DF for Physiotherapy

7/28/2019 DF for Physiotherapy

1/61


2/61


3/61


4/61


5/61

Strategies For ComplexFoot Affections In Diabetes

Professor of Surgery, Faculty of Medicine,Cairo University (Kasr Al-Ainy)

Sherif El-Sarky


6/61

Strategies ForComplex Foot

Affections In Diabetes

Sherif El-Sarky


7/61

1) Vascularity and viability of foot tissues.

2) Extent of bony affection.3) Localization of deep collections.

4) Decision for intervention.

5) Assessment of progress.

Diagnostic challenges


8/61

Disease control1) Infect ioneradication.

2) Dead tissueextirpation.

3)Healing

promoting.

Objectives

Limb salvage1) Anatomical integrity.

2) Function.

1) In the shortest possible time.

2) At the least possible costs.


9/61

1) Precise in i t ia l evaluat ion, for: foot

vascularity, extent of infection and tissue

viability.

2) Precise therapeutic decis ion makingfor

intervention and RVP.

3) Continuous moni tor ingfor progress:infection, viability and healing.

Strategies


10/61

Initialevaluation


11/61

1) Vascularity and viability of foot tissues.

2) Extent of bony affection.3) Localization of deep collections.

4) Assessment of progress.

Diagnostic challenges


12/61

Foot vascularity is assessed by:

1) Clinical evaluation.

2) Doppler study and Duplex scan for

any major vascular insufficiency

above the ankle.

3) MRA for vascularity below the ankle

(when suspected to becompromised).


13/61


14/61

Extent of infection is assessed by:

1) Clinical evaluation (differential pressure).

2) Bacteriological study (C&S).

3) Imaging for deep collections: contrast

study (sinography) and MRI.4) Osteomyelitis is detected by: probing

test, plain X-ray and MRI.

Tissue viability is assessed clinically

(bleeding, color, reaction ..).


15/61


16/61


17/61


18/61


19/61


20/61


21/61


22/61


23/61


24/61

TherapeuticDecision


25/61

Locally, therapy, consists of:

1) Dressing.

2) Intervention (drainage, debridement).

3) RVP.


26/61

1. Pedal infections occur in up to 25% of diabeticpatients (Lipsky et al, 1990).

2. They are the most common cause of hospitaladmission in diabetics (Eckman etal, 1995).

3. Diabetic foot is behind25% of total expenses ofhospital treatment in diabetics (Stiegler, 1989).

4. It is the most common cause of amputation(after trauma) in USA (Newman et al, 1991).

1. Pedal infections occur in up to 25% of diabeticpatients (Lipsky et al, 1990).

2. They are the most common cause of hospitaladmission in diabetics (Eckman etal, 1995).

3. Diabetic foot is behind25% of total expenses ofhospital treatment in diabetics (Stiegler, 1989).

4. It is the most common cause of amputation(after trauma) in USA (Newman et al, 1991).

Facts

Facts !


27/61

Bier's principle (direct administration of agents totissues by retrograde venous perfusion with arterialblockade) was introduced in 1908.

Since then, it was limited to regional anesthesia(local intravenous anesthesia).

Eighty years later (1988), it was re-discovered as a

potential approach for therapy in foot disorders, by theLatin American investigators Acevedo and Schoopfrom Chile.

Bier's principle (direct administration of agents totissues by retrograde venous perfusion with arterialblockade) was introduced in 1908.

Since then, it was limited to regional anesthesia(local intravenous anesthesia).

Eighty years later (1988), it was re-discovered as a

potential approach for therapy in foot disorders, by theLatin American investigators Acevedo and Schoopfrom Chile.

Principle

The Principle


28/61

RVP resul ts in high t issue concentrat ion ofadm in is tered d rugs .

1. Tissue concentration of 99 mTc labelled human

serum albumin after RVP was:. 3 times higher than after intra-arterial. 7 times higher than after systemic i.v. injection

2. Pharmacologically, tissueconcentration of2.5 times higher than

after systemic i.v.

RVP resu l ts in h igh t issue concentration

of adm in is tered d rugs .

Tissue concentration of 99 mTc labelled human

serum albumin after RVP was::. 3 times h igher than after intr a-arter ial

. 7 times higher than after system ic i.v. inject io n

Pharmacologically, tissue concentration of

Netilmycin after RVP was 2.5 times higher than

after systemic i.v. injection (Seidel et al, 1995).


29/61

Recent App l icat ioauthor(s) indication agent frequency duration

Partsch et al,

1993

trophic

lesions buflomedil 3/week 3 weeks

Acevedo et al,1993

foot ulcer Cefotaxime once once

Seidel et al,1994 DNPU Netilmycin daily 10 days

Buhler-Singeret al, 1995

DNPUcombinatio

ndaily 10 days

Previous Applications


30/61

Patientsgroup disorder number

A diabetic foot: acute infection 8B diabetic foot: trophic ulcer 4C diabetic foot: pedal ischemia 3

D nondiabetic traumatic ulcer 4

E nondiabetic pedal ischemia 5

Patient Groups


31/61

Assessment

o f the patien tand the les ion

Assessment

o f the patien tand the les ion


32/61

1. Diabetic history: duration of diabetes, control ofdiabetes, history of neuropathy, vascular disease,coronary arterydisease, hypertension.

2. Pedal history: previous diabetic foot affection, its

duration, prior surgical intervention, amputations.3. General examination4. Local examination:

. lesions were defined.

. neurological examination. Doppler study of the lower extremities

. culture and sensitivity of any discharge

. assessment of underlying bone involvement

1. Diabetic history: duration of diabetes, control ofdiabetes, history of neuropathy, vascular disease,coronary arterydisease, hypertension.

2. Pedal history: previous diabetic foot affection, its

duration, prior surgical intervention, amputations.3. General examination4. Local examination:

. lesions were defined.

. neurological examination. Doppler study of the lower extremities

. culture and sensitivity of any discharge

. assessment of underlying bone involvement

Diabet ic pat ien ts : groAssessment of the patient


33/61

Examination of diabetic ulcer

1. site, shape and ulcer area.

2. ulcer depth: visually and by bone probing,. grade-I: exposing bone (visually). grade-II: reaching bone (by probing). grade-III: deep (> 3 mm, not reaching bone). grade-IV: shallow (< 3 mm)

3. severity of infection and surrounding inflammation.4. presence of gangrene and its extent5. clinical signs suggesting bone involvement

Examination of diabetic ulcer

1. site, shape and ulcer area.

2. ulcer depth: visually and by bone probing,. grade-I: exposing bone (visually). grade-II: reaching bone (by probing). grade-III: deep (> 3 mm, not reaching bone). grade-IV: shallow (< 3 mm)

3. severity of infection and surrounding inflammation.4. presence of gangrene and its extent5. clinical signs suggesting bone involvement

Group C Patien tsExamination of pedal ulcer


34/61

MethodMethod


35/61

1. A dorsal foot vein, or a vein in the lower leg ispunctured.

2. The leg is elevated for 5 minutes to emptyveins.

3. A sphygmomanometer cuff is applied to thelower thigh and inflated, while elevated, to alevel higher than systolic pressure of thepatient.

4. The agent(s) employed is slowly injected intothe vein diluted in 120 ml of saline.

5. After 20 minutes, the pressure is released.

1. A dorsal foot vein, or a vein in the lower leg ispunctured.

2. The leg is elevated for 5 minutes to emptyveins.

3. A sphygmomanometer cuff is applied to thelower thigh and inflated, while elevated, to alevel higher than systolic pressure of thepatient.

4. The agent(s) employed is slowly injected intothe vein diluted in 120 ml of saline.5. After 20 minutes, the pressure is released.

TechnicMethod


36/61

Clip 1

Clip 3

Clip 2


37/61

Agentsgroup agent(s)

A antibiotic (Gentamycin or otherwise)

B DSE/G/H/X

C DSE/G/H/XD DSE/G/X/P

E DSE/PGE/G/X

Agents


38/61

Frequency

group frequency

A once to 3 times

B 3 / weekC 3 / weekD 3 / week

E 3 / week

Frequency


39/61

1Good whenarter ial perfusionto the l imb isinadequate...as systemic therapy isnot expected to reachtherapeutic level in thetarget tissue.Value of RVP1Good whenarter ial perfusionto the l imb isinadequate...as systemic therapy isnot expected to reachtherapeutic level in thetarget tissue.


40/61


41/61


42/61


43/61


44/61


45/61


46/61


47/61


48/61


49/61


50/61


51/61

2Good when awound or an ulceris the targetas the concentration ofthe therapeutic agents inwounds and ulcersreaches 3 times higherthan intact skin.Value of RVP2Good when awound o r an ulceris the targetas the concentration ofthe therapeutic agents inwounds and ulcersreaches 3 times higherthan intact skin. the " r ins ing effect"


52/61


53/61


54/61

3Good for d iabeticsin part icu laras it is associated withimprovement in theimpaired microcirculationof skin in these patients.Value of RVP3Good for d iabeticsin part icu laras it is associated withimprovement in theimpaired microcirculationof skin in these patients.


55/61

4Good when theagent is tox icas smaller doses arerequired to reach thesame therapeuticconcentration in targettissue, and blood levelafter fixation in tissue isless than followingsystemic injection.Value of RVP4Good when theagent is tox icas smaller doses arerequired to reach thesame therapeuticconcentration in targettissue, and blood levelafter fixation in tissue isless than followingsystemic injection.


56/61

5Good when theagent is g ivensystem ical ly byinfus ion and thepat ient is card iacas this avoids volumeoverload hazards.Value of RVP5 Good when theagent is g ivensystem ical ly byinfus ion and thepat ient is card iacas this avoids volumeoverload hazards.


57/61

Good when the

agent is eitherexpensive or notalways avai lable

as smaller doses andshorter courses arerequired.6Value of RVPGood when theagent is eitherexpensive or notalways avai lableas smaller doses andshorter courses arerequired.6


58/61

Good whensurgery:

has fai led ,is contraindicatedor is requ ired

local lyas it can be consideredas an alternative or

adjunctive therapy

Value of RVPGood whensurgery:

has fai led ,is contraindicatedor is requ ired

local lyas it can be consideredas an alternative or

adjunctive therapy


59/61

Good when t ime

is a cr i t ical facto ras it can be used as atemporizing therapy forrapidly progressing

lesions due to its rapideffects.8Value of RVPGood when t imeis a cr i t ical facto ras it can be used as atemporizing therapy forrapidly progressinglesions due to its rapideffects.8


60/61

Good for pat ientw i th poorcompl iance to

long-term therapy9Value of RVPGood for pat ientsw i th poorcompl iance tolong-term therapy9


61/61

100Value of RVPGood as a las t di tch therapy !!Good as a las t di tch therapy !!

Documents

DF for Physiotherapy