Staged diabetes management a systematic approach - part 9 ppsx

350 MICROVASCULAR COMPLICATIONS Photo 9.13 Foot examination; example of 10 g, 5.07 monofilament Photo 9.14 Foot examination; toe sensation and appropriate for the patient. Examine the in- side of the shoe for small objects (rocks, keys, buttons) that the patient may not be able to feel. While the use of the 10 g, 5.07 monofilament is considered the standard for screening for foot neuropathy; another option is the use of the low- pitched tuning fork (128 Hz) to screen for the presence or absence of vibratory sensation in the foot. Loss of vibratory sensation usually precedes the loss of protective sensation (measured using Photo 9.15 Foot examination; demonstration of appropriate use of 10 g, 5.07 monofilament the 10 g, 5.07 monofilament) allowing for the detection of earlier stages of neuropathy. Proper tuning fork testing is as follows: the patient is first taught the difference between pressure from applying the tuning fork and vibration. The tuning fork is placed on the patient’s distal interpha- langeal (DIP) joint on the first finger of the hand when it is not vibrating to demonstrate the concept of pressure followed by application to the same joint with the tuning fork vibrating. The patient is then asked to close their eyes and the vibrat- ing tuning fork is applied to the DIP joint of the unsupported great toe. The patient is instructed to inform the tester when they stop feeling the vibra- tion from the tuning fork. The tuning fork is then placed on the DIP joint on the first finger of the tester and the time until they stop feeling vibration is measured. Note, if the tester has neuropathy, the patient may serve as his or her own control and the vibrating tuning fork may be placed on the DIP joint of the patient’s first finger. If the tester (or patient) feels the vibration for less than 10 DETECTION AND TREATMENT OF FOOT COMPLICATIONS 351 Photo 9.16 Foot examination; heel sensation seconds, the patient is considered to have normal vibration sensation. If the tester (or patient) feels the vibration for 10 seconds or longer the patient has reduced vibration sensation and the patient should be tested using the 10 g, 5.07 monofil- ament for loss of protective sensation. In some patients the vibratory sensation is completely ab- sent and will require monofilament testing for loss of protective sensation. Repeat tuning fork testing on the other foot. Based on the presence or absence of high-risk findings, patients are assigned to low- or high- prevention stages. Low-risk patients receive pa- tient education directed at maintaining their low- risk status. High-risk individuals without ulcers receive protective footwear in addition to patient education. High-risk patients with ulcer receive immediate treatment. If a patient is found to have an ulcer on the first assessment, a more exten- sive evaluation is performed during that visit. Pa- tients with small ulcers and no complicating fac- tors are candidates for intensive outpatient man- agement. Patients with large ulcers and/or with complicating factors (i.e. sepsis, hyperglycemia, impaired blood flow) are staged to hospital care. The next section details guidelines for each stage. They include a brief description of the stage, the entry criteria, the baseline assessment and diagnosis, therapeutic interventions, and sta- bilization goals. These guidelines are also sum- marized in Figures 9.13 and 9.14. Low-risk normal foot A patient with diabetes is considered to have “low-risk feet” (see Photo 9.17 p. 360) if neu- ropathy, peripheral vascular disease, and history of lower-limb amputation and/or plantar ulcer are absent. The low-risk normal foot category rep- resents approximately 70 per cent of people with diabetes. The treatment goal for patients with low- risk feet is designed to prevent the development of foot disease by addressing modifiable risk fac- tors that increase the likelihood of developing a foot complication ( e.g. poor glycemic control, in- appropriate footwear, foot injury) and to promote healthy foot care habits. Foot self-care education, including referral for risk factor reduction, is the essential intervention for achieving these thera- peutic goals. Minimally, a yearly complete foot examinations is required to verify that patients with “low-risk feet” have not progressed to having “high-risk feet”. Entry criteria. Patients are considered to be at “low risk” if they have all of the following: • sensation to the 10 g, 5.07 monofilament in all plantar areas tested, except the heel • no foot deformities (hallux valgus or varus, claw or hammer toes, bony prominence, or Charcot foot) • palpable pulses (dorsalis pedis or posterior tibial) on both feet • an ankle brachial index (ABI) calculated from ankle/arm Doppler blood pressures measure- ments >0.80 • no current or prior lower extremity amputa- tion(s) or ulcer(s) 352 MICROVASCULAR COMPLICATIONS Low-Risk Normal Foot Ulcer prevention Patient self-care If any change in status, reclassify foot See Foot Assessment and Treatment High-Risk Normal Foot Ulcer prevention Protective footwear If any change in status, reclassify foot See Foot Assessment and Treatment High-Risk Simple Ulcer Treat simple ulcer Consider referral to specialist or obatin consultation if failure to improve in 2 weeks See Foot Ulcer Treatment High-Risk Complex Ulcer Treat complex ulcer Refer to specialist or obtain consultation if failure to improve within 1 week See Foot Ulcer Treatment Improved Healed Upon Assessment Normal Foot Sensate to 10 g, 5.07 monofilament; no ulcer Abnormal Foot Previous ulcer; insensate to 10 g, 5.07 monofilament; deformities present Active Ulcer Superficial involvement; Ͻ2 cm diameter and Ͻ0.5 cm deep Active Ulcer Extensive involvement; у2 cm diameter and/or у0.5 cm deep Figure 9.13 Diabetic Foot Master DecisionPath Baseline assessment. Shoes and socks should be removed to inspect feet for acute problems at each clinic visit. The presence of ulcers, redness, pain, trauma, infection, and nail deformity should be recorded. A complete foot examination should be performed annually and include monofilament testing, and observation for deformities. Perform a simple noninvasive vascular assessment such as a qualitative pulse check and/or an ankle brachial index (ABI) obtained by Doppler. The patient should be interviewed and medical records re- viewed for a history of plantar ulceration or lower- extremity amputation. Results of the examina- tion should be documented in the medical record. Since diabetic neuropathy is closely associated with foot disease, the history should include alco- hol abuse, smoking, and level of glycemic control. These risk factors are modifiable and should be addressed as part of diabetes care. Similarly, poor glycemic control (HbA 1c ≥ 2.0 percentage points above the upper limit of normal) should be vigor- ously treated (see Chapters 4–6). Therapeutic interventions for low-risk nor- mal foot. Self-care patient education is the principal intervention and can be offered as part of a formal structured curriculum or integrated into routine diabetes clinic visits. Assess the patient’s DETECTION AND TREATMENT OF FOOT COMPLICATIONS 353 Any of the following present: deformity; foot insensate to 10 g, 5.07 monofilament in any plantar areas (except heel); previous amputation; ischemic index calculated from Doppler Ͻ0.8? Patient with type 1 or type 2 diabetes Assess Condition of Feet Deformities (nail deformities; hallux valgus or varus; claw or hammertoes; bony prominence; Charcot feet) Ulcers, redness, trauma Test sensation with 10g, 5.07 monofilament Poor circulation Ischemic symptoms Amputation • • • • • • Ulcer present? NO NO YES YES Classification: Low-Risk Normal Foot Educate Patient Daily foot inspection; report any injury or abnormality; wear appropriate footwear; skin, nail and callus care; avoid foot soaks; tight glycemic control Follow-up Medical: assess feet at each visit Classification: High-Risk Abnormal Feet If deformity present, refer to podiatrist for extra-depth shoes with molded inserts If nail deformities or calluses, palliative foot care If neuropathies/no deformities, change footwear to commercially acceptable type If vascular disease (history of amputation, ischemic symptoms, poor circulation), refer for complete evaluation • • • • Move to Foot Ulcer Treatment Foot Classifications Low-Risk normal foot High-Risk abnormal foot High-Risk simple ulcer High-Risk complex ulcer • • • • Figure 9.14 Foot Assessment and Treatment DecisionPath current foot care and footwear practices, health beliefs, and support and barriers to care. Take ad- vantage of “teachable moments” by demonstrating educational principles when shoes are removed for foot inspection or during monofilament examina- tions. Consider including family members and/or a friend in the education process, especially if vi- sual or physical disability limits the patient in 354 MICROVASCULAR COMPLICATIONS adequately performing self-care. The content of the instruction should include: • daily foot inspection • prompt reporting of acute problems to the primary care provider • use of appropriate footwear • appropriate skin, nail, and callus care • smoking cessation • avoidance of foot soaks and caustic agents • maintenance of acceptable metabolic control Education should be presented at the yearly foot examination and reinforced during clinic visit foot inspections. Self-care practices and footwear use should be assessed at subsequent annual foot examinations. Patients who demonstrate limited or poor understanding of self-care practices should be reassessed and receive education at the next scheduled clinic visit. Patients should be offered advice on treatments for modifiable risk factors. Patients who express interest should be referred to available programs. Medical assistants and nursing staff should be involved in foot complication prevention by ask- ing patients to remove shoes and socks at every visit to provide a visual reminder for the provider and reduce time for inspection/examination. Many organizations have provided foot care training for these health professionals and they become re- sponsible for foot inspections and examinations. Evidence of foot problems (ulcers, deformities, insensitivity) are then reported to the provider. Maintain goal. A patient is stabilized when foot self-care demonstrated at follow-up visits is appropriate, i.e., skin hygiene, nail care, footwear, and health-seeking behaviors in response to self- identified problems. Understanding and self-care skills are reassessed and reinforced during annual diabetic foot examinations. The status of referrals for risk factor modification should be checked pe- riodically. Patients remain in this category unless high-risk factors develop. Photo 9.17 Low-risk normal foot Photo 9.18 High-risk abnormal foot High-risk abnormal foot The high-risk abnormal foot category includes pa- tients with diabetes who are at “high risk” (see Photo 9.18) for amputation because of the pres- ence of neuropathy, peripheral vascular disease, or a history of LEA or ulcer. This group represents approximately 25 per cent of people with diabetes. The therapeutic goal for this stage is secondary prevention or to prevent the development of ul- cers, minor trauma, and infection that can lead to amputation. To meet this goal, therapeutic inter- ventions for patients with high-risk feet include self-care education, podiatric care, and protective footwear. Entry criteria. Patients are considered to be at “high risk” with abnormal feet if they have no active ulcer and any of the following: DETECTION AND TREATMENT OF FOOT COMPLICATIONS 355 Photo 9.19 High-risk foot with simple ulcer • insensitivity to the 10 g, 5.07 monofilament in any plantar areas tested, except calluses and the heel • foot deformity(ies) (hallux valgus or varus, claw or hammer toes, bony prominence, or Charcot foot) • absent pulses (dorsalis pedis or posterior tib- ial) on either feet • an ankle branchial index calculated from an- kle/arm Doppler blood pressures measure- ments <0.80 • a history of lower extremity amputation(s) or ulcer(s) Baseline assessment. Foot inspections at each clinic visit, a complete foot examination annually, and an assessment of treatable risk factors should be performed and documented as outlined for the low-risk normal foot. Therapeutic interventions for high-risk ab- normal foot. The following services should be offered as part of an individualized care plan. 1. All patients should receive foot self-care patient education as outlined above for pa- tients with low-risk normal feet. In addi- tion, the content should include principles of footwear selection. Self-care practices should be re-evaluated at follow-up visits every 1–6 months. Patients with limited Photo 9.20 High-risk foot with complex ulcer understanding should be reinstructed and family members educated to assist in patient self-care. 2. For patients with minor nail deformities and calluses, offer palliative foot care as needed (usually every 1–2 months). Refer patients with severe nail deformities to a podiatrist. Calluses and nail deformities need to be treated prior to shoe fitting. 3. For patients with neuropathy and no de- formity, encourage the purchase of an ac- ceptable commercially available shoe of the patient’s own choosing. Running shoes re- duce the rate of callus build-up. Staff may wish to inventory local shoe retailers for ac- ceptable shoes and provide a list with prices to patients as a guide. Some of these shoes may have padded non-slip liners or inserts. For those shoes that do not, provide a ny- lon covered shoe insert. After the shoe fit- ting, arrange for a follow-up in the clinic at 1 month and then every 6 months to assess use and condition of footwear. 4. For patients with deformity with or with- out neuropathy, prescribe extra-depth shoes with molded inserts. Alternatively, some patients with severe deformities may re- quire molded shoes. Patients should be re- ferred to a contract pedorthist for insert and shoe fitting. After the shoe fitting, arrange for follow-up at 1 month and then every 356 MICROVASCULAR COMPLICATIONS 3–4 months to assess use and condition of footwear. 5. Refer selected patients at high risk for vas- cular disease for definitive evaluation and treatment. High-risk patients may include those with the following: – history of an amputation with prior vas- cular evaluation – ischemic symptoms such as claudication or rest pain – failure to heal despite aggressive ther- apy Because many patients with peripheral vascu- lar disease have cardiovascular and cerebrovas- cular disease, selection of a patient for vascular assessment/treatment r equires clinical judgment of the risk/benefit ratio. Contrast materials used during arteriography for definitive diagnosis can have significant adverse effects on renal function among those patients with pre-existing diabetic kidney disease. Patients with alcohol abuse should be referred to an alcohol treatment program. Patients who abuse tobacco should be educated and referred t o a smoking cessation program. Use opportunities to stress the importance of metabolic control in preventing progression of risk factors. Maintain goal. Patients are considered stabi- lized when they demonstrate foot self-care prac- tices and utilization of prescribed footwear. A tracking system, such as a diabetes registry with a high-risk foot “field,” can be used to enhance patient follow-up. A r egularly scheduled high- risk foot clinic may improve access for patients who need frequent follow-up. Patients who de- velop plantar ulcers are treated in accordance with guidelines outlined for high-risk simple ulcer and high-risk complex ulcer. High-risk simple ulcer Patients in the high-risk simple ulcer category (see Photo 9.19) include those with a small, superficial ulcer and no complicating features (peripheral vascular disease, infections, etc.). This stage rep- resents approximately 2–3 per cent of people with diabetes. The therapeutic goal is tertiary preven- tion, or complete healing of the ulcer. To meet this goal, therapeutic interventions focus on aggressive wound care (see Figure 9.15). Management usu- ally can be performed in the outpatient setting. Selected patients may require hospitalization to optimize adherence to the treatment regimen. Entry criteria. Patients who are treated in ac- cordance with the high-risk simple ulcer guide- lines include those with any of the following find- ings: • The ulcer is <2 cm in diameter and <0.5 cm deep. • Cellulitis is limited to a 2 cm margin and there is no ascending infection. • Temperature is <38 ◦ C (100.5 ◦ F). • White blood count is <12000. • There is no deep space infection such as abscess, osteomyelitis, gangrene, and a sinus tract. • Pulses are present, ankle brachial index is >0.8, and ischemic symptoms are absent. Baseline assessment. When a plantar ulcer is identified, a careful inspection of the foot must be performed. Debridement must be done and the size and depth measured and documented for follow-up comparison. Using a blunt metal instru- ment, probe the wound, looking for involvement below the subcutaneous tissue or sinus tracks. Note evidence of extensive infection such as gan- grene, lymphadenitis, osteomyelitis, or abscess. A plain film X-ray should be completed if a foreign body, gas gangrene, or osteomyelitis is suspected. Obtain vital signs and a white blood cell count (WBC) to assess for systemic involve- ment. Note that patients with significant infection may be afebrile and have normal WBC. Assess DETECTION AND TREATMENT OF FOOT COMPLICATIONS 357 Any of the following present: Ulcer у2 cm diameter and/or у0.5 cm deep; cellulitis with 2 cm margin or ascending infection; temperature у100.5˚F (38˚C); white blood count у12000; deep space infection; pulses absent; or ankle/brachial index р0.8 with ischemic symptoms? Patient with foot ulcer Assess Ulcer Measure width and depth of ulcer Temperature; white blood count Deep space infection: abscess, osteomyelitis, gangrene Pulses; ankle/brachial index Ischemic symptoms • • • • • NO Classification: High-Risk Simple Ulcer (small superficial ulcer with no complications) Weekly debridement; sterile dressing changes; limit weight bearing to foot If exudate or limited cellulitis, start oral antibiotic for staphylococcus and streptococcus Arrange home care follow-up • • • Follow-up Medical: Education: weekly until ulcer is resolved, then 2 month complete examination; assess foot at every visit daily foot inspection; report any injury or abnormality; wear appropriate footwear; skin, nail, callus care; avoid foot soaks; tight glycemic control If no improvement within two weeks, reclassify to high-risk complex ulcer; consider hospitalization Classification: High-Risk Complex Ulcer (active ulcer with extensive involvement) Hospitalize patient for wide surgical debride- ment; culture for infection; sterile dressing changes; no weight bearing on foot Consider becaplermin gel for neuropathic ulcers that have adequate blood supply If deep space infection, start parenteral antibiotic for staphylococcus and streptococcus Complete vascular evaluation if ischemia present • • • • Follow-up Medical: Education: daily until ulcer improves, then 2 month complete examination; arrange home care follow-up if improved reclassify to high-risk simple ulcer daily foot inspection; report any injury or abnormality; wear appropriate footwear; skin, nail, callus care, avoid foot soaks; tight glycemic control If no improvement within 2 weeks for simple ulcer or 1 week for complex ulcer, refer to specialist for surgical debridement and possible revascularization, amputation YES Figure 9.15 Foot Ulcer Treatment DecisionPath 358 MICROVASCULAR COMPLICATIONS patient’s alcohol use pattern and record tobacco use history. Check lower-extremity pulses, cal- culate ankle brachial index (ABI) from Doppler measurements, and determine digital pressure. As- sess and document patient education needs for foot and wound care. Assess social support and transportation needs (consider contacting public health nurse or home health nursing staff). Therapeutic interventions for high-risk simple ulcer. (See Photo 9.19 on page 360) Outpatient treatment should include the following: • Debridement every week in clinic (preferably by the same provider). Document ulcer size to facilitate future assessment of wound healing. • Limit weight bearing (bed rest, wheelchair, crutches, and/or contact cast). • Sterile dressing changes every day: topical antibiotics, consider an available hydrocol- loid for suppurative wounds. Avoid toxic agents (no betadine, H 2 O 2 , acetic acid, or Dakin’s solution). • Use oral antibiotics that cover staphylococcus and streptococcus infections for 2–4 weeks if an exudate or limited cellulitis is present. (Studies have shown that more than 90 per cent of limited diabetic foot infections re- spond to oral cephalexin or clindamycin, even though most are mixed infections.) Consider adding metronidazole to cover anaerobic in- fections if peri-wound erythema persists after 2 weeks of the initial antibiotic therapy. • Patient education to reinforce the care plan. • Home care follow-up every 1–3 days by a public health nurse to assess adherence to care plan until healing is accomplished. • Medical follow-up every week in clinic to monitor healing and modify care plan until healing is accomplished. For patients whose alcohol use pattern may ag- gravate wound healing or self-care practices, ini- tiate a referral to an alcohol treatment program. Consider hospitalization to supervise care Patients who use tobacco should be educated and referred to a smoking cessation program. Consider hospi- talization for patients with limited ability to adhere to self-care practices, poor visual acuity, insuf- ficient social support, and inability to minimize weight bearing. Maintain goal. A patient is stable when the ulcer heals. Future management should follow guidelines for the high-risk abnormal foot. Ulcers that are non-responsive to therapy (worse at any time or not improved after 2 weeks) become complicated ulcers and are managed according to guidelines for high-risk complex ulcer. High-risk complex ulcer Patients in with a high-risk complex ulcer (see Photo 9–20 p. 360) have large ulcers and/or have complicating factors. This represents approx- imately 1–2 per cent of people with diabetes. The therapeutic goal for patients with complicated ulcers is to reduce the size of the wound and eventually complete healing of the wound (see Figure 9.15). To meet this goal, interventions fo- cus on hospitalization and surgical consultation for wide surgical debridement, aggressive wound care, and re-vascularization if indicated. Amputa- tion is limited to nonviable tissue and considered only as a last resort. Entry criteria. Patients included in the high- risk complex ulcer category are those with any of the following findings: • an ulcer ≥2 cm in diameter and/or ≥0.5 cm deep • cellulitis with a margin >2 cm or the presence of ascending infection • temperature 38 ◦ C (100.5 ◦ F) • white blood count >12000 DETECTION AND TREATMENT OF FOOT COMPLICATIONS 359 • presence of deep space infection such as ab- scess, osteomyelitis, gangrene, or a sinus tract • absent pulses, an ankle brachial index <0.8, or the presence of ischemic symptoms • patients with simple ulcers that fail to improve after 2 weeks of management Baseline assessment. When a plantar ulcer is identified, a careful inspection of the foot must be performed. Debridement must occur, with re- moval of all necrotic material and eschars. Do aerobic and anaerobic cultures. The size and depth must be measured in centimeters and documented for follow-up comparison. Using a blunt metal instrument, probe the wound looking for involve- ment below the subcutaneous tissue, or sinus tracts. If the probe reaches the bone, suspect os- teomyelitis. Note evidence of extensive infection such as gangrene, lymphadenitis, osteomyelitis, or abscess. A plain film X-ray should be done to determine whether a foreign body, gas gan- grene, or osteomyelitis is present. Obtain vital signs, WBC, and ESR to assess for systemic involvement (although they may remain normal even with complex ulcers). Assess patient’s al- cohol use pattern and record tobacco use history. Check lower-extremity pulses, calculate ABI from Doppler measurements and digital pressure. As- sess and document overall glycemic control and patient education needs for foot and wound care. Assess social support and transportation needs (consider contacting a public health nurse). Therapeutic intervention for high-risk complex ulcer. All patients with a high-risk complex ulcer should be hospitalized. A consult- ing surgeon, wound care specialist or podiatrist knowledgeable in wound care should direct pa- tient care. However, the primary care provider can deliver much of the care. Inpatient care. Inpatient hospital care (see Chapter 10) should include the following: • Wide surgical debridement including cultures of excised tissue/bone suspicious for infection (aerobic and anaerobic). • Post-operative sterile dressing changes every day: topical antibiotics, consider an available hydrocolloid for suppurative wounds. Avoid toxic agents (no betadine, H 2 O 2 , acetic acid, Dakin’s solution). • Strict enforcement of non-weight bearing sta- tus on the affected limb. • Optimized metabolic control. • If deep space infection or cellulitis is present, treatment with parenteral antibiotics should be initiated. Provide broad-spectrum cover- age until selection can be guided by culture results. Switch to appropriate oral antibiotic when systemic symptoms abate and the in- fection nears resolution. • Patients with signs or symptoms of ischemia should proceed to definitive vascular evalua- tion and treatment. This includes patients with claudication or rest pain, abnormal findings on noninvasive vascular examinations, gangrene, or blue toe(s). Because many patients with diabetes have peripheral vascular disease, car- diovascular, and cerebrovascular disease, se- lection of a patient for vascular assessment and treatment requires clinical judgment of the risk/benefit ratio. Contrast materials used during arteriography for definitive diagnosis can have significant adverse effects on re- nal function among those patients with pre- existing diabetic kidney disease. • Patient education to promote required self- care practices following hospital discharge. • Communication with the primary-care pro- vider for subsequent outpatient wound care. • Therapeutic shoes to prevent reoccurrence of ulcer. Stabilization. A patient is stabilized when the wound size is decreased, infection is con- trolled, and vascular supply is sufficiently im- proved to promote wound healing according to the [...]... during surgery Diabetes Care 199 0; 13: 98 0 99 1 384 HOSPITALIZATION 9 Hirsch IB, Paauw DS, and Brunzell J Inpatient management of adults with diabetes Diabetes Care 199 5; 18: 870–878 10 Medical Management of Type 2 Diabetes 4th ed Alexandria, VA: American Diabetes Association, 199 8 11 Shulman C Diabetes mellitus and surgery In: Galloway J, Potvin J, Shulman C, eds Diabetes Mellitus 9th ed Indianapolis, In:... essential fatty acids and their eicosanoid derivatives Diabetes Med 199 0; 7: 574–5 79 4 Boulton AJ and Malik RA Diabetic neuropathy Med Clin North Am 199 8; 82: 90 9 92 9 5 Raskin P The relationship of aldose reductase activity to diabetic complications In: Baba S and Kareko T, eds Diabetes 199 4 Amsterdam: Elsevier, 199 4: 321–325 (Excerpta Medica International Congress Series 1100) 6 Max MB, Lynch SA, Muir... mellitus: mechanisms and an approach to diagnosis and treatment Mayo Clin Proc 199 3; 68: 691 –702 12 Fedorak RN, Field M and Chang EB Treatment of diabetic diarrhea with clonidine Ann Intern Med 198 5; 102: 197 – 199 13 Nakabayashi H, Fujii S, Miwa U, Seta T and Takeda R Marked improvement of diabetic diarrhea with the somatostatin analogue octreotide Arch Intern Med 199 4; 154: 1863–1867 14 Haines ST Treating... 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