AORN Journal
Volume 87, Issue 5 , Pages 935-950, May 2008

Surgical Management of Diabetic Foot Infections and Amputations

  • Thomas Zgonis, DPM

      Affiliations

    • Thomas Zgonis, DPM, is an assistant professor in the Department of Orthopaedics, Podiatry Division, and the director of the Reconstructive Foot and Ankle Fellowship at the University of Texas Health Science Center at San Antonio. Dr Zgonis has no declared affiliation that could be perceived as a potential conflict of interest in publishing this article.
    • ,
  • John J. Stapleton, DPM

      Affiliations

    • John J. Stapleton, DPM, is an associate of foot and ankle surgery at VSAS Orthopaedics, Allentown, PA, and a clinical assistant professor of surgery at Penn State College of Medicine, Hershey, PA. Dr Stapleton has no declared affiliation that could be perceived as a potential conflict of interest in publishing this article.
    • ,
  • Valerie A. Girard-Powell, RN

      Affiliations

    • Valerie A. Girard-Powell, RN, is a perioperative nurse at the University Hospital, San Antonio, TX. Ms Girard-Powell has no declared affiliation that could be perceived as a potential conflict of interest in publishing this article.
    • ,
  • Ryan T. Hagino, MD

      Affiliations

    • Ryan T. Hagino, MD, is an associate professor in the Division of Vascular Surgery at the University of Texas Health Science Center at San Antonio. Dr Hagino has no declared affiliation that could be perceived as a potential conflict of interest in publishing this article.

Article Outline

ABSTRACT 

THE INCIDENCE OF DIABETES with severe foot infections (eg, necrotizing fasciitis, gas gangrene, ascending cellulitis, infection with systemic toxicity or metabolic instability) has risen significantly during the past decade.

FOOT INFECTIONS are a major cause of hospitalization and subsequent lower extremity amputation among patients with diabetes mellitus who have a history of a preexisting ulceration.

SURGICAL MANAGEMENT often is required to address severe diabetic foot infections because they can be limb- or life-threatening. Critical limb ischemia, neuropathy, and an immunocompromised host, which often are associated with diabetic foot infections, complicate treatment and are associated with a poorer prognosis. AORN J 87 (May 2008) 935–946. © AORN, Inc, 2008.

 

The incidence of diabetes with foot complications has risen significantly during the past decade.1, 2, 3, 4, 5, 6 Severe diabetic foot infections include, but are not limited to, necrotizing fasciitis, gas gangrene, ascending cellulitis, compartment syndrome, and infection with systemic toxicity or metabolic instability. A severe diabetic foot infection has approximately a 25% risk of ultimately requiring a major lower extremity amputation.1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13 For this reason, surgery should be coordinated among an established multidisciplinary team whose members are knowledgeable in diabetic foot care.14, 15, 16 The timing of surgery and the strategies employed should be understood and agreed upon by all team members.

The first step in the overall strategy for surgically managing a diabetic foot infection is infection control through adequate surgical debridement and proper antibiotic selection. The second step consists of a comprehensive vascular assessment and timed intervention when necessary. The final step includes soft-tissue coverage through adjunctive wound therapy modalities, plastic surgery techniques, or pedal amputations. This coordinated surgical approach combined with comprehensive medical management of the patient is vital for overcoming the morbidity and mortality associated with a diabetic foot infection.17 This article presents a rational approach for reducing the morbidity, mortality, psychological distress, and lengthy hospitalizations associated with the management of patients with complicated diabetic foot infections.

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Initial Patient Evaluation 

Communication and collaboration between the medical and surgical disciplines of the diabetic foot-care team is necessary to determine whether the patient requires immediate or delayed surgical intervention. For many patients, a diabetic foot infection may be the first indication that the patient has diabetes mellitus. These patients initially may experience denial when presented with the prognosis of their infection or the recommendation that amputation is required to further prevent the spread of the infection. This may unnecessarily delay surgical treatment. Family support in conjunction with a multidisciplinary team approach addressing the devastating complications associated with diabetes mellitus are necessary throughout the patient's treatment to help the patient accept the diagnosis and remain compliant with the treatment care plan.

The clinician performs a thorough history and physical examination with an emphasis on evaluating preexisting conditions, such as

•congestive heart failure,

•coronary artery disease,

•morbid obesity,

•peripheral neuropathy,

•peripheral vascular disease, and

•renal insufficiency.

In addition, the clinician carefully evaluates clinical and laboratory findings to determine risk stratification and the timing of surgery. Most importantly, the team must address, in a timely fashion, the severity of the patient's infection, particularly in the presence of systemic toxicity or metabolic instability. Categorizing the severity of the infection is difficult because more than 50% of patients with limb-threatening infections do not mount a sufficient immune response to manifest systemic signs or symptoms.18 For this reason, an understanding between the surgeon and the medical team is paramount in determining the patient's medical stability as well as defining the risk that the infection poses to the patient and his or her lower extremity.

Significant metabolic and hemodynamic instability may occur in patients with severe diabetic foot infections. This may necessitate administration of IV fluids with electrolytes and IV insulin to correct for hyperglycemia, hyperosmolality, azotemia, and acidosis.2 Chronic anemia can compound blood loss intraoperatively, and the patient may need blood transfusions before and during surgery. Furthermore, team members should take clinical measures to protect the patient from experiencing a cardiovascular event.

A critically ill patient with multiple comorbidities who requires urgent or emergent surgery usually is transferred to the OR after he or she has been stabilized.2, 18 Surgery should not be delayed for more than 48 hours after presentation to the health care facility, however, because conditions such as gas gangrene and necrotizing fasciitis mandate emergent surgical intervention (Figure 1).2, 18, 19, 20, 21 A delay in emergent surgery is associated with a high rate of patient morbidity and mortality. Necrotizing fasciitis has been associated with a mortality rate of 24% to 33%.20 Often, immediate medical optimization is not feasible until surgery is performed and the anesthesia care provider has managed the high-risk patient with diabetes mellitus and a limb-threatening infection. For this reason, the anesthesia care provider must be informed of the patient's emergent condition and the necessity for surgical intervention so that a plan of care can be developed for the type of anesthesia required and can be implemented in a timely fashion to avoid any further delay of surgical intervention.

Appropriate antibiotic selection combined with early surgical intervention is imperative in controlling the extent of the infection and stabilizing the patient. An infectious disease specialist who can determine optimal antibiotic therapy also is an essential team member. Determining the initial antibiotic therapy required is empirical and based on the patient's history, clinical appearance, and antibiotic susceptibility results to anticipated organisms at the particular hospital. For severe diabetic foot infections, initial antibiotic therapy may commence with parenteral, broad-spectrum antibiotics that have activity against gram-positive and gram-negative cocci and anaerobic organisms.13, 22, 23, 24 In addition, agents with activity against methicillin-resistant Staphylococcus aureus(MRSA) may be considered for patients at risk of acquiring an MRSA infection, given its association with poor clinical outcomes.25, 26

Definitive antibiotic therapy is based on culture and sensitivity results from deep intraoperative specimen collection along with the patient's clinical response to the antibiotic therapy. Selection, route of administration, and dosage of antibiotics are confirmed with the infectious disease team to ensure the safest, easiest to administer, and most effective antibiotic regimen.

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Vascular Assessment 

A thorough vascular examination is needed to determine if arterial insufficiency and limb ischemia may be complicating the infection. The clinician should assess the patient for limb ischemia, which is demonstrated by

•decreased or absent pedal pulses,

•necrosis, or

•gangrene.

The clinician should closely evaluate the patient and document the severity of the infection and the risks that threaten limb survival. If the diabetic patient's foot is dysvascular, the severity of the infection and subsequent rate for major limb amputation increases.

Despite the significance of revascularization for limb survival when arterial insufficiency is present, initial emergent surgical intervention to eradicate infection may not be delayed just to further evaluate the patient's vascular status.12 Emergent diabetic foot surgery in the presence of a severe infection is of primary importance. A vascular surgery consult should be initiated immediately when critical limb ischemia is present or at the time of the initial emergent surgical debridement.12, 27, 28

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Wound Assessment 

Knowledge of the diabetic foot and clinical suspicion is vital to help clinicians avoid unnecessarily delaying surgical intervention. The extent of soft-tissue and bone involvement must be determined to decide the level of amputation required or the feasibility of diabetic limb salvage. Physical examination of the entire lower extremity, not simply the foot, is essential in determining the proximal extent of the infection.

Patients with diabetic foot infections almost always have a history of preexisting neuropathic ulcerations.29 Diabetic foot ulcers often are masked by an overlying callous or are located within the interdigital web spaces. For this reason, the clinician may sharply debride any hyperkeratotic tissue to evaluate for an underlying foot ulcer in a patient with diabetes mellitus who has dense peripheral neuropathy. The clinician should inspect interdigital web spaces as possible portals for bacterial entry, particularly when an obvious foot ulcer is not present but the patient is exhibiting clinical signs of infection.

When the wound is identified, the clinician should closely examine it to determine its size, depth, and surrounding margins and then inspect the wound for exposed deep structures such as tendon, joint capsule, or bone. If the patient complains of pain on palpation in the presence of neuropathy, the clinician should consider abscess formation and deep underlying infection.30 The clinician then should obtain appropriate wound and blood culture specimens in a sterile manner to determine the causative organism and to further evaluate the extent of the infection when bacteremia and septicemia are suspected.

The clinician should obtain x-rays to determine the absence or presence of osteomyelitis, gas in the soft tissues, and foreign bodies. If gas is seen or clinically suspected, x-rays should include the next proximal joint to ensure that the infection has not migrated proximally and to determine the level of emergent amputation to reduce the chance of morbidity and mortality.

The clinician may order additional imaging and laboratory studies to further confirm the diagnosis and treatment plan. The clinician initially orders a complete blood count with differential, sedimentation rate, and C-reactive protein. Computed tomography (CT) scans with contrast or magnetic resonance imaging can assist in the diagnosis of deep abscess that is not clinically apparent. The clinician should use caution when waiting for further imaging results to confirm the diagnosis, which may unnecessarily delay urgent surgery.

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OR Preparation 

The circulating nurse and scrub person prepare the OR for the procedure by gathering required instruments, supplies, and equipment, including

•a basic orthopedic instrumentation tray;

•a pneumatic reciprocating sagittal saw and appropriate blades with battery or power source;

•a pulse lavage or debridement irrigation system, depending on the severity of the diabetic foot infection and the surgeon's preference;

•culture tubes, supplies, and paperwork;

•a minimum of one 3 L bag of normal saline irrigation; and

•hemostatic agents as requested by the surgeon.

The circulating nurse ensures that a tourniquet and appropriately sized cuffs are available at the surgeon's request. If the patient has been on a course of antibiotics before surgery, the circulating nurse ensures that the next scheduled dose is available for administration after intraoperative soft-tissue and bone cultures have been obtained or when it is requested by the surgeon. The circulating nurse also ensures the availability of a glucometer and is prepared to perform multiple blood sugar tests intraoperatively; the nurse provides insulin to the anesthesia care provider as requested.

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Preoperative Area 

When the patient arrives in the preoperative area, the preoperative nurse helps the patient change into a surgical gown; starts an IV; organizes the medical record; and interviews the patient, confirming that the patient is aware of his or her condition and the proposed procedures. To avoid misconceptions, all members of the team must relay consistent information to the patient and his or her family members regarding the patient's condition and proposed procedures. The preoperative nurse confirms the proposed procedure with the patient, the patient's medical record and informed consent form, and the surgery schedule. If an amputation is to be performed, the nurse ensures that this is clearly stated on the consent form along with the level of amputation.

At times, amputations may need to be performed more proximally than was initially anticipated because of the extent of the infection identified intraoperatively. The consent form, therefore, always should include details regarding the possibility of a more proximal amputation in the presence of a diabetic limb- or life-threatening infection. This prepares the patient preoperatively and lessens further psychosocial distress postoperatively.

The preoperative nurse obtains the patient's history and performs a physical examination, focusing on identifying a systemic response to the infection (eg, presence of fever, rigors, nausea, vomiting, hypotension, unexplained hyperglycemia, tachycardia). The preoperative nurse continues close observation and documentation of any changes in the patient's systemic response to the infection and relays any changes from the initial history and physical examination to the medical and surgical team managing the patient.

The nurse reviews all test results (eg, serum chemistry analyses, hematological testing) as well as the time they were obtained to determine the current metabolic state and stability of the patient. The preoperative nurse reports the results of abnormal laboratory studies to the other team members. The nurse ensures that appropriate blood typing and cross matching has been completed and that two or more units of packed red blood cells are available for later use if needed. In addition, the nurse confirms and documents the patient's NPO status, identifying when the patient last had something to eat or drink.

The surgeon arrives in the preoperative area and answers any questions that the patient and his or her family members may have. While completing the informed consent and surgical site marking processes, the surgeon and patient cooperatively identify the correct lower extremity, and the surgeon and patient both initial the correct extremity before the patient is transferred to the OR.

The circulating nurse goes to the preoperative area to meet and assess the patient. After reviewing the medical record, the nurse verifies that the consent is complete and that the surgical extremity has been initialed by the patient and surgeon. The nurse ensures that the patient is able to verbalize the proposed procedures and that it is consistent with what is on the surgical consent form and surgery schedule. After assessing the patient and answering any questions that the patient and family members may have, the nurse prepares a nursing care plan specific to this patient (Table 1).

Table 1. Nursing Care Plan for Patients With Diabetes Undergoing Surgery
DiagnosisNursing interventionsInterim outcome criteriaOutcome statement
Risk for anxiety related to the stress of surgery and knowledge deficit of the diabetic disease process
•Determines knowledge level related to the diabetic disease process and need for surgical intervention, assesses readiness to learn, and identifies barriers to communication.

•Provides instruction (ie, verbal, written) for treatment options, surgical procedure, sequence of events, and discharge based on age and identified need.

•Ensures availability of a support group.

•Communicates patient concerns to the appropriate surgical team members.

•Evaluates response to instruction.

The patient verbalizes understanding of the procedure and expected outcomes before anesthesia induction and demonstrates decreased anxiety and increased ability to cope throughout the perioperative period.The patient demonstrates appropriate psychological response to the procedure and knowledge of potential side effects.
Risk for acute or chronic pain related to the surgical procedure and medical condition
•Assesses the patient's preoperative pain, previous experiences of pain, and cultural and value components related to pain and pain management.

•Identifies the patient's acceptable postoperative pain level.

•Provides pain management instruction and pain scale to assess pain control.

•Implements pain management guidelines by administering adequate quantities of pain medication and alternative pain management therapies.

•Evaluates the patient's response to pain management interventions.

The patient reports pain in a timely fashion and demonstrates adequate pain management throughout the perioperative period.The patient's clinical and nonverbal signs remain stable, indicating adequate pain control.
Increased potential for wound infection related to multiple sites for organism invasion secondary to the surgical procedure, presence of external fixation, and complications of impaired circulation and impaired sensation
•Assesses the patient preoperatively for susceptibility to infection (eg, presence of comorbidities, weight not within normal limits, deviations in laboratory values, alterations in skin integrity).

•Implements, monitors, and maintains aseptic technique throughout the peri operative period (eg, traffic control, wound dressings).

•Anticipates the need to culture the surgical wound and classifies the surgical wound.

•Administers prescribed prophylaxis (eg, antibiotic therapy) at appropriate times.

•Prepares separate instruments, back tables, and glove changes for different surgical sites to prevent cross contamination.

The patient's surgical wound remains free of signs of infection, the patient's blood glucose levels remain within the acceptable range, and the patient remains normothermic throughout the periopera tive period.The patient is free of signs and symptoms of infection.
•Reports signs and symptoms of wound infection (eg, elevation in body temperature with increased pulse and blood pressure, incisional redness or tenderness, purulent drainage, odor, abnormal laboratory results).

•Evaluates the patient's response to infection prevention and management interventions.

The patient is able to state adverse signs and symptoms that need to be reported immediately.

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Intraoperative Phase 

The circulating nurse and anesthesia care provider transport the patient to the OR on a stretcher and assist the patient in moving to the OR bed and into a supine position. The circulating nurse pads and secures all nonsurgical extremities and remains with the patient throughout induction of anesthesia. The anesthesia care provider induces anesthesia (eg, general, regional) or IV sedation and monitors the patient throughout the procedure. The surgeon administers a local anesthetic block using 0.5% bupivicaine plain.

The circulating nurse initiates a surgical time out to confirm the correct patient; surgery; surgical sites and laterality; and availability of all required instruments, equipment, and supplies before the procedure is started. If the patient presents with an open and infected draining wound, the circulating nurse isolates the infected wound by covering the site with an antiseptic-soaked sponge. The nurse then cleanses the extremity from the clean to dirty areas (ie, areas of high microbial counts within the surgical site are prepared last). The circulating nurse uses gentle preparation techniques because diabetic patients often have fragile skin.31 The scrub person and surgeon then drape the patient for surgery.

Surgery usually is performed without the use of a tourniquet. In certain circumstances, a tourniquet is required; if so, the tourniquet is released immediately after the surgical debridement to determine tissue viability and need of further surgical debridement.

A surgeon who operates on a patient's diabetic foot infection must have sound knowledge of foot and lower extremity anatomy because meticulous surgical debridement is necessary to prevent further postoperative complications or proximal amputations.32 The surgeon begins by thoroughly exploring the wound (Figure 2) and removing all necrotic, fibrotic, and infected tissue (Figure 3). He or she opens sinus tracts to identify the tissue planes and compartments of the foot that have been violated. The surgeon performs the “finger-test” technique intraoperatively to determine the extent of affected tissue planes. Deep fascial tissue should not be easily separated with a gentle forward pushing of the index finger along the anatomic tissue planes. A positive finding indicates rapidly disseminating infection and possible necrotizing fasciitis.20

After exploring the wound, the surgeon determines the portion of the foot that needs to be amputated or widely excised to adequately control the infection. This may include

•an open toe or ray (ie, toe and part of the metatarsal) resection;

•a transmetatarsal amputation; or

•a midfoot, rearfoot, or ankle disarticulation, if needed.

Making limited incisions to drain a wound should be avoided because infected tissue remains despite decompression of the infected area. The surgeon should excise all nonviable and infected soft tissue and bone, regardless of size and quantity, during the initial debridement to improve wound healing and chances of limb survival.33, 34, 35, 36 The surgeon excises exposed tendons to prevent further tracting of the infection. He or she then obtains a portion of the deep infected tissues or bone and sends the specimen to the microbiology and histopathology departments for reliable culture and sensitivity results.33, 34

After the surgeon is satisfied with the surgical debridement, he or she irrigates the patient's wound with copious quantities of saline, which reduces the wound's bacterial count. The surgeon may choose to use pulse lavage irrigation with 3 L of saline. Saline irrigation has been shown to significantly decrease aerobic and anaerobic bacterial counts compared with untreated controls.37 It is not known, however, whether adding antibiotics to the irrigation is beneficial in the management of severe diabetic foot infections, and this practice remains a surgeon's preference.

After wound irrigation is performed, the circulating nurse helps the scrubbed surgical team members change their outer pair of gloves; equipment is not reused from this point forward to reduce contamination. The surgeon and scrub person pack the open wound with a wet-to-dry dressing to provide a moist, wound-healing environment. Dressings usually are changed daily beginning 24 to 48 hours after the initial surgery. Serial surgical debridements also may be performed as necessary to further eradicate any remaining localized infection. Advanced healing modalities and dressings usually are initiated after the first dressing change and inspection of the surgical wound.

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Postoperative Phase 

After surgery for a diabetic foot infection, the patient is faced with additional challenges, multiple concerns, anxiety, and depression that should be addressed and efficiently managed immediately and long after surgery.38 Ultimately, the success of surgery throughout the postoperative course depends on the patient's healing capabilities, ability to cope psychologically, and ability to comply with the postoperative regimen.38

The postoperative phase consists of the care provided during hospitalization and preparation of the patient for additional surgery that might be required. The medical/surgical unit nurse assesses the patient's vital signs, laboratory studies, and clinical status on a daily basis. A multidisciplinary team approach continues throughout the postoperative period to ensure a successful outcome. The vascular surgeon determines the need for further vascular studies or vascular intervention. An infectious disease specialist determines the appropriate selection, route, and duration of antibiotic therapy. Wound care nurses perform necessary local wound care and adjunctive modalities after surgery. A foot and ankle specialist determines the need for serial debridements, level of amputation, and definitive soft-tissue closure. Although medical management of a patient with diabetes mellitus who has a foot infection is patient-specific, includes various specialties, and is dependent on the patient's comorbidities, the overall goal is to provide specialized care to optimize the patient's health and prevent further diabetic-related complications.

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Vascular Intervention 

Most patients with limb- or life-threatening diabetic foot infections will need to consider vascular intervention to achieve limb salvage. Soon after the initial surgical debridement, the surgeon requests that invasive and noninvasive vascular studies be performed. The vascular surgeon may prefer to perform revascularization within one to two days of the initial surgical debridement for a patient who has a severely infected, dysvascular foot.19, 35

Determining the need for revascularization begins with comparing the preoperative perfusion with the intraoperative assessment of arterial tissue perfusion after adequate debridement. Noninvasive vascular studies that include the ankle-brachial index, toe-brachial index, pulse-volume recordings, and transcutaneous oxygen pressures are performed initially to determine whether there is a need for invasive vascular studies.

The ankle-brachial index is a screening test specifically for peripheral vascular disease, but it may not be very useful in the diabetic patient because the index underestimates the severity of arterial insufficiency.39 The ankle-brachial index is affected by uncompressible calcified vessels, which are common in diabetic patients. This leads to falsely elevated values.39 Despite the shortcomings associated with the ankle-brachial index, a decreased value still is considered clinically significant. Qualitative wave forms and toe-brachial pressure index have been shown to be more efficacious compared to the ankle-brachial index in screening for arterial insufficiency in high-risk extremities among the diabetic population.40

Transcutaneous oxygen pressure measurements may be useful in predicting wound healing capability.41, 42, 43 The wound is expected to heal if values are greater than 30 mmHg.41, 42, 43

Noninvasive vascular studies in conjunction with the extremity's clinical appearance may indicate the need for further vascular intervention. Angioplasty is a reasonable initial means of revascularization for anatomically favorable vascular disease, followed by distal artery bypass if the angioplasty is unsuccessful.12, 44 Angioplasty usually is successful in treating short arterial occlusions and stenosis.44

Peripheral artery bypass has been shown to be a beneficial procedure for salvage of the ischemic diabetic limb that has undergone considerable tissue loss.45, 46 Peripheral bypass usually is needed to treat long arterial occlusions that are not amenable to angioplasty.12, 45, 47 Re-perfusion is essential before soft-tissue reconstruction can take place. If vascular intervention, including but not limited to endovascular and arterial bypass techniques, is not successful, a proximal amputation may need to be performed if limb ischemia persists and if team members agree on this course of action.

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Soft-Tissue Closure and Reconstruction 

Obtaining long-lasting wound closure after radical surgical debridement to control infection is one of the most challenging aspects in the surgical management of diabetic foot infections.48 Extensive soft-tissue loss usually is present. Successful soft-tissue reconstruction can be achieved only if persistent localized infection and arterial insufficiency have been resolved. Numerous techniques may be used to obtain wound closure in the diabetic foot after the initial surgical debridement. The procedure chosen is based on the patient's overall medical and clinical status. The simplest and least invasive modalities should be attempted first, when feasible. The surgeon must decide if a delayed primary wound closure with minimal tension is possible after revisional debridement or limited pedal amputation. Wounds that are not suitable for delayed primary closure, particularly those with continued drainage or extensive soft-tissue loss, usually are managed with advanced local wound care dressings in tandem with negative pressure wound therapy (Figure 4). This facilitates development of granulation tissue and helps eliminate wound bacterial count. In the most complex wounds, advanced plastic surgical techniques eventually are required to achieve wound closure. These include split thickness skin grafting (Figure 5), local flaps, muscle flaps, pedicle flaps, and free-tissue transfer.48 In addition, external fixation techniques may be used alone or in conjunction with plastic surgery techniques to

•off-load or position the extremity,

•correct underlying osseous deformities, and

•assist in the closure of large cleft defects

while permitting easy access for clinical assessments and local wound care when indicated (Figure 6).48, 49, 50 Finally, custom-molded shoes, inserts, or braces are used postoperatively to prevent future breakdown after soft-tissue coverage is achieved.

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Optimizing Chances for Limb Survival 

A rational approach to the surgical management of diabetic foot infections is essential for limb salvage and patient survival (Figure 7). A multidisciplinary diabetic foot-care team consisting of personnel from both surgical and medical disciplines is needed to adequately manage a diabetic foot infection. The surgeon should have experience and knowledge to evaluate the patient with a diabetic foot infection to determine when and how to intervene. The basic principles to be accomplished include, but are not limited to,

•patient stabilization;

•adequate surgical debridement combined with antibiotic administration;

•comprehensive vascular assessment and revascularization, if needed;

•delayed soft-tissue reconstruction; and

•postoperative medical and surgical education and intervention.

When these principles are achieved, the surgeon can optimize the likelihood of limb salvage.

Social and nutritional services as well as diabetic support groups are key components of the patient's education about diabetes mellitus and its devastating complications. Unfortunately, a foot infection often is the first “wake-up call” for the patient with diabetes mellitus and dense peripheral neuropathy. This clinical scenario should be used as an opportunity to further educate the patient on the necessity of adhering to the overall management of diabetes mellitus to prevent future complications.

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Examination 

Surgical Management of Diabetic Foot Infections and Amputations 

Purpose/Goal 

To educate perioperative nurses about caring for patients during surgical management of diabetic foot infections and amputations.

Behavioral Objectives 

After reading and studying the article on surgical management of a patient with a severe diabetic foot infection, nurses will be able to

1.identify the risks involved with a severe diabetic foot infection,

2.explain signs or symptoms of diabetic foot infections,

3.discuss preoperative management of a patient with a severe diabetic foot infection,

4.describe intraoperative care of the patient undergoing surgery for management of a diabetic foot infection, and

5.discuss the postoperative management of the patient who has undergone surgery for a diabetic foot infection.

Questions 

1.A severe diabetic foot infection has a _______ risk of ultimately requiring a major lower extremity amputation.
a.15%

b.20%

c.25%


2.Signs of limb ischemia include
1.decreased or absent pedal pulses.

2.fever.

3.gangrene.

4.necrosis.

5.presence of severe claudicating pain.

a.1 and 5

b.1, 3, and 4

c.2, 3, and 5

d.1, 2, 3, 4, and 5


3.If the patient complains of pain on palpation in the presence of neuropathy, the clinician should consider
a.abscess formation and deep underlying infection.

b.venous claudication.

c.blood clot formation.

d.intermittent claudication.


4.X-rays can help the clinician determine
1.whether osteomyelitis is present.

2.whether foreign bodies are present.

3.whether there is gas in the soft tissues.

4.the level of emergent amputation needed.

5.whether an infection has migrated proximally.

a.2 and 3

b.1, 4, and 5

c.2, 3, 4, and 5

d.1, 2, 3, 4, and 5


5.A systemic response to infection is indicated by the presence of
1.hypotension.

2.nausea and vomiting.

3.rigors.

4.tachycardia.

5.unexplained hyperglycemia.

a.1 and 5

b.2, 3, and 4

c.2, 3, 4, and 5

d.1, 2, 3, 4, and 5


6.If the patient presents with an open and infected draining wound, the circulating nurse cleanses the extremity circumferentially from the planned incision site outward.
a.true

b.false


7.Saline irrigation has been shown to significantly decrease aerobic and anaerobic bacterial counts.
a.true

b.false


8.The success of surgery during the postoperative course is dependent on the patient's
1.ability to comply with the postopera- tive regimen.

2.ability to cope psychologically.

3.healing capabilities.

a.1

b.3

c.1 and 2

d.1, 2, and 3


9._________________________ may be useful in predicting wound healing capability.
a.Toe-brachial pressure indices

b.Ankle-brachial indices

c.Transcutaneous oxygen pressure measurements

d.Qualitative wave forms


10.External fixation may be used to
1.assist in the closure of large cleft defects.

2.correct underlying osseous deformities.

3.off-load or position the extremity.

4.permit easy access for clinical assess- ments and local wound care.

a.1 and 3

b.2 and 4

c.1, 2, and 3

d.1, 2, 3, and 4


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Answer Sheet 

Surgical Management of Diabetic Foot Infections and Amputations 

Event #08036

Session #1902

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Learner Evaluation 

Surgical Management of Diabetic Foot Infections and Amputations 

This evaluation is used to determine the extent to which this continuing education program met your learning needs. Rate these items on a scale of 1 to 5.

Purpose/Goal 

To educate perioperative nurses about caring for patients during surgical management of diabetic foot infections and amputations.

Objectives 

To what extent were the following objectives of this continuing education program achieved?

1.Identify the risks involved with a severe diabetic foot infection.

2.Explain signs or symptoms of diabetic foot infections.

3.Discuss preoperative management of a patient with a severe diabetic foot infection.

4.Describe intraoperative care of the patient undergoing surgery for management of a a diabetic foot infection.

5.Discuss the postoperative management of the patient who has undergone surgery for a diabetic foot infection.

Content 

To what extent

6.did this article increase your knowledge of the subject matter?

7.was the content clear and organized?

8.did this article facilitate learning?

9.were your individual objectives met?

10.did the objectives relate to the overall purpose/goal?

Test Questions/Answers 

To what extent

11.were they reflective of the content?

12.were they easy to understand?

13.did they address important points?

Learner Input 

14.Will you be able to use the information from this article in your work setting?
1.yes

2.no


15.I learned of this article via
1.the Journal I receive as an AORN member.

2.a Journal I obtained elsewhere.

3.the AORN Journal web site.


16.What factor most affects whether you take an AORN Journal continuing education examination?
1.need for continuing education contact hours

2.price

3.subject matter relevant to current position

4.number of continuing education contact hours offered


What other topics would you like to see addressed in a future continuing education article? Would you be interested or do you know someone who would be interested in writing an article on this topic?

Topic(s): ____________________________________________________________________________

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References 

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  indicates that continuing education contact hours are available for this activity. Earn the contact hours by reading this article and taking the examination on pages 947–948 and then completing the answer sheet and learner evaluation on pages 949–950.You also may access this article online at http://www.aornjournal.org.The behavioral objectives and examination for this program were prepared by Rebecca Holm, RN, MSN, CNOR, clinical editor, with consultation from Susan Bakewell, RN, MS, BC, director, Center for Perioperative Education. Ms Holm and Ms Bakewell have no declared affiliations that could be perceived as potential conflicts of interest in publishing this article.This program meets criteria for CNOR and CRNFA recertification, as well as other continuing education requirements.AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019. Check with your state board of nursing for acceptance of this activity for relicensure.

PII: S0001-2092(08)00122-1

doi:10.1016/j.aorn.2008.02.014

AORN Journal
Volume 87, Issue 5 , Pages 935-950, May 2008

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