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 Pressure Ulcer
o Diabetic Ulcer
o Venous Ulcer
o 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

Prevention
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

Antibiotic and Glicemic

Control
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

Debridement, Antibiotic and

Glicemic Control
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

Debridement, Antibiotic and

Glicemic Control, Amputation can
be considerd
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

Wide Debridement, Antibiotic,

Glicemic Control, and Amputation
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

Antibiotic, Glicemic Control, and

Below Knee Amputation
 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
 Local Wound Care
o Remove fluid from
the wound
o Increase blood flow
 Local Wound Care
o Remove fluid from
the wound
o Increase blood flow
o Decrease bacterial
colonization, and
 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
 Markers of Healing

Enough Enough
Oxygen proteins

HbA1C

Markers of Healing
Hemoglobin Male : 13.8 – 17.2 Female : 12.1 – 15.1
Albumin 3.4 – 5.4 g/dl
HbA1c < 5.7 %
 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: Wound contraction; and the wound heal

Granulation tissue and epithelialization
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 antibiotic-
related problems
• Infecting pathogen is resistant to available
antibiotics
• Limb has uncorrectable ischemia (precluding
systemic antibiotic delivery)
Terima Kasih

Wassalam
H.N.Nazar