Diabetes Mellitus and Wound Healing-SMALL

8/6/2019 Diabetes Mellitus and Wound Healing-SMALL

1/42

..

)) --8585.(.(


2/42

Diabetes mellitusand wound healing


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.


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.


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.


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.


7/42


8/42

Carefulinspectionof the diabetic foot

onaregular basis isan easy ,cheapand effective measure topreventfoot complications.

Familyphysicianshave anintegralrole to ensure thatdiabeticsreceive

earlyandoptimalcare.


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.


10/42

Symptomsandsigns:Claudication,restpain inthe archat

night,absenthair,thinnedorshinyskin,thickenednail,rednessof the legondependencyandpallor on elevation.

N.B)

Inactivityandneuropathymaymaskclaudicationandrestpainand A-Vshuntingmaylimitpallorandcoldness.


11/42

NON INVASIVE VASCULAR TESTS

Test Abnormal valueTranscutaneousoxygen


12/42

Optimalulcerhealingrequiresadequatetissue perfusion.

Ulcer which failstoheal suspectischemia.

Vascularsurgeryconsultationandpossible revascularizationshould be

considered.

Controlof hypertension,hyperlipidemia

andcessationof smokingare essential.


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.


14/42

Autosympathectomyincreased bloodflowcharcotsjoint & deformity.

Nylonmonofilamenttestisasimple officetest forneuropathy.

+ve if nosensationwithpressure whichis

just enoughto bendthe filament.Motorneuropathycausesmuscle atrophy,weaknessresultingindeformity,planterpressure andaltersgait.


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.


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.


17/42

If bloodglucose>220 mg%31%nosocomialinfection.

If


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.


19/42


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).


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.


22/42

TreatmentTreatment

5items:Pressure reduction.

Resolve infection.Correctischaemia.Woundcare.

Bloodsugarcontrolwithinsulin anddiet.


23/42


24/42


25/42

Early surgical intervension tocorrect deformity as osseousprominence (e.g. metatarsal head,sesamoid bone,bunion,

hammer toe) if external pressureis not sufficient.

Ostectomy.


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.


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.


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


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.


30/42

Forresistantulcer:Forresistantulcer:--

1.Recombinanthumanplateletderivedgrowth factor formulatedintoageltime forwoundhealing.

2.Bioengineeredhumantissue producedbyseedinghumanskincellsontoan

absorbable meshsuppliesgrowthfactorsandstructuralproteins forwoundhealing.


31/42


32/42

4a-noninfected,nonischaemicwound.

b-acute charcotarthropathy.

5diabetic footinfection.

6criticalischaemia.

1,2,3risk factors for footulceration.

4,5,6risk factors foramputation.


33/42


34/42


35/42


36/42


37/42


38/42


39/42


40/42


41/42


42/42

Thankyou

Date post:	07-Apr-2018
Category:	Documents
Upload:	imang-dela-cruz
View:	215 times
Download:	0 times

Diabetes Mellitus and Wound Healing-SMALL

Documents