A simple wound on the foot of a diabetic patient can lead to multiple complications
BY ASSOC PROF
DR TAN TOH LEONG
AND DR EVELYN
CHAU YI WEN
Ever walked into a hospital treatment room filled with a foul-smelling stench? Or do you know someone who has amputated his foot due to poor diabetic control?
This is one of the most known complications of uncontrolled diabetes mellitus. Uncontrolled diabetes mellitus can lead to poor wound healing in the foot, causing an unpleasant smell.
Diabetic patients have a 15 per cent lifetime risk of having foot ulcers, and 25 per cent will undergo amputation due to unsalvageable wounds. Usually, ulcers are caused by poorly treated or neglected wounds.
Now, many may ask, how can a wound go unnoticed? Yes, it is possible for a chronic diabetic patient.
How is it so? Chronic diabetic patients may have a problem with their eyesight (retinopathy), altered sensation (neuropathy) and even kidney problems (nephropathy), not to mention the increased risk of heart attack, stroke, sexual dysfunction and so on.
Diabetes and infections
Diabetic patients may not notice a wound on their foot because of their poor eyesight and poor sensation over the foot. Treating a seemingly simple wound on a diabetic patient is not simple at all.
Diabetes and infections are bad partners. An infected site is usually warm, tender, red in colour, swollen and may even have pus draining from the site.
These reactions result from our body’s natural defence mechanism to restrict the spread of infection. While a diabetic patient is known to have reduced organ functional capacity and impaired immune mechanism, a high glucose level in the body reduces the killing capacity of our white cells, prolongs the inflammation process, causing further tissue damage.
When the body’s immune response fails to control the local infection on the wound, there is a risk that the infection can spread throughout the body, affecting other systems. This will then escalate, resulting in sepsis or even septic shock.
Why must we know about sepsis?
Sepsis is associated with high resource utilisation and caused high mortality, contributing to 11 million annual global deaths as of 2019. Sepsis is also one of the causes of death for Covid-19 infections.
So, what is sepsis? Sepsis is a life-threatening organ dysfunction caused by the dysregulated host response to infection. Different from a simple local infection, sepsis involves multiorgan dysfunction like the heart, kidneys, lungs, liver, and nervous system.
As a result, a simple wound on the foot can lead to kidney failure, needing dialysis or lung failure leading to intubation and even death. Often, diabetes is a major risk factor for the rapid escalation of the disease and contributes to higher mortality risk.
What can be done?
Once a patient is in sepsis, early treatment must be given before more organs fail. Early fluid resuscitation and antibiotics must be given. The source of infection, i.e., the diabetic foot ulcer, must be debrided.
Should the condition of the foot become too severe, amputation might be needed. Overall, diabetic patients have up to 40 times higher risk of getting lower extremity amputation than non-diabetics. Other than that, a corticosteroid may be needed to control the infection.
The endpoint is that the sugar level must be controlled. An annual eye check, frequent foot care, repeated diabetic education and control of other comorbidities must be ensured. — The Health
What is the targeted sugar control?
Fasting or before a meal: 4.4 – 7.0 mmol/L
90 minutes after meal: 4.4 – 8.5mmol/L
HbA1C level: 7.0 per cent
Tips for sugar control
- A balanced diet, low in saturated fat, low in sodium, high in fruits, vegetables, wholegrain, cereals, and legumes
- Weight management; for overweight and obese (BMI>23.0kg/m2) for weight loss at least 5-10 per cent
- Physical activity at least three times/week; and with no more than 48-72 hours without physical activity
- Tobacco cessation
- Glucose lowering drugs
Assoc Prof Dr Tan Toh Leong is Consultant Emergency Physician, Faculty of Medicine, Universiti Kebangsaan Malaysia (UKM) and Founder and President of Malaysian Sepsis Alliance (MySepsis), while Dr Evelyn Chau Yi Wen is a Trainee Lecturer in the Emergency Department, Faculty of Medicine, UKM and a Committee Member of MySepsis.