Diabetic Foot - PowerPoint

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   Diagnosis and management

   Clarify the amplitude of the problem of
    diabetic foot
   Recognize the different patho-physiologic
    mechanisms leading to diabetic foot problems
   Clarify the overall management of different
    problems related to the diabetic foot
    Amplitude of the problem:
   Diabetes mellitus is a rather very common systemic
   12-15 million people are diabetics in the US.
   20% of these patients will be hospitalized at least once
    in their life time with foot problems
   Diabetic patients account for more than two thirds of
    patients undergoing non-traumatic limb amputation
   This will cost a BILLION dollars every year
Grunfeld et al



   One of the triad of the pathological conditions
    characteristic of this disease (neuropathy,
    nephropathy and retinopathy)
   Pathogenesis:
       Changes in the vasa nervosa

       Metabolic disorders with release of nerve
       toxic substance
Neuropathy affects:

   Motor Nerves resulting in:
      wasting of small muscles of the foot and   foot
      deformities (claw foot)
   Autonomic nerves resulting in:
        Dryness of the skin and loss of sweat and
    oil secretion which leads to excessive callus
    formation and skin cracks

        Loss of neurogenic component of
    inflammatory response which leads to plunting
    of inflammatory response and less severe signs
    of a severe infections
   Sensory nerves:
        sensory loss of superficial and deep
    sensation is the most important part of sensory

       Patients are unaware of trauma to the foot
    and usually result in pressure sores over
    weight bearing points of the foot
   Neuropathic arthropathy:
        Joints can be affected by neuropathy
    resulting in the so called Charcot foot
        It is relatively painless progressive
    degenerative arthropathy of single or multiple
        caused by loss of proprioceptive and pain
        leads to foot deformity and abnormal
    pressure points
     peripheral neuropathy:
 Sensory and autonomic neouropathy provides
 site of entry of organisms and blunt neurogenic
 immune response
     Metabolic state:
Hyperglycaemia an manifest protienurea causes
 a state of immuno-suppression
     Infection causes
increased metabolic and
oxygen demands of
tissues and inability to
meet with this demand
will increase tissue
damage and necrosis
   Microbiology:
        Usually in limb threatening diabetic foot
    infections there is polymicrobial bacterial
    infection with gram positive, gram negative,
    and anaerobic bacterial infection .
        sometimes with very severe life threatening
    infections fungus infection is also present
    Diabetes mellitus is an independent risk factor for
atherosclerosis (coronary, cerebral and peripheral)

     Usually atherosclerosis affects crural vessel (anterior
tibial, posterior tibial and peroneal) with sparing of
aortoiliac and femoral segments
     Ankle vessels runoff are usually patent (posterior
tibial and dorsalis pedis) ,but they may lead to a diseased
foot arches (distal vessel disease)

   Medial calcification affects all vessels but the vessels
remain patent in spite heavy calcification
   Clinical examination:
        Careful history taking and thorough general
    examination is essential
        Careful inspection and palpation of the
    foot lesion (look and feel in all aspects of the
    foot and between toes). Probing any foot ulcer
    or sinus to detect bone affection
        Palpation of peripheral pulses is essential
    to exclude ischaemia
 Imaging studies:
Plain X ray: it is the basic study in all patients with diabetic
  foot it can show: osteomylitis, bone fractures, joint
  dislocations, foreign bodies, gas due to gas forming
  infections, soft tissue inflammatory hypertrophy
MRI scan: very sensitive in detecting the extent of soft tissue
  infection and bone and joint involvement
Bone scan and radio-active labeled leukocyte scan are of low
  clinical importance
Pedobarography: computerized method to detect points of
  high pressure in patients with neuropathic ulcers
   Vascular studies:
        Ankle brachial pressure index (ABPI): is usually
    of no value in diabetic patients because of calcified
    pedal vessels toe pressure is usually used in diabetics
    (toe pressure of 30 mm gH indicates good
        Duplex scan: can be done to evaluate blood
    vessels in non limb threatening infections and in
    follow up
        Angiography: It is done when planning for
    vascular reconstruction in case of ischemic diabetic
        MRA: Is used in case of severe renal impairment
    and severe dye hypersensitivity which is not
    uncommon in diabetics
   Treatment of neuropathic ulcers:
Avoid pressure over the ulcer
    Non weight bearing using crutches, wheel chairs
    and sometimes applying slabs and casts. Wearing a
    specially designed shoes specially prepared by foot
    care persons
Topical applications on the ulcers
    trimming of the surrounding callus. Antibiotic
    ointments and gels. Applying saline soaked gauze
Proper treatment of infection and ischaemia if present
 Treatment of infection:
Severe limb threatening diabetic foot infection
  should be treated as an emergency. Some of
  theses infection will require major limb
  amputation or may turn to a life threatening
  infections if not treated properly

Treatment consists of:
    Surgical drainage and debridement
    Antibiotic therapy
    Care of general condition and blood sugar
   Antibiotic therapy:
        In limb threatening diabetic foot infections the
    patient should be hospitalized and IV antibiotics
    administered to reach an efficient plasma
        It should cover gram positive and negative
    bacteria and anaerobes as well
        It should be started as empiric treatment and
    soon be changed according to culture and
   Surgical drainage:
       It is the corner stone
    in treatment of
    diabetic foot infection.
    It should be done as
    soon as possible. It
    should aim at draining
    all pus pockets and
    debriding all infected
    tissues including bone
    and joints
Some hints:
1. Skin incision should be longitudinal and further
   than infected subcutaneous tissue which is
   further opened further than the deeper infected
   planes so no pockets will remain
2. Cartilage and cortical bone do not heal well and
   should be removed
3. Tendons are avascular and should be removed as
   hi as possible
4. Never attempt to close a diabetic foot infection
   wound the role is OPEN drainage
5.   When planning your
     incisions and
     amputations be aware
     that the sole of the
     foot will be covered
     by sole skin and any
     remaining ulcer will
     not be in a pressure
     point ( long posterior
     flaps )
6.   The best dressing is dressings which
     maintain a humid environment. Avoid irritant
     applications which are in common use like
     hydrogen peroxide
7.   Remaining row clean areas can be covered
     later by flabs or split thickness skin grafts
   Diabetic foot infection with ischaemia:
        Ischaemia with diabetic foot infection is
    diagnosed when there is inability to feel the
    pedal pulses
        It’s a dangerous condition which is usually
    a limb threatening and sometimes turn up to be
    a life threatening
        The patient should be referred to a vascular
    surgeon consultation as soon as possible
        Urgent vascular reconstruction may be
    needed for limb salvage
Any questions…….?
Tank you

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