Podiatry Arena members do not see these ads

i have seen past 8 months 3 patients died with complication of diabetic foot.

37 years old women came with foot ulcer 2 months back and she was treated conservatively, suddenly she died with keto-acidosis? septicemia?
65 years female advised bk , pt refused and died after 3 months.
50 yr male had severe foot infection, treated with debridement under anaestheasia, died on 1 st post op day.

when to decide amputation, when to go for conservative.
i am afraid of treating these kind of patients now.\

suresh

Attached Images

DSCN2210 (Small) (Small).JPG (36.2 KB, 137 views)

Suresh

Be not dismayed. I too, like others, have had the unplesant experience of a diabetic patient dying soon after I treated him. However, it is our reponsibility to treat our patients to the best of our ability whatever the likely outcome. As an analogy, it would be wrong to refuse treatment to a known carcinoma sufferer, even though it is known that death is certain over the next weeks/months.

Hopefully, none of our colleagues would be so crass as to be judgmental in such cases but rather offer support.

Keep the faith

Bill liggins

Dear Suresh,
I think you need to remember that these patients are sick. By the time they have significant foot complications they will have other micro and macro - vascular complications. We have many patients that come in with severe ischaemic ulcers as well, and peripheral arterial disease significantly correlates to Cardiovascular disease, therefore increased risk of death. Let alone all the psychosocial problems.... These patients may die with any significant surgical intervention.

It IS very dis-heartening - but then there are those cases that you can make a real positive impact. Try and remember those.

Re: treating v's amputation. A lot more needs to be researched/published in this area. We have great difficulty in deciding amongst the team whether the problem area needs amputation or antibiotics and conservative management. Currently:
1. if arterial flow adequate and tissue hasn't been damaged irrevocably from aggressive infection, then no amputation +/- surgical debridement.
2. If infection left too long, and tissue has died (although blood flow good), then surgical debridement of wound bed/amputation if bone involved.
3. If no blood flow and infection present:
a. If revascularisation is possible - then infection treated first, revascularisation +/- amputation if tissue necrosis too great.
b. If no revascularisation possible - amputation - try for minor amp of affected tissue only - although aim to leave a foot that can bear pressure without breaking down.
4. If no blood flow and no infection and no revascularisation possible - if there is only digital involvement and pain isn't an issue the surgeons like to leave the areas to demarcate and we try and protect the areas so no further damage undertaken - surgery is too risky as the surgical site may not heal and more proximal amputation may be required.

We try and avoid major amputation as this leads to increased risk of death - in addition, most patients state that they refuse proximal amputation if less aggressive amputation is an alternative (albeit a less viable one). However, it is necessary in some cases. Then it becomes really important to focus on the other leg - this is at really high risk of ulceration......

I am writing a lot because we've just had a few patients die post amputation and it has made me really think about what we are doing - I really wish researchers would do more work in this area!!!

Rajna

dear rajana,
thank you for your reply...'
yes...i too work on this ..

suresh