Background
Of the many serious long-term complications of diabetes, foot complications are among the most devastating. At least 25% of people with diabetes will develop a foot ulcer during their life. People with diabetes are also 25 times more likely to lose a leg than people without diabetes.2
All patients should be assessed for diabetic peripheral neuropathy starting at diagnosis of type 2 diabetes and 5 years after the diagnosis of type 1 diabetes and at least annually thereafter. 1
Case scenario
Daw Htay Htay Mar, a 55 year-old chronic smoker, residing at Shwe Pyi Thar, was admitted to Medical Unit 2 with acute pulmonary edema due to an old myocardial infarct. She was recently admitted to Surgical Unit 3, YGH for wet gangrene of right foot with septic shock, which led to below-knee amputation. Pre-op, vascular assessment revealed peripheral arterial disease from the common femoral downwards on both legs. Blood sugar was uncontrolled with HbA1c 10.4% despite maximal oral hypoglycemic medications.
She was referred to the Department of Diabetes and Endocrinology for proper diabetic foot care. She complained of aching foot pain, tingling and numbness in her left foot at rest. On examination of the right foot, amputated stump wound was found not to have healed, with resultant ulcer (8×4 cm) covered with yellow slough and blackish wound edges. There was a large ulcer (20×11 cm) on the left medial malleolus, exposing tendons, muscles and bone which were blackish and dry (Wagner’s stage 5). Dorsalispedis, posterior tibial, popliteal pulses were not palpable and only faint femoral pulses were palpable on both sides. She could not sense monofilament and vibratory sense was also reduced. Ankle brachial index (Lt) was zero. Doppler ultrasound both legs showed severe peripheral arterial disease, occlusion of Rt popliteal artery and Lt anterior tibial artery, narrowing of Rt common femoral, superficial femoral, Lt common femoral, popliteal and posterior tibial artery. Lt foot X ray showed no obvious bony abnormalities.
ECG showed an old anterior infarct. She had cardiomegaly with reduced left ventricular ejection fraction and hypokinesia.Blood sugars are out of range and blood tests revealed raised CRP, ESR with leukocytosis. Luckily, her renal function is not impaired till that stage. (Creatinine 44-56 µmol/l)
Serial wound swab C&S showed Klebsiellapneumoniae, Pseudomonas aeruginosa, Acinetobacterlwoffii with resistance to most antibiotics. Sensitivity was seen Meropenam, imipenem, amikacin, co amoxiclav and ticarcillin.
Daily dressing was done with normal saline, metronidazole gel for wet and sloughy area and also tried various antibiotics course by course: according to culture results, IV meropenum, IV amikacin, PO linezolid were given. Acute myocardial infarct was also managed with dual antiplatelet for one month followed by aspirin 75 mg and cilostazole. Diuretics were adjusted when failure was controlled. She needed many pain control therapy with paracetamol, tramadol, gabapentin. Sugar control was optimized with premix insulin two times daily.
In spite of our efforts, the initial wound on the left foot expanded to a large area of dry gangrene along left saphenous vein and an area of wet gangrene appeared along peroneal and anterior tibialislongus tendon sheaths. After consulting with surgeons and orthosurgeons, a below-knee amputation of left foot was done two months after admission, with wound debridement of the amputated stump of the right foot. After the 2nd amputation, wound debridement was done three times on the amputated stumps and daily dressing and repeated courses of antibiotics were given which had taken 6 months of hospital stay. The patient is currently attending follow-up at DM clinic and both stumps have healed completely and doing physiotherapy at National Rehabilitation Hospital and preparing for artificial limbs. This is a tragedy of patients losing both limbs following diabetic foot ulcers.
Management strategies for diabetic foot problems in Yangon General Hospital
In Yangon General Hospital (YGH), the foot clinic was established in June 2016, and became more functional in January 2017 under the support of World Diabetes Foundation (WDF). It is mainly organized by endocrinologists and run twice a week in the Diabetes Outpatient Department. Services offered are foot screening for at feet risk foot on Thursdays and separate foot ulcer clinic on Friday where call us trimming, proper ulcer dressings and patient education regarding self-care are done.
Aim: All patients with diabetes should have their feet screened by healthcare providers at least annually. Patients with long-standing DM, previous history of foot problem and those with symptoms of neuropathy and ischemia should be prioritized.
Step 1. Foot risk assessment by Michigan Neuropathy Screening Score3 (symptoms & signs)
Symptom score ≥4 or sign score ≥2 indicate neuropathy. Vascular assessment by palpation of peripheral pulses. If faint or absent pulses, ankle brachial pressure index measurement by hand- held Doppler USG.
After risk assessment, the patients are divided into 4 risk groups;
1. Low risk
– no risk factors present except callus alone
2. Moderate risk
– deformity orneuropathy or
– non critical limb ischaemia
3. High risk
– previous ulceration or previous amputation or renal replacement therapy
– neuropathy and non- critical limb ischaemia or
– deformity and non- critical limb ischaemia or neuropathy
4. Active foot problem
– ulcer (esp., large ulcer>2cm, deep ulcer >0.5cm)
– spreading infection or
– critical limb ischaemia organgrene
– acute Charcot’s arthropathy
Follow up is set up as follows
1. Annually – for low risk patients
2. Frequently (3-6 months)– moderate risk
3. More frequently (1-2 months) – high risk
4. Admission – active foot problem
Step 2. Diabetic foot ulcer management
Investigations
Biochemical tests – Full blood count, urea, electrolytes, creatinine, hemoglobin A1C, lipid profile for comorbidities.
Microbiological test – wound swab culture and sensitivity of all infected wounds before starting antibiotics.
Radiological tests – when the ulcer is probing to bone, need x-ray to exclude osteomyelitis and arrange MRI if in high suspicion of Charcot foot.
Local wound care and dressing
Inspect the ulcer frequently (every 3 days, weekly or 2 weekly)
Debride the ulcer (with scalpel, spoon) and repeat as necessary
Cleansing with normal saline, diluted betadine (Never use Eusol dressing)
Dressing (gauge, hydrocolloid dressing, betaplast dressing)
Systemic treatment
– systemic antibiotics according to culture and sensitivities
– empirical treatment before culture result is available. (duration is 7 to 10 days : in case of osteomyelitis , should extend antibiotics to 2 to 4 weeks )
– mild – POAmoxicillin+Clavulanate TDS or
– Clindamycin 300 mg TDS or
– Levofloxacin 500 mg OD or
– moderate – IV Co AmoxiClav /Cefriaxone+ Metronidazole or
– IV Levofloxacin OD+ IV Metronidazoleor
– IV Imipenem–cilastatin
– severe- IV Piperacillin/tazobactam/IV Imipenem/cilastatin/IV Vancomycin plus IV Ciprofloxacin + IV Metronidazole for at least 2 weeks
Metabolic control and treatment adjustment by Physician
1. Ensure that sugar control is optimal : HbA1C should be <7 %
(insulin therapy is recommended for active infection)
2. Recommend ACEI or ARB to control blood pressure and prevent microvascular complications.
3. Lipid lowering with atorvastatin +/- fenofibrate is suggested.
4. Antiplatelet therapy for prevention of macrovascular complications
5. Psychosocial support and anti-depressive treatment for those with long-term sequelae.
Picture 2.below knee amputation (Lt) 24.2.18
References
- American Diabetes Association. Standards of Medical Care in Diabetes _2018. Diabetes Care. 2018;113(Supplement1).
- World Diabetes Foundation WDF_Annual Review 2016. Available at: http://www.worlddiabetesfoundation.org. pdf. Assessed on 20th April,2018
- Patient Version Michigan Neuropathy Screening Instrument MNSI. University of Michigan, 2000. Available at: www.med.uich.edu>svi>MNSI_patient. Assessed on 20th October, 2018.
Zar Chi Pyone1, Moe WintAung3, Khin Saw Than2, Khin Sanda4
1Assistant Lecturer, Department of Diabetes and Endocrinology, University of Medicine 1
2Professor, Department of Diabetes and Endocrinology, University of Medicine 1
3Professor/Head, Department of Diabetes and Endocrinology, University of Medicine 1
4Consultant, Department of Diabetes and Endocrinology, University of Medicine 1
