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
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
1.
2.
3.
4.
5.
6.
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
1.
2.
3.
4.
5.
6.
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
STAPHYLOCOCCUS AUREUS
ORAL
FLUCLOXACILLIN 500 MG QDS
SODIUM FUSIDATE 500 MG TDS
CLINDAMYCIN 300 MG TDS
IV
FLUCLOXACILLIN 500 MG QDS
GENTAMICIN 5 MG/KG/DAY
(ACCORDING TO LEVELS)
RIFAMPICIN 300 MG TDS
CLINDAMYCIN 150-600 MG QDS
METHICILLIN-RESISTANT
STAPHYLOCOCCUS
AUREUS(MRSA)
STREPTOCOCCUS
SODIUM FUSIDATE 500 MG TDS
TRIMETHOPRIM 200 MG BD
VANCOMYCIN 1 G BD
RIFAMPICIN 300 MG TDS
(ACCORDING TO LEVELS)
DOXYCYCLINE 100 MG DAILY
TEICOPLANIN 400MG DAILY
LINEZOLID 600 MG BD
LINEZOLID 600 MG BD
AMOXICILLIN 500 MG TDS
AMOXICILLIN 500 MG TDS
FLUCLOXACILLIN 500 MG QDS
CLINDAMYCIN 300 MG TDS
ERYTHRIMYCIN 500 MG QDS
VANCOMYCIN 1 G BD
(ACCORDING TO LEVELS
ANTIBIOTICS FOR TREATING THE INFECTED FOOT
ANTIBIOTIC TREATMENT
MICROORGANISM
ORAL
ENTEROCOCCUS
AMOXICILLIN 500 MG TDS
ANAEROBES
METRONIDAZOLE 400 MG TDS
CLINDAMYCIN 300 MG TDS
COLIFORMS(E.COLI,
PROTEUS,KLEBSIELLA,ENT
EROBACTER)
PSEUDOMONAS
CIPROFLOXACIN 500 MG BD
CEFADOXIL 1 G BD
RIMETHOPRIP 200 MG BD
CIPROFLOXACIN 500 MG BD
IV
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
(ACCORDING TO LEVELS)
PIPERACILLIN/CLAVULANATE 4.5 G
TDS
MEROPENEM 500 MG TO 1 G TDS
TICARCILLIN/CLAVULANAT 3.2 G TDS
CEFTAZIDIME 1-2 G TDS.
GENTAMICIN 5 MG/KG/DAY
(ACCORDING TO LEVELS)
PIPERACILLIN/CLAVULANATE 4.5 G
TDS
MEROPENEM 500 MG TO 1 G TDS
TICARCILLIN/CLAVULANAT 3.2 G TDS
WOUND CONTROL
Good wound control can be achieves by :
1. T : tissue debritment may be surgical,
chemical, enzymatic or biological.
2. I : control of infection & inflamation &
oedema.
3. M: Providing must environment to wound
using saline / hydrogel dressing.
4. 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
The End
Thank you