DIABETIC FOOT

Rengga Pradipta
Gempita Nuzuliyah
Diah Malenti
Kumareysh Vijay Vijayan

 Infeksi, ulserasi atau penghancuran

jaringan serta adanya kelainan
neurologis & berbagai tingkat
penyakit pembuluh darah perifer di
ekstremitas bawah yang dikaitkan
dengan penyakit diabetes (WHO)

Epidemiology
Di RSHS 44,2% dari seluruh
penderita diabetes mellitus yang
dirawat inap menderita diabetic foot
(2002)
50% kasus disebabkan diabetic foot

Ciri-Ciri
Tanda-tanda diabetes mellitus.
Infeksi ulkus pada kaki yang sukar
sembuh.
Tanda-tanda iskhemi dan neropati.

 3 gejala patologis yang bekerja

saling berinteraksi bersama secara
kompleks dan jarang sekali muncul
sendirian, yaitu
(1) neuropati, (2) infeksi, (3)
iskhemia

Mikrosirkulasi
Mikroangiopati pada penderita
diabetes mellitus adalah adanya
penebalan yang difus pada
membrana basalis pembuluh kapilar
yang antara lain ditemukan pada
kapilar kulit, kapilar otot skelet,
kapilar retina dan kapilar glomeruli
dan medula ginjal.

Neropati
Adanya gangguan persarafan otonom
akan menimbulkan aliran darah langsung
antara arteriola dan venula (arteriovenous shunt yang menyebabkan aliran
darah tidak memasuki kapilar),
mengakibatkan gangguan perfusi
jaringan menjadi tidak efisien.
Neropati dapat terjadi bersama-sama
dengan iskhemi.

Tanda Klinis
Infeksi jaringan Lunak
Osteomielitis
Iskemi

Predicting diabetic
neuropathy
Peak plantar pressure (requires
special equipment to identify specific
areas of high pressure under the
foot)
Vibration perception with a tuning
fork or biothesiometer
Cutaneous sensation with a
monofilament

Wegner Classification
Derajat

Luka

Abses

Selulitis

osteomielitis

gangren

Permukaan.
Dalam:
mencapai
tendo
atau
tulang.

Dalam

+ atau

+ atau

Dalam

+ atau

+ atau

+ atau

Jari kaki.

Gangren

+ atau -

+ atau -

+ atau -

Seluruh kaki.

Pembagian gejala iskemi

menurut Fountaine.
Fountaine I : gejala tidak khas:terasa
dingin terutama pagi hari (sindroma
Raynaud), pegal, linu.
Fountaine II : claudicatio intermittent
(nyeri atau kram pada otot betis setelah
berjalan beberapa meter).
Fountaine III : rest pain (nyeri yang terasa
terus-menerus walaupun pada saat istirahat).
Fountaine IV : terdapat ulkus atau gangren
pada ujung jari kaki atau pada bagian kaki
lainnya.

How To Prevent Foot Problems

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

Diabetic Foot Ulcer Treatment

Modalities
Microbiological control
Wound control
Vascular control
Mechanical control
Metabolic control
Educational control

Diagnosis and Evaluation

History
-General History
-Foot SpecificHistory
- Wound History

Physical Examination
A.General Examination
B.Local Examination
- MusculoskeletalDermatologicalVascular- NeurologicalFootwea

Diabetic Foot Ulcer

Diagnosis and Identification
1Lower extremityassessment
-Vascular
Diabetic Foot Infections
-Neurological
Assessment into
-Musculoskeletal
1.Non- limb threatening
2. Ulcer examination
2.2. Limb threatening
-Clinical
Treatment
-Search forosteomyelitis
- Surgical treatment- Wound
-Cultures &sensitivity
care- Antibiotic treatment-Radiographs
Hyperglycemia control- Correct
Treatment
electrolytes- Optimize
-Debridement- Wound care
comorbidities- Frequent
-Off loading
reassessmentof response to
-Infection treatment
treatment- If infection subsides
-Vascular management
butulcer persists,
-Medical Rx of comorbidities
followprinciples of diabeticulcer
-Surgical management
treatment- Prevention
-Reduce risk of recurrence
- Prevention

Investigations
-Laboratory Investigations.
-Imaging
-Vascular Investigations.
-Neurological Investigations.
- Assessment of plantar
footpressures

of Risk Factors
Diabetic Charcots Foot1.
Assessment
-Clinical
-Investigations
-To excludeosteomyelitis
2.Treatment
-Immobilizationand rest
-Protected weightbearing
-Surgery
-Prevention

Prophylactic foot care

Avoid smoking, walking barefoot, heating pads or hot
water bottles, and stepping into a bath without
checking the temperature.
The toenails should be trimmed to the shape of the
toe and filed to remove sharp edges.
The feet should be inspected daily, looking between
and underneath the toes and at pressure areas for
skin breaks, blisters, swelling, or redness. The patient
may need to use a mirror or, if vision is impaired, have
someone else perform the examination.
The feet should be washed daily in tepid water. Mild
soap should be used and the feet should be dried by
gentle patting. A moisturizing cream or lotion should
then be applied.

Prophylactic foot care

The patient's shoes should be snug, not tight, and the
socks should be cotton, loose fitting, and changed every
day.
Patients who have misshapen feet or have had a previous
foot ulcer may benefit from the use of special customized
shoes.
A prospective study found that the use of customized
shoes, reduced the development of new foot ulcers from 58
to 28% over one year of follow-up.
In another review, the use of a viscoelastic insole in
conjunction with well-fitting shoes (whether customized,
standard "comfort" or athletic shoes) was associated with a
decrease in plantar pressure; whether this results in a
reduced incidence of foot ulcers remains to be determined.

Antibiotic Management of
Diabetic Foot Infection

Usual organisms
No infection None
Mild infection
Staphylococcus aureus
Streptococci
Enterococci
S. epidermidis
Gram-negative aerobes
Severe limb or
polymicrobial:
life-threatening
S. aureus
infection
Group A beta-hemolytic streptococci
Enterococci
Gram-negative aerobes
Anaerobes

Antibiotic Management of
Diabetic Foot Infection

Antibiotic regimens
No infection
None
Mild infection
first-generation cephalosporin
dicloxacillin
amoxicillin-clavulanate
clindamycin
ofloxacin alone or with clindamycin
Severe limb- or
beta-lactam-beta-lactamase
inhibitor
life-threatening
clindamycin + quinolone
infection
clindamycin + ceftazidime
imipenem + vancomycin if life-threatening infection

 HATUR NUHUN