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
2017 2018

2.48% 5.41%

Ulkus DM ulkus DM
Lainnya lainnya
97.52 94.59
% %

Jumlah pasien : 725 Jumlah pasien : 739

ulkus DM : 18 pasien 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 swollen
hot 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