Assessment and Management of Wounds In Diabetes Maria Mousley Northamptonshire NHS Foundation Trust
Background At least 61000 people with diabetes in England have a foot ulcer at any given time There are around 6000 lower extremity amputations a year in people with diabetes Diabetic foot ulcers are the most common cause of non-traumatic limb amputation The risk of a lower extremity amputation in a person with diabetes is 23 x that of a person without diabetes
Background Diabetes is one of the biggest health challenges facing the UK today Diabetic foot problems have a significant financial impact on the NHS and a significant impact on patients quality of life.
Costs Average annual cost of one foot ulcer treatment? 3,600 (York Health Economics Consortium, The diabetic Foot. Vol 1; No 3, 109-115, 1998) Average cost of one lower limb amputation? 16,300-32,600 (IDF, 2005) Estimated Health Care budget in the UK Up to 502m per year (DoH 2002)
The Indirect Costs Pain Pain Restricted mobility Embarrassment Human Costs Costs Loss Loss of of earnings Social Social isolation Depression
Amputation Prevention Team (aka Diabetic Foot Team) Ward/OPD Referral Podiatry facilitator Primary Care / Community Referral Radiology Consultant Interventional Radiologist X-ray MRI Consultants Diabetologist Vascular Surgeon Orthopaedic Surgeon Microbiologist Extended Team Ward / Nursing Staff AHPs Supporting Team Vascular Laboratory Plaster Room Pathology Laboratory Adapted from RGF 1994 Diabetic Foot Team Services Ward Rounds OPD (complex clinic) Podiatry (ftwr, Wound Management)
Diabetic Foot Screening Diabetic Foot Protection Programmes Ward/OPD Referral Podiatry facilitator Primary Care / Community Referral MDfT Services Ward Rounds OPD (complex clinic) Specialist Podiatry (footwear, Wound Management) Amputation Prevention Team (aka Diabetic Foot Team)
Refer?...as?
Stage 1 - hard skin builds up (fire)
This may not be painful! (undetected) Pressure may not be noticeable at first
Stage 2 - Tissue damage begins beneath the surface (starts to spread)
Stage 3 - Skin breaks open and an ulcer is revealed. This is prone to infection. (spot the signs)
Prevention of Foot Attack Extravasation a precursor of ulceration
The faster you act the more of a foot you save
Escalating needs; deteriorating condition
Deterioration Wound getting worse Increase in size Increase in depth Development of complications
NEUROPATHIC VS ISCHAEMIC ULCERS Symptoms Circulation Site Presence of callus Signs of infection
Neuropathy Nerve damage in diabetes leads to altered pain sensation Tip of toes Big toe Ball of foot Heel area
Neuropathic Ulcer Granulation Deep Other structures exposed Callus Site: Weight bearing areas.
Clinical Examination Insensate foot: repeated minor trauma causes ulceration
The importance of neuropathy Ulcers will not heal unless offloaded Ulceration leads to infection, often exacerbated by poor diabetes control Untreated or inadequately treated infection leads to osteomyelitis Neuropathic ulcers may be small and apparently insignificant ALWAYS look under the dressing NB infection? cause
Pressure offloading Total contact casting is the gold standard AND REST!!!!!!!!
Peripheral Arterial Disease Palpate foot pulses:- Dorsalis Pedis Posterior Tibial Doppler sounds Monophasic? Ankle-Brachial Index (ABPI) <0.8
Ischaemic Ulcer Painful Cool Foot Pulseless Site: borders of the feet. Surrounding Erythema Necrotic centre
Neuroischaemic ulcers -Refer
Refer
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Summary of Neuropathic foot ulcers NICE Clinical Guideline CG10 Type 2 Diabetes - Foot care 2004 CREST guidelines 1998 www.gain-ni.org/guidelines/wound-managementdiabetic-foot.pdf Neuropathic foot Warm Numb Dry Usually painless Palpable pulses Neuropathic foot ulcers Commonly resulting from callus On weight-bearing areas Punched out appearance
Summary of Neuroischaemic foot ulcers NICE Clinical Guideline CG10 Type 2 Diabetes - Foot care 2004 CREST guidelines 1998 www.gain-ni.org/guidelines/wound-managementdiabetic-foot.pdf Neuro-ischaemic foot Cool/cold to touch Absent/diminished pulses Pain at rest Neuro-ischaemic foot ulcers Commonly result from tight shoe On non-weight-bearing areas of foot, toe tips & beneath toenails
Tissue Necrosis Neuropathy Infection Ischaemia The Deadly Triad (Edmonds 1984))
Line of least resistance
Spreading infection
Mr G W 52 years April 10 picked hard skin off foot at base of R hallux Not diabetic but family history of diabetes in two relatives one an amputee Foot became infected generally unwell Saw private podiatrist and advised to go to GP Prescribed flucloxacillin over the phone
2 days later reviewed by podiatrist not happy and referred to A&E seen by orthopaedic SHO and advised to continue antibiotics and return in 2 days 2 days later (1 week after first became unwell) saw GP blood glucose 16.8 pyrexial cellulitis Admitted under orthopaedic surgeons for iv antibiotics
IV flucloxacillin and benzylpenicillin (hospital guidelines advise co-amoxiclav for diabetic foot infections) cultures subsequently grew haemolytic strep, staph aureus and anaerobes 2 days after admission, debrided by orthopaedic surgeon Further debridement 1 week later Referred to vascular surgeon and podiatrist
Aug 2010 completely healed and patient ambulant in therapeutic footwear
Missed Opportunities Primary care Lack of specialist knowledge and referral routes failure to assess patient delayed diagnosis of diabetes Secondary care failure to recognise need for intravenous antibiotics when seen in A&E inadequate antibiotic cover inadequate debridement failure to involve the specialist diabetic foot team
Neuropathic ulcer presentation with cellulitis and
Neuropathic ulcer - tracking
Initial examination and assessment If the following are present, obtain urgent advice from an appropriate specialist: redness or warmth are present systemic sepsis deep seated infection limb ischaemia
Kissing Ulcers Kissing Ulcers (Ref. Jeffcoate & Macfarlane 1995)
Tip, Top Toe! Increased presure (Ref. Irion 2002)
Avoidable pressure ulcers are a key indicator of the quality of care. Preventing them will improve all care for at risk patients (harm free care)
Debridement
Neuropathic Ulcer No pain Warm Foot Pulses present Profuse slough Conversion to Infection
Management
Managing infection in the diabetic foot Clinical Knowledge Summaries Type 2 Diabetes 2008 Infection presents a threat to (life and) limb and should be treated promptly and aggressively Foot care infections in patients with diabetes are classified as non-limb threatening (urgent referral to a multidisciplinary diabetes foot care team within 24 hours) or limb-threatening (usually require hospital admission) Infected diabetic feet should only be treated by clinicians who have sufficient experience and facilities available A non-limb threatening infection can quickly become limb threatening
Managing infection in the diabetic foot Clinical Knowledge Summaries Type 2 Diabetes 2008 Non - limb threatening Infection - refer within 24 hours Includes those with infection of a superficial ulcer, no bone or joint involvement, no signs or symptoms of systemic toxicity, no significant ischaemia If referral within 24 hours is not possible, start empiric antibiotic treatment in interim. If deeper infection, seek urgent advice Review after 7 days Swabs should be taken before starting antibiotics
Managing infection in the diabetic foot Clinical Knowledge Summaries Type 2 Diabetes 2008 Limb threatening infection - consider hospital admission Includes those with spreading cellulitis, systemic signs of infection, lack of response to oral antibiotics, malodorous wounds, soft tissue necrosis or suspected bone involvement
Continuum of microbial load Increasing bioburden http://www.education.woundcarestrategies.com/coloplast/resources/clinical%20wound %20Assessment-Pocket%20Guide.pdf
Conversion to Infection and necrosis
Why high risk wounds? Vascular disease Nerve damage Hyperglycaemia Underlying susceptibility to infection
Classic Signs of Infection Rubor et tumor cum calore et dolore redness pain swelling heat (Celsus c. 3-64AD)
Diagnose Infection Based on any 2 features (Berendt & Lipsky 2003) Feature Temperature Colour Swelling Pain Exudate levels Neuropathic Comparative increase Erythematous eg.pillar box red Localised generalised Little or none Increased, +/- viscosity Ischaemic Little change - cooler Little change - dusky red Little change Increased pain Minor increase in volume
Infectious Diseases Society of America Classification System (Lavery et al 2007) Mild <2cm cellulitis / erythema Superficial ulcer >2 Signs of inflammation No systemic illness Moderate No systemic illness As in mild infection and in addition > 1 of the following: >2cm cellulitis Lymphangitis Involvement of Tendon Joint Bone Severe Infection in a patient with systemic toxicity or metabolic Instability
REMEMBER. Risk of treating infection too late, with it s associated morbidity & mortality, while giving antibiotics freely carries a risk of inducing antibiotic resistance.use of clinical skills & judgement is vital!
What antibiotic do I use? Broad Spectrum Eg. Co-amoxiclav Culture and sensitivity Culture directed narrower spectrum
Antibiotics in Diabetic foot Disease IDSA http://www.idsociety.org Scottish Diabetes Group Consensus (Leese et al The Diabetic Foot Journal vol 12 2 2009) Clinical Knowledge Summaries (CKS) http://www.cks.nhs.uk/diabetes_type_2/management/detailed_answers/foot_problem s
Treatment of infection Osteomyelitis
Management of diabetic foot ulcers When choosing wound dressings take into account: clinical assessment of the wound patient preference clinical circumstances eg granulating, sloughy, necrotic which wound dressing has the lowest acquisition cost.
Guidelines on wound and wound-bed management (2011) IWGDF Game et al 2012 Diab Metab Res Rev;28:232-233 In the absence of strong clinical or cost effective evidence, health care professionals should use wound dressings that best match clinical experience, patient preference, the site of the wound and the cost of the dressings. Wounds should be closely monitored and dressings changed regularly. (NICE, 2004 )
Health Technology Assessment
WHAT MAKES AN IDEAL DRESSING for High Risk Wounds.? Designed to minimise cross-contamination Maintains a moist environment for optimal wound healing (Sibbald et al, 2004) Absorption and retention at varying exudate levels (Chen et al, 2003) Minimises risk of damage to peri-wound skin (Jones et al, 2004) Conformable to the wound (Armstrong S.H. 2004) Versatile, for use on a wide range of wounds Comfortable for patient (Mortimer D) Control odour Easy to use Cost-effective
Wound bed colour... Black (necrotic) Yellow / grey (sloughy) Red (granulating) Pink (epithelising)
Think. Consideration should be given to the fact that these properties may be altered when dressing the feet (Morgan D, Formulary of Wpund Management Products, 7 th Ed: 26, 29-30, 1997) as dressings are not designed to take the high & repetitive forces exerted on the sole of the foot! (Baker N, Journal of Wound Care 6 (1): 1997) Friction Body weight pressure Movement High & repetitive forces Footwear accommodation INFECTION MASKED!
Vascular control.
Mechanical control. Rest Avoidance of pressure
Glycaemic control. Consider any systemic, metabolic or nutritional disturbances that may impair the response to infection and retard healing of wounds.
Educational control. Patient education / empowerment is critical if successful management is to be achieved. (Day J, Diabetes Metab Res Rev; 16 (Suppl 1): S70-74, 2000)
Key points for education (NICE 2004) Self-care and self-monitoring Knowledge of when & where to seek advice Awareness of possible consequences of neglecting the feet Management of symptoms (pain, odour)
Summary 1. Vascular disease 2. Nerve damage 3. Hyperglycaemia (infection) 4. Pt education
Questions?
Find out more Visit www.nice.org.uk/guidance/ www.woundsinternational.com
References Banga JD. (1994), Lower extremity arterial disease in diabetes mellitus Diabetes Reviews International 3;4:6-11 Dejgaard A. (1998), Pathophysiology and treatment of diabetic neuropathy Diabetic Medicine 15:97-112 Edmonds ME. (1984), The Diabetic Foot Practical Diabetes 1;1:36 Young MJ et al. (1993), A Multicentre study of the prevalence of diabetic peripheral neuropathy in the United Kingdom hospital clinic population Diabetologia 36:150-154