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Treatment of Diabetic Ulcers:

Treatment of Diabetic Ulcers: . Guiding Principle The primary treatment goal for diabetic foot ulcers is to obtain wound closure as expeditiously as possible. No relevant disclosures. Debbie Christensen RN CWOCN Manager Wound and Ostomy Department Sacred Heart Medical Center

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Treatment of Diabetic Ulcers:

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  1. Treatment of Diabetic Ulcers: Guiding Principle The primary treatment goal for diabetic foot ulcers is to obtain wound closure as expeditiously as possible.

  2. No relevant disclosures

  3. Debbie Christensen RN CWOCN Manager Wound and Ostomy Department Sacred Heart Medical Center dchristensen@peacehealth.org Office phone 541-222-2560

  4. The urgency to close DFU’s • 10 year prospective study of patients over 65, a neuropathic ulcer was predictive for a 45% mortality rate over 5 years.1 • Three most common factors leading to limb amputation: • Gangrene, infection, non-healing wound4 • Iversen, Tell, Riise, et al 2009 • Rogers, L. 2010

  5. Standard Treatment Fails to Heal DFU’s Standard treatment: • Wound Bed preparation: Debridement • Infection Control • Revascularization • Off Loading Only 25% of patients who received this standard treatment healed by 16 weeks.5,6 5. Steed and colleagues J AM CollSurg 1996 Multicenter randomized 6. Margolis and colleagues, Diabetes Care 1992 Meta-analysis

  6. A systematic review of literature revealed that between 30% - 40% of patients were not being treated according to current evidence.2 • A 2010 consensus panel identified that 20-30% of the care provided was inappropriate or dangerous.3 • Schuster and colleagues • Snyder, Kirsner and colleagues 2010 Consensus Report

  7. Evidence Based DFU Treatment Guidelines abound Association for the Advancement of Wound Care American College of Foot and Ankle Surgeons American Diabetes Association American Orthopedic Foot and Ankle Society Wound Ostomy Continence Nurses Society Wound Healing Society

  8. Guidlelines • Provide a standard framework for assessment and diagnosis. • Establish best practice standards for basic wound care interventions and expected progress. • Provide guidance for evidence based use of advanced wound therapies. • Provide a reference from which to measure outcomes.

  9. Medical Management Glucose Control: HbA1c. <7%. Neurologic Testing: Monofilament 5.07 Vascular Assessment Edema Management: Elevation vs. compression Nutrition: Diabetic education, Pre-albumin Social barriers: Living situation, lack of family support, financial Patient beliefs and motivation: Motivational interviewing8 8. CARL J. POSSIDENTE, and colleagues Am J Health-Syst Pharm. 2005

  10. Wound Assessment Measure the wound: Length x width x depth Consistency is key to tracking progress Probe to Bone Controversy8,9 Use appropriate size probe for the wound Can identify underlying foci of indolent infection in otherwise healthy appearing wound Wound tissue and Infection Healthy tissue is pink with advancing, adherent edge. Friable, dark tissue with undermined edges is not. 8.Lavery, et al Diabetes Care 2007 9. Grayson and colleagues, JAMA 1995

  11. Basic Standard Wound Care Off load : If the offloading device can be removed it will be Caution in use of wheel chairs and crutches9 Debridement Reduces bacterial bioburden, reduces infection Converts wound to an active, proliferative state. Suggested weekly and as needed5 Surgical and Sharp recommended. Enzyme: Santyl the only one still on market. Manage /Rule Out Infection Provide Moist Wound healing 9. Orsted and colleagues, WoundCare 2007 5. Steed and Colleagues Regranex study, numerous other studies

  12. Basic Standard Wound Care: Moist Wound Healing Goals: Maintain a moist wound surface Minimizes trauma to the wound tissue Minimize risk of infection Manage drainage to preserve peri-wound skin. 50% Reduction in wound size at 4 weeks Dressing selection should be based on choosing the most cost effective dressing which meets wound needs9 • Orsted and colleagues, WoundCare 2007

  13. Basic Standard Wound Care: Moist Wound Healing Cleanse with noncytotoxic cleansers10 Saline, clean water, wound cleansers, surfactants Wound gels and pastes: Amorphous wound gel, Cadexomer Iodine wound paste, Manuka honey Wound Fillers: Gauze, Calcium alginate, collagen Cover dressings: Gauze, foam , hydrocolloids, composite dressings, film dressing, silver impregnated dressings 10. WOCN guideline2004

  14. Home or Skilled Care Wound Supplies • Most Insurers cover primary and secondary dressings. • Coverage requires a complete prescription • Wound dimensions, date of assessment, supplies and frequency of change. • Limit number of dressing prescribed to accommodate for revised dressing needs as the wound changes. • Nursing Facilities and Home Health organizations are on strict formularies and need wound care orders written in generic terms. i.e. • Adhesive foam dressing vs. propriatary Allevyn, Hydrasorb , Polymem • Hydrocolloid • Calcium alginate

  15. Reassess wounds regularly • Frequency based on needs of the wound and the patient. • Failure to achieve 50% reduction in size over 4 weeks indicates need to reevaluate; • Patient comorbidities • Offloading • Adequacy of debridement and wound care If goals have been met in these areas consider use of advanced wound therapies. 3,13,14, 3. Snyder, Kirsner, et al, 13. Bolton, et al N Engl J Med. 2004 14.Sheehan and colleagues, Diabetes Care 2003

  16. Advanced Wound Therapies It is the basic care which prepares the wound for advanced therapies. Skip the basics and it will not make a difference what advanced therapies you use.7 • Frykberg, Wounds 2010

  17. Advanced Therapies Negative Pressure Therapy Kalypto, Svedman, Renasys, VAC Manage drainage, enhance wound contraction and angiogenasis Extracellular Matrix products Oasis, Integra, GRAFTJACKET regenerative tissue matrix, Provide a scaffold for tissue in growth and cellular migration Cellular Based Tissue Technologies Apligraf, Dermagraftt. Both have FDA approval15, 16 Provide growth factors to the wound to stimulate healing Hyperbarics

  18. Other Advanced Therapies • Platelet Rich Plasma • Ultrasonic spray (MIST, Celleration) • Electrical stimulation • Super oxidized water ( Dermacyn)

  19. Advanced Wound Therapies By using a combination of these advanced therapeutic products based on their supporting clinical science and evidence we should be able to improve DFU healing. Advanced Therapies of course come at an advanced cost. A number have a favorable reimbursement which drives use. Remember Bercaplamin….

  20. The Reality of Diabetic Ulcer Healing At the end you get back: A diabetic patient, With a Neuropathic foot, Who has a very expensive layer of skin over scar tissue. So what comes next?

  21. Managing ComorbiditiesLifestyle/Psychosocial Factors Patient Compliance • Patient Centered Plan of Care • The wound belongs to the patient and he must be an active participant in the plan to heal it. • Motivational interviewing/Motivational Enhancement • Discovering the barriers the patient perceives and assisting him to discover his own solutions may result in improved compliance. CARL J. POSSIDENTE, KATHRYN K. BUCCI, AND WALTER J. MCCLAIN Am J Health-Syst Pharm. 2005

  22. References • Iversen, Tell, Riise, et al. History of foot ulcer increases mortality among individuals with diabetes: Norway. Diabetes Care. 2009 • Schuster, McGlynn, Brook. How good is the quality of care in the United States? Milbank U1998 • Snyder, Kirsner, et al; Consensus Recommendations on Advancing the Standard of Care for Neuropathic foot Ulcer in Patients with Diabetes. 2010 http://www.o-wm.com/files/docs/ABH_WOUNDS.pdf • Rogers, L. Key concepts from the 2010 consensus statement. Wounds 2010 • Steed, Donohoe, Webster. Effect of extensive debridement and treatment on the healing of diabetic foot ulcers J AM Coll Surg 1996 • Margolis, Cantor, Berlin. Healing of neuropathic ulcers receiving standard treament: a meta-analysis. Diabetes Care 1992 • Frykenberg, Robert G. The science of advanced wound care: What should you be using in your office. Wounds 2010 • Lavery, Armstrong, Wunderlich, et al. Risk factors for foot infection in individuals with diabetes.. Diabetes Care 2007

  23. Grayson, Gibbons, Balogh, et al. Probing to bone in infected pedal ulcers. A clinical sign of underlying osteomyelitis, JAMA 1995 • CARL J. POSSIDENTE, KATHRYN K. BUCCI, AND WALTER J. MCCLAIN Am J Health-Syst Pharm. 2005 • Orsted, Searles, Trowell, et al. Best Practice Recommendation for the Prevention, Diagnosis, and Treatment of Diabetic Foot Ulcers: Update 2006 Adv Skin Wound Care 2007 • WOCN Society, Guideline for Management of Wounds in Patients with Lower-Extremity Neuropathic Disease • Bolton, Kirsner,Vileikyte. Clinical practice. Neuropathic diabetic foot ulcers . N Engl J Med. 2004 • Sheehan, Casell,, et al Percent change in wound area of diabeticfoot ulcers over a 4-week period is a robust predictor of complete helng in a 12-week prospective trial. Diabetes Care 2003 • Cavorsi, Vicari, Wirthin, et al Best-pratice algorithms for the use of bilayered living cell therapy…Wound Repair Regen. 2006 • Veves, Flanga, armstrong, et al. Graftskin, a human skin equivilent, is effective in management of noninfected neuropathic diabetic foot ulcer. Diabetes Care 2001

  24. Resources Patient Motivation • Patient-Centered Communication: Core Skills for Motivation and Change Activity Expires: 12-01-2011 http://www.impactedu.net/index.htm • Motivational Enhancement Therapy (article) http://trilogy200.respironics.com/pdf/1045805_MtvlEnhcmtTherp_Monograph.pdf • Motivational interviewing ( article) http://apps.pharmacy.wisc.edu/psw/MIArticle2.pdf • Smoking Cessation Resource link http://www.medicinenet.com/weight_control_and_smoking_cessation/eugene-or_city.htm • Diabetic Nutrition Education http://www.peacehealth.org/apps/course/CDetails.asp?CourseID=19 http://www.oregonmedicalgroup.com/index.cfm?fuseaction=site.content&type=aafphand&destination=/online/famdocen/home/common/diabetes/living/349.membersite.membersite.html

  25. Wagner and University of Texas Grading Scales for Diabetic Foot Ulcers http://www.medicalcriteria.com/site/index.php?option=com_content&view=article&id=114%3Adbtfoot&catid=49%3Adiabetes&Itemid=80&lang=en

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