Penatalaksanaan Ulkus Diabetes

Melitus Konservatif dan Operatif

dr. Nuryasin Kurniawan Sp.B, FINACS

outlines

• Definition

• Epidemiology

• Pathofisiology

• Clasification

• Treatment

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.

Diabetic ulcers

Diabetic ulcer is one of the complication

diabetes melitus in the form of open wound

on skin surface accompanied necrosis

(Frykberg,2002)

Berdasarkan penelitian Reiber,

lokasi ulkus :

> dipermukaan jari dorsal dan plantar (52%),

> daerah plantar (metatarsal dan tumit: 37%)

> daerah dorsum (11%).

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)

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

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 %.

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)

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

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

Ulkus DM di installasi Rawat Jalan Tahun 2017

Ulkus DM di installasi Rawat Jalan Tahun 2017

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

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)

PERIPHRAL VASCULAR DISEASE

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

Biomechanics of foot wear

AREAS AT RISK OF ULCERATION

FOOT WEAR

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

OSTEOMYLITIS

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

NEURO-OSTEOARTHROPATHY(CHARCOT FOOT)

NEURO-OSTEOARTHROPATHY(CHARCOT FOOT)

Pathophsiology of Foot Ulceration

Neuropathic

Ischemic

Neuro -ischemic

STAGES OF ULCER DEVELOPMENT

1. callus formation

2. Subcutaneous hemorrhage

3. Breakdown of skin

4. Deep foot infection with osteomyelitis

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)

Diabetic Foot Ulcer Treatment

> Multidisciplenary approach

> Staging dictate the treatment

option

> Continuity of care & life long

observation

Diabetic Foot Ulcer Treatment

Modalities

> Microbiological control

> Wound control

> Vascular control

> Mechanical control

> Metabolic control

> Educational control

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

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

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?

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.

Wound Debridment

• Debridement is the removal of necrotic,

damage, and infection tissue to improve the

healing potential of the remaining healty

tissue

debridement

• Neuropatic ulcers > need to be

debrided to determine the depth of the

ulcer and removal of necrotic tissue

• Ischaemic ulcer

Before debridement

After debridement

Amputation

• Amputation is made on clinical finding that

the ulceration is not healing/ infection

worsening in spite of intensive antibiotic

therapy

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

Major Amputation

> Mortality

> Risk of contra-lateral amputation

> Strict indication

> Careful choice of the level

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

THANK YOU