I have a patient who had a failed mesh placement and a panniculectomy and who has developed at least three separate fistulas with a very large amount of output (3-4 L/24 hrs). Any suggestions? I am using an Eakin wound management pouch hooked up to wall suction.
Pain in Diabetic Foot Ulcers
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Managing the Cause
Local wound care for a person with a diabetic foot ulcer should occur only after assessment of the patient as a whole (see Figure 1). The patient's general health should include a review of symptoms, especially the major diabetic complications from the head down: stroke, retinopathy, heart, kidneys, hypertension, peripheral vascular disease, and neuropathy. Knowledge of co-existing conditions and medicines taken also may be important in determining the patient's ability to heal. Diabetic control has an impact on wound healing1 and can be accurately assessed with a blood test for Hgb AIC (ideal control under .084 or 8.4%) that approximates the average blood sugar over the past 90 days or the lifespan of the red blood cell containing the hemoglobin.
"Pain is the gift no one wants."2 This sentiment was offered by Dr. Paul Brand, an eminent physician and former head of the National Hansen's Disease Center. To be certain, the etiology of the diabetic foot wound and the majority of foot pathology centers on the absence of pain or loss of protective sensation (LOPS). People with diabetes and neuropathy, through a combination of high plantar pressure and repetitive stress (daily activity), may wear a hole in their foot just as one would wear a hole in a stocking.3,4 Teaching patients with diabetic neuropathy and their respective healthcare providers to respond to the absence of pain is paramount to both treatment and prevention. This does not, however, discount the importance of responding to pain when it is present. In fact, the presence of pain in the neuropathic (high-risk) diabetic foot is not normal and should raise significant concerns. Ulcers related to diabetes are often caused or impacted by several health-related issues, including vascular disease, infection, Charcot arthropathy, and painful neuropathy.
Critical peripheral ischemia. Peripheral ischemia, while often defined by values on various noninvasive examinations, is probably best described as the body's demand for oxygen exceeding its supply. When the body cannot meet the demand, pain associated with ischemia is frequently encountered upon exertional activities such as walking (intermittent claudication). In its most extreme cases, ischemia can cause pain at rest. A patient with this condition requires a consultation with a vascular surgeon for possible medical or surgical intervention to improve flow.5-7
An assessment of arterial circulation starts with the inspection of the extremity. An ischemic limb demonstrates dependent rubor and is blanched on elevation of the leg. An absence of hair distally should be noted, with thickened or possibly absent nails. Palpation demonstrates a cool distal extremity and absent pulse. Pulses are generally palpable in the foot at around 80 mm Hg; however, the ischemic limb pulses may not be palpable and 50 mm Hg is necessary for healing a wound in a person with diabetes. To determine if the circulation is adequate for healing despite the lack of a pulse, non-invasive vascular studies are necessary. The ankle-brachial ratio may be falsely high with calcified vessels. Toe pressures greater than 50 mm Hg or transcutaneous oxygen pressure greater than 20 to 30 mm Hg may be necessary to ensure sustained healing in the average patient. Vessel calcification disables the accurate assessment of vascular flow.
Diabetic foot infection (deep compartment). Foot infections, particularly those involving deep plantar spaces, can cause foot pain even through very severe neuropathy. Unfortunately, this pain is often overlooked, as signs and symptoms of infection in the patient with diabetes are often subtle.
References:
1. Krasner D, Ovington L. ADA holds consensus conference on diabetic foot wound care. Ostomy/Wound Management. 1999;45(6):18-20. 2. Brand PW, Yancey P. The Gift of Pain. Grand Rapids, Mich.: Zondervan;1997. 3. Lavery LA, Armstrong DG, Vela SA, Quebedeaux TL, Fleischli JG. Practical criteria for screening patients at high risk for diabetic foot ulceration. Arch Intern Med. 1998;158:158-162. 4. Armstrong DG, Abu Rumman PL, Nixon BP, Boulton AJM. Continuous activity monitoring in people at high risk for diabetes-related lower extremity amputation. J Am Podiatr Med Assoc. 2001;91:451-455. 5. Akbari CM, Pomposelli FB, Gibbons GW, et al. Lower extremity revascularization in diabetes: late observations. Arch Surg. 2000;135(4):452-456. 6. Gibbons GW, Marcaccio EJJ, Burgess AM, et al. Improved quality of diabetic foot care, 1984 versus 1990: reduced length of stay and costs, insufficient reimbursement. Arch Surg. 1993;128:576-581. 7. Akbari CM, LoGerfo FW. Diabetes and peripheral vascular disease. J Vasc Surg. 1999;30(2):373-384. 8. Armstrong DG, Perales TA, Murff RT, Edelson GW, Welchon JG. Value of white blood cell count with differential in the acute diabetic foot infection. J Am Podiatr Med Assoc. 1996;86(5):224-227. 9. Lavery LA, Armstrong DG, Quebedeaux TL, Walker SC. Puncture wounds: normal laboratory values in the face of severe infection in diabetics and non-diabetics. Am J Med. 1996;101(5):521-525. 10. Caputo GM, Joshi N, Weitekamp MR. Foot infections in patients with diabetes. Am Fam Physician. 1997;56(1):195-202. 11. Tomas MB, Patel M, Marwin SE, Palestro CJ. The diabetic foot. Br J Radiol. 2000;73(868):443-450. 12. Grayson ML, Gibbons GW, Balogh K, Levin E, Karchmer AW. Probing to bone in infected pedal ulcers. A clinical sign of underlying osteomyelitis in diabetic patients. JAMA. 1995;273(9):721-723. 13. Sanders LJ, Frykberg RG. Charcot's joint. In: Levin ME, O'Neal LW, Bowker JH, eds. The Diabetic Foot. 2nd ed. St. Louis, Mo.: Mosby-Year Book;1993. 14. Armstrong DG, Lavery LA. Acute Charcot's arthropathy of the foot and ankle. Phys Ther. 1998;78:74-80. 15. Armstrong DG, Todd WF, Lavery LA, Harkless LB. The natural history of acute Charcot's arthropathy in a diabetic foot specialty clinic. Diabet Med. 1997;14:357-363. 16. Sanders LJ, Frykberg RG. The Charcot foot. In: Frykberg RG (ed). The High Risk Foot in Diabetes Mellitus. New York, NY: Churchill Livingstone; 1991:325-335. 17. Lavery LA, Armstrong DG, Wunderlich RP, Boulton AJM, Tredwell JL. Diabetic foot syndrome: evaluating the prevalence and incidence of foot pathology in Mexican American and non-hispanic whites from a diabetes disease management cohort. Diabetes Care. 2003: In press. 18. Sinha S, Munichoodapa CS, Kozak GP. Neuroarthropathy (Charcot joints) in diabetes mellitus. Medicine. 1972;51:191-210. 19. Fabrin J, Larsen K, Holstein PE. Long-term follow-up in diabetic Charcot feet with spontaneous onset. Diabetes Care. 2000;23(6):796-800. 20. Armstrong DG, Lavery LA. Monitoring healing of acute Charcot's arthropathy with infrared dermal thermometry. J Rehabil Res Dev. 1997;34(3):317-321. 21. Ward K, Dellacorte M, Grisafi P. Pathophysiology of diabetic neuropathy. J Am Podiatr Med Assoc. 1993;83(3):149-152. 22. Boulton A. What causes neuropathic pain? Journal of Diabetes Complications. 1992;6(1):58-63. 23. Boulton AJ, Gries FA, Jervell JA. Guidelines for the diagnosis and outpatient management of diabetic peripheral neuropathy. Diabet Med. 1998;15(6):508-514. 24. Oyibo SO, Prasad YD, Jackson NJ, Jude EB, Boulton AJM. The relationship between blood glucose excursions and painful diabetic peripheral neuropathy: a pilot study. Diabet Med. 2002;19(10):870-873. 25. Malik RA, Newrick PG, Sharma AK, et al. Microangiopathy in human diabetic neuropathy: relationship between capillary abnormalities and the severity of neuropathy. Diabetologia. 1989;32(2):92-102. 26. Simmons Z, Feldman EL. Update on diabetic neuropathy. Curr Opin Neurol. 2002;15(5):595-603. 27. Jensen PG, Larson JR. Management of painful diabetic neuropathy. Drugs Aging. 2001;18(10):737-749. 28. Wishner WJ, Rubin RR. Empowerment in amputation prevention. In: Bowker JH, Pfeifer MA (eds). Levin and O'Neal's The Diabetic Foot, 6th Ed. St. Louis, Mo.: Mosby;2001. 29. Aikens JE, Lustman PJ. Psychological and psychological aspects of diabetic complications. In: Bowker JH, Pfeifer MA (eds). Levin and O'Neal's The Diabetic Foot, 6th Ed. St. Louis, Mo.: Mosby;2001. 30. Levin M. Pathogenesis and general management of foot lesions. In: n: Bowker JH, Pfeifer MA (eds). Levin and O'Neal's The Diabetic Foot, 6th Ed. St. Louis, Mo.: Mosby;2001. 31. Steed DL. Diabetic ulcer study group. Clinical evaluation of recombinant human platelet-derived growth factor for the treatment of lower extremity diabetic ulcers. J Vasc Surg. 1995;21:71-81. 32. Sibbald RG. Topical treatment of infection. Ostomy Wound Management. 2003; In press. 33. Dow G, Browne A, Sibbald RG. Infection in chronic wounds: controversies in diagnosis and treatment. Ostomy Wound Management. 1999;45(8):23-40. 34. Wassilew SW. Infections of the skin caused by gram-negative pathogens. Foot infections - wound infections- folliculitis. Zeitschrift Hautkrankheiten. 1989;64(1):17-20. 35. Romanelli M, Looverbosch D, Heyman H, Meaume S, Ciangherotti, Charpin S. An open multi-center randomised study comparing a self-adherent soft silicone foam dressing versus a hydropolymer dressing, in patients with pressure ulcer stage II according to the EPUAP guidelines. Poster Presentation. European Wound Management Association meeting 2002. Ostomy/Wound Management. 2003; In press. 36. Lavery LA, Fleishli JG, Laughlin TJ, Vela SA, Lavery DC, Armstrong DG. Is postural stability exacerbated by off-loading devices in high risk diabetics with foot ulcers? Ostomy Wound Management. 1998;44(1):26-34. 37. Frykberg RG. Diabetic foot ulcers: pathogenesis and management. Am Fam Physician. 2002;66(9): 1655-1662. 38. Armstrong DG. Is diabetic foot care efficacious or cost effective? Ostomy Wound Management. 2001;47(4):28-32.
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