A clinician's guide to the treatment of foot burns occurring in diabetic patients

Chinese clinical practice guidelines for perioperative blood glucose management

With the increased incidence of diabetes, the number of diabetic patients who require surgical treatment is also increasing. Unfortunately, practices in this area lack standardisation. The purpose of this multidisciplinary, evidence-based guidelines for perioperative blood glucose management is to provide a comprehensive set of recommendations for clinicians treating diabetes with different types of surgery. The intended audience comprises Chinese endocrinologists, surgeons, anaesthetists, clinical pharmacists, nurses and professionals involved in perioperative blood glucose management. The guidelines were formulated as follows. First, a multidisciplinary expert group was established to identify and formulate key research questions on topics of priority according to the Population, Intervention, Comparator and Outcomes (PICO) process. We conducted a meta-analysis of available studies using Review Manager version 5.3, as appropriate. We pooled crude estimates as odds ratios with 95% confidence intervals using a random-effects model, and used the Grading of Recommendations Assessment, Development, and Evaluation methods to assess the quality of the retrieved evidence. Finally, 32 recommendations were gathered that covered 11 fields-management and coordination, endocrinologists' consultation, diabetes diagnosis, surgery timing and anaesthesia method, blood glucose target values and monitoring frequency, hypoglycaemia treatment, oral administration of blood glucose lowering drugs, use of insulin, enteral and parenteral nutritional, postoperative treatment and medication and education and training. Twenty-five systematic reviews and meta-analyses were conducted for these guidelines to address the PICO questions. These guidelines are intended to improve perioperative blood glucose management and help doctors in specifying medical diagnosis and treatment, and will be implemented / disseminated extensively in China.

Foot burns: A comparative analysis of diabetic and non-diabetic patients

INTRODUCTION

Foot burns represent a small part of the body with many challenges. The impact of diabetes on clinical outcomes adds further issues in management that clinicians must consider in their management. These factors have serious implications on morbidity and long term sequelae. Our aim is to analyse epidemiological trends of foot burns and examine the differences between diabetic and non-diabetics at Concord hospital from 2014 to 2019.

METHODS

A retrospective audit from 2014-19 at Concord General Repatriation Hospital Burns Unit summarised patient demographics, burn injury, diabetic status, operations and length of stay. All foot burn injuries from 2014-19 of all ages and gender that attended Concord burns hospital were included in this study.

RESULTS

We treated 797 patients who presented with foot burns, of which 16.2% were diabetic. The average age was higher in diabetics (60.72 years) than non-diabetics (39.72 years) and more males suffered burns compared to females in both groups (p < 0.001). There was a larger portion of elderly patients (greater than 65 years old, 15.1% of total) who sustained foot burns in the diabetic group compared to the non-diabetic group (p < 0.001). The most affected season was summer (27.0%), but diabetic patients were 1.7 times more likely to sustain injury in winter than non-diabetics. Diabetics were 3.8 times more likely to have contact burns compared to non-diabetic patients (p < 0.001). In a multivariable linear regression analysis, factors that contributed to increased length of stay included elderly status, place of event, diabetic status, number of operations, ICU admission, wound infection, amputation, and admission [F (16, 757 = 41.149, p < 0.001, R² = 0.465].

CONCLUSIONS

With the increase of diabetes, our multidisciplinary approach to diabetic foot care should include nursing, medical and surgical disciplines to identify patients at risk. The data highlights that a focus on prevention and education for diabetes is central to optimize glycaemic control and burn management, whilst providing a multidisciplinary network on discharge.

Evaluation of spatio-temporal gait parameters and gait symmetry in diabetic polyneuropathic patients with burn injury: A pilot study

PURPOSE

The purpose of this study was to investigate the effects of burn injury on spatio-temporal gait parameters and gait symmetry in individuals with diabetic polyneuropathy (DPN)-related lower extremity burn injury.

METHODS

Demographic information and the physical examinations of the lower extremities of 14 patients with unilateral lower extremity burn injury due to DPN (DPN_B) and 14 uninjured patients with DPN (DPN₀) were recorded. The GAITRite computerized gait analysis system was used to evaluate the spatio-temporal parameters of gait. Symmetry Index (SI) was calculated to determine gait symmetry. The Mann Whitney U test was used to determine the demographical and clinical differences between the groups, the Wilcoxon's test was used to compare both sides of all the participants for all gait parameters and linear regression analysis was used to find the variables that affect gait parameters.

RESULTS

The groups were similar in terms of their demographic information except for age. Compared with the DPN₀ group, DPN_B group had increased extent of area with sensory loss and severity of DPN, decreased ankle joint range of motions and intrinsic foot muscles strength and they displayed lower gait speed, step length, stride length and swing percentage but their double support and stance percentage were increased.

CONCLUSION

This study results have shown that, spatio-temporal gait parameters of DPN_B patients are different. These differences in spatiotemporal parameters are found on both sides, probably owing to the symmetric and bilateral sensory loss is superior to unilateral burn injury due to symmetrical and bilateral sensory loss. Gait analysis should be considered in order to reveal the changes in gait parameters and to improve appropriate healing process of patients with DPN-related lower extremity burn injury.

Lower Extremity Burns, Complications, and Outcome

We have encountered many burn cases with lower extremity burn with adverse outcome. The study was a retrospective cohort study in 2 years, mean (SD) of follow up was 12(7) months. All demographic data, cause burn, time, total burn surface area (TBSA), presence lower extremity burn and its burn surface area (BSA), foot burn, delay in treatment, smoking, infection, morbidity, co-morbid diseases, length of stay (LOS), amputation, mortality, and outcome were gathered from patients’ files. Statistical analysis was done with SPSS 21software. We had 14,215 burn patients, of them 995 were admitted according to criteria of ABA. Six hundred and ten (61.3%) were male and 358 (37%) female. Male to female ratio was 1.58:1. The mean age ± SD was 33.64 ±23.45. Mean (SD) of lower extremity BSA was 12.09 ± 9.18%. The patients who had 10 to 19% burn, had 3 times more risk of mortality than patients with 0 to 9% burn (P &lt; .018). And those with 20 to 29% burn had 35 times more risk of mortality comparing to patients with 0 to 9% burn. The difference was significant too. (P &lt; .000). Delay in treatment, presence of co-morbid diseases and diabetes would not do any increase in mortality. The sex, weight, cause of burn, diabetes, and delay in treatment have not any influence on the death risk. But age and lower extremity BSA have influence on the risk of death. According to statistical study: with every 1-year increase in age, death rate increased by 4% (P &lt; .0001). With every 1% increase in lower extremity BSA, death rate increase by 9% (P &lt; .0005) and with every 1 day increase in LOS, the death rate increase by 4%. Statistical study shows lower extremity burn, TBSA, age, and LOS have great influence on the outcome of these patients. Sex, weight, cause of burn, and delay in treatment have not affected the risk of mortality.

Update on hyperbaric oxygen therapy in burn treatment

Hyperbaric oxygen therapy (HBOT) has been shown to improve tissue hypoxia, neovascularization and ischemia reperfusion injury and reduce pathologic inflammation in various clinical settings and was proposed to be a game changer in treatment of burns. Improved and faster wound healing as well as a reduction of morbidity and mortality after thermal and concomitant carbon monoxide poisoning are expected. In defiance of the observed benefits for burn wounds and carbon monoxide poisoning in animal models and few randomized controlled trials there is an ongoing controversy regarding its use, indications and cost effectiveness. Furthermore, the use of HBOT, its indications and the evidence behind its efficiency are still widely unknown to most physicians involved in the treatment of burn patients. Therefore, a review of the up to date evidence-based literature was performed with a focus on available data of HBOT in burn care, to elaborate its use in acute thermal injury and carbon monoxide intoxication. Although beneficial effects of HBOT seem very likely insufficient evidence to support or disprove the routine use of HBOT in the treatment of burn care was found. Although difficult to carry out because of the high interindividual variability of burns and chronic wounds, the need for larger high-quality prospective randomized double-blinded controlled multicenter trials are necessary to be able to evaluate useful applications, expense and cost-efficiency of HBOT for burn care.

Critical appraisal and systematic review of guidelines for perioperative diabetes management: 2011-2017

PURPOSE

To systematically evaluate the quality, consistency and the evidence support of guidelines for perioperative diabetes management.

METHODS

We retrieved guidelines through systematic search, critically evaluated their quality and compared the recommendations of included guidelines. Five aspects were compared: target level, management of hyper- and hypoglycaemia, frequency of monitoring, management of insulin, and management of oral anti-diabetic drugs (OADs).

RESULTS

Fourteen guidelines met our criteria, and 342 recommendations were extracted, the results of Appraisal of Guidelines for Research and Evaluation II (AGREE II) evaluation showed that none of the mean score in each domain was higher than 50%. On average, most guidelines had only one domain scored above 50%. Most recommendations (78.9%) did not specify their supporting evidence, 71 (20.8%) were formed using grading criteria, none cited systematic review or meta-analysis. Recommendations were inconsistent across different guidelines.

CONCLUSIONS

The existing guidelines about perioperative management of diabetes needs improvement in methodology, as well as the production of evidence with high quality. Evidence-based guidelines are required for the perioperative management of diabetes.