REFERAT ULKUS DEKUBITUS

Pembimbing Letkol (CKM) dr. Dadiya, Sp. B

Karina Mega Wulansari01.2111.6428

Kepaniteraan Klinik Ilmu BedahRST. Tk.II dr.Soedjono Magelang

Fakultas Kedokteran UNISSULA Semarang2015

Pendahuluan Perawatan kulit yang tidak teratur dan konsisten dapat mengakibatkan

terjadinya gangguan integritas kulit.

Gangguan integritas kulit dapat diakibatkan oleh tekanan yang lama, iritasi

kulit, atau immobilisasi dan berdampak timbulnya luka dekubitus

Angka kejadian luka dekubitus di Indonesia mencapai 33,3% dimana angka

ini cukup tinggi bila dibandingkan dengan angka prevalensi ulkus dekubitus di

ASEAN yang hanya berkisar 2,1%–31,3% .

Ulkus dekubitus yang tidak ditangani dapat menyebabkan terjadinya

osteomyelitis,sepsis bahkan kematian.

Tujuan

Referat ini disusun sebagai bahan informasi bagi penulis serta para pembaca, khususnya kalangan medis, agar dapat lebih memahami tentang ulkus dekubitus serta penanggulangan dan pencegahannya

Definisi

Dekubitus berasal dari bahasa latin “decumbree” merebahkan diri

Suatu luka akibat posisi penderita yang tidak berubah dalam jangka waktu lebih dari 6 jam (Sabandar, 2008).

(National pressure Ulcer Advisory panel (NPUAP), 1989 dalam Potter & perry, 2005) mengatakan dekubitus merupakan nekrosis jaringan lokal yang cenderung terjadi ketika jaringan lunak tertekan diantara tonjolan tulang dengan permukaan eksternal dalam jangka waktu lama.

Faktor Resiko Dekubitus

Gangguan Input Sensorik Gangguan Fungsi Motorik Perubahan Tingkat KesadaranGips, Traksi, Alat Ortotik dan Peralatan Lain

Potter & Perry (2005)

Braden dan Bergstrom (2000)

Faktor yang mempengaruhi pembentukan Ulkus DekubitusGaya Gesek Friksi KelembabanNutrisi Buruk Anemia Kakeksia ObesitasDemamGangguan Sirkulasi Perifer Usia

Patogenesis

Advanced sacral pressure ulcer shows effects of pressure, shearing, and moisture.

The organisms most commonly isolated from pressure ulcers are as follows:

Proteus mirabilisGroup D streptococciEscherichia coliStaphylococcusPseudomonasCorynebacterium

Lokasi Terjadinya Ulkus Dekubitus

Klasifikasi National Pressure Ulcer Advisory Panel (NPUAP) Ulkus Dekubitus

(Suspected) deep tissue injury Stage I

Stage IIStage III

Stage I V

Unstageable

A purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure or shear.Intact skin with signs of impending ulceration, initially presenting blanchable erythema indicating reactive hyperemiaA partial-thickness loss of skin involving epidermis and dermisA full-thickness loss of skin with extension into subcutaneous tissue but not through the underlying fasciaA full-thickness tissue loss with extension into muscle, bone, tendon, or joint capsuleA full-thickness tissue loss in which the base of the ulcer is covered by slough or eschar to such an extent that the full depth of the wound cannot be appreciated

Diagnosis

Laboratory studies that may be helpful include the following:Complete blood count (CBC) with differentialErythrocyte sedimentation rate (ESR)Albumin and prealbuminTransferrinSerum protein

When indicated by the specific clinical situation, the following should be obtained:

Urinalysis and culture in the presence of urinary incontinenceStool examination for fecal WBCs and Clostridium difficile toxin when pseudomembranous colitis may be the cause of fecal incontinenceBlood cultures if bacteremia or sepsis is suggested

Additional studies that may be considered include the following:Plain radiographyBone scanMagnetic resonance imagingTissue or bone biopsy

Diagnosis

Komplikasi Ulkus Dekubitus

Infeksi, umumnya bersifat multibakterial baik aerobik maupun anaerobik. Keterlibatan jaringan tulang dan sendi seperti periostitis, osteotitis, osteomielitis, dan arthritis septik. Septikemia Animea Hipoalbuminea Kematian

Subandar (2008)

Heaps of verrucous white tissue around the ulcer suggest malignant transformation, as observed with Marjolin ulcers.

Illustrated is Girdlestone arthroplasty for femoral head osteomyelitis pyarthrosis of hip joint. Femoral head is removed, and hip joint space is reconstructed with vastus lateralis muscle flap.

Patient has urethral fistula within his pressure ulcer. When he performs Valsalva maneuver, urine leaks through this opening.

Pencegahan Dekubitus Potter & Perry (2005), menjelaskan tiga cara dalam pencegahan dekubitus, yaitu :

Higiene dan Perawatan Kulit Pengaturan Posisi Alas pendukung (kasur dan tempat tidur terapeutik)

Potter & Perry (2005), mengidentifikasi 9 parameter yang digunakan ketika

mengevaluasi alat pendukung :

Harapan hidup Kontrol kelembaban kulit Kontrol suhu kulitPerlunya servis produk Perlindungan dari jatuh Kontrol infeksi Redistribusi tekanan Kemudahan terbakar api Friksi

Penatalaksanaan DekubitusGuidelines developed by the Agency for Healthcare Policy and Research (AHCPR) Pressure Ulcer Panel for managing existing pressure ulcers include the following:

Use positioning devices to raise a pressure ulcer off the support surface; if the patient is no longer at risk for pressure ulcers, these devices may reduce the need for pressure-reducing overlays, mattresses, and beds; avoid using donut-type devices Assess all patients with existing pressure ulcers to determine their risk for developing additional pressure ulcers; if the patient remains at risk, use a pressure-reducing surface If patients can assume a variety of positions without bearing weight on the lesion and without “bottoming out,” a static support surface should be usedIf the patient cannot assume a variety of positions without bearing weight on the ulcer, if the patient fully compresses the static support surface, or if the pressure ulcer does not show evidence of healing, a dynamic surface should be usedFinally, if the patient has large stage III or stage IV pressure ulcers on multiple turning surfaces, a pressure-relieving product is warranted 

Wound ManagementDébridement and debriding agents

Enzymatic débridement Mechanical nonselective débridement Sharp débridement

Solutions for wound cleansing Povidone-iodine Acetic acid (0.5%) Sodium hypochlorite (2.5%)

Wound dressings Hydrocolloid dressings form Gel dressings Transparent adhesive dressings Alginate dressings

Antimicrobials and antibioticsAntibiotic creams such as silver sulfadiazine may be applied to

wounds to decrease bacterial load. Silver sulfadiazine has an excellent antimicrobial spectrum of activity, low toxicity, ease of application, and minimal pain. It inhibits DNA replication and modification of the cell membrane of Staphylococcus aureus; Escherichia coli; Candida albicans; Klebsiella, Pseudomonas, and Proteus species; and Enterobacteriaceae.

Mafenide, an antimicrobial agent that is bacteriostatic to many gram-positive and gram-negative organisms, including Pseudomonas aeruginosa, can penetrate an eschar and promote autolytic softening of the eschar prior to debridement.

Surgical Débridement

Radical bursectomy is performed by placing methylene blue–moistened sponge in bursa and excising pressure ulcer circumferentially, removing all granulation tissue, even from wound base.

Options for Wound ClosureDirect cl osureSkin graftsSkin flapsMyocutaneous flapsFree flaps

Surgical Management of Specific Pressure

Ulcer Types

Ischial Pressure Ulcer

With gluteal thigh flap, superiorly based flap is elevated, with inferior gluteal artery located between greater trochanter and ischial tuberosity as its axis. Gluteal thigh flap may be raised

to include inferior portion of gluteus maximus, which increases arc of rotation to allow flap also to be used to reconstruct sacral defects.

Sacral Pressure Ulcer

Sacral pressure ulcer before and after flap closure. Small sacral pressure sores can be

reconstructed with the inferior-based skin rotation flap, with or without the superior gluteus maximus myocutaneous flap.

Small sacral pressure ulcer reconstructed with inferiorly based skin rotation flap.

Small sacral pressure ulcer reconstructed with inferiorly based skin rotation flap.

Trochanteric pressure ulcer

Skin paddle is harvested 10 cm in width and designed over muscle along axis from anterior superior iliac spine to lateral tibial condyle

Inferior limit of cutaneous territory can be extended to 6 cm above knee and 25-35 cm in length. Lateral femoral circumflex artery can be found approximately 6-8 cm inferior to anterior superior iliac spine.

TERIMA KASIH