• Email:
  • Password:
  • Remember Me
 
Print   Subscribe    Share
DPM
Are palpable pulses really a good sign of blood flow in the diabetic foot?
Section:  Diabetic Foot
Palpating pulses in the foot is part of the routine evaluation for blood flow. But what does it really mean in the diabetic foot? If pulses are palpable, does it mean that circulation is adequate? I have seen cases of poor wound healing and progressive gangrene in the presence of palpable pedal pulse.

Do you think palpable pulses are a good indicator of adequate blood flow in the diabetic foot?
Poll Results:
Yes
33% 33% (7 votes)
No
57% 57% (12 votes)
Uncertain
10% 10% (2 votes)
MEMBER COMMENTS
RE:
I've listened to Gary Gibbons, MD (vascular surgeon, the Deaconess, Boston) on multiple occasions state that diabetic patients with a threatened limb require maximal flow to heal. I believe we have all seen patients like Dr. Liu describes. In a patient that presents with a new wound to my center, we always obtain non-invasive measures macrovascular flow (ABI, TBI, segmental pressures, PVR). I am surprised how often they don't correlate with the presence or absence of pulses. We often obtain microvascular measures as well (OxyVu, but TcPO2, SPP are adequate too). It is also surprising seeing the discordance between macro and micro vascular studies.

Also, remember about 8% of healthy patients have a non palpable DP pulse, and anatomical studies have shown the DP artery to be absent 2% of the time.
Macro Vs. Micro Circulation
The issue at hand deals with micro vs. macro-circulation. The presence of palpable pulses is a good indicator of patent macro-circulation but I agree with Dr. Roger's that evaluation of the micro-circulation via TcPO2 and SPP is necessary when dealing with healing surgical or chronic wounds in patients with diabetes.

The key is to remember the presence of palpable pulses does not necessarily mean that there is enough local blood supply to heal a lower extremity ulceration.
RE: Physical exam is not very reliable
There was a recent JAMA article (2006) on this very topic. They did a systematic review of physical exams & PAD (Peripheral Arterial Disease). What we see and feel is not very accurate at all, and we cannot (and should not) confidently rule in or rule out PAD with physical exams only.

What does it mean? I urge every clinician to use some kind of objective testing device at all times. It can be a handheld doppler (inexpensive and with trained hands, reasonably accurate) or more sophisticated as Laser-Doppler SPP (Skin Perfusion Pressure) device.

If you are interested in topic, I have a web lecture up on this PRESENT site regarding PAD and non-invasive vascular tests.

To answer the origial post, "No, palpable pulses (or what I think is palpable pulses) are not good enough for me. I want to see SPP/PVR before I start treating my wound patients."
Re: Are palpable pulses really a good sign of blood flow in the diabetic foot?

Thank you for bringing up this topic.  I would like to describe a situation that makes me uncomfortable and I would ask for your feedback.  I was taught that when a patient needs compression wraps for a venous stasis ulcer that the patient should have an ABI done to confirm that the patient has adequate arterial flow.  The ABI should be 0.8 or greater in order to safely wrap the extremity.  I have come across more than one physician that has told me to wrap an extremity without performing an ABI because the patient "has a good pedal pulse".  Usually I refuse to wrap the leg and one of two things happens.  Either the doctor wraps it himself or they send the patient for an ABI and there have been instances where the ABI result did not support a treatment plan that included compression.  I was happy to see this discussion.  Thank you!