(A) Blood glucose control
In principle, it is necessary to switch to insulin therapy and keep blood glucose control within the ideal range as much as possible, which is the basis of treatment for diabetic foot therapy. Blood glucose should be controlled below 10.0mmol/L or as close to normal as possible.
(B) Use of antibiotics
The use of antibiotics should be adequate, broad-spectrum, and adequate, taking into account both gram-positive and negative bacteria, and considering the infection of anaerobic bacteria; the control of infection should be noted that generally no local antibiotics are used, and the co-infected wound should be adequately flushed and cleared (if the local ischemia is serious, then it should be carried out on the basis of resolving the local blood supply). Adequate debridement is required to resolve local blood supply).
For superficial infections, oral broad-spectrum antibiotics may be used, and oral therapy may be continued for several weeks; for deep infections, intravenous medication should be given initially, followed by oral maintenance medication for several weeks (up to 12 weeks) + anti-anaerobic therapy. Deep infections may sometimes require surgical drainage, including removal of infected bone tissue and amputation.
(iii) Improving local blood supply requires both dilatation of peripheral large vessels and improvement of microcirculation.
Commonly used drugs: cilostazol, prostaglandin (PGE2), beriberi sodium, Ambulac, CCB, ACEI, alpha-blockers, dibazol and pancreatic kinin-releasing enzyme proliferator (Yikai: microcirculation-based), etc.
(iv) Improve the general condition of the body
Patients with diabetic foot disease mostly have different degrees of malnutrition, and the higher the grading of diabetic foot disease and the more severe the infection, the higher the degree and incidence of malnutrition.
On the basis of treatment with insulin, protein intake is sufficient, and on the basis of the calculated protein requirement, increase by 10%-20%; patients who cannot eat normally can consider some enteral nutrition solution or parenteral supplementation; treatment of wound infection and exudation, after infection and exudation control, plasma albumin can rise in most patients within 2 weeks; patients with proteinuria, relevant treatment should be taken to reduce urinary protein In severe hypoproteinemia, early intravenous supplementation of albumin is needed to improve tissue edema.
(E) Pay attention to cardiac function
The incidence of cardiac insufficiency is higher in patients with diabetic foot disease than in those with non-diabetic foot disease, and the incidence of heart failure increases with foot disease and affects the prognosis of patients with foot ulcers, while diabetic vasodilator therapy may increase the risk of heart failure. In the majority of patients, the symptoms of heart failure are often masked by the signs and symptoms associated with foot ulcers.
The principles of treatment are the same as those for chronic congestive heart failure, with the following caveats;
(1) Patients with unstable metabolism, digitalis use attention to poisoning, timely monitoring of changes in heart rhythm and determination of drug concentrations;
(2) Diuretics as routine treatment, in addition to attention to electrolytes, but also pay attention to blood pressure and the impact on the local blood supply of the ulcer;
(3) Increased chest tightness and shortness of breath during treatment often indicates myocardial ischemia or decreased myocardial contractility;
(4) Any cardiac-related changes in the patient’s signs and symptoms, especially during vasodilatation and anticoagulation therapy, are signs that intervention is needed;
(5) Insignificant improvement in clinical signs and symptoms after heart failure-related treatment is a sign of poor prognosis.
(F) Stem cell therapy
has been used for the treatment of diabetic foot ulcers, but the recent efficacy is not obvious at present, and the long-term efficacy is not very certain. Further clinical studies and observations with large samples are needed, and it is not recommended for the treatment of diabetic foot routinely.
(vii) Local debridement and drug exchange
Local treatment is very important for the healing of diabetic foot ulcers and the control of infection. The principles are.
(1)Gradual and thorough debridement: thoroughly debride inactivated tissues and bones to turn them into clean wounds, which are favorable for functional and morphological recovery, and try to avoid removing viable tissues that affect function; multiple shallow wounds that are close together (especially those with penetration), tissue bridge incision to turn them into one wound; wounds that are too deep can be cut from the side to promote drainage;
(2) drainage should be unobstructed, including postural drainage and negative pressure suction;
(3) Eliminate edema (as long as there is edema, all ulcers are not easy to heal and are not related to the cause of the ulcer) and pay attention to postural drainage and keep the ulcer surface dry;
(4) Rational use of dressings and local medications (insulin, Demerol and nerve growth factor, etc.);
(5) Suture the wound (with caution).
If, after medical evaluation and comprehensive management, the diabetic foot is combined with foot or lower limb necrosis or severe infection cannot be controlled, surgical involvement is actively invited for treatment such as debridement, blood circulation reconstruction and amputation.