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DM and amputation(IC LONG HOI IAN).pptx
- 1. Tutor: Dr. LEION TENG Family medicine IC: LONG HOI IAN The relationship between Diabetic amputations and DM control
- 2. What isDM, complication of DM - What is diabetes mellitius - Complications of DM What is diabetic foot ulcer - Epidemiology of diabetic foot ulcer - Development of diabetic foot ulcer Management of diabetic foot ulcer in Family medicine/ Health centre - Reduce the risk of amputation - Control underlying disease – DM - Prevention of diabetic foot ulcer Time line 1
- 3. What is diabetesmellitius Diabetes mellitius - a group of common endocrine diseases characterized by sustained high blood glucose levels. - due to either the pancreas not producing enough insulin, or the cells of the body not responding properly to the insulin produced. 2
- 4. Complications of DM Short-TermComplications - Hypoglycemia - Hyperosmolar Hyperglycemic Nonketotic Syndrome - Diabetic ketoacidosis Long-Term Complications - Macrovascular disease: *AMI *STROKE *Peripheral Vascular Disease - Microvascular disease : *Retinopathy *Nephropathy *Neuropathy- Neurotrophic ulcers - diabetic foot ulcer 3
- 5. Epidemiology of diabeticfoot ulcer Annual incidence of diabetic foot ulcer worldwide :9.1 to 26.1 million. Around 15 to 25% of patients with diabetes mellitus will develop a diabetic foot ulcer during their lifetime. 4
- 6. Development of diabeticfoot ulcer Initial stage: callus. The callus results from neuropathy Motor neuropathy : physical deformity of th e foot Sensory neuropathy : sensory loss which leads to ongoing trauma Autonomic neuropathy: Drying of the skin Frequent trauma of the callus results in subc utaneous hemorrhage and eventually, it becomes an ulcer. 5 5
- 7. Management of diabeticfoot ulcer in Health centre - Reduce the risk of amputation - Control underlying disease – DM - Prevention of diabetic foot ulcer 6 6
- 8. Reduce the riskof amputation – control HbA1c 7 7
- 9. Reduce the riskof amputation – control HbA1c 8 8
- 10. Reduce the riskof amputation – control HbA1c 9 9
- 11. Reduce the riskof amputation – control HbA1c In those study, all suggest that well control DM with lower HbA1c, can reduce the rick of amputation. 10
- 12. Management of diabeticfoot ulcer in Health center - Reduce the risk of amputation - Control underlying disease – DM - Prevention of diabetic foot ulcer 11
- 13. Control underlying disease– DM Management of DM - Life style change - Exercise - Self-monitoring of blood glucose - Oral medicine/insulin 12
- 14. Oral medicine –SGLT2 SGLT2 - Benefit : HbA1c reduction 0.6~0.9% low risk of hypoglycemia BP – lowering effect Weight loss cardiovascular benefit 13
- 15.
- 16. Management of diabeticfoot ulcer in Family medicine/ Health centre - Reduce the risk of amputation - Control underlying disease – DM - Prevention of diabetic foot ulcer 15
- 17. Prevention of diabeticfoot ulcer 1. check feet daily 2. Wash feet daily 3. Don’t try to remove any lesion by themselves 4. Cut toenails carefully 5. Wear clean, dry socks 6. Buy shoes that fit correctly 7. Diabetes foot screening test 16
- 18. Diabetes foot screeningtest Test 10 sites of the foot No feeling>4 sites loss of protective sensation Sensitivity and specificity: 97% and 83% 17
- 19. Take home message 1.Control HbA1c in a lower level can reduce the risk of amputation in DM patient. 2. Prevention of diabetic foot ulcer, each as foot management by patient, Diabetes foot screening test. 18
- 20.
- 21. Thank you forlistening
Editor's Notes
- #2 Good morning, doctor, thank you to join our presentation, first I have to thank you my tutor DR LEI ON TENG to guild me to finish this presentation. Today, I want to share about the relationship between Debritic amputation and DM control
- #3 About this presentation, it will separate 3 part. First part I will take about DM Second part is what is diabetic foot ulcer Third part is what can we do in health center about diabetic foot ulcer
- #4 DM is a group of common endocrine disease characterized by sustained high blood glucose level, due to either the pancreas not producing enough insulin, or the cell of the body not responding properly to the insulin produced.
- #6 The complication of DM there are have short term and long term complication Short tern complication such as hypoglycemia, hyperosmolar hyperglycemic nonketotic syndrome, and diabetic ketoacidosis Long tern complication are macrovascular and microvascular disease, macrovascular disease such as AMI, STROKE peripheral vascular disease Microvascular disease such as retinopathy, nephropathy and neuropathy, neuropathy is the main reason of diabetic foot ulcer
- #7 The annual incidence of diabetic foot ulcer worldwide is between 9.1 to 26.1 million. Around 15 to 25% of patients with diabetes mellitus will develop a diabetic foot ulcer during their lifetime.
- #8 The initial stage is the development of a callus. The callus results from neuropathy The motor neuropathy causes physical deformity of the foot sensory neuropathy causes sensory loss which leads to ongoing trauma Drying of the skin because of autonomic neuropathy is also another contributing factor Finally, frequent trauma of the callus results in subcutaneous hemorrhage and eventually, it becomes an ulcer.
- #9 In the third part, I will separate 3 part to talk about the management of diabetic foot ulcer in health center Frist , I will talk about how to reduce the risk of amputation
- #10 This is a study in Japan, they compared about age and HbA1c to the risk of amputation in diabetes patient, they recommended the rates of amputation were significantly greater those old than 60 years old and HbA1C more than 8%
- #11 Another study, they compared HbA1c level between groups with Lower extremity amputation and without Lower extremity amputation by meta-analysis. They found that the odds ratio for Lower extremity amputation incidence was 1.22 for every 1% HbA1C. This study support that high level of HbA1C is an important risk factor for amputation in patient with diabetes.
- #12 This is a study in journal of the American college of surgeon, they compared 2 group of patient, once is intensive glycemic control Hba1c less than 6% and other is standard glycemic control hba1c form 7% to 9% They suggest that intensive glycemic control was associated with a reduction in the risk for lower extremity amputation.
- #13 In those study, all suggest that well control DM with lower HbA1c, can reduce the rick of amputation.
- #14 Next , I will talk about second part management in HC, control DM
- #15 About management of DM, we can ask patient to have life style change, exercise, self motioning blood glucose. Final step is oral medicine and insulin
- #18 Nowadays, SGLT2 is a popular medicine, have a lot of benefit for DM or heart failure patient Such reduce HbA1C almost 1%, lower risk of hypoglycemia, lowering blood pressure effect, weight loss and cardiovascular benefit.
- #19 But in 2017, a study for canagliflozin , one of SGLT2, they found that this medicine will increased the risk of amputation in DM patient. In UpToDate also suggest avoid SGLT2 in DM foot ulcer patient.
- #20 Third part, I will talk about prevention of diabetic foot ulcer
- #21 About the prevention of foot ulcer , we have some medical advice for patient. check feet daily for any lesion, redness or tenderness. Wash feet daily with warm water, and dry it gently, Don’t try to remove any lesion by themselves, it will increased the risk of infection Cut toenail carefully and avoid ingrown toenail Wear clean and dry sock to protest their feet Buy shoes that fit correctly, provide support and cushioning for the heel, arch and ball of the foot. 7. Last is screening test for DM foot in HC
- #22 In Diabetic foot screening test, we will test 10site of one foot, test both foot in same test. If there are more than 4 sites no feeling, we consider that foot loss of protective sensation. This test have a high sensitivity and specificity, easy to perform in health center sitting.
- #27 One of the commonly used classifications is by Wagner from 1981. It classifies wounds into six grades 0/no ulcer, only pain 1/Superficial ulcer 2/Deep ulcer involving tendon. ligament 3/Deep ulcer with abscess or osteomyelitis 4/Gangrene involving the forefoot 5/Gangrene involving the entire Foot
- #28 There is the end of my presentation, there are some take home message Control HbA1c in a lower level can reduce the rick of amputation in DM patient. To prevent diabetic foot ulcer, is important to have foot management by patient and perform diabetic foot screening test every year.