Front line management of the Diabetic Foot

Transcription

1 Front line management of the Diabetic Foot n o ti e b a i D + s te k o Sm = g in p Am a t u Sam Fratesi MD

2 Smoking + diabetes = amputation

3 Almost 2 million Canadians have diabetes In amputated diabetics 50% ulcer develop contralateral limb <2 years 50% contralateral amputation within 5 years 3 year mortality after 1st amputation..50%

4 15% of diabetics will develop a foot ulcer in their lifetime amputation in the diabetic is times higher than the non-diabetic every year 1 in every 250 diabetics will undergo amputation

5 Multifactorial etiology of diabetic foot ulcer neuropathy Arterial insufficiency impaired cell immunity Non-compliance diabetic foot ulcer infection trauma

6 Diabetic ulcers Etiology of skin breakdown A N G I O P A T H Y N E U R O P A T H Y INFECTION

7 85% of leg amputations in the diabetic preceded by a foot ulcer Major cause of a diabetic related hospital admission is a foot related problem

8 60 % of diabetics with foot ulceration have neuropathy without clinically significant arterial disease 20% have ulcers primarily due to arterial disease 20 % have ulcers secondary to a combination of both neuropathy and arterial disease

9 Diabetic neuropathy Pathophysiology autonomic Skin abnormality,immune deficiency poor circulation sensory Continuous/repetitive trauma motor Foot deformity/abnormal pressure points

10 METARSAL HEAD PROMINENCE AND ULCERATION ulceration is over the plantar surface of the metatarsal heads.

11 HAMMER-TOE DEFORMITY Claw-toe deformity with loss of function of intrinsic muscles of foot

12 CHARCOT'S FOOT Progressive neuropathy + Repetitive trauma + osteoporosis

13 ISCHEMIC FOOT ULCER

14 Diabetic ulcer risk Peripheral neuropathy Foot deformity Limited joint movement Elevated plantar pressure Prior ulcer/amputation Peripheral vascular disease Susceptibility to infection

15 Structural deformity

16 Autonomic neuropathy

17 Sensory neuropathy

18 Insensate foot

19 Motor neuropathy

20 Combined motor/sensory neuropathy

21 Tissue loss in the diabetic foot High foot pressure Callus/trauma ulceration Diabetic foot amputation Failure to heal infection

22 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

23 Atherosclerosis of the lower limb in the diabetic: Diabetes>20 years > 50% lose peripheral pulse Diabetics have small vessel disease plus more trifurcation disease than non-diabetics Distal revascularization has saved many diabetic limbs Smoking + diabetes = amputation

24 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 blood supply to heal

25 Wounds by stage Stage 1 redness of skin that does not turn white with pressure Stage2 abrasion,blister,ulcer..partial thickness..involves epidermis/dermis Stage3 full thickness skin loss into subcut. tissue necrosis present Stage 4 extensive..through fascia into supporting structures (muscle/bone )

26 SAH Topical Wound Overview RED YELLOW BLACK assessment after proper cleansing

27 6 simple questions 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?

28 Neurological assessment of diabetic ankle reflexes vibration sensation pain sensation Diminished protective sensation to monofilament testing (10 gram / 5.07 mm Semmes-Weinstein)?

29 USE OF 10-GRAM MONOFILAMENT

30 Factors to enhance wound environment in diabetic patients with foot ulceration: Aggressive debridement to remove necrotic tissue and slough Control of infection Optimize oxygenation Avoidance of further trauma Ulcer dressings and topical wound therapy

31 Infections in diabetic foot ulcers: Foot infection is a common cause for diabetic hospitalization An altered immune responses may mask the clinical severity of infections. Less than 50 % with limb threatening infections have a significant fever or elevated WBC count. ice berg effect quite common

32 Wound culture techniques: surface cultures from diabetic wounds may not correlate 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

33 Infected diabetic foot ulcers: The importance of aerobic/anaerobic culture The more serious the infection, the higher the probability of multiple organisms particularly if a deep infection Milder infections tend to have fewer organisms particularly if superficial Gm(+) cocci is the most common but is the lone ranger in<50%

34 Osteomyelitis in the diabetic foot Initially plain X Ray may be normal Technetium bone scans 70% reliable with lower specificity Addition of Gallium improves the sensitivity and specificity Indium WBC scanning is best scanning method but more expensive and less readily available. MRI probably best test of bone infection.

35 Wound Assessment All wounds should be probed for extent and hidden sepsis

36 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

37 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 healthy tissue

38 A foot soak gone bad maceration

39 Diabetic foot ulcers: newer therapies Recombinant human growth factor therapy (Regranex*) Bio-engineered human skin (Dermagraft*) replacements VAC therapy (KCI) These do not replace nor are they first line strategies

40 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

41 Initial Assessment Total Care Considerations Wound Evaluation General Health Assessment Pressure Relief Assessment Psychosocial/Environment Expectations/Goals Defined Comfort/Pain Knowledge/Education Prevention

42 Diabetic foot assessment The importance of structural deformity (Charcot, hammer or claw toe),limited joint mobility, neuropathy and impaired circulation The physical examination must include a thorough inspection, vascular assessment neuro assessment and check out the footwear

43 Management of the ulcer Debride..gets rid of the necrotic tissue/callus.allows proper assessment.increases cytokines in the wound(platelets) Off-Load the pressure.reduce friction and shear forces prescription footwear, orthotics,ortho wedge boots,silicone socks Total contact casts and removable casts

44 Ulcer management Use of antimicrobials..the importance of recognizing and treating the infected ulcer.in pt vs out patient therapy oral vs IV therapy Wound care Avoid abuse of antibiotic topical Tx Extremely important education and followup

45 Wound care protocols standard wound care management protocols Bioengineered tissue Growth factors

46 Diabetic wound dressings Promote debridement,repair and growth Reduce the pain Absorb any exudate Maintain humidity but not mascerate Keep out the bacteria

47 Early treatment of the diabetic foot improves function and quality of life infection control maintain health status reduce costs

48 Steps in Saving the Diabetic Foot Patient Education Identification of Risk Factors Recognition and Treatment of etiology Wound Management Augmentative Interventions

49 Patient Education Goal Oriented Problem Centred Offers Feedback Group Discussion Varied Presentation

50 Identification of Risk Factors prior diabetic ulcer advancing age peripheral vascular disease diabetic neuropathy

51 Identification of Risk Factors Peripheral Vascular Disease

52 Identification of Risk Factors Peripheral Neuropathy - motor - autonomic - sensory

53 Identification of Risk Factors Autonomic Peripheral Neuropathy

54 Identification of Risk Factors Peripheral Sensory Neuropathy

55 Identification of Risk Factors Structural Deformity

56 Structural Deformities Biomechanical Deficiencies - pes cavus - pes planus

57 Underlying Etiology Extrinsic Intrinsic Trauma Foreign Body Limited Joint Mobility Foot Deformity Improper Footwear Poor Pressure Relief Foot Mechanics Neoplasm Surfaces Infection Ischemia

58 Recognition and Treatment of Underlying Etiology Intrinsic Cause Limited joint mobility Foot deformity

59 Recognition and Treatment of Underlying Etiology Intrinsic Cause Foot Mechanics

60 Principles of Wound Management Debridement Pressure Reduction Removal of Bacterial Burden Promote Healing

61 Wound Management Pressure Reduction

62 Wound Management Remove Bacterial Burden

63 Augmentative Interventions Deflective Padding Plastazote, PPT, Silipos gel Toe muffs, crests pads, MTP cookies, toe separators Crest Pad

64 Augmentative Interventions Therapeutic Off-Loading Devices Orthowedge boots, IPOS heel boots, air cast boots, contact casting, circular Poseys

65 Augmentative Interventions Off-Loading Devices IPOS Heel Boot

66 Augmentative Interventions Off-Loading Devices High-Top Ambulatory Boots

67 Insoles and Orthotics Soft Density Full Length Cost Effective Regular Monitoring and Maintenance

68 Augmentative Interventions Footwear Extra-depth and Extra-width P.W. Minor New Balance SAS Soft Spot Clark Birkenstock NAOT

69 Augmentative Interventions Off-the-Shelf Footwear

70 Augmentative Interventions Custom Footwear

71 Diabetic Foot Ulcers are Predictable and Preventable

72 Foot Disease is the Most Common Complication of Diabetes Leading to Hospitalization Reiber and Kosak

73 8 commandments of foot care 1) Wash daily Thou shalt. 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

74 Smoking + diabetes = amputation