Honestly, if there is any complication of diabetes mellitus that is insidious at onset and that may be precipitously catastrophic, it is a diabetic foot ulcer with acute celullitis. The common history is that he or she was not even aware of when the injury took place in the first instance and that it has NOT been PAINFUL. Then you as a caregiver may even think that the patient had a carefree attitude towards his clinical condition. The painful truth is that diabetic foot ulcer with possible cellulitis is preventable.
What could be very disturbing is that you find some well-informed people with this lesion hiding it from their physicians and doing all sorts of inappropriate dressings and some even attributing it to stepping on POISON. It is only when there is a potential catastrophic flare up that they come calling. It is at this point that they present in the hospital in this environment. The caregiver must realise that this is a life-threatening medical and possible surgical emergency if all fails. To the uninitiated, the swelling and oozing of fluid from the leg as a result of cellulitis may be frightening and most of the time out of proportion to the provoking ulcer. This is not also helped by the odour of the whole situation.
This is where the thought of amputation usually creeps in. This shouldn’t be the case. As a rule, the patient MUST be hospitalised. The issue of resource constraint should not be considered. If the patient cannot afford profit driven private health facility, he should immediately be sent to a government secondary health facility to rough it out there. For starters, knowing that diabetes is a metabolic disorder that, in turn affects, other metabolic activities in the body, it is expedient to bring the blood sugar level to the normal range as soon as possible. No dosage regimen is standard or recommended but SOLUBLE INSULIN through the INTRAVENOUS route should be given until there are signs of HYPOGLYCAEMIA (low blood sugar).
If there is an in house laboratory, the need for hourly blood sugar estimation cannot be over emphasised. In remote areas, diabetics usually are advised to have equipment like ACUCHEK. This could be very useful in our clime in monitoring blood sugar level while the crisis lasts. In terms of antibiotics, there should be no debates. The best available, irrespective of cost, and preferably a CEPHALOSPRIN must be in the combination use at maximum dosage. Though it is known that the offending organisms in the BACTERAEMIC (bacteria in the blood) and possibly SEPTICAEMIA (when the bacteria is rapidly multiplying in the blood) phases are usually gram positive STAPHYLOCOCCUS and STREPTOCOCCUS, it is safer to assume a polymicrobial infection of both gram negative, anaerobes and aerobes in addition to the earlier mentioned.
Thus the relevant antibiotics and chemotherapeutic agent must be included in this situation. Electrolyte imbalance and dehydration must be corrected and if there is sign of anaemia, blood should be transfused as soon as the temperature comes down. In terms of diagnosis with respect to knowing the offending organism, a wound swab of the ulcer crater after debridement is preferred. The truth is that the result of this investigation in reality hardly makes any difference on the choices of antibiotics used for the patient. The ultimate determinant on whether to change what the patient was started on would depend on the clinical response and for some caregivers, changing to culture result would depend on the sensitivity and cost effectiveness. This really means cheaper antibiotic for long-term maintenance.
In our environment, it is always advisable that at no point in time should insulin be replaced by oral anti-diabetic drugs. Here the role of long acting LENTE insulin should be emphasised and the dosage adjusted accordingly depending on the level of control. This should be maintained till the ulcer heals. Caring for the ulcer in this environment involves basically continuous wound DEBRIDEMENT (nurses would say SCRAPING) and wet dressing. The scraping is such that the sludge of dead cells and scar tissue often described by penologists as LIPOSCLRODERMA must be removed till the wound bleeds.
Wound dressing these days have many options and trials are still going on with new products and concepts. What all seem to accept is that for speedy heeling, the wound needs to be kept wet possibly with physiological solution. There are so many biologically active bandages that may enhance the granulation process in diabetic ulcer. The soon-to-become trend is the usage of TRANSFORMING GROWTH FACTOR BETA as an active player to enable the proliferation of fibroblasts and blood forming cells known as ANGIOBLASTS.
Lately, it has been shown that pressurised oxygen, in what is aptly described as HYPERBARIC OYGEN THERAPY, has reduced the need for amputation while improving the healing process. The cost of procuring hyperbaric facility, in the long run, is projected to greatly reduce the total cost of managing diabetic ulcer worldwide. In a resource constraint environment like ours, combinations of diluted hydrogen peroxide with other physiological solution like Normal Saline to dress the ulcer during the early phase of massive necrosis has been found to be very useful. These ulcers are usually packed with granulated or crushed METRONIDAZOLE (flagyl) soaked in saline solution. This simple method with adequate control of diabetes has been proven to be very effective.
In the very near future, STEM CELL therapy is seriously being considered. For clarification, a stem cell is a PROGENITOR or a primitive cell from where many cell types evolve and differentiate into specialised cells. A very good example is the MEGAKARYOCYTE from where all blood cells, be it white or red and platelets, are derived. In fact, this has made the PIGs bladder a potential source of harvesting stem cells for the management of hard to heal diabetic ulcer due to its lack of differentiation. A high protein diet and reasonable calorie intake must always be emphasised. Cheap source of proteins, like soya beans, may make a lot of difference in this situation. Always remember that protein energy malnutrition (KWASHIOKOR) could be a sequel of this condition.
As a rule, the management of diabetic ulcer should be a multidisciplinary endeavour. With an arsenal today loaded with potent and effective antibiotics, clear understanding of the dynamics of the extra cellular matrix, biotechnology and genetic engineering the days of below knee amputation of diabetic patients may just be going with the wind.