dr.hilman.revisi kaki dm26
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Bedah Vaskuler Bedah Vaskuler
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Strategi dalam menghadapi pasienStrategi dalam menghadapi pasien
Kelainan Vaskuler Kelainan Vaskuler
Kelainan Vaskuler mengenai :Kelainan Vaskuler mengenai :- Sistem arteriSistem arteri- Sistem venaSistem vena- Sistem limfeSistem limfe
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KelainanKelainan
ArteriArteri VenaVena Limfe Limfe“Six Ps”- Pulseless- Painful
- Pale- Paraesthesia- Paralysis- Perishing cld
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Keluhan :
Akut : nyeri ! ke"iruan
dingin
Krnis : nyeri
ulkus
gangren
dingin
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P#$%P&#$AL VAS'(LA$ )%S#AS#SP#$%P&#$AL VAS'(LA$ )%S#AS#S
Bedah Vaskuler *K(%+$S(P,-'.Bedah Vaskuler *K(%+$S(P,-'.
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• /$0.B0A,1%%/%S 0BL%/#$A,S/$0.B0A,1%%/%S 0BL%/#$A,S
2Buerger )isease32Buerger )isease3
• '0.PL%'A/%0, 0* ).'0.PL%'A/%0, 0* ).
• A/&#$0S'L#$0S%SA/&#$0S'L#$0S%S
KAK% )%AB#/%KKAK% )%AB#/%K
- Kelainan endkrinKelainan endkrin
- Kelainan vaskuler Kelainan vaskuler
- Kelainan syaraf Kelainan syaraf
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KAKI DIABETIK KAKI DIABETIK
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• Kmplikasi : %nsidens amputasi 45 2K3Kmplikasi : %nsidens amputasi 45 2K3
Penurunan angka amputasi nn ).Penurunan angka amputasi nn ).
4665466578 978 9
888888;8 9;8 9
$S'. : 4667 ! 4665 : < ;5=5 9$S'. : 4667 ! 4665 : < ;5=5 9
258 9 dari 48>888 nn trauma3258 9 dari 48>888 nn trauma3
4665 ! 888 : 487 rang4665 ! 888 : 487 rang
Pasien /rauma :Pasien /rauma :
274+487 rang x 488 93 ? 78 9274+487 rang x 488 93 ? 78 9
Pasien ). :Pasien ). :
2@+487 rang x 488 93 ? @8 92@+487 rang x 488 93 ? @8 9
• Lama PeraatanLama Peraatan
• Biaya 2'st &spital3Biaya 2'st &spital3
• 1ii1ii
• $eha"ilitasi : - pst amputasi muscle exercise$eha"ilitasi : - pst amputasi muscle exercise
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Jumlah Kasus Pasien Diabetes Mellitus Jumlah Kasus Pasien Diabetes Mellitus(Amputasi)(Amputasi)
Jumlah Kasus PasienTrauma
Tahun 2001 - 2004Tahun 2001 - 2004Tahun 2001 -2004
!"M - Ja#arta!"M - Ja#arta !"M - Ja#arta
$amaBulan
Tahun2001
Tahun2002
Tahun200%
Tahun2004
$amaBulan
Tahun2001
Tahun2002
Tahun200%
Tahun2004
Januari 1 % 4 % Januari 0 1 0 2
&ebruari 0 1 4 0 &ebruari 2 0 2 2
Maret % % ' Maret 1 1 1 %
April 0 0 * April 1 2 1 %
Mei 0 1 1 2 Mei 0 0 1 %
Juni 0 1 % Juni 0 2 0 '
Juli 1 1 1 2 Juli 0 0 0 1
A+ustus 0 1 2 A+ustus 0 1 2 0
!eptember
2 % 1 !eptember
0 0 % 2
,#tber 1 4 4 % ,#tber 2 0 2
$pember
0 4 4 1 $pember
0 0 1 0
Desember 1 1 % Desember
0 0 ' %
Jumlah . 2 % 4% Jumlah ' 22 2
Ttal 11' Ttal '2
Pasien DM / 11'1* ran+ 100 3'
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K0.PL%KAS% :K0.PL%KAS% :
CC .akr Vaskuler :.akr Vaskuler : - 0tak- 0tak Dantung Dantung
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- Perier- Perier
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55 Mi#r 6as#uler /Mi#r 6as#uler /
- Mata- Mata
+in7al+in7al
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Syaraf Syaraf
,eurpati
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Pasien datang dengan keluhanPasien datang dengan keluhan
EE ,yeri :,yeri :
- Pegal- Pegal
- Klaudikati %ntermiten- Klaudikati %ntermiten
- $estpain- $estpain
EE %nfeksi :%nfeksi :
- Selulitis- Selulitis - A"ses - A"ses
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-(lserasi(lserasi
- 1angren- 1angren
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Anamnesis :
F $asa nyeri di"etis
klaudikati intermiten
F /rauma 2luka3 selulitis
F Luka G sukar sem"uhF 1angren
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PEMERIKSAAN FISIK :PEMERIKSAAN FISIK :
Abdomen : masa (aneurisma)Abdomen : masa (aneurisma)
Inspeksi :Inspeksi :
permukaan kulitpermukaan kulit bulu kakibulu kaki
kukukuku
ulkus (neuroiskemik), gangrenulkus (neuroiskemik), gangren lokasi lukalokasi luka
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Inspeksi
Palpasi :- Perabaan kulit
- Pulsasi sistem vaskular
- ABI (Ankle Brachial Index) ABI >
!ab"rat"rium
- #ula $arah
- %aal hati
- A&re&asi tr"mb"sit
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PALPAS% :PALPAS% : H suhu kulitH suhu kulit
H capillary refill testH capillary refill test
P(LSAS% : prximal ! distalP(LSAS% : prximal ! distal
,ilai :,ilai :• nrmal ! a"sennrmal ! a"sen
• kekuatankekuatan
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PalpasiPalpasi
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P#.#$%KSAA, P#,(,DA,1P#.#$%KSAA, P#,(,DA,1
)arah :)arah : H rutin= faal hepar= ureum= creatininH rutin= faal hepar= ureum= creatinin
H agregasi trm"sitH agregasi trm"sit
,n %nvasif :,n %nvasif :
H *t plsH *t pls
HH Laser fluksimetriLaser fluksimetri
H (S1 )ppler H (S1 )ppler
H '/ AngigrafiH '/ Angigrafi
H .$AH .$A
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%nvasif : Arterigrafi%nvasif : Arterigrafi H direkH direk
indirekindirek
H hasil :H hasil : - knvensinal- knvensinal
- )SA 2)igital Su"tractin Angigraphy3- )SA 2)igital Su"tractin Angigraphy3
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A,KL# B$A'&%AL %,)#I 2AB%3
• Per"edaan tekanan sistlik a>ankle dengan a>"rachial
F %ndikasi : setiap ada kelainan+gangguan
vaskular perifer 2anggta gerak3
F /ehnik
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B#)A& :B#)A& :
$aan Lkal$aan Lkal• %nsisi :%nsisi :
- drainase- drainase
- simple- simple - multiple- multiple
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,ekrtmi ! )e"ridement,ekrtmi ! )e"ridement
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e#nstru#sie#nstru#si
9as#ular9as#ular
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AmputasiAmputasi
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Pr"tesePr"tese
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Penurunan faktr resik :Penurunan faktr resik :- merkk- merkk
- hipertensi- hipertensi
- hiperlipidemia- hiperlipidemia
- riayat keluarga- riayat keluarga
- edukasi :- edukasi : ke"ersihan kakike"ersihan kaki
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Kasus emergensiKasus emergensi
FF Ascending infectinAscending infectin
- %nsisi- %nsisi - Amputasi- Amputasi
/+Suprtif+Alternatif /+Suprtif+Alternatif - &iper"arik- &iper"arik
- 0n 2xygen therapy3- 0n 2xygen therapy3
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/rans Atlantic %nter Sciety
'nsensus 1rup 2/AS'3
SP%/S ? Impured Sensation
= Impured Tissue Perfusion
= %nfection
= Amount /issue Loss
= Size
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%<%< &a#tr pre8ipsisi ;&a#tr pre8ipsisi ;
- i@a?at DM- i@a?at DM
- >ipertensi- >ipertensi
- Mer## - Mer##
- >?perlipi8emia- >?perlipi8emia
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The 8iabeti= t s?n8rme en=mpasses aThe 8iabeti= t s?n8rme en=mpasses a
number pathl+ies in=lu8in+ /number pathl+ies in=lu8in+ /
- 8iabeti= neurpath?- 8iabeti= neurpath?
- peripheral 9as=ular 8isease- peripheral 9as=ular 8isease
- "har=t neurarthrpath?- "har=t neurarthrpath?- t ul=eratin- t ul=eratin
- stem?elitis- stem?elitis
- amputatin- amputatin
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4he aeti"l"&y "f f""t ulcerati"n : 4he aeti"l"&y "f f""t ulcerati"n :
Purely neur"pathic : 56 7 - 8/ 70 m"re recentPurely neur"pathic : 56 7 - 8/ 70 m"re recent 98 798 7
Purely ischemicPurely ischemic : / 7 : / 7 0 70 7
;ixed neur"ischemic : <6 7 - 56 7;ixed neur"ischemic : <6 7 - 56 7 6<09 76<09 7
multidisciplinary f""t clinicsmultidisciplinary f""t clinics
i = f h l i l
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$irect e=ect "f hyper&lycaemia "n neur"nal$irect e=ect "f hyper&lycaemia "n neur"nal
metab"lismmetab"lism
Abn"rmalities in nitric "xide metab"lismAbn"rmalities in nitric "xide metab"lism perineuralperineuralvas"c"nstricti"n nerve dama&evas"c"nstricti"n nerve dama&e
$istal sens"ry p"lyneur"pathy is the m"st imp"rtant type$istal sens"ry p"lyneur"pathy is the m"st imp"rtant type Aut"n"mic neur"pathy reducesAut"n"mic neur"pathy reduces
- s*eatin& (skin)- s*eatin& (skin)
- "pen A3 Shunt- "pen A3 Shunt bl""d ?"*bl""d ?"* Aut"n"mic neur"pathyAut"n"mic neur"pathy
- instrinsic muscle "f the f""t- instrinsic muscle "f the f""t
- altered f""t sh"pe- altered f""t sh"pe
cl"ved t"e pr"minent metatarsal headscl"ved t"e pr"minent metatarsal heads @eur"pathy is resp"sible f"r a hi&h pr"p"rti"n @eur"pathy is resp"sible f"r a hi&h pr"p"rti"n
- vascular disease- vascular disease
- infecti"n- infecti"n%""t ulcerati"n
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4he distributi"n "f vascular disease in the l"*er 4he distributi"n "f vascular disease in the l"*erlimb is th"u&ht t" be di=erent in diabetic0 m"relimb is th"u&ht t" be di=erent in diabetic0 m"refreuent inv"lvement "f vessels bel"* the kneefreuent inv"lvement "f vessels bel"* the knee: <29 had intra p"pliteal (< x n"n diabetic: <29 had intra p"pliteal (< x n"n diabeticdisease)disease)
- $"ppler : *ave f"rm as l"ss "f the n"rmal$"ppler : *ave f"rm as l"ss "f the n"rmal
triphasictriphasic
- 4ranscutane"us "xy&en tensi"n 4ranscutane"us "xy&en tensi"n
accurately re?ects skin "xy&enati"naccurately re?ects skin "xy&enati"n an ulcer *ill heal level f"r amputati"nan ulcer *ill heal level f"r amputati"n
Arteri"&raphyArteri"&raphy &"ld standar&"ld standar
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Bi"mechanical aspectsBi"mechanical aspects
' !imited 1"int m"bility is a further c"ntributin&!imited 1"int m"bility is a further c"ntributin&fact"r t" elevated plantar pr"cessuresfact"r t" elevated plantar pr"cessures
' +hr"nic hyper&lycamia results in #lyc"sylati"n "f+hr"nic hyper&lycamia results in #lyc"sylati"n "f
pr"teins and *hen c"lla&en is inv"lve thepr"teins and *hen c"lla&en is inv"lve the
c"lla&en bundles bec"me thickened and cr"ss c"lla&en bundles bec"me thickened and cr"ss linkedlinked thick0 thi&ht0 *axy skin0 restricti"n "fthick0 thi&ht0 *axy skin0 restricti"n "f
1"int m"rement 1"int m"rement
alters the mechanics "f *alkin& and isalters the mechanics "f *alkin& and is
str"u&hy ass"ciated *ith hi&h plantar pr"ssurestr"u&hy ass"ciated *ith hi&h plantar pr"ssure
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Sp"ntane"us ulcerati"n c"mbinati"n "fSp"ntane"us ulcerati"n c"mbinati"n "f
trauma and neur"pathy0 unsersitivitytrauma and neur"pathy0 unsersitivity tissuetissue
dama&edama&e
lcerati"nlcerati"n
@eur"pathy causes atr"phy "f the intrinsic@eur"pathy causes atr"phy "f the intrinsic
muscle "f the f""t (pred"minanthy plantarmuscle "f the f""t (pred"minanthy plantar?ex"n "f the t"es) alterin& the ?ex"r2extens"r?ex"n "f the t"es) alterin& the ?ex"r2extens"r
balance at the metatars"phalan&eal 1"intsbalance at the metatars"phalan&eal 1"ints
neur"pathy
hi&h f""t pressures
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