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Donald Aronggear, MD

Diabetic Foot Ulcer

2
BERAPA LAMA LUKA INI AKAN SEMBUH?
Ulcers
• The incidence of diabetic foot ulcers is up to 25% over a
patient’s lifetime.
• The onset is variable in patients with type 1 diabetes.
• Foot ulcers occur in 15-25% of people with diabetes, which
equates to slightly more than 2% annually and between 5-
7.5% of those patients with neuropathy.
• Foot ulcers and infections are the most common reason for
hospital admission in people with diabetes in the United
States. The prevalence of diabetic ulcers is 7-8%.
• Since diabetes and obesity are growing at epidemic
proportions and with an increasing elderly population with
chronic conditions, will make coordinated care more essential
and valued.
Etiology

• The etiology of a diabetic foot ulcer


(DFU) is multifaceted. No single risk
factor is responsible for a foot ulcer.
Aetiology of DFUs
In most patients, peripheral neuropathy and peripheral
arterial disease (PAD) (or both) play a central role and
DFUs are therefore commonly classified as :
• Neuropathic
• Ischaemic
• Neuroischaemic
Typical features of DFUs according to
aetiology
TESTING FOR VASCULAR STATUS

Using a monofilament to
test for neuropathy
Classification and severity of diabetic
foot infections
Classification for Diabetic Foot Infections – Saint Elian
Wound Score System and Infectious Disease Society of
America
Saint Elian Score System for 10 subcategorized wound
severity factors and III Grades for prognosis
Areas at risk for DFU

Charcot foot.
Top — Charcot foot
with plantar ulcer.
Middle — Charcot
foot with sepsis.
Bottom — Chronic
Charcot foot
Key features of common wound
classification systems for DFUs
Treatment

The goal of ulcer treatment is to achieve rapid wound


closure to prevent serious downstream consequence
such as amputation and reduced quality of life

Treatment of DFUs can be difficult, and underlying


patient comorbidities and lack of patient compliance
can affect healing
Treatment

Successful diagnosis and treatment of patients


with DFUs involves a holistic approach that
includes:
• Optimal diabetes control
• Effective local wound care
• Infection control
• Pressure relieving strategies
• Restoring pulsatile blood flow.
EXAMINATION OF THE ULCER
A physical examination should determine:
• Is the wound predominantly neuropathic, ischaemic or neuroischaemic?
• If ischaemic, is there critical limb ischaemia?
• Are there any musculoskeletal deformities?
• What is the size/depth/location of the wound?
• What is the colour/status of the wound bed?
Black (necrosis)
Yellow, red, pink
• Is there any exposed bone?
• Is there any necrosis or gangrene?
• Is the wound infected? If so, are there systemic signs and symptoms of
infection (such as fevers, chills, rigors, metabolic instability and confusion)?
• Is there any malodour?
• Is there local pain?
• Is there any exudate? What is the level of production (high, moderate, low,
none), colour and consistency of exudate, and is it purulent?
• What is the status of the wound edge (callus, maceration, erythema,
oedema, undermining)?
ANATOMY

EPIDERMIS

DERMIS

HYPO DERMIS/
SUBCUTIS
WOUND STAGES
STAGE 1

Luka terjadi pada daerah Epidermis

Luka terlihat kemerahan atau


warna lebih gelap secara persisten,
baik merah, biru atau keunguan

Perubahan terjadi suhu pada luka,


bisa lebih hangat atau lebih dingin,
jaringan mengencang atau lebih
kendor, gatal- gatal dan terasa nyeri
WOUND STAGES
STAGE 2

Partial Thickness
Luka terjadi pada daerah Epidermis hingga
Dermis

Luka superficial dan secara klinis terlihat


terjadi abrasi, blister bahkan berlubang
WOUND STAGES
STAGE 3

Full Thickness
Terjadi kerusakan pada kulit, bisa terjadi
nekrosis pada daerah subkutan bahkan
hingga dibawah
fascia

Secara klinis luka terlihat seperti lubang yang


dalam dengan atau tanpa rongga didalam
luka
WOUND STAGES
STAGE 4
Full Thickness
Kerusakan yang luas terjadi, nekrotik,
kerusakan Juga dapat terjadi hingga otot,
tulang bahkan Support system yang lain
seperti tendon, kapsul Sendi

Undermining, sinus tract seringkali


dijumpai Pada stage 4
WOUND STAGES
UNSTAGABLE

Jaringan tebal, kering,


jaringan nekrotik atau
sering disebut sebagai
ESCHAR
HOLISTIC WOUND ASSESMENT

ETHIOLOGY :
- Mechanical : pressure, shear, friction, stripping
- Chemical: Incontinence, drainage
- Vascular : Arterial ulcer, venous ulcer, diabetic ulcer, etc
- Infection: Candidiasis, herpes
- Allergic
- Miscellaneous: radiation, thermal

DURATION OF WOUND/ WOUND AGE


Pressure ulcer and arterial or venous ulcer, If until 2 – 4 weeks
no good biopsy
HOLISTIC WOUND ASSESMENT

HEALING PROCESS IMPEDE : comorbid


condition
- Malignancies, diabetic, etc
-Medication :Chemotherapy, Corticosteroid
- Tissue perfusion
- Nutrition and Hydration
- Psychosocial barrier : Family, financial
DFU WOUND MANAGEMENT
Types of wound dressings available
Wound management dressing guide
DFU WOUND MANAGEMENT
The purpose of this table is to provide guidance about
appropriate dressings and should be used in conjunction with
clinical judgement and local protocols.
Where wounds contain mixed tissue types, it is important to
consider the predominant factors affecting healing and address
accordingly.
Where infection is suspected it is important to regularly inspect
the wound and to change the dressing frequently.
Wound dressings should be used in combination with
appropriate wound bed preparation, systemic antibiotic
therapy, pressure offloading and diabetic control
WOUND ASSESMENT
1.Wound Stages 1-4
2.Wound Location
3.Type of Tissue (Epithel,
Granulation, slough)
4.Dimention
5.Exudates
6.Odor
7.Wound Edge
8.Peri- wound skin
9.Sign of Infection
10.Wound Pain
WOUND ASSESMENT
1. Wound Location

2. Wound Stages(1-4)
WOUND ASSESMENT
3. Wound Base

4. Type of tissue
WOUND ASSESMENT
5. Dimentions

6. Exudate
WOUND ASSESMENT
7. Wound Edges

8. Peri-wound skin
WOUND ASSESMENT
10. Sign of Infection
WOUND BED PREPARATION (WBP)
TUJUAN (WBP)
1. Menghilangkan faktor yang menghambat
penyembuhan luka
2. Meningkatkan support system autolytic
debridemant
3. Absorbsi Eksudat
4. Menghilangkan bau tidak sedap
5. Menghindari terjadinya infeksi
6. Mempersiapkan dasar luka, agar bisa di mulai
proses penyembuhan luka dengan baik, dibantu
dengan modern dressing
WOUND BED PREPARATION (WBP)
WOUND BASE COLOR /WARNA DASAR LUKA (Red, Yellow, Black)
1. RED (MERAH)
Warna dasar merah terang atau
merah tua, tampak lembab adalah
granulasi, vaskulerisasi baik tetapi
mudah berdarah

Warna dasar luka merah muda/


pucatmerupakan lapisan epithelisasi
yang merupakan fase akhir dari
penyembuhan
WOUND BED PREPARATION (WBP)
WOUND BASE COLOR /WARNA DASAR LUKA (Red, Yellow, Black)

2. YELLOW (KUNING)
Dasar warna luka kuning/ kuning kecoklatan/ kuning pucat,
kondisi luka terkontaminasi, terinfekasi
Avaskularisasi dikenal dengan nama SLOUGH
WOUND BED PREPARATION (WBP)
WOUND BASE COLOR /WARNA DASAR LUKA (Red, Yellow, Black)

3. BLACK (HITAM)
Warna dasar luka hitam/ hitam kecoklatan/hitam kehijauan
merupakan jaringan nekrotik.
Avascularisasi
WOUND BED PREPARATION (WBP)
WOUND BASE COLOR /WARNA DASAR LUKA (Red, Yellow, Black)

4. BIO FILM
Biofilm didefinisikan sebagai komunitas mikroorganisme yang
membentuk kapsul dan didalam nya membangun polymeric
matrix yang sangat kuat, tekstur nya seperti agar- agar. Apabila
tidak di buang, maka WBP tidak terjadi dan proses
penyembuhan luka tidak dapat berjalan
WOUND BED PREPARATION (WBP)
TIME MANAGEMENT
WOUND BED PREPARATION (WBP)
TIME MANAGEMENT
T = TISSUE MANAGEMENT, remove
non viable tissue

Debridemant
• Surgical
• CSWD (Conservative Sharp WD)
• Autolysis Debridemant
• Mechanical Debridemant
• Biological Debridemant
WOUND BED PREPARATION (WBP)
TIME MANAGEMENT
I = INFLAMATION & INFECTION
CONTROL
• Mencuci luka dengan
menggunakan NaCl atau PHMB
• Diberikan dressing yang
mengandung ionic silver atau
anti mikroba topikal yang lain
• Apabila sudah terjadi infeksi
sistemik, maka perlu diberikan
tambahan obat antibiotik
WOUND BED PREPARATION (WBP)
TIME MANAGEMENT
M = MOISTURE BALLANCE

• Menjaga keseimbangan kelembaban


luka
• Untuk dry wound, berikan topikal
dressing yang mampu memberi
kelembaban luka
• Untuk luka yang high exudate,
berikan dressing yang mampu
absorb high exudat
WOUND BED PREPARATION (WBP)
TIME MANAGEMENT
E= EPITHELISATION

Proses Epithelisasi memerlukan


suasana lembab yang seimbang
(moisture balance) diperlukan
dressing yang mampu menjaga
keseimbangan kelembaban luka
karena akan Merangsang proses
terjadinya epithelisasi
WOUND BED PREPARATION (WBP)
TIME MANAGEMENT
WOUND BED PREPARATION (WBP)
TIME MANAGEMENT
WOUND BED PREPARATION (WBP)
Proses WBP diperlukan waktu 2- 4 minggu
Apabila luka sudah ter- preparasi dengan baik, maka luka
sudah siap
Untuk memulai proses penyembuhan.
Diperlukan dressing yang mampu menjaga kelembaban luka
agar proses
Granulasi dan apithelisasi berjalan lebih cepat
BERAPA LAMA LUKA INI AKAN SEMBUH?
BERAPA LAMA LUKA INI AKAN SEMBUH?
BERAPA LAMA LUKA INI AKAN SEMBUH?

Jadi waktu penyembuhan luka sekitar 33


minggu
N= Waktu penyembuhan
APA YANG AKAN DILAKUKAN APABILA SETELAH
4 MINGGU PROSES TIME DILAKUKAN TETAPI
LUKA TIDAK MENUNJUKKAN PERKEMBANGAN?

• Lakukan kultur, untuk mendapatkan


pengobatan antibiotik sistemik
General principles of bacterial
management
At initial presentation of infection it is important to assess its severity, take
appropriate cultures and consider need for surgical procedures
• Optimal specimens for culture should be taken after initial cleansing and
debridement of necrotic material
• Patients with severe infection require empiric broad-spectrum antibiotic
therapy, pending culture results. Those with mild (and many with moderate)
infection can be treated with a more focused and narrow-spectrum antibiotic
• Patients with diabetes have immunological disturbances; therefore even
bacteria regarded as skin commensals can cause severe tissue damage and
should be regarded as pathogens when isolated from correctly obtained
tissue specimens
• Gram-negative bacteria, especially when isolated from an ulcer swab, are
often colonising organisms that do not require targeted therapy unless the
person is at risk for infection with those organisms
General principles of bacterial
management
• Blood cultures should be sent if fever and systemic toxicity
are present
• Even with appropriate treatment, the wound should be
inspected regularly for early signs of infection or spreading
infection
• Clinical microbiologists/infectious diseases specialists have a
crucial role; laboratory results should be used in combination
with the clinical presentation and history to guide antibiotic
selection
• Timely surgical intervention is crucial for deep abscesses,
necrotic tissue and for some bone infections
Conclusions

Successful diagnosis and treatment of patients


with DFUs involves a holistic approach that
includes:
• Optimal diabetes control
• Effective local wound care
• Infection control
• Pressure relieving strategies
• Restoring pulsatile blood flow.
Thank You