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Principles of management of diabetic foot lesions and its Prevention

Principles of management of diabetic foot lesions and its Prevention

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Principles of management of diabetic foot lesions and its Prevention

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  1. Principles of management of diabetic foot lesions and its Prevention Dr AK Verma Department of Endocrine Surgery Sanjay Gandhi Postgraduate Institute of Medical Sciences Lucknow

  2. Introduction • Foot lesions- 7% of people with Diabetes mellitus • Costly to- both patients and state • Factors delaying wound healing • Impaired wound healing in DM • Barrier to early referral and assessment • Amputations due to Peripheral vascular disease, Neuropathy and severe infection

  3. Introduction Cont. • Common in- Older patients and those with longer duration • Treatment options-limited, but coordinated care is needed • Infection- mostly secondary to ulcer • Nature and severity of infection varies • Of all amputations – 80% done in diabetics

  4. Predisposing factors • Old Age, Atherosclerosis • Long standing/ brittle diabetes, poor control • Associated disease states and immunosuppressive states • Post transplantation • Hypoproteinemia and prolonged diseases

  5. Causative factors • Foreign bodies • Improper nail pairing • Nail infections • Sensory and motor loss • Corns, callosities • Foot deformities • Trauma, burns • Bare foot walking and improper shoe wear

  6. Home Page[<< Prev] Image 11 of 186 [Next >>] Foreign body Last updated on 25 January 2000. This page is maintained by Department of PodiatryPlease send comments to Cameron Kippen © Department of Podiatry 2000

  7. Home Page[<< Prev] Image 90 of 186 [Next >>] Peripheral neuropathy Last updated on 25 January 2000. This page is maintained by Department of PodiatryPlease send comments to Cameron Kippen © Department of Podiatry 2000

  8. Home Page[<< Prev] Image 40 of 186 [Next >>] Fungal infection Last updated on 25 January 2000. This page is maintained by Department of PodiatryPlease send comments to Cameron Kippen © Department of Podiatry 2000

  9. Home Page[<< Prev] Image 26 of 186 [Next >>] Skin Corn Hard Last updated on 25 January 2000. This page is maintained by Department of PodiatryPlease send comments to Cameron Kippen © Department of Podiatry 2000

  10. Home Page[<< Prev] Image 25 of 186 [Next >>] Corn hard after shaving Last updated on 25 January 2000. This page is maintained by Department of PodiatryPlease send comments to Cameron Kippen © Department of Podiatry 2000

  11. Home Page[<< Prev] Image 35 of 186 [Next >>] Skin Fissure Last updated on 25 January 2000. This page is maintained by Department of PodiatryPlease send comments to Cameron Kippen © Department of Podiatry 2000

  12. Clinical presentation • Wide clinical spectrum • Localised cellulitis • Nonhealing ulcer • Ulcer with minimal discoloration • Gangrene of the toe/toes • Gangrene of forefoot/whole foot(dry/wet) • Deformities • Deformities with ulcerations

  13. Home Page[<< Prev] Image 124 of 186 [Next >>] Gangrene Last updated on 25 January 2000. This page is maintained by Department of PodiatryPlease send comments to Cameron Kippen © Department of Podiatry 2000

  14. Principles of management-1 A multidisciplany Approach • Resuscitation first, diagnosis later (biochemistry/haematology/radiology/microbiology) • General supportive measures -Correction of Anaemia/ hypoproteinemia/renal failure/dehydration -switching over to IV Insulin therapy -high calorie/protein diet -IV broadspectrum poly antimicrobial therapy( covering aerobes and anaerobes) -monitoring of polymicrobial infections by frequent microbial studies

  15. Principles of management-2 III. Local care Guiding principle: Limb saving attitude • Assesment of vascularity: Clinical: skin colour, temperature, hairs, nail colour and circulation, pulses. Poor pulse: best assessed by doppler A/B Index: N=0.8, if <0.5 chances of tissue survival is poor

  16. Home Page[<< Prev] Image 32 of 186 [Next >>] Doppler ultrasound Last updated on 25 January 2000. This page is maintained by Department of PodiatryPlease send comments to Cameron Kippen © Department of Podiatry 2000

  17. Principles of management-3 • Localisation of abscess Clinical, Ultrasound, CT/ MRI • Assessment of neuropathy touch, temperature, position and joint senses (cotton,blunt,pin, biosthesiometer) • Look for other diabetic complications renal, opthalmic, cardiac, neurologic etc

  18. Surgical management-1 • Guiding principle- Limb saving attitude • Minimum but adequate surgery • Quick/Emergency debridement under whatever anaesthesia possible • All dead and necrotic tissue must be removed • Don’t do primary closure • Frequent daily minor debridements are a must • Limb elevation if edematous

  19. Surgical management-2 • Open tendon sheaths liberally • Excise tendons if necessary • Explore all possible pus pockets • Institute double drainage for larger and deeper pus pockets • Have lots of patience • Frequent OT debridements may be required

  20. Revascularisation procedures • Angioplasty • Angioplasty with stenting • Arterial bypass • Insitu Saphenous vein bypass

  21. Role of orthotics • Pressure of loading-significance • Devices- • Casts • Insoles • Custom made shoes • Artificial limbs

  22. Newer aids for wound healing • Platelet derived growth factors( regranex) • Granulocyte stimulating factors(cGSF) • Electrical stimulation-magnetotherapy etc • Plantar pressure measurement and recording systems

  23. Prevention-I • An ounce of prevention is better than a pound of cure • Foot rehydration especially at night • Proper foot wear • Well fitting, pressure offloading,washable,soft, no shoe laces. • No bare foot walking • Socks-cotton, wash daily,wear reversed, change frequently

  24. Prevention-2 • Foot care • Examination at bed time: cut, abrasion, foreign body, redness, blister, callosity/corn and local rise of temperature at any point. Must be done by some one with good vision in good light • Pairing of nails • Interdigital web cleaning and examination, use of antiseptic powder

  25. Prevention-3 • Must examine shoe before wearing • Must be treated like a small newborn child • Foot examination should be a part of every clinical visit • Must contact the doctor at the slightest problem

  26. THANK YOU