best practice guidelines: wound management in diabetic foot ulcers

More documents

Recommendations

Info

DFU WOUNDMANAGEMENTFIGURE 9: Neuropathic ulcerpre- (top) and post- (bottom)debridementFIGURE 10: Neuroischaemic ulcerpre- (top) and post- (bottom)debridementas ischaemia, infection or inflammation)and consider patient concordance withrecommended treatment regimens (such asnot wearing offloading devices or not takingantidiabetic medication) 69 .Sharp debridementNo one debridement method has beenshown to be more effective in achievingcomplete ulcer healing 70 . However, inpractice, the gold standard technique fortissue management in DFUs is regular, local,sharp debridement using a scalpel, scissorsand/or forceps 1,7,27,37,71, . The benefits ofdebridement include 72 : Removes necrotic/sloughy tissue andcallus Reduces pressure Allows full inspection of the underlyingtissues Helps drainage of secretions or pus Helps optimise the effectiveness of topicalpreparations Stimulates healing.Sharp debridement should be carried outby experienced practitioners (eg a specialistpodiatrist or nurse) with specialisttraining 22,69 .Practitioners must be able to distinguishtissue types and understand anatomy toavoid damage to blood vessels, nerves andtendons 69 . They should also demonstratehigh-level clinical decision-making skills inassessing a level of debridement that is safeand effective. The procedure may be carriedout in the clinic or at the bedside.Ulcers may be obscured by the presenceof callus. After discussing the plan andexpected outcome with the patient inadvance, debridement should remove alldevitalised tissue, callus and foreign bodiesdown to the level of viable bleeding tissue38,69 (Figures 9 and 10). It is importantto debride the wound margins as well asthe wound base to prevent the ‘edge effect’,whereby epithelium fails to migrate across afirm, level granulation base 73,74 .Sharp debridement is an invasive procedureand can be quite radical. Practitioners mustexplain fully to patients the risks and benefitsof debridement in order to gain theirinformed consent. One small study pilotingan information leaflet showed that manypatients did not understand the proceduredespite having undergone debridement onseveral previous occasions 68 .Vascular status must always be determinedprior to sharp debridement. Patients needingrevascularisation should not undergoextensive sharp debridement because ofthe risk of trauma to vascularly compromisedtissues. However, the ‘toothpick’approach may be suitable for woundsrequiring removal of loose callus 45 . Seekadvice from a specialist if in doubt about apatient’s suitability.Other debridement methodsWhile sharp debridement is the goldstandard technique, other methods may beappropriate in certain situations: As an interim measure (eg by practitionerswithout the necessary skill sets tocarry out sharp debridement; methodsinclude the use of a monofilament pad orlarval therapy) For patients for whom sharp debridementis contraindicated or unacceptablypainfulWhen the clinical decision is that anotherdebridement technique may bemore beneficial for the patient For patients who have expressed anotherpreference.Larval therapy The larvae of the greenbottlefly can achieve relatively rapid, atraumaticremoval of moist, slimy slough, and caningest pathogenic organisms present in thewound 69 . The decision to use larval debridementmust be taken by an appropriatespecialist practitioner, but the techniqueitself may then be carried out by generalistor specialist practitioners with minimaltraining 69 .Larval therapy has been shown to be safeand effective in the treatment of DFUs 75 .However, it is not recommended as the solemethod of debridement for neuropathicDFUs as the larvae cannot remove callus 76 .A recent review of debridement methodsfound some evidence to suggest that larvaltherapy may improve outcomes whencompared to autolytic debridement with ahydrogel 72 .310 BEST PRACTICEBEST PRACTICEGUIDELINESGUIDELINES:FOR SKINWOUNDAND WOUNDMANAGEMENTCARE ININEPIDERMOLYSISDIABETIC FOOTBULLOSAULCERS
DFU WOUNDMANAGEMENTHydrosurgical debridement This is an alternativemethod of wound debridement, whichforces water or saline into a nozzle to createa high-energy cutting beam. This enablesprecise visualisation and removal of devitalisedtissue in the wound bed 77 .Autolytic debridement This is a naturalprocess that uses a moist wound dressingto soften and remove devitalised tissue.Care must be taken not to use a moisturedonatingdressing as this can predispose tomaceration. In addition, the application ofmoisture-retentive dressings in the presenceof ischaemia and/or dry gangrene is notrecommended 38,76 .Not debriding a wound, not referring apatient to specialist staff for debridement, orchoosing the wrong method of debridement,can cause rapid deterioration with potentiallydevastating consequences.Inflammation and infection controlThe high morbidity and mortality associatedwith infection in DFUs means that earlyand aggressive treatment — in the presenceof even subtle signs of infection — is moreappropriate than for wounds of otheraetiologies (with the exception of immunocompromisedpatients) (Table 4, page12) 38 . In one study, nearly half of patientsadmitted to a specialised foot clinic inFrance with a diabetic foot infection wenton to have a lower-limb amputation 78 .Both the IDSA 46 and the InternationalDiabetes Federation (IDF) recommendclassifying infected DFUs by severity andusing this to direct appropriate antibiotictherapy 27 . Clinically uninfected woundsshould not be treated with systemic antibiotictherapy. However, virtually all infectedwounds require antibiotic therapy 46 .Superficial DFUs with skin infection (mildinfection)For mild infections in patients who have notrecently received antibiotic treatment 7,46 : Start empiric oral antibiotic therapy targetedat Staphylococcus aureus andß-haemolytic Streptococcus Change to an alternate antibiotic if theculture results indicate a more appropriateantibiotic Obtain another optimum specimen forculture if the wound does not respond totreatment.Role of topical antimicrobials The increasingprevalence of antimicrobial resistance(eg meticillin-resistant S. aureus [MRSA]) orother complications (eg Clostridium difficileinfection) has led to a rise in the use oftopical antimicrobial treatments forincreased wound bioburden 79 (Box 3).Antimicrobial agents that are used topicallyhave the advantage of not driving resistance.Such agents provide high local concentrations,but do not penetrate intact skin or intodeeper soft tissue 80 .Topical antimicrobials may be beneficial incertain situations 79 : Where there are concerns regardingreduced antibiotic tissue penetration —for example, where the patient has a poorvascular supply In non-healing wounds where the classicsigns and symptoms of infection are absent,but where there is a clinical suspicionof increased bacterial bioburden.In these situations topical antimicrobials(either alone or as an adjunctive therapyto systemic therapy) have the potential toreduce bacterial load and may protect thewound from further contamination 79 . In addition,treatment at an early stage may preventspread of infection to deeper tissues 82 .An initial two-week period with regularreview is recommended for the use of topicalantimicrobials in wounds that are mildlyinfected or heavily colonised. A recentconsensus offers recommendations on appropriateuse of silver dressings 83 . If aftertwo weeks: There is improvement in the wound, butcontinuing signs of infection, it may beclinically justifiable to continue the chosentreatment with further regular reviews The wound has improved and the signsand symptoms of wound infection are nolonger present, the antimicrobial shouldbe discontinued and a non-antimicrobialdressing applied to cover the open wound There is no improvement, consider discontinuingthe antimicrobial treatmentand re-culturing the wound and reassessingthe need for surgical therapy orrevascularisation.BOX 3: Common topicalantimicrobial agents thatmay be considered for useas an adjunctive therapy fordiabetic foot infections* Silver — dressings containingsilver (elemental,inorganic compound ororganic complex) or silversulphadiazine cream/dressings Polyhexamethylenebiguanide (PHMB) —solution, gel or impregnateddressings Iodine — povidone iodine(impregnated dressing) orcadexomer iodine (ointment,beads or impregnateddressings) Medical-grade honey —gel, ointment or impregnateddressings*NB: Topical antimicrobialagents should not be usedalone in those with clinicalsigns of infectionBEST PRACTICE GUIDELINES: WOUND MANAGEMENT IN DIABETIC FOOT ULCERS 11
Page 1 and 2: INTERNATIONAL BEST PRACTICEBEST PRA
Page 3 and 4: INTRODUCTIONIntroductionDFUs are co
Page 5 and 6: AETIOLOGY OFDFUsAetiology of DFUsTh
Page 7 and 8: ASSESSING DFUsFIGURE 5: Procedure f
Page 9 and 10: ASSESSING DFUsBOX 1: Signs of sprea
Page 11: DFU WOUNDMANAGEMENTDFU wound manage
Page 15 and 16: DFU WOUNDMANAGEMENTantimicrobial ag
Page 17 and 18: DFU WOUNDMANAGEMENTTABLE 6: Wound m
Page 19 and 20: DFU WOUNDMANAGEMENTexclusion of inf
Page 21 and 22: Integrated care approachINTEGRATEDC
Page 23 and 24: REFERENCES1. National Institute for
Page 25 and 26: REFERENCES94. International Consens

best practice guidelines: wound management in diabetic foot ulcers

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?