Diabetic Foot Care E-Book

Alethea V. M. Foster

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 350

Veröffentlichungsjahr: 2011

Beschreibung

Health Economics and Financing Diabetic Foot Care: Case Studies in Clinical Management uses an illustrated patient case study format to demonstrate the multidisciplinary care and clinical management of patients with feet and lower limb problems as a result of diabetes. Every case has colour illustrations highlighting both the initial presentation of the foot, right through to treatment and long term follow-up care. Of particular focus are the management problems, barriers to effective care, preventable mistakes, unnecessary delays in presentations, challenging situations, conflicts, dilemmas and solutions that podiatrists and diabetic specialists face. Sections in the book include: Neuropathic and neuroischaemic foot, neuropathic ulcers, ischaemic ulcers, infections, gangrene, traumatic injuries, Charcot's osteoarthropathy, dermatological problems associated with diabetes, painful neuropathy, diabetic foot emergencies, angiology and foot surgery/amputation. With key points and summaries at the beginning and end of each section, this book is clear and easy to navigate, making it an ideal tool for diabetes specialists, diabetes nurses and podiatrists. Titles of Related Interest Practical Manual of Diabetic Foot Care 2EEdmonds. 978-1-4051-6147-3> The Foot in Diabetes 4E Boulton. 978-0-470-01504-9 Handbook of Diabetes 4E Bilous. 978-1-4051-8409-0

Leseprobe

Contents

Acknowledgements

Introduction

1 Neuropathic Case Studies

1.1 Introduction

1.2 Differing presentations of infection and complications of infection

1.3 Co-Morbidities in addition to diabetes and neuropathy

1.4 Deformity, ulceration and infection treated by surgical debridement and reconstruction

1.5 Patients with neuropathic feet in whom psychological factors have impacted on their management

1.6 Long term patients followed in the Diabetic Foot Clinic with neuropathic foot problems

2 Ischaemic Case Studies

2.1 Introduction

2.2 Infection and its presentations

2.3 Patients with severe co-morbidities

2.4 Revascularisation

2.5 Wound care

2.6 Emboli

2.7 Complications

2.8 Pain in the neuroischaemic foot

2.9 Conservative care

3 Charcot Case Studies

3.1 Introduction

3.2 Early diagnosis

3.3 Different presentations

3.4 Surgery

3.5 Conservative care

4 Renal Case Studies

4.1 Introduction

4.2 Patients with normal serum creatinine initially who develop low creatinine clearance with infection

4.3 Low creatinine clearance and complications

4.4 Continuous ambulatory peritoneal dialysis (CAPD) and complications

4.5 Haemodialysis and complications

4.6 Renal transplant and complications

4.7 Revascularisation in renal patients

Index

This edition first published 2011 © 2011 by John Wiley & Sons Ltd

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Library of Congress Cataloguing-in-Publication Data

Foster, Alethea V. M.

Diabetic foot care : case studies in clinical management / Alethea Foster and Michael Edmonds.

p.; cm.

Includes index.

ISBN 978-0-470-99823-6 (cloth)

1. Foot–Diseases–Treatment–Case studies. 2. Diabetes–Complications–Treatment–Case studies. 3. Foot manifestations of general diseases–Case studies.

I. Edmonds, M. E. II. Title.

[DNLM: 1. Diabetic Foot–therapy–Case Reports. 2. Diabetic Foot–diagnosis–Case Reports. WK 835 F754d 2010]

RC951.F674 2010

616.6′1–dc22

2010025371

This book is dedicated to all our living patients, as a tribute to men and women of remarkable fortitude and courage,and is also dedicated to the memory of our patients who have died valiantly fighting diabetes and who have shown us how diabetes can be a killer

Acknowledgements

We are grateful to colleagues past and present, who include: Simon Fraser, Huw Walters, Mary Blundell, Cathy Eaton, Mark Greenhill, Susie Spencer, Maureen McColgan-Bates, Mel Doxford, Sally Wilson, Adora Hatrapal, E Maelor Thomas, Mick Morris, Joh PhilpottHoward, Jim Wade, Andrew Hay, Robert Lewis, Anne- Marie Ryan, Irina Mantey, Robert Hills, Rachel Ben-Salem, Muriel Buxton-Thomas, Mazin Al-Janabi, Dawn Hurley, Stephanie Amiel, Stephen Thomas, Daniela Pitei, Paul Baskerville, Anthony Giddings, Irving Benjamin, Mark Myerson, Paul Sidhu, Joydeep Sinha, Patricia Wallace, Gillian Cavell, Lesley Boys, Magdi Hanna, Sue Peat, Colin Roberts, David Goss, Colin Deane, Sue Snowdon, Ana Grenfell, TimCundy, Pat Ascott, Lindis Richards, Kate Spicer, Debbie Broome, Liz Hampton, Timothy Jemmott, Michelle Buckley, Rosalind Phelan, Maggie Boase, Maria Back, Julie Lambert, Avril Witherington, Daniel Rajan, Hisham Rashid, Ghulam Mufti, Karen Fairbairn, Ian Eltringham, Nina Petrova, Lindy Begg, Barbara Wall, Mark O’Brien, Sacha Andrews, Barry Pike, Jane Preece, Briony Sloper, Christian Pankhurst, Jim Beaumont, Matthew McShane, Tim Cooney, Lin Pan, Cheryl Clark, Marcello Perez, Nicholas Cooley, Paul Bains, Patricia Yerbury, Charlotte Biggs, Anna Korzon Burakowska, David Ross, Jason Wilkins, David Evans, Dean Huang, Carol Gayle, David Hopkins, Rif Malik, Keith Jones, Bob Edmondson, Enid Joseph, Karen Reid, David Williams , Doris Agyemang-Duah, Jennifer Tremlett, Venu Kavarthapu, Om Lahoti and Mark Phillips, Paula Gardiner, Ian Alejandro, Barbara Chirara, Victoria Morris, Hany Zayed, Paul Donohoe and Sui PhinKon and two great stalwarts of the Foot Clinic, Peter Watkins and the late David Pyke.

The Podiatry Managers and Community Podiatrists from Lambeth, Southwark and Lewisham have also contributed greatly to the work of the Foot Clinic at King’s over many years.

We are particularly grateful for the advice of the members of the Dermatology Department, Anthony du Vivier, Daniel Creamer, Claire Fuller, Elisabeth Higgins, Sarah MacFarlane, Rachel Morris-Jones and Saqib Bashir.

We also are also thankful to Stephen and Audrey Edmonds and to Nina Petrova for technical help with the production of the manuscript.

We give special thanks to Yvonne Bartlett, Alex Dionysiou, David Langdon, Lucy Wallace, Margaret Delaney and Moira Lovell from the Department of Medical Photography at King’s.

We are particularly grateful to Fiona Woods Project editor, STM books, Wiley- Blackwell and Sarah Abdul Karim, Production Editor, Content Management, Wiley- Blackwell and Aparajita Srivastava, Senior Project Manager, Thomson Digital for their patience and help.

Introduction

In this book, we describe cases from the King’s Diabetic Foot Clinic archive, most of which have not previously been described in any of our books. We have always believed that there are lessons to be learned from every single patient, and if those lessons can be passed on to other health care professionals through this book then the patients described will not have suffered or died in vain. Each patient is unique and complex and a wonderful learning resource.

The book is aimed at all health care professionals who care for or come into contact with diabetic patients. By reading these case reports we hope that all these professionals should come to understand the subtleties and complexities of diabetic foot presentations, and in particular the general points about diabetic foot patients, namely, that patients with diabetic foot problems quickly reach the point of no return and often have multiple co- morbidities which affect the progress of their foot condition. Indeed, the exacerbation of their foot problem often aggravates their co-morbidities. However, close medical attention to their co-morbidities both in the Diabetic Foot Clinic and on the Hospital wards can lead to a positive outcome and an improvement in their foot condition. The underlying principles of diabetic foot care are early diagnosis and intervention and meticulous follow- up. All health care professionals should be aware of this.

Patients often have other co-morbidities that contribute to their pathogenesis of the diabetic foot, for example, renal failure. This can then be affected by the diabetic foot lesion with worsening renal failure especially in the presence of infection, and the renal status will also impact on their overall progress.

Within these case studies we have tried to get across the feeling of how it is in the real world, trying to manage diabetic foot patients with long-term, end-stage diabetes, within the Diabetic Foot Clinic and on the Hospital wards. We describe the failures as well as the successes, the frustrations as well as the achievements and the camaraderie of working within a multidisciplinary team of like-minded and dedicated practitioners

The patients described are difficult patients and vulnerable patients and managing them well is hard work. Complex medical and psychosocial factors lead to difficulties and barriers. By describing our clinical experiences, the problems we and our patients have faced, and the lessons we have learned over the years in managing these unpredictable patients with multiple co-morbidities, we hope it will become clear that these patients need to be managed within an expert environment. Sometimes the only way to achieve healing is with advanced techniques. The support of a multidisciplinary team is essential: the combined skills of vascular surgeon and interventional radiologist, orthopaedic surgeon microbiologist, dermatologist, psychologist, physician, podiatrist, nurse and orthotist are often needed. Although we have always promoted the importance of basic foot care and preventive education, there is sometimes also a need for access to advanced techniques to achieve healing.

We describe the multidisciplinary and supportive approach to patients that we use at King’s to try to keep patients out of trouble. All diabetic foot patients with severe problems that we have seen at King’s had one or more of the following four problems:

Neuropathy,

Ischaemia,

Charcot’s osteoarthropathy

Renal impairment,

and this book is broken into four main sections devoted to those four categories of patient. There are some areas of overlap in the case histories: some patients have spent periods of their diabetic lives in all of the sections, progressing from neuropathy to the development of Charcot’s osteoarthropathy and on to neuroischaemia and eventual renal failure.

The same principles of care recur time and time again. First and foremost is the need to classify and stage the foot, and we use our King’s Simple Staging System, which follows the diabetic foot along the road to amputation, and can be used as a framework for organising care. It goes as follows:

First we classify the foot as neuropathic or neuroischaemic. We then stage the foot.

Stage 1   The normal footStage 2   The high risk foot (with one or more of the following: neuropathy, ischaemia, deformity, swelling, callus)Stage 3   The ulcerated footStage 4   The infected footStage 5   The necrotic footStage 6   The unsalvageable foot

We have described this Simple Staging System to manage patients in our previous diabetic foot books. The principles of management according to the Simple Staging System have been applied to every patient in the book – it has become second nature to us to use this tool – but we have not elaborated on this in detail with every patient case as doing that would become repetitious and tedious. We have tried to stress the most relevant and interesting points in each case without labouring the points that have already been covered in other case histories.

In our selection of case histories we have tried to illustrate new developments in each area, over the 29 years that the King’s Diabetic Foot Clinic has existed, and also the problems that can arise when new techniques are applied to diabetic patients. The cases in this book illustrate the ‘King’s Approach’, and the same principles of care recur time and time again: the importance of catching problems early, the aggressive management of infection, never underestimating apparently small problems, especially when they occur in a foot with ischaemia or a patient with renal impairment, the gradual building up of a relationship of trust over many years, and the constant search for potential problems which can be prevented, delayed or de-toothed with education or a change in the management or just a little compromise on either side. Lastly, the involvement of patients and their families in the clinical decisions made is, we believe, essential to successful management of the high- risk diabetic foot: the patients with supportive, caring, observant families do best.

Although the foot problems are serious, with greater overall mortality than cancer of the colon, and at least fifty percent of the patients described are in the last few months or years of their lives, nonetheless, the life of the diabetic foot patient can be extended and their happiness and mobility optimised by good foot care.

Alethea FosterMichael Edmonds

London, 2010

Glossary of terms

Throughout this book we refer to:

ABPI Ankle brachial pressure index bd twice daily BMD Bone mineral density CAPD Continuous ambulatory peritoneal dialysis CROW Charcot restraint orthotic walker CRP C-reactive protein CVA Cerebrovascular accident EMG Electromyography ESBL Extended sensitivity beta lactamase IM Intramuscular INR International Normalised Ratio IV Intravenous MRA Magnetic Resonance Angiography MRI Magnetic Resonance Imaging MRSA Methicillin resistant staphylococcus aureus MSU Mid stream specimen of urine PICC Peripherally inserted central catheter PTBWRO Patellar-tendon-bearing weight-relieving orthosis qds four times daily tds three times daily VAC Vacuum assisted closure VPT Vibration perception threshold measured at the apex of the big toe WBC White blood count

1

Neuropathic Case Studies

1.1 Introduction

In the past we have often described the neuropathic foot as a ‘forgiving’ foot, and there is little doubt that of the four main categories of patients – neuropaths, neuroischaemics, renals and Charcots – described in this book it is the neuropathic patients who do the best. It is, however, important never to underestimate the problems of the diabetic patient with neuropathy, which is a devastating deficit. In many of these patients, neuropathy affects other anatomical systems such as the cardiovascular, gastrointestinal and urogenital systems, and not just their feet and legs, and as a result they are incredibly frail and vulnerable, with greatly increased susceptibility to infections and other insults. When managing the neuropathic patient with foot problems, particular regard must be paid to all these susceptibilities and vulnerabilities. It is often said of these patients with neuropathic feet “Good pulses, not ischaemic, not in trouble” – but the neuropathic patient is actually very fragile and may rapidly develop severe problems and therefore can get into trouble very quickly.

In choosing sections for this chapter, we have included those that substantially affect the patient with diabetic neuropathic feet: highlighting first the role of infection, the “great destroyer”, which is a real mask of Janus, putting on so many different and deceptive faces in the diabetic patient (a theme that is repeated in every chapter). Second comes the effect of neuropathy in conjunction with other co-morbidities that are present in the neuropathic patient. Third, we look at the effect of reconstruction of the deformed or unstable neuropathic foot. Fourth, we consider the significance of psychological factors, and finally, the importance of long term care.