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Penatalaksanaan Ulkus Diabetes
Melitus Konservatif dan Operatif
dr. Nuryasin Kurniawan Sp.B, FINACS
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outlines
• Definition
• Epidemiology
• Pathofisiology
• Clasification
• Treatment
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Menurut American Diabetes
Association, diabetes melitus
merupakan suatu kelompok penyakit
metabolik dengan karakteristik
hiperglikemia yang terjadi karena
kelainan sekresi insulin, kerja insulin, atau kedua-duanya.
Etiologi
1. Fungsi sel pankreas dan sekresi insulin yang berkurang
2. Perubahan karena lanjut usia sendiri yang berkaitan dengan resistensi insulin, akibat kurangnya massa otot dan perubahan vaskular.
3. Aktivitas fisik yang berkurang, banyak makan, badan kegemukan.
4. Keberadaan penyakit lain, sering menderita stress, operasi.
5. Sering menggunakan bermacam-macam obat-obatan.
6. Adanya faktor keturunan.
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Diabetic ulcers
Diabetic ulcer is one of the complication
diabetes melitus in the form of open wound
on skin surface accompanied necrosis
(Frykberg,2002)
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Berdasarkan penelitian Reiber,
lokasi ulkus :
> dipermukaan jari dorsal dan plantar (52%),
> daerah plantar (metatarsal dan tumit: 37%)
> daerah dorsum (11%).
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Diabetic Foot
Definition:
Infection, ulceration or destruction of
deep tissues associated with
neurological abnormalities & various
degrees of peripheral vascular
diseases in the lower limb
(based on WHO definition)
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Epidemiology
40% - 60% of all non traumatic lower
limb amputation
85% of diabetic related foot
amputation are preceded by foot ulcer
4 out of 5 ulcer in diabetics are
precipitated by trauma
4% -10% is the prevalence of foot ulcer
in diabetics
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Epidemiology
Menurut Kemenkes RI, diperkirakan tahun 2030 prevalensi diabetes melitus di Indonesia mencapai 21,3 juta orang.
Hasil Riskesdas 2013, prevalensi diabetes melitus berdasarkan wawancara terjadi peningkatan dari 1,1 % tahun 2007 menjadi 2,1 tahun 2013 dan yang terdiagnosis dokter sebanyak 1,5 %.
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Epidemiology
DI Yogyakarta :
Prevalensi penderita diabetes melitus terdiagnosis dokter di terjadi peningkatan dari (1,1 %) tahun 2007 menjadi (2,6 %) tahun 2013,
Sedangkan prevalensi penderita dabetes melitus terdiagnosis dokter atau dengan gejala juga terjadi peningkatan dari (1,6 %) tahun 2007 menjadi (3,0%) tahun 2013.
(Riskesdas 2007,2013)
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Ulkus DM di Bangsal Bedah
RSUD NAS
2.48%
97.52%
2017
Ulkus DM
Lainnya
5.41%
94.59%
2018
ulkus DM
lainnya
Jumlah pasien : 725
ulkus DM : 18 pasien
Jumlah pasien : 739
ulkus DM :40 pasien
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Ulkus DM di Instalasi Rawat Jalan
RSUD NAS
• Prosentase penyakit Non insulin Dependen DM terjadi peningkatan dari 1,92 % tahun 2017 menjadi 2,71 % tahun 2018 serta Insulin Dependen DM juga mengalami peningkatan dari 1,35 % tahun 2017 menjadi 2,54 % tahun 2018.
• Prosentase Kejadian ulkus DM di Instalasi Rawat jalan RSUD Nas terjadi peningkatan dari 0,75 % tahun 2017 menjadi 2,36 % tahun 2018
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Ulkus DM di installasi Rawat Jalan Tahun 2017
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Ulkus DM di installasi Rawat Jalan Tahun 2017
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etiologi
a. Diabetik neuropati
> kerusakan serabut motorik (kelemahan otot, atrofi otot, deformitas)
> kerusakan serabut sensoris (penurunan sensasi nyeri sehingga memudahkan terjadinya ulkus di kaki
> kerusakan serabut autonom (menimbulkan kulit kering, terbentuknya fissure kulit dan edema kaki)> History & careful foot examination are mandatory to diagnose neuropathy> Up to 50%of type2 diabetic patient have significant neuropathy & at risk of foot ulcer
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b. Pheripheral vascular diseases> PVD is the most important factors related to outcome of diabetic foot ulcer> PVD is diagnosed by simple clinical examination> non invasive vascular test determines probability of healing> Symptoms of ischemia may be masked by neuropathy> Microangiopathy shouldn't be accepted as primary cause of ulcer> Conservative approach for treatment> Outcome of revascularization is similar to that in non-diabetic> arteriosklerosis (penurunan elastis dinding arteri) > aterosklerosis (akumulasi “plaques”pada dinding arteri)
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PERIPHRAL VASCULAR DISEASE
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c. Biomechanics of foot wear> Biomechanical abnormalities are consequence of neuropathy, they lead to abnormal foot pressure> Foot deformity & neuropathy increase the risk of ulcer> Pressure relief is essential for ulcer healing and/or prevention> Frequent inspection of shoes & insoles is mandatory> Appropriate foot wear significantly reduce ulcer recurrence
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Biomechanics of foot wear
AREAS AT RISK OF ULCERATION
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FOOT WEAR
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d.Infection
> Infection in diabetic foot is limb threatening
> Signs of infection may be absent in diabetic pt. with foot ulcer
> Superficial infection is usually caused by gram +ve cocci, deep infection is poly microbial
> Surgical debridment is essential in acute deep infection> Osteomylitis
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OSTEOMYLITIS
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d. Neuro-osteoarthropathy
> Non- infective pathology
> Should be suspected in any swollenhot erythematous foot
> Differentiation from infection is important to prevent misdiagnosis & possible amputation> Treatment should aim at preventing severe deformity
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NEURO-OSTEOARTHROPATHY(CHARCOT FOOT)
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NEURO-OSTEOARTHROPATHY(CHARCOT FOOT)
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Pathophsiology of Foot Ulceration
Neuropathic
Ischemic
Neuro -ischemic
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STAGES OF ULCER DEVELOPMENT
1. callus formation
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2. Subcutaneous hemorrhage
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3. Breakdown of skin
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4. Deep foot infection with osteomyelitis
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Staging of Diabetic Foot
Stage Clinical condition
0 Intack skin (impending ulcer
1 Superficial
2 Deep to tendon bone or ligmament
3 Osteomielitis
4 Gangrene of toes or forefoot
5 Gangren of entire foot
(Wagner)
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Diabetic Foot Ulcer Treatment
> Multidisciplenary approach
> Staging dictate the treatment
option
> Continuity of care & life long
observation
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Diabetic Foot Ulcer Treatment
Modalities
> Microbiological control
> Wound control
> Vascular control
> Mechanical control
> Metabolic control
> Educational control
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How To Prevent Foot Problems
5 corner stones> Regular inspection & examination of foot & foot wear
> Identification of high risk patient
> Education of patient, family & health care providers
> Appropriate foot wear
> Treatment of non ulcerative pathology
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Physiology of wound healing
There are 4 phases of wound healing
1. Haemostasis
2. Inflamation
3. Proliferasi
4. Maturation
• The length of time taken to progress through
these phases varies for each wound
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Wound dressing
Aseptic technique
Change dressing daily, more regulary when strike
through noted on dressing
Diabetic foot wounds should be kept dry and clean
at all times
Do not soak the foot or bath/shower the patient
Apply saline with gauze to clean wound surface
Simple wound dressing over ulcer site and secured
Offload with appropriate foot wear/bed rest/ turn
patient regulary
Rewiew wound regulary and refer early if wound
deteriorates
Antibiotics?
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Principles of wound dressing
Microorganism are present in the
environment, on the articles and on the skin.
Pathogenic organism are trasmitted from the
source to the new host directly or directly.
Bacteria travel along with the dust particles
Cleaning an area where trere is less number
of organism, before cleaning an area where
there are more organism, minimize the
spread of organism to the clean area.
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Wound Debridment
• Debridement is the removal of necrotic,
damage, and infection tissue to improve the
healing potential of the remaining healty
tissue
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debridement
• Neuropatic ulcers > need to be
debrided to determine the depth of the
ulcer and removal of necrotic tissue
• Ischaemic ulcer
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Before debridement
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After debridement
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Amputation
• Amputation is made on clinical finding that
the ulceration is not healing/ infection
worsening in spite of intensive antibiotic
therapy
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Amputation in Diabetic Patient
> Increased minor\major amputation
increased the no of deformed feet
> Minor amputation is needed :
* Gangrene
* As part of debriment
* for correction of foot deformities
> Minor amputation doesn’t significantly
compromise walking ability
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Major Amputation
> Mortality
> Risk of contra-lateral amputation
> Strict indication
> Careful choice of the level
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Amputation
> Distal (limb-saving) > for gangren of feet
- toe - mod foot
- ray - symes
- transmetatarsal - guillotine
> Major (live-saving) > rapidly spreading symptomatic
gangrene
- gas gangrene
- below knee
- gritti-stokes
- through knee
- above knee
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THANK YOU