It has been established that patients with diabetes mellitus are quite vulnerable to foot ulcerations which can be linked to the intricate triad of trauma, peripheral sensory neuropathy, and vasculopathy. The healing process of the foot ulcerations is deterred significantly by the local infections of diabetic foot ulcers (DFU). The infection translates to a poor peripheral circulation which in turn affects the responses to aggressive debridement antimicrobial therapy. An estimate of fifteen percent to twenty-five percent of diabetes mellitus patients will develop diabetic foot ulcers (DFU) (Shen, Liu, Lo, Chen, & Chang, 2016). Consequently, wound infections resulting from diabetic foot ulcers are a common reason for hospitalization among these patients. Further, research has established that foot ulcerations contribute to about seventy to eighty percent of lower extremity amputations among diabetes mellitus patients.
Diabetic foot ulcers in most cases progress because the patients tend to register a limited response to antibiotics and aggressive debridement, especially with poor peripheral circulation. An unhealed ulcer which subsists for more than a month in the ischemic distal limb is described as critical limb ischemia (CLI). In such a case, percutaneous transluminal angioplasty and other revascularization procedures like bypass surgery can be considered for the wound to advance to the proliferative stage from an inflammatory stage of wound healing (Shen et al., 2016). The revascularization processes also help with enhancing the effects of antimicrobial therapy. If revascularization cannot be achieved because of patient refusal or procedural failure, then limb amputation can be done when the infection threatens patients’ survival or if it causes significant morbidity.
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A typical example is the case of an 85-year-old female patient with an over thirty-year history of diabetes mellitus and hypertension which she managed by using oral hypoglycemic and antihypertensive medications. She experienced penetrating foot injuries from toothpicks on the right foot. Within a period of six months, the 85-year old had developed two diabetic foot ulcers on the lateral and medial plantar areas. Following hospitalization, fasciotomy and debridement were performed on day two to minimize bio-burden and to control the infection (Shen et al., 2016). To restore vascularity, percutaneous transluminal angioplasty was suggested but the patient was hesitant to undergo the procedure pointing procedure failure, vessel injury complications and possibilities of puncture.
All aspects of healing are controlled by applying multidisciplinary management to the treatment of diabetic foot ulcers. Oral systemic antimicrobial therapy alone is not sufficient for handling diabetic foot ulcer cases. The progression of the disease is thwarted by serial debridement. After the infection has been controlled, it is advised to resume modern moist wound bed dressings which in turn stimulate the healing process (Shen et al., 2016). Topical therapy is also advised which helps with creating a moist wound environment suitable for granulation, autolysis of nonviable tissue, angiogenesis and quicker migration of epidermal cells across the wound base. There are other potential adjunct methods including maggot therapy and hyperbaric oxygen therapy which could have been employed in this case.
In essence, the management of diabetic foot ulcers which are made complex by infections and critical limb ischemia is quite challenging since the ulcers have a tendency of progressing into limb amputation or life-threatening situations. The most attractive option for these patients is percutaneous transluminal angioplasty which is not always successful in all patients. In the case of the 85-year-old female, topical therapy is believed to have spared the patient from amputation and potential associated complications.
Reference
Shen, J. H., Liu, C. J., Lo, S. C., Chen, Y. T., & Chang, C. C. (2016). Topical therapy as adjuvant treatment to save a limb with critical ischemia from extensive and deep diabetic foot infection when revascularization is not feasible. Journal of Wound, Ostomy and Continence Nursing , 43 (2), 197-201.
