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un HAPPY FEET!

un HAPPY FEET!. Dr Deirdre Hussey. Mr TM. 67 y.o. -severe pain on sole of his left foot -wet gangrene of middle toes of left foot -unable to weight bear -Fever and rigors x 24hrs -Discharged in post L TP angioplasty. Mr TM. Insulin dependent diabetic Renal transplant 2006 CABG x 3

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un HAPPY FEET!

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  1. unHAPPY FEET! Dr Deirdre Hussey

  2. Mr TM • 67 y.o. -severe pain on sole of his left foot -wet gangrene of middle toes of left foot -unable to weight bear -Fever and rigors x 24hrs • -Discharged in post L TP angioplasty

  3. Mr TM • Insulin dependent diabetic • Renal transplant 2006 • CABG x 3 • Gallstones • HTN

  4. Meds: -Cellcept -Aspirin -Bisoprolol -Novarapid - NKDA Ex smoker x 5 years Lives with wife and 3 daughters TM

  5. WCC 30.75 Neut 26.3 Hb 13.6 Plts 445 CRP 380 ESR 90 Urea 10.2 Creat 102 Na 135 K 4.2 Bili 9 ALT 119 Aphos 209 TM

  6. TM • Incision and drainage of plantar abscess, amputation of toes 3-5 • Debridement of wet necrotic tissue • Amputation 2nd toe and metatarsal

  7. TM • 2/52 Abx- wound still sloughy and wet • VAC dressing applied • Dramatic improvement and reduction in sloughy tissue • Wound dry and healing • Discharged with Freedom VAC

  8. TM

  9. TM

  10. Discussion • 23.7 million diabetics in USA • Diabetes healthcare cost $113 billion in 2007 (ADA) • 600,000 diabetic foot ulcers per year • $17,000 to treat an infected diabetic ulcer (without surgery)

  11. Discussion • 338 diabetic amputations in Ireland in 2008 • 50% of all amputation • 30,000 euro per procedure • €1m for 334 patients in 2007 • €852k for 284 patients in 2006 • €954k for 318 patients in 2005

  12. Discussion • Dressings • Antibiotics and glycaemic control • Local Debridement • Amputation • VAC Dressing

  13. VAC • Vacuum Assisted Closure • Negative Pressure system • Promotes tissue debridement, promotes healing • Optimum pressure 100-125mmHg

  14. Discussion

  15. Discussion • The principal indications for the use of the mains powered VAC are: • Acute and traumatic wounds • Sub acute wounds (i.e. dehisced incisions) • Pressure ulcers • Chronic open wounds (stasis ulcers and diabetic ulcers) • Meshed grafts • Flaps • The small ambulant unit is recommended for: • Venous stasis ulcers • Lower extremity diabetic ulcers • Pressure ulcers • Lower extremity flaps • Dehisced incisions • Grafts • Contraindications for both systems include: • Fistulas to organs or body cavities • Necrotic tissue in eschar • Osteomyelitis (untreated) • Malignancy in the wound

  16. Discussion • Negative pressure wound therapy after partial diabetic foot amputation: a multicentre, randomised controlled trialArmstrong DG, Lavery LA; Diabetic Foot Study Consortium,Lancet. 2005 Nov 12;366(9498):1704-10.

  17. Discussion • RCT, 18 centres, 16 week trial • 162 patients (NPWT=77, control = 85) • Wounds treated until healed or trial period completed • 56% NPWT healed v’s 39% in control group • Faster healing in NPWT group • Adverse events equal in both groups

  18. Discussion • An economic evaluation of VAC therapy compared with wound dressings in the treatment of diabetic foot ulcers; FlackS,Apelqvist J, Keith M, Trueman P, Williams D;J Wound Care. 2008 Feb;17(2):71-8

  19. Discussion • Improved healing rates • More QALYs • Lower cost of care ($52,830 versus $61,757 per patient

  20. Teaching Points • Diabetic complications enormous burden on healthcare • VAC excellent adjunct to antibiotics/surgery • Mechanism of action • Indication/contraindications of use

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