What are the management instructions for pressure wounds in diabetic patients?

Management of Pressure Wounds in Diabetic Patients

Diabetic pressure wounds require a structured approach including debridement, appropriate dressing selection, pressure off-loading, infection control, and vascular assessment to optimize healing and reduce morbidity and mortality.

Initial Assessment and Wound Classification

• Assess the foot's arterial supply in every diabetic patient with a pressure wound by checking dorsalis pedis and posterior tibial pulses; if pulses are not palpable, further vascular assessment is needed 1
• Evaluate for peripheral neuropathy using a 10-g Semmes-Weinstein monofilament test at key sites on the foot (plantar surface of heel, metatarsal heads, arch, and toe tips) 1
• Measure and document wound size, depth, extent of surrounding cellulitis, and quality/quantity of drainage to track healing progress 1
• Use a sterile, blunt metal probe to assess wound depth, detect foreign bodies, soft-tissue abscesses, communications with joint cavities, or palpable bone 1

Wound Debridement

• Sharp debridement is the preferred method for removing slough, necrotic tissue, and surrounding callus in diabetic pressure wounds 1
• Debridement reduces pressure at callused sites, removes colonizing bacteria, and permits examination for deep tissue involvement 1
• Warn patients that bleeding is likely during debridement and that the wound will appear larger after the procedure 1
• Consider contraindications to aggressive debridement, particularly in primarily ischemic wounds 1
• For extensive wounds or adherent eschar, consider multiple debridement sessions or surgical debridement in an operative suite 1

Wound Dressings

• Select dressings based primarily on exudate control, comfort, and cost 1
• Match dressing type to wound characteristics 1:
  • Continuously moistened saline gauze: for dry or necrotic wounds
  • Hydrogels: for dry/necrotic wounds to facilitate autolysis
  • Films (occlusive/semiocclusive): for moistening dry wounds
  • Alginates: for drying exudative wounds
  • Hydrocolloids: for absorbing exudate and facilitating autolysis
  • Foams: for exudative wounds
• Avoid using topical antimicrobials for treating most clinically uninfected wounds 1

Pressure Off-loading

• Off-loading pressure from the wound is vital for healing 1
• Total contact casts are considered the gold standard for redistributing pressure and accelerating healing of neuropathic ulcers 1
• Use total contact casts with caution in patients with severe peripheral arterial disease or active infection 1
• Consider removable off-loading devices when total contact casts are contraindicated, but be aware that patient adherence may be lower 1
• For post-surgical wounds, pressure off-loading should be tailored to minimize pressure at the wound site 1

Infection Management

• Obtain appropriate specimens for culture before initiating antibiotic therapy when infection is suspected 1
• Tissue samples provide more accurate culture results than superficial swab specimens 1
• Do not use antibiotics for clinically uninfected wounds 2
• For infected wounds, select antibiotics based on culture results and infection severity 2
• Prompt management of foot infection with antibiotics, debridement, and surgical intervention is essential 1

Adjunctive Therapies

• Consider negative pressure wound therapy (NPWT) for post-operative (surgical) diabetic foot wounds to reduce wound size 1
• NPWT is not recommended over standard care for non-surgical diabetic foot ulcers 1
• Consider systemic hyperbaric oxygen therapy for non-healing ischemic diabetic foot ulcers despite best standard care 1
• Consider sucrose-octasulfate impregnated dressings for difficult-to-heal neuro-ischemic diabetic foot ulcers 1
• Consider placental-derived products as adjunctive treatment when standard care has failed to reduce wound size 1
• Consider autologous combined leucocyte, platelet, and fibrin patch for difficult-to-heal ulcers 1

Monitoring and Follow-up

• Measure and record wound size, extent of surrounding cellulitis, and quality/quantity of drainage regularly 1
• If a diabetic foot wound fails to heal despite good wound care, reevaluate management including perfusion assessment and infection control 1
• Consider biopsy of recalcitrant or atypical wounds to rule out malignancy 1
• Document healing progress with measurements and photographs when possible 1

Common Pitfalls to Avoid

• Failing to assess vascular status before aggressive debridement 2
• Using footbaths that can induce skin maceration 2
• Delaying surgical consultation for deep or severe infections 2
• Inadequate off-loading of pressure from the wound 2, 3
• Treating clinically uninfected wounds with antibiotics 2
• Failing to obtain appropriate cultures before starting antibiotics 2

Special Considerations

• For wounds with arterial insufficiency, revascularization assessment should be prioritized before aggressive debridement 1
• Most diabetic foot ulcers take at least 20 weeks to heal, requiring consistent long-term care 1
• A multidisciplinary approach involving wound care specialists, vascular surgeons, infectious disease specialists, and podiatrists optimizes outcomes 2, 4