Limb Preservation From Toe to Heart

Limb preservation begins with an understanding of the multifaceted complications related to comorbidities and barriers to wound healing. The epidemic of diabetes mellitus reached more than 29 million people (more than 9% of the United States population) in 2014 alone, and continues to grow. Intertwining diabetes with other intrinsic and extrinsic risk factors, such as lack of exercise, smoking, poor diet, hypertension, dyslipidemia, abdominal obesity, and renal and cardiovascular disease, creates the “perfect storm” for metabolic syndrome. Interestingly, many patients don’t know they’re experiencing symptoms of diabetes for 8-10 years.¹ By this time, the damage to the cardiovascular system has already created micro- and macrovascular dysfunction that compromises arterial blood flow and creates peripheral arterial disease (PAD). On average, one in three patients living with diabetes who is older than 50 is at risk for PAD, which may lead to heart attack, stroke, renal failure, and an amputation. In many situations, it’s the chronic wound/ulcer on the toe or the foot that identifies the patient as at risk for heart attack and/or stroke.² Critical limb ischemia (CLI) is known as decreased arterial blood flow to the limb, typically in the lower extremities (including legs, feet, and toes), that places a patient at risk of amputation. Historically, the underlying condition goes undetected for months or years. Many non-wound care specialists may have noted during the history and physical exam a history of diabetes, hypertension, and high cholesterol — and then scrolled directly to the wound. In severe cases of CLI, a patient may experience excruciating pain in the calf or foot resembling the same level of pain as a myocardial ischemia episode. Meaning, in other words, our patients may be experiencing a “foot attack.” Benefits of a having a multidisciplinary/wound specialist team approach identifies many key factors impacting wound healing and limb preservation that may be missed by traditional methods of trying to choose the “right dressing.” This article will discuss the wound care clinician’s role in improving limb preservation outcomes through better screening and assessment, diagnosis, and treatment of comorbidities such as PAD and CLI.³  

PAD & LIMB PRESERVATION 

Many wound care clinicians share a passion for this area of medicine and understand that wound healing is a process that requires a comprehensive, multidisciplinary team approach that utilizes staff members from healthcare disciplines across the spectrum of care. We also typically have to begin our treatment plans at a point in time when the primary care physician or other healthcare professional has decided the patient’s chronic wound may not be healing as “expected.” Since wound healing requires management of all underlying conditions, it’s important for the wound care clinician to review all past medical and surgical history as well as any current or past laboratory and diagnostic results prior to initiating the true wound healing process. This may be referred to as the clinical scientific identification of wound healing. According to the Centers for Medicare & Medicaid Services, there are specific medical-necessity requirements related to wound/ulcer management and any adjunctive therapy modalities utilized. Together, Meaningful Use, clinical quality measures, and the U.S. Wound Registry recommended “core measures” such as controlling high blood pressure, optimal glucose and nutritional management, tobacco cessation/intervention, medication management, and assessment and management (ie, offloading, compression therapy) of complex chronic conditions. (The USWR also has a quality measure focused on arterial screening of patients with limb ulcers.) A lack of appreciation for these core measures to care quality may be the reason many patients are living with chronic lower extremity wounds/ulcers related to arterial and/or venous disease, and why they may experience venous leg ulcers and/or lower extremity arterial disease. As many of our patients live with multiple comorbidities, their wounds/ulcers may be considered to be known as “mixed-disease ulcers,” so it’s important to identify and manage all existing risk factors. Modalities such as offloading, compression therapy, sharp excisional debridement, and infection management should occur simultaneously and concurrently. Patients experiencing metabolic syndrome — mixed cardiovascular/diabetes conditions — are frequently underdiagnosed and undertreated, even though they’re at high risk for PAD/CLI due to underlying neuroischemic symptoms resembling diabetic neuropathy pain versus ischemic pain.^4,5 

DEVELOPING THE PROTOCOLS   

In addition to possessing “wound experts,” the multidisciplinary team approach should include the primary care physician, revascularization specialists, surgeon, podiatrist, endocrinologist, therapists, home care staff, long-term care personnel, personal caregivers, and, not to be forgotten in terms of their role in all of this, the patients. If clinicians don’t have the buy-in and involvement of the patient, higher risk for amputation occurs. The patient must be an “informed consumer” and an active participant in the plan of care through the clinician’s efforts to deliver education and to ensure education is comprehended. 

In-clinic protocols should call for a comprehensive pathophysiology assessment, including baseline labs to monitor for anemia, malnutrition, and infection (including complete metabolic panel for glucose and albumin levels). If any of these numbers are abnormal, further testing, such as glycated hemoglobin A1c, prealbumin, erythrocyte sedimentation rate, and C-reactive protein, should be considered. In addition, radiological exams for wounds/ulcers that are open longer than 30 days or are at risk for deeper injury, Charcot foot deformation, exposed hardware, or osteomyelitis have become more strongly considered. Further testing can include MRI and/or CT scans, depending on the uniqueness of the patient. Patients may also require consultation from a foot and ankle or podiatric wound specialist surgeon for Charcot or surgical repair and advanced wound therapy management/offloading techniques. Additional necessary steps may call for further diagnostic testing, including noninvasive studies such as skin perfusion pressure testing, arterial Dopplers, and ankle-brachial index with toe pressures. Invasive vascular studies should be considered to determine if the patient could benefit from surgical or endovascular revascularization by a CLI specialist. 

It’s not uncommon to identify underlying additional cardiovascular disease and/or chronic renal failure due to the complication of chronic diabetes and/or smoking risk factors causing calcified vessel disease. These patients are not only living with a wound/ulcer on their leg or foot; they are at high risk for heart attack, stroke, renal dialysis, or death. The multidisciplinary team approach should be utilized to create a limb preservation environment that includes improving mobility and quality of life in addition to promoting proper healing of the wound/ulcer.⁶  

CONCLUSION 

All wound care and CLI/PAD experts, from different professional perspectives, patient-care settings, and geographical locations, should share the same best practices for limb preservation through core quality measures. Patients living with a lower extremity wound/ulcer present a complex pathophysiology assessment from “toe to heart.” Tapping into the benefits of how each of us shares the same populations of patients by offering many different attributes to healing these wounds/ulcers and improving quality of care can be experienced by utilizing the multidisciplinary team approach as well as through attempts to be innovative and allowing our expertise to guide new techniques, technologies, and protocols that will enhance wound healing and quality of life. n

Audrey Moyer-Harris is program director at Mercy Hospital Jefferson’s Wound & Hyperbaric Center, Crystal City, MO. She is also an active member of the Association for the Advancement of Wound Care (AAWC) and the Wound, Ostomy and Continence Nurses Society,™ and serves on multiple committees. She is also a member of the Today’s Wound Clinic (TWC) editorial board and the AAWC speakers’ bureau. Eric J. Lullove is a staff physician at West Boca Center for Wound Healing, Boca Raton, FL; co-chairs the healthcare policy committee of the AAWC; and is the AAWC liaison to the Alliance for Wound Care Stakeholders. He is also a member of the TWC editorial board and serves as a consultant for Hollister Wound Care,^® Integra^® LifeSciences, and Skye^® Biologics. J.A. Mustapha is an interventional cardiologist specializing in critical limb ischemia at Metro Health University of Michigan Health, Wyoming, MI.

References

1. 2014 National Diabetes Statistics Report. Centers for Disease Control and Prevention. Accessed online: www.cdc.gov/diabetes/data/statistics/2014statisticsreport.html

2. Moyer-Harris A. The underestimation of PAD & its impact on wound care. TWC. 2015;9(5):10-13.

3. Clayton W, Elasy TA. A review of the pathophysiology, classification and treatment of foot ulcers in diabetic patients. Clin Diabetes. 2009; 27(2):52-8.

4. Lullove E. Meaningful use: do you really know what you’re doing? TWC. 2015;9(5):30.

5. Quality Measures in Wound Care. U.S. Wound Registry. 2014. Accessed online: www.uswoundregistry.com/specifications.aspx

6. Diaz-Sandoval LJ, Mustapha JA, Saab F, Vantil B. The CLI continuum of care model: a multidisciplinary approach to improve outcomes. CLI Compendium. 2014;1(1):1-5.