CV: dr. Maiherizansyah SpPD

Presentasi berjudul: "CV: dr. Maiherizansyah SpPD"— Transcript presentasi:

1 CV: dr. Maiherizansyah SpPD
Lahir : Tualang Cut, 14 Mei 1985 Istri : Annisa Putri Yudhita, 1 putri : Aysel Adreena Zansyah Dokter Umum: FK UGM 5 Februari 2009 SPPD : FK UGM 19 April 2016 Pekerjaan: RSUD Calang Kab. Aceh Jaya RSUD Kab. Gorontalo Utara RSUD Kab. Maluku Tenggara Barat RS Medicare Sorek Kab. Pelalawan 2017-sekarang RSUD T Umar Kab. Aceh Jaya

2 dr. Maiherizansyah SpPD
Kaki Diabetes dr. Maiherizansyah SpPD

3 Kaki diabetes Kelainan tungkai kaki bawah akibat komplikasi kronis diabetes melitus yang tidak terkontrol. Kaki diabetes disebabkan oleh: * gangguan pembuluh darah * gangguan persarafan (neuropati) * infeksi

4 Keterlambatan penanganan :
Tidak tahu Takut amputasi Kelalaian Keterbatasan sarana Finansial Under treatment

5 Gejala neuropati Neuropati sensorik Neuropati motorik
perasaan baal atau kebal (parestesia), kurang berasa (parestesia) terutama di ujung kaki, pegal, nyeri Neuropati motorik Kelemahan sistem otot, otot mengecil/deformitas, sulit mengatur keseimbangan tubuh, penonjolan tulang caput metatarsal. Neuropati otonomik Kulit kaki kering, pecah, tidak ada keringat

6 Gejala gangguan pembuluh darah
Sakit pada tungkai bila berdiri, berjalan, dan melakukan kegiatan fisik Jika diraba kaki terasa dingin (tidak hangat) Rasa nyeri kaki pada waktu istirahat dan malam hari Sakit pada telapak kaki setelah berjalan Jika luka – sukar sembuh Tekanan nadi kaki kecil atau hilang Perubahan warna kulit: pucat, kebiruan

7 Neuropati Perifer 80% lesi kaki diabetik Hilangnya sensasi protektif
Hilangnya kewaspadaan akan trauma Ulserasi 7

8 Biomekanik Kaki Diabetes
Luka atau Kalus Distribusi tekanan kaki Deformitas Hipotrofi otot intrinsik Neuropati motorik 8

9 5 Cornerstones of diabetes foot care management
1. Identification of risk factors 5. Use appropriate footwear 2.Foot examination regularly 3. Education (patients, providers and family) 4.Treatment before Ulcer occurs

10 n Risk Factors for diabetic foot ulceration Intrinsic Factors
Peripheral Neuropathy Micro-Macrovascular Diseases Structural Deformity Limited Joint Mobility Nephropathy Age Duration of Diabetes Visual Acuity Previous Ulceration

11 Risk Factors for diabetic foot ulceration
Extrinsic Factors Minor mechanical trauma Thermal Injury Chemical Burns Improper use of nail cutter Smoking Poor knowledge of diabetes Psychological Factors Alternative medication 1 2 Frykberg, Diabetic Microvascular Complications Today, May/June 2006

12 Pathway to diabetic foot ulceration
Peripheral NeuropathyPeripheral Neuropathy Minor TraumaMinor Trauma Deformity Edema Peripheral IschemiaPeripheral Ischemia Callus Infections Components leading to foot ulceration Reiber GE, Vileikyte, Boyko EJ et al. Causal pathways for incident lower–extremity ulcers in patients with from two settings. Diabetes Care 1999:

13 Intrinsic Factors Peripheral Neuropathy
Autonomic Decreased Sweating Dry Skin Decreased Elasticity Fissure Ulcer

14 Intrinsic Factors Peripheral Neuropathy
Motoric Weakness Atrophy Deformity Abnormal Stress High Plantar Pressure Callus Formation

15 Intrinsic Factors Peripheral Neuropathy
Sensoric Loss of protective sensation Decreased pain threshold Lack of temperature sensation and proprioception For performance of the 10-g monofilament test, the device is placed perpendicular to the skin, with pressure applied until the monofilament buckles. It should be held in place for ~1 s and then released. Lower panel: The monofilament test should be performed at the highlighted sites while the patient's eyes are closed. (From: Boulton AJ, Armstrong DG, Albert SF, et al.: Comprehensive foot examination and risk assessment: a report of the task force of the foot care interest group of the American Diabetes Association, with endorsement by the American Association of Clinical Endocrinologists. Diabetes Care 2008; 31(8): )

16 Intrinsic Factors Peripheral Arterial Disease (PAD)
Risk Factors* PAD Correlated with atherosclerosis A1c >7%  26 % PAD More aggressive Narrowing vessel lumen - obstructive Distal tissue necrosis Hyperglycemia Eleveted systolic BP hyperlipidemia Smoking Cardiovascular disease * UKPDS

17 Clinical Classification of diabetic foot (Edmond)
Grade 1 Grade 2 Grade 3 Grade 4 Grade 5 Grade 6 Normal foot, no risk factors of neuropathy, ischemia, deformities No active ulcers, have ≥1 risk factors: neuropathy, ischemia, deformities, callus and swelling, nail deformities Skin breakdown; fisurre, blitser, ulcer Usually in plantar surface Foot develop infections, Discharge purulent, cellulitis, neuropathy and or ischemia Tissue necrosis with or with out intake foot, neuropathy, ischemia, neuroischemi, infection Unsalvageable foot, need major amputation, extensive necrosis, destroyed foot, severe infection

18 6 Steps for a complete Diabetes Foot Examination
Assessment Significant Finding 1.Patient History - Previous foot ulceration - Previous amputation - Diabetic > 10 years - A1c > 7 % - Impaired vision - Neuropathic symptoms - Claudicatio 2.Gross Inspection - Hammer toes - Claw toes - Halux valgus - Corn, callus, callus with ulcer, bunion - Prominent metatarsal head 3.Dermatologic Examination - Dry skin - Absence of hair - Yellow or erythematous scale - Ulcer or healed ulcer - Interspace maceration - Moist - Unhealing ulceration 4.Nail Deformities - Yellow, thickened nail - Ingrowing nail edge - Long or sharp nails halux valgusA hallux abducto valgus deformity, commonly called a bunion, is a deformity characterized by lateral deviation of the great toe, often erroneously described as an enlargement of bone or tissue around the joint at the head of the big toe.

19 Last 2 steps in the assessment
Test Significant Finding 5. Screening for Neuropathy - Semmes-Weinstein monofilamen 10 gram Lack of perception at one or more side - Tuning fork 128Hz Negative of vibration perception - Biothesiometer: Vibration perception Vibration perception threshold >25 volt 6. Vascular Examination Palpation of dorsalis pedis and tibialis posterior artery Ankle Brachial Index Color doppler Decrease or absent pulse ABI < 0.9 consistent with PAD ABI >1.2 0.9 – 1.2 <0.9 <0.6 Interpretation Rigid or calcified vessels or both Normal (or calcified) Ischemia Severe ischemia

20 Ankle-brachial index (ABI):
SBP in ankle (dorsalis pedis and posterior tibial arteries) ___________________________________ SBP in upper arm (brachial artery)

21 Resiko komplikasi kaki diabetik:
Amputasi Cacat Meninggal pencegahan

22 Apa yang harus dilakukan pasien?

23 Yang harus dilakukan 1. Periksa kaki setiap hari
Apakah ada kulit retak, melepuh, luka, perdarahan 2. Bersihkan kaki setiap hari pada waktu mandi dengan air bersih dan sabun Keringkan kaki dengan handuk bersih, lembut, yakinkan kering benar terutama sela jari

24 Yang harus dilakukan 3. Pakai alas kaki (sandal atau sepatu) untuk melindungi kaki, juga saat di rumah 4. Gunakan sepatu atau sandal yang baik sesuai ukuran kaki dan enak dipakai. Syarat: * Ukuran – sepatu lebih dalam panjang ½ inchi lebih dari jari kaki * Bentuk – tidak runcing tinggi tumit kurang dari 2 inchi * Bagian dalam bawah (insole) tidak kasar, tidak licin, terbuat dari busa karet, plastik dengan tebal mm * Ruang dalam sepatu longgar

25 Yang harus dilakukan 5. Periksa sepatu sebelum dipakai: apakah ada kerikil, benda tajam (duri, jarum). Lepas sepatu selang 4-6 jam, gerakkan pergelangan dan jari kaki agar sirkulasi darah baik 6. Bila ada luka kecil, obati luka dan tutup dengan pembalut bersih. Periksa apakah ada tanda radang

26 Yang harus dilakukan 7. Segera ke dokter bila kaki mengalami luka
8. Periksakan kaki ke dokter secara rutin

27 Apa yang tidak boleh dilakukan?

28 Yang tidak boleh dilakukan
1. Merendam kaki 2. Mempergunakan botol air panas atau peralatan listrik untuk memanaskan kaki 3. Jangan gunakan batu / silet untuk menghilangkan kapalan (callus)

29 Yang tidak boleh dilakukan
4. Merokok 5. Memakai sepatu atau kaos kaki sempit 6. Menggunakan obat-obat tanpa anjuran dokter untuk menghilangkan ‘mata ikan’

30 Yang tidak boleh dilakukan
7. Menggunakan sikat atau pisau untuk kaki 8. Membiarkan luka kecil di kaki, sekecil apapun luka itu

31 Management Wound control Metabolic control Microbiological control Vascular control Mechanical control Educational control

32 Wound Control Incision, drainage, debridement and necrotomy
1 Incision, drainage, debridement and necrotomy Management of infections in tissue and bone Exudate Management Keep control of proliferation phase and infections

33 Metabolic Control Hyperglycemia Will inhibit process of wound recovery
2 Hyperglycemia Will inhibit process of wound recovery Inhibit growth factor, collagen synthesis and fibroblast activities 2. Hypoalbuminemi 3. Hypertension 4. Decrease of heart and kidney function 5. Dyslipidemia 6. Anemia 7. Other diseases caused by diabetes

34 Infection Control Need aggressive therapy
3 Need aggressive therapy Usually there are no symptoms or signs of infection External Infection: Positive gram bacteria Internal Infection: Negative gram bacteria

35 Gram positive Microorganism Oral IV Staphylococcus aureus
Flucloxacillin 500mg qds Sod fusidate 500mg tds Clindamicin 300mg tds Rifampicin 300mg tds Gentamicin 5mg/kg/day Clindamicin mg qds MRSA Trimetoprim 200mg bd Linezolid 600mg bd Vancomycin 1 g bd Teicoplanin 400mg daily Streptococcus Doxycicline 100mg daily first dose 200mg Amoxycillin 500mg tds Clindamycin 300mg tds Erythromicin 500mg qds Clindamycin 150–600mg qds

36 Microorganism Oral IV Anaerobes Metronidazole 400mg tds Clindamycin 300mg tds Metronidazole 500mg tds Clindamycin mg qds

37 Gram negative Microorganism Oral IV Coliforms
(E coli, Proteus, Klebsiella, Enterobacter) Ciprofloxacin 500mg bd Cefadroxil 1g bd Trimetropim 200mg bd Ciprofloxacin 200 mg bd Ceftazidime 1-2 g tds Ceftriaxone 1-2g/daily Gentamicin 5mg/kg/d Meropenem 500mg-1g/d Ticarcillin/clavulanat3.2g tds Pseudomonas Ceftazidime 1-2g tds Meropenem 500mg-1g tds

38 Vascular Control Neuroischemic Foot
4 Neuroischemic Foot Atherosclerosis can cause total block in the blood vessels Decrease of blood flow to the wound Critical Limb ischemia: Amputation Warning

39 Pharmacotherapy of Claudication
Cilostazol (100 mg orally 2 times/d) is indicated as an effective therapy to improve symptoms and increase walking distance in patients with lower extremity PAD and intermittent claudication (in the absence of heart failure). ACC/AHA 2006 PAD Guidelines

40 Mechanic Control Principle: Reduce stress on the wound Off loading
5 Principle: Reduce stress on the wound Off loading Might be bed rest Non-weight bearing Use of walker, wheel-chair or crutches Use special shoes (‘half-shoes’) Distribute the body weight to all surfaces of the foot

41 Summary Check feet regularly to prevent ulcers.
2 risk factors for diabetic foot: intrinsic and extrinsic. Check feet regularly to prevent ulcers. Diabetes foot care management: identification of risk factors, foot examination regularly, treatment before ulcer occurs, use appropriate foot wear, education. Management of foot ulcers: wound control, metabolic control, infection control, vascular control, mechanic control.

42 Terima kasih