diabetes mellitus and wound healing-small
TRANSCRIPT
-
8/6/2019 Diabetes Mellitus and Wound Healing-SMALL
1/42
..
)) --8585.(.(
-
8/6/2019 Diabetes Mellitus and Wound Healing-SMALL
2/42
Diabetes mellitusand wound healing
-
8/6/2019 Diabetes Mellitus and Wound Healing-SMALL
3/42
Wound healing is impaired indiabetics due to many
mechanisms:1)Blood sugar impairing blood flow and the
release of oxygen.
2)Protein malnutrition with decreasedcollagen synthesis d.t.frequency of chronicillness and poor nutrition.
3)Impaired local immune & cell defences.
4)Anabolic activity with insulin and
growth hormone.
-
8/6/2019 Diabetes Mellitus and Wound Healing-SMALL
4/42
5)Neutrophil function involving bactericidalability,phagocytosis and chemotaxis may beaffected.
6)Relative tissue hypoxia in wounds due tovascular problems.
7)Retinopathy impaired vision delay
patient awareness,reporting and care ofwounds.
8)Nephropathy foot pressure andulceration.
-
8/6/2019 Diabetes Mellitus and Wound Healing-SMALL
5/42
9)Hyperglycemia causes defective phagocy-tosis & migration of cells important in the
inflammatory response.
10)Dysfunction of fibroblasts when glucose isunavailable impaired collagen depositionand endothelialproliferation.
11)Vasodilatationof the microcirculationmaynotoccurasaresponse toinjury.
-
8/6/2019 Diabetes Mellitus and Wound Healing-SMALL
6/42
Diabetic footisthe mostcommoncauseof non traumatic L.L amputation.
The riskof L.L. amputationis 15 to 46timeshigherindiabeticsthannondiabetics.
25%of alldiabeticadmissionsare due tofootcomplications.
85%of amputation indiabeticulcercanbe prevented by early detection&
appropriate treatment.
-
8/6/2019 Diabetes Mellitus and Wound Healing-SMALL
7/42
-
8/6/2019 Diabetes Mellitus and Wound Healing-SMALL
8/42
Carefulinspectionof the diabetic foot
onaregular basis isan easy ,cheapand effective measure topreventfoot complications.
Familyphysicianshave anintegralrole to ensure thatdiabeticsreceive
earlyandoptimalcare.
-
8/6/2019 Diabetes Mellitus and Wound Healing-SMALL
9/42
Risk factors for L.L.amputation
in diabetic foot
I. Peripheral arterial occlusive
disease: 4 times more prevalent in diabetics
than non diabetics.
Typically involves the tibial and peroneal arteries but spares thedorsalis pedis artery.
-
8/6/2019 Diabetes Mellitus and Wound Healing-SMALL
10/42
Symptomsandsigns:Claudication,restpain inthe archat
night,absenthair,thinnedorshinyskin,thickenednail,rednessof the legondependencyandpallor on elevation.
N.B)
Inactivityandneuropathymaymaskclaudicationandrestpainand A-Vshuntingmaylimitpallorandcoldness.
-
8/6/2019 Diabetes Mellitus and Wound Healing-SMALL
11/42
NON INVASIVE VASCULAR TESTS
Test Abnormal valueTranscutaneousoxygen
-
8/6/2019 Diabetes Mellitus and Wound Healing-SMALL
12/42
Optimalulcerhealingrequiresadequatetissue perfusion.
Ulcer which failstoheal suspectischemia.
Vascularsurgeryconsultationandpossible revascularizationshould be
considered.
Controlof hypertension,hyperlipidemia
andcessationof smokingare essential.
-
8/6/2019 Diabetes Mellitus and Wound Healing-SMALL
13/42
II.Absent protective sensation due toperipheral neuropathy :
Neuropathy is present in58% ofdiabetics,and in 82%of diabetics withfoot wounds.
The lack of protective sensationcombined with unaccomodated foot
deformities undue stressulcer.
Autonomic neuropathysweating
dry skin+fissure
infection.
-
8/6/2019 Diabetes Mellitus and Wound Healing-SMALL
14/42
Autosympathectomyincreased bloodflowcharcotsjoint & deformity.
Nylonmonofilamenttestisasimple officetest forneuropathy.
+ve if nosensationwithpressure whichis
just enoughto bendthe filament.Motorneuropathycausesmuscle atrophy,weaknessresultingindeformity,planterpressure andaltersgait.
-
8/6/2019 Diabetes Mellitus and Wound Healing-SMALL
15/42
III.Foot deformity and limited jointmobility:
As Hummer toe,calluses,bunions,Charcots
foot.
Commonindiabeticsd.t. atrophyof intrinsicmusculature responsible forstabilizingthetoes.
Injury:puncture wound,hotwatersoaks.
-
8/6/2019 Diabetes Mellitus and Wound Healing-SMALL
16/42
IV.History of previous ulceration andamputation.
V. Obesity.
VI.Impaired vision.
VII.Poor footwearskin breakdown+inadequately protects the skin from
high pressure and shear forces.
VIII.Poor glucose controlimpaired
wound healing.
-
8/6/2019 Diabetes Mellitus and Wound Healing-SMALL
17/42
If bloodglucose>220 mg%31%nosocomialinfection.
If
-
8/6/2019 Diabetes Mellitus and Wound Healing-SMALL
18/42
Prevention of ulcerPrevention of ulcer
formationformationAttention to foot care+proper managementof minor foot injuries.
Daily foot inspection by the patient or caretaker.
Gentle cleansingwithsoap andwater,topicalmoisturizerhealthyskin.
-
8/6/2019 Diabetes Mellitus and Wound Healing-SMALL
19/42
-
8/6/2019 Diabetes Mellitus and Wound Healing-SMALL
20/42
Physicianshouldinspectpatientsshoes for
improper fitorinadequate support.
Use athleticshoes,thickabsorbentsocks.
Patientswith footdeformitiesuse customshoes.
Patients should avoid hot soaks,heatingbads,and harsh topical agents such ashydrogen peroxide,iodine (e.g.Betadine)and
astringent(e.g.witch hazel).
-
8/6/2019 Diabetes Mellitus and Wound Healing-SMALL
21/42
Minor foot injuries and infections,cuts,scrapes,blisters and tinea pedis must beadequately treated.
Maintain good foot - care habits.
Prophylactic surgery for specific footdeformitiy e.g. to eliminate areas of peakpressure.
Establish a complete understanding ofneuropathy and its sequalae to the patients &providers.
-
8/6/2019 Diabetes Mellitus and Wound Healing-SMALL
22/42
TreatmentTreatment
5items:Pressure reduction.
Resolve infection.Correctischaemia.Woundcare.
Bloodsugarcontrolwithinsulin anddiet.
-
8/6/2019 Diabetes Mellitus and Wound Healing-SMALL
23/42
-
8/6/2019 Diabetes Mellitus and Wound Healing-SMALL
24/42
-
8/6/2019 Diabetes Mellitus and Wound Healing-SMALL
25/42
Early surgical intervension tocorrect deformity as osseousprominence (e.g. metatarsal head,sesamoid bone,bunion,
hammer toe) if external pressureis not sufficient.
Ostectomy.
-
8/6/2019 Diabetes Mellitus and Wound Healing-SMALL
26/42
Infection controlInfection control
Antibiotics according to culture andsensitivity fromdeeperparts of wounds.
Wound:
Depridment untila bleeding healthy edge+removal of callusand necrotic tissue.
Pusshould be drained.
Avoid full - strength topicalsolutionsandantiseptic(eg,povidone iodine)as can be
cytotoxic.
-
8/6/2019 Diabetes Mellitus and Wound Healing-SMALL
27/42
Osteomyelitis may be presentindeepulcers especiallyif bone is visible orpalpablein 85%.
Diagnosis by Xray,three phase bone scanandradiolablelledleucocyte scan.
Depridment of all devitalized bone isnecessary+parenteral antibiotic.
Antibioticimpregnated beadsachieve
therapeuticlocallevelsinspite of poortissueperfusionandavoidsystemicside effects.
-
8/6/2019 Diabetes Mellitus and Wound Healing-SMALL
28/42
Ischaemia controlIschaemia control
Slow healingdespite appropriate caresuggests ischaemia.
Vasodilators are usually ineffective.
Vascular surgeon consultation is a mustfor revascularization.
Systemic hyperbaric oxygen therapy iseffective in limb ischaemia.
dd
-
8/6/2019 Diabetes Mellitus and Wound Healing-SMALL
29/42
Wound careWound careDepridment.
Wound dressing(warm,moist,free ofexternal contamination).
Saline wet and dr y dressing(hydro-colloids,alginates,foams,films).
Treatment of oedema: elevation,elasticstocking orpneumatic compressionpumps.
-
8/6/2019 Diabetes Mellitus and Wound Healing-SMALL
30/42
Forresistantulcer:Forresistantulcer:--
1.Recombinanthumanplateletderivedgrowth factor formulatedintoageltime forwoundhealing.
2.Bioengineeredhumantissue producedbyseedinghumanskincellsontoan
absorbable meshsuppliesgrowthfactorsandstructuralproteins forwoundhealing.
-
8/6/2019 Diabetes Mellitus and Wound Healing-SMALL
31/42
-
8/6/2019 Diabetes Mellitus and Wound Healing-SMALL
32/42
4a-noninfected,nonischaemicwound.
b-acute charcotarthropathy.
5diabetic footinfection.
6criticalischaemia.
1,2,3risk factors for footulceration.
4,5,6risk factors foramputation.
-
8/6/2019 Diabetes Mellitus and Wound Healing-SMALL
33/42
-
8/6/2019 Diabetes Mellitus and Wound Healing-SMALL
34/42
-
8/6/2019 Diabetes Mellitus and Wound Healing-SMALL
35/42
-
8/6/2019 Diabetes Mellitus and Wound Healing-SMALL
36/42
-
8/6/2019 Diabetes Mellitus and Wound Healing-SMALL
37/42
-
8/6/2019 Diabetes Mellitus and Wound Healing-SMALL
38/42
-
8/6/2019 Diabetes Mellitus and Wound Healing-SMALL
39/42
-
8/6/2019 Diabetes Mellitus and Wound Healing-SMALL
40/42
-
8/6/2019 Diabetes Mellitus and Wound Healing-SMALL
41/42
-
8/6/2019 Diabetes Mellitus and Wound Healing-SMALL
42/42
Thankyou