Diabetic Wound Healing and Loss of Limb: Evidence-based Assessment

Evidence-based assessment on Diabetic wound healing and loss of limb; an eBook on the Pathophysiology and interrelated medical approach on Diabetes

Evidence-based assessment on Diabetic wound healing and loss of limb

Background

Diabetes Mellitus is one of the most commonly encountered metabolic conditions. In contemporary times, the prevalence of individuals having Diabetes has significantly increased, accounting for more than 2 to 5% of the global incidence rate of known metabolic disorders (Sapra & Bhandari, 2020). The etiology of the disease process stems from the insufficiency of insulin production in the beta cells of the pancreas which serves a vital physiologic function in controlling the blood glucose levels. The resulting disruption in the balance of the pancreatic hormone leads to the hyperglycemic state in the body. The pathophysiological outcome then leads to a wide variety of clinical symptoms ranging from neuropathy, nephropathy, poor tissue perfusion, and other microvascular and macrovascular complications. One of the most dreadful experiences associated with the complication of Diabetes is the poor wound healing process and the Diabetic foot wound-related infections are the most common resulting clinical picture. It is projected that about 50% of all patients having diabetes foot will have amputations in the succeeding years if their blood glucose levels remain uncontrolled.

Risk factors

The predisposing factors associated with the diagnosis of Diabetes Mellitus are most commonly lifestyle-related (if the person is diagnosed with type 2 Diabetes Mellitus). Otherwise, people with inherent Diabetes Mellitus (commonly referred to as Type 1 Diabetes Mellitus) are usually diagnosed in their childhood years and are genetically predisposed to acquiring the disease. Several studies have suggested that the precipitating factors that increase a person’s chance of having Diabetes are food preferences. The different individual predilection when it comes to the selection of dietary patterns and eating habits is the number one factor that is seen in predicting “at-risk” individuals.

For amputation candidates, the risk factor most commonly reported that increases the propensity of limb loss is frequent wound infections and injuries. The most common sites of injury are the lower extremities and the distal regions of the body. In an inquiry conducted, it was found that the co-morbid prevalence of arterial disease (maybe due to the microvascular complication of diabetes) and neuropathy are the two most commonly associated pathological reports among patients who have undergone Bilateral Knee Amputation. These two limb-specific risk factors for amputation have been manifested by 7 per 100,000 diabetics. Conclusively, the risk for limb loss proportionally increases with the onset of other complications.

Diagnosis and Treatment

The diagnosis of Diabetes Mellitus is focused on the routine monitoring of the blood glucose levels either through the use of different diagnostic exams. The FBS (fasting blood sugar) is a diagnostic exam specifically designed to highlight the glucose levels of the body in the absence of carbohydrate intake for 8 to 10 hours. Subsequently, some patients are also diagnosed through the post-prandial glucose test wherein an individual is given a certain amount of carbohydrate 2 hours before the test. The two aforementioned diagnostics aims to look for abnormally “high” levels of blood glucose levels. It is empirically proven that if a person is diabetic then the cell could not properly utilize the blood glucose and this would result in the abnormally high blood glucose readings. Consequently, another screening test was designed to note if the level of compliance of diabetic patients by calculating the total blood glucose levels of the past three months. This screening test is called Hba1C or otherwise most commonly referred to as glycosylated hemoglobin. It is highly advised that regular follow-up consultations and screenings be initiated to rule out the presence of a developing microvascular complication (Sapra & Bhandari, 2020).

The treatment for diabetes and diabetes-related injuries is centralized on the lowering of blood glucose levels. For type 1 Diabetics, a daily dose of insulin shot is given before meal intake and is given subcutaneously. For type 2 Diabetics, a prescription oral hypoglycemic agent is usually administered to control the blood glucose levels. In diabetic patients with presenting wounds or ulcerations, the primary treatment goal is the implementation of aseptic wound care strategies to alleviate pain induced by the damage of tissue. If the patient’s wound or foot infections continue to progress or is seen to have severely necrotized, a schedule for amputation is considered.

Assessment

The primary assessment upon the admission of a diabetic patient includes the evaluation of compliance to treatment plan and the consistent monitoring of the blood glucose levels. Additional parameters include cephalocaudal assessment together with the patient’s anthropometric measurement. For diabetic patients with uncontrolled blood sugar levels, a classification system is used in determining the extent of wound damage and the type of ulceration present. It is a usual encounter that patients with extensive neuropathies present with an unsuspected case of foot injuries and ulcerations. In a study conducted, a foregoing argument on the promulgation of a more structured clinical and vascular assessment was instigated to help classify the patient who is more likely to have an amputation. The considerations included were the personalization of surgical interventions recommended for each patient. The said inquiry also delves into the different approaches taken to remodify the endovascular procedures in the treatment of diabetic arterial complications such as diabetic foot ulcers and diabetic amputations.

Wagner-Meggitt Classification 

A classification system used to categorize diabetic infections and recognize a patient’s susceptibility to developing ulceration was proposed to appropriately designate the treatment plan according to the varying cases of diabetic wound complications. Though still not universally accepted, the Wagner-Meggitt Classification system is still used to guide clinicians in assessing the wound depths of different diabetic patients (Weledji, & Fokam, 2014). This classification system categorizes the diabetic wound ulcerations using a 5-point grading system. Grade (0) intact skin, no signs of skin damage, Grade (1) Evident superficial ulcer, Grade (2) deep ulceration extending to the tendon, bone, or joint, Grade (3) deep ulceration with abscess formation and signs of osteomyelitis, Grade (4) forefoot gangrene, Grade (5) whole foot gangrene. The results from the queries involved in standardizing this classification system are mostly still reviewed as to its efficiency in providing empirical evidence and establishing its dominance as a standard predictor of outcome.

University of Texas Classification system 

The University of Texas Classification system primarily assesses the depth of ulcerations with an accompanying staging system that further elaborates whether the wound or injury has an underlying ischemic presentation. Grade (0) pre or post ulcerated sites have healed, Grade (1) superficial wounds excluding tendon, capsules or bones, Grade (2) wounds involving the tendon or capsule, Grade (3) wounds penetrating the bones or joint. Associated with each wound grade is an accompanying staging system; Stage (A) clean wounds, Stage (B) non-ischemic infected wounds, Stage (C) ischemic non-infected wounds, Stage (D) ischemic infected wounds. This classification system ultimately gives partially relevant information regarding the identification of wounds and the evaluation of potential wound complications for diabetic patients (Wukich et al., 2013)

SINBAD Classification system

The SINBAD (Site, Ischemia, Neuropathy, Bacterial Infection, and Depth) classification system was initially employed to give relevant information regarding the outcomes of diabetic foot ulcers and the potential complications that could arise from the mismanagement of these cases. In one research, the validity of the SINBAD classification system was tested in a comparative study among diabetic patient (Chuan et al., 2015).  The results have implicated that the SINBAD classification indicates a more reliable scoring guide in predicting diabetic wound complications and healing.

PEDIS Classification system

Another classification system was developed to evaluate the perfusion, extent, depth, infection, and sensation of the wound injuries from diabetic patients. This classification system was validated to provide an easier to follow the guideline in determining the other important parameters related to diabetic ulcers and infections. This was fundamentally created to help predict clinical outcomes for patients and to help clinicians establish prognosis and evaluation. The PEDIS (Perfusion, Extent, Depth, Infection, and Sensation) classification system is currently used in the clinical practice to identify the presence of wounds and give doctors an insight of the essential contributory factors leading to primary amputation. A comparative study was conducted to distinguish disparity between the other classification systems. The results have shown that the assessment tools used to identify the presence of diabetic wounds and predict the proclivity of amputation are efficient in delivering the necessary data (Chuan et al., 2015). Conclusively, it was found out that increasing the stage in the classification system (regardless of the grading) is linked with increased risk of primary amputation and prolonged wound healing.

Literature Review Summarization

From the aforementioned literature and inquiries, it can be surmised that the assessment tools specifically designed to aid in the identification of diabetic wound and categorization in terms of grading and staging have significantly changed the treatment and diagnostic approach. The in-depth studies associated with the testing of the reliability of these tools have supported the evidence-based treatment plan in the identification of wounds and the ideal intervention necessary to prevent further infections and loss of limb. The incorporation of these classification systems engenders easier assessment and planning related to the care and management of diabetic wound complications and injuries. It is also emphasized within the appraised findings that the amputation of the necrotized limb should only be resorted as a last option if the severity of the wound is extreme.

In contemporary clinical assessment protocols, the implementation of the said classification systems has enabled various clinicians to easily identify a diabetic patient’s wound according to its staging, grading, and type. Moreover, the utilization of the categories embedded within the classification systems has geared towards the creation of an evidence-based preventive measure against potential infections and amputation In conclusion, it is important that the application of these classification systems be studied for future modifications.

Change in Clinical Practice

Since the focus of this study caters to diabetic patients, it is necessary to instigate gradual change in patient outcomes through the usage of learning materials that supplement their understanding of health promotion and preventive measures. A simplified graphic organizer can be considered in this case since the different diabetic wound classification systems requires a systematic and ladderized grading and staging system. By employing these simple and concise graphic organizers, the patient will be able to understand when to look for untoward signs and complications. This is a fundamental strategy to encourage the patient to become more involved in the health promotion process.

Resources

The implementation of the aforementioned change strategy would most likely cost the time of the patients and the healthcare providers since it involves a more familiar interaction to further health-seeking behavior. The creation of the graphic organizer is estimated to cost around  $220 with the inclusion of the needed materials like paper, ink, and other miscellaneous.

In general, the ultimate benefit of this action is the less occurrence of diabetic foot injuries and amputation. The patients themselves could enjoy quality life as they educate themselves with the potential risks of being negligent about their conditions. The information that is given to the patients could instill encouragement and health-seeking behaviors.

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