PICOT Question
In geriatric patients with diabetic foot ulcerations, does vacuum-assisted closure (VAC) improve recovery time in wound management than moist gauze dressing?
Setting/Context
Diabetic foot ulcers manifest as chronic wounds, inflammation, or sepsis localized to the lower limbs in elderly people with diabetic Mellitus (DM) (Schaper, Apelqvist & Bakker, 2012). The neuropathic ulcers constitute a major risk factor for infection from microbes. The problem results from peripheral polyneuropathy that affects blood supply leading to a lack of sensation. It is observed in older people living with type 2 diabetes that causes nervous degeneration leading to painless ulcerations in the foot. The sensory neuropathy coupled with impaired blood circulation makes the foot vulnerable to bruises that cause non-healing wounds. Footwear is the leading cause of the problem. The lack of sensation causes patients to wear tightly fitting shoes that increase the risk of developing bruises or ulcerations. If the wound is not treated properly, an infection could arise, which increases the likelihood of lower extremity amputation.
Description of the Problem
Diabetic foot ulcers (DFUs) develop due to “peripheral neuropathy and ischemia” attributed to the peripheral arterial disease (PAD) (Schaper, Apelqvist & Bakker, 2012, p. 869). In diabetic patients, neuropathy accounts for over 60% of the DFUs in elderly patients and is due to hyperglycemia-related metabolic dysfunction. Krug et al. (2012) note that the hyperglycemic condition leads to elevated sorbitol and fructose in the body, inhibiting the production of myoinositol that is necessary for normal neuron transmission. Peripheral neuropathy also results from reduced nicotinamide ADPs that detoxify reactive oxygen, leading to oxidative stress in the neurons that cause ischemia (Krug et al., 2012). The nerve cell dysfunction and vasoconstriction shows as diminished motor and sensory activity. Further, impaired functioning of the oil glands due to autonomic malfunction makes the skin dry and prone to tears. The dysfunctional innervations and muscular damage cause foot abnormalities characterized by painless lesions and ulcerations.
Impact of the Problem
The high morbidity of DFUs in elderly diabetic patients has had an impact on the clinical work environment. In diabetic foot centers, the primary role of providers is to identify patients with at-risk feet for management. In the diagnosis, the patient’s history of ulceration, PAD, or neuropathic complications is recorded to determine the risk of the disease (Krug et al., 2012). Furthermore, the assessment entails examining diabetic symptoms, such as neuropathy and vascular conditions, and capturing lifestyle factors, e.g., smoking, which increases the risk of neuropathy. The data are used to assess the risk of DFU.
Quality care requires regular visual inspection of the limbs for ulcerations. The nursing staff examines the toes for lesions or infections that might result from inappropriate footwear. The existence of callus is recorded, as it is indicative of DFU. Nursing care also encompasses noting the temperature variations between the lower limbs, which might indicate vascular disease. The development of ulcers increases the risk of DFU, which often result in amputations. However, patient outcomes can be improved through proper nursing care. Over 40 percent of lower limb amputations can be avoided through wound care interventions (Krug et al., 2012).
The Gravity of the Problem
The population of diabetic patients globally is estimated to reach 366 million adults by the year 2030 (Krug et al., 2012). Diabetics are at a greater risk of DFU than non-diabetics are. CIT states that diabetic patients are up to 25% more likely to suffer DFU complications than non-diabetics are. In the U.S., the incidence rate of diabetic foot ulcerations and infections is about 3% annually. The development of DFUs heightens the risk of having a wound on the affected limb. Improper care causes wound progression resulting in the surgical removal of part of the limb. Up to 85% of amputations in diabetics are attributed to DFUs (Schaper, Apelqvist & Bakker, 2012). However, wound care can prevent about 40% of the cases.
The Proposed Solution
Various treatments for DFUs exist, including moist dressing of the wound and VAC. In the latter technique, a negative sub-atmospheric pressure is applied via a pump to the wound to promote healing. Several studies, including RCTs and case series, provide evidence for the efficacy of this method over standard wound care. This paper proposed the VAC for the management of wounds in elderly diabetics with DFUs.
Rapid Appraisal
Article 1 describes foot ulcers among diabetics as the cause of chronic wounds that lead to amputation. However, it does not provide statistics to illustrate the severity of the problem. The article indicates that, in the U.S., the DFU incidence rate is approximately 3% annually. Its findings indicate that VAC, the proposed solution, is superior to a moist wound dressing in treating DFUs.
Article 2 explains that foot ulcers account for most of the hospitalizations of patients with DM. The statistical information provided indicates that DM patients have a 25% risk of suffering foot ulcerations with 85% of them ultimately undergoing amputation. The article does not give the incidence rate, morbidity, or mortality of DFU in the general population. The findings support the proposed solution, indicating that negative pressure wound therapies are safe and effective in DFU wound management.
Article 3 describes diabetic foot ulcer is a common complication of DM associated with a high death rate and disease burden. It indicates that diabetics are up to 40 times more likely to undergo non-traumatic lower limb amputation resulting from DFU complications than non-diabetics are. According to the article, 10% of patients with DM are affected by DFU. The article gives no direct evidence for the use of VAC, but it shows that alternatives to moist dressing could improve patient outcomes.
Article 4 describes a longitudinal cohort study to assess the efficacy of hyperbaric oxygen technique in treating DFUs. It explains that DFU is a severe complication caused by diabetes. However, no statistics are given to illustrate the prevalence, morbidity, or mortality of DFU in the population. The article establishes that HBO at 100% pressure has little effect on wound healing. The finding calls for an evaluation of the negative pressure wound therapies, such as the one proposed.
Article 5 indicates that up to a fifth of the adult population in the US are living with DM. It estimates that the likelihood of developing DFU for diabetics ranges between 10 and 25%. It further states that only 30% of DFUs heal under standard care; thus, the condition causes are significant morbidity in patients with DM. The study shows that cellular devices can improve patient outcomes; hence, useful alternatives to standard wound care. It supports the need for evidence-based interventions for DFU treatment.
In article 6, DFUs are described as a group of disabling complications associated with DM. The estimated prevalence of DFU ranges between 4 and 10% among diabetics. In contrast, the DFU incidence rate stands at about 25% with limb amputations accounting for the high morbidity in older patients. Patients with ischemic ulcers receiving standard care showed reduced outcomes, underscoring the need for alternative therapies, such as the VAC proposed in this paper.
Article 7 describes DFUs as a range of foot problems, such as ulcers and infections, common in patients with DM. The article states that DFU accounts for the high length of hospital stay by diabetics. However, it does not disclose the average prevalence, morbidity, or mortality rate of foot ulcers in the population. It establishes the significance of negative pressure therapies in wound management. Therefore, it supports the use of VAC in DFU treatment.
Article 8 attributes the development of chronic wounds to DFU. It identifies frequent hospitalization and high costs as the public health outcomes of DFU. However, no statistics are provided to back up this claim. Also, no examples provided to illustrate the incidence rate, mortality, and morbidity of the disease. The article establishes that negative pressure wound therapy enhances granulation, which promotes healing. This finding supports the proposed solution.
Article 9 describes foot ulcers as a major health problem for diabetics that accounts for high medical costs. It estimates the prevalence of DFU to be 25% among patients with DM. It does not provide examples of the morbidity or mortality rates associated with DFU. The qualitative article identifies negative pressure wound therapy as a promising intervention for wound management. Thus, it supports the use of the VAC technique in DFU treatment.
In article 10, DFUs are described as recurrent foot lesions in diabetics that increase hospitalization rates. The article attributes significant morbidity in diabetic patients is attributed to persistent foot wounds. There is no statistical data are given to indicate the severity of the issue or mortality rates. The finding that negative pressure wound therapy increases the levels of collagen regenerating factors supports the proposed solution.
Article 11 states that chronic wounds are a common complication of DFU. The article gives neither the statistics nor the morbidity and mortality rates of DFU. The negative pressure therapy results in improved outcomes for patients with chronic wounds. This finding is consistent with the proposal for the use of VAC in diabetic wound management.
Article 12 describes a study examining the role of negative pressure wound therapy (NPWT) in the healing of foot ulcers. No statistical information is given to illustrate the gravity of DFU. It establishes that gauze-based NPWT is associated with minimal pain compared to moist dressing. This finding supports the use of VAC to treat wounds in patients with DFUs.
Article 13 identifies foot ulcerations as the common symptoms of diabetes mellitus. It indicates that the prevalence of DFU in America ranges between 4 and 12%. Besides, the incidence rate of this condition is about 4.1% in the US. In this study, diabetic peripheral neuropathy was associated with increased foot lesions.
Article 14 explains that the diabetic foot is the persistent wounds or lesions common in elderly diabetics. It does not give statistical information to illustrate the severity of DFU. Also, no examples of morbidity, incidence rate, or mortality are given. It’s finding that NPWT can be used to treat the diabetic foot supports the proposed solution.
Article 15 distinguishes DFU as a serious health problem for diabetics. The article does not state statistics to explain the gravity of the problem or its incidence rate. It establishes that the efficacy of negative pressure wound therapy in wound treatment is not significant. Therefore, this finding does not support the proposed solution.
References
Dumville, J.C., Hinchliffe, R.J., Cullum, N., Game, F., Stubbs, N., Sweeting, M. & Peinemann, F. (2013). Negative Pressure Wound Therapy for Treating Foot Wounds in People with Diabetes Mellitus. Cochrane Database Systematic Reviews, 17(10), 103-112.
Fernando, M.E., Crowther, R.G., Pappas, E., Lazzarini, P.A. & Cunningham, M. (2014). Plantar Pressure in Diabetic Peripheral Neuropathy Patients with Active Foot Ulceration, Previous Ulceration and No History of Ulceration: A Meta-Analysis of Observational Studies. PLoS ONE, 9(6), 99-105.
Fraccalvieri, M., Ruka, E., Bocchiotti, M., Zingarelli, E. & Bruschi, S. (2012). Patients’ Pain Feedback Using Negative Pressure Wound Therapy with Foam and Gauze. International Wound Journal, 8(5), 492-499.
Fraccalvieri, M., Zingarelli, E., Ruka, E., Antoniotti, C., Coda, R., Sarno, A.,…Bruchi, S. (2011). Negative Pressure Wound Therapy Using Gauze and Form: Histological, Immunohistochemical, and Ultrasonography Morphological Analysis of the Granulation Tissue and Scar Tissue. Preliminary Report of a Clinical Study. International Wound Journal, 8(4), 355-364.
Jan W, Shah H, Khan M, Fayaz M, Ullah N. (2012). Comparison of Conventional Pyodine Dressing with Honey Dressing for the Treatment of Diabetic Foot Ulcers. Journal of Postgraduate Medicine Institute, 26(4), 402–407.
Krug, E., Berg, L., Lee, C., Hudson, D., Birke-Sorensen, H. & Depoorter, M. (2012). Evidence-based Recommendations for the Use of Negative Pressure Wound Therapy in Traumatic Wounds and Reconstructive Surgery: Steps towards an International Consensus. Injury, 42(1), 1-12.
Lev-Tov, H., Li, C.S., Dahle, S. & Isseroff, R.R. (2013). Cellular versus Acellular Matrix Devices in Treatment of Diabetic Foot Ulcers: Study Protocol for a Comparative Efficacy Randomized Controlled Trial. Trials, 14(8), 141-149.
Lone, A., Zaroo, M., Laway, B., Pala, N., Bashir, S. & Rasool, A. (2014). Vacuum-assisted Closure versus Conventional Dressings in the Management of Diabetic Foot Ulcers: a Prospective Case–control Study. Diabetic Foot Ankle, 5(10), 34-41.
Margolis, D.J., Gupta, J., Hoffstad, O., Papdopoulos, M., Glick, H.A.,Thom, S.R. & Mitra, N. (2013). Lack of Effectiveness of Hyperbaric Oxygen Therapy for the Treatment of Diabetic Foot Ulcer and the Prevention of Amputation: a Cohort Study. Diabetes Care, 36(7), 1961–1966.
Nain, P., Uppal, S., Garg, R., Bajaj, K. & Garg, S. (2011). Role of Negative Pressure Wound Therapy in Healing of Diabetic Foot Ulcers. Journal of Surgical Technique and Case Report, 3(1), 17-22.
Ravari, H., Modaghegh, M., Kazemzadeh, G., Johari, H., Vatanchi, A., Sangaki, A. & Shahrodi, M. (2013). Comparision of Vacuum-Asisted Closure and Moist Wound Dressing in the Treatment of Diabetic Foot Ulcers. Journal of Cutaneous and Aesthetic Surgery, 6(1), 17-20.
Schaper, N.C., Apelqvist, J. & Bakker, K. (2012). Reducing Lower Leg Amputations in Diabetes: a Challenge for Patients, Healthcare Providers and the Healthcare System. Diabetologia, 55, 869-72.
Seo, S., Yeo, J., Kim, I., Kim, J., Cho, T. & Lee, D. (2013). Negative-pressure Wound Therapy Induces Endothelial Progenitor Cell Mobilization in Diabetic Patients with Foot Infection or Skin Defects. Experimental and Molecular Medicine, 45(11), 62-71.
Sumpio, B.E. (2012). Contemporary Evaluation and Management of the Diabetic Foot. Scientifica, 9(1), 1-17.
Yang, S.L., Han, R., Liu, Y., Hu, L.Y., Li, X.L. & Zhu, L. (2014). Negative Pressure Wound Therapy is Associated with Up-regulation of bFGF and ERK1/2 in Human Diabetic Foot Wounds. Wound Repair and Regeneration, 22(4), 584-544.
Yarwood-Ross, L. & Dignon, A.M. (2012). NPWT and Moist Wound Dressings in the Treatment of the Diabetic Foot. British Journal of Nursing, 12(21), 26-32.
Yotsu, R., Pham, M., Oe, M., Nagase, T. & Sanada, H. (2014). Comparison of Characteristics and Healing Course of Diabetic Foot Ulcers by Etiological Classification: Neuropathic, Ischemic, and Neuro-ischemic Type. Journal of Diabetes and Its Complications, 28(4), 528-535.