Amputations: ‘A pandemic within the pandemic’

In our last article, we wrote about the impact of the COVID-19 pandemic on wound care and indicated how the use of DEBRICHEM® could provide a solution for patients in situations where they cannot access their clinic to receive care. 

In this article, we will zoom in on the consequences of the COVID-19 pandemic and the imposed lockdowns that kept chronic wound patients from visiting their local hospital or wound clinic[1].

The current health emergency has changed the organisation of health institutions to focus attention on pandemic management. This has led to profound changes in the treatment of patients without COVID-19 and resulted in difficult access to care with delays in diagnosis and treatment[2]. Wound care has largely moved to the home setting with remote monitoring and little access to clinicians[3].

Research has been carried out in various countries to map the consequences of the change in these treatment strategies, for example, in the Netherlands, new guidelines were introduced to prioritize patients for surgical intervention during the COVID-19 pandemic. This has led to the postponement of all elective surgeries and a shift of regular healthcare to urgent care only[4]. Patients with  underlying comorbidities such as vascular diseases or diabetes require rapid treatment of their non-healing wounds in most cases. As a result of  care being temporarily postponed for vascular patients, while new patients were unable to enter the clinic for diagnosis and treatment, the number of major amputations increased from 18% in 2019 to 42% in 2020[4].

In addition to the human cost of losing a limb, a lower limb amputation also comes with incremental co-morbidities. Major amputation leads to severe morbidity and is associated with a high 1-year mortality rate of 44%[4]. The measurements taken during the COVID-19 lockdown period have had a significant effect on non COVID-19 wound care in several countries. These studies show that this has increased the number of major amputations.

For diabetic patients, a multitude of co-morbidities can set the stage for chronic ulcers which can ultimately lead to amputations: Numbness in the feet due to diabetic neuropathy, for example, can make people less aware of injuries and development of foot ulcers. The lack of pain in these ulcers may result in late action to address their wound, which can in turn, lead to a further advanced chronic wound with severe infection before being seen by a clinician[5]. Under normal conditions, lower-extremity amputations are a common complication among patients with diabetes throughout the world[6]. About 15% of all people with diabetes will develop a foot ulcer at some point and up to 24% of these patients with a foot ulcer need an amputation over time when the foot ulcer worsens.

Sena and Galleli (2020) describe a significantly greater number of amputations performed in their surgery department during the COVID-19 lockdown in Italy[2]. The writers state that they believe that the COVID-19 pandemic has led to poor treatment of wounds either because of delayed access or fear of contagion. This has led to an increase admission of severe chronic wound infections resulting in amputations in first line treatment. The number of amputations by their department increased over 50% for the same period one year before the lockdown. 

Caruso et al. (2020) write about similar experiences in their clinic and estimate a three-fold increase in risk for amputation as a result of diabetic foot ulcers[7]. From their perspective, the mandatory lockdown significantly affected patients with chronic diseases, especially people with diabetes and diabetic foot ulceration. They found a higher proportion of patients coming through the emergency care than the regular outpatient setting.

All articles conclude that the higher risk of amputation observed during COVID-19 lockdown confirms the need for proper and timely management of chronic wound patients to prevent dramatic outcomes responsible for reducing the quality of life and mortality [7]. Policymakers and physicians should be aware of the impact on vulnerable patients. For these patients, medical care should be easily accessible and adequate during a future pandemic.

When the home setting becomes central to the management of these patients, it reduces the need to travel to a clinic to access care and it is more likely that the patient is compliant and not overlooked. Not all common therapies are suitable for the home setting in chronic wound care, which is where the use of our novel product DEBRICHEM® can provide a possible solution to the problems described above, especially in situations where there is limited access to health care facilities or a sterile room. 

DEBRICHEM® is a disruptive new treatment option to address the infection in wounds. The topical agent offers a very effective alternative to surgical debridement, the current standard of care[8].  Due to its uncomplicated use, Debrichem could be highly beneficial also during the COVID-19 pandemic or similar situations where patients cannot reach hospitals to access regular treatment.

With DEBRICHEM®, problems caused by infections can be stopped at an early stage and thus prevent amputations as well as the comorbidities and increased mortality that comes along with amputation. 

References

[1]: Lee C. Rogers et al, (2020) A Pandemic within in a Pandemic; J. Am. Podiatry Medd Ass, 20-248

[2] Sena, G., & Gallelli, G. (2020). An increased severity of peripheral arterial disease in the covid-19 era. Journal of Vascular Surgery. doi:10.1016/j.jvs.2020.04.489 

[3]: Schlager JG, Kendziora B, Patzak L, et al. Impact of Covid-19 on woundcare in Germany. Int. Wound J. 2021 ; 1-7

[4] Schuivens, P. M. E., Buijs, M., Boonman-de Winter, L., Veen, E. J., de Groot, H. F. W., Buimer, T. G., … van der Laan, L. (2020). Impact of the COVID-19 lockdown strategy on vascular surgery practice: more major amputations than usual. Annals of Vascular Surgery. doi:10.1016/j.avsg.2020.07.025 

[5] https://www.health.com/condition/type-2-diabetes/how-to-avoid-amputations-if-you-have-diabetes

[6] Van Houtum, W. H., Rauwerda, J. A., Ruwaard, D., Schaper, N. C., & Bakker, K. (2004). Reduction in Diabetes-Related Lower-Extremity Amputations in the Netherlands: 1991-2000. Diabetes Care, 27(5), 1042–1046. doi:10.2337/diacare.27.5.1042 

[7] Caruso, P., Longo, M., Signoriello, S., Gicchino, M., Maiorino, M. I., Bellastella, G., … Esposito, K. (2020). Diabetic Foot Problems During the COVID-19 Pandemic in a Tertiary Care Center: The Emergency Among the Emergencies. Diabetes Care, dc201347. doi:10.2337/dc20-1347 

[8] Schultz G et al. Wound Rep Reg 2017; 25: 763. https://doi.org/10.1111/wrr.12590

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