Peripheral vascular disease in diabeticsDr. Hossam Hassan, MD, FRCSNWAFH

PAD: A Call to Action

-What is peripheral arterial disease (PAD)? and why is it so dangerous?

-Diagnosing PAD in the primary care setting

-The importance of aggressive riskmanagement of PAD

-Evidence base for protecting patients with PAD

Atherosclerosis affects up to 10% of the Western population older than 65 years 12.2% required amputation Predicted mortality rates for patients with claudication at 5, 10, and 15 years of follow-up are approximately 30%, 50%, and 70%, respectively. most commonly manifests in men older than 50 years

The risk factors for PAOD diabetes, hypertension, hyperlipidemia, family history, sedentary lifestyle, and tobacco use

Smoking Greatest of all the cardiovascular risk factors Damage is directly related to the amount of used. Counseling patients on the importance of smoking cessation is paramount in management.

Diabetes epidemicIncidence of diabetes in the world in 2000 was 171,000,000Projected incidence in 2030 is 366,000,000In 2010, 12.3% of adults in the United States had diabetes

Incidence by Country

Society in Transition

Cost in Developed Countries25% of diabetic patients develop a foot problem in their lifetime2008: estimated 20.8 million with DM in USA Total of $19bn spent on diabetic foot ulcers$11bn spent on amputationUp to $21bn could be saved annually with practical and effective preventative foot-care education Rogers et al, JAPMA, 2008;98:166

Cost in Undeveloped Countries2010: estimated 51 million with DM in India Population-based study from ChennaiCost of illness study: 4677 subjects screened: 1050 with DM, 718 agreed to take partMedian direct cost for DM $526, indirect $103Costs increased according to complicationsExtrapolated to all India annual cost of Diabetes in India US$32bn. Tharkar et al, DRCP 2010;89:334

Prevalence of metabolic syndrome in each patientgroup (%)Cross-Sectional survey of 1,045 vascular disease patients0204060CHDStrokeAAAPADOlijhoek JK et al. Eur Heart J 2004; 25: 342-348.Metabolic syndrome is more common in PAD than in CHD or strokeAAA = Abdominal Aortic Aneurysm

Prevalence of PAD increases with ageFigure adapted from Creager M, ed. Management of Peripheral Arterial Disease. Medical, Surgical and Interventional Aspects. 2000. 1 Meijer WT et al. Arterioscler Thromb Vasc Biol 1998; 18: 185-192.2.Criqui MH et al. Circulation 1985; 71: 510-515. Patients with PAD (%)Rotterdam Study (ABI Test

Mortality is very high in patients with severe PADRelative 5-year mortality1. Criqui MH. Vasc Med 2001; 6 (suppl 1): 37. 2. McKenna M et al. Atherosclerosis 1991; 87: 11928. 3. Ries LAG et al. (eds). SEER Cancer Statistics Review, 19731997. US: National Cancer Institute; 2000.

Resnick HE et al. Circulation 2004; 109: 733-739.There is a strong two-way association between decreased ABI and increased risk for cardiovascular death1 Baseline ABI*Percent0204060

Only 1 in 10 patients with PAD has classical symptoms of intermittent claudication Only 1 in 10 of these patients has classical symptoms of intermittent claudication (IC)1 in 5 people over 65has PAD ABI

A screening ABI should be performed in patients with diabetes

The American Diabetes Association recommends screening for PAD in patients with diabetes1. American Diabetes Association. Diabetes Care 2003; 26: 3333-3341.2. Estes JM, Pomposelli FB Jr. Diabet Med 1996: 13: S43- S57.Those 10 yearsThose >50 years of age

If normal an exercise test should be carried out The ABI test should be repeated every 5 yearsFoot care is also important in diabetic patients as PAD is a major contributor to diabetic foot problems2

Risk factor management approach Smoking cessationWeight reductionTotal cholesterol

Key learning pointsEnsure aggressive and early risk management of patients who are at high risk but may be asymptomatic

Screen patients with diabetes >50 years of age, and those

Diabetic Foot Ulcers63% of all diabetic ulcers are due to a combination of:Neuropathy TraumaDeformity

Many are further complicated by Peripheral Arterial Disease (PAD) and infection

How do we screen patients?Comprehensive foot examHgA1CHistory reviewing risk factor

Development of UlcersTypically painless, even with severe infectionOften just report soiled socks

A diabetic foot ulcer should heal if:There is adequate arterial inflowAny infection is appropriately managedPressure is removed from the wound and its margins

Diabetic Lower Extremity UlcersCascade of Events:NeuropathyIschemic changesInjuryMassive tissue disruption(tunneling, undermining, cavity formation)Cellular dysfunction leukocytes / macrophagesInfection

NeuropathyIncorporates metabolic and vascular defectsResults in neuronal demyelination and atrophyMotor muscle atrophyAutonomic decrease in perspirationSensory loss of protective sensation

Structural DeformityLeads for focal area of high pressureDue to atrophy of the intrinsic musculature responsible for stabilizing the toes

Trauma Resulting from Neuropathic ChangesMotor neuropathy Altered gait and foot deformities

Autonomic neuropathyDry skin and fissures

Sensory neuropathyUnrecognized trauma Ill fitting shoesStepping on pins, pebbles, etc

Deformity Resulting from Neuropathic Changes

Cause high compressive & frictional forces around area of deformity = skin breakdownDirectly related to ill fitting footwear

Prevention in Patients with NeuropathyNeed to screen patient for neuropathyTest with Semmes-Weinstein MonofilamentUses touch pressure sensation by utilizing a 10 gram monofilamentDefines level of loss-of-protective sensationFailed monofilament test defined as inability to sense 4 of 10 locations per plantar aspect of the foot

Peripheral Arterial DiseaseDiabetes Mellitus increases the risk of lower extremity PADPAD leads to additional healing complications and increased risk for infectionOne in three patients with diabetes over the age of 50 has PADThe American Diabetes Association recommends screening for PAD in all diabetic patients older than 50 years

Clinical classification

Claudication, defined as reproducible ischemic muscle pain relieved with rest , is one of the most common manifestations of peripheral vascular disease

Ulcer on the toes, web spaces

Ischemic gangrenes of the toes, web spaces,

General Physical ExaminationAtrophy of calf muscles, loss of extremity hair, and thickened toenails are clues to underlying peripheral arterial occlusive disease (PAOD).

PulsesPalpation of pulses from the abdominal aorta to the foot, Auscultation for bruits in the abdominal and pelvic regions Absence of a pulse signifies arterial obstruction proximal to the area palpated.

Screening for PAD

When pulses are not present, further assessment of with a handheld Doppler device.An audible Doppler signal assures some blood flow No Doppler signals, a vascular surgeon should be immediately consulted

Ankle-brachial index (ABI), ratio of systolic blood pressure at the ankle to the arm.

Ankle-Brachial Index

Duplex ultrasound scanning

Contrast Angiography

Despite recent advances in the non-invasive evaluation of lower extremity PAD, contrast angiography remains the gold standard.Vasc Endovascular Surg. 2002;36:439445

Angiography

Angiography

Risk factors modification(strict control of HTN, DM and Lipids)Conservative medical management

Smoking cessation counselling

Exercise Program is the most effective

Exercise pyramid for Healthy life

Pharmacological therapy (Aspirin, clopidogril, pentoxfylline)

Physician Responsibilities Inspect patients shoes for areas of inadequate support or improperMost patients are okay with athletic shoes and thick absorbent socksPatients with deformities or special support needs benefit from custom shoesProvide education about proper care and follow upControl blood sugars

Patient EducationDaily foot inspection by the patient or caregiverGentle cleansing with soap and water, followed by topical moisturizersMinor foot injuries and infections can be unintentionally exacerbated by home remedies that impede healingAvoid hot soaks, heating pads, hydrogen peroxide, betadineCleanse minor wound and apply topical antibiotic to maintain a moist wound environment

How Should Diabetic Foot Ulcers Be Treated?Multidisciplinary Approach to Treatment

May involve a number of the following:General surgeryVascular surgeryDieticiansInfectious diseaseEndocrinologyDiabetes EducatorsRadiologyPhysical TherapyOrthotistNursing

Care Plan ObjectivesDetermine and Manage EtiologiesComprehensive History and Physical AssessmentNon-invasive studiesManagement of etiologiesLaboratory EvaluationNutrition statusGlucose controlCo-morbid disease managementUlcer managementOff-loadingPatient Education

Determine and Manage EtiologiesHistory and PhysicalPatient and their family medical historyHistory of the ulcerThorough assessment of the patientLower Extremity AssessmentSemmes Weinstein and Tuning Fork - Assesses for neuropathyHand-held Doppler - Dorsalis pedis and posterior tibial pulse signalsNon-invasive studiesVascular studiesRadiographic studies

Transcutaneous Oximetry (TcPO2) measures the oxygenation of the tissues around the ulcer

Skin Perfusion Pressure (SPP) - measures the pressure at which blood flow first returns to the capillaries following a controlled release of occlusion from a blood pressure cuff.

Arterial Duplex Ultrasound - Duplex ultrasonography of the arteries

Ankle-Brachial Index (ABI)/Segmental Pressures/Toe Pressures - Assess pressure at multiple levels on the limb or digit

Angiography invasive study providing detailed imaging of the arteries

Vascular Studies

Radiographic StudiesX-ray should be performed on all diabetic foot ulcerations to rule out foreign body presence

MRI recommended by ADA as best non-invasive diagnostic imaging for osteomyelitis

Bone Biopsy - the definitive diagnostic study for osteomyelitis allowing for culture and sensitivity of the specimen

Management of EtiologiesPAD and Osteomyelitis are two common secondary etiologies affecting healing of the diabetic ulcer

Both must be identified and corrected/optimized for successful ulcer healing to occur

Other etiologies also need to be identified and corrected/optimized for successful ulcer healing

Ulcer ManagementDiagnose and treat underlying etiologiesAdequate debridement Dressing choice based on ulcer needsTreatments that stimulate healingNegative Pressure Wound Therapy (NPWT)Biologic productsBioengineered tissuesGrowth factorsHyperbaric Oxygen Therapy (HBOT)Offload!!!!

Adequate DebridementSerial sharp ulcer bed preparationRemoves senescent cells, necrotic tissue, converts a chronic ulcer to an acute wound, re-initiates healing cascadeCenters that utilize sharp debridement exhibit the highest degree of healing. T.K. Carlson

Approaches to ulcer Care For the Diabetic PatientSimple dressings that meet the needs of the ulcer

Antimicrobial therapy topically and systemically

Advanced Treatment ModalitiesGrowth FactorsBio-engineered TissueNegative Pressure Wound TherapyHyperbaric Oxygen Therapy

Plastic surgery skin grafts/flaps

Advanced dressings can reduce costs up to 50% particularly when you consider the cost of an infectionUtilizing the wrong dressing can increase the cost of treating ulcers and cause further complications for the patientThoroughly assess the state of the ulcer bed before prescribing treatment plan/dressingsNothing works well on the DFU without proper offloading

Advanced Treatment Modalities

Off-Loading: A Standard of CareProper off-loading:Reduces pressureReduces shearReduces shockTransfers weigh from sensitive or painful areasCorrects or supports flexible deformitiesAccommodates fixed deformities

Off-Loading: A Standard of CareOff-loading includes:Rest/elevationFelt/foamMulti- podus splint/bootRemovable cast walker/walking bootTotal contact casting (TCC)Wedge shoeSurgical shoe with pressure relief insoleOther assistive devices used in additionCrutchesWheelchairsWalkers

Orthotic For Ulcers That Dont Heal

Orthotics For Ulcers That Do HealTherapeutic footwear should be placed upon healingPrevents recurrenceAccommodates deformitiesDistributes the pressure equally throughout the foot(The image is a copyrighted product of AAWC (www.aawconline.org) and has been reproduced with permission)

Patient EducationMust take an active role in their careUlcer managementRoutine nail careDisease managementDecreases the chance of reoccurrenceFoot hygieneDaily inspectionProper footwearPrompt treatment of new lesionsElective surgery to correct structural deformities before ulcerations occur(The image is a copyrighted product of AAWC (www.aawconline.org) and has been reproduced with permission)

PAD is a reliable warning sign that a patient is at high risk for life threatening cardiovascular and cerebrovascular events

PAD is easily overlooked by both patients and physicians assess whether patients presenting with symptoms or associated risk factors have PAD

Treatments are available to protect the patients with PAD from future MI or strokeSummary

Summary With the increase in diabetes in both the younger and aging population, we are at risk for greater complications

Common causes of Diabetic Foot Ulcers include: neuropathy, trauma, deformity, high plantar pressures

Common secondary etiologies include: peripheral arterial disease (PAD) and osteomyelitis

SummaryTreatment Objectives of Diabetic foot ulcersDetermine and manage the etiologiesEstablish blood supplyOff-loading followed by therapeutic footwear upon healingPatient educationOff-loading the pressure at the site of the ulcer is a standard of care

SummaryTreating the diabetic foot often includes:Debridement (clinical and/or surgical) Advanced treatment options HBONPWTBiologic products:Growth factorsBio-engineered tissuesDiabetic patients must be active participants in their care to decrease the chance of reoccurrence

Thank You

*PAD: A Call to ActionThe objective of this slide kit is to help primary care physicians (PCPs) recognise PAD and to raise awareness amongst PCPs that PAD is a risk marker for broader more serious risk; a patient who is diagnosed with PAD is at high risk of life-threatening cardiovascular and cerebrovascular ischemic complicationsThis slide kit has been developed in response to the PAD Call to Action Paper. The paper was written by a group of medical experts who wanted to extend this important message about PAD to the broad medical community1. This slide kit aims in particular to put into action four of the items called for in this paper: Increase awareness of PAD and its consequences (serious future cardiovascular and cerebrovascular complications) Improve the identification of patients with symptomatic PADImprove treatment rates among patients who have been diagnosed with symptomatic PADIncrease the rates of early detection among the asymptomatic population

Reference:Belch JJ et al. Critical issues in peripheral arterial disease detection and management. Arch Intern Med 2003; 163: 884 892.****Metabolic Syndrome is more common in PAD patients than in CHD or strokeOlijhoek et al (Netherlands) recently investigated the prevalence of metabolic syndrome in patients with various manifestations of vascular disease. The study population for their cross-sectional survey consisted of 502 patients recently diagnosed with CHD, 236 with stroke, 218 with PAD and 89 with abdominal aortic aneurysm (AAA).Metabolic syndrome was diagnosed according to Adult Treatment Panel III criteria.The prevalence of metabolic syndrome in the study population as a whole was 45% (not shown). In PAD patients it was 57%, in CHD patients 40%, in stroke patients 43%, and in AAA patients 45%.

Reference:Olijhoek JK et al. The Metabolic Syndrome is associated with advanced vascular damage in patients with coronary heart disease, stroke, peripheral arterial disease or abdominal aortic aneurysm. Eur Heart J 2004; 25: 342-348.

*Prevalence of PAD increases with ageThe prevalence of peripheral arterial disease (PAD) is age dependent. In the Rotterdam study (n=5,450), the prevalence of PAD based on the ankle-brachial index (ABI) increased from 9% of subjects 55 to 59 years of age to 57% of patients 85 to 89 years of age.1 Similarly, the prevalence of PAD increased from 2.5% in subjects 40 to 59 years of age to 18.8% in subjects 70 to 79 years of age in the San Diego population study (n=624). Prevalence was diagnosed using noninvasive tests of limb perfusion: segmental blood pressure, flow velocity, postocclusive reactive hyperemia and pulse reappearance half time.2

Discussion PointsBased on the statistics from the Rotterdam study, in a practice of 2,000 patients with about 300 patients over 85 it could be estimated that approximately 170 patients would be diagnosed with PAD. Q. How does this correlate to the experience in your own practice; how many patients would you estimate have been diagnosed with PAD in your patient population and how many might there be of whom you are not aware?

References:Meijer WT, Hoes AW, Rutgers D et al. Peripheral arterial disease in the elderly: the Rotterdam Study. Arterioscler Thromb Vasc Biol 1998; 18: 185-192.Criqui MH, Fronek A, Barrett-Connor E et al. The prevalence of peripheral arterial disease in a defined population. Circulation 1985; 71: 510-515. *Mortality is very high in patients with severe PADRisk of death associated with peripheral arterial disease (PAD) is as high as for many common cancers.1 In a US study of 744 patients tested for PAD, those with severe PAD (ABI < 0.4) had a 5-year survival probability of only 56%.2 This is comparable to the 52% survival in white patients with non-Hodgkins lymphoma, as recorded from 19861993 by Ries et al.3 Data for colon and breast cancer are reported in the same source.

References:1. Criqui MH. Peripheral arterial disease - epidemiological aspects. Vasc Med 2001; 6 (suppl 1): 37.2.McKenna M et al. The ratio of ankle and arm arterial-pressure as an independent predictor of mortality. Atherosclerosis 1991; 87: 119128. 3. Ries LAG et al. (Eds). SEER Cancer Statistics Review, 19731997. US: National Cancer Institute; 2000.

*There is a strong two-way association between decreased ABI and increased riskfor cardiovascular deathThere is a clear association between the extent of PAD and the risk of myocardial infarction (MI) and stroke1.

Reference:1. Dormandy JA, Creager MA. Ankle: arm blood pressure index as a predictor of atherothrombotic events: evidence from CAPRIE. Cerebrovasc Dis 1999; 9(suppl 1): 14.

*Only 1 in 10 patients with PAD has classical symptoms of intermittent claudicationThe GetABI study shows the prevalence of PAD in a typical unselected sample of patients in a primary care setting is substantial. On average, about every fifth unselected patient (age-adjusted prevalence 19.8%) in primary care has an ABI < 0.9, indicating generalised atherothrombosis.Sensitivity of diagnosis proportion of PAD patients in whom PAD is detected correctly by means of the WHO Intermittent Claudication (IC) questionnaire was 11.1% when using the ABI as a yardstick against which the questionnaire was completed.

Reference:Diehm C et al. High prevalence of PAD and co-morbidity in 6880 primary care patients: crosssectional study. Atherosclerosis 2004; 172; 95-105.

*The American Diabetes Association recommends screening for PAD patients withdiabetesIn patients with type 2 diabetes, peripheral arterial occlusive disease (PAD) is a major contributor to diabetic foot problems. Common foot problems include loss of feeling in feet, changes in the shape of feet, infection, ulceration, or gangrene that may lead, in severe cases, to amputation of a toe, foot or leg. Further, prevention of foot problems may be easier than treating foot problems.

*Risk factor management appraochAll patients with peripheral arterial disease (PAD), regardless of severity, should undergo risk-factor modification to achieve desired levels of cholesterol, blood pressure, and plasma glucose control. Smoking cessation has been shown to slow the progression of PAD to critical limb ischemia and reduce the risk of myocardial infarction and death from vascular causes.1 Lowering cholesterol levels in patients with coronary artery disease has also produced benefits in patients with PAD. Statins not only reduce cholesterol levels, they may also improve endothelial function. Intensive control of blood glucose levels prevents the microvascular complications of diabetes and should be adhered to in patients with PAD. Blood pressure reduction is also very important in this high risk group of patients and aggressive treatment of hypertension is warranted. In addition to lowering blood pressure, angiotensin converting enzyme inhibitors may confer additional protection against cardiovascular events independent of blood pressure lowering and can reduce renal complications in patients with type-2 diabetes. In the general population blood pressure of 120/80 is optimal, however this is almost unachievable by antihypertensive treatment in regular clinical practice.Antiplatelet therapy has been shown to reduce the risk of vascular ischemic events (MI, stroke, and vascular death) in this population. The risk of death and disability from stroke and MI merits the use of these agents.1Consider current guidelines (ACC/AHA are due to release new guidelines on PAD in mid 2004) including any local guidelines.

Reference:Hiatt WR. Medical treatment of peripheral arterial disease and claudication. N Engl J Med 2001; 344: 1608-1621.

* Nerve damage occurs in people who have had diabetes because their blood sugar level is higher than normal. Over time, high blood sugar levels damage the blood vessels and nerves. That's why people who don't control (or can't control) their blood sugar very well seem more likely to get diabetic neuropathy. Men have diabetic neuropathy more often than women. Diabetic neuropathy is a type of nerve damage that happens in people who have diabetes. This damage makes it hard for their nerves to carry messages to the brain and other parts of the body. It can cause numbness (loss of feeling) or painful tingling in parts of the body. Diabetic neuropathy can also cause changes in: Strength and feeling in different body parts Ability of the heart to keep up with the body's needs Ability to digest food Ability to have an erection (in men)

The effects of atrophy and neuronal demyelination produce a combination of motor, autonomic and sensory deficits.

Motor deficits are evidenced by weakness of the anterior tibial compartment and pedal muscular atrophy. This causes unstable digits and associated peak pressures which may result in deformity.

Autonomic neuropathy is associated with multiple foot complications. These can include dry, fissured skin due to insufficient sweat gland activity. The dry, fissured skin can lead to ulceration and infection.

Sensory neuropathy is the most commonly discussed and troublesome type of neuropathy for it leads to loss of protective sensation causing complications from the most minor of unnoticed trama to the foot.Source for information: Sheffield, P.J., Smith, A.P.S., & Fife, C. (Eds.) (2004). Wound Care Practice. Flagstaff, AZ: Best Publishing.

*Ill fitting shoes and sensory deprivation can lead to trauma which patients will not recognize until it is too late.

*Ulcers related to arterial insufficiency usually result from minor tissue trauma in areas of decreased blood flow. Good ulcer management focuses on meticulous wound care, avoidance of more trauma and restoring blood flow to the affected area. Severity of symptoms depends on a variety of individual factors such as activity level, psychological expectations, and coexisting risk factors smoking, diabetes, age, male hypertension, hyperlipidemia, thrombocytosis.

While risk factors for PAD take years to produce the arterial narrowing, acute modification of risk factors has surprisingly beneficial affects for healing these types of ulcers. Patients should stop smoking, control their glucose levels and control their hyperlipidemia.

ACC/AHA 2005 Practice Guidelines for the Management of Patients with Peripheral Arterial Disease Alan T. Hirsch, MD et al. Circulation 2006; 113; 463-654.Diabetes group warns vascular complication is under diagnosed and undertreated. M Mitka. JAMA 2004; 291:809-10.Diabetes Care. Volume 31, number 3: March 2008. American Diabetes Association.******A screening ABPI be performed in all diabetic patients >50 years of age; if the results are normal, the test should be repeated every 5 years.A screening ABPI should be considered in patients with diabetes 10 years.A diagnostic ABPI should be performed in any patient with symptoms of PAD.************Medicare pays for a pair of custom shoes each year*Multidisciplinary approach is crucial when dealing with diabetic patients. Wound centers usually have all of these specialists on staff that can allow for aggressive and rapid treatment of these ulcers for diabetic patients. May involve all of these specialties to monitor and control all the numerous co-morbidities to enhance the wound healing ability of this patient population.

*The objectives of a care plan, for the person with a diabetic foot wound, are multifold. First and foremost, all the contributing etiologies needs to be identified. Disease states nutritional status also need to be evaluated for proper management to minimize their affect on wound healing. Once these have been identified and corrected or managed, aggressive ulcer care can begin to accelerate the wound healing process. For any care plan to work for the diabetic foot wound, therapeutic offloading and patient education are a must.

*Absence of pedal pulses and presence of palpable popliteal pulses is a classic finding in diabetic arterial disease because of selective involvement of tibial arteries below the knee.

***These studies are simple to perform and guides clinicians towards future studies or interventions. These studies are performed in hospital outpatient departments.Most of these studies are also non-invasive. Due to the fact that diabetic patients vessels calcify, one should always order toe pressures on these patients as that is the only vessel that does not calcify*Radiographic studies should be a standard part of the diagnostic evaluation for the diabetic foot ulcer. Many result from traumatic injury, so a basic x-ray should be performed to rule out foreign body presence and fractures.Osteomyelitis is also common in the chronic diabetic foot ulcer, so and MRI or, even better, a bone biopsy should be considered to evaluate for osteomyelitis.***Once etiologies have been identified and managed, then aggressive treatment may be offered. Debridement removes dead tissue that may harbor bacteria and delay healing. Steed, et al, 1996, reports that healing is expedited by serial sharp debridement. It is important to re-initiate the inflammatory phase of wound healing to jump-start the chronic wound that has stalled in the proliferative phase (Bates-Jensen, B, 2001)Apligraf Produces Growth Factors that Stimulate Angiogenesis enhancing healingProteins expressed by activated fibroblasts: Angiogenic growth factors Vascular endothelial growth factor (VEGF) Homodimeric protein secreted by a variety of vascularized tissues induces endothelial proliferation and vascular permeabilityInduced in wound edge keratinocytes and macrophages, possibly in response to KGF and TGF- Basic Fibroblast Growth Factor (bFGF)bFGF or FGF-2, released by damaged endothelial cells and macrophages at wound site, is an important mediator of angiogenesisbFGF induces VEGF in vascular endothelial cells

Serial wound bed preparationCautious sharp debridement as indicatedAdvantagesRemoves senescent cells & necrotic tissueRemoves high bio-burdenConverts a chronic wound to an acute wound re-initiating the healing cascadeBenefits: studies support expedited healing

**It is important to re-initiate the inflammatory phase of wound healing to jump-start the chronic wound that has stalled in the proliferative phase. Sharp debridement independent of wound care, demonstrates quicker healing. Debridement removes senescent cells, nonviable tissue, reduces bio-burden, and stimulates the wound bed.

**Some wounds will respond quickly to basic conservative wound management and others will need more advanced therapies. The more sophisticated the wound center the more advanced offerings there will be available. It is important to have all necessary offerings for the benefit of the patient.

**The addition of knowledgeable wound care clinicians helps in knowing what modality is best for the patient. **reducing pressure on the diabetic foot ulcer is a vital integral component of effective wound management. Pedorthics is concerned with the design, manufacture, fit and modification of shoes and related foot appliances as prescribed for the reduction of painful or disabling conditions of the foot or limb. Proper off-loading helps reduce pressure, shear, shock, and transfer from sensitive or painful areas. It is important that diabetic patients are properly fitted for off-loading devices because they can often correct or support flexible deformities or accommodate fixed deformities. Joint motion can also be controlled and or limited. ***Diabetic foot ulcers that fail to heal often lead to amputation.

Photo provided by Ted Tomter**Patient education is imperative in successful wound healing and prevention of new ulcerations.******Diabetes is not going away. It is on the rise and affecting the younger population more and more.

Costs are astronomical and only increasing so it is imperative that the complications of diabetes be treated aggressively to decrease the overall cost of treatment as well as help the patient remain a vital, contributing person in society. We need to help these patient treat their co-morbidities quicker and control the factors we can control to decrease the chance of complications.

Diabetic patients routinely suffer from neuropathy which increase their chance of trauma and deformity to their lower extremities. PAD is also on the increase and affects more diabetics and is often unrecognized. We need to perform tests on diabetic patients sooner rather than later to determine if they have these co-morbidities in order to be able to prevent the complication of ulcers and poor healing.**There needs to be standardized charting and a common language between clinicians. That is why the Wager Grading scale is an excellent scale to use. Grading Diabetic Ulcers from a grade of 0 to 5 allows any clinician to understand what is involved in the description of the wound and what steps need to be taken to formulate a plan a care for this fragile group of people.

Identifying the etiology quickly and accurately should be the first priority in treating the diabetic foot ulcer. Performing appropriate lab work and providing off-loading of the area are also essential in treating these ulcers. Determining the level of blood supply to the affected limb and re-establishing the blood flow if possible is also critical in limb salvage for these individuals.

Following a pathway and performing simple, non-invasive tests such as a Semmes-Weinstien test, hand-held Doppler, TcPO2, SPP, Venous and Arterial Doppler's with segmental and toe pressures is essential to determine if more invasive testing is indicated. Angiography should be utilized with caution in this population of patients due to possible renal problems/involvement but remains the gold standard of care.

There are a variety of off-loading devices available on the market today to relieve pressure at the ulcer site. **It is important to remember that dressings do not heal the wound, but the advanced dressings, such as those with silver, collagen, and growth factors can certainly assist the body to heal more naturally and in a quicker fashion, thereby decreasing the overall cost of treating these chronic problems. Utilizing such products as Oasis, Apligraf, and Dermagraft also allow physicians to provide a matrix to assist with wound healing without taking a graft from the patient themselves and then having 2 wounds to worry about. Negative pressure therapy enhances granulation tissue formation by applying sub-atmospheric pressure to stimulate angiogenesis to the wound bed. HBOT is an excellent adjunctive therapy as well as those patients with a Wagner Grade 3 or higher wound may qualify for this type of therapy. Hyperbaric Oxygen increases the amount of oxygen in the blood stream thereby assisting the hypoxic wound to heal.

Patients need to take an active role in their health. For those patients with diabetes, they should inspect their feet daily, be taught proper foot hygiene, the importance of appropriate footwear which often must be supplied by a professional, and prompt treatment of any lesion. They may also want to have an elective surgery to correct a structural deformity before and ulceration occurs. This encourages and supports patient satisfaction and helps them have a certain quality of life while dealing with a difficult disease process.**Thank you for your participation today. Are there any questions?