Diabetic foot is a disease state in which ulcers and gangrene occur in the lower extremities of diabetic patients due to neuropathy that decreases the protective function of the lower extremities, and macrovascular and microvascular lesions that cause inadequate arterial perfusion resulting in impaired microcirculation. Diabetic foot is a serious complication of diabetes, and is one of the important causes of disability and even death in diabetic patients, which not only causes pain to patients, but also adds a huge economic burden to them.
I. Clinical types
According to the nature of diabetic foot lesions, can be divided into wet gangrene, dry gangrene and mixed gangrene 3 clinical types.
1, wet gangrene: clinically seen diabetic foot is mostly of this type, accounting for about 3/4 of the diabetic foot, mostly due to impaired circulation and microcirculation at the extremity, often accompanied by peripheral neuropathy, skin injury infection and septic. Local redness, swelling, heat, pain, dysfunction, severe cases are often accompanied by general discomfort, toxemia or sepsis and other clinical manifestations.
2, dry gangrene: dry gangrene of the foot in diabetic patients is less, accounting for only 1/20 of patients with foot gangrene, which occurs in diabetic patients with arterial and small arterial atherosclerosis, severe narrowing of the vascular cavity; or arterial thrombosis, resulting in blockage of the vascular cavity, blood flow is gradually or abruptly interrupted, but venous blood flow is still open, resulting in a decrease in local tissue fluid, resulting in blockage of the corresponding area of the distal limb supplied with blood by the artery Dry gangrene occurs, and the degree of gangrene is related to the site and degree of vascular obstruction. Smaller arterial blockage, the gangrene area is small often forming focal dry necrosis, larger arterial blockage, the area of dry gangrene is larger, or even complete necrosis of the entire extremity.
3, mixed gangrene: diabetic patients with mixed gangrene than dry gangrene is slightly more common. About 1/6 of patients with diabetic foot. dry gangrene caused by blockage of an artery in one part of the limb, poor blood flow; and the other part combined with infection and septicemia. Mixed gangrene is characterized as a focal point of both wet and dry gangrene that occurs in different parts of the same extremity. Patients with mixed gangrene are generally sicker, with more ulcerated areas and larger areas, often involving large portions or all of the hand and foot. In severe infections, there may be general malaise, increased body temperature and white blood cells, and the development of toxemia or sepsis. Dry gangrene of the extremities is often accompanied by vascular embolism in other areas, such as cerebral thrombosis and coronary artery disease.
Second, treatment
Once the diabetic foot occurs, the condition should be evaluated as clearly as possible before treatment: determine the etiology; determine the type and extent; evaluate vascular patency by physical examination or Doppler; examine secretions and perform bacterial and drug sensitivity tests promptly; evaluate peri-ulcerative edema, inflammation and necrosis; X-ray for osteomyelitis and subcutaneous gas; exclude systemic infection, etc. Select appropriate systemic treatment, local treatment or surgery according to the condition.
1.Systemic treatment generally includes metabolic control, vasodilation, blood circulation and blood stasis activation, and application of antibiotics (if infection exists).
(1) Metabolic control: mainly refers to good control of blood sugar, poor control of blood sugar is not conducive to the healing of ulcers and control of infection. The occurrence of diabetic foot ulcers, especially the stress caused by combined infections, etc. can further increase blood glucose, and it is generally necessary to switch to insulin therapy and keep blood glucose control within the ideal range as much as possible, which is the basis for the treatment of diabetic foot. Blood glucose should be controlled below 11.1mmol/L or as close to normal as possible.
(2) Dilate blood vessels and activate blood circulation to improve blood supply to the tissues: clinics often use.
①Low molecular dextrose 500ml or add salvia 10-20ml, intravenous drip, 1 time/d;
②Scopolamine, general dose 0.5~1.5mg/kg, oral in mild cases, intravenous in severe cases;
③Closure of lumbar 2, 3 and 4 sympathetic nerves to relieve vasospasm of lower limbs;
④Prostaglandin E intravenous injection, has a good vasodilating effect;
⑤ Anti-platelet drugs such as cilostazol (PEDA) have good peripheral vasodilating effect in addition to anti-platelet, which has good adjuvant effect on diabetic foot ulcer, and other drugs such as Salvia and Chuanxiong can also be used.
(3) Treatment of neuropathy: vitamin B preparations can be applied, and neurotrophic drugs can be applied to improve nerve function.
(4) The use of antibiotics: diabetic foot ulcers are often prone to secondary infection, and the rapid deterioration of the condition is an important cause of foot gangrene, given that the infection is often a mixture of multiple strains of bacteria, and often combined with anaerobic bacterial infections, some patients can be clinically asymptomatic and hematologically infected features even if there is a serious lower limb infection. In general, broad-spectrum antibiotics and metronidazole should be given in cases where the pathogenic bacteria are unknown, and treatment should be adjusted if necessary after bacterial and drug sensitivity test results are reported.
(5) Hyperbaric oxygen therapy: it can improve blood circulation and lower limb hypoxia and can be tried.
2.Local treatment mainly includes local debridement and wound treatment.
(1) Debridement: There is still some controversy, but most advocate adequate debridement, incision and drainage of the infected foci. The debridement should be extended to healthy tissues with bleeding, excise all necrotic tissues, and try to protect the tendons and ligamentous tissues with vitality; gangrene with small mouth cavities should be enlarged; multiple cystic abscesses should have multiple incisions to keep drainage open. Small debridements can be performed bedside, but most cases may require a trip to the operating room under anesthesia.
Local blisters and hemorrhagic blisters should be treated with a sterile syringe of choice under strict sterilization, with their contents withdrawn by the low level of the blister and local application of 2.5% iodine to prevent infection, with appropriate local pressure to dry them out.
(2) Trauma treatment: adhere to daily drug changes, local application of a mixture of antibiotics, insulin and scopolamine (654-2) (such as 5% saline 250-500 ml and human insulin 40 U and gentamicin 240,000 U or other antibiotics and scopolamine (654-2) injection 40 mg) for cleaning and wet dressing, in which insulin can locally improve the function of leukocytes The local application of insulin can improve the function of leukocytes, stimulate the growth of epithelial cells and fibroblasts and protein synthesis, which is conducive to the healing of wounds; the local application of antibiotics can enhance the effect of anti-infection; the local application of scopolamine (654-2) can improve blood circulation. Exposure without bandage as much as possible during daytime, bandage is feasible at night to avoid damage; it can be supplemented with Chinese herbal powder to remove decay and muscle, anti-inflammatory and pain relief and improve microcirculation; mechanical padding to reduce weight-bearing of ulcer site, bed rest and use of special shoes, etc.; in addition, local irradiation by Zhoulin spectrometer or light bulb is beneficial to keep the wound dry and improve blood circulation for half an hour each time, 3 to 4 times a day; elevation of the affected limb is beneficial to reduce local edema (ulcers of any cause, as long as there is edema, ulcers are not easy to heal), supplemented with diuretics if necessary. Recently, it has been reported that the application of Kanghuier diabetic foot series wound care products (debridement gel, exudate absorption paste and ulcer paste, etc.) helps to remove necrotic decaying tissue from the trauma, enhance exudate absorption of local tissues, promote the growth of granulation tissue and accelerate the absorption of trauma.
3.Surgical treatment
(1) Arterial reconstruction: It is an important method for treating ischemia or gangrene of the extremity caused by large vessel obstruction, which can save some patients from amputation. Methods are.
① Vascular bypass surgery: the patency rate of blood vessels is about 60%, and the commonly used method is vascular bypass diversion, that is, a section of autologous or artificial vascular bridge is set up between the normal blood supply artery segment and the distal non-stenotic artery of the diseased vessel to improve the distal blood supply to the limb;
(ii) Endovascular resection: for large vessels and limited arterial obstruction and stenosis;
(iii) Percutaneous endovascular angioplasty: better for iliac artery occlusion;
④Endovascular laser treatment;
(5) Large omental graft with tip is commonly used for anterior tibial, posterior tibial and peroneal artery occlusions.
(2) Amputation: the conservative treatment is ineffective, in order to save the life of the method of last resort, the best preoperative angiography to determine the amputation plane, without affecting the healing of the amputation plane, should try to preserve the function of the affected limb after surgery and facilitate the installation of prosthesis.
4.Chinese medicine treatment
It can be applied to clear heat and detoxify, invigorate blood circulation, remove decay and create muscle, or made into a cream for external use, which has achieved good clinical effect.
5.Bone marrow stem cell transplantation
Bone marrow stem cells have the function of directional differentiation into various cells needed by human body, and basic and clinical research found that transplantation of bone marrow stem cells into ischemic limbs can form vascular endothelial cells locally and produce neovascularization without generating other unwanted tissues. The method is as follows: bone marrow is obtained under local anesthesia, followed by isolation of bone marrow stem cells, for which mature technology is available, and finally the isolated bone marrow stem cells are transplanted into the ischemic limb. This method is applicable to all diabetic patients with limb ischemia (equally effective for non-diabetic patients), from early intermittent claudication to late foot ulcers and even limb necrosis, and generally the earlier the course of treatment the better the effect, early treatment can alleviate or completely relieve intermittent claudication and resting pain, and in patients with diabetic foot ulcers can promote ulcer healing or shrinkage, etc. The method is relatively simple to operate, and the efficacy is more certain, which is worthy of further clinical observation and research.