malignant diabetes and associated mortality can we do anything about it? terri dejohn, m.d. medical...
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MALIGNANT DIABETES AND ASSOCIATED
MORTALITY
CAN WE DO ANYTHING ABOUT IT?
Terri DeJohn, M.D.Medical Director
Hyperbaric Medicine and Wound Treatment Center
OBJECTIVESOBJECTIVES
Identify factors which contribute to increased mortality in the DFU patient.
Learn who to call for help and when to make that call.
DIABETES IS INCREASING
26 million people in the U.S. have diabetes
1.9 million diagnosed in 2010
15% will develop Diabetic Foot Ulcers (DFU)
AMPUTATIONSAMPUTATIONS
15% of DFU15% of DFU’’s End in s End in AmputationAmputation
per 10,000 Diabetics
AMPUTATION INCIDENCE IN MINORITIES
MEN have twice the incidence of amputation as women in all races
Armstrong DG. Int Wound J. 2007;Dec;4(4):286-7.
MALIGNANT DIABETES
MORTALITY RISK IMPROVES MORTALITY RISK IMPROVES WITH TREATMENT BY A WITH TREATMENT BY A
MULTI-DISCIPLINARY TEAMMULTI-DISCIPLINARY TEAM
In 5 Years
Living
Dead
MULTIFACTORIAL ETIOLOGY
Diabetes
Amputation
MULTIFACTORIAL ETIOLOGY
Diabetes
Amputation
MULTIFACTORIAL ETIOLOGY
Amputation
Vascular Disease
Infection
Ulceration
Deformity
Neuropathy
Diabetes
LIMB SALVAGE TEAM
MULTIFACTORIAL ETIOLOGY
Amputation
Vascular Disease - CV
Infection - IMMUNE
Ulceration - DERMATALOGIC
Deformity- ORTHOPEDICNeuropathy - NEUROLOGIC
Diabetes - ENDOCRINE
OUTCOMES OFMULTIDISCIPLINARY TEAMS
AUTHOR JOURNAL OUTCOME
Najarian J.Fam Prac. 1998 48% Amputations
Patout Diabet Care 200049% Ulcerations79% Amputations89% Admissions
CherryDiab Tech Ther
2002
32% Admissions34% ER Visits49% OP Visits
LaveryDiab Research
ClinicPract 2005
52% Amputations38% Admissions28% LOS
Moving from aWound Clinic
or Lone Practitioner
to aLimb Salvage
Team
Rapid Referral to Multi-disciplinary
TeamReferral before 25 days resulted in a 79% reduction in amputations.
•vanAcker, et al, DFCon2011 Establishing a National Diabetic Foot Model
RECOMMENDATIONS RECOMMENDATIONS FROM EVIDENCE FROM EVIDENCE
CONSENSUS RECOMMENDATIONS ON ADVANCING THE STANDARD OF CARE FOR TREATING NEUROPATHIC FOOT ULCERS IN PATIENTS WITH DIABETES
APRIL 2010 OSTOMY AND WOUND MANAGEMENT
TREATMENT OF DFUTREATMENT OF DFU’’ssDEFINE
DISCUSS
DEBRIDE (VESSELS AND BED)
DEBUG
DECIDE
DE-LOAD
DEFINEDEFINE
SKIN AND ULCER EXAM
• Skin
• Sensation
• Deformity
• Ulcer: Size, Location, Base, Wound edge, Tunnel, Necrosis
DEFINEDEFINEINFECTION
• Drainage
• Odor
• Redness
• Swelling
• Probe Bone
• If suspicious: ESR, CRP (If both are normal, Osteomyelitis is unlikely), Culture
IMAGINGIMAGING
Plain films
MRI or CT
VASCULAR VASCULAR EVALUATIONEVALUATION
A tiered approach is recommended :
1. Pulses, ABI, and/or TBI
2. Segmental pressure volume, SPP and TcPO2
3. Vascular consultation
TISSUE HYPOXIATISSUE HYPOXIA
TcPO2 < 40mmHg suggests impaired healing
Risk of amputation is 161 times greater if TcPO2 <20 rather than TcPO2 >40
Risk amputation is 55 time greater if ABI is <0.45 rather than >0.7
DEFINEDEFINE
LABSCBC
HgA1cCholesterol, HDL, LDLHomocysteine (Hcy)
Effects of Hyperglycemia on Cells
1. Decreased proliferation and differentiation of keratinocytes (1)
2. Inhibition of fibroblast proliferation (2)
3. Decreased response of cells to growth factors (2,3)
4. Decreased migration of keratinocytes and fibroblasts (4)
(1) Sparvchikov N, ed al. Diabetes 2001; 50: 1627-635
(2)Hehenberger K, et al. Cell Biochem Funct 1997; 15: 197-201
(3)Fard A, et al. Arterioscler Throm Vasc Biol 2000; 20: 2039-2044
(4)Lerman OZ, et al. Am J Pathol 2003; 162:303-312
HEMOGLOBIN A1C HEMOGLOBIN A1C & WOUND HEALING& WOUND HEALING
Methods: A retrospective analysis of data gathered from multi-center, controlled, prospective, randomized FDA approved clinical trials is being conducted.
Results: The final linear regression model (P<0.0001) found that higher HgbA1C levels were associated with lower percentages of wound healing (P=0.05).
For every 1% increase in HgbA1c there is a
decrease of 3% in expected healing area
Hanft J, et al, South Miami Hospital & Harvard Medical School, APMA Scientific Meeting Abstract, 2009
Wound Healing in the Diabetic
Impact of HgA1c on Wound Healing
0
10
20
30
40
50
60
70
Worsening Decreasing
HgA1c
Per
cen
tag
e o
f H
eali
ng
Control
Control
Dermagraft
Apligraft
DEFINE
LABSCBC
HgA1cCholesterol, HDL, LDLHomocysteine (Hcy)
Homocysteine (Hcy)Homocysteine (Hcy)
Known risk factor for atherosclerotic vascular disease and is an inhibitor of nitric oxide (NO) bioactivity
↑ Hcy was observed in
50% of patients with chronic wounds
63% of patients with diabetic, neuropathic ulcers
•Figure 6.
TREATMENT OF TREATMENT OF HYPER- HcyHYPER- Hcy
METANX
L-methylfolate
Pyridoxal 5'-phosphate
Methylcobalamin
Results in 3X’s lower serum Hcy
DEFINEDEFINENUTRITION
• Nutrition Screen
• Albumin, Pre-Albumin, Transferrin
CONSIDER PROTEIN SUPPLEMENTS
.5 - .75 gm / kg of body weight
DEFINEDEFINESMOKING
• Nicotine
• Cyanide
• Carbon Monoxide
CONSIDER E-CIGARETTE
DEFINED DISEASE DEFINED DISEASE PROCESSESPROCESSES
ULCER
DEFORMITY
INFECTION
VASCULAR STATUS
DIABETIC CONTROL
NUTRITIONAL STATE
DEFINE & DISCUSSDEFINE & DISCUSS
Initial definition to determine what issues contribute to the problem
Discuss with appropriate specialists
DEFINE AND DISCUSSDEFINE AND DISCUSS
Tissue Hypoxia
Deformity
Infection
Diabetic Control
Nutrition
Vascular surgeon
Ortho/ Podiatry/ Pedorthotist
Infectious Disease
Endocrinologist/ Diabetic Ed
Dietician
DEBRIDEDEBRIDE
DebridementDebridement
–SharpSharp
–MechanicalMechanical
–ChemicalChemical
–AutolyticAutolytic
DE-BUGDE-BUG
BIOFILMS
Biofilms are present in 60% of chronic wound biopsies
Only 6% of Acute Wound Biopsies
Biofilms retard wound healing
Schierle WWR 17:2009
BIOFILMSBiofilms induce a chronic inflammatory
response
• Reactive Oxygen Species (ROS)
• Proteases ( MMP, neutrophil elastase)
Chronic inflammation leads to damage of proteins that are essential for healing.
• Extracellular Matrix Proteins
• Growth factors and receptors
DECIDE: DECIDE: WHAT DRESSINGWHAT DRESSING
Wound care dressing orders for 202 patients Wound care dressing orders for 202 patients receiving home health or HMO carereceiving home health or HMO care
42% Wet-to-Dry42% Wet-to-Dry
7.5% Enzymatic7.5% Enzymatic
7% Dry Gauze7% Dry Gauze
Cowan L, Stechmiller J. Cowan L, Stechmiller J. Advances in Skin and Wound CareAdvances in Skin and Wound Care Dec, 2009Dec, 2009
DECIDE: DECIDE: WHAT DRESSINGWHAT DRESSING
TO DRY:•Alginates•Foams•ABD’s•Polymers•NPWT
TO MOISTEN:•Hydrogel
•Medihoney
•Ointments
DECIDE: DECIDE: WHAT DRESSINGWHAT DRESSING
ANTIMICROBIAL
Silver
Iodosorb
Medihoney
ACTIVE DRESSING
Collagens
Regranex
Skin Substitutes
DE-LOADDE-LOAD(Off- Load)(Off- Load)
OFF LOADING DEVICES
OFF LOADINGTOTAL CONTACT CASTING
Only device proven to effectively off load
REMOVABLE DEVICES ARE REMOVED
Only 28% of daily activity done with device
Armstrong, Diabetes Care 2003
BENCHMARKING
Off Loading is the #1 Benchmark
Diabetic Control
Vascular Exam
A 50% reduction in wound area at 4 weeks
is a surrogate marker predictive of wound healing.
% Area Reduction at 4 weeks
Percentage of Area Reduction =
(A1 - A2) ÷ A1 x 100
A = Length x Width
FAILURE TO ACHIEVE 50% CLOSURE
@ 4 WEEKS REQUIRES ADVANCED
THERAPIES
FAILURE ADVANCED TXFAILURE ADVANCED TX
Negative Pressure
Wound Therapy
FAILURE ADVANCED TXFAILURE ADVANCED TX
Living Skin Substsitutes
Living Skin Substitutes
FAILURE ADVANCED TXFAILURE ADVANCED TX
Hyperbaric Oxygen Therapy
Deformity can be Deformity can be mitigated with mitigated with appropriate appropriate footwear.footwear.
Severe deformity Severe deformity may be corrected may be corrected with surgerywith surgery
FAILURE ADVANCED TXFAILURE ADVANCED TX
MOVING FORWARD
LEAVING EXPERT OPINION BEHIND
GOING TO EVIDENCE BASED RECOMMENDATIONS TO DEVELOP PROTOCOLS
Even with adequate blood flow 24% of patients closed at 12 weeks 31% at 20 weeks
Using standardize protocols in a multi-center wound care network
68% healing rate at 20 weeks