Diabetes Study Day talk 4th July 17.pdfhad DM.1 International Diabetes Federation Diabetes Atlas, 7th Ed, 2015 • UK DM Prevalence 2016 = ... Pathway to Ulceration in Patient with

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The Diabetes Education & Resource Centre

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Diabetes Study Day 4th July 2017

Diabetes Podiatry Service

Sarah Jane Hayhurst

Diabetes Lead Podiatrist

https://www.google.co.uk/url?sa=i&rct=j&q=&esrc=s&source=imgres&cd=&cad=rja&uact=8&ved=0ahUKEwiwp4rcxc7TAhVkLcAKHaeiAF4QjRwIBw&url=https://commons.wikimedia.org/wiki/File:NHS-Logo.svg&psig=AFQjCNHTax3pC259ICKDEh9xKgCiz3SmDg&ust=1493722941488116

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Diabetes: Worldwide

• Diabetes is a global epidemic.

– In 2015 415 million people

had DM.1

International Diabetes Federation Diabetes Atlas, 7th Ed, 2015

• UK DM Prevalence 2016 =

5.6%.2

– 3.6 million diagnosed with

DM.2

– A further 1 million

undiagnosed T2.2


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Diabetes

• The prevalence of DM is

nearly 3 x higher than

the prevalence of all

cancers combined.2

Diabetes UK, State of the Nation, 2016


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• NHS Rotherham CCG – Resident population 260,100,

– 48,900 are over 65-years of age,

• 8.9% of the population have DM,

• Compared with 6.4% in England.3,12

• Diabetic Foot Ulcers – 15 - 25% lifetime incidence.4

– Annual incidence 1.9 - 4.1%.5-7

– This equates to approximately 380 – 779 active ulcers per year in the Rotherham area

Current active diabetic foot

disease caseload – 201.


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0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

Site Ischaemia Neuropathy BacterialInfection

Area Depth

National Diabetes Foot Care Audit 2014 – 20168 We have larger, deeper ulcers with more infection

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Major amputations per 1,000

people aged 17+ with diabetes

Minor amputations per 1,000 people aged 17+ with diabetes


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Gold Standard Care -

Guidelines Active Diabetic Foot Disease


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All Guidelines • Optimal glycaemic control

• Optimal wound care

• Optimal offloading

• Aggressive management

of infection

• Access to vascular

• Access to imaging

• Education


So whats the problem?

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Loss of protective

Sensation

https://www.google.co.uk/url?sa=i&rct=j&q=&esrc=s&source=imgres&cd=&cad=rja&uact=8&ved=0ahUKEwiwp4rcxc7TAhVkLcAKHaeiAF4QjRwIBw&url=https://commons.wikimedia.org/wiki/File:NHS-Logo.svg&psig=AFQjCNHTax3pC259ICKDEh9xKgCiz3SmDg&ust=1493722941488116http://www.google.co.uk/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&ved=0CAcQjRw&url=http://imgkid.com/tick-and-cross.shtml&ei=yoJ1VM_TJc6IuATW34CwCg&psig=AFQjCNHxT5FVRO3CyFEWED-QTFkbK6F16Q&ust=1417073190399052http://www.google.co.uk/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0CAcQjRw&url=http://imgkid.com/tick-and-cross.shtml&ei=v4J1VK_7N4uRuQSBqYGQCw&psig=AFQjCNHxT5FVRO3CyFEWED-QTFkbK6F16Q&ust=1417073190399052

Signs and symptoms of peripheral

neuropathy [13]

•“Feet feel asleep” / numbness / “dead feeling”

•Tingling / pins and needles / “ant bites”

•Burning pain

•Shooting pains / “like electric shock”

•Lancinating pains / “knife like”

•Contact pain, often with day-time clothes and bedclothes on (allodynia)

•Pain on walking described as “walking barefoot on marbles” or walking barefoot on hot sand or broken

glass.

•Sensations of heat or cold in the feet, persistent achy feeling in the feet, cramp-like sensations in the legs

•Foot ulceration

•Ataxia (a lack of muscle control during voluntary movements)

•Weakness

•Falls

•Orthostatic hypotension

•Nocturnal exacerbations

Inspect for foot deformity

High

plantar

pressure

sites

Charcot / rocker bottom

deformity

Toe deformities:

Hammer / Mallets / Clawing

intrinsic minus foot

hallux abducto valgus

Signs and symptoms of PVD [14]

• Skin colour may be pale / white

• Skin appearance thin / fragile “Parchment-like”

• Hair less

• Muscle atrophy

• Weak pulses / pulse less

• Cool to cold temperature

• Atrophic nails

• Capillary refilling time >3 seconds

• Intermittent Claudication

• Rest pain

• Cyanosis

• Tissue loss/ ulceration

• Gangrene

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Ankle Brachial Pressure Index Toe pressures/ Toe Brachial Index [15]

Grade ABPI

Normal 0.91 - 1.30

Mild 0.60 – 0.90

Moderate 0.40 – 0.60

Severe < 0.40

Poorly Compressible >1.30


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Toe pressures/Toe Brachial Index


MOTOR

Muscle wasting & atrophy (weakness)

Deformity

Abnormal pressure

High plantar pressure

Callus formation

SENSORY

Loss of protective sensation

Loss of biological incentive to seek

help

AUTONOMIC

Anhidrosis & dry skin

↓Sympathetic tone (altered blood flow

regulation)

CHARCOT

MICRO

STRUCTURAL Capillary BM

thickening

FUNCTIONAL AV Shunting

MACRO

STRUCTURAL Atherosclerosis

Occlusive narrowing

(stenosis)

Critical limb ischemia

↓ Nutrient Capillary Blood Flow

ISCHEMIA

Diabetic Foot Ulcer (Anemia, nutritional deficit)

Amputation

Structural Deformity

& Cheiroarthropathy

ESRF & Dialysis

Impaired response

to infection

Trauma (Footwear & Barefoot Walking)

DPN (micro) Vascular

Pathway to Ulceration in Patient with DM [modified from 20 & 21]

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Things we need to look for

-Fungus

-Nail care: thickened, damaged, fungal infection

-In growing toe nails +/- infection

-Corns -Callus


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Podiatry Treatment


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If you can’t see it, how can you assess it?

Wound bed preparation & debridement - if required and safe - based on aetiology!

Pre-debridement WA Post-debridement WA


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Remove devitalised tissue and reduce bacterial burden!

Wound bed description and severity in notes is dependent on debridement!

No debridement = eschar (necrosis?) With debridement = granulating


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• Always clean the wound with sterile solution

(saline/water)

• Cover with a sterile dressing

• Monitor the wound, if the

wound deteriorates inform ward doctors

• Refer to Dr Franke Endocrine Consultant

• Refer Podiatry

• Refer Tissue Viability Nurses

Cover & clean all wounds


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Typical

features of

Diabetic Foot

Ulcers

according to

aetiology17


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Images from: International Best Practise Guidelines


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WA Check List

Chronic neuropathic ulcer, 1.5 yrs, A1 TWC

1st PMA – transfer lesion, no pain

100% unhealthy granulation

Size 1.6cm x 1.3cm, 0.3cm, no probing

Macerated fibrotic edges

Periwound macerated callus

Heavy serous exudate, no odour

No overt signs of infection

Wound history/causal factors

Aetiology

Type of wound

Location

Wound bed

Size (PROBING / STATIC = WHY)

Underlying tissues

Wound edges (UNDERMINING?)

Periwound

Exudate type & consistency

Odour

Pain (IN NEUROPATHIC PATIENT?)

INFECTION

Suspicion of malignancy

Classification


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INFECTION: Never underestimate it! Classical Signs? [16]


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PROBING - Hidden Depths


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Stage 1

Haemostasis

- Initial bleeding

- Vasoconstriction of vessels to minimise blood

loss

- Platelet aggregation

- Temporary clot formation

Stage 2

Inflammatory Response

- Release of inflammatory mediators

- Vasodilatation

- Phagocytosis commences

Increased permeability of vessels

Localised swelling, redness & tenderness

- Macrophages release growth factors

- Regulation of healing process

Stage 3

Proliferation

- Macrophages stimulate angiogenesis

- Promotion of new tissue

- Proliferation of connective tissue

- Wound decreases in size by granulation, contraction

and epitheliaslisation

Stage 4

Maturation

- This phase can last for many months# Initially the

scar is red and raised

- In time the blood supply to the area reduces and

the scar will become pale and flatten

Four Stages of wound healing19


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Inform patient of

diabetic foot

emergency advise/

what to look for &

where to get help


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LOW No risk factors

Callus alone is considered low risk

Annual screening by trained Healthcare Professional


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MODERATE

Deformity * or

Neuropathy (loss of sensation) or

Lower limb peripheral arterial disease

Refer to specialist podiatrist


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HIGH

Previous ulceration or

Previous amputation or

On renal replacement therapy (dialysis or transplant) or

Neuropathy (loss of sensation) and lower limb peripheral arterial disease together

or

Neuropathy (loss of sensation) in combination with callus and/or

deformity* or

Lower limb peripheral arterial disease in combination with callus and/or

deformity*

Refer to specialist podiatrist


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ACTIVE Ulceration or

Spreading infection or

Critical limb ischemia (severe peripheral arterial disease)

Gangrene

Suspicion of acute Charcot foot or an

unexplained hot, red, swollen foot with or without pain

Rapid referral (within one working

day) MDT, for triage within one further working day


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Red, hot, swollen!

https://goutandyou.com/gout-in-pictures/


Types of off-loading devices KEY: FW = forefoot wounds, MW = midfoot wounds, HW = heel wounds

Non-pneumatic

removable cast

walker (RCW)

(FW, MW)

Heel wedge

half-shoe (HW)

Total contact

insole

(prevention &

post-healing)

Peg-assist

insert, used in

combination

with RCW or

post-op shoe

(FW, MW, HW)

Pneumatic

RCW (FW,

MW)

Total contact

cast (FW, MW)

Forefoot

wedge half-

shoe (FW)

Wound care

rocker shoe

(FW, MW)

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Diabetic foot ulcers precede up to 83% of major amputation [22]

Take home message

and 93% of minor amputations [22] 85%are preventab e[23]


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NOW...

Hands on !!


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References 1. International Diabetes Federation. IDF Diabetes Atlas, 7th edn. Brussels, Belgium: International

Diabetes Federation; 2015. 2. Diabetes UK. State of the nation 2016: Time to take control of diabetes. 2016. 3. Public Health England. Cardiovascular disease profile – Diabetes April 2016: NHS Rotherham

CCG. Available at: http://webarchive.nationalarchives.gov.uk/20170302112650/http://www.yhpho.org.uk/ncvincvd/pdf/Diabetes/03L_Diabetes.pdf

4. Singh N, Armstrong DG, Lipsky BA. Preventing foot ulcers in patients with diabetes. JAMA. 2005;293(2): 217–28.

5. Abbott CA, Carrington AL, Ashe H, et al. The North-West Diabetes Foot Care Study: incidence of, and risk factors for, new diabetic foot ulceration in a community-based patient cohort. Diabet Med. 2002;19(5):377–84.

6. Lavery LA, Armstrong DG, Wunderlich RP, Tredwell J, Boulton AJ. Predictive value of foot pressure assessment as part of a population-based diabetes disease management program. Diabetes Care. 2003;26(4):1069–73.

7. Ramsey SD, Newton K, Blough D, et al. Incidence, outcomes, and cost of foot ulcers in patients with diabetes. Diabetes Care. 1999;22(3):382–7.

8. Health and Social Care Information Centre. National Foot Care Audit Local Report: Providers. 2014-2016. Available at: content.digital.nhs.uk/footcare


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References 9. Health and Social Care Information Centre. National Diabetes Inpatient Audit 2016. Hospital Level

Analysis – England. Available at: content.digital.nhs.uk/footcare

10. The Yorkshire and Humber Clinical Networks. Yorkshire and the Humber VISUAL Diabetes Footcare

Activity Profile – August 2016. Available at: www.yhscn.nhs.uk

11. Armstrong DG, Lavery LA & Harkless LB. (1998) Validation of a diabetic wound classification

system: The contribution of depth, infection, and ischemia to risk of amputation. Diabetes Care,

21(5) pp: 855-859.

12. Cardiovascular disease data and analysis: a guide for health professionals. Diabetes Prevalence

estimates for local population. 2015. Available at: https://www.gov.uk/guidance/cardiovascular-

disease-data-and-analysis-a-guide-for-health-professionals.

13. The Journal of Foot & Ankle Surgery. Diabetic Foot Disorders A Clinical Practise Guideline. Practise

Guideline (2006 revision). 2006. p.S-6.[accessed 07 Oct 2016]. Available from:

http://www.jfas.org/article/S1067-2516(07)60001-5/pdf

14. 14. Diabetes UK. Putting Feet First. Annual foot review for everyone with Diabetes over 12 years

old. 2015. Available from: https://www.diabetes.org.uk/Professionals/Resources/shared-

practice/Footcare/

15. American Diabetes Association. Peripheral Arterial Disease in people with Diabetes. Diabetes Care.

2003; 26(12): 3333-3341. [accessed 14 Oct 2016). Available form:

http://care.diabetesjournals.org/content/26/12/3333.

https://www.google.co.uk/url?sa=i&rct=j&q=&esrc=s&source=imgres&cd=&cad=rja&uact=8&ved=0ahUKEwiwp4rcxc7TAhVkLcAKHaeiAF4QjRwIBw&url=https://commons.wikimedia.org/wiki/File:NHS-Logo.svg&psig=AFQjCNHTax3pC259ICKDEh9xKgCiz3SmDg&ust=1493722941488116https://www.gov.uk/guidance/cardiovascular-disease-data-and-analysis-a-guide-for-health-professionalshttps://www.gov.uk/guidance/cardiovascular-disease-data-and-analysis-a-guide-for-health-professionalshttps://www.gov.uk/guidance/cardiovascular-disease-data-and-analysis-a-guide-for-health-professionalshttps://www.gov.uk/guidance/cardiovascular-disease-data-and-analysis-a-guide-for-health-professionalshttps://www.gov.uk/guidance/cardiovascular-disease-data-and-analysis-a-guide-for-health-professionalshttps://www.gov.uk/guidance/cardiovascular-disease-data-and-analysis-a-guide-for-health-professionalshttps://www.gov.uk/guidance/cardiovascular-disease-data-and-analysis-a-guide-for-health-professionalshttps://www.gov.uk/guidance/cardiovascular-disease-data-and-analysis-a-guide-for-health-professionalshttps://www.gov.uk/guidance/cardiovascular-disease-data-and-analysis-a-guide-for-health-professionalshttps://www.gov.uk/guidance/cardiovascular-disease-data-and-analysis-a-guide-for-health-professionalshttps://www.gov.uk/guidance/cardiovascular-disease-data-and-analysis-a-guide-for-health-professionalshttps://www.gov.uk/guidance/cardiovascular-disease-data-and-analysis-a-guide-for-health-professionalshttps://www.gov.uk/guidance/cardiovascular-disease-data-and-analysis-a-guide-for-health-professionalshttps://www.gov.uk/guidance/cardiovascular-disease-data-and-analysis-a-guide-for-health-professionalshttps://www.gov.uk/guidance/cardiovascular-disease-data-and-analysis-a-guide-for-health-professionalshttps://www.gov.uk/guidance/cardiovascular-disease-data-and-analysis-a-guide-for-health-professionalshttps://www.gov.uk/guidance/cardiovascular-disease-data-and-analysis-a-guide-for-health-professionalshttps://www.gov.uk/guidance/cardiovascular-disease-data-and-analysis-a-guide-for-health-professionalshttps://www.gov.uk/guidance/cardiovascular-disease-data-and-analysis-a-guide-for-health-professionalshttp://www.jfas.org/article/S1067-2516(07)60001-5/pdfhttp://www.jfas.org/article/S1067-2516(07)60001-5/pdfhttp://www.jfas.org/article/S1067-2516(07)60001-5/pdfhttp://www.jfas.org/article/S1067-2516(07)60001-5/pdfhttp://www.jfas.org/article/S1067-2516(07)60001-5/pdfhttps://www.diabetes.org.uk/Professionals/Resources/shared-practice/Footcare/https://www.diabetes.org.uk/Professionals/Resources/shared-practice/Footcare/https://www.diabetes.org.uk/Professionals/Resources/shared-practice/Footcare/http://care.diabetesjournals.org/content/26/12/3333

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References 16. Armstrong DG, Lavery LA and Harkless LB. Validation of a diabetic wound classification system. The

contribution of depth, infection and ischemia to risk of amputation. Diabetes Care. 1998; 21(5): 855-859

17. International Best Practice Guidelines: Wound Management in Diabetic Foot Ulcers. Wounds

International, 2013. Available from: www.woundsinternational.com

18. Swanson T, Grothier L, Schultz G. Wound Infection Made Easy,. 2014. Available at

www.woundsinternational.com .

19. Ousey K, McIntosh C. Lower Extremity Wounds. A problems-based learning approach. John Wiley &

Sons, Lts; England. 2008.

20. Boulton AJM. The pathway to foot ulceration in diabetes. Med Clin N Am. 2013; 97(5): 775-

790.

21. Frykberg RG, et al. Diabetic foot disorders: A clinical practice guideline. The Journal of Foot &

Ankle Surgery. 2006; 45(5): S1-S64.

22: Veves A (ed.), Giurinin JM (ed.) and LoGerto FW (ed.). The Diabetic Foot Medical and

Surgical Management. 2010. p. 37. [accessed 07 Oct 2016]. Available from:

file:///C:/Users/Sarah/Desktop/The%20Diabetic%20Foot%203rd%20ed%202012.pdf.

23: International Working Group on the Diabetic Foot. Time to Act. Netherlands; Los Druk &

Design BV Naaran. 2011.
https://www.google.co.uk/url?sa=i&rct=j&q=&esrc=s&source=imgres&cd=&cad=rja&uact=8&ved=0ahUKEwiwp4rcxc7TAhVkLcAKHaeiAF4QjRwIBw&url=https://commons.wikimedia.org/wiki/File:NHS-Logo.svg&psig=AFQjCNHTax3pC259ICKDEh9xKgCiz3SmDg&ust=1493722941488116http://www.woundsinternational.com/http://www.woundsinternational.com/file:///C:/Users/Sarah/Desktop/The Diabetic Foot 3rd ed 2012.pdf

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Diabetes Study Day talk 4th July 17.pdfhad DM.1 International Diabetes Federation Diabetes Atlas, 7th Ed, 2015 • UK DM Prevalence 2016 = ... Pathway to Ulceration in Patient with