Table of Contents  
EXPERT GUIDELINES FROM DFSI
Year : 2020  |  Volume : 7  |  Issue : 2  |  Page : 116-120

Guidance for diabetic foot management during COVID-19 pandemic


1 Department of Surgery, Apollo Hospitals; Department of Peadiatric Surgery, Hycare Superspeciality Hospitals, Chennai, Tamil Nadu, India
2 Department of Peadiatric Surgery, Hycare Superspeciality Hospitals; Department of Plastic Surgery, Kauvery Hospitals, Chennai, Tamil Nadu, India
3 Department of Endocrinology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
4 Department of Endocrinology, Amrita Institute of Medical Sciences, Kochi, Kerala; Department of Surgery, Raheja Hospital, Mumbai, Maharashtra, India

Date of Submission23-Apr-2020
Date of Acceptance24-Apr-2020
Date of Web Publication17-Jun-2020

Correspondence Address:
Dr. Rajesh Kesavan
Department of Surgery, Apollo Hospitals; Department of Peadiatric Surgery, Hycare Superspeciality Hospitals, Chennai, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_43_20

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  Abstract 


The Indian COVID-19 situation is and will demand more and more hospital bed capacity to manage. With diabetic foot disease (DFD) being a leading cause of hospital bed occupancy, managing these patients based on evidence-based guidelines can significantly reduce the rates of hospitalization. Every hospital bed that is not needed for a patient with DFD , gives room for occupancy by a patient suffering from COVID-19. The goal of doctors treating diabetic foot is aimed at early successful treatment of infections and preventing amputations, decreasing the hospital stay of inpatients, and effective cost reduction. Hence, changing our way of approach to managing a patient with diabetic foot and implementing new and unique ways is the need of the hour at this time of crisis. This guidance also has a section on managing diabetes in people with diabetic foot during the COVID19 pandemic.

Keywords: COVID-19, diabetic foot management, triage, teleconsultation


How to cite this article:
Kesavan R, Murthy V B, Rastogi A, Bal A. Guidance for diabetic foot management during COVID-19 pandemic. Indian J Vasc Endovasc Surg 2020;7:116-20

How to cite this URL:
Kesavan R, Murthy V B, Rastogi A, Bal A. Guidance for diabetic foot management during COVID-19 pandemic. Indian J Vasc Endovasc Surg [serial online] 2020 [cited 2020 Jul 4];7:116-20. Available from: http://www.indjvascsurg.org/text.asp?2020/7/2/116/286907




  Introduction Top


People with diabetes represent a precarious population that is at increased risk of morbidity and mortality from COVID-19.[1] Hence, decreasing their hospital visits by differentiating those with life/limb-threatening (Infectious Diseases Society of America [IDSA] Grade 3 and 4) from nonlimb-threatening infections forms the basis of triaging.[2] Wound care centers away from hospitals can take care of most patients except in the critical category.


  Triage Top


The following guidelines are for diabetic foot specialists based on best available evidence and expert opinion from the global surgical community adapted to the Indian context.

At the time of triage, inquiry should be made about possible COVID-19 symptoms of cough or sore throat or fever and if present, prescribed protocol should be followed. Furthermore, we must constantly remember that features of sepsis might be absent or diminished in people with diabetes and the elderly, while, on the other hand, a sepsis in a patient could be also due to COVID.[3]

Patient complaints can be:

  • Foot pain
  • Erythema
  • Swelling
  • Foot ulcer.


Please follow the color-coded flowchart and table to understand presentation, evaluation, and management.

Red: Indicates critical state at presentation and is taken as the first priority.

Orange: Indicates emergency situation at presentation and is the second priority.

Yellow: Indicates that extra care needs to be taken and is the third priority.

Green: Indicates a stable situation.

Any patient with features of breathlessness, ssfever, tachycardia, and rule out sepsis (could also be due to COVID 19) must be referred to a hospital with intensive care unit (ICU) facilities (CRITICAL).

Management of patients without active wounds

The management of patient presenting with pain is illustrated in [Figure 1].
Figure 1: Management of patients presenting with pain

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The management protocol for patient presenting with erythema is outlined in [Figure 2].
Figure 2: Management of patients with complaints of erythema

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A patient presenting with swelling is managed according to the protocol shown in [Figure 3].
Figure 3: Management of patients with swelling

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Management of patients with wounds

The patients presenting with active wounds are managed according to the IDSA classification and guidelines outlined in [Figure 4].
Figure 4: Management of patients with active wound

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  Need for a Uniform Approach Top


[Table 1] outlines the appropriate standard of care to be offered to patients with DFD at this time of crisis and is based on our experience in handling the intricacies in the manangement of such patients since the pandemic began. Technology is used to be in touch with the patients at home unable to travel during the lockdown. Home care services are used to provide continuity of care. Shifting of patients at the appropriate time to the hospital and ICU goes a long way in not only providing a rational and sensible use of resources but also keeping the interest of these patients and not be a stress to the hospital services already reeling under the burden of COVID 19 pandemic. The aim is also to keep the diabetic foot and wound care patients and related health-care workers safe during such a highly infective stage.
Table 1: Triaging and management of diabetic foot patients*

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Diabetic foot evaluation does not restrict itself to the assessment of the infection alone. The various subgroups of patients who present to us have additional features which must be considered. A “simple” cellulitis can jeopardize the glycemic control and trip the already compromised organ functions to critical levels. To provide a continuous care in a multispecialty multidisciplinary manner, a record of the events must be done in a simple and scientific manner so that the condition of the patient can be shared among the involved specialties to understand the exact condition of the patient.

[Table 1] shows not only the condition of the foot but also the status of the different types of ulcers among our existing patients and condition of the organ systems. A preliminary impression of the condition of the patient is derived based on a holistic evaluation of the patient.


  Teleconsultation Top


In accordance with the recent guidelines on telemedicine published by the medical council of India, we have come up with a teleconsultation protocol.[4] Almost all patients except critical ones can be triaged via teleconsultation.

[Figure 5] is a representation of the teleconsultation guidelines that can be followed.
Figure 5: Teleconsultation algorithm

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Diagnosis based on photos are not always reliable and triaging can vary between clinicians. Hence, practicing clinicians are advised to use their discretion in making decisions.

Primary consultation can end in three ways:

  • The clinician requests for laboratory investigations including complete blood count, renal profile and erythrocyte sedimentation rate/C-reactive protein and reschedules the consultation to review the reports
  • The clinician requests the patient for in-person consultation due to:


    • The technical limitations in assessing the wound when there is suspicion of infection involving deeper tissues
    • Patient requires emergency admission
    • Requires outpatient assessment with minor debridement.
    • If the clinician is convinced about healthy wound status, he/she concludes the consultation and the patient is advised on preventive aspects of foot care.


The teleconsultation is incomplete without patient's education. The key elements of which will be:

  • Strict usage of footwear with socks indoors and while walking around the house
  • Twice daily examination of both the feet with/without the help of the caregiver
  • Wash the feet twice daily followed by drying and application of moisturizer (to areas of foot other than web spaces)
  • As the number of steps walked is going to decrease as patients are confined indoors, patients are advised to use any comfortable protective footwear as it is always better than bare foot walking. Patients should be advised to use separate set of footwear for indoor and outdoor use to avoid contamination of the place of living
  • Follow the guidelines of protection against COVID-19 with special emphasis on those on immunosuppressive therapy
  • To watch for danger signs/symptoms including – thickening of skin, fissures/ulcer/blister, fever, redness, warmth, pain, and discharge
  • The patients with improving wounds being managed by teleconsultation to be taught the application of a simple nonadherent dressing and to be emphasized on keeping it healthy. They are advised simple offloading measures as any offloading is better than no offloading
  • It would be prudent to assess the mental state of the patient secondary to the pandemic and lockdown and address his/her fear of contracting the disease if any during the entire consultation and try to offer mental health support if necessary.


There is always the limitation of the confidential information shared via consultation being exploited by the hackers. The clinician must be extremely vigilant, and any file transfer comprising confidential information such as photos, biological examination reports, or radiography must be carried out with secure messaging applications on secure platforms.[5] The records of teleconsultation must be saved by the clinician for medicolegal purposes and future reference.

Battling COVID-19 as diabetic foot specialists – safety and ethical issues

  • All elective cases are to be postponed
  • Consent discussion with patients must cover the risk of COVID-19 exposure and the potential consequences[6]
  • Structured system of transfer of COVID-positive patient to the operating room (OR, operation theater) via communication between the surgeon, anesthetist, and perioperative staff
  • We must presume that the entire OR is contaminated[7] and hence:


    • Follow negative pressure in OR/allow 30 min time between cases for air exchange
    • Minimal number of staffs in the OR
    • Hospital charts, pagers, and cell phones must be left outside the OR
    • Dedicated runner should be posted outside of the OR to obtain supplies
    • All single-use equipment (even unopened) in the room is thrown away at the end of the case
    • Electrosurgery units should be set to the lowest possible settings for the desired effect. Use of monopolar electrosurgery, ultrasonic dissectors, and advanced bipolar devices should be minimized, as these can lead to particle aerosolization. If available, monopolar diathermy pencils with attached smoke evacuators should be used.


  • All members of OR to wear standard surgical personal protective equipment (PPE) including a face shield, N95 respirator, waterproof gown, double gloves, and shoe covers
  • Clinicians are more likely to infect themselves when removing their PPE.[8] Proper gowning and doffing to be assisted and monitored by a buddy system (colleague).


Guidance for people with diabetes and diabetic foot during coronavirus pandemic

People with diabetic foot, especially foot infections, have compromised immune response and hence are considered to be vulnerable population for serious illness and unfavorable outcomes resulting from coronavirus infection.[9],[10] It has been noted that people with coexisting comorbidities including diabetes mellitus were more frequent among those who died from coronavirus.

What precautions need to be taken?

  1. Never omit your preexisting antidiabetic medications: Keep a sufficient stock of medicines for at least 3–4-week buffer stock, especially if you are under quarantine
  2. If on insulin: insulin vials/pen fills/syringes should be in adequate stock and stored at appropriate place (preferably at 4°C, door of refrigerator). Never omit insulin because it may increase chances of hyperosmolar nonketotic coma or diabetic ketoacidosis.


What to do?

  1. Frequent monitoring of blood glucose: should be performed by a glucometer available at home. If the glucometer is not available, consideration to be given to have one along with adequate number of glucometer strips
  2. Adequate hydration: should be maintained, especially if on sodium glucose cotransporter type 2 inhibitors
  3. Hypoglycemia: Frequent meals should be consumed with more frequent blood glucose monitoring if encompassing episodes of hypoglycemia or had prior hypoglycemia
  4. Contact: Nearest health services contact number and address should be available and be approached in cases of:


    • Symptomatic Hypoglycemia: More likely if having diabetic foot infections with renal compromise
    • Blood glucose persistently >250 mg/dl with osmotic symptoms of polyuria and polydipsia.


    However, it is advisable not to frequent the hospital for routine ailments in these times when medical facility may be utilized by triage to those with severe/life-threatening illness.

  5. Lifestyle measures and Exercise: Continue lifestyle measures as recommended by your physician as before including a healthy diet, green leafy vegetables and fruits. Do continue exercise routine at home including resistance exercises
  6. Antihypertensives: Continue your antihypertensive medication for blood pressure (BP) as prescribed by your physician with appropriate home-based BP monitoring devices. If you are on angiotensin-converting enzyme inhibitors, they should also be continued.


Acknowledgments

The authors would like to thank Dr. Aarthi Viswanathan Subramanian and Dr. Mohanasundaram Thiruvengadam.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Rogers LC, Lavery LA, Joseph WS, Armstrong DG. All feet on deck-the role of podiatry during the COVID-19 pandemic: Preventing hospitalizations in an overburdened healthcare system, reducing amputation and death in people with diabetes [published online ahead of print, 2020 Mar 25]. J Am Podiatr Med Assoc 2020;10.7547/20-051. doi:10.7547/20-051.  Back to cited text no. 1
    
2.
Lipsky BA, Senneville É, Abbas ZG, Aragón-Sánchez J, Diggle M, Embil JM, et al. Guidelines on the diagnosis and treatment of foot infection in persons with diabetes (IWGDF 2019 update). Diabetes Metab Res Rev 2020;36 Suppl 1:e3280.  Back to cited text no. 2
    
3.
Bates M, Edmonds M, Kavarthapu V, Manu C, Rashid H, Vas PR. Diabetes Foot Care in the COVID-19 Pandemic. London, UK: King's College Hospital, NHS Foundation Trust, 2020. Available from: https://www.d-foot.org/resources/columns/feet- first/diabetes-foot-care-in-the-covid-19-pandemic. [Last accessed on 2020 Apr 20].  Back to cited text no. 3
    
4.
Medical Council of India. Telemedicine Practice Guidelines Enabling Registered Medical Practitioners to Provide Healthcare Using Telemedicine; 25 March, 2020  Back to cited text no. 4
    
5.
Téot L, Geri C, Lano J, Cabrol M, Linet C, Mercier G. Complex wound healing outcomes for outpatients receiving care via telemedicine, home health, or wound clinic: A randomized controlled trial. Int J Low Extrem Wounds 2019;1534734619894485. doi: 10.1177/1534734619894485. Online ahead of print.  Back to cited text no. 5
    
6.
Aurora Pryor.SAGES and EAES Recommendations Regarding Surgical Response to COVID-19 Crisis; 29 March, 2020.  Back to cited text no. 6
    
7.
Royal College of Surgeons.COVID-19: Good practice for surgeons and surgical teams, Professional and Clinical Standards. Available from: https://www.rcseng.ac.uk/standards-and-research/standards-and-guidance/good-practice-guides/coronavirus/covid-19-good-practice-for-surgeons-and-surgical-teams/. [Last accessed on 2020 Apr 01].  Back to cited text no. 7
    
8.
Brat GA H, SP, Chhabra K, Gupta A, Scott J. Protecting Surgical Teams During the COVID-19 Outbreak: A Narrative Review and Clinical Considerations. Annals of surgery. 2020; Covid Special Edition. Available from: https://journals.lww.com/annalsofsurgery/Documents/COVID%20Surgery_VF.pdf. [Last accessed on 2020 Apr 18].  Back to cited text no. 8
    
9.
Guan WJ, Ni ZY, Hu Yu, Liang WH, Ou CQ, He JX, Lei L, et al. Clinical Characteristics of Coronavirus Disease 2019 in China. N Engl J Med 2020;382:1708-20. PMCID: PMC7092819 doi:10.1056/NEJMoa2002032.  Back to cited text no. 9
    
10.
Fang L, Karakiulakis G, Roth M. Are patients with hypertension and diabetes mellitus at increased risk for COVID-19 infection? [published correction appears in Lancet Respir Med 2020 May 18]. Lancet Respir Med 2020;8:e21. doi:10.1016/S2213-2600(20)30116-8.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1]



 

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