Download cpd on complicated skin and soft tissue infection

CASE MANAGEMENT DISCUSSIONPRESENTATION AND SHARING OF
INFORMATION ON COMPLICATED
SKIN AND SOFT TISSUE INFECTION
Rommel Q. de Leon, MD
Department of Surgery
Ospital ng Maynila Medical Center
GENERAL DATA
D. F.
58/M
From
Intramuros, Manila
CHIEF COMPLAINT
NON-HEALING WOUND,
FOOT, RIGHT
HISTORY OF PRESENT ILLNESS
• 2 weeks PTA  Patient noted crusting
lesions over the
dorsum and interdigital
areas of the right
foot noted to be nonhealing accompanied
by pruritus
No medications taken
No consult done
HISTORY OF PRESENT ILLNESS
• 1 week PTA  Spread of the lesions to
other parts of the foot
Lesions with foulsmelling discharge
Swelling and erythema
No medications taken
No consult done
HISTORY OF PRESENT ILLNESS
• Few hrs PTA  Increased severity of
swelling
Increased spread of
lesions
Consult
PAST MEDICAL HISTORY
• (+) Diabetes Mellitus Type II x 20 yrsRegular and Intermediate Insulin
- Regular Insulin 5 u SQ for CBG > 250 mg/dl
- Intermediate insulin 16 u in AM
8 u in PM
NON-COMPLIANT
• S/P BKA, Left- 2004, OMMC
• PTB Minimal- 2004, OMMC Rx: anti-Koch’s, noncompliant
FAMILY HISTORY
• (+) Diabetes Mellitus Type II- both
parents
PERSONAL AND SOCIAL
HISTORY
• Smoker, 20 pack years
• Alcoholic Beverage Drinker 4x a week
PHYSICAL EXAMINATION
• GENERAL SURVEY: conscious, coherent, NICRD
BP= 120/ 80
CR= 78
RR= 22
T= 37º
• HEENT: pink palpebral conjunctiva, anicteric sclera,
no TPC, no CLAD
• CHEST / LUNGS: SCE, no retractions, clear breath
sounds
• HEART: adynamic precordium, NRRR, no murmur
PHYSICAL EXAMINATION
• ABDOMEN: flat, NABS, soft, non-tender
PHYSICAL EXAMINATION
(lower extremities)
PHYSICAL EXAMINATION
PHYSICAL EXAMINATION
(lower extremities)
• BKA scar, Left foot
• DERMATOLOGIC: (+) swollen erythematous right
foot; (+) multiple crusting weeping lesions over the
dorsum of the forefoot and on the interdigital areas,
R; (+) ulcerating wound with multiple crusting
weeping lesions, dorsum and sole foot, R
• VASCULAR: (+) pitting edema above the ankle;
diminished dorsalis pedis pulses; strong posterior
tibial, popliteal and femoral pulses; poor capillary
filling time (> 3 sec); (-) temperature gradient
PHYSICAL EXAMINATION
(lower extremities)
• NEUROLOGIC: Poor light touch perception; poor
pinprick sensation; poor two-point discrimination;
poor temperature discrimination
SALIENT FEATURES
1.
2.
3.
4.
5.
58/M
2 wks history non-healing wound right foot with
pruritic crusting lesions accompanied by erythema
and swelling that spread to other parts of the foot
with foul-smelling discharge
(+) DM Type II x 20 yrs, non-compliant to
medications
(+) History of previous amputation for diabetic
gangrene of the left foot (2004-OMMC)
(+) DM Type II both parents
SALIENT
FEATURES
6. PE of the Right foot:
DERMATOLOGIC: (+) swollen erythematous right foot;
(+) multiple crusting weeping lesions over the dorsum
of the forefoot and on the interdigital areas, R; (+)
ulcerating wound with multiple crusting weeping
lesions, dorsum and sole foot, R
VASCULAR: (+) pitting edema above the ankle;
diminished dorsalis pedis pulses; strong posterior
tibial, popliteal and femoral pulses; poor capillary filling
time (> 3 sec); (-) temperature gradient
NEUROLOGIC: Poor light touch perception; poor
pinprick sensation; poor two-point discrimination; poor
temperature discrimination
DM TYPE II PATIENT
POOR DM CONTROL
NON-HEALING WOUND ON THE FOOT
SIGNS AND
SYMPTOMS OF
INFECTION
SUPERFICIAL
DEEP
DM TYPE II PATIENT
POOR DM CONTROL
NON-HEALING WOUND ON THE FOOT
SIGNS AND
SYMPTOMS OF
INFECTION
SUPERFICIAL
-FUNGAL INFECTION
WITH SUPERIMPOSED
BACTERIAL INFECTION
DEEP
- SWELLING AND INDURATION
- DERMATOLOGIC PRESENTATION
- ERYTHEMA AND EDEMA ABOVE
THE ANKLE
- WOUND BREAKDOWN
- ULCERATION / UNDERMINING
- VASCULAR CHANGES
- DIMINISHED SENSORY
PERCEPTION
CLINICAL DIAGNOSIS
CLINICAL DIAGNOSIS
DEGREE OF
CERTAINTY
MANAGEMENT
DEEP SOFT TISSUE
INFECTION PROBABLY 2º TO
DIABETIC FOOT, RIGHT
DM TYPE II POORLY
CONTROLLED
S/P BKA, L
90%
SURGICAL
SUPERFICIAL SOFT TISSUE
INFECTION PROBABLY 2º TO
FUNGAL INFECTION WITH
SUPERIMPOSED BACTERIAL
INFECTION
DM TYPE II POORLY
CONTROLLED
S/P BKA, L
10%
MEDICAL
PARACLINICAL DIAGNOSTIC
PROCEDURE
• DO I NEED A PARACLINICAL DIAGNOSTIC
PROCEDURE?
YES.
- TO INCREASE THE DEGREE OF CERTAINTY OF
MY PRIMARY CLINICAL DIAGNOSIS
- THEY HAVE DIFFERENT TREATMENT
MODALITIES
GOALS OF PARACLINICAL
DIAGNOSTIC PROCEDURE
• DETERMINE THE DEPTH OF
INFECTION
PARACLINICAL DIAGNOSTIC
PROCEDURES
DIAGNOSTIC
PROCEDURE
BENEFIT
RISK
COST
AVAILABILITY
PLAIN
RADIOGRAPHS
++
RADIATION
EXPOSURE
Php 150
+++
CT SCAN
+++
RADIATION
EXPOSURE
Php 30005000
++
++
LESS
SPECIFICITY
RADIATION
EXPOSURE
Php 6000
+
NA
NA
Php
1000012000
+
TECHNETIUM
BONE SCANS
WHITE BLOOD
CELL
SCINTIGRAPHY
MRI
+++
HIGHLY SPECIFIC
AND SENSITIVE
+++
NA
• XRAY RESULTS:
- OSTEOPOROTIC OSSEOUS
STRUCTURE WITH SOME
OSTEOLYTIC CHANGES
ON THE DISTAL DIGITS
-SOFT TISSUE ABSCESSES
NOTED ON ALL DIGITS
PRE-TREATMENT DIAGNOSIS
DIABETIC FOOT, RIGHT
DIABETES MELLITUS TYPE II
POORLY CONTROLLED
S/P BKA, LEFT
GOALS OF TREATMENT
1. REMOVAL OF NECROTIC TISSUE
2. CONTROL OF THE INFECTION
3. RESTORATION OF VASCULAR
PERFUSION
4. MEDICAL MANAGEMENT OF
HYPERGLYCEMIA
TREATMENT OPTIONS –
GOALS 1 TO 3
TREATMENT
OPTIONS
BENEFIT
RISK
COST
AVAILABILITY
DEBRIDEMENT*
++
FAILURE RATE=
71%
RISK OF
OPERATION
Php 3000
+++
SYME’S /
FOREFOOT
AMPUTATION*
++
FAILURE RATE=
49%
RISK OF
OPERATION
Php 3000
+++
MAJOR
AMPUTATION
(BELOW THE
KNEE)*
+++
SUCCESS RATE=
92-99%
RISK OF
OPERATION
Php 30005000
+++
* ALL PROCEDURES REQUIRE ADEQUATE ANTIBIOTIC COVERAGE
TREATMENT OPTIONS –
GOAL 4
TREATMENT
OPTIONS
BENEFIT
RISK
COST
AVAILABILITY
ORAL ANTIHYPERGLYCEMIC
AGENTS
++
Hypoglycemia
Php
2000/wk
+++
+++
(Indicated in
patients with
ongoing infection)
Hypoglycemia
Php
3000/wk
+++
INSULIN
TREATMENT PLAN (SURGICAL)
BELOW THE KNEE AMPUTATION,
RIGHT
TREATMENT PLAN (MEDICAL)
INSULIN (SHORT AND LONG ACTING)
FOR CONTROL OF HYPERGLYCEMIA
PRE-OP PREPARATION
• PSYCHOSOCIAL SUPPORT
• SCREENING FOR MEDICAL PROBLEMS
DM TYPE II- CBC, CBG MONITORING, FBS, BUN,
CREATININE, SERUM K, URINALYSIS,
LIPID PROFILE, HgbA1C
CHEST X-RAY – PTB MINIMAL
ECG- NON-SPECIFIC ST-T WAVE CHANGES
PRE-OP PREPARATION
• OPTIMIZE PHYSICAL CONDITION OF THE PATIENT
FLUID RESUSCITATION
ADEQUATE ANTIBIOTIC COVERAGE
CONTROL OF HYPERGLYCEMIA (Co-Management with IM)
CBG monitoring AC/HS
Regular Insulin 5 units SQ for CBG > 250 mg/dl
Intermediate Insulin 16 units SQ in AM, 8 units
SQ in PM
SURGICAL TREATMENT
(Intra-op)
•
Tourniquet
•
Level of bony
resection marked
and AP diameter
measured
•
Anterior and
posterior flaps (1/2
AP diameter)
marked
SURGICAL TREATMENT
(Intra-op)
•
Skin, subcutaneous
fat and fascia
divided in the same
line as with the
periosteum of the
antero-medial
surface of the tibia
•
Flaps elevated to the
level of the
amputation
INTRAOPERATIVE FINDINGS
• Gangrenous material noted with foulsmelling purulent discharge
• Good pulses and good muscle viability with
brisk bleeding noted at the level of
amputation
SURGICAL TREATMENT
(Intra-op)
•
Superficial peroneal
nerve identified, pulled
distally and divided
•
Anterior tibial vessels
and deep peroneal
nerve divided
•
Anterior muscles
sectioned 0.75 cm distal
the bony resection
SURGICAL TREATMENT
(Intra-op)
•
Tibia bevelled at
level of resection
prior to division
of the bone
•
Fibula sectioned 3
cm proximal to
tibia
SURGICAL TREATMENT
(Intra-op)
•
Posterior vessels and nerve divided
•
Posterior flap and aponeurosis of gastrocnemius
fashioned to meet anterior muscles
•
Tourniquet released and obtained haemostasis
SURGICAL TREATMENT
(Intra-op)
•
Wound closed in
layers (fascia, fat
and skin) and apply
a stump bandage
OPERATION DONE
BELOW THE KNEE
AMPUTATION, RIGHT
FINAL DIAGNOSIS
DIABETIC FOOT, RIGHT
DIABETES MELLITUS TYPE II
POORLY CONTROLLED
S/P BKA, LEFT
POST-OPERATIVE CARE
• SUPPLY THE BASIC NEEDS OF THE PATIENT
• COMFORT
• ANALGESICS
• CBG MONITORING AND CONTROL OF
HYPERGLYCEMIA
• MEDICATIONS – ANTIBIOTICS
• FLUIDS AND ELECTROLYTES
• REHABILITATION / POSSIBLE PROSTHESIS
POST-OPERATIVE CARE
• SUPPORT ORGAN FUNCTION
• WOUND CARE
• MONITORING FOR COMPLICATIONS
• ADVICE ON
• HOME CARE
• FOLLOW-UP PLAN
POST-OPERATIVE CARE
• PATIENT DISCHARGED ON 3RD POD:
1. LIVE
2. WITH NO COMPLICATION
3. SATISFIED
4. WITH NO MEDICO-LEGAL SUIT
FOLLOW-UP PLAN
• REMOVAL OF SUTURES AFTER 10-14 DAYS
• ADVICE ON WOUND CARE
• ORAL ANTIBIOTICS FOR 5-7 DAYS
• CONTINUATION OF CBG MONITORING
• CONTROL OF HYPERGLYCEMIA WITH COMANAGEMENT WITH INTERNAL MEDICINE
• ADVICE FOR PROSTHESES AND REHABILITATION
SHARING OF
INFORMATION
DIABETIC FOOT
DEFINITION
• “Infection, ulceration and/or destruction of deep
tissues associated with neurological
abnormalities and various degrees of peripheral
vascular disease in the lower limb” (WHO, 1985)
• “The term “diabetic” foot indicates that there are
specific qualities about the feet of people with
diabetes that sets this disease apart from other
conditions that affect the lower extremity”
(Habershaw & Chzran, 1995)
DEFINITION
• “…the many different lesions of the skin, nails,
bone and connective tissue in the foot which
occur more often in diabetic patients than nondiabetic patients such as ulcers, neuropathic
fractures, infections, gangrene and
amputations”(De Heus-van Putten, 1994)
• “The term ‘diabetic foot’ implies that the
pathophysiological processes of diabetes
mellitus does something to the foot that puts it at
increased risk for tissue damage”. (Payne &
Florkowski, 1998)
GENERALITIES
THREE BROAD TYPES OF DIABETIC
FOOT ULCERS:
• neuropathic
• ischaemic
• neuroischaemic
Diabetic foot ulcers are classified using
the commonly used Wagner’s
Classification
Grading
Features
0
Pre-ulcer. No open lesion. May have deformities, erythematous
areas of pressure or hyperkeratosis.
1
Superficial ulcer. Disruption of skin without penetration of
subcutaneous fat layer.
2
Full thickness ulcer. Penetrates through fat to tendon or joint
capsule without deep abscess or osteomyelitis.
3
Deep ulcer with abscess, osteomyelitis or joint sepsis. It includes
deep plantar space infections, abscesses, necrotizing fascitis and
tendon sheath infections.
4
Gangrene of a geographical portion of the foot such as toes,
forefoot or heel.
5
Gangrene or necrosis of large portion of the foot requiring major
limb amputation.
Depth-Ischemia Classification of
Diabetic Foot Lesions
DEPTH
CLASSIFICATION
DEFINITION
TREATMENT
0
At-risk foot, no ulceration
Patient education, accommodative
footwear, regular clinical examination
1
Superficial ulceration, not
infected
Offloading with total contact cast (TCC),
walking brace or special footwear
2
Deep ulceration exposing
tendons or joints
Surgical debridement, wound care,
offloading, culture-specific antibiotics
3
Extensive ulceration or
abscess
Debridement or partial amputation,
offloading, culture-specific antibiotics
*Adapted from Brodsky, J: The Diabetic Foot. In Surgery of the Foot and Ankle, Coughlin,
MJ, and Mann, RA, editors. Mosby Inc., St. Louis, 1999. Table 21-2, page 911.
Depth-Ischemia Classification of
Diabetic Foot Lesions
ISCHEMIA
CLASSIFICATION
DEFINITION
A
Not ischemic
B
Ischemia without gangrene
TREATMENT
Noninvasive vascular testing, vascular
consultation if symptomatic
C
Partial (forefoot) gangrene
Vascular consultation
D
Complete foot gangrene
Major extremity amputation, vascular
consultation
GENERALITIES
ANATOMICAL DISTRIBUTION:
1. ~50% of ulcers are on the toes
2. ~30-40% are on the plantar metatarsal
head
3. ~10-15% are on the dorsum of the foot
4. ~5-10% are on the ankle
5. up to 10% are multiple ulcers
Mechanisms Of Injury That Destroy
The Foot
1) Direct mechanical disruption of tissue (eg patient
stepping on nail while barefoot abruptly breaking
the skin barrier)
2) Small amount of force that is sustained over time
that leads to ischaemia (eg tight shoe may lead to
breakdown of union site)
3) Moderate amount of force that is repeated over
and over leads to inflammation and enzymatic
autolysis of tissue (eg plantar metatarsal
ulceration)
4) Infection
PRECIPITATING EVENTS THAT
INCREASE RISK FOR TISSUE DAMAGE
1.
Accidental cuts
2.
Shoe trauma
3.
Repetitive stress
4.
Thermal trauma
5.
Iatrogenic
6.
Vascular occlusion
7.
Skin or nail conditions
DEMOGRAPHIC RISK FACTORS
- Age (older at greater risk)
- Gender (male is at 2x greater)
- Ethnicity (some ethnic groups are at
signifcantly increased risk for foot
complications)
- Social situation (living alone 2x greater risk)
DIABETES RELATED RISK FACTORS
• Duration of diabetes
• Glycaemic control
• Loss of protective sensation - main risk factor;
permissive of unperceived injury
• Motor neuropathy (muscle wasting and gait
changes; the “intrinsic minus foot” – high arched,
claw toes, intrinsic muscle wasting)
• Autonomic neuropathy - microvascular dysfunction;
Anhidrotic, dry, cracked skin
DIABETES RELATED RISK FACTORS
• Peripheral vascular disease (4x more common in
those with diabetes)
• Increased plantar pressures
• Limited joint mobility (AGE’s/glycation of collagen;
restricts movement of key joints; related to
increased plantar pressures)
DIABETES RELATED RISK FACTORS
• Immune/Defence mechanisms (infections are more
common; the immune responses are impaired due to
vascular supply factors, chemotatic factors and a
reduced neutrophil response)
• Previous ulceration (this is THE main risk factor for
ulceration)
OTHER RISK FACTORS
• Body weight (higher prevalance in those with type 2
diabetes)
• Smoking
• Footwear
HISTORY
• GENERAL
• FOOT-SPECIFIC
• WOUND / ULCER HISTORY
PHYSICAL EXAMINATION
1. MUSCULOSKELETAL
2. DERMATOLOGIC
3. VASCULAR
4. NEUROLOGIC
5. FOOTWEAR
Musculoskeletal Examination
• Attitude and posture of lower extremities and foot
• Orthopedic deformities – Hammertoes / Bunions / Pes planus
or cavus / Charcot deformities / amputations / prominent
metatarsal heads
• Limited joint mobility
• Tendo - Achilles contractures / equinus
• Gait evaluation
• Muscle group strength testing
• Plantar pressure assessment
Dermatological Examination
• Skin appearance: color, texture, turgor, quality, and dry skin
• Calluses or heel fissures
• Nail appearance: Onychomycosis, dystrophic, atrophy,
hypertrophy, paronychia
• Presence of hair
• Ulceration, gangrene, infection
• Interdigital lesions
• Tinea pedis
Vascular Examination
• Pulses (dorsalis pedis, posterior tibial, popliteal, femoral)
• Capillary return (normal < 3 seconds)
• Venous filling time (normal < 20 seconds)
• Presence of edema
• Temperature gradient
• Colour changes: Cyanosis, dependent rubor, erythema
• Changes of ischemia: Skin atrophy; nail atrophy, abnormal
wrinkling, diminished pedal hair
Neurological Examination
• Vibration perception: Tuning fork 128cps
• Light pressure: cotton wool
• Pain: Pinprick
• Two-point discrimination
• Temperature perception: hot and cold
Neurological Examination
• Deep tendon reflexes: ankle, knee
• Clonus testing
• Babinski test
• Romberg's test
Footwear Examination
• Type and condition of shoes / sandals
• Fit
• Shoe wear, pattern of wear, lining wear
• Foreign bodies
• Insoles, orthoses
WORK-UP
LABORATORY INVESTIGATIONS :
1.
2.
3.
4.
5.
6.
7.
Fasting or random blood sugar (FBS,RBS)
Glycohemoglobin (HbA1C)
Full blood count (FBC)
Erythrocyte sedimentation rates (ESR)
Serum chemistries (BUSE)
Wound and blood cultures(C&S)
Urinalysis (Urine FEME, C&S)
WORK-UP
IMAGING STUDIES:
1.
2.
3.
4.
5.
6.
PLAIN RADIOGRAPHS
CT SCAN
RADIOISOTOPE TECHNETIUM
GALLIUM 67 CITRATE LEUKOCYTE SCAN
INDIUM 111 LEUKOCYTE SCAN
MRI
WORK-UP
VASCULAR INVESTIGATIONS:
• Doppler segmental artery pressures.
• Ankle-brachial indices (ABI) – may be misleading
due to calcification of the arteries giving rise to
higher pressures at the ankle. Normal value 1.1, <0.9
abnormal.
• Toe pressure measurements (not readily available
locally) – Less calcification in digital vessels enable
toe pressures to be measured more accurately and
be more reliable in the assessment of healing
potential
• Transcutaneous oxygen tension (TcPO2)
Principles of Treatment
• Debridement of necrotic tissue
• Wound care
• Reduction of plantar pressure (off-loading)
• Treatment of infection
Principles of Treatment
• Vascular management of ischaemia
• Medical management of co morbidities
• Surgical management to reduce or remove bony
prominences and / or improve soft tissue cover
• Reduce risk of recurrence
TREATMENTOF INFECTION
PARAMETERS
NON-LIMB THREATENING
LIMB THREATENING
1. Foot ulcer
Superficial or subtle
Deep and overt
2. Foot infection
Mild to moderate, may arise from Severe, gangrene, necrotising
scratches, small punctures,
fascitis and abscesses may be
fissures
present
3. Cellulitis from ulcer
< 2 cm
> 2 cm
4. Osteomyelitis
Absent, wound does not probe
to joint or bone
Present, wound probes to bone
or joint
5. Clinical features
Stable, no symptoms or signs of
sepsis or systemic involvement
Ill, with features of sepsis or
systemic involvement. e.g. fever,
hyperglycemia
6. Ischemia
Absent
Present, vascular consultation
needed
7. Hospitalization
No, close supervision on
outpatient basis
Yes, required to treat infection
and systemic involvement
TREATMENT OF INFECTION
1. surgical treatment
2. antibiotics treatment
3. wound care
4. treatment of metabolic and co-morbid
problems
TREATMENT OF INFECTION
5. frequent reassessment of response of
treatment
6. patient education
7. prevention
8. orthotics / prosthetic management
SELECTION OF LEVELS OF
AMPUTATION
THE CLASSICAL SITES OF AMPUTATION OF
LIMBS WERE DETERMINED ON THE BASIS
OF THE FOLLOWING CONSIDERATIONS:
1. The disease process for which the amputation was
done to eradicate the pathology.
2. The vascular supply to the skin flaps.
3. The requirements of limb fitting procedures and
techniques available at that time.
Suggested empirical antibiotic treatment for diabetic foot infection
(Lipsky- Evidence based antibiotic therapy of diabetic foot infections,
FEMS, Immun Med Micro 26 (1999) 267-276)
Severity of infection
Recommended
Alternatives
Mild / Moderate
(MONOMICROBIAL)
Cephalexin
Amoxcillin/Clavulanate
Clindamycin
Ofloxacin ±
Clindamycin
- Cotrimoxazole
Moderate / Severe
(POLYMICROBIAL)
Ampicillin / Sublactam
Clindamycin + Ciprofloxacin
Trovofloxacin
Metrodinazole +
Ceftazidime
Life threatening
(POLYMICROBIAL)
Imipenem / Cilastin
Clindamycin + Tobramycin +
Ampicillin
Vancomycin +
Aztreonam +
Metronidazole
PREVENTION / PATIENT
EDUCATION
•
Take Care of Your Diabetes
•
Check Your Feet Every Day
•
Wash Your Feet Every Day
•
Keep the Skin Soft and Smooth
PREVENTION / PATIENT
EDUCATION
•
Wear Shoes and Socks At All Times
•
Protect Your Feet From Hot and Cold
•
Keep the Blood Flowing to Your Feet
•
Be More Active
•
Communicate With Your Doctor
SUBCUTANEOUS SLIDING SCALE VERY RAPID OR
RAPID INSULIN ALGORITHM:
TO SUPPLEMENT INSULIN REGIMEN ALREADY IN
PLACE
• Monitor glucose level and administer insulin:
• o Every 4-6 hours if using regular insulin (rapid
acting)
• o Every 2-4 hours if using lispro or aspart insulin
(very rapid acting)
• For glucose level >250 mg/dl, check more
frequently
• If after 4-6 hours no change in glycemic control
is realized, consider insulin dosing
• according to next higher weight class
SUBCUTANEOUS SLIDING SCALE VERY RAPID OR
RAPID INSULIN ALGORITHM:
TO SUPPLEMENT INSULIN REGIMEN ALREADY IN
PLACE
Weight Class I Weight Class II
CBG (mg/dl)
<150
150-200
201-250
251-300
301-350
351-400
>400
Weight Class III
(<175 lbs/80 kg)
(175-220 lbs/81-99 kg) (>220 lbs/100 kg)
Insulin Units
0
1
2
4
6
8
Begin Insulin
Infusion
Insulin Units
1
2
4
6
8
10
Begin Insulin
Infusion
Insulin Units
2
4
6
8
10
12
Begin Insulin
Infusion
REFERENCES:
1.
2.
3.
4.
5.
Frykberg RG, Armstrong DG, Giurini J, Edwards A, Kravette M, Kravitz S,
Ross C, Stavosky J, Stuck R, Vanore J. Diabetic foot disorders: a clinical
practice guideline. American College of Foot and Ankle Surgeons. J Foot
Ankle Surg 2000;39(5 Suppl):S1-60.
Frykberg RG. Diabetic foot ulcers: current concepts. J Foot Ankle Surg
1998;37:440-6.
Hurvitz G, Zalavras C, Thordarson DB. Debridement and primary closure
of nonhealing foot wounds. Am J Orthop. 2004 Oct;33(10):507-9.
McElwain JP, Hunter GA, English E.Syme's amputation in adults: a longterm review. Can J Surg. 1985 May;28(3):203-5.
Robbs JV, Ray R (1982) Clinical predictors of below knee stump
healing following amputation for ischaemia. South African Journal
of Surgery 20: 305-10
REFERENCES:
6.
7.
8.
9.
Andersen S, Gjedsted J, Christiansen C, Tønnesen E. The roles of
insulin and hyperglycemia in sepsis pathogenesis. Journal of Leukocyte
Biology. 2004;75:413-421.
Brodsky, J: The Diabetic Foot. In Surgery of the Foot and Ankle,
Coughlin, MJ, and Mann, RA, editors. Mosby Inc., St. Louis, 1999. Table
21-2, page 911.
http://som.flinders.edu.au/FUSA/ORTHOWEB/notebook/general/amputati
ons.html#bka
http://www.latrobe.edu.au/podiatry/diabetesresources/diabetes_lecture_4
.htm
MCQ
1. Which of the following Wagner’s Diabetic
Ulcer Grade is characterized by a fullthickness ulcer?
a. Grade 1
b. Grade 2
c. Grade 3
d. Grade 4
e. Grade 5
MCQ
1. Which of the following Wagner’s Diabetic
Ulcer Grade is characterized by a fullthickness ulcer?
a. Grade 1
b. Grade 2
c. Grade 3
d. Grade 4
e. Grade 5
MCQ
2. What area/s is/are the most common
anatomical distribution of diabetic ulcers?
a. Dorsum of the foot
b. Ankle
c. Multiple ulcers
d. Toes
e. Plantar metatarsal heads
MCQ
2. What area/s is/are the most common
anatomical distribution of diabetic ulcers?
a. Dorsum of the foot
b. Ankle
c. Multiple ulcers
d. Toes
e. Plantar metatarsal heads
MCR
•
•
•
•
•
A if 1,2 & 3 are correct
B if 1 & 3 are correct
C if 2 & 4 are correct
D if only 4 is correct
E all of the above are correct
MCR
3. Which of the following are features of a
limb threatening diabetic ulcer?
1. Cellulitis > 2 cm from ulcer
2. Wound does not probe joint or bone
3. With features of sepsis
4. Close supervision on an out-patient
basis
MCR
3. Which of the following are features of a
limb threatening diabetic ulcer?
1. Cellulitis > 2 cm from ulcer
2. Wound does not probe joint or bone
3. With features of sepsis
4. Close supervision on an out-patient
basis
MCR
4. Which of the following antibiotic
regimens can be given to a severe
diabetic foot infection?
1. Amoxicillin/Clavulanate
2. Imipinem/Cilastin
3. Clindamycin + Tobramycin + Ampicillin
4. Ampicillin/Sulbactam
MCR
4. Which of the following antibiotic
regimens can be given to a severe
diabetic foot infection?
1. Amoxicillin/Clavulanate
2. Imipinem/Cilastin
3. Clindamycin + Tobramycin + Ampicillin
4. Ampicillin/Sulbactam
MCR
5. Which of the following laboratory
examinations can assess the success of
the level of amputation of a patient who
underwent a major limb aputation?
1. FBS
2. ESR
3. CBG
4. HgbA1C
MCR
5. Which of the following laboratory
examinations can assess the success of
the level of amputation of a patient who
underwent a major limb aputation?
1. FBS
2. ESR
3. CBG
4. HgbA1C