best practice guidelines: wound management in diabetic foot ulcers

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FOREWORDSupported by an educationalgrant from B BraunThe views presented in thisdocument are the work of theauthors and do not necessarilyreflect the opinions of B Braun.Published byWounds InternationalA division of SchofieldHealthcare Media LimitedEnterprise House1–2 HatfieldsLondon SE1 9PG, UKwww.woundsinternational.comTo cite this document.International Best PracticeGuidelines: Wound Managementin Diabetic Foot Ulcers.Wounds International,2013. Available from: www.woundsinternational.comThis document focuses on wound management best practice for diabeticfoot ulcers (DFUs). It aims to offer specialists and non-specialists everywherea practical, relevant clinical guide to appropriate decision making and effectivewound healing in people presenting with a DFU.In recognition of the gap in the literature in the field of wound management,this document concentrates on the importance of wound assessment,debridement and cleansing, recognition and treatment of infection andappropriate dressing selection to achieve optimal healing for patients. However,it acknowledges that healing of the ulcer is only one aspect of managementand the role of diabetic control, offloading strategies and an integratedwound care approach to DFU management (which are all covered extensivelyelsewhere) are also addressed. Prevention of DFUs is not discussed inthis document.The scope of the many local and international guidelines on managing DFUsis limited by the lack of high-quality research. This document aims to gofurther than existing guidance by drawing, in addition, from the wide-rangingexperience of an extensive international panel of expert practitioners. However,it is not intended to represent a consensus, but rather a best practiceguide that can be tailored to the individual needs and limitations of differenthealthcare systems and to suit regional practice.EXPERT WORKING GROUPDevelopment groupPaul Chadwick, Principal Podiatrist, Salford Royal Foundation Trust, UKMichael Edmonds, Professor of Diabetes and Endocrinology, Diabetic Foot Clinic, King's CollegeHospital, London, UKJoanne McCardle, Advanced Clinical and Research Diabetes Podiatrist, NHS Lothian UniversityHospital, Edinburgh, UKDavid Armstrong, Professor of Surgery and Director, Southern Arizona Limb Salvage Alliance (SALSA),University of Arizona College of Medicine, Arizona, USAReview groupJan Apelqvist, Senior Consultant, Department of Endocrinology, Skåne University Hospital, Malmo,SwedenMariam Botros, Director, Diabetic Foot Canada, Canadian Wound Care Association and ClinicalCoordinator, Women's College Wound Healing Clinic, Toronto, CanadaGiacomo Clerici, Chief Diabetic Foot Clinic, IRCC Casa di Cura Multimedica, Milan, ItalyJill Cundell, Lecturer/Practitioner, University of Ulster, Belfast Health and Social Care Trust, NorthernIrelandSolange Ehrler, Functional Rehabilitation Department, IUR Clémenceau (Institut Universitaire deRéadaptation Clémenceau), Strasbourg, FranceMichael Hummel, MD, Diabetes Center Rosenheim & Institute of Diabetes Research, HelmholtzZentrum München, GermanyBenjamin A Lipsky, Emeritus Professor of Medicine, University of Washington, USA; Visiting Professor,Infectious Diseases, University of Geneva, Switzerland; Teaching Associate, University of Oxford andDeputy Director, Graduate Entry Course, University of Oxford Medical School, UKJosé Luis Lázaro Martinez, Full Time Professor, Diabetic Foot Unit, Complutense University, Madrid,SpainRosalyn Thomas, Deputy Head of Podiatry, Abertawe Bro Morgannwg University Health Board,Swansea, WalesSusan Tulley, Senior Podiatrist, Mafraq Hospital, Abu Dhabi, United Arab Emirates3C BEST PRACTICEBEST PRACTICEGUIDELINESGUIDELINES:FOR SKINWOUNDAND WOUNDMANAGEMENTCARE ININEPIDERMOLYSISDIABETIC FOOTBULLOSAULCERS
INTRODUCTIONIntroductionDFUs are complex, chronic wounds, whichhave a major long-term impact on themorbidity, mortality and quality of patients’lives 1,2 . Individuals who develop a DFU are atgreater risk of premature death, myocardialinfarction and fatal stroke than those withouta history of DFU 3 . Unlike other chronicwounds, the development and progression ofa DFU is often complicated by wide-rangingdiabetic changes, such as neuropathy andvascular disease. These, along with thealtered neutrophil function, diminished tissueperfusion and defective protein synthesisthat frequently accompany diabetes, presentpractitioners with specific and unique managementchallenges 1 .DFUs are relatively common — in the UK,5–7% of people with diabetes currently haveor have had a DFU 4,5 . Furthermore, around25% of people with diabetes will develop aDFU during their lifetime 6 . Globally, around370 million people have diabetes and thisnumber is increasing in every country 7 . DiabetesUK estimates that by 2030 some 552million people worldwide will have diabetes 8 .DFUs have a major economic impact. A USstudy in 1999 estimated the average outpatientcost of treating one DFU episode as$28,000 USD over a two–year period 9 . Averageinpatient costs for lower limb complicationsin 1997 were reported as $16,580 USDfor DFUs, $25,241 USD for toe or toe plusother distal amputations and $31,436 USDfor major amputations 10,11 .such as the effect on physical, psychologicaland social wellbeing and the fact that manypatients are unable to work long term as aresult of their wounds 6 .A DFU is a pivotal event in the life of aperson with diabetes and a marker of seriousdisease and comorbidities. Without earlyand optimal intervention, the wound canrapidly deteriorate, leading to amputation ofthe affected limb 5,13 .It has been estimated that every 20 secondsa lower limb is amputated due to complicationsof diabetes 14 .In Europe, the annual amputation rate forpeople with diabetes has been cited as 0.5-0.8% 1,15 , and in the US it has been reportedthat around 85% of lower-extremityamputations due to diabetes begin with footulceration 16,17 .Mortality following amputation increaseswith level of amputation 18 and ranges from50–68% at five years, which is comparableor worse than for most malignancies 13,19(Figure 1).The statistics need not make for such grimreading. With appropriate and carefulmanagement it is possible to delay or avoidmost serious complications of DFUs 1 .FIGURE 1: Relative five-year mortality (%) (adapted from 19 )The EURODIALE study examined total directand indirect costs for one year across severalEuropean countries. Average total costsbased on 821 patients were approximately10,000 euros, with hospitalisation representingthe highest direct cost. Based on prevalencedata for Europe, they estimated thatcosts associated with treatment of DFUsmay be as high as 10 billion euros per year 12 .In England, foot complications account for20% of the total National Health Servicespend on diabetes care, which equates toaround £650 million per year (or £1 in every£150) 5 . Of course, these figures do not takeaccount of the indirect costs to patients,Prostate cancerBreast cancerHodgkin's lymphomaNeuropathic DFUAmputationColon cancerIschaemic DFUPeripheral arterial diseaseLung cancerPancreatic cancerBEST PRACTICE GUIDELINES: WOUND MANAGEMENT IN DIABETIC FOOT ULCERS 1
Page 1: INTERNATIONAL BEST PRACTICEBEST PRA
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 and 12: DFU WOUNDMANAGEMENTDFU wound manage
Page 13 and 14: DFU WOUNDMANAGEMENTHydrosurgical de
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

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