Preliminary Version For Proof reading

Jan-Dec 2016 / Volume 9 / Issue 1 http://www.swcrjournal.com/

ISSN 2229-3221

An open access official publication of Society for Wound Care and Research

Preliminary Version For Proof reading

JSWCR is indexed with ‘Index Copernicus’, ‘Open J-Gate’, ‘EBSCO Host (USA)’ & ‘Ulrich (USA)’ International 1 Indexing and Databases

JSWCR 2016 © 2016 The Society for Wound Care and Research JSWCR 2016; 9(1):17-25

SWCR GUIDELINES

SWCR Guidelines For Diabetic Foot Ulcer (DFU) Pramod Kumar1, MS, MCh, DNB, MBA, Ravi Kumar Chittoria2 MS, MCh, DNB, MNAMS, PhD, PDGTM SP Bajaj3 MS, MCh, Arun Kumar Singh4, MS, MCh, Vinay K Tiwari5 MS, MCh, Devendra Kumar Gupta6 MS, MCh,, Dinesh Kadam7 MS, MCh, DNB, Satish8 MS, MCh, (1Professor of Plastic Surgery and Medical superintendent, Srinivas Institute of Medical Sciences and Research center, Mukka, Mangalore, Karnataka, India; 2Prof and Head, Department of Plastic Surgery & Nodal Officer Telemedicine, JIPMER, Pondicherry, India; 3Senior Consultant Plastic Surgeon, Jaipur Golden Hospital, Rohini, New Delhi, India; 4Prof & Head, Department of Plastic Surgery, K G Medical College, Lucknow, UP, India; 5Head, Department of Plastic Surgery, PGIMER & RML Hospital, New Delhi; 6Consultant Plastic Surgeon, Bareilly, UP, India; 7 Head, Department of Plastic Surgery, A J Institute of Medical Sciences, Mangalore, Karnataka, India; 8 Senior Specialist, Department of Orthopedics, PGIMER RML Hospital, New Delhi, India)

INTRODUCTION

The Society for Wound Care and Research (SWCR) is a unique blend of Academic, Clinical, Research and Social Service. It was founded in the year 2006 under mentorship of Prof Dr Pramod Kumar with an aim to promote practice of better wound care and research, render community health care related to trauma/wound by bringing out publications in the form of journals, newspaper articles, books/handbills, maintain a web site, establish scholarships, foundations and lectureship and to provide grants and other benefactions either in India or elsewhere which are designed to enhance the learning in, and practice of, wound care and research or to contribute to the establishment of the same1. Society released its first guideline, “SWCR Guidelines for Wound Management” in 2nd International & 7th National Annual Conference of SWCR (Wound Care Con-2-13) held at JIPMER Pondicherry and was published in the Journal of SWCR in 20142. In the executive meeting during 8th National Annual Conference of SWCR (Wound Care Con 2014), it was decided to prepare ‘SWCR Guidelines For Diabetic Foot Ulcer (DFU)’ and to release during 9th National Annual Conference (WoundCon 2015) to be held at KGMC, Lucknow, India. In WoundCon2015, a brainstorming Scientific Session was kept on ‘Diabetic Foot’ with the aim of coming out common consensus to release ‘SWCR Guidelines for Diabetic Foot Ulcer (DGU)’. ‘SWCR Executive Members’, ‘Members

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SWCR Guidelines For of Committee of Diabetic Foot’ and Senior Faculties and Delegates participated and at the end of the session various practical aspects related to prevention, screening, diagnosis and management were incorporated and guidelines were released and decided to be published in next issue of Journal of SWCR-2016. Aim ‘SWCR’ Guidelines for Diabetic Foot Ulcer (DFU) was developed to meet following objectives: 1.

2. 3.

4.

To use available SWCR acronym2 so that these guidelines should be easy to remember. To develop Scientific, Evidence based, practical guidelines for DFU. To develop guidelines which should applicable to all kinds of DFUs irrespective of site (Forefoot, Mid Foot, Hind Foot) and duration (acute/chronic). To develop guidelines to optimize results and outcomes in cases of DFUs.

SWCR acronym Redefined acronym SWCR2 was used with special emphasis to control of diabetes during clinical decision, correction of foot deformities during and foot care along with use of special footwear during repair-reconstructrehabilitation stage (Fig 1).

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1. Systemic Analysis ‘Wound’

SWCR Guidelines

of

‘Patient

and

Includes ‘History’, ‘Patient Assessment’, ‘Wound Assessment, ‘Wound Score’, ‘Wound Documentation’ and ‘Investigations’. History History should include: •duration and types of diabetes (type-1, type-2); history of hypoglycemic attacks;

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Patient Assessment Patient assessment should include: •assessment of vital records (pulse rate, respiratory rate, blood pressure, temperature); •thorough head to toe general examination to look for pallor, icterus, lymphadenopathy, facial or lower limb edema, visual equity; nutritional status3; •Systemic examination of respiratory system, cardiovascular system, neurologic system (to look for presence of peripheral neuropathy), and 'Repair' 'Reconstruct' & 'Rehabilitate‘ with special emphasis to correction of foot deformities, foot care and use of special footwear R:

C: 'Clinical

S: Systematic Analysis of 'Patient' & ‘wound '

W: Wound Bed Preparation (WBP)

Decisions with emphasis to control diabetes and its complications

Fig 1. SWCR guidelines for Diabetic Foot Ulcer (DFU)

•duration (acute/chronic) and onset (acute/insidious) of ulceration in the foot; •history of injury (trivial trauma or prick) to foot; •site and numberof ulcers (Single/Multiple); •history of loss of sensation; •history of discharge from ulcer (type, amount, odour); •history of loss of functions (due to ulcer, autoamputation of toes); •history of fever; •history of facial or leg edema; •details of Medical treatment (whether on oral hypoglycemics or insulin) and Surgical treatment (debridement, skin grafting, flap surgery arterial revascularization, amputations); •history of presence of other co-morbidities like hypertension, Coronary Artery Disease (CAD), Stroke, Chronic obstructive airways disease (COAD), malignancy and chronic kidney disease; •history of smoking, alcohol intake, obesity; •Ambulatory or bed ridden; 18 •family support, social environment, socioeconomic conditions, level of education.

musculoskeletal system (for distal pulses and vascularity). Wound Assessment Assessment of the wound is a prerequisite to the selection of an appropriate medical or surgical treatment. Wound inspection should include: •site, size, shape, number of ulcers (single or multiple); •type of discharge, margin, edge, floor; •presence of local oedema, odour, •undermining, •necrotic tissue, slough; •granulation tissue; •surrounding skin; •exposed vital structures like bone, tendons, fascia, vessels, nerves, implants; •features of osteomyelitis (loose bony pieces, sinuses, pockets of pus); Palpation should include: •Confirm all the findings of inspection; •base of ulcer; •edema is pitting or non-pitting;

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•local temperature, tenderness; •Look for Loss of tissue/body parts and amount of Limb shortening.4 Wound Score and Wound documentation Wounds should be assessed initially & regularly (weekly) and progress should be documented by Wound Score (using Bates Jansen’s Wound Assessment Tool) 4 and Digital Record of Wound Surface Area (using J-Image Digital Wound Surface Area Record Software) 5. Investigations Patient of diabetes should be thoroughly investigated to find status of diabetes, associated neuropathy, nephropathy, cardiopathy, ophthalmopathy, vasculopathy, Charcoat Foot (including osteomyelitis). Further, patient should be investigated to rule out underlying morbidities like anaemia, hypoproteinemia etc. Finally patient should be investigated for anaesthesia fitness and risk associated with anaesthesia. Hence, series of investigations which patient of diabetes undergo include Haemoglobin, Total & Differential Counts, Peripheral Blood Smear, Bleeding Time, Clotting Time, Blood Grouping, Fasting & Post Prandial Blood Sugar, Hb1AC, Urine Routine & Microscopic Examination for Albumin & Ketones, Liver Function Tests including Total Proteins & Serum Albumin, Renal Function Tests (Blood Urea, Serum Creatinine, Serum Electrolytes (for assessing renal condition); Lipid Profile (for dyslipedemia); ECG & Echocardigram (for cardiac evaluation); Venous & Arterial Colour Doppler Study, Recording of Ankle Brachial Index (ABI-PT- posterior tibial/ DP- dorsalis pedis)/ Toe Brachial Index (TBI), CT Angiography and Plethysmography (for assessing vascular status) (Fig 2); Transcutaneous Oxymetry (for assessing tissue oxygenation); Xray Chest, X-ray of foot, Bone Scan/MRI/Infection Scan/PET Scan (to rule out Osteomyelitis); Wound Culture & Sensitivity for Bacteria and Fungus, Wound Biopsy (to rule out malignant changes in Chronic Wounds) 6. Nerve Conduction Study (NCS)- fine touch with Monofilament (10gm), hot and cold sensation, vibation sensation using digital biothesiometer help to diagnose and grade neuropathy (Fig 3). Podiascan7 is done for static planter foot pressure distribution (Fig 4). 19

2.

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Wound Bed Preparation

Wound Bed preparation (WBP) is a Systematic approach to wound for identifying and removing barriers to healing. There are four components of Wound Bed Preparation (WBP) known by acronym ‘TIME’ which addresses the pathophysiological abnormalities underlying chronic wounds. Tissue Management Tissue is either devitalized or deficient. Devitalized tissue needs removal whereas Deficient tissue needs replacement. Debridement or removal of devitalized or nonfunctional tissue includes removal of fibrous scar or callous tissue from the wound. Biofilms are bacterial colonies surrounded by a protective coat of polysaccharides over the wound. Wound debridement plays an important role in reducing the levels of bacterial biofilms, which are tightly attached to components of the extracellular matrix of chronic wound beds, to the surfaces of bones (osteomyelitis), or to the surfaces of orthopedic implants. Debridement can be Autolytic (moist interactive dressings such as hydrogels, hydrocolloids etc) which can help to provide an optimal environment for autolytic debridement and create an environment capable of liquefying slough and promoting tissue granulation) or debridement can be done by Sharpe knife (called Surgical or Sharp Debridement)8-10, Ultrasonically11-12, Hydrojet System, Enzymatically (Honey, Papain-Urea, Collgenase, Fibrinolysin, Deoxyribonuclease) 13, Mechanically (Wet-to-Dry Dressings) 14, Chemically (Hydrogen peroxide, Super Oxidized Solution, Nano or Ionic Silver), Biologically (Maggot Therapy) etc depending upon the facility available, condition of the wound and fitness for anesthesia/surgery15. Infection and Inflammation Chronic wounds are suspended in chronic inflammatory phase and are invariably infected. Chronic wounds are often heavily colonized with bacterial or fungal organisms. This is due in part to the fact that these wounds remain open for prolonged periods, but is also related to other factors such as poor blood flow, hypoxia and the underlying disease process. Clinical

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infection resulting in failure to heal must be treated aggressively and promptly. The complete removal of bacteria from a wound is neither possible nor necessary in order to promote healing. All chronic wound contain bacteria, and

their presence in the wound does not necessarily indicate that infection has occurred or lead to impairment of wound healing. Bacterial colonization is not in itself of any clinical significance and should not be

Fig 2. Automatic arterial testing report showing ABI and TBI report

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Fig 3. Report of vibration sense testing over plantar aspect of foot using bioaesthesiometer

Fig 4. Report of static plantar pressure study using podia scan 21

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considered with a clinical diagnosis of wound infection.16The presence of sheets of soft adherent material or “Biofilms” represent a protected foci of infection and bacterial resistance within the wound and affords the bacteria protection from the effects of anti-microbial agents especially antibiotics and antiseptics.17 In contrast to antibiotics, which have a more specific mode of action, and are effective against a narrow range of bacteria, broad spectrum topical antimicrobials are less likely to develop resistance. Systemic antibiotic therapy should be used where active infection cannot be managed with local therapy e.g. in the presence of fever, underlying deep structure infection and spreading cellulitis. All Infection should be controlled with Local Antimicrobials, preferably without harming the normal cells (Super Oxidized Solution)18 or other available antimicrobials (Nano Crystalline Silver/ Colloidal Silver/ Ionic Silver) and if need Systemic Antibiotics should be started according to Tissue Culture & Sensitivity report. Systemic antiinflammatory drugs should be started to control inflammation & edema in the wound.19

Plasma (APRP),23 Autologous Lipo Aspirate Therapy (ALAT),24 Autologous Bone Marrow Aspirate Therapy (ABMAT),25 Transcutaneous Oxygen Therapy (TCOT),26 Hyper Baric Oxygen Therapy (HBOT),27 Growth Factors,28 Skin Substitutes29etc. These adjuvant therapies may be continued till wound bed get ready for cover by skin graft or flap.

Moisture Balance Excess Moisture causes maceration & decrease in moisture (dry wound) causes tissue death. Establishing the optimal balance of moisture in the wound bed has dramatic effects on the healing of open wounds. Type of dressing should be titrated according to the moisture in the wound. Excess moisture in the wound needs compression bandages/highly absorbent dressings or vacuum based mechanical systems like Limited Access Dressing (LAD) 20/Negative Pressure Dressing21 whereas dry wounds need moisture holding dressings (Hydrogels). Dressing must be able to maintain optimum moisture levels under compression, shear and friction forces. Rest to the wound by Splint, Elevation of affected part, OffLoading reduces exudate & edema.22

Is Wound Bed Ready for Repair & Reconstruction? If there is no growth (especially Streptococcus haemolyticus, Methicillin Resistant Staphylococcus, Pseudomonas) and granulation is healthy then wound may be considered for repair & reconstruction according to ladder of reconstruction.31

Limited Access Dressing (LAD) alone has been shown to be effective in wound bed preparation 2. Clinical Decisions Few important Clinical Decisions to be taken during and after the wound bed preparation like: How long to give Systemic Antibiotics? Give antibiotics judicially on scientific grounds justified till the wound or patient needs it. Means follow wound/tissue culture & sensitivity report weekly, correlate clinically and decide accordingly. In case of underlying osteomyelitis antibiotic may be required up to 6 weeks to 3 months and even more.30

Patient Preparation Patient preparation means screening, diagnosis, treatment and control of diabetes and finally preparing patient for reconstruction. Patient preparation needs team work including nurses, general physician, ophthalmologist, nephrologist, cardiologist, interventional radiologist, vascular surgeon, endocrinologist, general surgeon, orthopedician, podiatrist, physiotherapist, Edge of the Wound/Epithelial Cell Migration occupational therapist, nutritionist and plastic Advancement surgeon. A well trained qualified nurse acts as a Observation of a healthy sheet of epithelial cells bridge between patient and treating physician migrating from the edge of a chronic wound is the and/or surgeon. Dietician/Nutritionist provides diet most sensitive indicator of the effectiveness of the control of diabetes and prevents nutritional other three components of TIME. Once T, I & M deficiencies commonly seen in a diabetic patient. are taken care, E (Edge) of the wound starts General physician is the first to diagnose the showing epithelial cell migration. To increase the diabetes during screening or as incidental finding. speed of epithelialization & wound bed granulation Endocrinologists not only provide glycemic control there is an important role of adjuvant therapies like22 but also detect complications of diabetes. Stem Cell Therapy, Autologous Platelet Rich

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b

a

Fig 5 a-e. Photograph showing wound over plantar surface of left foot with loss of flexors of 1st and 2nd toe (a), Wound granulation was prepared under LAD (b), deformity was corrected by arthodesis of mp joints (c), and wound was covered by skin graft under LAD (d,e)

d

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c

e

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Ophthalmologist detects and manages ophthalmic complications associated with diabetes. In case of renal complications (urinary tract infection, renal failure needing dialysis), a nephrologist intervention is required. Diabetes is associated with dyslipedemia and cardiac complications for which cardiologist intervention is required. Interventional radiologists not only diagnose vascular angiopathy associated with diabetes by CT angiography, Doppler study but also intervene to improve vascularity by interventional radiology procedures like balloon angioplasty. Similarly, vascular surgeon helps in improving the limb vascularity by vascular surgeries like bypass surgery. Early debridement and later amputations are done by general surgeon. Patient with Charcot foot involving bones and joints need orthopedician intervention. A podiatrist helps in providing correct foot wear and off-loading measures. Physiotherapist and occupational therapist helps in early rehabilitation. Once wound bed is prepared and patient is fit for anaesthesia then plastic surgeon provides wound cover by skin graft/flap. Is Patient fit for Repair & Reconstruction? Patient with Hemoglobin > 10 gm%, serum albumin > 3.5 gm%, with control of underlying Diabetes (Blood sugar at an approriate level on day to day basis, and HbA1C level