Pencegahan dan Tatakelola
Ulkus Diabetikum
Pandu Herpri Sasongko
9 April 2021
Bagian Ilmu Penyakit Dalam
RSUD dr. R. Soeprapto Cepu
2021
Definisi
Ulkus diabetikum adalah luka terbuka atau
luka yang biasanya ditemukan di bagian
bawah kaki
Definisi
Ulkus diabetikum adalah luka terbuka atau
luka yang biasanya ditemukan di bagian
bawah kaki
Ulkus Kaki Diabetikum/ Infeksi Kaki Diabetikum
(Diabetic Foot Ulcer/ Diabetic Foot Infection)
Definisi
Infeksi, ulkus, dan atau kerusakan
jaringan yang berhubungan dengan
kelainan neurologis dan penyakit
pembuluh darah perifer pada tungkai
bawah
Epidemiologi
• Insiden tahunan ulkus kaki diabetik di
seluruh dunia adalah antara 9,1 hingga
26,1 juta.
• Sekitar 15 sampai 25% pasien diabetes
melitus akan mengalami ulkus kaki
diabetik selama hidup mereka.
Faktor Resiko
Sensoris Neuropathy Lack of protective sensation
Neuropathy Motoris Neuropathy Changes in foot anatomy
Otonom Neuropathy Lack of sweat
Neuro-
Pressure points
arthropathy
PVD/PAD Iskemia
decreased immune
defenses
Hyperglycemia
poor wound healing
Faktor Resiko
Poor eye sight
Patient
disabilities
Previous amputations
Compliance with
preventive measures,
Patient
behaviour
Hygiene
Lack of patient
education
Health care system Glycemic control
failures targets not met
poor implementation of
preventive strategies
Nail abnormality
• Foot deformity
• Structural deformities in the foot such as presence of
hammertoes, claw-toes, hallux valgus, callus,
prominent metatarsal heads, status after neuro-
osteoarthropathy, amputation or other foot surgery.
Definisi Neuropati Diabetes
• Diabetic neuropathy
– Presence of symptoms and/or signs of
peripheral nerve dysfunction in people
with diabetes, after exclusion of other
causes.
– Charcot-foot
• Non-infectious destruction of bone and joint
associated with neuropathy :
Neuro-osteoarthropathy.
Artropati Charcot
Artropati Charcot
Definisi Neuropati Diabetes
Tes Monofilamen
Definisi PAD
• Peripheral arterial disease (PAD)
– Disease of mostly small blood vessels in
the extremities (hands and feet), as
narrowing of arteries.
– Claudication
• Pain in foot, thigh or calf during walking, which
is relieved
Definisi PAD
SKOR ABI (Ankle-Brachial Index)
Definisi PAD
SKOR ABI (Ankle-Brachial Index)
Arteriografi
Manifestasi Klinis
• Superficial infection
– An infection of the skin
• (not extending trough muscles, tendon,
• bone and joint).
– A pathological state caused by invasion and multiplication of
microorganisms in tissues accompanied by tissuedestruction
and/or a host inflammatory response.
• Superficial ulcer
– Full thickness of the skin not extending the sub cutis
• Ulcer
– Sore; full thickness of the skin.
Critical limb ischemia
– Persistent rest pain requiring
regular analgesia for more than 2
weeks, ulceration or gangrene
attributable to objectively proven
peripheral arterial disease.
Gangrene
• Necrosis (mortification) of the skin and
underlying structures (muscles, tendon,
joint or bone) with irreversible damage
where healing can not be anticipated
without loss of some part of the extremity.
Pemeriksaan Fisik
• Wound
– Size and depth:
• necrosis, gangrene, foreign body
• involvement of muscle, tendon, bone, or joint –
• inspect, debride, and probe the wound
– Presence, extent and cause of infection:
• purulence, warmth, tenderness, induration, cellulitis,
• bullae, crepitus, abscess, fasciitis, osteomyelitis
History ulcus or amputation
History ulcus or amputation
History ulcus or amputation
Klasifikasi
Konsensus
Internasional
Kaki diabetik
2003
Klasifikasi
• P : Perfusi ( grade 1,2,3)
• E : Ekstensi
• D : Depth/dalam (grade 1,2,3)
• I : Infeksi (grade 1,2,3,4)
• S : Sensasi (grade 1,2)
Perfusi
Grade Uraian
I Pulsasi a. dorsalis pedis &
a. tibialis posterior teraba.
gejala & tanda PAD (-) ABI normal
II Claudicatio (+)
ABI < 0,9
gejala & tanda PAD
(+) tapi iskemia (-)
III ABI < 0,9
Sistolik ankle < 50 mmHg
PAD (+) Iskemia (+)
Sistolik Toe < 30 mmHg
Ekstensi/ukuran
Cara Ukuran dalam cm
menilai luka setelah
debridement
Depth/tissue loss/ kedalaman
Grade Uraian
I Ulkus superfisial, tidak merusak
dermis
II Ulkus dalam menembus fascia
sampai tendon atau otot
II Ulkus dalam sampai menembus
tulang
INFEKSI
I GEJALA DAN TANDA INFEKSI (-)
II Infeksi superfisial dan subkutan
Edema, eritema < 2 cm
III Infeksi lebih dalam, edema dan eritema
> 2 cm, infeksi sistemik (-)
IV Infeksi lebih dalam, edema dan eritema
> 2 cm, infeksi sistemik (+) SIRS (+)
Sensasi
Grade Uraian
I Sensasi masih baik
II Test Monofilament 10 gr (-)
Test Garpu tala (-)
Klasifikasi
Wagner
Grade 0 Grade 1 Grade 2 Grade 3 Grade 4 Grade 5
Tidak ada Superfisial Ulkus meluas Kaki infeksi nekrosis/ Kaki yg tidak
ulkus Partial/ Full ke ligament, Edema/ abses gangrene lokal dapat di
Hanya Thickness tendo, kapsul Kulit merah melibatkan selamatkan
deformitas sendi, fasia kulit sub kutis Nekrosis luas
dalam, tanpa Infeksi fasia , sendi,
Osteomielitis harus
abses atau tulang. amputasi
osteomielitis Gejala sistemik
Ulkus dasar
nya otot
Approach to treating
foot wound
Slide 39
5 Cornerstones of diabetes foot care
management
1. Foot examination
regularly
2. Identification of
4. Treatment before
risk factors
Ulcer occurs
3. Education
(patients, providers 5. Use appropriate
and family) footwear
Foot Examination
The recommendation is
(1)examination of the feet and lower legs for
any foot deformity;
(2) palpation of foot pulses;
(3) testing of foot sensation using 10-g
nylon monofilament or vibration;
(4) inspection of footwear
Slide 41
5 Cornerstones of diabetes foot care
management
1. Foot examination
regularly
2. Identification of
4. Treatment before
risk factors
Ulcer occurs
3. Education
(patients, providers 5. Use appropriate
and family) footwear
Identifikasi Faktor Resiko
Sensoris Neuropathy Lack of protective sensation
Neuropathy Motoris Neuropathy Changes in foot anatomy
Otonom Neuropathy Lack of sweat
Neuro-
Pressure points
arthropathy
PVD/PAD Iskemia
decreased immune
defenses
Hyperglycemia
poor wound healing
Identifikasi Faktor Resiko
Poor eye sight
Patient
disabilities
Previous amputations
Compliance with
preventive measures,
Patient
behaviour
Hygiene
Lack of patient
education
Health care system Glycemic control
failures targets not met
poor implementation of
preventive strategies
Slide 44
5 Cornerstones of diabetes foot care
management
1. Foot examination
regularly
2. Identification of
4. Treatment before
risk factors
Ulcer occurs
3. Education
(patients, providers 5. Use appropriate
and family) footwear
Edukasi
(pasien & keluarga)
• Basic foot care advice and the importance
of foot care.
• Foot emergencies and who to contact.
• Footwear advice.
• The person's current individual risk of
developing a foot problem.
• Information about diabetes and the
importance of blood glucose control
Slide 46
5 Cornerstones of diabetes foot care
management
1. Foot examination
regularly
2. Identification of
4. Treatment before
risk factors
Ulcer occurs
3. Education
(patients, providers 5. Use appropriate
and family) footwear
Treatment
• Offloading.
• Control of foot infection.
• Control of ischaemia.
• Wound debridement.
• Wound dressings.
Principles of therapy (1)
1. Avoid prescribing antibiotics for uninfected
ulcerations.
2. Determine the need for hospitalization
(severe infection or critical limb ischemia require
hospitalization)
3. Stabilize the patient
– Restoration of fluid and electrolyte balance
– Correction of hyperglycemia, hyperosmolarity, acidosis,
and azotemia
– Treat other exacerbating factors
Most DFIs are polymicrobial, with aerobic
gram-positive cocci (GPC), and especially
staphylococci, the most common causative
organisms. Aerobic gram-negative bacilli are
frequently copathogens in infections that are
chronic or follow antibiotic treatment, and
obligate anaerobes may be copathogens in
ischemic or necrotic wounds.
Principles of therapy (2)
3. Choose an antibiotic regimen
– Severe infection:
• start broad spectrum IV abx (ensure GPC, gram
negative and anaerobic coverage)
– Mild-Moderate infection:
• Relatively narrow spectrum only covering aerobic
GPC
• No evidence for anti-anaerobic therapy
• Oral therapy with highly bioavailable agents is
appropriate
– Mildly infected open wounds with minimal
cellulitis:
• Limited data support the use of topical antimicrobial
therapy.
Infection First Choice Alternative
Mild Oral levofloxacin or moxifloxacin
Mild-Moderate Oral amoxicillin-clavulanic acid Oral clindamycin
Oral cotrimoxazole
Oral linezolid
IV ertapenem IV amoxicillin-clavulanic acid
Moderate- ± or
Severe IV daptomycin or IV linezolid IV 3rd generation cephalosporin + IV
or IV glycopeptide1 metronidazole
or
IV fluoroquinolone2 + IV metronidazole
or
IV piperacilln-tazobactam3
or
IV imipenem or IV meropenem3
±
IV daptomycin or IV linezolid
or
IV glycopeptide1
IV imipenem or meropenem IV tigecycline
Severe or +
IV piperacillin-tazobactam IV fluoroquinolone2 or IV amikacin
+
IV daptomycin or IV linezolid
or
IV glycopeptide1
IDSA
Principles of therapy (3)
4. Determine the need for surgery
– Debridement to revascularization
– Urgent surgical consultation for life- or
limb-threatening infections
• (eg nec fasc, gas gangrene, compartment
syndrome, critical ischemia, etc)
Principles of therapy (4)
5. Adjunctive treatment
– G-CSF:
does not speed healing but reduces the need
for operative procedures
(preliminary meta-analysis of 5 randomized
trials)
– Hyperbaric oxygen therapy:
reserved for chronic, non-healing ulcers.
Evidence indicates it reduces the risk of major
amputation related to a diabetic foot ulcer
(Cochrane review)
Phases of normal wound healing
Scar maturation
Collagen fibril crosslingking
Remodeling 1 week to 6 months
Endothelial cells
Epithelial cells
Wounding
Colagen
Fibroblasts
Proliferation days 2 through 20
Lymphocytes
Macrophages
Neutrophiles
Inflammation days 1 through 7
Proteoglicans
Fibrin
Platelets
Hemostasis 1 hour
Time from injury
Lobmann et al. Diabetes Care 2005
Follow up
1. Re-evaluate the wound
2. Review the offloading and wound-
care regimens –
determine effectiveness of the regimen
and patient’s compliance
3. Evaluate the glycemic control
Summary
• Foot infections
– Large morbidity and mortality
– Frequent visits to health care professionals
– First cause of leg amputation
• Diabetic foot infections require attention to
local (foot) and systemic (metabolic) issues
by a multidisciplinary foot care team.
TERIMA KASIH
