งานนำเสนอเรื่อง: "Every 30 seconds, a lower limb is lost to diabetes somewhere in the world นำเสนอโดยนพ. เพชร รอดอารีย์ ประชุมเรื่องเบาหวานกับการดูแลเท้า ณ โรงแรมมารวยกาเด็นท์"— ใบสำเนางานนำเสนอ:
Every 30 seconds, a lower limb is lost to diabetes somewhere in the world นำเสนอโดยนพ. เพชร รอดอารีย์ ประชุมเรื่องเบาหวานกับการดูแลเท้า ณ โรงแรมมารวยกาเด็นท์ กรุงเทพมหานคร วันที่ 21 พ. ย. 2548
Diabetes Registry Project 2003 The Endocrine Society of Thailand Diabetes Complication in the Thailand Diabetes Registry N = 9,419
Diabetes Registry Project 2003 The Endocrine Society of Thailand Risk of amputation FactorsWithout amputation With amputation Adjust OR (95% CI) P-value of adjust OR HbA1C > 7 (%) ( ) Present of retinopathy (%) ( ) Blindness (%) ( ) History of foot ulcer (%) ( ) < Absent peripheral pulse (%) ( ) < Insulin use (%) ( ) 0.023
Lower limb amputation in Thailand Diabetes registry (TDR) Amputated 1.5% Below knee 31.7% Toe 64.1% A.K. 4.2% Diabetes Registry Project 2003 The Endocrine Society of Thailand OR: Hx of foot ulcer = 59.2 ( ) OR: absence of pulse = 5.3 ( ) 3.9% absence of pulse 5.9% foot ulcer
UNADJUSTED FREQUENCY OF PAD USING ABI BY GENDER AND COUNTRY % Countries PAD Epidemiologic study (PAD-SEARCH)
Screening and monitoring for diabetes complications in the past 12 months YesNo Eyes exam Retinopathy34.2 Cataract33 Feet exam Any problems13.5 SM blood glucose SM urine glucose Ref: Diabcare-Asia 2003 Thailand (in press)
PAD in Diabetes Over 1/2 are asymptomatic or have atypical symptoms About 1/3 have claudication The risk of PAD in diabetes is increased by age, duration of diabetes, presence of peripheral neuropathy and some ethnics Diabetes Care 2003;26:
Mortality Over a Period of 10 Years in Patients with Peripheral Arterial Disease N Engl J Med 1992;326:381-6
PAD: symptoms & signs Absense Pulse Cold sensation Shiny skin Pallor Loss of hair on foot & toes Intermittent claudication Nocturnal & rest pain Gangrene, Ulcer
> 1.30 Non compressible Normal Mild to moderate PAD Intermittent Claudication Intermittent Claudication Severe PAD Rest pain, Ischemic ulcer Rest pain, Ischemic ulcer NEJM 2001:344:21:p Systolic ankle blood pressure Systolic brachial blood pressure
Role of primary clinician Establish the diagnosis of PAD symptomatology symptomatology ABI ABI Other vasucular lab. Test Other vasucular lab. Test Discuss the risk/benefit of therapeutic alternatives Modify risk factors of systemic atherosclerosis Perform treadmill stress testing Refer to exercise programme NEJM 2002; 347(24);
Treatment for claudication TreatmentDose/interventionEfficacysafety Exercise35-50 min/day 3-5 time/wk Treadmill/track walking % improvement in max. walking distance and QoL. Well tolerated; CVD complications are rare AngioplastyBased on anatomyImprove max. walking distance equal to exercise; improve QoL equal to surgery <0.5% morbidity and mortality SurgeryBased on anatomy75-100% improvement in max. walking distance; improve QoL. 2-3% mortality; 5-10% morbidity pharmacotherapy NEJM 2002; 347(24);
Questions Question 1: Any change in the foot since the last evaluation Question 2: Does the patient have a foot ulcer now or a history of foot ulcer? Question 3: Is there pain in the calf muscles when walking--i.e., pain occurring in the calf or thigh when walking less than one block that is relieved by rest?
Foot Exam Item 1: Are the nails thick, too long, ingrown, or infected with fungal disease? Item 2: Foot Deformities Item 3: Pedal Pulses Item 4: Skin Condition Toe Deformities (Hammer/Claw Toes) Bunions (Hallux Valgus) Plantar View of Charcot Joint
Sensory Foot Exam The sensory exam should be done in a quiet and relaxed setting Apply sufficient force to cause the filament to bend The total duration of the approach approximately 1-2 seconds
Risk Categorization Risk Category DefinitionManagement Guidelines High Risk One or more of the following: 1.Loss of protective sensation 2.Absent pedal pulses 3.Severe foot deformity 4.History of foot ulcer 5.Prior amputation Conduct foot assessment every 3 months. Demonstrate preventive self-care of the feet. Refer to specialists and a diabetes educator as indicated. (Always refer to a specialist if Charcot joints are suspected.) Assess/prescribe appropriate footwear. Certify Medicare patients for therapeutic shoe benefits. Place "High Risk Feet" sticker on medical record.
Risk Categorization Risk Category DefinitionManagement Guidelines Low RiskNone of the five high risk characteristics below. Conduct an annual foot screening exam. Assess/recommend appropriate footwear. Provide patient education for preventive self-care.
Management Plan patient education, any diagnostic studies, footwear recommendations, referrals, follow-up care.
Ischemic Ulcer Treatment Guideline Ischemic Ulcer Evaluate severity of ischemia Mild Moderate Severe Good Evaluate Health Status Poor Evaluate status of Peripheral arteries with Angiography Good Poor Conservative Treatment Arterial Bypass Surgery Amputation
Risk factors for foot ulcer Peripheral neuropathy Autonomic neuropathy Peripheral Arterial disease (PAD) Limited joint motion Foot pressure abnormalities Foot trauma Uncontrolled and Duration of diabetes Blindness Risk for amputation Peripheral neuropathy Vascular insufficiency Infection Hx of fooot ulcer/amputation Deformities Trauma Vision lose Poor glycemic control