Diabetic foot treatment
I. 0 diabetic foot management
This level belongs to the pre-necrotic stage also known as the high-risk foot stage, where the skin is not yet open to injury or lesions. However, it often shows insufficient blood supply to the extremity, decreased skin temperature, dryness, tingling and burning pain, numbness, and dullness or loss of sensation. Bone destruction, chronic injury to tendon ligaments, metatarsal head subsidence, metatarsophalangeal joint flexion, often forming claw toe, mallet toe, bunion, deformity of the foot and Charcot joint, etc., high risk foot and other manifestations. As a result, it causes displacement of the negative point of the foot, the new negative point is vulnerable to injury, tendon ligaments are easily torn, and bone destruction is prone to pathological fractures. Inadequate blood supply to the extremity is prone to ischemic gangrene, and neuropathy is prone to penetrating ulcers and infection leading to severe gangrene. Principles of management at this level.
(1) Prevention of gangrene is the main focus, and the foot is protected from injury. In addition to in-depth publicity and education by medical personnel, it is more important to strengthen the patient’s awareness of self-protection and to improve the patient’s own defenses to achieve early prevention, early detection and early treatment.
(2) Active control of diabetes, reasonable distribution of diet, strict control of hyperglycemia, hyperlipidemia, high blood viscosity, active prevention of atherosclerosis; improve limb ischemia and nerve function; appropriate exercise, prohibit smoking, alcohol abuse, can be long-term use to improve circulation and microcirculation, blood circulation drugs, soften blood vessels, reduce blood viscosity, promote blood circulation, restore peripheral nerve function.
(3) Active prevention of risk factors
1, keep the feet clean and hygienic, should wash the feet every day, the general foot washing water temperature should not exceed the patient’s lower limb body surface temperature, to prevent scalding blistering sensation beam septic. Toenail clipping should not be too short and lose the ability to defend.
2, pay attention to the foot warmth, to prevent frostbite. But be careful with hot water bags, electric blankets, infrared, physical therapy, fireplace heating, to avoid scalding infection. And be careful to use the massager massage hands and feet to prevent friction skin blistering infection resulting in gangrene.
3, the foot has a deformity, can wear rectangular shoes to correct the negative focus of the foot, or wear casual shoes, shoes and socks to life feet, should not be too tight or too loose. Shoes and socks should be clean, good ventilation, preferably wearing soft-soled cloth shoes, cotton socks, do not wear open-toed shoes, (sandals), prohibit barefoot walking. Patients should not exercise strenuously and avoid excessive weight bearing on both feet. Prevent trauma, check the foot every day for skin injuries and treat them properly. Toe or foot deformity should be orthopedic surgery as soon as possible to remove hidden problems.
4, smoking, calluses, bone spurs, nail infection, cysts or tinea pedis promptly ask the doctor for treatment, and educate the patient not to handle by themselves. In order to prevent bacterial infection by poor disinfection, which can lead to gangrene.
5.For those who have insufficient blood supply to the lower extremities and circulatory disorders, timely examination of the lower extremity vascular color ultrasound Doppler should be performed. In cases of severe arterial obstruction, early revascularization or interventional radiology treatment should be performed if necessary to eradicate hidden problems.
This level of prevention is a long-term task for patients and health care providers. We should focus on small problems and think about the health of patients. No minor injuries and various risk factors should be left unattended. If prevention efforts are strong and handled properly, extremity gangrene can be completely avoided.
Second, the first level of diabetic end gangrene treatment
This level belongs to the early stage of gangrene, the skin has open injuries or lesions. Such as blisters, blood blisters, corns or calluses, 1-2 degree burns or frostbite and other superficial ulcers due to skin injury. However, the lesion has not yet reached the muscle tissue. The principles of its management: three stages of basic treatment, debridement and myogenesis, can be carried out simultaneously.
(1) Patients with younger age, less other related complications, still good blood supply to the extremity and smaller trauma should grasp the timing while controlling the basic treatment of diabetes mellitus, and decortication can be carried out as early as possible to gradually remove the ulcerated tissue, which is conducive to ulcer healing.
(2) Patients who are older, weaker, have more other complications, have insufficient blood supply to the lower extremity, and have peripheral neuropathy, but with mild gangrenous lesions. Treatment focuses on controlling diabetes mellitus and using effective antibiotics to prevent infection. To improve blood supply to the extremity, change the medication once a day to remove the ulcerated tissue, but it is not advisable to overly clear the wound, and when the blood supply to the extremity is improved, then do the clearing treatment. And give drugs to activate blood circulation, remove blood stasis, remove decay and create muscle.
(3) For the treatment of blisters and hemorrhagic blisters, generally patients undergo the basic treatment stage, and under strict sterilization conditions, a sterile syringe is chosen to draw out the contents from the low level of the blister and apply 2.5% iodine to prevent infection to make it dry. For corns and calluses, make partial or complete excision and apply muscle-generating drugs such as muscle-generating powder, muscle-generating cream or epidermal growth factor to promote skin growth and early healing of the wound. If properly treated, it can be cured successfully.
Management of Grade II diabetic gangrene
Due to subcutaneous tissue infection forming foci of pus or cellulitis, pathogenic bacteria have invaded deep muscle tissue, causing serious muscle infection, forming focal or multiple small abscesses, or purulent secretions spread along the muscle gap and expand to form sinus tracts, plantar dorsal foot penetrating ulcers, purulent secretions often flow from the mouth of the sinus tracts, but tendon ligaments are not yet destroyed, the prognosis is better if treated properly, treatment principles.
(1) Basic treatment stage.
1.Local treatment needs to be carried out on the basis of controlling diabetes mellitus and improving blood circulation in the extremity.
2, local infection early, before the formation of abscess foci should be strengthened anti-infection, static point a large number of effective antibiotic control of infection. Local physiotherapy and infrared irradiation can be used, but burns should be prevented, and local redness and swelling can be coated with Chinese medicine double yellow liquid wet compress to achieve anti-inflammation and dispel swelling and continue or control the development. If handled properly can avoid spreading and expanding to form sinus tracts and abscesses.
3.Late stage of local infection, which has formed limited abscess with fluctuating sensation or formed sinus tract, should be treated at the same time to grasp the timing of incision and drainage to prevent small abscess from fusing to form large abscess cavity. If the patient is older and has poor blood supply to the lower extremities, in addition to incision and drainage, there is no urgency to make a major invasive surgery for the time being and wait for the general condition to improve before decomposition. Generally, patients with fasting blood sugar control at 6.6-8.3mmol/L, improved blood supply to the lower limbs and corresponding control of local inflammation can enter the decay stage.
4.Decomposition stage: Cellulitis or multiple abscesses should be incised and drained to keep the drainage open. However, avoid squeezing or excessive flushing to avoid spreading and expanding the infection along the muscle gap. The necrotic tissue is mostly removed gradually by nibbling, but special attention should be paid to protect the tendons and ligaments, which will play an important role in the prognosis of restoring the function of the foot and creating conditions for improving the quality of life of patients.
5, the myogenic stage: after the decay stage treatment, necrotic tissue and purulent secretions significantly reduced, granulation tissue began to newborn, can enter the myogenic stage. However, basic treatment is still needed to control diabetic hyperglycemia, improve circulation and microcirculation, and prevent secondary infection. For gangrenous wounds, topical 654-2 film, ointment and Chinese medicine powder can be applied. To activate blood circulation, remove blood stasis, remove decay and produce muscle, relieve inflammation and pain, improve local wound microcirculation, promote the growth of granulation tissue, so that the gangrene heals as soon as possible.
Grade 3: Management of diabetic gangrene
The extent and depth of gangrene at this level is further aggravated by expansion. Tendons and ligamentous tissues have been destroyed, and dry gangrene is caused by the sudden interruption of blood flow in a small artery, resulting in local acute ischemia, limited blackening and necrosis or drying of a few toes or a part of the heel, sole, or dorsum of the foot; in wet gangrene, the infection is further aggravated by the fusion of limited or mezzanine abscesses, the formation of large abscess cavities, and the destruction of muscles, tendons, and ligamentous tissues. The plantar or dorsal part of the foot is elevated and has a fluctuating sensation when touched. The inflammatory reaction around the abscess is obvious, often with redness, swelling, heat, pain, general discomfort, rising body temperature, increased white blood cell count, and some patients may have clinical manifestations of toxemia. However, the bone is not yet destroyed. Principles of treatment at this level.
(1) Basic treatment stage
1. Most patients need insulin therapy to control diabetes mellitus. Improve the blood supply to the extremities, and at the same time, give priority to control the toxemia appearing from the infection, choose effective broad-spectrum antibiotics intravenous drip to lower the body temperature and white blood cells to the normal range. And give supportive therapy, without affecting heart and kidney function, increase the amount of intravenous fluid input to promote toxin discharge and control toxemia.
2, for local abscesses early incision and drainage, reduce its internal pressure, for small mouth cavity large gangrene, should expand the incision, for multi-cyst abscesses should be more than one incision, to maintain unobstructed drainage, so that purulent secretions smoothly discharge, but should not be excessive extrusion or flushing, and prohibit the affected foot weight bearing.
3, for elderly patients with diabetic gangrene or severe atherosclerosis so that the limb is undersupplied with blood and other cardiac, cerebral and renal complications more, before control although gangrene has been cut and drained, but still avoid a large area of thorough expansion, but more nibbling methods to gradually remove necrotic tissue. For dry gangrene should wait until the demarcation with healthy tissue is clear before treatment.
(2) decay stage
1, the timing of debridement is important. When the patient has undergone basic treatment, the general condition improves, blood sugar and infection are basically controlled, circulation and microcirculation are improved, various related complications are basically controlled, and local inflammation is reduced, the debridement stage can be entered.
2. Increase the scope and strength of debridement and gradually remove necrotic tissues. But try to protect the tendons and ligament tissues that have the ability to live.
3.Surgical removal of focal or a few dry gangrene of the toes with clear demarcation from healthy tissues.
(3) Myogenic phase
The timing of the myogenic and decortication stages is relative and cannot be absolutely separated. Generally, in the late decortication stage, necrotic tissue is gradually cleared, secretions are significantly reduced, and the wound surface is relatively clean and red, and the study should focus on the application of myogenic drugs. However, local antibiotics are still needed to prevent infection and should especially protect the nascent granulation tissue.
Grade IV: Management of diabetic end gangrene
This grade is severe gangrene, with severe infection that has caused bone destruction, osteomyelitis and osteoarthrosis or has formed pseudarthrosis. Wet or dry severe gangrene occurs in some fingers and toes or in some hands and feet. Due to severe local infection foot bones are immersed in the pus cavity, which directly aggravates the bone infection or osteomyelitis and bone destruction. Make tendons, ligaments lose attachment points, bone joints lose surrounding tissue tendon ligament fixation and tension balance. It is easy to occur pathological fracture and the formation of pseudo-joint. In addition, this level of clinical also often encounter the lower extremities and dorsum of the foot, plantar larger arteries suddenly blocked, resulting in part of the toe or part of the foot blood supply stopped, and lead to ischemic dry necrosis,. Its treatment principles.
(1) Basic treatment stage
1, the level of gangrene is serious, should be selected with effective antibiotics intravenous drip, increase anti-infective efforts, most patients need insulin control diabetes. Actively improve the blood supply to the extremity, increase the blood circulation and improve circulation and microcirculation drugs, 15 days per course until the circulation is improved. If necessary, interventional radiology can be used to recanalize the large blood vessels.
2. Actively control heart, kidney, brain and other acute and chronic complications. Strengthen supportive therapy, pay attention to the heart and electrolyte balance, correct anemia and hypoproteinemia, enhance the patient’s body resistance.
3, local treatment of gangrene, for wet gangrene, gradually remove necrotic tissue while basic treatment, keep the drainage open, and change the medication 1-2 times a day. Special vigilance should be given to anaerobic bacterial infections, although gas gangrene is rare, once it occurs can be life-threatening and should be dealt with as soon as possible. However, those with dry gangrene or bone destruction should not be treated prematurely and urgently. It is best to remove it when conditions are ripe, pending the decay stage, otherwise the development of ulcerative gangrene may be aggravated.
(2) decay stage
1. The timing of decay and muscle growth is basically the same as the timing of tertiary gangrene treatment. Due to the specificity of diabetic gangrene, early and late debridement have a great impact on the treatment of gangrene. Premature and complete debridement is not conducive to controlling the development of gangrene because the patient’s blood sugar and infection have not been controlled, the ischemia of the extremity has not been improved, and various complications have not been basically controlled, while the rush to complete debridement often goes against the wishes, and the larger the debridement area, the deeper the ulceration. And it is not easy to amputate the toe in a hurry to succeed. However, too late to clear the wound to decay, and is not conducive to the growth of new granulation tissue, affecting the healing time of gangrenous wounds, therefore, must master the timing of clearing the wound to decay, staged treatment.
2, for patients with grade IV wet gangrene, more in blood sugar control close to normal, local infection is reduced, related complications are controlled accordingly, and the general condition is basically improved. The method of nibbling is often used to gradually remove necrotic tissue and increase the depth of drainage to avoid drainage that is too shallow and too tightly curled to block the sinus tract, which should ensure unobstructed drainage. Adequate amount of topical antibiotics can be placed inside the drainage strip to directly inhibit bacterial reproduction and growth. In patients with suspected anaerobic bacterial infection or deeper sinus tracts with more purulent secretions, the trauma can be left open locally, with hyperbaric chamber or infrared irradiation. For large areas of gangrene or those who have formed pseudarthrosis, a tubular plaster fixation should be given and the window should be opened for drug exchange.
3. Treatment of dry gangrene or partial blackening of the toes. Most in the limb blood supply improved, local inflammation reduced, dry necrosis and healthy tissue after clear demarcation, can be removed from the base of the toe; if part of the dorsal plantar dry gangrene occurs, the necrotic toe can be removed along with the metatarsal bone. Multiple toe gangrene and metatarsal necrosis, partial amputation of the metatarsal bone can be made, according to the maximum plane of gangrene can be done metatarsal appendage joint dissection.
4, the treatment of amputation of the broken end of the toe, wet gangrene or dry gangrene, amputation of the toe or the front of the foot metatarsal dissection, postoperative wound open or closed, should be determined on a case-by-case basis. Open wounds for local drug exchange, drainage is beneficial, but the trauma is too large and prone to secondary infection affects healing. For dry gangrene of the first toe without obvious infection, and the arterial pulsation of the foot is still good, more toe amputation near healthy tissue, suture the flap and place drainage; for wet gangrene amputation of the toe or metatarsal joint severance, often take a semi-open wound, surgery to try to retain more flap for suturing, suturing the purpose of preventing postoperative flap contracture. However, the sutures should not be too tight and there should not be too many sutures to achieve easy dressing of the trauma. If the sutures turn black, the sutures may be too tight causing local ischemic necrosis. The sutures should be removed early and intermittently, and the flap should be pulled by sterilized butterfly tape instead, which can prevent the flap from necrosis and contracture and help to shorten the growth time of the wound.
5, for the bone destruction infection, in addition to active antibacterial infection, in the clean-up should have lost vitality, detached from the periosteum of the dead bone to remove. Chronic osteomyelitis is an important factor in the persistence of gangrene in diabetic extremities. Treatment with antibiotics is not completely effective, and due to the small size of the foot bone, bone drilling and drainage is not easily successful. When the gangrene is not healed or is affecting the healing process, it should be removed.
(3) Myogenic phase
Due to severe infection or ischemic necrosis of a large area, the ulceration is deeper and more severe. Moreover, such patients are bedridden for a long time and are in poor physical condition, requiring a longer period of basic treatment and decay treatment phase.
Grade V: Management of diabetic end gangrene
This disease, diabetic extremity gangrene, is extremely severe gangrene in gangrene. There are three common types of clinical manifestations: first, wet gangrene of a large part or all of the hand or foot due to severe infection; second, ischemic dry gangrene of a large part or all of the hand or foot due to complete obstruction of a larger artery in the extremity; and third, mixed gangrene of a large part or all of the hand or foot due to both infection and severe ischemia of the extremity. It often spreads to the ankle and lower leg and is life-threatening.
(1) Basic treatment stage
1, because the vast majority of this level requires amputation, therefore, in the basic treatment stage should focus on preoperative preparations, first control diabetic hyperglycemia, improve blood circulation in the extremity, strengthen systemic and local anti-infection efforts, correct water and electrolyte disorders, control acute and chronic complications. Improve the patient’s organism resistance to disease.
2.Identify the direct cause, check vascular color Doppler as early as possible, and do angiography if necessary to understand the site and degree of lower limb vascular obstruction. Check the limb X-ray bone film as early as possible to understand the bone destruction; and monitor blood glucose, blood lipids, blood routine and bacterial culture or smear of gangrenous secretions to understand the pathogenic strain.
(2) Decomposition stage
1, patients with atherosclerosis or thrombosis of the larger lower extremity arteries blocking the N artery or iliac and femoral arteries can be done to remove the embolus or perform revascularization and interventional therapy, so that the large vessels are then unblocked to improve the blood supply to the lower extremity, the treatment of gangrene can achieve satisfactory results, otherwise the treatment of gangrene or amputation is not easy to succeed.
2, as the level of gangrene requires amputation, before the amputation of the gangrene local to prevent secondary infection, but do not relax the treatment. The concept of disinfection should be strengthened to remove necrotic tissue, maintain unobstructed drainage, remove purulent secretions, reduce the risk of toxemia and sepsis, with gas gangrene, tetanus and other special strains of infection.
3, lower limb amputation plane selection, mostly in the proximal end above the arterial obstruction site. The best site is the junction of the upper middle 1/3 of the lower leg below the knee, to provide convenience for patients to use the knee joint to install prosthesis.