Wounds: Diabetic foot

1. Wounds: Diabetic foot Key slides

2. Diabetic footNICE Clinical Guideline CG10 Type 2 Diabetes - Foot care 2004ABC Wound Healing:Diabetic Foot Ulcers BMJ 2006 332 407-410SIGN Clinical Guideline Management of Diabetes No 55 2001 ‘The diabetic foot may be defined as a group of syndromes in which neuropathy, ischaemia, and infection lead to tissue breakdown resulting in morbidity and possible amputation’ WHO 1995 • Peripheral neuropathy in feet leads to loss of sensation and autonomic dysfunction • Peripheral vascular disease in the form of atherosclerosis of the leg vessels causes loss of circulation (ischaemia which is often bilateral, multisegmental, and distal) • Infection often complicates neuropathy and ischaemia and is responsible for considerable damage in diabetic feet

3. Pathology of diabetic foot diseaseNICE Clinical Guideline CG10 Type 2 Diabetes - Foot care 2004CREST guidelines 1998 www.gain-ni.org/Guidelines/wound-management-diabetic-foot.pdf • Neuropathic foot • Warm • Numb • Dry • Usually painless • Palpable pulses • Neuropathic foot ulcers • Commonly resulting from callus • On weight-bearing areas • Punched out appearance • Neuro-ischaemic foot • Cool/cold to touch • Absent/diminished pulses • Pain at rest • Neuro-ischaemic foot ulcers • Commonly result from red mark caused by friction (e.g. tight shoe) • On non-weight-bearing areas of foot, toe tips & beneath toenails

4. General management approachNICE Clinical Guideline CG10 Type 2 Diabetes - Footcare 2004 • Effective care involves a partnership between patients and professionals and all decision-making should be shared • Arrange recall and annual review as part of ongoing care • As part of annual review, trained personnel should examine patients’ feet to detect risk factors for ulceration. • Examination of patients’ feet should include: • Testing of foot sensation using a 10g monofilament or vibration • Palpation of foot pulses • Inspection for any foot deformity and footwear • Classify foot risk as • At low current risk • At increased risk • At high risk • Ulcerated foot • If patient has had previous foot ulcer or deformity or skin changes manage as high risk

5. Care of people at low risk of foot ulcersNICE Clinical Guideline CG10 Type 2 Diabetes - Foot care 2004 • Low risk means: • Normal sensation and palpable pulses • No previous ulcer • No foot deformity • Normal vision • Agree a management plan including foot care education with each person: • Annual foot check • Patient’s can cut own nails with appropriate education • No specific chiropody input needed • Patient education: swelling, pain, colour change, breaks in skin

6. Care of people at increased risk of foot ulcersNICE Clinical Guideline CG10 Type 2 Diabetes - Foot care 2004 • Increased risk means: • Neuropathy or absent pulses • Previous vascular surgery • Significant visual impairment • Physical disability e.g. stroke, obesity • Arrange regular review: 3–6 monthly, by foot protection team • Patient education: swelling, pain, colour change, breaks in skin • At each review: • Inspect patient’s feet • Consider need for vascular assessment • Evaluate footwear • Enhance foot care education (high quality, cushioned trainers rather than shoes)

7. Care of people at high risk of foot ulcersNICE Clinical Guideline CG10 Type 2 Diabetes - Foot care 2004 • High risk means: • Neuropathy or absent pulses • Deformity • Callus with risk factor • Previous ulcer • Arrange frequent review: (1–3 monthly) foot protection team • Patient education: swelling, pain, colour change, breaks in skin • At each review: • Inspect patient’s feet • Consider need for vascular assessment • Evaluate and ensure the appropriate provision of • intensified foot care education/ specialist footwear and insoles/ skin and nail care • Ensure arrangements for access to foot protection team for those people with disabilities/ immobility.

8. Care of people with foot care emergencies and foot ulcersNICE Clinical Guideline CG10 Type 2 Diabetes - Foot care 2004 • Foot care emergency means: • New ulceration • Critical ischaemia • Swelling • Severe infection • New discolouration • Refer to multidisciplinary foot care team within 24 hours to: • Investigate and treat vascular insufficiency • Initiate and supervise wound management • Use dressings and debridement as indicated • Use systemic antibiotic therapy for cellulitis/bone infection • Ensure an effective means of distributing foot pressures • Try to achieve optimal glucose levels and control of risk factors for cardiovascular disease

9. Managing infection in the diabetic foot Clinical Knowledge Summaries Type 2 Diabetes 2008 • Infection presents a threat to the limb and should be treated promptly and aggressively • Foot care infections in patients with diabetes are classified as non-limb threatening (urgent referral to a multidisciplinary diabetes foot care team within 24 hours) or limb-threatening (usually require hospital admission) • Infected diabetic feet should only be treated by clinicians who have sufficient experience and facilities available • A non-limb threatening infection can quickly become limb threatening

10. Managing infection in the diabetic foot Clinical Knowledge Summaries Type 2 Diabetes 2008 Non - limb threatening Infection - refer within 24 hours • Includes those with infection of a superficial ulcer, no bone or joint involvement, no signs or symptoms of systemic toxicity, no significant ischaemia • If referral within 24 hours is not possible, start empiric antibiotic treatment in interim. • If deeper infection, seek urgent advice • Review after 7 days • Swabs should be taken before starting antibiotics Limb threatening infection - consider hospital admission • Includes those with spreading cellulitis, systemic signs of infection, lack of response to oral antibiotics, malodorous wounds, soft tissue necrosis or suspected bone involvement

11. Who should be referred? Clinical Knowledge Summaries Type 2 Diabetes 2008 Refer the following to a multidisciplinary team within 24 hours: • New ulceration (wound) • New swelling • New discoloration (redder, bluer, paler, blacker, over all or part of the foot) • Signs or symptoms of infection (redness, pain, swelling, or discharge) • Deep ulcer — hospital admission may be more appropriate, clinical judgement is required

12. Who should be referred? Clinical Knowledge Summaries Type 2 Diabetes 2008 Hospital admission is usually needed if any of the following are present: • Pink or pale, painful, pulseless foot (indicating critical ischaemia). • Clinical judgement is required as some less severe, chronic cases of peripheral vascular disease where pulses are present but reduced, could be managed in a multidisciplinary clinic • Spreading cellulitis, lymphangitis • Crepitus • Systemic symptoms of infection • Lack of response of infection to oral antibiotics • Suspicion of bone involvement (osteomyelitis) • Immunocompromised or physiological instability

13. Diabetic footNICE Clinical Guideline CG10 Type 2 Diabetes - Foot care 2004 Clinical Knowledge Summaries Type 2 Diabetes 2008SIGN Clinical Guideline Management of Diabetes No 55 2001 • Diabetic foot problems are a common complication of diabetes with prevalence of 20 - 40% for neuropathic causes and 20 - 40% for vascular disease causes also, with 5 - 7% leading to foot ulceration in any one year. • Many causes of diabetic foot ulcers are avoidable • Diabetic foot is the main cause of non-traumatic amputations • Access to a podiatrist reduces the number and size of foot calluses and improves self-care • Much of the evidence supports a multidisciplinary team approach to management with recall and review • Good patient foot care education may prevent diabetic foot ulcers • Frequent assessment and reassessment is paramount to include history, skin assessment, vascular assessment, neurological assessment, foot deformity, nail infections, musculoskeletal assessment and footwear examination