Assessment and Management of Wounds In Diabetes

Maria Mousley

Northamptonshire NHS Foundation

Trust

Background� At least 61000 people with diabetes in

England have a foot ulcer at any given time

� There are around 6000 lower extremity

amputations a year in people with diabetes

� Diabetic foot ulcers are the most common

cause of non-traumatic limb amputation

� The risk of a lower extremity amputation in a

person with diabetes is 23 x that of a person

without diabetes

Background� Diabetes is one of the

biggest health challenges

facing the UK today

� Diabetic foot problems

have a significant financial

impact on the NHS and a

significant impact on

patients’ quality of life.

CostsCostsCostsCostsCostsCostsCostsCosts……………………

Average annual cost of one foot ulcer treatment?£3,600(York Health Economics Consortium, The diabetic

Foot. Vol 1; No 3, 109-115, 1998)

Average cost of one lower limb amputation?£16,300 - £32,600(IDF, 2005)

Estimated Health Care budget in the UK

Up to £502m per year(DoH 2002)

The Indirect CostsThe Indirect CostsThe Indirect CostsThe Indirect CostsThe Indirect CostsThe Indirect CostsThe Indirect CostsThe Indirect Costs……………………

Restricted

mobility

Restricted

mobility

EmbarrassmentEmbarrassment

Loss of

earnings

Loss of

earnings

DepressionDepression

Social

isolation

Social

isolation

PainPain

Human

Costs

Human

Costs

Podiatryfacilitator

Radiology

Consultant Interventional

Radiologist

X-ray

MRI

Extended TeamWard / Nursing Staff

AHPs

Diabetic Foot

Team ServicesWard Rounds

OPD (complex clinic)

Podiatry (ftwr,

Wound Management)

Consultants

Diabetologist

Vascular Surgeon

Orthopaedic Surgeon

Microbiologist

Ward/OPD

Referral

Primary Care /

Community

Referral

Amputation Prevention Team (aka Diabetic Foot Team)

Supporting TeamVascular Laboratory

Plaster RoomPathology Laboratory

Adapted from RGF 1994

Podiatryfacilitator

MDfT Services

Ward Rounds

OPD (complex clinic)

Specialist Podiatry (footwear,

Wound Management)

Ward/OPD

Referral

Primary Care /

Community

Referral

Amputation Prevention Team (aka Diabetic Foot Team)

Diabetic Foot ScreeningDiabetic Foot Protection Programmes

Refer?..................as?

Stage 1 - hard skin builds up (fire)

Pressure may not be noticeable at first

This may not be painful! (undetected)

Stage 2 - Tissue damage begins

beneath the surface (starts to spread)

Stage 3 - Skin breaks open and an ulcer

is revealed. This is prone to infection.

(spot the signs)

Extravasation – a precursor of ulceration

Prevention of Foot Attack

The faster you act the more of a foot you save

Escalating needs; deteriorating condition

Deterioration� Wound getting worse

� Increase in size

� Increase in depth

� Development of complications

NEUROPATHIC VS ISCHAEMIC ULCERS� Symptoms

� Circulation

� Site

� Presence of callus

� Signs of infection

Neuropathy Nerve damage in diabetes leads to altered pain sensation

Big toe

Ball of foot

Heel area

Tip of toes

Neuropathic

Ulcer

Site: Weight bearing areas.

DeepOther structures

exposedCallus

Granulation

Clinical Examination

Insensate foot:repeated minor trauma causes ulceration

The importance of neuropathy� Ulcers will not heal unless offloaded

� Ulceration leads to infection, often

exacerbated by poor diabetes control

� Untreated or inadequately treated infection

leads to osteomyelitis

� Neuropathic ulcers may be small and

apparently insignificant – ALWAYS look

under the dressing

� NB – ‘infection ? cause’

Pressure offloading Total contact casting is the gold standard……… AND REST!!!!!!!!

Peripheral Arterial Disease� Palpate foot pulses:-

Dorsalis Pedis

Posterior Tibial

� Doppler—sounds� Monophasic?

� Ankle-Brachial Index

(ABPI) <0.8

Ischaemic

Ulcer

Necrotic centre

Surrounding

Erythema

Site: borders of the feet.

Painful

Cool FootPulseless

Neuroischaemic ulcers -Refer

Refer

Refer

Summary of Neuropathic foot ulcersNICE 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

Summary of Neuroischaemic foot ulcersNICE Clinical Guideline CG10 Type 2 Diabetes - Foot care 2004CREST guidelines 1998 www.gain-ni.org/Guidelines/wound-management-diabetic-foot.pdf

• Neuro-ischaemic foot ulcers

– Commonly result from tight shoe

– On non-weight-bearing areas of foot, toe tips & beneath toenails

� Neuro-ischaemic foot

� Cool/cold to touch

� Absent/diminished pulses

� Pain at rest

Tissue

Necrosis

InfectionNeuropathy Ischaemia

The Deadly Triad

(Edmonds 1984))

‘Line of least resistance’

Spreading infection

Mr G W 52 years� April 10 – picked hard skin off foot at base of

R hallux

� Not diabetic but family history of diabetes in

two relatives – one an amputee

� Foot became infected – generally unwell

� Saw private podiatrist and advised to go to

GP

� Prescribed flucloxacillin over the phone

� 2 days later – reviewed by podiatrist

� not happy and referred to A&E

� seen by orthopaedic SHO and advised to

continue antibiotics and return in 2 days

� 2 days later (1 week after first became

unwell) saw GP

� blood glucose 16.8

� pyrexial

� cellulitis

� Admitted under orthopaedic surgeons for iv antibiotics

� IV flucloxacillin and benzylpenicillin

(hospital guidelines advise co-amoxiclav for

diabetic foot infections)

� cultures subsequently grew haemolytic strep,

staph aureus and anaerobes

� 2 days after admission, debrided by

orthopaedic surgeon

� Further debridement 1 week later

� Referred to vascular surgeon and podiatrist

Aug 2010 completely healed and patient ambulant in

therapeutic footwear

Missed Opportunities� Primary care

� Lack of specialist knowledge and referral routes

� failure to assess patient

� delayed diagnosis of diabetes

� Secondary care

� failure to recognise need for intravenous antibiotics when seen in A&E

� inadequate antibiotic cover

� inadequate debridement

� failure to involve the specialist diabetic foot

team

Neuropathic ulcer – presentation with cellulitis and …………

Neuropathic ulcer - tracking

� If the following are present, obtain urgent

advice from an appropriate specialist:

� redness or warmth are present

� systemic sepsis

� deep seated infection

� limb ischaemia

Initial examination and assessment

‘‘‘‘Kissing UlcersKissing UlcersKissing UlcersKissing Ulcers’’’’

(Ref. Jeffcoate & Macfarlane 1995)

Kissing Ulcers

Tip, Top Toe!

(Ref. Irion 2002)

Increased presure

Avoidable pressure ulcers are a key indicator of the quality of care. Preventing them will improve all care for at risk patients (harm free care)

Debridement

Neuropathic Ulcer

•No pain•Warm Foot•Pulses present

Profuse slough

Conversion to Infection

ManagementManagementManagementManagementManagementManagementManagementManagement……………………

Managing infection in the diabetic foot Clinical Knowledge Summaries Type 2 Diabetes 2008

� Infection presents a threat to (life and) 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

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

Managing infection in the diabetic foot Clinical Knowledge Summaries Type 2 Diabetes 2008

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

Continuum of microbial load

http://www.education.woundcarestrategies.com/coloplast/resources/Clinical%20Wound

%20Assessment-Pocket%20Guide.pdf

Increasing bioburden

Conversion to Infection and necrosis

Why Why Why Why Why Why Why Why ‘‘‘‘‘‘‘‘high riskhigh riskhigh riskhigh riskhigh riskhigh riskhigh riskhigh risk’’’’’’’’ woundswoundswoundswoundswoundswoundswoundswounds……………………????????Vascular disease

Nerve damage

Hyperglycaemia

Underlying susceptibility to infection

Classic Signs of Infection

Rubor et tumor cum calore et

doloreredness swelling heat

pain

(Celsus c. 3-64AD)

Diagnose Infection Based on any 2 features Diagnose Infection Based on any 2 features Diagnose Infection Based on any 2 features Diagnose Infection Based on any 2 features ((((BerendtBerendtBerendtBerendt & & & & LipskyLipskyLipskyLipsky 2003)2003)2003)2003)

Minor increase in

volume

Increased, +/-

viscosity

Exudate levels

Increased painLittle or nonePain

Little changeLocalised –generalised

Swelling

Little change -dusky red

Erythematouseg.pillar box red

Colour

Little change -

cooler

Comparative

increase

Temperature

IschaemicNeuropathicFeature

�Infection in a patient with

systemic toxicity or metabolic Instability

�No systemic illness

�As in mild infection

and in addition > 1 of the following:

�>2cm cellulitis

�Lymphangitis

�Involvement of Tendon

Joint

Bone

�<2cm cellulitis / erythema

�Superficial ulcer

�>2 Signs of inflammation

�No systemic illness

SevereModerateMild

Infectious Diseases Society of America Classification System (Lavery et al 2007)

REMEMBERREMEMBERREMEMBERREMEMBER…………....

Risk of treating infection too late, with it’s associated morbidity & mortality…, while giving antibiotics freely carries a risk of inducing antibiotic resistance….use of clinical skills & judgement is vital!

What antibiotic do I use?

Broad Spectrum

Eg. Co-amoxiclav

Culture and sensitivity

Culture directed

narrower spectrum

Antibiotics in Diabetic foot Disease

� IDSA http://www.idsociety.org

� Scottish Diabetes Group Consensus (Leese et

al The Diabetic Foot Journal vol 12 2 2009)

� Clinical Knowledge Summaries (CKS)� http://www.cks.nhs.uk/diabetes_type_2/management/detailed_answers/foot_problem

s

Treatment of infection

Osteomyelitis

� When choosing wound dressings take into account:

– clinical assessment of the wound

– patient preference

– clinical circumstances eggranulating, sloughy, necrotic

– which wound dressing has the lowest acquisition cost.

Management of diabetic foot ulcers

Guidelines on wound and wound-bed management (2011)IWGDF Game et al 2012 Diab Metab Res Rev;28:232-233

‘In the absence of strong clinical or cost effective evidence, health care professionals should use wound dressings that best match clinical experience, patient preference, the site of the wound and the cost of the dressings.’

‘Wounds should be closely monitored and dressings changed regularly.’

(NICE, 2004 )

Health Technology Assessment

WHAT MAKES AN IDEAL DRESSING for WHAT MAKES AN IDEAL DRESSING for WHAT MAKES AN IDEAL DRESSING for WHAT MAKES AN IDEAL DRESSING for WHAT MAKES AN IDEAL DRESSING for WHAT MAKES AN IDEAL DRESSING for WHAT MAKES AN IDEAL DRESSING for WHAT MAKES AN IDEAL DRESSING for ‘‘‘‘‘‘‘‘High High High High High High High High RiskRiskRiskRiskRiskRiskRiskRisk’’’’’’’’ WoundsWoundsWoundsWoundsWoundsWoundsWoundsWounds…………………….?.?.?.?.?.?.?.?

• Designed to minimise cross-contamination

• Maintains a moist environment for optimal wound healing

(Sibbald et al, 2004)

• Absorption and retention at varying exudate levels (Chen

et al, 2003)

• Minimises risk of damage to peri-wound skin (Jones et al,

2004)

• Conformable to the wound (Armstrong S.H. 2004)

• Versatile, for use on a wide range of wounds

• Comfortable for patient (Mortimer D)

• Control odour

• Easy to use

• Cost-effective

WWWWWWWWoundoundoundoundoundoundoundound bedbedbedbedbedbedbedbed colour...colour...colour...colour...colour...colour...colour...colour...

� Black (necrotic)

� Yellow / grey (sloughy)

� Red (granulating)

� Pink (epithelising)

ThinkThinkThinkThinkThinkThinkThinkThink……………………........Consideration should be given to the fact that these properties

may be altered when dressing the feet (Morgan

D, Formulary of Wpund Management

Products, 7th Ed: 26, 29-30, 1997) as

dressings are not designed to take the

high & repetitive forces exerted on the sole of the foot! (Baker N,

Journal of Wound Care 6 (1): 1997)

High & repetitive forces

Body weight

pressure

Footwear accommodation

Movement

Friction

INFECTION MASKED…!

Vascular controlVascular control……..

Mechanical controlMechanical controlMechanical controlMechanical controlMechanical controlMechanical controlMechanical controlMechanical control……………………........Rest

Avoidance of

pressure

GlycaemicGlycaemicGlycaemicGlycaemicGlycaemicGlycaemicGlycaemicGlycaemic controlcontrolcontrolcontrolcontrolcontrolcontrolcontrol……………………........

Consider any systemic, metabolic or

nutritional disturbances that may impair

the response to infection and retard

healing of wounds.

Educational controlEducational controlEducational controlEducational controlEducational controlEducational controlEducational controlEducational control……………………........

Patient education / empowerment is critical if successful management is to be achieved.

(Day J, Diabetes Metab Res Rev; 16 (Suppl 1): S70-74, 2000)

Key points for education (NICE 2004)

� Self-care and self-monitoring

� Knowledge of when & where to seek advice

� Awareness of possible consequences of

neglecting the feet

� Management of symptoms (pain, odour)

SummarySummarySummarySummarySummarySummarySummarySummary1. Vascular disease

2. Nerve damage

3. Hyperglycaemia (infection)

4. Pt education

Questions?

Find out more�Visit www.nice.org.uk/guidance/

� www.woundsinternational.com

ReferencesReferencesReferencesReferencesBanga JD. (1994), Lower extremity arterial disease in diabetes mellitus Diabetes Reviews International 3;4:6-11 Dejgaard A. (1998), Pathophysiology and treatment of diabetic neuropathy Diabetic Medicine 15:97-112 Edmonds ME. (1984), The Diabetic Foot Practical Diabetes 1;1:36 Young MJ et al. (1993), A Multicentre study of the prevalence of diabetic peripheral neuropathy in the United Kingdom hospital clinic population Diabetologia36:150-154