KAKI DIABETIK

DAN
PENATALAKSANAAN
Dr dr Jazil Karimi SpPD K-EMD, FINASIM
Kuliah 2020
 TOPIK BAHASAN
• PENDAHULUAN
• PATOFISIOLOGI KAKI DIABETIK
• FAKTOR RISIKO
• MENEGAKKAN DIAGNOSIS
• KLASIFIKASI KLINIK
• ULKUS DIABETIK
• NEUROPATI DIABETIK
• PERIPHERAL ARTERIAL DIASEASE (PAD)
• PENATALAKSANAAN KAKI DIABETIK
• KESIMPULAN
Kasus kaki diabetes berupa ulkus terinfeksi,
Merupakan kasus DM terbanyak dirawat di bangsal IPD.

Risiko amputasi sangat besar bila ulkus tidak terdeteksi dini dan
dirawat secara adekwat utk menghindari amputasi. Sebab 80%
kasus amputasi di awali ulkus yang diabaikan.

Pahami patofisiologi terjadi ulkus, berdampak

mengurangi risiko amputasi.
Struktur anatomi kaki

Struktur yang rumit

Banyak kompartemen kecil
Jaringan avaskular
Bersekat-sekat
Infeksi mudah menjalar
 Why foot care is important to diabetes management

Diabetes Patients

Have 15 – 40 fold Have a 15 % life Every 30 5-year suvival

higher risk of leg time risk of seconds a lower rate after
amputation than developing foot limb lost caused major
non diabetic
ulcer by diabetes amputation <
50 %
Stlh amputasi

• 85% of diabetes-related amputations are happening in patients with foot ulcers

• 85% of diabetes-related amputations are happening in patients with foot ulcers
• Early detection can prevent 40-85 % lower limb amputation
• Early detection can prevent 40-85 % lower limb amputation
Slide 6
Frykberg et al. J Foot Ankle Surg, 2000. IDF, International Working Group on Diabetic Foot 2007
• Setiap pasien diabetes perlu dilakukan pem kaki
secara  minimal sekali pertahun, meliputi:
1.Inspeksi kelainan yang ada = pucat ? Udem ?
2. Perabaan pulsasi a. dorsalis pedis dan
a.tibialis posterior = di atas os calus
3. Pemerikisaan neuropati sensorik
dgn Filamen Semmes-Weinstein = tanya sensasi pada bbrp
tempat , kemudian bandingkan dngan palpasi standar ( pada
daerah non neuropati / daerah proximal )
 TOPIK BAHASAN
• PENDAHULUAN
• PATOFISIOLOGI KAKI DIABETIK
• FAKTOR RISIKO
• MENEGAKKAN DIAGNOSIS
• KLASIFIKASI KLINIK
• ULKUS DIABETIK
• NEUROPATI DIABETIK
• PERIPHERAL ARTERIAL DIASEASE (PAD)
• PENATALAKSANAAN KAKI DIABETIK
• KESIMPULAN
 Pathophysiology of diabetic foot
Diabetes Mellitus

Neuropathy Trauma Vascular Disease

MOTOR SENSORY AUTONOMIC MICROVASCULAR MACROVASCULAR

Weakness
Anhidrosis Structural Structural
Atrophy
dry skin capillary BM atherosclerosis
Deformity Loss of
thickening
Abnormal Protective Occlusive
Stress Sensation narrowing
High Plantar Functional AV
Pressure Sympathetic Shunting
Ischemia
Callus Tone
Formation

Structural
Impaired Response to
Deformity Infection Ischemia
Cheiroarthropathy
Amputation Diabetic Foot Ulcer Amputation
Slide 9
Diabetic Foot Disorders: A Clinical Practice Guideline (2006 Revision) Ab , senstivitas s
Causes of Ulcers (Extrinsic Factors)
Kyoto Foot Meeting 2010

Tdk
pake
sepatu
, jalan
di
panas

Slide 10
 TOPIK BAHASAN
• PENDAHULUAN
• PATOFISIOLOGI KAKI DIABETIK
• FAKTOR RISIKO
• MENEGAKKAN DIAGNOSIS
• KLASIFIKASI KLINIK
• ULKUS DIABETIK
• NEUROPATI DIABETIK
• PERIPHERAL ARTERIAL DIASEASE (PAD)
• PENATALAKSANAAN KAKI DIABETIK
• KESIMPULAN
 Faktor Resiko Kaki Diabetik

1. terdapat gangguan syaraf tepi

2. kelainan pembuluh darah
3. kelainan biomekanik
4. kelainan struktur kaki
5. beban yang berlebih pada kaki
6. riwayat luka/ganggren pada kaki
7. kelainan pertumbuhan kuku
8. sepatu yang tidak adekuat
9. tingkat pendidikan
 Risk Factors for diabetic foot ulceration
Intrinsic Factors Extrinsic Factors

• Peripheral Neuropathy • Minor mechanical

• Micro- and Macrovascular trauma Paling banyak

Diseases • Callus
• Immunopahty • Thermal Injury
• Structural Deformity • Chemical Burns
• Limited Joint Mobility • Improper use of nail
• Nephropathy cutter
• Age • Smoking
• Duration of Diabetes • Poor knowledge of
• Visual Acuity diabetes
• Previous Ulceration • Psychological Factors
Slide 13
Frykberg, Diabetic Microvascular Complications Today, May/June 2006
• Alternative medication
 Pathway to diabetic foot ulceration
Mati rasa ,
Ga tau ada
100%
luka ,
90%
infeksi
80% 78% 77%
70% 63%
60%
50%
40% 37% 35%
30%
30%
20%
10%
1%
0%
9/10/21 9/10/2 9/10/21 9/10/ 9/10/21
1 9/10/21 9/10/21 21
9/10/21

Slide 14
Reiber GE, Vileikyte, Boyko EJ et al. Causal pathways for incident lower–extremity ulcers in patients with from two settings. Diabetes Care 1999: 157-162
 TOPIK BAHASAN
• PENDAHULUAN
• PATOFISIOLOGI KAKI DIABETIK
• FAKTOR RISIKO
• MENEGAKKAN DIAGNOSIS
• KLASIFIKASI KLINIK
• ULKUS DIABETIK
• NEUROPATI DIABETIK
• PERIPHERAL ARTERIAL DIASEASE (PAD)
• PENATALAKSANAAN KAKI DIABETIK
• KESIMPULAN
6 Steps for a complete Diabetes Foot Examination

DIABETES FOOT EXAMINATION

Gross Derma- Screening

Patient Nail Defor- Vascular
Assess- tologic for
History maties Examination
ment Examination neuropathy
Ulkus ? Neuropati ? Apa ada jamur
Deformitas , kulit ?
? kering ?

Slide 16
 First 4 steps in the assessment
Assessment Significant Finding
Patient History - Previous foot ulceration
- Previous amputation
- Diabetic > 10 years
- A1c > 7 %
- Impaired vision
- Neuropathic symptoms
- Claudicatio

Gross Inspection - Hammer toes

- Claw toes
- Halux valgus
- Corn, callus, callus with ulcer, bunion
- Prominent metatarsal head

Dermatologic - Dry skin

Examination - Absence of hair
- Yellow or erythematous scale
- Ulcer or healed ulcer
- Interspace maceration
- Moist
- Unhealing ulceration

Nail Deformities - Yellow, thickened nail

- Ingrowing nail edge
- Long or sharp nails

Slide 17
 Last 2 steps in the assessment
Assessment Test Significant Finding

Screening for - Semmes-Weinstein Lack of perception at one or

Neuropathy monofilamen 10 gram more side

- Tuning fork 128Hz Negative of vibration

perception

- Biothesiometer: Vibration Vibration perception threshold

perception >25 volt

Vascular - Palpation of dorsalis pedis • Decrease or absent pulse

Examination and tibialis posterior artery • ABI < 0.9 consistent with
- Ankle Brachial Index PAD
- Color doppler

Achle brachial indeks ( ABI ) ABI Interpretation

>1.2 Rigid or calcified vessels or both
0.9 – 1.2 Normal (or calcified)
<0.9 Ischemia
<0.6 Severe ischemia Slide 18
 Risk Classification based on Foot Assessment
Score Category Risk Profile Check-up
Frequency
• Pulsation ADP and ATP good
• No deformities (hammer toe, claw toes, halux
0 Low Risk valgus, prominent metatarsal head) Once a year

• Pulsation ADP and ATP good

• And/or deformities (hammer toe, claw toes,
halux valgus, prominent metatarsal head) Once every 6
1 Increased Risk
months

• ABI < 0,9 or ADP/ ATP not palpable

• Deformities ( hammer toe, claw toes, halux
valgus, , prominent metatarsal head Once every 3
2 High Risk
months

• History of ulcer or amputation

• Ulcer Once every 1-3
3 Very High Risk
months

Slide 19
 Intervention based on Risk Classification
Score Category Intervention

• Encourage extended knowledge on diabetes and foot care

• Encourage self-care
0 Low Risk

• Inspect patient’s feet

• Review need for vascular assessment
1 Increased Risk • Evaluate footwear
• Enhance foot care education

• Inspect patient's feet

• Review need for vascular assessment
• Evaluate provision and provide appropriate
2 High Risk • Intensified foot care education
• Specialist footwear and insoles
• Skin and nail

• Multidisciplinary foot care team :

• They should have unhindered access to suites for managing major
3 Very High Risk wounds,
• Urgent inpatient facilities Melibatkan tim : ipd ,
• Antibiotic administration bedah , dll

Slide 20
 TOPIK BAHASAN
• PENDAHULUAN
• PATOFISIOLOGI KAKI DIABETIK
• FAKTOR RISIKO
• MENEGAKKAN DIAGNOSIS
• KLASIFIKASI KLINIK
• ULKUS DIABETIK
• NEUROPATI DIABETIK
• PERIPHERAL ARTERIAL DIASEASE (PAD)
• PENATALAKSANAAN KAKI DIABETIK
• KESIMPULAN
 Patogenesis
Clinical Classification of diabetic foot (Edmond)
Grade 1 Grade 2 Grade 3 Grade 4 Grade 5 Grade 6

Normal foot, No active Skin Foot develop Tissue necrosis Unsalvageable

no risk factors ulcers, have ≥1 breakdown; infections, with or with foot, need
of neuropathy, risk factors: fisurre, blitser, Discharge out intake major
ischemia, neuropathy, ulcer purulent, foot, amputation,
deformities faktor
ischemia, Usually in cellulitis, neuropathy, extensive
deformities,
resiko plantar surface neuropathy ischemia, necrosis,
callus
Ada faktor and
resiko : and or neuroischemi, destroyed foot,
swelling, nail
penyempitan ischemia infection severe
deformities
darah , gangguan infection
kuku , kaku infeksi Pro
Gangrene
inflamasi

Slide 22
Klasifikasi Texas Diabetic Foot Risk - yg
baru

Risk Group 0 Tanpa neuropati, tanpa PAD

Risk Group 1 Neuropati, +/- deformitas

Risk Group 2 PAD +/- neuropati

Risk Group 3 Riwayat Luka atau amputasi pada

kaki
 TOPIK BAHASAN
• PENDAHULUAN
• PATOFISIOLOGI KAKI DIABETIK
• FAKTOR RISIKO
• MENEGAKKAN DIAGNOSIS
• KLASIFIKASI KLINIK
• ULKUS DIABETIK
• NEUROPATI DIABETIK
• PERIPHERAL ARTERIAL DIASEASE (PAD)
• PENATALAKSANAAN KAKI DIABETIK
• KESIMPULAN
Ulkus : break down kulit
Causes of Ulcers (Extrinsic Factors)
Kyoto Foot Meeting 2010

Slide 25
 ETIOLOGI ULKUS

Neuropatik 55 %

Neuro Iskemik 34 %

Iskemik 10 %
• Tahapan terbentuknya ulkus
dari kallus/mata ikan

Terdapat 2 faktor yang berpengaruh :

- gesekan ( friction )
- tekanan ( pressure )
 Perbedaan Gambaran klinis
antara :

Kaki Neuropati Kaki Neuro Iskemik

Ulkus pada plantar pedis Ulkus pada tepi kaki

Kalus yang tebal Kalus yang tipis/tidak ada
Kaki hangat Kaki dingin
Pulsasi arteri baik Pulasai arteri lemah/tidak ada
Tc O2 > 30 mmHg Tc O2 < 30 mmHg
 TOPIK BAHASAN
• PENDAHULUAN
• PATOFISIOLOGI KAKI DIABETIK
• FAKTOR RISIKO
• MENEGAKKAN DIAGNOSIS
• KLASIFIKASI KLINIK
• ULKUS DIABETIK
• NEUROPATI DIABETIK
• PERIPHERAL ARTERIAL DIASEASE (PAD)
• PENATALAKSANAAN KAKI DIABETIK
• KESIMPULAN
Gangguan di meilin , ada pembuluh darah mikro , diabet = rusak
mikro = rusak mielin = rangsangan sensasi dikulit terganggu .
 NEUROPATI DIABETIK :
Ruang Lingkup dan Risiko

• 60%-70% Individu dengan Diabetes

• Risiko meningkat dg usia dan lamanya penyakit:

– Rerata tertinggi: diabetes >25 tahun
– Kadar HbA1C yang tak terkendali
– Hiperkolesterolemia (LDL)
– Obesitas
 Definisi
Kerusakan syaraf akibat diabetes:

• Simtomatik:
– Rasa nyeri 
– Rasa kesemutan atau tebal dimulai pada
ujung-ujung ekstremitas.

• Asimtomatik:
– Kerusakan organ – sistem pencernaan,
reproduksi, jantung.
 Intrinsic Factors

Peripheral Neuropathy

Autonomic Motoric Sensoric

Decreased Sweating
• Loss of protective

Dry Skin sensation

• Decreased pain
Decreased Elasticity
threshold
Fissure / Callus • Lack of temperature
sensation and
Ulcer proprioception

Thermal Trauma Ill fitting

in ‘bajaj’ Shoes
Slide 33
 Gejala - gejala
• Baal, tebal, kesemutan, atau nyeri
pada : jari kaki, telapak kaki, betis, lengan, tangan dan jari
tangan.
• Berkurangnya massa otot pada kaki dan tangan.
• Gangguan pencernaan, mual dan muntah.
• Diare atau konstipasi = pengosongan lambung yg terganggu
• Pusing atau kunang2 setelah bangkit dari posisi duduk ke
berdiri.
• Gangguan berkemih
• Disfungsi ereksi pd pria, vagina yang kering pd wanita.
• Kelemahan
 Jenis-jenis
• Distal symmetric sensorimotor polyneuropathy
(DPN) = sifat . Kiri kanan ? Iya , curiga neuropati

• Neuropati Otonom

• Neuropati Fokal dan Multifokal

ADA. Medical Management of Type 2 Diabetes. 7th Edition. 2012.

 Pentingnya Penapisan dan Deteksi Dini

• Pasien sering mengalami progresifitas penyakit

 dari DPN ringan - sedang - berat sebelum
diagnosis.

• Dapat tidak menunjukkan tanda / gejala

• DPN dapat menjadi komorbid terhadap

komplikasi makrovaskular lainnya (contoh
Penyakit Arteri perifer)
Boulton AJ. Diabetologia. 2004;47:1343-53.
Caselli A, et al. Diabetes Care. 2002;25;1066-70.
Tesfaye S, et al. N Engl J Med. 2005;352:341-50.
Vinik AI, Mehrabyan A. Med Clin North Am. 2004;88:947-99.
 MENEGAKKAN DIAGNOSIS
Penggunaan Monofilamen :
• Prinsip : menilai kemampuan sensasi dengan
beban tekanan
• Cara nya :
Membandingkan sensasi suatu area di kaki
terhadap standar normal.
 Standar Pengobatan DPN

1. Kendali glikemik yg optimal adalah satu-satunya upaya

pencegahan yg sudah terbukti.
2. Obat-obatan untuk mengurangi keluhan
direkomendasikan untuk meningkatkan kualitas hidup
pasien.

ADA. Standards of Medical Care in Diabetes-2012 Diabetes Care 35 (Suppl 1).

 Therapy of Diabetic Neuropathy
2. Pain Management

1. Glucose control

Tricyclic Antidepressant,
Anticonvulsant (misal:
Protein Kinase C inhibitor Gabapentin, Pregabalin)

3. Physiotherapy
(+ foot care)
4. Psychotherapy
 Pengelolaan nyeri dan kesemutan

• Kendali glikemik seoptimal mungkin

• Tricyclic antidepressants
• Duloxetine *
• Pregabalin*
• Opioid dan Opioid-like drugs
• Patch Lidokain
• Mengatur tempat tidur sedemikian rupa shg sprei dan
selimut tidak banyak bergesekan di tungkai dan kaki.
• Akupuntur

* FDA approved for treating painful diabetic peripheral neuropathy

 TOPIK BAHASAN
• PENDAHULUAN
• PATOFISIOLOGI KAKI DIABETIK
• FAKTOR RISIKO
• MENEGAKKAN DIAGNOSIS
• KLASIFIKASI KLINIK
• ULKUS DIABETIK
• NEUROPATI DIABETIK
• PERIPHERAL ARTERIAL DIASEASE (PAD)
• PENATALAKSANAAN KAKI DIABETIK
• KESIMPULAN
 Peripheral Artery Disease
(PAD)
• PAD berhubungan dengan peningkatan risiko
infark miokard, ketidakmampuan fungsional, dan
hilangnya anggota gerak
– 20% prevalensi pd pasien > 40 tahun
– 29% prevalensi pd pasien > 50 tahun
– 27% memiliki progresifitas simtomatik selama
lebih dari 5 tahun.
– ~ 4% pasien terjadi amputasi selama lebih dari 5
tahun

ADA. Diabetes Care. 2003;26:3333-41.

 Pathologic Progression of PAD
Atherosclerosis > Thrombus Formation >
Ischemia > Limb Pain > Impairment

Atherosclerosis and platelet Narrowed arteries and Ischemia leads to painful

activation lead to the formation of a thrombus symptoms, cell death,
formation of a thrombus in impedes blood flow to the and results in physical
arteries periphery and results in impairment
Ross R. N Engl J Med. 1999; 340:115-126.
ischemia
 Intrinsic Factors
Peripheral Arterial Disease (PAD)
Risk Factors* PAD

• Hyperglycemia • Correlated with atherosclerosis

• Eleveted systolic blood • A1c 1%  26 % PAD
pressure • More aggressive
• hyperlipidemia • Narrowing vessel lumen …
• Smoking obstructive
• Cardiovascular disease • Distal tissue necrosis

Slide 45
* UKPDS
Sign & Symptom
Classification of PAD

Currently, the Fontaine classification is one

of the most well known classifications.
Iwai T, Critical Limb Ischemia, Ann Thorac Cardiovasc Surg 10, No. 4, 2004
 Gejala PAD
• Sering asimtomatik
• Klaudikasio intermiten
– Nyeri, kram di betis, paha, atau bokong.
– Nyeri bertambah hebat jika berjalan atau aktifitas
dan berkurang saat istirahat.

• Nyeri saat istirahat

• Kehilangan jaringan
• Gangren
ADA. Diabetes Care. 2003;26:3333-41.
 Tanda-tanda PAD

• Hilangnya pulsasi di kaki (ADP, ATP)

• Ankle-brachial index (ABI)

– Ratio tekanan darah sistolik di ankle terhadap lengan
atas .
– 95% sensitif dan 100% spesifik relatif thd angiogram
– Pembuluh darah yg terkalsifikasi dapat meningkatkan
rasio
 PAD: Skrining
• pemeriksaan ABI pada pasien usia > 50 tahun yg
memiliki faktor risiko (contoh: merokok, hipertensi,
hiperlipidemia, dan lamanya diabetes >10 thn)

• Rujuk pasien dg klaudikasio yg hebat atau ABI

positif untuk penilaian vaskular lebih lanjut.

• Pertimbangkan latihan fisik, obat-obatan, dan

pilihan bedah.

Standards of Medical Care in Diabetes-2012 Diabetes Care 35 (Suppl 1).

 PALPASI ARTERI KAKI
Lakukan palpasi arteri secara standar :
• Raba arteri dengan menggunakan 4 jari
tangan ---- dimana ibu jari tangan berfungsi
sebagai konter tekanan
• Nilai : intensitas isi nadi dengan cara
bandingkan terhadap standar isi nadi normal.
DIAGNOSTICS
Method of palpating the femoral
artery
clinical evaluation

• Counterpressure on
the lower abdomen
pushes the skin
crease toward the
inguinal ligament and
reduces the risk of
missing the pulse.
DIAGNOSTICS
Method of palpating the popliteal
artery
clinical evaluation • patient's knee slightly
flexed
• use thumbs to apply
counter pressure
while palpating the
artery
• which lies deep in the
popliteal fossa, with
fingers.
DIAGNOSTICS
Method of palpating the dorsalis pedis artery

clinical evaluation
DIAGNOSTICS
Method of palpating the tibialis posterior
artery
• using the
clinical evaluation fingertips
for the
posterior
tibial while
applying
counter
pressure
with the
thumb.
• Pulse intensity should be assessed and should be recorded
numerically as follows:
− 0, absent
− 1, diminished
− 2, normal
− 3, bounding

• The shoes and socks should be removed, the feet inspected, the
color, temperature, and integrity of the skin and intertriginous
areas evaluated, and presence of ulcerations recorded.

• Additional findings suggestive of severe PAD, including distal hair

loss, trophic skin changes, and hypertrophic nails, should be
sought and recorded.
Elevation Pallor/Dependent Rubor
DIAGNOSTICS
stenotic area
clinical evaluation
Don’t Wait For This To Happen...
 The Diagnosis Of PAD

 clinical evaluation
 ankle-brachial index (ABI),
 duplex ultrasonography (US),
 and was confirmed by means of
lower-limb angiography
Ankle-Brachial Index (ABI)
DIAGNOSTICS
Measurement of the Ankle-Brachial Index

Alving, B. M. et al. Hematology 2003;540-558

Copyright ©2003 American Society of Hematology.
 Contoh Kasus

• Tn M, Datang dengan keluhan sering buang air

kecil di malam hari. Dia juga mengeluhkan rasa
kesemutan di kedua kaki. Ibunya menderita
diabetes dan meninggal dunia karena serangan
jantung. Ayahnya juga penderita diabetes dan
meninggal karena gagal ginjal. Saat ini ia sangat
ketakutan akan kemungkinan terjadi komplikasi
diabetes.
• GDP 180 mg/dl dan GD2JPP 290 mg/dl
 Pertanyaan
• Masalah apa saja yg ada pada pasien ini?
• Kapan dan Bagaimana anda
mengevaluasi komplikasi diabetes?
• Bagaiman anda mengelola pasien ini?
 TOPIK BAHASAN
• PENDAHULUAN
• PATOFISIOLOGI KAKI DIABETIK
• FAKTOR RISIKO
• MENEGAKKAN DIAGNOSIS
• KLASIFIKASI KLINIK
• ULKUS DIABETIK
• NEUROPATI DIABETIK
• PERIPHERAL ARTERIAL DIASEASE (PAD)
• PENATALAKSANAAN KAKI DIABETIK
• KESIMPULAN
 Slide 66

5 Cornerstones of diabetes foot care

management
1. Foot examination
regularly

5. Identification of
2. Treatment before
risk factors
Ulcer occurs

4. Education
(patients, providers 3. Use appropriate
and family) footwear
 Intrinsic Factors
Foot Deformities / Biomechanical

Slide 67
 Standar Perawatan kaki
• Pemeriksaan kaki yg menyeluruh utk
mengidentifikasi faktor risiko prediktif
 obati sebelum terjadi ulkus, untuk
mencegah amputasi

• Mengadakan edukasi perawatan kaki secara

mandiri

• Pendekatan multidisiplin secara personal kpd

individu dengan ulkus dan kaki yang risiko tinggi

Standards of Medical Care in Diabetes-2012 Diabetes Care 35 (Suppl 1).

 Edukasi Pasien
• Buat penilaian terhadap pasien  mengenai
pengetahuan dan pengelolaan penyakitnya
• Menerangkan implikasi klinis dari hilangya
sensasi
• Monitoring kaki harian

• Perawatan kuku dan kulit

• Pemilihan alas kaki utk mencegah luka

Standards of Medical Care in Diabetes-2012 Diabetes Care 35 (Suppl 1).

 Prevention of Diabetes Foot
( Treatment before
Ulcer occurs )

DO DON’T’s
Check your feet everyday Walk without shoes
Always wear footwear Use shoes that don’t fit
Check your footwear before wearing them Use socks that don’t fit to your foot
Use shoes that fit Let your skin become dry
Buy shoes in the afternoon Use sharp items to remove warts
Always use socks of cotton Smoke
Wash your feet with soft soap and dry Use ring on finger
them
Cut your nails in a flat way Use high heels or shoes with sharp edges

Check your feet regularly at the doctor Over use of irritative lotion

Use lotion regularly at your skin Use hot water to dip your feet

Slide 70
 Management of Foot Ulcers
2
Metabolic
Control

1 3

Wound Infection
Control Control

4
5 Mechanic Vascular
Control Control

Slide 71
International Working Group on the Diabetic Foot 2007
1 Wound Control

1. Incision, drainage,
debridement and necrotomy
2. Management of infections in
tissue and bone
3. Exudate Management
4. Keep control of proliferation
phase and infections

Slide 72
2 Metabolic Control

1. 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

Slide 73
 Kendali gula pd DMT1
• Korelasi kuat antara risiko terjadinya komplikasi
mikrovaskular dan pajanan glikemik yg terus
menerus:
– Menurunkan GD menunda onset dan
memperlambat progresifitas komplikasi
mikrovaskular
– Risk reductions terhadap terjadinya berbagai
komplikasi sekitar 35-75%

Diabetes Control and Complications Trial Research Group: The effect of intensive treatment of diabetes on the development and
progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med 1993;329:977-86.
Reichard P, Nilsson BY, Rosenqvist V: The effect of long-term intensified insulin treatment on the development
of microvascular complications of diabetes mellitus. N Engl J Med 1993;329:3049.
3 Infection Control

1. Need aggressive therapy

2. Usually there are no symptoms
or signs of infection
3. External Infection: Positive
gram bacteria
4. Internal Infection: Negative
gram bacteria
5. Might need surgery

Slide 75
3 Use of Antibiotics
Choice of antibiotics should be determined by:
1. Condition of the Infection:
- Stage of infection and history of antibiotics
- Bone infection, condition of blood vessels
2. Type of bacteria (sensitivity test)
- Anarob, aerob, gram positive / gram negative

3. Condition of the patient

- Allergy, heart and kidney function

4. Drug Profile
- Safety, drug interactions, adverse events,
frequency and dosage and price

Slide 76
4 Vascular Control

1. Neuroischemic Foot
2. Atherosclerosis can cause total
block in the blood vessels
3. Decrease of blood flow to the
wound
4. Critical Limb ischemia:
Amputation Warning

Slide 77
 Goal of treatment

Treatment of PAD should aim at not only to

improve QOL by alleviating lower limb
symptoms
 but also prolonging survival and prognosis.
 Management of PAD

• Risk Factor Modification

• Medical Treatment
• Intervention Procedures
 PAD dengan Klaudikasio Intermiten (KI) :

• Diskusikan risiko- benefit pilihan terapi

( farmakologik, endovaskuler, dan bedah)
• Dilakukan supervisi program latihan jalan
dan di evaluasi setiap 3 bulan sekali guna
menilai kemajuan yang dicapai, bersamaan
dengan pemberian terapi farmakologi.
• Rujuk ke senter latihan rehabilitasi, dimana
jenis latihan berupa treadmill dan track
walking terbukti paling efektif :
1.Lama latihan tergantung kondisi pasien dan
umumnya di awali selama 35 menit,
2.Metode exercise –rest exercise pattern.
Ditingkatkan bertahap 5 menit pada setiap sesi
latihan sampai mencapai lama latihan 50 menit.
3.Frekwensi latihan dianjurkan 3-5 kali per
minggu.
 PAD dengan ITK (Iskemi tungkai kritis)

• Pemberian antibiotik bila didapatkan ulkus atau infeksi tungkai

• Segera diberikan heparinisasi ( unfrationated atau low
molecular).
• Konsultasi kepada konsultan Bedah vaskuler
1. Menilai etiologi ( emboli atau trombus,
hypercoagulable state, trauma, phlegmasia cerulea
dolens ),
2. Apakah perlu tindakan revaskularisasi ( trombolitik,
endovaskuler dan bedah) atau hanya terapi
medikamentosa dan bahkan amputasi pada
iskemia irreversible bila diperlukan.
5 Mechanic Control

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

Slide 85
 From Theory to real-life – studies on foot care in RSCM

RSCM 2003 RSCM 2007

9/10/21 9/10/21
32%

50%
9/10/21
9/10/21

26%

9/10/21 9/10/21
9/10/21 9/10/21
9/10/21 9/10/21
9/10/21

Slide 86
 TOPIK BAHASAN
• PENDAHULUAN
• PATOFISIOLOGI KAKI DIABETIK
• FAKTOR RISIKO
• MENEGAKKAN DIAGNOSIS
• KLASIFIKASI KLINIK
• ULKUS DIABETIK
• NEUROPATI DIABETIK
• PERIPHERAL ARTERIAL DIASEASE (PAD)
• PENATALAKSANAAN KAKI DIABETIK
• KESIMPULAN