infections are polymicrobial, with up to five to seven different specific organisms often involved. The microbiology of diabetic foot wounds is variable depending on the extent of involvement

47 Management of Diabetic Foot

48 MANAGEMENT Management of diabetic foot infections requires Glycemic Control Pressure Relieving Strategies Good nutrition Antimicrobial therapy Effective local wound care Fluid and electrolyte balance. Restoring pulsatile blood flow ۴٨

49 Management of DFU Basically, a diabetic foot ulcer will heal if the following three conditions are satisfied: Pressure is removed from the wound and the immediate surrounding area Arterial inflow is adequate. Infection is treated appropriately. Although this approach might seem simplistic, failure of diabetic foot ulcers to heal is usually a result of failure to pay sufficient attention to one or more contributing conditions, including pressure on the wound, infection, ischemia, and inadequate débridement. ١٣TH EDITION WILLIAMS textbook of ENDOCRINOLOGY

50 Pressure is removed from the wound and the immediate surrounding area Off loading The most common cause of nonhealing of neuropathic foot ulcers is the failure to remove pressure from the wound and immediate surrounding area. ١٣TH EDITION WILLIAMS textbook of ENDOCRINOLOGY

51 ١-The most common cause of nonhealing of neuropathic foot ulcers is the failure to remove pressure from the wound and immediate surrounding area strongly suggest that Pressure is removed from the wound and the immediate surrounding are ١٣TH EDITION WILLIAMS textbook of ENDOCRINOLOGY

52 ٢-The next most common error is inappropriate management of infection. Topical applications are usually unhelpful, and if clinical infection is present, it must be treated appropriately. ٣-Another common error is the failure to appreciate ischemic symptoms that are atypical due to altered pain sensation as a result of neuropathy. ١٣TH EDITION WILLIAMS textbook of ENDOCRINOLOGY

53 The most difficult ulcer to heal is the neuroischemic ulcer, and symptoms and even signs of ischemia may be altered in the diabetic state. Therefore, appropriate noninvasive investigation and arteriography are indicated for patients with a nonhealing diabetic foot ulcer if there is any question about the vascular status. ١٣TH EDITION WILLIAMS textbook of ENDOCRINOLOGY

54 Inappropriate wound débridement is another reason for slow healing or nonhealing of a diabetic foot ulcer. Appropriate débridement and removal of all dead and macerated tissue is essential in the local treatment of a diabetic foot ulcer and has been shown to result in more rapid healing of ulcers compared with wounds that are inadequately débrided. ١٣TH EDITION WILLIAMS textbook of ENDOCRINOLOGY

55 ULCER CLASSIFICATION The first step in managing diabetic foot ulcers is assessing, grading,and classifying the ulcer. Classification is based upon clinical evaluation of the extent and depth of the ulcer and the presence of infection or ischemia, which determine the nature and intensity of treatment. To assess for ischemia, all patients with diabetic foot ulcers should have ankle-brachial index and toe pressure measurements. ١٣TH EDITION WILLIAMS textbook of ENDOCRINOLOGY

56 Neuropathic Foot Ulcer Without Osteomyelitis (Wagner Grades ١, ٢; UT Grades ١a, ١b, ٢a, ٢b) that typically occur under weight-bearing areas off-loading a foot wound In the treatment of neuropathic ulcers with a good peripheral circulation, antibiotics are not indicated unless there are clear clinical signs of infection, including prominent discharge, local erythema, and cellulitis.

57 Theoretically, complete healing of all superficial and neuropathic ulcers should be possible without the need for amputation. In the treatment of neuropathic ulcers with a good peripheral circulation, antibiotics are not indicated unless there are clear clinical signs of infection, including prominent discharge, local erythema, and cellulitis. The presence of any of these features in Wagner grade ١ or ٢ ulcers would warrant reclassification in the UT system from ١a or ٢a to ١b or ٢b. In such cases, deep wound swabs should be taken and broad-spectrum oral antibiotic treatment should be started ١٣TH EDITION WILLIAMS textbook of ENDOCRINOLOGY

58 Neuroischemic Ulcers (Wagner Grades ١, ٢; University of Texas Grades ١c, ١d) similar to those for neuropathic ulcers, with the following important exceptions. Antibiotic therapy is usually recommended for most neuroischemic ulcers. Investigation of the circulation is indicated, including noninvasive assessment and, if required, arteriography with appropriate subsequent surgical management or angioplasty

59 Osteomyelitis (Wagner Grade ٣; UT Grades ٣b, ٣d) Wagner or UT grade ٣ ulcers are deeper and involve underlying bone, often with abscess formation. Osteomyelitis isa serious complication of foot ulceration and may be present in as many as ۵٠% of diabetic patients with moderate to severe foot infections. If the physician can probe down to bone in a deep ulcer, the presence of osteomyelitis is strongly suggested. Plain radiographs are indicated for any nonhealing foot ulcer and are useful in the diagnosis of osteomyelitis in more than two thirds of patients, although the radiologic changes may be delayed. In difficult cases, further investigation, such as MRI, bone scans, or an indium-١١١ (١١١In)-labeled white blood cell scan can be useful in diagnosing bone infection. ١٣TH EDITION WILLIAMS textbook of ENDOCRINOLOGY

60 Although the treatment of osteomyelitis is traditionally surgical and involves resection of the infected bone, there have been reports of successful long-term treatment with antibiotics effective against the underlying bacterium, most commonly Staphylococcus aureus. Therefore, agents such as clindamycin (which penetrates bone well) or flucloxacillin are often used. Most recently, a randomized controlled trial has confirmed that antibiotic therapy for ٩٠ days was equally efficacious when compard to local surgery for diabetic foot osteomyelitis. ١٣TH EDITION WILLIAMS textbook of ENDOCRINOLOGY

61 Gangrene (Wagner Grades ۴, ۵) The presence of gangrene or areas of tissue death is always a serious sign in the diabetic foot. However, localized areas of gangrene, especially in the toes, that are without cellulitis, spreading infection, or discharge can occasionally be left to spontaneously autoamputate. The presence of more extensive gangrene requires urgent hospital admission; treatment of infection, often with multiple antibiotics; control of the diabetes, usually with intravenous insulin; and detailed vascular assessment. It is in this area that the team approach is most important, with close collaboration among the diabetes specialist, the vascular surgeon, and the radiologist. ١٣TH EDITION WILLIAMS textbook of ENDOCRINOLOGY

62 CLASSIFICATION OF INFECTION Mild infection Moderate infection Severe infection ۶٢

63 Mild infection Presence of ٢ manifestations of ١. Inflammation (purulence, or erythema, pain, tenderness, warmth, or induration), ٢. Any Cellulitis/erythema extends ٢ cm around the ulcer, ٣. Infection is limited to the skin or superficial subcutaneous tissues ۴. No other local complications or systemic illness. ONLINE ۶٣

64 Mild infection ١.Treated with outpatient oral antimicrobial therapy. ٢.Treated with outpatient OHA ٣.Or insulin therapy(type ١ or type٢treated by insul) ۶۴

65 Moderate infection Infection in a patient who is ١. Systemically well and metabolically stable ٢. Which has ١ of the following characteristics: cellulitis extending >٢ cm, deep-tissue abscess, gangrene, and involvement of muscle, tendon, joint or bone.

66 Severe infection Infection in a patient with Limb threatening diabetic foot infections. Systemic toxicity or metabolic instability (eg, fever, chills, tachycardia, hypotension, confusion, vomiting, leukocytosis, acidosis, severe hyperglycemia, or azotemia).

67 Duration of therapy Mild infection : ١-٢ weeks Moderate infection : ٢ to ۴ weeks, unless osteomyelitis Severe infection : soft tissue up to ۴ weeks unless osteomyelitis Osteomyelitis: depends on degree of resection ۶٧

68 severe infections warrant hospitalization for urgent surgical consultation, antimicrobial administration, and medical stabilization, most mild infections and many moderate infections can be managed in the outpatient setting with close follow-up

69 Hospitalization may be needed for mild or moderate infections if the patient; cannot manage glycemic control at home, is unable to obtain or comply with proper wound careor offloading, needs parenteral antibiotics and or needs more urgent diagnostic studies or surgical consultation

70 Glycemic control

71 Glycemic control Optimized glucose control Decreases by ۵٠% chance of foot problems

72 Management aims ١- No excess mortality. ٢- No complication ٣- Normal wound healing. ۴- No increase duration of hospitalization. ۵- No D.K.A or sever hyperglycemia. ۶- No hypoglycemia ٧٢

73 Glucose targets Glucose targets greater than >١٨٠ mg/dl or <١١٠ mg/dl are not recommended in DFU

74 Which limit is Ideal? BS between ١٠٠ ١٨٠ mg/dl. HbA١c<٧.۵ ٧۴

75 Which limit is critical? BS more than ٢٠٠ mg/dl ٧۵

76 Glycemic Goals BAD GOOD BAD Hypoglycemia Somewhere in the Middle Hyperglycemia <۴٠ ٧٠ ١١٠ ١۴٠ ١٧٠ >٢٠٠

77 Side Effects of BG >٢٠٠ mg/dl Reduced Intravascular Volume Dehydration Electrolyte Fluxes Impaired WBC Function Immunoglobulin Inactivation Complement Disabling Increased Collagenase, Decreased Wound Collagen

78 Adverse Effects of Hyperglycemia Hyperglycemia Increases risks of postoperative infections and delirium Prolonged hospital stay, resource utilization Increased renal dysfunction and renal allograft rejection in transplant

79 Glycemic control hospitalized patients outpatient Only Insulin (IV or SC) Insu. or OHA (SC)

80 indications for insulin therapy in relation to Wagners Classification of diabetic foot Grade ٠ No ulceration in a high-risk foot ١ Superfi cial ulceration ٢ Deep ulceration that penetrates to thetendon, bone or joint ٣ Osteomyelitis or a deep abscess ۴ Localized gangrene ۵ Extensive gangrene requiring a major amputation Note: Optional where OHAs alone are ineffective Insulin Therapy Optional Optional Mandatory Mandatory Mandatory Mandatory

81 Diet O.H.A Insulin mild O.H.A Insulin infection sever Insulin Insulin Insulin infection ٨١

82 Insulin, (IV or SC), is the preferred regimen for effectively treating hyperglycemia in the hospital The use of oral antidiabetic agents should be avoided in the hospital setting because no data are available on their safety and efficacy in the inpatient setting. ٨٢

83 Sulfonylureas may increase the risk of hypoglycemia in hospitalized patients with poor appetite or ordered dietary restrictions. they may worsen cardiac and cerebral ischemia( by inhibiting ATP-sensitive potassium channels, resulting in cell membrane depolarization and increased intracellular calcium concentration) ٨٣

84 As majority of foot ulcerations are associated with infections and eventually require some or other surgery, insulin therapy becomes a main- stay to achieve a good glycaemic control

85 Beneficial Mechanistic Effects of Insulin Therapy The positive effects of insulin administration are attributed to its anti-inflammatory, vasodilatory(stimulate nitric oxide release and induce the expression of endothelial nitric oxide synthase ), antioxidant effects as well as its ability to inhibit lipolysis and platelet aggregation ٨۵

86 Several studies have reported that elevated levels of cytokines and inflammatory markers associated with severe hyperglycemia return to normal shortly after the treatment with insulin and resolution of hyperglycemia

87 Insulin therapy in diabetic foot subcutaneous insulin therapy: Multiple injections of short acting insulin along with intermediate or long acting insulin, are indicated in patients with foot lesions who are being managed as outpatients Intravenous insulin therapy: Patients with advanced diabetic foot lesions who require hospitalization, have invariably a poor glycaemic control as evident by a raised plasma glucose and HbA١c values, ketonuria or even ketoacidosis.

88 Intravenous insulin therapy: Patients with advanced diabetic foot lesions who require hospitalization, have invariably a poor glycaemic control as evident by a raised plasma glucose and HbA١c values, ketonuria or even ketoacidosis.

89 Step ٢: Estimate the Amount of Insulin Adequate Nutrition = Total Daily Dose (TDD) For patients already treated with insulin, subcutaneous regimen Weight-based estimate: TDD = ٠.۴ units x Wt in Kg Adjust down to ٠.٣ units x Wt in Kg for those with hypoglycemia risk factors, including kidney failure, type ١ diabetes (especially if lean), frail/low body weight/ malnourished elderly,. Adjust up to ٠.۵-٠.۶ units (or more) x Wt in Kg for those with hyperglycemia risk factors, including obesity and high-dose glucocorticoid treatment

90 Step ٣: Decide Which Components of Insulin the Patient Will Require, and Which Percentage of the TDD Each Should Represent Basal insulin can generally be estimated to be ١/٢ of the TDD Nutritional insulin makes up the remaining ١/٢ of the TDD

91 How to Initiate Insulin Therapy (if not already on insulin OR if uncontrolled diabetes) Regimen Tracts Dose Low Standard Moderate Aggressive (DM I, Lean DM II) (Normal weight DM) (Overweight DM) (Obese DM) Total Daily Dose (TDD) ٠.٣ units/kg/da y ٠.۴ units/kg/d ٠.۵unit/kg/ d ٠.۶unit/kg/ d Basal ½ TDD Prandial ½ TDD divided into ٣ meals Correction Scale Yup, they will also receive this too It should be the same rapid/short acting insulin as used for prandial insulin See next page

92 Correction Scale with Meals Regimen Tracts Dose Low Standard Moderate Aggressive (DM I, Lean DM II) (Normal weight DM) (Overweight DM) (Obese DM) Total Daily Dose (TDD) ٠.٣ units/kg/d ٠.۴ units/kg/d ٠.۵unit/kg/ d ٠.۶unit/kg/ d ١۶١-٢٠٠ ١ units ٢ units ٣ units ۴ units ٢٠١-٢۵٠ ٢ units ۴ units ۵ units ۶ units ٢۵١-٣٠٠ ٣ units ۶ units ٧ units ٨ units Note that correction scale can be given at night

93 If ٢ readings >١٨٠ in ٢۴ hours, diabetes is uncontrolled ٩٣

94 Glycemic Goals If ٢ readings >١٨٠ in ٢۴ hours, diabetes is uncontrolled and a change should be made to scheduled insulin Our definitions: >٣٠٠ Severe Hyperglycemia ١٨٠-٢٩٩ Hyperglycemia ١٠٠-١٨٠ Controlled <٧٠ Hypoglycmia <۴٠ Severe Hypoglycemia

95 Initiating Insulin Therapy in the Hospital Obtain patient weight in kg Calculate total daily dose (TDD) as ٠.٣ U/kg to ٠.۵ U/ kg/day Choose the dosing schedule Give ۵٠%-۶٠ ۶٠% % of TDD as basal insulin Give ۴٠%-۵٠ ۵٠% % of TDD as nutritional insulin Use correction insulin for BG above goal range Adjust according to results of bedside glucose monitoring Adjust dose for NPO status or changes in clinical status ٩۵

96 Glucose Monitoring in Hospital Bedside capillary point of care (POC) testing is the preferred method for guiding ongoing glycemic management of individual patients POC testing is usually performed ۴ times aday: before meals and at bedtime for patients who are eating For patients who are restricted to nothing by mouth or are receiving continuous enteral nutrition,: POC testing is recommended every ۴ to ۶ hours ٩۶

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99 Neuropathic Foot Ulcer Without Osteomyelitis (Wagner Grades ١, ٢; UT Grades ١a, ١b, ٢a, ٢b) The most important feature in the management of neuropathic foot ulcers that typically occur under weight-bearing areas such as the metatarsal heads and great toe is the provision of adequate pressure relief This is usually achieved by a cast such as a TCC or a removable Scotch cast boot. The TCC has long been recognized as the gold standard for offloading a foot wound and was confirmed as correct in a randomized, controlled trial in which Armstrong and colleagues compared three off-loading techniques and found that the TCC was associated with the shortest healing time. the removable cast walker (RCW) resulted in slower healing than the TCC, ١٣TH EDITION WILLIAMS textbook of ENDOCRINOLOGY

100 Neuroischemic Ulcers (Wagner Grades ١, ٢; University of Texas Grades ١c, ١d) The principles of management of neuroischemic Wagner grade ١ and ٢ ulcers are similar to those for neuropathic ulcers, with the following important exceptions. TCCs are not usually recommended for management of neuroischemic ulcers, although removable casts and pneumatic cast boots (Aircast) may be used in cases without infection. Antibiotic therapy is usually recommended for most neuroischemic ulcers. Investigation of the circulation is indicated, including noninvasive assessment and, if required, arteriography with appropriate subsequent surgical management or angioplasty. ١٣TH EDITION WILLIAMS textbook of ENDOCRINOLOGY

101 Recommendations: Foot Care Perform a comprehensive foot evaluation annually to identify risk factors for ulcers & amputations. B All patients with diabetes should have their feet inspected at every visit. C History should contain prior hx of ulceration, amputation, Charcot foot, angioplasty or vascular surgery, cigarette smoking, retinopathy & renal disease; and should assess current symptoms of neuropathy and vascular disease. B American Diabetes Association Standards of Medical Care in Diabetes. Microvascular complications and foot care. Diabetes Care ٢٠١٧; ۴٠ (Suppl. ١): S٨٨-S٩٨

102 Recommendations: Foot Care (٢) Exam should include inspection of the skin, assessment of foot deformities, neurologic assessment & vascular assessment including pulses in the legs and feet. B American Diabetes Association Standards of Medical Care in Diabetes. Microvascular complications and foot care. Diabetes Care ٢٠١٧; ۴٠ (Suppl. ١): S٨٨-S٩٨

103 Recommendations: Foot Care (٣) Patients with symptoms of claudication, decreased, or absent pedal pulses should be referred for ABI & further vascular assessment. C A multidisciplinary approach is recommended for individuals with foot ulcers and high-risk feet. B The use of specialized therapeutic footwear is recommended for patients with high-risk feet. B American Diabetes Association Standards of Medical Care in Diabetes. Microvascular complications and foot care. Diabetes Care ٢٠١٧; ۴٠ (Suppl. ١): S٨٨-S٩٨

104 Recommendations: Foot Care (۴) Refer patients who smoke or who have hx of lower-extremity complications, loss of protective sensation, structural abnormalities or PAD to foot care specialists for ongoing preventive care and lifelong surveillance. C Provide general foot self-care education to all patients with diabetes. B American Diabetes Association Standards of Medical Care in Diabetes. Microvascular complications and foot care. Diabetes Care ٢٠١٧; ۴٠ (Suppl. ١): S٨٨-S٩٨

105 Recommendations: Foot Care (۵) To perform the ١٠-g monofilament test, place the device perpendicular to the skin; Apply pressure until monofilament buckles. Hold in place for ١ second & release. The monofilament test should be performed at the highlighted sites while the patient s eyes are closed. Boulton A, Armstrong D, Albert, S et. al. Comprehensive Foot Examination and Risk Assessment. Diabetes Care. ٢٠٠٨; ٣١: ١۶٧٩-١۶٨۵