Please join Emily Greenstein, APRN, CNP, CWON, FACCWS for this mini on-demand video where she discusses diabetic foot ulcers and how to treat them.
Thank you for joining us today. My name is Emily Greenstein and I'm a certified wooden Rostami nurse practitioner at Stanford Health in Fargo, North Dakota. Today, I'm going to talk to you about diabetes and the impact it has on wound care today. So this is just some important information to remember that all photographs in here are my own um that the use of any of the systems is to be done under a treating physician or provider and that everything I will talk about today is um my own opinion and will be nothing off label will be presented. So disclosures um I am a consultant for Casey I, which is now part of three a.m. So first of all, let's start off by just looking at some statistics, we all know that diabetes is a huge problem in this country and it's becoming a even bigger problem worldwide. It's projected that 366 million people by the year of 2030 will be impacted by diabetes. These people are at high risk for complications including the development of foot ulcers. Foot ulcers are affecting about 20% of all diabetics. The even more scary statistic is that once and also develops. There is an incredibly high increased risk for amputation. As a matter of fact, about 85% of all cases that end an amputation first have an ulcer that precedes it. So looking at that foot ulcers affect about 1.5 million people a year. So now let's look at the path of physiology of a diabetic foot ulcer. How do these ulcers form and you don't just wake up one day and have an ulcer on your foot. So, more than 60% of diabetic foot ulcers are a result of peripheral neuropathy. There is also a ski mia from the peripheral vascular disease. So what happens is these patients may lose sensation in their feet. Um There might be some structural changes that are a result of the diabetes also, which results in internal pressure, causing these alterations as well as external pressure from their footwear. When we look at neuropathy and we look at the path of physiology behind neuropathy, it is a huge spectrum that's completely connected. We have a patient who's in a hyper glycemic state so their blood sugar is really high. This leads to increased all those reductase sorbitol degenerates, which then in turn leads to an increase in intracellular glucose. Once that intracellular glucose has increased, it leads to sorbitol and fructose getting metabolized and into the synthesis of nerve cells. So what happens is that high sugar starts to break down that normal neuron conductivity which leads to an increase in oxidative stress. Once you have an increase of oxidative stress that leads to a vessel constriction, loss of sensation, autonomic neuropathy and all of those things can lead to the development of an ulcer. So next time we talk about the diabetic foot ulcer we need to look at infection. So patients who have diabetic foot ulcers are at higher risk for the development of an infection because of the unique anatomy at third foot, an infection may result from a simple puncture wound from a neuropathic ulcer from the nail plate or from the interdigital web space. So I look at patients who have diabetes um thinking that they might have that micro vascular blood flow problems. They are at high risk for a small problem turning into a large problem really fast. We also got to look at the microbiology and that is usually dependent on the patient's environment and the severity of the infection itself. So looking at can this patient be treated as an outpatient setting or do they need to be hospitalized and given? Um I. V. Antibiotics we also need to look at. Is the infection mild or a superficial ulcer? Is it pretty contained to the local area? Those types of ulcers are usually infected with aerobic or gram positive cock. I when we look at the deeper or limb threatening ulcers in diabetics so many of you may have heard of um necrotizing fasciitis. Those are usually calling microbial and they can be gram positive and gram negative. The most common cause of necrotizing fasciitis in the diabetic foot is strep beef. Next when we talk about ischemia. So in patients who have diabetes they are at high risk for the microvascular and macro vascular problems. So there's non inclusive micro circulation and impairment which occurs because if you go back to that side, if you remember their high glucose levels are damaging the cells resulting in high oxidative stress resulting in a leukemia. There's a macro angiography which is the larger vessels. So they may have blocked vessels in the larger. So looking at your morals or your papa teal arteries all way down to the microvascular ones. So we want to look at capillary blood flow and the response to stimuli. When we're doing an assessment, we want to do a thorough vascular assessment on all of our diabetic patients also. And I can talk about for these patients are at high risk for atherosclerosis predominantly of the tibial area. So when you're looking at doing a vascular assessment on this patient, it is important to get a D. I. S. But it's also important to get a test called an arterial duplex. So the arterial duplex study is actually going to show us which vessels are blocked. And it's also going to show us the wave forms. So meaning when we look at these tests, a lot of times patients with diabetes will have on an A. B. I. Something that says non compressible vessels, but at the same time it will have a wave form that says mono physic by physics or fry physics. What we're looking for is patients who have that mina physic or by physic blood flow. They need some type of intervention done. So doing in arterial duplex will show us exactly which vessels are diseased. So I'm just gonna go through a couple of cases now. So this is a case of a patient who had vascular compromise. He was a male 61 years old. He had type one diabetes. He was insulin dependent his last eight once he was 9.7 Um he said that the wound started as a burn secondary to fireworks. He was messing around out on four July As you can see, he came in on day zero. The alteration was their day 15. It was starting to get a schematic. So he has um dried esseker on there. He did get revascularization at this point and then on day 25 it was still um Intact Esseker. On day 30 he ended up getting the co amputated and it did go on to healing. So if I talked about the importance of a vascular assessment, making sure you're getting that. Maybe I done. This is an example of a patient who has diabetes. He had an A. B. I done the vessels were considered non compressible. But as you can see if you look in the report, it says non compressible with by physic wave forms, meaning that the blood flow is impaired down to the foot at some point. So then this is a little bit hard to see. But you can see. Then we went on to order the arterial duplex and the arterial duplex does show the patient has to build disease um that the blood flow was compromised. He ended up getting an angiogram. Done. The angiogram showed the right common iliac and external iliac arteries had minimal changes without stenosis. Internal iliac artery was patents. Um He had a wide open for moral papa pio is patent with mild apple's product changes the pt and peritoneal extending to the ankle, there's some narrowing and they were able to open those up. So as a result after the patient had his procedure. So he was revascularization. Then we went ahead and focused on wound management. So for this patient wound management included the use of a uh topical program, Kuzma Matrix, um The carousel, A. B. Jelling fiber and then phone borders along with offloading with a camber. So the other thing that's very important in patients with diabetes is making sure that you're offloading the area or offloading pressure to the area. This can be accomplished with either total contact cast or a cam boot walker um or some different orthotics that are available on the market for this patient. You can see he kind of his wound was a little bit more stuff covered. Um It was a little more slimy. So that's why we started originally with the carousel eiji jelling fiber. If you're not familiar with that, it is a dressing that has oxy salts in it. So when the oxy salts are activated, what happens is they release a derivative of hydrogen peroxide into the wound bed, which helps bring more oxygen to the tissues and helps break up that slope. So once we got all of that stuff cleaned out, we got the wound looking a lot better. We weren't concerned about um any bio bourbon or infection at that time, we did transition him to the program prisma in just a home type dressing. So in conclusion diabetes can impact healing and wounds. We know that it's very important for tight glycemic control in these patients. We know that patients with diabetes can be unique in their foot structure. Many times these patients will have changes either due to previous amputations, they might have changes due to something peripheral neuropathy resulting in a shark. Oh, joint where the arch of the foot starts to drop. They may have the development of bunions. They can have just different changes that will impact their gate. It will impact how they walk. It will impact the pressure areas on their foot. So just making sure that you're aware of that in your assessments and then diabetic patients are at high risk for the development of life and limb threatening amputations, patients with diabetes are at high risk for the development of infections that can lead to limb and life threatening amputations. Um So it's very important to tell your patients with diabetes to do regular foot exams to make sure that they're letting their doctor know right away if they noticed anything different and then diabetic patients can have that micro and macro vascular compromise. So making sure when you're seeing these patients that you're doing a really good job of doing a thorough vascular exam as well as the physical exam of the foot and ulcer remembering that. Um Just because you do an A. B. I. And it says that the vessels are non compressible or they might be falsely elevated. That means they're not compressible. Also to go on and get in arterial duplex which will show us more of um which diseases or which vessels are compromised. And then just remembering when you're treating these people also that the gold standard is offloading. So making sure that you have them in some type of off loading device, whether it's a total contact cast or a cam boot or orthotics. And then remembering that once these patients do develop an ulceration that you're treating it with topical, whom therapy that promotes a moist wound healing environment that prevents infection or treats infection or biofilm that may be present. And then making sure that you're protecting the period wounds, skin from maceration. These alterations are really at high risk for um being really wet and soggy. So you want to make sure that you're keeping the area as dry as possible and um the patient is understanding of the care plan and that everybody is on board with that. So thank you for your time.