management of - moh.gov.my management of diabetic foot... · na t e • forms gel on wound and...

MANAGEMENT OF

(SECOND EDITION)

QUICK REFERENCE FOR HEALTHCARE PROVIDERS

Ministry of HealthMalaysia

Academy ofMedicine Malaysia

Family MedicineSpecialists

Association ofMalaysia

Malaysian Endocrine& Metabolic Society

Malaysian OrthopaedicAssociation

8

QUICK REFERENCE FOR HEALTHCARE PROVIDERS MANAGEMENT OF DIABETIC FOOT (SECOND EDITION)

2 7

1. Diabetic foot can be defined as infection, ulceration or destruction of tissues of the foot associated with neuropathy and/or peripheral arterial disease (PAD) of people with diabetes mellitus (DM).

2. Screening for diabetic peripheral neuropathy and PAD should be performed on all DM patients at diagnosis and repeated at least annually.

3. Patients with active diabetic foot problem should be referred urgently and seen within 24 hours in secondary/tertiary care.

4. University of Texas Classification is the preferred classification for diabetic foot.5. Patient education should be an integral part in the management of diabetic foot;

performed at least annually and more frequent in higher risk patients.6. Prevention of Diabetic Foot Ulcer (DFU) consists of metabolic control, preventive

footwear and preventive surgery.7. Appropriate analgesia and antibiotics (as an adjunct) are important

pharmacotherapy in DFU.8. Appropriate wound dressing is done to maintain adequate moisture in addition to

surgical debridement to remove dead tissue by trained healthcare providers in DFU.

9. Revascularisation should be offered in DM patients with PAD.10. All patients with diabetic foot who has amputation should be referred for

rehabilitation.

KEY MESSAGES

CLINICAL PRACTICE GUIDELINES SECRETARIATMalaysian Health Technology Assessment Section (MaHTAS)

Medical Development Division, Ministry of Health MalaysiaLevel 4, Block E1, Presint 1,

Federal Government Administrative Centre 62590Putrajaya, MalaysiaTel: 603-88831229

E-mail: [email protected]

This Quick Reference provides key messages & a summary of the main recommendations in the Clinical Practice Guidelines (CPG) Management of Diabetic Foot (Second Edition).

Details of the evidence supporting these recommendations can be found in the above CPG, available on the following websites:Ministry of Health Malaysia : www.moh.gov.myAcademy of Medicine Malaysia : www.acadmed.org.myMalaysian Orthopaedics Association : http://www.moa-home.com Malaysian Endocrine and Metabolic Society : http://www.mems.my Family Medicine Specialists Association of Malaysia : http://fms-malaysia.org Malaysian Association of Rehabilitation Physicians : https://marp.online

QUICK REFERENCE FOR HEALTHCARE PROVIDERS MANAGEMENT OF DIABETIC FOOT (SECOND EDITION) QUICK REFERENCE FOR HEALTHCARE PROVIDERS MANAGEMENT OF DIABETIC FOOT (SECOND EDITION)

TYPE

S O

F W

OU

ND

DR

ESSI

NG

IN D

IAB

ETIC

FO

OT

No.

Ty

pes

of d

ress

ing

Adv

anta

ges

Dis

adva

ntag

es In

dica

tions

C

ontr

aind

icat

ions

Rev

iew

in

terv

als

Bas

ic w

ound

con

tact

dre

ssin

gs

1.

Gau

ze/b

asic

abs

orbe

nt

with

par

affin

or s

imila

r (a

ntis

eptic

s or

an

tibio

tics)

•R

educ

es a

dher

ence

of

dres

sing

to th

e w

ound

•W

idel

y av

aila

ble

• M

inim

al e

xuda

te a

bsor

ptio

n •

Req

uire

s se

cond

ary

dres

sing

All

wou

nds

Alle

rgy

Dai

ly

Adv

ance

d w

ound

dre

ssin

gs

1.

Hyd

roge

l •

Pro

vide

s m

oist

env

ironm

ent

•

Act

s as

enz

ymat

ic

debr

idem

ent

•P

rom

otes

gra

nula

tion

• R

equi

res

seco

ndar

y dr

essi

ng

• S

loug

hy w

ound

• D

ry w

ound

s •

Hig

hly

exud

ativ

e w

ound

s •

Alle

rgy

1 - 2

day

s

2.A

lgin

ate

•Fo

rms

gel o

n w

ound

and

m

aint

ain

moi

stur

e •

Act

s as

cav

ity fi

ller

•A

bsor

bent

in e

xuda

tive

wou

nds

• P

rom

otes

hae

mos

tasi

s •

Low

alle

rgen

ic

• R

equi

res

seco

ndar

y dr

essi

ng

• G

el c

an b

e co

nfus

ed w

ith

slou

gh o

r pus

in w

ound

• M

oder

atel

y or

hig

hly

exud

ativ

e w

ound

s •

Nee

d fo

r hae

mos

tasi

s

• D

ry w

ound

s •

Alle

rgy

3.H

ydro

fibre

• M

aint

ains

moi

stur

e •

Long

er w

ear t

ime

• N

on-tr

aum

atic

upo

n re

mov

al •

Red

uces

risk

of m

acer

atio

n •

Can

be

used

on

infe

cted

w

ound

s

• N

ot h

elpf

ul fo

r dry

wou

nds

• R

equi

res

seco

ndar

y dr

essi

ngs

Mod

erat

ely

or h

ighl

y ex

udat

ive

wou

nds

Alle

rgy

4.Fo

am

• M

aint

ains

moi

stur

e •

Hig

hly

abso

rben

t •

Cus

hion

ing

prop

erty

Lim

ited

size

Mod

erat

ely

or h

ighl

y ex

udat

ive

wou

nds

• D

ry w

ound

s •

Wou

nds

that

nee

d fre

quen

t rev

iew

5.H

ydro

collo

id •

Mai

ntai

ns m

oist

ure

• C

lean

s an

d de

brid

es b

y au

toly

sis

• E

asy

to u

se •

Wat

erpr

oof

Indu

ces

peri-

wou

nd

mac

erat

ion

Mild

ly to

mod

erat

ely

exud

ativ

e w

ound

s •

Dry

wou

nds

• In

fect

ion

• H

ighl

y ex

udat

ive

wou

nds

6.S

ilver

•

No

know

n re

sist

ance

• B

acte

ricid

al S

ome

silv

er d

ress

ings

di

scol

our t

he w

ound

Infe

ctiv

e w

ound

s A

llerg

y

7.O

ther

s

2 - 3

day

s

2 - 3

day

s

2 - 3

day

s

2 - 5

day

s

3 - 5

day

s

Not

wid

ely

used

- so

me

may

be

used

in s

peci

alis

ed c

entre

s e.

g. c

olla

gen,

mat

rix a

nd re

gene

rativ

e dr

essi

ngs

(cul

ture

d ep

ider

mis

, gr

owth

fact

ors,

ste

m c

ells

, etc

.)

Active foot problems (presence of any of the below):• ulceration • spreading infection• critical limb ischaemia• gangrene• suspicion of an acute charcot neuroarthropathy or an unexplained hot, red, swollen foot with or without pain

All patients with diabetes

Foot assessment:• skin• neurological• vascular• musculoskeletal

Active footproblem?

Refer Algorithm B

Previous historyof ulceration, amputation or on renal replacement

therapy?

High risk* Early referral to FootProtection Services

NO YES

YES

NO Deformity/neuropathy/non-critical

limb ischaemia

Moderaterisk*

Lowrisk*

Refer to FootProtection Services

Callus alone• Total contact insole• Foot care education• Yearly screening

Normalfindings

• Foot care education• Yearly screening


ALGORITHM A. SCREENING OF DIABETIC FOOTFOOT PROTECTION TEAM

Foot Assessment• Semmes-Weinstein monofilament examination should be combined with another modality

(pin prick or 128-Hz tuning fork) in the screening of peripheral neuropathy.• Palpation of foot pulses should be the initial screening method for PAD.

• Foot protection team is led by a Family Medicine Specialist or physician with special training in diabetic foot problems and supported by podiatrists, diabetic team (including diabetic educators), wound care team and rehabilitation services.

• It provides services in prevention of diabetic foot problems for low, moderate and high risk feet and management of simple active diabetic foot problems in the community that do not require admission.

MULTIDISCIPLINARY FOOT CARE TEAM• The multidisciplinary foot care team in the hospital is led by the orthopaedic

surgeon and/or physician and consists of other specialists in diabetes management e.g. vascular surgeons, rehabilitation physicians, occupational therapists, podiatrists, diabetes educators and wound care team.

• It manages active or complex diabetic foot problems.

DIABETIC FOOT EDUCATIONPersonal foot care should be emphasised which includes:• checking that feet are in good order • keeping feet clean• providing skin care• keeping toenails at a good length • choosing and wearing good fitting footwear• getting help if a problem is noticed

FOOTWEAR ADVICERisk status Actions

All foot at-risk

All foot at-risk

Moderate or high-risk

• Advise on using footwear that fits, protects and accommodates the shape of the feet (with socks).

• Prescribe appropriate off-loading devices for ulcer healing

• Prescribe footwear with: custom-made in-shoe orthoses or insoles for people with

foot deformity or pre-ulcerative lesions off-loading orthoses or insoles for people with healed

plantar foot ulcer• Review prescribed footwear periodically to ensure it still fits,

protects, and supports the foot • Advise on wearing footwear at all times, both indoors and

outdoorsFoot ulceration


ALGORITHM B. ACTIVE FOOT PROBLEMS (WITH RISK STRATIFICATION)DIABETIC FOOT RISK STRATIFICATION

*Refer urgently for admission if patients present with general illness (e.g. sepsis or diabetic emergencies) irrespective of foot problems.RECOMMENDED REFERRAL SCHEDULE

Diabetic foot risk

Risk Referral

Findings

No abnormalitiesNormal

Callus aloneLow Risk

Any of the following: • deformity• neuropathy• non-critical limb ischaemia

Any of the following:• ulceration • infection• critical limb ischaemia• gangrene• suspicion of an acute Charcot neuroarthropathy, or an

unexplained hot, red, swollen foot with or without pain

Moderate Risk

One of the following:• previous ulceration• previous amputation• on renal replacement therapy• neuropathy and non-critical limb ischaemia• neuropathy with callus and/or deformity• non-critical limb ischaemia with callus and/or deformity

High Risk

Active Diabetic Foot Problem

No referral needed. Yearly review at primary care

Referral within three months to foot protection services

Early referral within two weeks to foot protection services

Urgent referral within 24 hours to multidisciplinary foot care team

Normal/Low risk

Moderate risk

High risk

Active diabetic foot problem

Active foot problems*

Without ulcer(UT 0) With ulcer

Superficial(UT IA) Infection

Ischaemia(pulses notpalpable)

(UT IC/IIC/IIIC)

Infectionand

ischaemia(UT ID/IID/IIID)

Superficialulcer notrequiringsurgical

intervention(UT IB)

Deep ulcerrequiringsurgical

intervention(UT IIB/IIIB)

Manage asoutpatient by

FootProtectionServices

Oralantibiotics

ReferMultidisciplinary Foot Care Team

University of Texas Classification of Diabetic Foot

UT: University of Texas

GRADE 0 GRADE I GRADE II GRADE III

With ischaemia

With infection and ischaemia

STAGE A

STAGE BSTAGE CSTAGE D

Pre- or post-ulcerativelesion completely

epithelialised

Superficial wound, not involving tendon,

capsule or bone

Wound penetratingto tendon or capsule

With infection With infectionWith ischaemia


With infectionWith ischaemia


Wound penetratingto bone or joint

With infectionWith ischaemia





Active footproblem?

Refer Algorithm B


therapy?


NO YES

YES


limb ischaemia

Moderaterisk*

Lowrisk*



Normalfindings













All foot at-risk

All foot at-risk









2 7

1. Diabetic foot can be defined as infection, ulceration or destruction of tissues of the foot associated with neuropathy and/or peripheral arterial disease (PAD) of people with diabetes mellitus (DM).

2. Screening for diabetic peripheral neuropathy and PAD should be performed on all DM patients at diagnosis and repeated at least annually.

3. Patients with active diabetic foot problem should be referred urgently and seen within 24 hours in secondary/tertiary care.

4. University of Texas Classification is the preferred classification for diabetic foot.5. Patient education should be an integral part in the management of diabetic foot;

performed at least annually and more frequent in higher risk patients.6. Prevention of Diabetic Foot Ulcer (DFU) consists of metabolic control, preventive

footwear and preventive surgery.7. Appropriate analgesia and antibiotics (as an adjunct) are important

pharmacotherapy in DFU.8. Appropriate wound dressing is done to maintain adequate moisture in addition to

surgical debridement to remove dead tissue by trained healthcare providers in DFU.

9. Revascularisation should be offered in DM patients with PAD.10. All patients with diabetic foot who has amputation should be referred for

rehabilitation.

KEY MESSAGES

CLINICAL PRACTICE GUIDELINES SECRETARIATMalaysian Health Technology Assessment Section (MaHTAS)

Medical Development Division, Ministry of Health MalaysiaLevel 4, Block E1, Presint 1,

Federal Government Administrative Centre 62590Putrajaya, MalaysiaTel: 603-88831229

E-mail: [email protected]

This Quick Reference provides key messages & a summary of the main recommendations in the Clinical Practice Guidelines (CPG) Management of Diabetic Foot (Second Edition).

Details of the evidence supporting these recommendations can be found in the above CPG, available on the following websites:Ministry of Health Malaysia : www.moh.gov.myAcademy of Medicine Malaysia : www.acadmed.org.myMalaysian Orthopaedics Association : http://www.moa-home.com Malaysian Endocrine and Metabolic Society : http://www.mems.my Family Medicine Specialists Association of Malaysia : http://fms-malaysia.org Malaysian Association of Rehabilitation Physicians : https://marp.online


TYPE

S O

F W

OU

ND

DR

ESSI

NG

IN D

IAB

ETIC

FO

OT

No.

Ty

pes

of d

ress

ing

Adv

anta

ges

Dis

adva

ntag

es In

dica

tions

C

ontr

aind

icat

ions

Rev

iew

in

terv

als

Bas

ic w

ound

con

tact

dre

ssin

gs

1.

Gau

ze/b

asic

abs

orbe

nt

with

par

affin

or s

imila

r (a

ntis

eptic

s or

an

tibio

tics)

•R

educ

es a

dher

ence

of

dres

sing

to th

e w

ound

•W

idel

y av

aila

ble

• M

inim

al e

xuda

te a

bsor

ptio

n •

Req

uire

s se

cond

ary

dres

sing

All

wou

nds

Alle

rgy

Dai

ly

Adv

ance

d w

ound

dre

ssin

gs

1.

Hyd

roge

l •

Pro

vide

s m

oist

env

ironm

ent

•

Act

s as

enz

ymat

ic

debr

idem

ent

•P

rom

otes

gra

nula

tion

• R

equi

res

seco

ndar

y dr

essi

ng

• S

loug

hy w

ound

• D

ry w

ound

s •

Hig

hly

exud

ativ

e w

ound

s •

Alle

rgy

1 - 2

day

s

2.A

lgin

ate

•Fo

rms

gel o

n w

ound

and

m

aint

ain

moi

stur

e •

Act

s as

cav

ity fi

ller

•A

bsor

bent

in e

xuda

tive

wou

nds

• P

rom

otes

hae

mos

tasi

s •

Low

alle

rgen

ic

• R

equi

res

seco

ndar

y dr

essi

ng

• G

el c

an b

e co

nfus

ed w

ith

slou

gh o

r pus

in w

ound

• M

oder

atel

y or

hig

hly

exud

ativ

e w

ound

s •

Nee

d fo

r hae

mos

tasi

s

• D

ry w

ound

s •

Alle

rgy

3.H

ydro

fibre

• M

aint

ains

moi

stur

e •

Long

er w

ear t

ime

• N

on-tr

aum

atic

upo

n re

mov

al •

Red

uces

risk

of m

acer

atio

n •

Can

be

used

on

infe

cted

w

ound

s

• N

ot h

elpf

ul fo

r dry

wou

nds

• R

equi

res

seco

ndar

y dr

essi

ngs

Mod

erat

ely

or h

ighl

y ex

udat

ive

wou

nds

Alle

rgy

4.Fo

am

• M

aint

ains

moi

stur

e •

Hig

hly

abso

rben

t •

Cus

hion

ing

prop

erty

Lim

ited

size

Mod

erat

ely

or h

ighl

y ex

udat

ive

wou

nds

• D

ry w

ound

s •

Wou

nds

that

nee

d fre

quen

t rev

iew

5.H

ydro

collo

id •

Mai

ntai

ns m

oist

ure

• C

lean

s an

d de

brid

es b

y au

toly

sis

• E

asy

to u

se •

Wat

erpr

oof

Indu

ces

peri-

wou

nd

mac

erat

ion

Mild

ly to

mod

erat

ely

exud

ativ

e w

ound

s •

Dry

wou

nds

• In

fect

ion

• H

ighl

y ex

udat

ive

wou

nds

6.S

ilver

•

No

know

n re

sist

ance

• B

acte

ricid

al S

ome

silv

er d

ress

ings

di

scol

our t

he w

ound

Infe

ctiv

e w

ound

s A

llerg

y

7.O

ther

s

2 - 3

day

s

2 - 3

day

s

2 - 3

day

s

2 - 5

day

s

3 - 5

day

s

Not

wid

ely

used

- so

me

may

be

used

in s

peci

alis

ed c

entre

s e.

g. c

olla

gen,

mat

rix a

nd re

gene

rativ

e dr

essi

ngs

(cul

ture

d ep

ider

mis

, gr

owth

fact

ors,

ste

m c

ells

, etc

.)




Active footproblem?

Refer Algorithm B


therapy?


NO YES

YES


limb ischaemia

Moderaterisk*

Lowrisk*



Normalfindings













All foot at-risk

All foot at-risk









MANAGEMENT OF

(SECOND EDITION)

QUICK REFERENCE FOR HEALTHCARE PROVIDERS

Ministry of HealthMalaysia

Academy ofMedicine Malaysia

Family MedicineSpecialists

Association ofMalaysia

Malaysian Endocrine& Metabolic Society

Malaysian OrthopaedicAssociation

8

QUICK REFERENCE FOR HEALTHCARE PROVIDERS MANAGEMENT OF DIABETIC FOOT (SECOND EDITION)

management of - moh.gov.my management of diabetic foot... · na t e • forms gel on wound and...

Documents