Diabetic foot

Views:
 
Category: Education
     
 

Presentation Description

Foot, infections are very common in diabetic patients. These lessions are management chalange for the clinicians.

Comments

Presentation Transcript

PREVENTION OF DIABETIC FOOT COMPLICATIONS :

PREVENTION OF DIABETIC FOOT COMPLICATIONS Dr. Shahzad Alam Shah MBBS;FCPS Assistant Professor of Laparoscopic Surgery Fatima Jinnah Medical College/ Sir Ganga Ram Hospital Lahore

Diabetic Foot ?:

Diabetic Foot ?

Diabetic Foot Presentatations:

Diabetic Foot Presentatations Callus Formation Pre-ulceration Ulceration Ischemia Infection Gangrene Deformities

FOOT ULCERS IN DIABETES:

FOOT ULCERS IN DIABETES Precipitate 85% of amputations: “Rule of 15” 15% of diabetes patients Foot ulcer in lifetime 15% of foot ulcers Osteomyelitis 15% of foot ulcers Amputation Clinical Care of the Diabetic Foot , 2005

AMPUTATIONS IN DIABETES:

AMPUTATIONS IN DIABETES Tragic: “Rule of 50” 50% of amputations transfemoral/transtibial level 50% of patients 2 nd amputation in  5y 50% of patients Die in  5y Clinical Care of the Diabetic Foot , 2005

Slide6:

Sensory  Joint Motor Autonomic PAD Neuropathy Mobility Neuropathy Neuropathy Protective Muscle atrophy and  Sweating Ischemia sensation 2 ° foot deformities 2° dry skin Foot pressure  Foot pressure Fissure  Healing Minor trauma esp. over recognition bony prominences Callus Pre-ulcer ULCER Infection AMPUTATION Minor Trauma: Interdigital Maceration Mechanical (Moisture, Fungus) Chemical Thermal PATHOGENESIS OF DIABETIC FOOT ULCER AND AMPUTATION

OTHER RISKS FOR DIABETIC FOOT ULCER/AMPUTATION:

OTHER RISKS FOR DIABETIC FOOT ULCER/AMPUTATION Failure to adequately care for the feet: Inadequate patient education Inadequate patient motivation Depression, anxiety, anger more common in diabetes Physical disability Cannot see feet 2  to retinopathy Cannot reach feet 2 to obesity, age (?50% of patients) Limited access to podiatry services

CAUSAL PATHWAYS FOR FOOT ULCERS:

CAUSAL PATHWAYS FOR FOOT ULCERS % Causal Pathways NEUROPATHY Neuropathy: 78%  Minor trauma: 79% DEFORMITY Deformity: 63%  Behavioral issues ? MINOR TRAUMA - Mechanical ( shoes ) POOR SELF- - Thermal FOOT CARE - Chemical ULCER Diabetes Care 1999; 22:157

DETECTING FEET-AT-RISK:

DETECTING FEET-AT-RISK History : Prior amputation Prior foot ulcer PAD: known or claudication at < 1 block Exam : Major foot deformities PAD Absent DP and PT pulses Prolonged venous filling time Reduced Ankle-Brachial Index (ABI) Pre-ulcerative cutaneous pathology Arch Intern Med 1998; 158:157

PHYSICAL EXAMINATION OF THE FEET IN PERSONS WITH DIABETES:

PHYSICAL EXAMINATION OF THE FEET IN PERSONS WITH DIABETES

SENSORY NEUROPATHY IN DIABETES:

SENSORY NEUROPATHY IN DIABETES Loss of protective sensation in feet Sensory loss sufficient to allow painless skin injury Major risk factor for foot ulcer in diabetes Detect with 5.07/10g Semmes-Weinstein monofilament Prevalence of insensate feet to 10g monofilament: Age > 40y: 30% of diabetic patients Age > 60y: 50% of diabetic patients Up to 50% have no neuropathic symptoms Diabetes Care 2006; 29(Suppl 1):S24 Diabetes Care 2004; 27:1591

PAD IN DIABETES:

PAD IN DIABETES Prevalence (ABI < 0.9): 20-30% 10-20% in type 2 diabetes at Dx 30% in diabetics  age 50y 40-60% in diabetics with foot ulcer Complications : Claudication and functional disability Increases risk for concurrent CAD and CVD Delays ulcer healing Increases amputation risk Not increase foot ulcer risk

EXAM TO DETECT PAD IN DIABETES:

EXAM TO DETECT PAD IN DIABETES Venous filling time Technique: Sitting: ID pedal vein bulging above skin Supine: Elevate leg to 45 ° for 1 min Sitting:  time to pedal vein bulging above skin

Slide15:

EXAM TO DETECT PAD IN DIABETES Ankle Brachial Index

INTERPRETATION OF THE ABI:

INTERPRETATION OF THE ABI ABI Normal 0.91-1.30 Mild obstruction 0.71-0.90 *Moderate obstruction 0.41-0.70 *Severe obstruction  0.40 **Poorly compressible >1.30 2 ° to medial Ca ++ *Poor ulcer healing with ABI  0.50 **Further vascular evaluation needed

MOTOR NEUROPATHY AND FOOT DEFORMITIES:

MOTOR NEUROPATHY AND FOOT DEFORMITIES Hammer toes Claw toes Prominent metatarsal heads Hallux valgus Collapsed plantar arch

Slide18:

From Levin and Pfeifer, The Uncomplicated Guide to Diabetes Complications , 2002 Hammer Toes Claw Toes

Slide19:

From Levin and Pfeifer, The Uncomplicated Guide to Diabetes Complications , 2002 Hallux Valgus

Slide20:

From Boulton, et al Diabetic Medicine 1998, 15:508

PRE-ULCER CUTANEOUS PATHOLOGY:

PRE-ULCER CUTANEOUS PATHOLOGY Neuropathy  inappropriate footwear: Persistent erythema after shoe removal Callus Callus with subcutaneous hemorrhage: “pre-ulcer” Autonomic neuropathy and secondary dry skin: Fissure  ulceration Augment callus formation Poor self-care of the feet: Interdigital maceration with fungal infection Nail pathology

RISK-STRATIFIED FOOTCARE MANAGEMENT FOR DIABETES PATIENTS:

RISK-STRATIFIED FOOTCARE MANAGEMENT FOR DIABETES PATIENTS

HIGH RISK: CATEGORY 1-3 PATIENTS:

HIGH RISK: CATEGORY 1-3 PATIENTS Annual comprehensive foot exam Inspect feet at every visit Podiatry care Intensive patient education Detect/manage barriers to foot care Therapeutic footwear, if needed

BASIC FOOT CARE CONCEPTS:

BASIC FOOT CARE CONCEPTS Daily foot inspection May require mirror, magnification, or caregiver Educate patient to recognize/report ASAP: Persistent erythema Enlarging callus Pre-ulcer (callus with hemorrhage)

BASIC FOOT CARE CONCEPTS:

BASIC FOOT CARE CONCEPTS Commitment to self-care: Wash/dry daily Avoid hot water; dry thoroughly between toes Lubricate daily (not between toes) Debride callus/corn to reduce plantar pressure 25% Avoid sharp instruments, corn plasters No self-cutting of nails if: Neuropathy, PAD, poor vision

BASIC FOOT CARE CONCEPTS:

BASIC FOOT CARE CONCEPTS Protective behaviors: Avoid temperature extremes No walking barefoot/ stocking - footed Appropriate exercise if sensory neuropathy Bicycle/swim > walking/treadmill Inspect shoes for foreign objects Optimal footwear at all times

THERAPEUTIC FOOTWEAR: GOALS:

THERAPEUTIC FOOTWEAR: GOALS Inappropriate footwear: Contributes to 21-76% of ulcers/amputations Optimal footwear should: Protect feet from external injury Reduce plantar pressure, shock and shear forces Accommodate, stabilize, support deformities Suitable for occupation, home, leisure Diabetes Care 2004; 27:1832 Diab Metab Res Rev 2004; 20(Suppl1):S51

Slide48:

Dr. Shahzad Alam Shah MBBS;FCPS Assistant Professor of Laparoscopic Surgery Fatima Jinnah Medical College/ Sir Ganga Ram Hospital Lahore Thanks

authorStream Live Help