DIABETES FOOT MANAGMENT DIABETES FOOT MANAGMENT TEAMWORK TEAMWORK

By.Dr.J.L.ShahBy.Dr.J.L.Shah M.D. (Medicine)M.D. (Medicine)

Physician & DiabetologistPhysician & Diabetologist

Sonal Hospital &Diabetes ClinicSonal Hospital &Diabetes ClinicKhand Bazar,Lalgate,Surat.Khand Bazar,Lalgate,Surat.

PUT FEET FIRST

AMPUTATIONS

BURDEN & MAGNITUDEBURDEN & MAGNITUDE 60 million feet at risk.60 million feet at risk. 25% of Diabetes Patient Experience foot 25% of Diabetes Patient Experience foot

Problem in their lifetime.Problem in their lifetime. Risk of Amputation 40 times high Risk of Amputation 40 times high

Compared to Non Diabetics.Compared to Non Diabetics. 75% of all lower limb Amputation are 75% of all lower limb Amputation are

Performed in Diabetics. Performed in Diabetics. Every 30 sec one Diabetic looses Every 30 sec one Diabetic looses his/her toes / foot / limb in the world.his/her toes / foot / limb in the world. Prolong Hospitalization & high Cost of Prolong Hospitalization & high Cost of

Treatment. Treatment.

STAGES IN DIABETIC FOOTSTAGES IN DIABETIC FOOT1.1. Healthy foot.Healthy foot.

2.2. High Risk foot.High Risk foot.

3.3. Ulcerated foot.Ulcerated foot.

4.4. Infected foot.Infected foot.

5.5. Necrotic foot.Necrotic foot.

6.6. Un salvageable footUn salvageable foot

MANAGEMENTMANAGEMENT Multi disciplinary approach to save Multi disciplinary approach to save

maximum number of limbs.maximum number of limbs. Proper timely & adequate management Proper timely & adequate management

coupled with foot care education can save coupled with foot care education can save 80-85 % Amputation.80-85 % Amputation.

High sensitivity to the senseless foot of High sensitivity to the senseless foot of patient is needed by the health care patient is needed by the health care provider. provider.

COMPONENTS OF MANAGEMENTCOMPONENTS OF MANAGEMENT

1.1. Metabolic ControlMetabolic Control

2.2. Mechanical ControlMechanical Control

3.3. Educational ControlEducational Control

4.4. Vascular ControlVascular Control

5.5. Microbiological ControlMicrobiological Control

6.6. Wound ControlWound Control

METABOLIC CONTROLMETABOLIC CONTROL In all stages tight Glycemic control is important.In all stages tight Glycemic control is important. Hyperglycemia is important Risk factor for Hyperglycemia is important Risk factor for

development of neuropathy & Occlusive development of neuropathy & Occlusive Vascular disease.Vascular disease.

Hyperglycemia in Ulcerated foot reduces Hyperglycemia in Ulcerated foot reduces fibroblast proliferation & growth factor impairs fibroblast proliferation & growth factor impairs protease activity & Hence retard ulcer healing.protease activity & Hence retard ulcer healing.

Hyperglycemia reduces Chemo taxis & Hyperglycemia reduces Chemo taxis & Phagocytosis & Humoral antibodies. Phagocytosis & Humoral antibodies. Tissueglucose is good media for bacterial Tissueglucose is good media for bacterial Proliferation so, for microbiological control in Proliferation so, for microbiological control in infected ulcer Glycemic control is essential.infected ulcer Glycemic control is essential.

Tight Glycemic control in infected Patient should Tight Glycemic control in infected Patient should be achieved by insulin infusion followed by SC be achieved by insulin infusion followed by SC MDI Regime. MDI Regime.

METABOLIC CONTROLMETABOLIC CONTROLBesides Hyper Glycemic Control of BP, Besides Hyper Glycemic Control of BP,

Dyslipidemia & Cessations of Smoking is required.Dyslipidemia & Cessations of Smoking is required.For BP Control in Patient with Neuroischemic foot For BP Control in Patient with Neuroischemic foot

blocker Should be used with Caution blocker Should be used with CautionStatins & fibrate are effective & safe in Controlling Statins & fibrate are effective & safe in Controlling

Dyslipidemia.Dyslipidemia.All Patient need antiplatelate Therapy & DVT All Patient need antiplatelate Therapy & DVT

Prophylaxis with LMWH in Patient needing Prophylaxis with LMWH in Patient needing Prolonged bed rest.Prolonged bed rest.

Many Patient have associated Renal & Cardiac Many Patient have associated Renal & Cardiac Failure requiring Proper adjustment in drug Failure requiring Proper adjustment in drug dosage. dosage.

MECHANICAL CONTROLMECHANICAL CONTROL

Hyper Glycemia affects Practically all tissues Hyper Glycemia affects Practically all tissues of the foot. Changes in foot architecture lead of the foot. Changes in foot architecture lead to altered biomechanics of foot with to altered biomechanics of foot with development of high planter pressure under development of high planter pressure under Wt.barring points in naturopathic foot.Wt.barring points in naturopathic foot.So, naturopathic ulcers are essentially So, naturopathic ulcers are essentially pressure source & offloading is must for their pressure source & offloading is must for their healing.healing.Histological Studies have proven the efficacy Histological Studies have proven the efficacy of off loading within 48 hrs. where ulcers of off loading within 48 hrs. where ulcers changes its characteristics from nonhealing changes its characteristics from nonhealing to heeling. to heeling.

MECHANICAL CONTROLMECHANICAL CONTROLNeuroischemic ulcers also Respond well to off Neuroischemic ulcers also Respond well to off loading.loading.

In severely infected foot non weight barring is In severely infected foot non weight barring is desirable with use of crutches wheelchair or desirable with use of crutches wheelchair or zimer’s frame.zimer’s frame.

TCC is gold standard for off loading with healing TCC is gold standard for off loading with healing rate as high as 80% but is costly cumbersome & rate as high as 80% but is costly cumbersome & associated with some complication associated with some complication

Removable cast walkers therapeutics shoes, half Removable cast walkers therapeutics shoes, half shoe ,PRAFO are the other modality of off loading shoe ,PRAFO are the other modality of off loading in ambulatory patient.in ambulatory patient.

Healing is directly proportional to impulse loading. Healing is directly proportional to impulse loading.

HEALING OF NEUROPATHIC HEALING OF NEUROPATHIC ULCER USING CUSTOMISED ULCER USING CUSTOMISED

AFOAFOStudy of 10 patient Study of 10 patient presented in NNDU presented in NNDU 2004 at Singapore.2004 at Singapore.

10 patient with 13 weeks 10 patient with 13 weeks neuropathic ulcer neuropathic ulcer (wagnergrade-1) were (wagnergrade-1) were studied using off loading studied using off loading with Customize AFO.with Customize AFO.

All Patient healed within All Patient healed within 6 week time.6 week time.

EDUCATIONAL CONTROLEDUCATIONAL CONTROLRoutine foot care for all diabetics.Routine foot care for all diabetics.

Prophylactic diabetes foot ware & trauma Prophylactic diabetes foot ware & trauma Prevention education to high risk patient.Prevention education to high risk patient.

Education regarding early sign of infection & Education regarding early sign of infection & Immediate reporting .Immediate reporting .

Non weight bearing & off loading in Ulcerated Non weight bearing & off loading in Ulcerated and infected foot. and infected foot.

Rehabilitation & Psycho-social support in Rehabilitation & Psycho-social support in patient with major Amputation . patient with major Amputation .

VASCULAR CONTROLVASCULAR CONTROLVascular assessment with ABPI & Vascular assessment with ABPI &

transcutaneous otranscutaneous o22 tension as marker, is tension as marker, is

essential in all diabetic patient.essential in all diabetic patient.ABPI < 0.5, oABPI < 0.5, o22 tension < 30 mm hg or TBPI tension < 30 mm hg or TBPI

<30 mm hg denote severe ischemia.<30 mm hg denote severe ischemia. In severe Neuroischemic foot attempts to In severe Neuroischemic foot attempts to

improve vascular perfusion by angioplasty or improve vascular perfusion by angioplasty or bypass surgery should be done. bypass surgery should be done.

VASCULAR CONTROLVASCULAR CONTROL Aggressive debridement should be avoided Aggressive debridement should be avoided

when possible in patient with severe when possible in patient with severe ischemia.ischemia.

Infection should be treated very aggressively Infection should be treated very aggressively as it can have disastrous out come.as it can have disastrous out come.

Analgesic may be needed to relieve rest Analgesic may be needed to relieve rest pain.pain.

Larva therapy & hyper baric oLarva therapy & hyper baric o22 therapy may therapy may

be useful adjunctive treatment. be useful adjunctive treatment.

MICROBIOLOGICAL CONTROLMICROBIOLOGICAL CONTROL Infection occur in both neuropathic & neuro Infection occur in both neuropathic & neuro

ischemic foot frequently.ischemic foot frequently.Symptom & signs of infection are masked by Symptom & signs of infection are masked by

neuropathy.neuropathy.Patient may present with localized infected Patient may present with localized infected

ulcer, with surrounding erythema with diffuse ulcer, with surrounding erythema with diffuse spreading erythema ,with massive soft tissue spreading erythema ,with massive soft tissue infection with systemic features of toxemia infection with systemic features of toxemia shock.shock.

With severe infection only 50 % patient have With severe infection only 50 % patient have systemic features of fever & toxemia.systemic features of fever & toxemia.

MICROBIOLOGICAL CONTROLMICROBIOLOGICAL CONTROL85% of foot ulcers beings as clean wound detection 85% of foot ulcers beings as clean wound detection of early infection & adequate microbiological control of early infection & adequate microbiological control block road to amputation.block road to amputation.Osteomyelitis may be associated with any of the Osteomyelitis may be associated with any of the presentation & all cases with exposed bone, ability presentation & all cases with exposed bone, ability to probe to the bone, x-ray /MRF evidences of to probe to the bone, x-ray /MRF evidences of osteomyelitis ,should be treated as osteomyelitis.osteomyelitis ,should be treated as osteomyelitis.Most infection are polymicrobial in nature & culture Most infection are polymicrobial in nature & culture from deep tissue swab from deep curetting should from deep tissue swab from deep curetting should be obtained initially & then weekly if needed.be obtained initially & then weekly if needed.If soft tissue infection is responding well to If soft tissue infection is responding well to conservative treatment OM should be treated conservative treatment OM should be treated conservatively. conservatively. Most patient respond well to conservative Rx. Most patient respond well to conservative Rx.

ANTIBIOTICS FOR TREATING THE INFECTED FOOT

ANTIBIOTIC TREATMENT

ORALMICROORGANISM IV

STAPHYLOCOCCUS AUREUS

METHICILLIN-RESISTANT

STAPHYLOCOCCUS AUREUS(MRSA)

STREPTOCOCCUS

FLUCLOXACILLIN 500 MG QDS

SODIUM FUSIDATE 500 MG TDS

CLINDAMYCIN 300 MG TDS

RIFAMPICIN 300 MG TDS

SODIUM FUSIDATE 500 MG TDS

TRIMETHOPRIM 200 MG BD

RIFAMPICIN 300 MG TDS

DOXYCYCLINE 100 MG DAILY

LINEZOLID 600 MG BD

AMOXICILLIN 500 MG TDS

FLUCLOXACILLIN 500 MG QDS

CLINDAMYCIN 300 MG TDS

ERYTHRIMYCIN 500 MG QDS

FLUCLOXACILLIN 500 MG QDS

GENTAMICIN 5 MG/KG/DAY

(ACCORDING TO LEVELS)

CLINDAMYCIN 150-600 MG QDS

VANCOMYCIN 1 G BD

(ACCORDING TO LEVELS)

TEICOPLANIN 400MG DAILY

LINEZOLID 600 MG BD

AMOXICILLIN 500 MG TDS

VANCOMYCIN 1 G BD(ACCORDING TO LEVELS

ANTIBIOTICS FOR TREATING THE INFECTED FOOT

ANTIBIOTIC TREATMENT

MICROORGANISM ORAL IV

ENTEROCOCCUS

ANAEROBES

COLIFORMS(E.COLI, PROTEUS,KLEBSIELLA,ENTEROBACTER)

PSEUDOMONAS

AMOXICILLIN 500 MG TDS

METRONIDAZOLE 400 MG TDS

CLINDAMYCIN 300 MG TDS

CIPROFLOXACIN 500 MG BDCEFADOXIL 1 G BDRIMETHOPRIP 200 MG BD

CIPROFLOXACIN 500 MG BD

AMOXICILLIN 500 MG TDSVANCOMYCIN 1 G BD(ACCORDING TO LEVELS)METRONIDAZOLE 500 MG TDSCLINDAMYCIN 150-600 MG QDS

CIPROFLOXACIN 500 MG BDCEFTAZIDIME 1-2 G TDSCEFTRIAXONE1-2 G DAILYGENTAMICIN 5 MG/KG/DAY (ACCORDING TO LEVELS)PIPERACILLIN/CLAVULANATE 4.5 G TDSMEROPENEM 500 MG TO 1 G TDSTICARCILLIN/CLAVULANAT 3.2 G TDS

CEFTAZIDIME 1-2 G TDS.GENTAMICIN 5 MG/KG/DAY (ACCORDING TO LEVELS)PIPERACILLIN/CLAVULANATE 4.5 G TDSMEROPENEM 500 MG TO 1 G TDSTICARCILLIN/CLAVULANAT 3.2 G TDS

WOUND CONTROL WOUND CONTROL Good wound control can be achieves by :Good wound control can be achieves by :

1.1. T : tissue debritment may be surgical, T : tissue debritment may be surgical, chemical, enzymatic or biological.chemical, enzymatic or biological.

2.2. I : control of infection & inflamation & I : control of infection & inflamation & oedema.oedema.

3.3. M: Providing must environment to wound M: Providing must environment to wound using saline / hydrogel dressing.using saline / hydrogel dressing.

4.4. E : edge control. E : edge control.

WOUND CONTROLWOUND CONTROL all irritant chemicals & antibiotics damage all irritant chemicals & antibiotics damage

the granulating tissues and should be the granulating tissues and should be avoided.avoided.

various dressing materials used for diabetes various dressing materials used for diabetes foot wound include saline soaked gauze , foot wound include saline soaked gauze , foams ,hydrocolloids , hydrogels ,Alginates, foams ,hydrocolloids , hydrogels ,Alginates, hydrophilicfibre dressing.hydrophilicfibre dressing.

Advanced wound healing products includes Advanced wound healing products includes dermagraft ,apligraf,PDGF,promogran etc.dermagraft ,apligraf,PDGF,promogran etc.

Supplementary wound healing techniques Supplementary wound healing techniques includes skingraft ,VAC ,maggot therapy, includes skingraft ,VAC ,maggot therapy, hyperbaric oxygen. hyperbaric oxygen.

CASE STUDY WITH CASE STUDY WITH PLERMINPLERMIN

SURGICAL APPROACH TO SURGICAL APPROACH TO DIABETES FOOT CARE DIABETES FOOT CARE

Elective & prophylactic surgery for reducing ulcer risk Elective & prophylactic surgery for reducing ulcer risk in stage-1&2 patient include correction of hammer& in stage-1&2 patient include correction of hammer& claw toe. well osteotomy, metatarsal resection, claw toe. well osteotomy, metatarsal resection, cismoidectomy, Akilistendon lengthing, etc. may be cismoidectomy, Akilistendon lengthing, etc. may be considered when conservative treatment failed.considered when conservative treatment failed.

Risk of GA should be dually considered as pt. may Risk of GA should be dually considered as pt. may have cardiac & renal failure.have cardiac & renal failure.

SA & LA may be sufficient for elective procedure SA & LA may be sufficient for elective procedure emergency surgery for major amputation &urgent emergency surgery for major amputation &urgent IND may necessary in some patient. IND may necessary in some patient.

CONCLUSIONCONCLUSION

T : TIMELYT : TIMELY E : EFFECTIVEE : EFFECTIVE A : ACCURATEA : ACCURATE M : MANAGEMENTM : MANAGEMENT

The EndThe End

Thank youThank you