ulkus kaki diabetik - Perhimpunan Dokter Umum Indonesia

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ulkus kaki diabetik - Perhimpunan Dokter Umum Indonesia
ULKUS KAKI DIABETIK
dr.H.N.Nazar. SpB, FINACS, Trauma(K), MHKes
CURICULUM VITAE
Nama
: Dr. H. N. Nazar, Sp.B, (K) Trauma, FInaCS, MHKes
Tmpt /Tgl Lahir
: Maninjau, 14 Januari 1950
Pendidikan :
• Kedokteran Umum
: FK USU tahun 1978
• Spesialis Bedah Umum
: FK UI tahun 1990
• Konsultan Traumatologi
: Tahun 2005
• Magister Hukum
: Pasca Sarjana Unika Soegijapranata tahun 2008
Organisasi :
• PP PABI
: 2000 – sekarang
• PP IKABI
: 2008 – sekarang
• PB IDI
BHP2A
: 2009 – sekarang
MPPK/Divisi Pembelaan Anggota
: 2012 – sekarang
POKJA Implementasi Tarif Pembayaran Medis
: 2012 – sekarang
Ketua Biro Hukum Pembinaan dan Pembelaan Anggota
: 2012 – sekarang
Tim MONEV-SETGAB. BPJS-Kemenkes
: 2014 – sekarang
Ketua Panel Ahli Kolegium Dokter Indonesia
: 2015 – sekarang
Definition of Diabetic Foot
WHO and the International Working Group on
the Diabetic Foot:
Diabetic foot is defined as the foot of diabetic
patients with ulceration, infection and/or
destruction of the deep tissues, associated
with neurological abnormalities and various
degrees of peripheral vascular disease in the
lower limb
International Working Group on the Diabetic Foot. In: International Consensus on the diabetic foot. International Working Group on the
Diabetic Foot. 1999. The Netherlands. P 20-96
Four Kinds of Chronic Wounds
o
o
o
o
Pressure Ulcer
Diabetic Ulcer
Venous Ulcer
Arterial Ulcer
Diabetic Ulcers
• Chronic ulcer in a diabetic patient, not
primarily due to other causes
• Extrinsic causes: smoking, friction, burn
• Intrinsic causes: neuropathy, macrovascular
and microvascular disease, immune
dysfunction, deformity, reopened previous
ulcer
Wagner Classification System
Grade Lesion
0
No open lesions, may have
deformity or cellulitis
1
Superficial ulcer
2
Deep ulcer to tendon or joint
capsule
3
Deep ulcer with abscess,
osteomyelitis, or joint sepsis
4
Local gangrene – forefoot or
heel
5
Gangrene of entire foot
Wagner Classification System
Grade Lesion
0
No open lesions, may have
deformity or cellulitis
1
Superficial ulcer
2
Deep ulcer to tendon or joint
capsule
3
Deep ulcer with abscess,
osteomyelitis, or joint sepsis
4
Local gangrene – forefoot or
heel
5
Gangrene of entire foot
Wagner Classification System
Grade Lesion
0
No open lesions, may have
deformity or cellulitis
1
Superficial ulcer
2
Deep ulcer to tendon or joint
capsule
3
Deep ulcer with abscess,
osteomyelitis, or joint sepsis
4
Local gangrene – forefoot or
heel
5
Gangrene of entire foot
Wagner Classification System
Grade Lesion
0
No open lesions, may have
deformity or cellulitis
1
Superficial ulcer
2
Deep ulcer to tendon or joint
capsule
3
Deep ulcer with abscess,
osteomyelitis, or joint sepsis
4
Local gangrene – forefoot or
heel
5
Gangrene of entire foot
Wagner Classification System
Grade Lesion
0
No open lesions, may have
deformity or cellulitis
1
Superficial ulcer
2
Deep ulcer to tendon or joint
capsule
3
Deep ulcer with abscess,
osteomyelitis, or joint sepsis
4
Local gangrene – forefoot or
heel
5
Gangrene of entire foot
Wagner Classification System
Grade Lesion
0
No open lesions, may have
deformity or cellulitis
1
Superficial ulcer
2
Deep ulcer to tendon or joint
capsule
3
Deep ulcer with abscess,
osteomyelitis, or joint sepsis
4
Local gangrene – forefoot or
heel
5
Gangrene of entire foot
Co-Morbidity
• Peripheral vascular disease occurs in 11% of
diabetic patients
• Peripheral neuropathy occurs in 42% of
diabetic patients
• PVD is associated with delayed ulcer healing
and increased rates of amputation
Patophysiology of Diabetic Foot
Ulcers
• Neuropathic
Loss of protective sensation due to Neuropathy:
• Sensorimotor / Peripheral (mostly asymptomatic;
other paresthesia, hyperaesthesia)
• Autonomy (reduce sweating, dry skin; loss of
sympathetic control of AV shunting)
• Ischemic
Peripheral vascular disease
Pathogens in Diabetic Ulcer
• Mild severity: tend to be Staph and Strep
• Moderate severity (i.e. non-limb threatening):
Staph, Strep, and gram neg
• Severe/limb-threatening: usually 5 to 6
organisms, including Staph, Strep, E. coli,
Enterobacter, Bacteroides, Proteus,
Pseudomonas, and MRSA
Management of Diabetic Ulcer
•
•
•
•
•
•
•
Relief of pressure and protection of the ulcer
Restoration of skin perfusion
Treatment of infection
Metabolic control and treatment of comorbidity
Local wound care *
Education of patient and relatives
Determining the cause and preventing recurrence
Local Wound Care
o Remove fluid from
the wound,
o Increase blood flow,
o Decrease bacterial
colonization, and
o Stimulate the growth
of granulation tissue
to promote wound
closure.
Local Wound Care
o Remove fluid from
the wound,
o Increase blood flow,
o Decrease bacterial
colonization, and
o Stimulate the growth
of granulation tissue
to promote wound
closure.
Local Wound Care
o Remove fluid from
the wound,
o Increase blood flow,
o Decrease bacterial
colonization, and
o Stimulate the growth
of granulation tissue
to promote wound
closure.
Local Wound Care
o Remove fluid from
the wound,
o Increase blood flow,
o Decrease bacterial
colonization, and
o Stimulate the growth
of granulation tissue
to promote wound
closure.
Other Possibly
Helpful Treatments
•
•
•
•
•
•
Moist dressings (clearly better than dry)
Hyperbaric O2
Dermagraft (cultured skin—human)
Platelet-derived growth factor
Antibiotics (ineffective if uncomplicated)
Questionable effectiveness: U/S, electrical
stimulation
Kelainan pertumbuhan kuku
Case: Infected Diabetic Foot
Case
Severe tissue damage Diabetic wound
Repeated Necrotomy and debridement
Daily wound care is only application of saline moist gauze and dry gauze
Secondary healing intention:
Granulation tissue and epithelialization
Wound contraction; and the wound heal
Ascending Infection of Diabetic Ulcer
• Clinical
 Post
amputation
Easy to remember..
• Treat the Infection !
– Necrotomy, debridement, wound care, broad
spectrum and proper antibiotic
• Treat the Hyperglycemia !
• Assess the vascular condition, treat if exist!
• Nutrition!
Undergoes Surgical Indication
• Foot infection is associated with substantial bone
necrosis or exposed joint
• Foot appears to be functionally nonsalvageable
• Patient is already nonambulatory
• Patient is at particularly high risk for antibioticrelated problems
• Infecting pathogen is resistant to available
antibiotics
• Limb has uncorrectable ischemia (precluding
systemic antibiotic delivery)
Terima Kasih
Wassalam
H.N.Nazar