Intelligent care for diabetic footDr. Qutaiba Abdullah AldoriBurn & Reconstructive Surgeon at Azadi –Hospital –Kerkuk/Iraq .

Diabetic foot•According to the World

Health Organization and to the International Working

Group on the Diabetic Foot

• defined as The foot of diabetic pt with ulceration, infection and/or destruction of the

deep tissues, associated with neurological abnormalities

and various degrees of peripheral vascular disease in

the lower limb

• DM is now thought to be in excess of 200 million• Pt. is affected .

• This figure is predicted to reach 333 million by 2025• The current population of the United States of

America is 323,668,578 • 15% of all diabetics with Diabetic foot ulcers

• almost 85% of foot ulcers proceed to amputations.

• Submitted by Lorenzo.Piemonte on Wed, 07/01/2015 - 14:00

• Did you know that every 20 seconds an amputation caused by diabetes occurs somewhere in the world?

objective• If we keep the diabetic foot patient in well hydrated state for two weeks the response of healing is dramatically increase in a positive way.

Diabetic foot pathologiesInternal

Trauma

(calluses,

ingrown nails

and foot

deformities)

External

Trauma,

(from ill-

fitting shoes

In soles,burns and

foreign bodies),

Pathogenesis still hidden

• The concept of Many research

•People with high blood glucose levels have increased risks of

dehydration and dehydration

• increased risks of DM Complications

Predictable Causes of dehydration in

diabetics• 1 / Glycosuria , each glucose molecule

surrounded by 6 water molecules taken out of body with urine .

• 2/ Poor water intake• a\ A stressful event such as infection, or recent

surgery• b\Congestive Heart Failure ,heart attack ,stroke.• c\Impaired thirst sensation .• d\ Limited access to water (especially in patients

with dementia or who are bedbound or living lonely)

• e\ Older age.

Unpredictable Causes of dehydration in

diabetics • Dehydration Synthesis (Condensation) Reactions

• &• Hydrolysis Reactions

Just to remind pleasefor 72 kg human weight containing 40

liters • (2/3 of body water 25 liters is

Intracellular fluid )• (1/3 of body water) about 15

liters is Extracellular fluid,(1/5 of

extracellular fluid) averages

3 liters Plasma 

(4/5 of extracellular fluid) are 12

liters Interstitial fluid

Dehydration Synthesis (Condensation) Reactions & Hydrolysis Reactions

Hydrolysis Reactions

Dehydration Synthesis

Dehydration Synthesis (Condensation) Reactions & Hydrolysis Reactions

Hydrolysis Reactions

Dehydration SynthesisGlycog

en polyme

r

Glucose monomer

ATP

H2O

insulin

Hidden Pathogenesis of DFU

• Disturbances in• Hemorheological picture

of blood• &

• Copeptin level ,a surrogate marker for

vasopressin (AVP)

Viscosity A measurement of the thickness

and stickiness of an individual's blood.

Dr. Ajay Kumar• Abnormal high blood viscosity in diabetes

mellitus• Conclusion• The causes of rise of whole blood viscosity are• 1- Rise in haematocrit: due to increase in capillary

permeability in Diabetes Mellitus. • 2- Decrease in RBC deformability: it is found that the

elevated glucose level causes stiffness in red cell membrane in Diabetes Mellitus.

• 3- Increase in Red Cell Aggregation.• 4- Plasma Fibrinogen Level Rises which is one of the causes

for rise in plasma viscosity.

• Red blood cells at rest have an average diameter• of 7.8 micro meter and must deform markedly to

pass• the smallest capillaries of the microcirculation• (3–7 micro meter ).

Diabetic Peripheral Neuropathy

Rheological Picture in pt.T1D &T2D

• Maya Mantskava Microcirculation Research Center Georgia

• . Therefore we conclude that blood rheological disorders are similar in both types of diabetes mellitus.

• The disturbed blood fluidity related to the increased RBC aggregability in the microcirculation promotes, in particular, the development of the gangrene in both types of diabetes mellitus.

B Viscosit

y B

Glucose

Several studies show

• Water intake inversely independently associated with

Hyperglycemia

• Water intake affect (Copeptin) vasopressin

secretion•

• Copeptin directly associated with increase Risk of DM

• PLASMA COPEPTIN IS ASSOCIATED WITH INSULIN

RESISTANCE IN A SWISS POPULATION-BASED STUDY.

• Canivell, S.; Ponte, B.; Pruijm, M.; Ackermann, D.; Guessous, I.; Ehret, G.; Paccaud, F.; Pechere-Bertschi, A.; Mohaupt, M.; Vogt, B.; Burnier, M.; Devuyst, O.; Martin, P.Y.; Bochud, M.

• Conclusions: • Insulin resistance was associated

with higher copeptin levels.

• Copeptin, a surrogate marker for vasopressin, is associated with

chronic kidney disease progression in patients with diabetes mellitus

• W.E. Boertien1, I.J. Riphagen1, I. Drion2, A. Alkhalaf2, S.J.L. Bakker1,• K.H. Groenier3, J. Struck4, H.J.G. Bilo2,5, N. Kleefstra2,5, R.T. Gansevoort1;• 1Nephrology, UMCG, Groningen, Netherlands, 2Diabetes Centre, Isala• Clinics, Zwolle, Netherlands, 3General practice, UMCG, Groningen,• Netherlands, 4BRAHMS GmbH, Thermo Fisher Scientific, Hennigsdorf,• Germany, 5Internal Medicine, UMCG, Groningen, Netherlands.

• . Conclusion: • It would be interesting to study the effect of

lowering vasopressin levels (e.g. by drinking more water) on the progression of chronic kidney disease in diabetic patients

• Jessica M Sontrop, Nephrology,• Department of Medicine,• London Health Sciences• Centre, London, Ontario,

• Change in water intake and change in plasma copeptin,

• At the end of 6 weeks we conclude that ,the increase in water intake was associated with a significant decrease in the concentration of plasma copeptin.

VISCOSITY

Copeptin

MICROANGIOPATHYDFUCVD

RENAL APRETINOPATHY

DEHYDRATION

NormalVISCOSITY

LESSMICROANGIOPATHY

DFUCVD

RENAL APRETINOPATHY

HYDRATION

Copeptin

Our study • 11 pt with Diabetic foot submitted

for same guide lines of management (NICE clinical guideline 119 )

•

• NICE =National Institute for• Health and Clinical Excellence

National Institute for Health and Clinical

Excellence

Admission &

EvaluationMultidisciplinary Foot care

Team Management

pt.

EDUCATE Pt

The only difference is the additional

item increase of water intake to 1.5-2 liters per

day.

case no.1G3s1

9 1 2016 20 1 2016 14 3 2016

AFTER 11 DAYAFTER 9 Week

• case no.2• G3s4

AFTER 12 Week

• case no.3• G2s2

AFTER 6 Week

• case no.4• G2sb

AFTER 6 Week

• case no.5• G2s1

AFTER 6 Week

• case no.6• G3s4

• case no.6• G3s4

• case no.6• G3sd

• case no.6• G3s4 •

12 weeks after StSg

• case no.7• G2sb

After 16 week

• case no.9• G1s2

• case no.9• G1sb •

AFTER 2 Week

• case no.10• G3s4

After 16 week

• case no.11• G1s2

After 2 week