DIABETIC FOOT COMPLICATIONS
CASE 2
•A 58 years old male presenting to A&E with fever and general unwellness. His wife describes that he has been having worsening Rt foot pain for the last 3 days and started to become smelly on the day before.
•PMHx
DM-II on insulin, HTN, IHD
•Physical Examination
Wet necrosis of the Right foot
Difficult to feel any pedal pulses in the foot because of tissue edema but good signals with hand held doppler over DPA can be heard
•Blood Tests
Hb 89 g/dl, WBC 18 x 109/L, CRP 220 mg/dl
•Questions:
1.Discuss the steps of your immediate and long term management plan.
Immediate:
Resuscitation and start IV fluids
Start IV antibiotics
Urgent Aneasthetic review in A&E
Foot x-ray
Consenting for urgent foot debridement (with possibility of forefoot amputation depending of extent of infection)
Send tissue samples from theatre for Microbiology C&S
Long term:
Assessment for PVD and if any revascularisation is needed
Patient is currently in sepsis:
Immediate:
Resuscitation and start IV fluids
Start IV antibiotics
Urgent Aneasthetic review in A&E
Foot x-ray
Consenting for urgent foot debridement (with possibility of forefoot amputation depending of extent of infection)
Send tissue samples from theatre for Microbiology C&S
Long term:
Assessment for PVD and if any revascularisation is needed
long term antibiotic plan if needed depending on cultures
Wound care in hospital and after discharge
Offloading and referral to orthotics for proper foot wear
Follow up in outpatient clinic and patient compliance
Assessment of genereal condition and vital signs
CBC RFT LFT Pt INR albumin blood grouping prepare blood and plasma
Hydration with fluid chart start empirical antibiotic
Foot xray
Wound culture
Peripheral vascular ex ABI arterial duplex
Anesthiae and cardiac assessment
Accordingly prepare the pt for urgent intervention either extensive debridment vs angioplast with debridment
full vascular examination + examination of any assending infection crepitus
full labs bld glucose level acetone abg serum electrolyte ecg x ray foot ap oblique
anathesia consultation
correction general condition
urgent extensive surgical debridement
Discuss the steps of your immediate and long term management plan.
Immediate:
This is a critically ill septic surgical patient, so I’ll start with ABCDE approach and delivering sepsis 6, so..
-high flow O2, putting pulse oximetry.
-assessment of HR, RR, cap refill, BP, ask for bedside Echo and ECG and portable plain foot radiography.
-insert a foley catheter, UOP monitoring.
-2 wide-bore cannula, getting full lab bloods, ABG, lactate, blood group and save/X-match.
-starting IV fluids, assessing conscious level, RBS (DKA?)
-taking blood cultures, wound swab, then starting broad spectrum antibiotics.
While notifying the op theatre, the anesthesiae, the ICU unit (DKA? severe acidosis? borderline hemodynamics? need for vasopressors? or cardiac monitoring if Pt is IHD & cardiomyopathic?)
then doing Urgent surgical debridement and drainge.
long term management plan:
After stabilization of Pt’s condition, reassessment should be done so ..
-Detailed vascular history, examination, with ABPI and wound assessment, arterial LL Duplex to determine the vascular status of the limb, reassessment of peri-operative risk,
then deciding if he is in need for revascularization or not and which method would fit him better.
-wound care (dressing, off-loading, eradication of infection).
1.Discuss the steps of your immediate and long term management plan.
Immediate management include urgent surgical debridment after proper preparation
Patient is anemic so he needs 2 units of packed RBC’s immediately to correct the anemia and increase possibility of wound healing.
X-Ray of the foot to detect the extention of infection and possibility of bone involvement.
Culture and sensitivity of the wound is mandatory followed by strong imperical broad spectrum antibiotic according to regimen till the C&S .
Surgical debridment include mid planter drainage and debridment of all necrotic tissue with opening of all foot compartments.
Long term management
1- improve wound healing by repeated dressing by silver containing dressing or VAC assessted therapy.
2- patient education about diabetic foot infection.
3- long term rehabilitation by offloading Total contact cast or removable cast for wound healing after eradication of infection.
4- follow up routinly for proper detection of any infection and early intervention.
5- Arterial dupplex to detect PAD and revascularization if needed.