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Diabetic neuropathy Wound healing

Diabetic neuropathy Wound healing. The diabetic foot. Neuropathy – principal problem Vascular disease – secondary. Four types of ulcers. Neuropathic ulcers Ischaemic ulcers Neuroischaemic ulcers Venous ulcers. Determine aetiology. Neuropathic? Vascular? Mixed? predominant pathology?

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Diabetic neuropathy Wound healing

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  1. Diabetic neuropathyWound healing Slides current until 2008

  2. The diabetic foot • Neuropathy – principal problem • Vascular disease – secondary Slides current until 2008

  3. Four types of ulcers • Neuropathic ulcers • Ischaemic ulcers • Neuroischaemic ulcers • Venous ulcers Slides current until 2008

  4. Determine aetiology • Neuropathic? • Vascular? • Mixed? predominant pathology? • Determine wound management • Act quickly Slides current until 2008

  5. Neuropathiculcers • Area of pressure • Callus • Red granulating base • Low-to-moderately exudative • Bounding pulses • Painless Slides current until 2008

  6. Intrinsic – biomechanical Slides current until 2008

  7. Extrinsic – thermal Slides current until 2008

  8. Extrinsic – footwear Slides current until 2008

  9. Extrinsic – chemical Slides current until 2008

  10. Management of neuropathic ulcers • Treat infection • Debridement of callus • Reduce pressure • Restrict walking • Dressings Slides current until 2008

  11. Pre- and post-debridement Slides current until 2008

  12. Felt deflection • Reduces pressure by 61% • Simple and cheap • Replace weekly • Impractical for exudating ulcers • Risk of tinea/skin tears Slides current until 2008

  13. Ulcer healing with felt deflective padding Week 1: pre-debridement Week 1: post-debridement Week 3 Week 6: healed Slides current until 2008

  14. Pre-fabricated casts • Simple to use • Will not fit all feet • Removable • Less effective in maintaining foot shape Slides current until 2008

  15. Ischaemic ulcer • On toes and foot margins • Pale granulation, sloughy tissue or eschar • Dry with irregular borders • Painful • Pulses weak or impalpable Slides current until 2008

  16. Management of ischaemic ulcers • Vascular assessment and treatment • Treat infection • Pain management • Dressings • Avoid compression/bandaging Slides current until 2008

  17. Treatment goals • Control infection • Improve blood supply • Optimize wound healing environment • Protect wound from trauma Slides current until 2008

  18. Neuro-ischaemic ulcer • Mixed neuropathic and vascular processes • One process more dominant • Need to assess Slides current until 2008

  19. Practice tips: neuropathic ulcers • Foams 2 cm larger than the wound • Use gels sparingly • Keep foot dry – wash separately • Do not use occlusive dressings • Extra pads increase pressure and occlude the wound Slides current until 2008

  20. Practice tips: ischaemic ulcers • Gels contraindicated in the presence of ischaemia • Do not debride • Do not use compression • Keep foot dry in shower and wash separately • Be very careful with tapes to prevent skin tears Slides current until 2008

  21. Foot infection • Swelling, redness, heat • Odour from ulcer • Increase in exudate • Failure to heal • Elevated blood glucose levels Pain may not be present if the person has loss of sensation. Signs of inflammation may be absent in people with severe ischaemia. Slides current until 2008

  22. In diabetes, clinical signs may be masked leading to delayed diagnosis of infection. Slides current until 2008

  23. Do not withhold antibiotics until results of culture available Rely on clinical judgement Slides current until 2008

  24. Antibiotic treatment is an essential aspect of treating diabetic foot ulcers – maintain until ulcer has healed.Depending on clinical response, frequent changes and long-term antibiotics may be required. Slides current until 2008

  25. Foot infection • Ulcer = risk of infection • Osteomyelitis (sausage toe) • Amputation Slides current until 2008

  26. Treatment of osteomyelitis • Antibiotics • minimum of 3 months until there is evidence of healing on x-ray or scan • Infected bones may need to be removed surgically Slides current until 2008

  27. Primary prevention No successful clinical trials Metabolic control Smoking cessation Secondary prevention Identify high risk feet Foot education Foot care Management of active foot problems (ulceration) Prevention of the diabetic foot disease Slides current until 2008

  28. Key points • Assess • Determine aetiology • Arrange appropriate wound management Slides current until 2008

  29. Case study • 70-year old man • Type 2 diabetes • Diabetes for 35 years • Smoker for 35 years Slides current until 2008

  30. Case study • Pulses absent • ABI’s Left - 0.69 Right - 0.71 • Left 1st MPJ ulcer • Right hallux (great toe) ulcer – had bypass now ABI improved to 1.00 Slides current until 2008

  31. Case study Biothesiometer • >50 volts Monofilament • cannot feel Reflexes • absent Slides current until 2008

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