Other therapeutics Wound management Key slide notes: Diabetic foot

Slide 1
Patients with diabetes who develop foot ulcers, are prone to more complications than non-diabetic patients, and there is a very real risk of losing a limb following diabetic foot ulceration. Prevention and risk management is important in managing care, and this is an area where healthcare professionals and commissioners need to be aware of the national guidance and its supporting evidence.

Slide 2
What exactly do we mean by the phrase the diabetic foot? We have a WHO definition defining the diabetic foot as a group of syndromes in which tissue breakdown occurs because of neuropathy, ischaemia and/or infection. Peripheral neuropathy causes loss of sensation and autonomic dysfunction. Ischaemia in the foot is where atherosclerosis of the leg vessels causes reduced circulation. Infection can complicate either and can lead to limb loss if treatment is delayed.

Slide 3
Here we look at the differences between neuropathic feet and neuroischaemic feet in more detail. In general, good circulation still exists in a neuropathic foot and the foot is warm to touch with palpable pulses. However, the neuropathic foot will have decreased sensitivity, feel numb and is often painless. If ulcers form, they tend to form on the weight bearing areas on the soles of the feet. The picture on the right shows a neuropathic diabetic ulcer with a punched out appearance. Such an ulcer may have formed under a callus on the margin of a weight bearing area of the foot, which pressed on the underlying tissue causing ulceration. The picture at the bottom left hand side of the slide shows a neuro-ischaemic foot ulcer. The foot itself is cool to touch because of poor circulation with absent or diminished pulses. There may also be pain, usually at rest. Neuro-ischaemic ulcers when they occur are located on the non-weight bearing foot margins and are usually caused by friction, for example from the pressure caused by ill-fitting tight shoes. They can also occur on the toe tips and beneath the toenails. The classic sign of pre-ulceration of the neuro-ischaemic foot is a red mark on the skin where friction has occurred. Ischaemia can be identified through the ankle brachial pressure index measurement the ABPI the same test we use to identify the difference between arterial and venous leg ulcers.

An ABPI less than 1 is indicative of ischaemia. However, as arteries in patients with diabetes can be atherosclerotic, the ABPI value may be unreliable. Generally, an ABPI above 1.3 should be viewed with caution and further investigation may be warranted. Comparing the waveform from the Doppler unit to the blood
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pressure can help indicate if arthrosclerosis is present, as the waveform will be damped where arterial narrowing is present.

Slide 4
In terms of managing diabetic foot ulcers, NICE advises a multidisciplinary, systematic approach to prevention and management of diabetic foot problems. The guidelines emphasise the importance of prevention of complications by having systems for regular recall and review of patients with diabetes. These systems should ensure that no one drops through the net and misses out on regular review, as prevention of complications is key. Each review should be systematic and, as a minimum, measure foot sensation, pulses and an inspection for deformity. Foot risk at each review is classified as either current low risk, increased risk, high risk or ulcerated foot. If a patient has had a previous foot ulcer or deformity or skin changes, they should be managed as high risk.

Slide 5
Low-risk patients are those with normal sensation, palpable pulses, no previous ulcer, no foot deformity and normal vision. In this group annual checks are advised with the patient given information to help them identify problems early on and to seek help when needed.

Slide 6
Patients at higher risk are those with neuropathy or absent pulses or previous vascular surgery or significant visual impairment or physical disability. In these patients, the reviews need to be more frequent at intervals of 36 months. The reviews should be conducted by a foot protection team and patient education and information needs to be reinforced especially with regard to footware.

Slide 7
For patients at high risk of a foot ulcer those with neuropathy, absent pulses, deformity or callus with risk factor or previous ulcer the same recommendations for those at increased risk apply, but the frequency of review is increased to 13 monthly. Its also recommended that the patient have specialist access to the foot protection team if needed.

Slide 8
The last category of risk is those patients with foot care emergencies and ulcers. Emergencies include new ulceration, critical ischaemia, swelling, severe infection, discolouration. These patients require rapid referral within 24 hours to the foot care team. The multidisciplinary team should manage the wound, any infection, relieve pressure and manage any complicating factors such as controlling glucose levels.

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Slide 9
Infection if present should be identified and treated as quickly as possible. With any ulcer there is a chance of bacteria invading the wound, but infections in these wounds will increase complications and worsen outcomes if not detected. Infection in the diabetic foot is serious, as it can lead to the loss of a limb. With other chronic wounds, infection should only be treated where clinical signs of infection are present, such as pyrexia or cellulitis. However, in people with diabetes the inflammatory response can be impaired by hyperglycaemia or may be less obvious with neuropathy or ischaemia in the tissues. Early signs of infection may be missed, so its important to have a low threshold for suspecting infection in diabetic foot ulcers. For this reason its advised that if a non-limb threatening infection is suspected the patient is referred to a specialist diabetes team within 24 hours. If the infection is considered as limb-threatening then immediate hospital admission is advised. Frequent re-assessment is required, as a non-limb threatening infection can become limb threatening relatively quickly.

Slide 10
The classification of the infected ulcer as limb threatening or non-limb threatening depends on the infective organism, the level of tissue and joint or bone involvement, and the condition of the individual patient. Limb threatening infections include those with cellulitis, systemic signs of infection, lack of response to oral antibiotics, malodorous wounds, soft tissue necrosis or suspected bone involvement. National guidance advises that diabetic foot infections should be treated with systemic antibiotics, not topical antimicrobials. Tissue specimens obtained by biopsy, curettage or aspiration of the ulcer are preferable to wound swab specimens, but in primary care where this isnt possible, a wound swab should be taken from the ulcer base and empirical treatment started with flucloxacillin (500 mg four times a day for one week). Erythromycin or clarithromycin can be used as alternatives where the patient is penicillin sensitive or allergic. The wound will need daily or alternate day assessments, with a review after 3 days when culture sensitivities are known, changing the antibiotic if needed. For patients with limb threatening infections those with cellulitis, discolouration, systemic signs of infection, malodorous wounds, soft tissue necrosis or suspected bone involvement hospital admission should be considered.

Slide 11
Who should be referred? CKS lists here those who need referral to a specialist team within 24 hours.
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It is worth mentioning here that these recommendations for referral to specialist diabetes teams can be built into practice based commissioning plans, to help bring care closer to home. NICE has recently produced advice and detailed support packs on how this can be done.

Slide 12
Hospital admission is usually needed for those with critical ischaemia, spreading cellulitis, crepitus, systemic signs of infection or lack of response to oral antibiotics, osteomyelitis or those who are immunocompromised.

Slide 13
In summary, diabetic foot problems are a common complication of diabetes and about 57% of diabetic foot problems lead to ulcers. The most important point to remember is that most diabetic foot ulcers are preventable. Given the enormous cost to the patient and the NHS, systems should be in place to minimise risk and prevent ulcers developing in patients with diabetes. NICE Diabetic foot care guidance recommends patient education and regular foot review by trained personnel to prevent ulcer development and to identify people at risk of foot ulceration. Care of people at increased risk of foot ulcers should be managed by a foot protection team, and care of people with existing ulcers should be managed by a multidisciplinary foot care team. Frequent assessment and reassessment of patients with diabetes should include a complete history as well as vascular, neuropathic, infection, skin, musculoskeletal, footwear and foot deformity assessments.

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