Inpatient Management of Diabetic Foot Disorders: A Clinical Guide

Abstract

The implementation of an inpatient diabetic foot service should be the goal of all institutions that care for patients with diabetes. The objectives of this team are to prevent problems in patients while hospitalized, provide curative measures for patients admitted with diabetic foot disorders, and optimize the transition from inpatient to outpatient care. Essential skills that are required for an inpatient team include the ability to stage a foot wound, assess for peripheral vascular disease, neuropathy, wound infection, and the need for debridement; appropriately culture a wound and select antibiotic therapy; provide, directly or indirectly, for optimal metabolic control; and implement effective discharge planning to prevent a recurrence. Diabetic foot ulcers may be present in patients who are admitted for nonfoot problems, and these ulcers should be evaluated by the diabetic foot team during the hospitalization. Pathways should be in place for urgent or emergent treatment of diabetic foot infections and neuropathic fractures/dislocations. Surgeons involved with these patients should have knowledge and interest in limb preservation techniques. Prevention of iatrogenic foot complications, such as pressure sores of the heel, should be a priority in patients with diabetes who are admitted for any reason: all hospitalized diabetic patients require a clinical foot exam on admission to identify risk factors such as loss of sensation or ischemia. Appropriate posthospitalization monitoring to reduce the risk of reulceration and infection should be available, which should include optimal glycemic control and correction of any fluid and electrolyte disturbances.

Building a scalable diabetic limb preservation program: four steps to success

“…This model often incorporates podiatric and vascular surgeons (‘Toe and Flow’ model) as the core of an interdisciplinary team but which may include a diverse group of health professionals [5–8]. We have previously identified seven essential skills, first described by Fitzgerald and co-workers and later refined to eight skills by Wukich and colleagues, to define the key skill sets associated with care across a limb preservation program (Table 1) [9,10]. The partnership of these specialists allows for rapid coordinated management of vascular, mechanical, and soft tissue reconstruction.…”

“…The ability to initiate and modify culture-specific and patient-appropriate antibiotic therapy.7. The ability to perform appropriate postoperative monitoring to reduce risks of re-ulceration and infection [5,9,10]. 8.…”

“…8. The ability to provide basic foot care education and referral into (and monitoring of) a home education program [3,11,10]. …”

Is surgical debridement necessary in the diabetic foot treated with photodynamic therapy?

“…Gangrene and osteomyelitis are two clinical situations with an indication for amputation. The susceptibility of diabetic patients to develop foot ulcers and osteomyelitis leads to a high risk of lower limb amputations, which is around 15–70 times higher than in non-diabetic patients [1–4]. …”

“…Series of debridement procedures, which may be required to achieve complete cleaning of the wound, can take the medical doctor to decide for amputation [4]. Therefore, debridement surgery and amputation are justified in order to save the patient.…”