Caputo G M, Cavanagh P R, Ulbrecht J S, Gibbons G W, Karchmer A W
Department of Medicine, Pennsylvania State University College of Medicine, Milton S. Hershey Medical Center, Hershey 17033.
N Engl J Med. 1994 Sep 29;331(13):854-60. doi: 10.1056/NEJM199409293311307.
Limb- or life-threatening complications in patients with diabetes can be prevented with an integrated, multidisciplinary approach. Most patients seen in clinical practice are in the early stages of the disease process. Glycemic control retards the progression of neuropathy, which is the most important risk factor for ulceration. Early detection of the loss of protective sensation and implementation of strategies to prevent ulceration will reduce the rates of limb-threatening complications. Clinicians should routinely examine the feet of diabetic patients. Education in foot care, proper footwear, and close follow-up are required to prevent or promptly detect neuropathic injury. If ulceration occurs, removal of pressure from the site of the ulcer and careful management of the wound will allow healing in most cases. The failure to heal despite these measures should prompt a search for associated arterial insufficiency. If infection is present, appropriate antimicrobial therapy combined with immediate surgical intervention, including revascularization when necessary, will increase the chances of saving the limb. With this comprehensive approach, it is possible to achieve the goal of a 40 percent decrease in amputation rates among diabetic patients by the year 2000.
采用综合、多学科方法可预防糖尿病患者出现肢体或危及生命的并发症。临床实践中见到的大多数患者处于疾病进程的早期阶段。血糖控制可延缓神经病变的进展，而神经病变是溃疡形成的最重要危险因素。早期发现保护性感觉丧失并实施预防溃疡的策略将降低肢体威胁性并发症的发生率。临床医生应定期检查糖尿病患者的足部。需要进行足部护理、合适鞋具及密切随访方面的教育，以预防或及时发现神经病变损伤。如果发生溃疡，解除溃疡部位的压力并仔细处理伤口，在大多数情况下伤口会愈合。尽管采取了这些措施仍未愈合，应促使医生查找是否存在相关的动脉供血不足。如果存在感染，适当的抗菌治疗联合立即进行手术干预，必要时包括血管重建，将增加挽救肢体的机会。通过这种综合方法，有可能实现到2000年将糖尿病患者截肢率降低40%的目标。
