GUIDANCE FOR DIABETIC FOOT MANAGEMENT DURING COVID-19 PANDEMIC

Dr. Rajesh Kesavan MS,FPS1,2*, Dr. V.B.Narayana Murthy FRCS 2,3, Dr. Ashu Rastogi MD, DM4, Dr. Arun Bal MS,PhD5,6

DIABETIC FOOT SOCIETY OF INDIA

Motto- Optimising hospitalisation, Provide home care, Helping decongest ICUs, Preserving limb and life

The Indian COVID-19 situation is and will demand more and more hospital bed capacity to manage.
With diabetic foot disease being a leading cause of hospital bed occupancy, managing these patients
based on evidence-based guidelines can significantly reduce the rates of hospitalisation. Every hospital
bed not needed by a person with diabetic foot disease (DFD), gives room for 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.

TRIAGE

People with diabetes represent a precarious population that is at increased risk of morbidity and
mortality from COVID-19. Hence decreasing their hospital visits by differentiating those with life/limb
threatening (Infectious Disease Society of America grade 3 and 4) from non-limb threatening
infections forms the basis of TRIAGING. Wound care centres away from hospitals can take care of most
patients except in the critical category.

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 enquiry should be made about possible COVID-19 symptoms of cough or sore
throat or fever and if present, prescribed protocol should be followed. Also, 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 1.

Patient complaints can be:

• Foot pain
• Erythema
• Swelling
• Foot ulcer

1Dept of Surgery, Apollo Hospitals, Chennai & Secretary, DFSI, 2 Hycare Superspeciality Hospitals, Chennai, 3,Consultant Plastic Surgeon, Kauvery
Hospitals, Chennai, Vice-President, DFSI, 4Assistant Professor, Dept. of Endocrinology and Metabolism, Postgraduate Institute of Medical Education
and Research, Chandigarh, Vice-President, DFSI, 5Visiting Professor, Amrita Institute of Medical Sciences, Kochi, 6Consultant Surgeon, Raheja
Hospitals, Mumbai and President, Diabetic Foot Society of India.

*Corresponding Author: Rajesh Kesavan, Hycare Superspeciality Hospitals, MMDA, Arumbakkam, Chennai, India,
Email: rajdr@me.com, Phone:+91-44-23637700/+919962400066
Please follow the colour coded flow chart and table to understand presentation, evaluation and
management .

RED – Indicates critical state at presentation and is taken as first priority

Orange = Indicates Emergency situation at presentation and is second priority

Yellow – Indicates that extra care needs to be taken and is third priority

Green Indicates a stable situation

Any patient with features of

d • Breathlesness
• Fever
• Tachycardia
• Rule out Sepsis
(Could also be due to Covid 19)

Referral to hospital with ICU

facilities (CRITICAL)

Figure 1
 Management of patients without active wounds

PAIN

Ischemic Neuropathic

Acute limb ischemia- Sudden onset of • Neuropathic

Chronic limb
evaluation when
cold, pale, pulseless and painful limb ischemia feasible
• Rule out Ischemia
• Reassurance
• Footcare advice

Urgent referral to hospital with Doppler evaluation

facilities to manage vascular surgery
and
emergencies
Vascular Surgeon
Consult

Figure 2
 ERYTHEMA

Inflammatory
Infection
Conditions

• If Mild/moderate- oral
antibiotics and anti-
inflammatory drugs
• If Severe- needs diabetic
foot specialist intervention

Figure 3

SWELLING

Active Charcot Cellulitis

Diabetic Foot • If Mild and non-purulent-

Specialist outpatient management with
Consultation in the oral antibiotics
Clinic for Total
Contact Cast • If Moderate or Severe and
non-purulent- admission,
systemic antibiotics and limb
elevation

Figure 4
Management of Patients with Wounds

WOUND

IDSA CLASS 1
IDSA CLASS 3 & 4
(Uninfected)
(Moderate and
IDSA CLASS 2 Severe Infection)
(Mild infection)
Footcare advice

• Requires diabetic foot

• Oral specialist consultation in
antibiotics person in clinic
• Footcare • Patient with features of
advice sepsis (CRITICAL)- Referral
to hospital with ICU facilities

Figure 5

Need for a uniform approach

A table to understand the intricacies noticed in the management of these patients over the last two
weeks and changes made in the management of these patients is presented with a view to provide
appropriate standard of care in these difficult times. Technology is used to be in touch with the
patients at home unable to travel during the lockdown. Homecare services 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 keeps 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.
Diabetic foot evaluation does not restrict itself to the assessment of the infection alone. The various
subgroup of patients who present to us have additional features which must be taken into account. A
“simple” cellulitis can jeopardies the glycemic control and trip the already compromised organ
functions to critical levels. In order to provide a continuous care in a multispecialty multidisciplinary
manner, a record of the events have to be done in a simple and scientific manner so that the condition
of the patient can be shared among the involved specialties in order to understand the exact condition
of the patient.

The table below records 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 de rived based on a holistic evaluation of the patient.

Table 1

Patients with other co -morbid conditions like COPD, Chronic Renal Failure etc. need physician
evaluation and decision making should be made in accordance.
TELECONSULTATION

In accordance with the recent guidelines on telemedicine published by the Medical Council of India
we have come up with a teleconsultation protocol. Almost all patients except critical ones can be
triaged via teleconsultation.

Patient connects with clinician via

video call (with implied consent)

Patient and clinician confirm each

other’s identities

Patient caregiver asked to send the photo of

wound (if any)

• At least in 3 different angles

• With flashlight on
• One of the photos with both feet
together for comparison
• Videos of wound and foot if necessary

Patient is asked for history of :

• Fever
• Pain
• Discharge from wound
• Sore throat/cough (COVID)
• How the wound happened
• Fluctuating sugar levels

Caregiver asked to assess for:

• Swelling in the feet

• Warmth /tenderness around the
wound
• Check if patient is febrile

Figure 7
(Diagnosis based on photos are not always reliable and triaging can vary between clinicians. Hence practicing
clinician 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 ESR/CRP and reschedules the consultation to review the reports

• The clinician requests the patient for in person consultation due to

o the technical limitations in assessing the wound when there is suspicion of
infection involving deeper tissues
o patient requires emergency admission
o requires outpatient assessment with minor debridement.

• If the clinician is convinced about healthy wound status, he concludes the

consultation and the patient is advised on preventive aspects of footcare.

The teleconsultation is incomplete without patient 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 are 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 non-adherent 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 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 3. 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.
• Structured system of transfer of COVID positive patient to the Operating Room
(Operation Theatre) via communication between the surgeon, anaesthetist and
perioperative staff.

• We must presume that the entire OR is contaminated and hence:

o Follow negative pressure in OR/ allow 30 minutes time between cases for air
exchange
o Minimal number of staffs in the OR
o Hospital charts, pagers, and cell phones must be left outside the OR
o Dedicated runner should be posted outside of the OR to obtain supplies
o All single-use equipment (even unopened) in the room is thrown away at the
end of the case
o 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. Proper
gowning and doffing to be assisted and monitored by a buddy system(colleague).
Guidance for People With Diabetes And Diabetic Foot During Corona Virus Pandemic

People with Diabetic Foot especially foot infections have compromised immune response, hence are
considered to be vulnerable population for serious illness and unfavourable outcomes resulting from
corona virus infection.9,10 It has been noted that people with co-existing co-morbidities including
diabetes mellitus were more frequent amongst those who died from corona virus.

A. What precautions need to be taken?

1. Never omit your pre-existing anti-diabetic 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 40C, door of refrigerator). Never omit insulin because it may increase chances of
hyperosmolar non-ketotic coma or Diabetic ketoacidosis.

B. What to do?

3. Frequent monitoring of blood glucose: should be performed by glucometer available at home. If

glucometer is not available, consideration to be given to have one along with adequate number of
glucometer strips.

4. Adequate hydration: should be maintained especially if on SGLT2 inhibitors.

5. Hypoglycemia: Frequent meals should be consumed with more frequent blood glucose monitoring
if encompassing episodes of hypoglycemia or had prior hypoglycemia.

6. 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 above 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.

7. Life-style measures and Exercise: Continue life style 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.
8. Anti-hypertensives: Continue your anti-hypertensive medication for blood pressure (BP) as
prescribed by your physician with appropriate home-based BP monitoring devices. If you are on ACE
inhibitors, they should also be continued.

Conflict of interest: None

Contributions: Diabetic Foot society of India Executive Committee members have equally
contributed.

The authors wish to thank Dr Aarthi Viswanathan Subramanian, and Dr. Mohanasundaram
Thiruvengadam, for their assistance.

REFERENCES

1. Diabetes Foot Care in the COVID-19 Pandemic, M. Bates et al, Diabetic Foot Clinic, King’s
College Hospital, London, UK
2. Telemedicine Practice Guidelines Enabling Registered Medical Practitioners to Provide
Healthcare Using Telemedicine, Medical Council of India,March 25,2020.
3. Telemedicine and opportunities in wound care. An overview of solutions for beginners Luc
Téot Montpellier University Hospital.
4. SAGES and EAES recommendations regarding surgical response to COVID-19 crisis, Aurora
Pryor, March 29,2020.
5. COVID-19: good practice for surgeons and surgical teams, Royal College of Surgeons.
6. Protecting Surgical Teams During the COVID-19 Outbreak: A Narrative Review and Clinical
Considerations, Gabriel A. Brat MD MPH FACS et al,Annals of Surgery.
7. Lee C. Rogers, Lawrence A. Lavery, Warren S. Joseph, David G. Armstrong, (2020) 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.
Journal of the American Podiatric Medical Association In-Press.
8. Lipsky et al. Guidelines on the diagnosis and treatment of foot infection in persons with
diabetes (IWGDF 2019 update). Diab Metab Res Rev. 2020. e3280
9. Guan W, Ni Z, Hu Y, et al. Clinical course of corona virus disease 2019 in China. N Eng J Med
2020. Published online Feb 28 2020.
10. Fang L, Karakiulakis G. Roth M. Are patients with hypertension and diabetes mellitus at
increased risk for COVID-19 infetion? Lancet 2020. Published online March 11, 2020