DIABETES FOOT MANAGMENT TEAMWORK By.Dr.J.L.Shah M.D. (Medicine) Physician & Diabetologist Sonal Hospital &Diabetes Clinic Khand Bazar,Lalgate,Surat.

PUT FEET FIRST PREVENT AMPUTATIONS

BURDEN & MAGNITUDE 60 million feet at risk. 25% of Diabetes Patient Experience foot Problem in their lifetime. Risk of Amputation 40 times high Compared to Non Diabetics. 75% of all lower limb Amputation are Performed in Diabetics. Every 30 sec one Diabetic looses his/her toes / foot / limb in the world. Prolong Hospitalization & high Cost of Treatment.

STAGES IN DIABETIC FOOT Healthy foot. High Risk foot. Ulcerated foot. Infected foot. Necrotic foot. Un salvageable foot

MANAGEMENT Multi disciplinary approach to save maximum number of limbs. Proper timely & adequate management coupled with foot care education can save 80-85 % Amputation. High sensitivity to the senseless foot of patient is needed by the health care provider.

COMPONENTS OF MANAGEMENT Metabolic Control Mechanical Control Educational Control Vascular Control Microbiological Control Wound Control

METABOLIC CONTROL In all stages tight Glycemic control is important. Hyperglycemia is important Risk factor for development of neuropathy & Occlusive Vascular disease. Hyperglycemia in Ulcerated foot reduces fibroblast proliferation & growth factor impairs protease activity & Hence retard ulcer healing. Hyperglycemia reduces Chemo taxis & Phagocytosis & Humoral antibodies. Tissueglucose is good media for bacterial Proliferation so, for microbiological control in infected ulcer Glycemic control is essential. Tight Glycemic control in infected Patient should be achieved by insulin infusion followed by SC MDI Regime.

METABOLIC CONTROL Besides Hyper Glycemic Control of BP, Dyslipidemia & Cessations of Smoking is required. For BP Control in Patient with Neuroischemic foot  blocker Should be used with Caution Statins & fibrate are effective & safe in Controlling Dyslipidemia. All Patient need antiplatelate Therapy & DVT Prophylaxis with LMWH in Patient needing Prolonged bed rest. Many Patient have associated Renal & Cardiac Failure requiring Proper adjustment in drug dosage.

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

MECHANICAL CONTROL Neuroischemic ulcers also Respond well to off loading. In severely infected foot non weight barring is desirable with use of crutches wheelchair or zimer’s frame. TCC is gold standard for off loading with healing rate as high as 80% but is costly cumbersome & associated with some complication Removable cast walkers therapeutics shoes, half shoe ,PRAFO are the other modality of off loading in ambulatory patient. Healing is directly proportional to impulse loading.

HEALING OF NEUROPATHIC ULCER USING CUSTOMISED AFO Study of 10 patient presented in NNDU 2004 at Singapore. 10 patient with 13 weeks neuropathic ulcer (wagnergrade-1) were studied using off loading with Customize AFO. All Patient healed within 6 week time.

EDUCATIONAL CONTROL Routine foot care for all diabetics. Prophylactic diabetes foot ware & trauma Prevention education to high risk patient. Education regarding early sign of infection & Immediate reporting . Non weight bearing & off loading in Ulcerated and infected foot. Rehabilitation & Psycho-social support in patient with major Amputation .

VASCULAR CONTROL Vascular assessment with ABPI & transcutaneous o2 tension as marker, is essential in all diabetic patient. ABPI < 0.5, o2 tension < 30 mm hg or TBPI <30 mm hg denote severe ischemia. In severe Neuroischemic foot attempts to improve vascular perfusion by angioplasty or bypass surgery should be done.

VASCULAR CONTROL Aggressive debridement should be avoided when possible in patient with severe ischemia. Infection should be treated very aggressively as it can have disastrous out come. Analgesic may be needed to relieve rest pain. Larva therapy & hyper baric o2 therapy may be useful adjunctive treatment.

MICROBIOLOGICAL CONTROL Infection occur in both neuropathic & neuro ischemic foot frequently. Symptom & signs of infection are masked by neuropathy. Patient may present with localized infected ulcer, with surrounding erythema with diffuse spreading erythema ,with massive soft tissue infection with systemic features of toxemia shock. With severe infection only 50 % patient have systemic features of fever & toxemia.

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

ANTIBIOTICS FOR TREATING THE INFECTED FOOT ANTIBIOTIC TREATMENT MICROORGANISM ORAL 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 TRIMETHOPRIM 200 MG BD DOXYCYCLINE 100 MG DAILY LINEZOLID 600 MG BD AMOXICILLIN 500 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 TEICOPLANIN 400MG DAILY LINEZOLID 600 MG BD AMOXICILLIN 500 MG TDS (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 BD CEFADOXIL 1 G BD RIMETHOPRIP 200 MG BD AMOXICILLIN 500 MG TDS VANCOMYCIN 1 G BD (ACCORDING TO LEVELS) METRONIDAZOLE 500 MG TDS CLINDAMYCIN 150-600 MG QDS CIPROFLOXACIN 500 MG BD CEFTAZIDIME 1-2 G TDS CEFTRIAXONE1-2 G DAILY GENTAMICIN 5 MG/KG/DAY PIPERACILLIN/CLAVULANATE 4.5 G TDS MEROPENEM 500 MG TO 1 G TDS TICARCILLIN/CLAVULANAT 3.2 G TDS CEFTAZIDIME 1-2 G TDS.

WOUND CONTROL Good wound control can be achieves by : T : tissue debritment may be surgical, chemical, enzymatic or biological. I : control of infection & inflamation & oedema. M: Providing must environment to wound using saline / hydrogel dressing. E : edge control.

WOUND CONTROL all irritant chemicals & antibiotics damage the granulating tissues and should be avoided. various dressing materials used for diabetes foot wound include saline soaked gauze , foams ,hydrocolloids , hydrogels ,Alginates, hydrophilicfibre dressing. Advanced wound healing products includes dermagraft ,apligraf,PDGF,promogran etc. Supplementary wound healing techniques includes skingraft ,VAC ,maggot therapy, hyperbaric oxygen.

CASE STUDY WITH PLERMIN

SURGICAL APPROACH TO DIABETES FOOT CARE Elective & prophylactic surgery for reducing ulcer risk in stage-1&2 patient include correction of hammer& claw toe. well osteotomy, metatarsal resection, cismoidectomy, Akilistendon lengthing, etc. may be considered when conservative treatment failed. Risk of GA should be dually considered as pt. may have cardiac & renal failure. SA & LA may be sufficient for elective procedure emergency surgery for major amputation &urgent IND may necessary in some patient.

CONCLUSION T : TIMELY E : EFFECTIVE A : ACCURATE M : MANAGEMENT

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