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1362576264 lab measures in diabetic foot mumbai

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lab measures in diabetic foot mumbai

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1362576264 lab measures in diabetic foot mumbai

  1. 1. LABORATORY MEASURES INLABORATORY MEASURES IN DIABETIC FOOTDIABETIC FOOT Dr. Ghanshyam GoyalDr. Ghanshyam Goyal ILS Multispeciality ClinicILS Multispeciality Clinic S. K. Diabetes & Research Centre,S. K. Diabetes & Research Centre, KolkataKolkata
  2. 2. Logic of Foot ExaminationLogic of Foot Examination  DFU are expensive, potentially limb/life threatening butDFU are expensive, potentially limb/life threatening but Highly PreventableHighly Preventable  DFU affect 15% of all Diabetic SubjectsDFU affect 15% of all Diabetic Subjects  Pts. DPN have annual incidence of DFU 7.2%Pts. DPN have annual incidence of DFU 7.2%  DFU account for 20% of Diabetes-related hospitalDFU account for 20% of Diabetes-related hospital admission (USA)admission (USA)  Cause of DFU : 45 – 60 % Neuropathic, 25 – 45% areCause of DFU : 45 – 60 % Neuropathic, 25 – 45% are neuro-ischemic, ~10% ischemicneuro-ischemic, ~10% ischemic
  3. 3. Priorities of Physical ExaminationPriorities of Physical Examination  Non-Diabetic Subject – English –Non-Diabetic Subject – English – Head – to – Foot ExaminationHead – to – Foot Examination  Diabetic Subject - Sanskrit -Diabetic Subject - Sanskrit - ApadaMastakApadaMastak ( Foot – to – head )( Foot – to – head ) Foot Examination is a priority in a DiabeticFoot Examination is a priority in a Diabetic SubjectSubject
  4. 4. High Risk PatientsHigh Risk Patients  Duration of Diabetes > 10 yearsDuration of Diabetes > 10 years  Male > FemaleMale > Female  Poor Blood Glucose ControlPoor Blood Glucose Control  Patients with Cardiovascular, Renal or, RetinalPatients with Cardiovascular, Renal or, Retinal ComplicationsComplications John A. Colwell : Diabetes, p.38., 2003John A. Colwell : Diabetes, p.38., 2003
  5. 5. High Risk Foot - CausesHigh Risk Foot - Causes  NeuropathiesNeuropathies  VasculopathiesVasculopathies  Foot Architecture – Congenital / AcquiredFoot Architecture – Congenital / Acquired  Mechanical – Overweight, Shoes, CallusMechanical – Overweight, Shoes, Callus  Others – Poor vision, elderly, ChronicOthers – Poor vision, elderly, Chronic HyperglycemiaHyperglycemia Examination and approach should address theseExamination and approach should address these issues.issues.
  6. 6. Sensory Neurons – Fibers TypeSensory Neurons – Fibers Type Fiber TypeFiber Type SizeSize ModalityModality A-alphaA-alpha 13-20 microns13-20 microns myelinatedmyelinated Limb propioceptionLimb propioception A-betaA-beta 6 – 12 microns6 – 12 microns myelinatedmyelinated L.P., vibration &L.P., vibration & pressurepressure A – deltaA – delta 1 5 microns1 5 microns Mechanical sharpMechanical sharp painpain CC 0.2-1.5 microns0.2-1.5 microns unmyelinatedunmyelinated Thermal, burningThermal, burning painpain
  7. 7.  InspectionInspection – Skin, nailsSkin, nails – Architecture – pes planus, claw toeArchitecture – pes planus, claw toe  Palpation – ADP & Post. Tibial, BonesPalpation – ADP & Post. Tibial, Bones  Auscultation – bruitAuscultation – bruit  SpecialSpecial – MonofilamentMonofilament – Tuning forkTuning fork – Biothesiometry (VPT > 25)Biothesiometry (VPT > 25) – Hand-held DopplerHand-held Doppler
  8. 8.  Sensorimotor nerve functions investigated bySensorimotor nerve functions investigated by four bedside testsfour bedside tests  MonofilamentMonofilament  Achilles Tendon reflexesAchilles Tendon reflexes  VPTVPT – Tuning forkTuning fork – BiothesiometerBiothesiometer
  9. 9. Lab MeasuresLab Measures AA SensationSensation Large fibre: Tuning fork; monofilament &Large fibre: Tuning fork; monofilament & biothesiometer’biothesiometer’ Small fibre: Pain, TemperatureSmall fibre: Pain, Temperature BB VascularityVascularity Exam. Of pulses;Exam. Of pulses; A/B index.A/B index. CC PressuresPressures (Planter)(Planter) Movement – big toeMovement – big toe Harris matHarris mat Foot scanFoot scan DD RadiologyRadiology X-ray; USG; Nuclear scan; MRIX-ray; USG; Nuclear scan; MRI EE MetabolicMetabolic Hemogram, Sugar, Hba1c, RenalHemogram, Sugar, Hba1c, Renal parameters, Serum albuminparameters, Serum albumin FF MIcrobiologyMIcrobiology Wound C/S, Blood C/SWound C/S, Blood C/S
  10. 10. Semmes-Weinstein MonofilamentSemmes-Weinstein Monofilament  5 g,5 g, 10 g10 g, 75 g, 75 g  Sites – not standardized (RecommendedSites – not standardized (Recommended sites : Great toe, heels & MT heads)sites : Great toe, heels & MT heads)  Gently touch skin and apply pressure untilGently touch skin and apply pressure until filament buckles – ask patientfilament buckles – ask patient  DO NOT apply on ulcersDO NOT apply on ulcers  Corns & Calluses are usually insensitiveCorns & Calluses are usually insensitive  Sensitivity 95%, specificity 87% (10g)Sensitivity 95%, specificity 87% (10g)
  11. 11. Vibration PerceptionVibration Perception  128 Hz Tuning Fork128 Hz Tuning Fork  Large diameter fibersLarge diameter fibers  Sensitivity > 80 %Sensitivity > 80 %  Specificity ~ 60 – 70 %Specificity ~ 60 – 70 %  Site not Standardized – base of great-toeSite not Standardized – base of great-toe nail and on medial malleolusnail and on medial malleolus
  12. 12. BiothesiometerBiothesiometer
  13. 13. Temperature SensationTemperature Sensation  Warmth -- Smallest, unmyelinated CWarmth -- Smallest, unmyelinated C fibersfibers  Cold – Small, myelinated ACold – Small, myelinated Aδδ fibersfibers  Heating / Cooling detector uses theHeating / Cooling detector uses the Peltier principle (metal element is heatedPeltier principle (metal element is heated or, cooled according to the direction ofor, cooled according to the direction of electric currentelectric current
  14. 14. NeurotipsNeurotips  Disposable, made up of plastic with aDisposable, made up of plastic with a sharp metal end and a blunt endsharp metal end and a blunt end  Marketed by Owen Mumford, Oxford, UKMarketed by Owen Mumford, Oxford, UK  Detects loss of touch sensation (superiorDetects loss of touch sensation (superior to safety pins, needles or, hat-pins)to safety pins, needles or, hat-pins)
  15. 15. HCP SensitometerHCP Sensitometer ..  Assessment ofAssessment of Thermal (Hot/cold) perceptionThermal (Hot/cold) perception thresholdthreshold
  16. 16. Hand-held DopplerHand-held Doppler  Excellent tool for vascular assessment at bed-Excellent tool for vascular assessment at bed- sideside  Normal sound Biphasic or TriphasicNormal sound Biphasic or Triphasic  Atherosclerotic vessels – monophasicAtherosclerotic vessels – monophasic  Ankle Brachial Index : < 0.9 usually indicatesAnkle Brachial Index : < 0.9 usually indicates angiogram positive disease (falsely highangiogram positive disease (falsely high because of high S.P. in atherosclerotic vessels).because of high S.P. in atherosclerotic vessels).
  17. 17. Ankle / Brachial PressureAnkle / Brachial Pressure Index (ABI)Index (ABI)  Normal ABI = 1Normal ABI = 1  Ischemia < 0.85Ischemia < 0.85 Ankle / Brachial PressureAnkle / Brachial Pressure Index (ABI)Index (ABI)
  18. 18. VASCULAR DOPPLER REPORTVASCULAR DOPPLER REPORT
  19. 19. Ankle/Brachial IndexAnkle/Brachial Index  > 1.0> 1.0 NormalNormal  0.9-1.00.9-1.0 Minimal diseaseMinimal disease  0.5-0.90.5-0.9 ClaudicationClaudication  <0.5<0.5 Rest pain, Severe arterialRest pain, Severe arterial diseasedisease
  20. 20. Who Undergoes Vascular EvaluationWho Undergoes Vascular Evaluation  All patients with foot lesionsAll patients with foot lesions  Examination of pulsesExamination of pulses  ABPIABPI  Duplex scanDuplex scan  AngiographyAngiography
  21. 21. Foot Pressure studies in DNFoot Pressure studies in DN  Semi QuantitativeSemi Quantitative – Pressure statPressure stat – Harris matHarris mat  QuantitativeQuantitative – Foot ScanFoot Scan – In shoe techniqueIn shoe technique – Bare foot techniqueBare foot technique
  22. 22. Pressure StatPressure Stat Harris matHarris mat
  23. 23. ParomedParomed  Static weight bearingStatic weight bearing  Dynamic Gait patternDynamic Gait pattern  Dynamic ImpulsesDynamic Impulses  Quantum valuesQuantum values  3-D analysis of peak3-D analysis of peak plantar pressuresplantar pressures during the ambulationduring the ambulation periodperiod 0 N/cm2 to 19 N/cm2 20 N/cm2 onwards
  24. 24. X-ray FootX-ray Foot  Soft tissue swellingSoft tissue swelling  Foreign bodyForeign body  Gas gangreneGas gangrene  Vascular calcificationVascular calcification  Loss of foot archLoss of foot arch  Charcot’s arthropathyCharcot’s arthropathy  AmputationsAmputations  OsteomyelitisOsteomyelitis
  25. 25. Foot: MR ImagingFoot: MR Imaging  Anatomical detailsAnatomical details  Osteomyelitis (Abnormal marrowOsteomyelitis (Abnormal marrow signal, soft tissue mass and corticalsignal, soft tissue mass and cortical destruction)destruction)  Neuropathic jointNeuropathic joint -- Disorganised destruction, dislocation,Disorganised destruction, dislocation, marrow edema, effusion, loss of jointmarrow edema, effusion, loss of joint definitiondefinition
  26. 26. Charcots FootCharcots Foot
  27. 27. Selected Antibiotics Regimens for Initial Empiric Therapy of FootSelected Antibiotics Regimens for Initial Empiric Therapy of Foot Infections in Patients with Diabetes MellitusInfections in Patients with Diabetes Mellitus InfectionInfection Antimicrobial regimenAntimicrobial regimen Non-limbNon-limb threateningthreatening Cephalexin 500mg p.o. q6hCephalexin 500mg p.o. q6h Clindamycin 300 mg p.o. q8hClindamycin 300 mg p.o. q8h Amoxicillin-clavulanate (875/125 mg) one q12hAmoxicillin-clavulanate (875/125 mg) one q12h Dicloxacillin 500 mg p.o. q6hDicloxacillin 500 mg p.o. q6h Levofloxacin 500-750 mg qdLevofloxacin 500-750 mg qd Limb threateningLimb threatening Ceftriaxone 1 g IV daily plus clindamycin 450-600 mg IVCeftriaxone 1 g IV daily plus clindamycin 450-600 mg IV q8hq8h Ciprofloxacin 400 mg IV q12h plus clindamycin 450-600 mgCiprofloxacin 400 mg IV q12h plus clindamycin 450-600 mg IV q8hIV q8h Ampicillin / sulbactam 3 g IV q4-6hAmpicillin / sulbactam 3 g IV q4-6h Piperacillin / tazobactam 3.375 g IV q4h or 4.5 g IV q6hPiperacillin / tazobactam 3.375 g IV q4h or 4.5 g IV q6h Fluoroquinolone IV plus metronidazole 500 mg IV q6hFluoroquinolone IV plus metronidazole 500 mg IV q6h Life threateningLife threatening Impenem cilastatin 500 mg IV q6hImpenem cilastatin 500 mg IV q6h Piperacillin / tazobactam 4.5 g IV q6h plus gentamicin 1.5Piperacillin / tazobactam 4.5 g IV q6h plus gentamicin 1.5 mg/kg IV q8hmg/kg IV q8h Vancomycin 1 g IV q12h plus gentamicin plusVancomycin 1 g IV q12h plus gentamicin plus metronidazolemetronidazole
  28. 28. SummarySummary  Periodic Examination of Foot is Mandatory in allPeriodic Examination of Foot is Mandatory in all Diabetic PatientsDiabetic Patients  Identification of Early foot problems canIdentification of Early foot problems can prevent major events &prevent major events & CostCost  Identification of High Risk Foot is possible atIdentification of High Risk Foot is possible at Primary Care SettingPrimary Care Setting  Education of Physician AND Patient is importantEducation of Physician AND Patient is important for Prevention of Foot Complicationsfor Prevention of Foot Complications

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