docAmputasi Kaki - Kementerian Kesihatan Malaysia
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Amputasi Kaki - Kementerian Kesihatan Malaysia
PENGENDALIAN PERKHIDMATAN PENYAKIT TIDAK BERJANGKIT (NCD) UNTUK PARAMEDIK KEMENTERIAN KESIHATAN MALAYSIA KULIAH 34 REHABILITASI : AMPUTASI KAKI ANJURAN : BAHAGIAN PEMBANGUNAN KESIHATAN KELUARGA DAN BAHAGIAN KAWALAN PENYAKIT Modul Latihan Pengendalian Perkhidmatan NCD Untuk Paramedik KKM KANDUNGAN o o o o Patofisiologi amputasi kaki Pesakit berisiko amputasi kaki Klassifikasi dan diagnosa Rawatan dan rehabilitasi kes amputasi kaki (prinsip umum) Modul Latihan Pengendalian Perkhidmatan NCD Untuk Paramedik KKM PATOFISIOLOGI Neuropati 3 komponen yang bertindak dalam pelbagai kombinasi ‘Vasculopathy’ ‘Immunopathy’ DIABETIC TRIAD Modul Latihan Perkhidmatan NCD Untuk Paramedik KKM PATOFISIOLOGI NEUROPATI Neuropati Motor Sensori Otot dan kaki menjadi lemah Ketidakseimbangan posisi badan ↓ nocicepsi ↓ Proprioception, Tidak mengetahui posisi kaki Kecacatan, tekanan dan koyak Kecederaan Autonomik Kurang peluh Tekanan kepada tulang, sendi dan plantar Pembentukan callus Kulit kering Fisur dan kulit pecah Luka Modul Latihan Pengendalian Perkhidmatan NCD Untuk Paramedik KKM A-V Shunt Meningkatkan pengaliran darah ke kaki Vena kaki menimbul, Kaki panas Jangkitan PATOFISIOLOGI PENYAKIT ARTERI PERIFERI Penyakit Arteri Periferi Plak arteroma menyebab lumen arteri menjadi sempit Artherosclerosis Penyempitan dan penutupan lumen arteri Iskemia kaki Jari menjadi gangren akibat arterosclerosis Luka kaki Necrosis/ Gangren Jangkitan Modul Latihan Pengendalian Perkhidmatan NCD Untuk Paramedik KKM KAKI BERISIKO…. • • • • • • • • • • Ischaemia Numbness Structural Deformities Callus and / or Corn Absence of Pedal Pulses A capillary refill time in excess of 3 secs Limb pain and / or parasthesia Intermittent Claudication History of Foot Ulcer Loss of sensation of light touch,sharp and blunt touch Modul Latihan Perkhidmatan NCD Untuk Paramedik KKM Pre-ulcer AJM Boulton, H Connor, PR Cavanagh, The Foot in Diabetes, 2002 Modul Latihan Perkhidmatan NCD Untuk Paramedik KKM Modul Latihan Perkhidmatan NCD Untuk Paramedik KKM Modul Latihan Perkhidmatan NCD Untuk Paramedik KKM Diabetic Foot Ulcer • Diabetic Foot Ulcer menyebabkan ‘NonTraumatic Lower Extremity Amputation’ (LEA). • 15% daripada Pesakit diabetes mengalami ulser kaki. • Risiko LEA adalah 8 kali ganda di kalangan mereka yang pernah mendapat ulser kaki • 25% daripada semua kemasukan pesakit diabetes ke wad adalah disebabkan ulser kaki diabetes Modul Latihan Perkhidmatan NCD Untuk Paramedik KKM “Tragic “Rule of 50” • 50% drp amputasi Paras Transfemoral/ transtibial • 50% drp pesakit amputasi kedua dlm 5 tahun • 50% drp pesakit Meninggal dunia 5 tahun Clinical Care of the Diabetic Foot, 2005 Modul Latihan Perkhidmatan NCD Untuk Paramedik KKM Tragic “Rule of 15” • 15% drp pesakit DM > Ulser kaki sepjg hidup • 15% drp ulser kaki > Osteomyelitis • 15% drp ulser kaki > Amputasi Clinical Care of the Diabetic Foot, 2005 Modul Latihan Perkhidmatan NCD Untuk Paramedik KKM Kulit sekeliling ulser Penilaian: warna, kelembapan, kelembutan Saiz ‘Wound bed’ Ukur saiz Kedalaman ulser PENILAIAN LUKA Bhg tepi ulser ‘Assess for undermining & condition of margin’ Modul Latihan Perkhidmatan NCD Untuk Paramedik KKM Assess for: necrotic and granulation tissue, fibrin slough, epithelium, exudate,odor KLASSIFIKASI • King’s College Foot Classification • Wagner’s Classification • University of Texas Classification KING’S COLLEGE FOOT CLASSIFICATION • • • • • • Stage 1: The Normal Foot Stage 2: The High Risk Foot Stage 3: The Ulcerated Foot Stage 4: The Cellulitic Foot Stage 5: The Necrotic Foot Stage 6: Major Amputation •Simple classification to use •Specific management recommended for each stage Stage 1: The Normal Foot • No Risk Factor present: – – – – – Neuropathy Ischemia Deformity Callus Swelling Stage 2: The High Risk Foot • One or More Risk Factors present: • Neuropathy • Peripheral Vascular Disease • Deformity • Callus • Swelling Stage 3: The Ulcerated Foot • Skin breakdown and ulceration • No classification as each ulcer must be assessed on its own merits • Differentiate between neuropathic and neuroischemic • X-ray newly presenting ulcers for: – – – – Osteomyelitis Foreign body Gas Charcot changes Stage 4: The Cellulitic Foot • Microbiological control is lost and foot has become cellulitic • Local infection • Spreading sepsis • Sloughing of soft tissue • Vascular compromise • Blue discolouration Stage 5: The Necrotic Foot Gangrene (necrosis) Type: Dry, Wet Stage 6: Major Amputation Pain is agonizing and cannot be controlled Overwhelming infection Extensive necrosis Rare in neuropathic UJIAN • Full Blood Count • Renal profile • HbA1C (Glycosylated Haemoglobin) - indicator of diabetes control over last 3 months • Culture of wound • X-rays of the foot and leg, ECG, CXR, Urine Modul Latihan Perkhidmatan NCD Untuk Paramedik KKM Ankle Brachial Index (ABI) Ankle systolic pressure measured using a cuff and a handheld continuous wave Doppler Ultra Sound Probe placed over pedal vessels (DP or TP = whichever is higher) Ankle Systolic Pressure Brachial Systolic Pressure ABI: Normal Ischaemia Critical Ischaemia 1 to 1.2 <0.8 <0.5 Adapted from: Norman PE, Eikelboom JW, Hankey GJ. Peripheral arterial disease: prognostic significance and prevention of atherothrombotic complications. Medical Journal of Australia 2004; 181:150-154. Figure 1, p.151 Ankle-Brachial Index • Screening: 2004 ADA recommendation – “Consider” at age 50 years and every 5 years • Diagnosis: – Claudication, absent DP/PT pulses, foot ulcer • Limitations: – Underestimates severity in calcified arteries Diabetes Care. 2005;28:2206 Diabetes Care. 2004;27(Suppl 1):S15-S35 Interpretation of the ABI Interpretation Normal Mild obstruction Moderate obstruction* Severe obstruction* Poorly compressible** 2° to medial calcification ABI 0.90-1.30 0.70-0.89 0.40-0.69 <0.40 >1.30 *Poor ulcer healing with ABI < 0.50 **Further vascular evaluation needed PRINCIPLES OF TREATMENT • • • • • • • • Debridement of necrotic tissue Wound care Reduction of plantar pressure (off-loading) Treatment of infection Vascular management of ischaemia Medical management of co morbidities Surgical management to reduce or remove bony prominences and / or improve soft tissue cover Reduce risk of recurrence Debridement of necrotic tissues Removal of all non-viable tissues and slough • Surgical debridement • Mechanical debridement (surgical debridement, wet-todry dressings and high- pressure irrigation) • Enzymatic debridement (topical proteolytic enzymes; controversial) • Autolytic debridement (naturally in healthy, moist wound environment with adequate circulation) Wound Care • After debridement, the ulcer is covered to protect it from trauma and contaminants. • Moist wound environment will facilitate healing • Wound size, depth, location, surface and discharge Reduction of plantar pressure (Off-loading) Allow healing The methods of off-loading include: • Total non-weight bearing • Total contact cast (gold standard for neuropathic foot) • Foot cast or boots • Removable walking braces with rocker bottom soles • Total contact orthoses – custom walking braces • Patellar tendon bearing braces • Half shoe or wedge shoes • Healing sandal – surgical shoe with molded insole • Accommodative dressing: felt, foam, felted-foam, etc • Shoe cutouts (toe box, medial, lateral or dorsal pressure points). • Assistive devices: crutches, walker, cane, etc. Charcot restraint orthotic walker (CROW) Bottine shoe with a full-contact insole and a rocker bar with an early pivot point Depth-inlay soft leather laced shoe with custom accommodative pressuredissipating foot orthosis Vascular Management of Ischaemia • Vascular reconstruction surgery • Any clinically suspicious lower extremity ischaemia should be fully investigated and corrected before any definitive foot surgery is contemplated Surgical Management • Chronic foot ulcers – best treated surgically – removal of infected bone or joints – metatarsal head resections, partial calcanectomy, exostectomy, sesamoidectomy and digital arthroplasty • Structurally deformed foot – correction of hammertoes, excision of exostoses, bunions and tendo-achilles lengthening • Gangrene and ulcers with OM – Amputation – goal of treatment is preservation of function, not just preservation of tissue – first step in rehabilitation DIABETIC CHARCOT’S FOOT • impairment of the efferent sensory input from joint receptors • progressive destruction of foot architecture – pathological fracture, joint dislocation and fragmentation of articular cartilage • Assessment – Clinical examination • acute Charcot’s foot will have swelling, erythema, raised skin temperature, joint effusion and bone resorption in an insensate foot • 75% of patient with Charcot’s foot have some degree of pain in an otherwise insensate foot, thus complicating diagnosis • in the presence of a concomitant ulcer, Dx of OM may be difficult to rule out AETIOLOGY • classically due to neuroarthropathy • hypervascular diabetic limb – ↑blood flow ↑osteoclastic activiti bone and joint destruction • ischaemic intrinsic muscles alter loading dynamics of the foot joint instability • Investigations – plain X-ray : osteoarthropathy – white cell count (WBC), ESR : rule out OM – bone biopsy : • most specific way of distinguishing between osteomyelitis and osteoarthropathy. • pathognomonic biopsy showing neuropathic osteoarthropathy • consists of multiple shards of bone and soft tissue embedded in the deep layers of synovium Neuropathic Charcot's joint Osteomyelitis Goals of Treatment • interrupt destructive process • maintain adequate alignment of midfoot and ankle • early diagnosis • prevent progression • Treatment – Acute stage: immobilization and rest – Post-acute: protected weight bearing • After 4-6 months, patients may resume using their usual footwear – Surgery : create a stable and plantigrade foot • commonly, exostectomies for prominent plantar (rocker bottom) deformities • Others: ankle fusion, tibiocalcaneal fusion, isolated or multiple midfoot fusion and triple arthrodesis WOUND MANAGEMENT FACTORS AFFECTING WOUND HEALING • Systemic – Age – Nutrition – Trauma – Metabolic diseases – Immunosuppression – Connective tissue disorders – Smoking – Stress FACTORS AFFECTING WOUND HEALING • Local – – – – – – – – Mechanical injury Infection Edema Ischemia//necrotic tissue Topical agents Ionizing radiation Low oxygen tension Foreign bodies Factors that delay the wound healing process Local Factors • Continued pressure • Desiccation and dehydration • Infection or heavy colonization • Necrosis • Incontinence leading to maceration • Lack of oxygen delivery to the tissues Systemic Factors • Old age • Chronic diseases (e.g DM, anaemia) • Malnutrition • Vascular insufficiency • Immunodefiency • Smoking • Stress • Poor health Topical Therapy: Principles • • • • • • • Remove necrotic tissue and foreign bodies or particles Identify and eliminate infection Obliterate dead space Absorb excess exudate Maintain a moist wound surface Provide thermal insulation Protect the healing wound from trauma and bacterial invasion Doughty, Acute and Chronic Wounds, 1992 Wound Care Product Selection: Other Considerations • • • • Is wound partial or full thickness? Is wound dry or draining? Is wound superficial or deep? Need to develop treatment protocols based on wound characteristics rather than wound type. Types of Topical Wound Dressings • • • • • • • • • • Hydrocolloid dressings Hydrogel dressings Alginate dressings Hydrofiber dressings Transparent film dressings Foam dressings Absorption dressings Gauze dressings Biologic dressings Other Rehabilitasi Kes Amputasi • Perlu dimulakan secepat mungkin untuk memaksimumkan tahap pemulihan • Physiotherapy dan Occupational Therapy yang berkaitan keperluan pesakit boleh menyumbang kepada pemulihan Modul Latihan Perkhidmatan NCD Untuk Paramedik KKM Tahap Amputasi dan Rehabilitasi • Pesakit amputasi ringan boleh dirawat sebagai pesakit luar • Pesakit tahap sederhana disarankan untuk menerima rawatan rehabilitasi di pusat atau unit rehabilitasi strok • Pesakit strok tahap teruk disarankan untuk mendapat rawatan jangka panjang di pusat khas rehabilitasi strok. Modul Latihan Perkhidmatan NCD Untuk Paramedik KKM TAKE HOME MESSAGE • Anggota kesihatan perlu mengetahui pesakit yang berisiko mendapat amputasi • Anggota kesihatan perlu tahu mengesan komplikasi kaki di peringkat awal dan memberi rawatan ulser dan masalah kaki yang lain • Pemeriksaan kaki perlu dibuat pada keduadua belah kaki, termasuk ‘stump’ Modul Latihan Perkhidmatan NCD Untuk Paramedik KKM SELAMATKAN KAKI PESAKIT ANDA DENGAN MEMBERIKAN RAWATAN MASALAH-MASALAH KAKI DIABETIK YANG BETUL Modul Latihan Perkhidmatan NCD Untuk Paramedik KKM
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