Diabetic Foot Ulcers: Wound Management

AHRQ Guideline

Areas of Agreement and Difference

A direct comparison of recommendations presented in the above guidelines for wound management of diabetic foot ulcers (DFUs) is provided.

Areas of Agreement

Wound Dressings

IWGDF and SVS/APMA/SVM make strong recommendations for the use of dressing products that maintain a moist wound bed, control exudate and avoid maceration of surrounding intact skin. The guideline developers agree that available evidence does not support the use of any single dressing type (e.g., hydrogels, hydrocolloids, foam dressings, alginates, honey) over another. Dressing selection should therefore be guided by the characteristics of the individual wound, acquisition cost, and ease of use. IWGDF adds comfort to this list. IWGDF recommends against the use of antimicrobial dressings with the goal of improving wound healing or preventing secondary infection. The UHMS guideline does not address wound dressings.

Debridement

IWGDF and SVS/APMA/SVM agree that sharp debridement of slough, devitalized/necrotic tissue and surrounding callus material should be performed at regular intervals. According to SVS/APMA/SVM, considering the lack of evidence for superiority of any given debridement technique, initial sharp debridement is suggested, with subsequent choice of method based on clinical context, availability of expertise and supplies, patient tolerance and preference, and cost-effectiveness. IWGDF similarly notes that, even though professional opinion is united in support of the use of debridement, the experimental evidence to justify debridement in general and of any particular method of debridement is not strong. Nevertheless, IWGDF makes a strong recommendation on the basis of low-quality evidence for the use of sharp debridement, taking relative contraindications such as severe ischemia into account. The UHMS guideline does not address debridement.

Hyperbaric Oxygen (HBO2) Therapy

There is general agreement among the three guideline developers that HBO2 therapy may be an appropriate adjuvant intervention for selected patients. IWGDF makes a weak recommendation on the basis of moderate-quality evidence for the consideration of systemic HBO2 therapy in order to accelerate healing of DFUs. Further blinded and randomized trials are required to confirm its cost-effectiveness, as well as to identify the population most likely to benefit from its use, notes the guideline developer. SVS/APMA/SVM suggests the use of HBO2 therapy in patients with DFUs who have adequate perfusion that fails to respond to 4 to 6 weeks of conservative management. Considering the cost and the burden of prolonged daily treatment, the developer encourages careful patient selection and suggests the use of transcutaneous oximetry to help stratify patients and predict those most likely to benefit.

HBO2 therapy for the treatment of DFUs is the focus of the UHMS guideline. The developer makes recommendations for its use according to the grade of the DFU in the Wagner wound classification system. UHMS explains that, despite consensus between foot and ankle surgeons and hyperbaric physicians that the Wagner grade is archaic and inadequate, most of the historical and contemporary studies and most reimbursement determinations with regard to the use of HBO2 for DFUs are based on the Wagner DFU wound appearances. In order to reduce the risk of major amputation and incomplete healing, UHMS suggests adding HBO2 to the standard of care in patients with Wagner Grade 3 (deep tissue involvement and abscess, osteomyelitis, or tendonitis) or greater DFUs who have just undergone surgical debridement of the infected foot as well as in patients with Wagner Grade 3 or greater DFUs that have shown no significant improvement after 30 or more days of treatment. The developer suggests against using HBO2 in patients with Wagner Grade 2 or lower DFUs.

 

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