Glycosuria pain is a chronic, progressive, systemic disease. It is not only diabetes, clinical medicine, another local ulceration, infection, surgical symptoms and signs often occur before or accompanied by gangrene, vascular disease, neuropathy, local infection and other related heart, brain, kidney, retinal disease, lung infections, ketoacidosis and other acute and chronic complications. Therefore, involving multi-disciplinary examination, diagnosis and treatment. First, in the course of treatment should pay attention to the following questions.
The basis of treatment needs throughout the entire process from beginning to end treatment of the main contents include control of diabetes, improve microcirculation and blood vessels re-dredge, anti-infective and correct all relevant acute and chronic complications, and supportive therapy. At this stage of treatment medication, require treatment throughout the entire process from beginning to end. Properly handle the relationship between the part and the whole, bogey saw local wounds, ignoring the practice of the state body.
Local wound debridement should not rush to the acute phase in the diabetic foot, local swelling and heat pain is more obvious, but with the exception of acute purulent incision and drainage, the surgical debridement should not be over-treatment, in order to prevent gangrene from gaining ground.
Removal of necrotic tissue, the preferable way to erode significantly in the basic treatment effect, patients generally improved, adverse metabolic state can be corrected, diabetes, and systemic and local infection under control, recycling and micro-circulation can be improved. At this point the part and the healthy tissue foot gangrene relatively clear boundaries can be cured into the rot phase. Qu rot at this stage focused on a gradual removal of necrotic tissue, to take "eating away" approach; the same time increase the drainage efforts to create conditions for wound healing.
Medical and surgical treatment of lower extremity revascularization should not be neglected, and endovascular interventional treatment of diabetic foot is one of the means in recent years, the new, mainly to solve the diabetic vascular disease caused by dry gangrene of the foot. But since the majority of diabetic foot gangrene is due to microvascular disease and nerve disease caused by, therefore, want to emphasize that comprehensive surgical treatment. According to lesion extent and location, select the appropriate method of treatment.
Diabetic peripheral vascular disease treatment
Diabetic peripheral vascular disease mainly include two aspects: ① mean arterial blood vessels and lower limb atherosclerosis (AS) caused by stenosis or occlusion: ② As the limb peripheral capillaries, microcirculatory disturbance caused by peripheral tissue ischemia.
Diabetes mellitus treatment of peripheral vascular disease risk factors, including the treatment and the disease treatment.
From the mechanism of drug therapy, at present used in clinical anticoagulant, defibrase, thrombolysis, anti-platelet therapy, dilation of blood vessels and blood circulation drugs such as traditional Chinese medicine, have the role to improve the peripheral circulation, both can be applied to diabetic peripheral vascular disease treatment. However, as diabetic peripheral vascular disease is a chronic, progressive nature of the occurrence and development of the disease, except in the event of acute peripheral vascular disease, such as acute thrombosis and other outside, and many anti-platelet, expand blood vessels and blood circulation of Chinese medicine and other drugs to combat diabetes, peripheral vascular disease.
The first generation of thrombolytic drug thrombolytic drugs streptokinase (SK) and urokinase (UK) as the representative. SK and UK thrombolytic strong, but the thrombolytic specificity is not strong, the short half-life, in turn dissolves fibrin, while the blood fibrinogen degradation, which led to bleeding and other serious adverse events.
In order to overcome the shortcomings of first-generation thrombolytic drugs, developed a second generation thrombolytic drug, tissue-type plasminogen activator (t-PA) as the representatives, including recombinant tissue-type plasminogen activator (M-TPA or rt-PA), methoxy benzoyl plasminogen activator chain enzyme complexes (AP-SAC) and so on. These drugs have a certain degree of thrombolysis specificity, half-life increased significantly, but also with anticoagulant, anti-platelet drugs such as the treatment of thrombosis, but more adverse reactions. The third-generation thrombolytic drugs is the use of genetic engineering and monoclonal antibody technology to transform the second-generation product made of a new PA products. Third-generation thrombolytic drugs and the first and second comparison, in specificity, efficiency and adverse effects in thrombolytic therapy has greatly improved, but still at an experimental stage.
Second-generation thrombolytic drugs compared with the first generation of major breakthrough, but the ideal still a certain gap between thrombolytic drugs. Developed in recent years, the third-generation thrombolytic drugs at the same time, people have gradually come looking for a good safety and adverse reactions is small, a good natural sources of drug efficacy, while its converted products of genetic engineering. The natural medicine has been developed mainly staphylokinase, fibrinolytic enzyme, Nattokinase and so on.
Anticoagulant
① heparin unfractionated heparin (UFH). UFH on coagulation inhibition in three stages, but the insoluble thrombus has been formed. UFH in the digestive tract can not be absorbed orally, subcutaneous injection of 5 000 IU/12 hours, bioavailability 20% ~ 30%, the dose increased, bioavailability will also increase. Intravenous anticoagulation can instantly play a role. Plasma half-life of 15 hours, anticoagulation sustainable 4 to 6 hours with a variety of plasma protein binding and inactivation by renal excretion. The placenta can not be used during pregnancy. Application of UFH anticoagulation should pay attention to the existence of contraindications, dosage should individual to enable the activated partial thromboplastin time (APPT) extended to the normal value of 1.5 ~ 2.5 times as declared. PTE and DVT commonly used intravenous infusion conditions were preferable to use continuous intravenous pump micro pump to start 1 000 IU / hour, after further adjustment according to APTT, duration 7 to 10 days. UFH major adverse reaction was bleeding due to multiple by the excessive light by mucocutaneous bleeding and in serious cases can cause gastrointestinal or intracranial bleeding, should stop using UFH, while giving the antagonist, and protamine, the dose with the last meeting UFH dosage. In acute allergic reactions seen in application of heparin UFH 5 ~ 10 minutes, patients with sudden chills, fever, heart palpitations, nausea, decreased blood pressure, also can occur from asthma, urticaria and respiratory distress, and should immediately stop using UFH, and to the anti-allergy treatment. Others still have heparin-induced thrombocytopenia (HIT), osteoporosis, increase in the number of eosinophils. ② low molecular weight heparin (LMWH): with UFH compared, LMWH with a hypodermic full absorption, bioavailability high ( "80%), longer half-life, adverse reaction to small and does not require laboratory monitoring of coagulation indicators in general, etc., effect of at least similar to UFH. Application of LMWH should pay attention to whether the anticoagulant contraindications, pregnant women should be used with caution. Because different manufacturers use different units of low molecular weight heparin in the system, but have different specifications, it is advised to carefully read the instructions before use. The main adverse reactions LMWH bleeding, injection site petechia petechiae, thrombocytopenia, usually do not need special treatment, LMWH reduction can be more seriously, antagonist, protamine can be used in and. ③ Arixtra (fon-daparinux): In acute coronary syndrome (ACS) and percutaneous coronary angioplasty (PCI) in terms of efficacy and safety, a large multi-center study found that, fondaparinux excellent result on enoxaparin, while the bleeding and a lower incidence of adverse reactions.
Vitamin K antagonist present, the clinically most commonly used is warfarin (warfarin), occasional use of new anticoagulant. After oral administration of warfarin, make the blood showed a transient hypercoagulable state, it began to warfarin can not be used alone, does not recommend the use of the amount of the initial shock. Soon after oral administration of warfarin from the intestinal absorption of 90% and plasma protein binding, free-type have biological activity. In liver metabolism by cytochrome P450 enzymes, metabolites and glucuronic acid binding by the urine and feces. Half-life of 35 ~ 45 hours, 20 ~ 30 hours after treatment markedly, 5 days up to the maximum anticoagulant effect. After stopping anticoagulant effects of sustainable 4 to 5 days. Teratogenic effects produced by the placenta, it is not appropriate for pregnant women. Since the onset of warfarin slowly, and there is a transient procoagulant effect, so clinically for the treatment of PTE and DVT in general, when LMWH or UFH in the application the day after beginning oral warfarin, 3 Ⅲ g, 1 times / day, for at least two overlapping applications 5 days. In the application of warfarin 3 days later blood inspected the international normalized ratio (INR), such as the INR ≤ 2 can continue to take, such as the INR> 2 should be an appropriate reduction of warfarin. In the application of warfarin 6 days after the re-taking of blood investigations INR, such as the INR <2, should the appropriate amount, 1 week after review
