ADVANCED WOUND CARE:An experience in diabetic foot ulcer

PSMIK, Fakultas Kedokteran UNHASEditor in Chief Jurnal Luka Indonesia

Griya Afiat Makassar, Wound Care and Home Care

Saldy Yusuf.,PhD.,ETN

Kongres Nasional PERS, Novotel Hotel, Palembang 25-27 Juli 2017

Topics

1. Current status DFU in Indonesia2. Risk Assessment3. Wound care of DFU4. Case series.

2

PREVALENSI DIABETES MELLITUS

1. Waspadji S, Ranakusuma A, Suyono S, Supartondo S, Sukaton U. Diabetes Mellitus in an Urban Population in Jakarta, Indonesia. Tohoku J exp Med. 1983;141:219-228.2. Mihardja L, Delima, Siswoyo H, Ghani L, Soegondo S. Prevalence and determinants of diabetes mellitus and impaired glucose tolerance in Indonesia (a part of basic health

research/Riskesdas). Acta Med Indones. 2009;41(4):169-74.3. Shaw, J.E., Sicree RA, Zimmet PZ. Global estimates of the prevalence of diabetes for 2010 and 2030. Diabetes Res Clin Pract. 2010;87(1):4-14.4. Guariguata L, Whiting DR, Hambleton I, Beagley J, Linnenkamp U, Shaw JE. Global estimates of diabetes prevalence for 2013 and projections for 2035. Diabetes Res Clin Pract.

2014;103(2):137-149.5. Pramono, L. a, Setiati, S., Soewondo, P., Subekti, I., Adisasmita, A., Kodim, N., & Sutrisna, B. (2010). Prevalence and predictors of undiagnosed diabetes mellitus in Indonesia. Acta

Medica Indonesiana, 42, 216–223. 3

1.63%

5.7% 6%7.00%

6.00%

5.00%

4.00%

3.00%

2.00%

1.00%

0.00%

PREVALENCE DM IN INDONESIA1,3,4

19831 20072 20303

ta

12 Juta

0

2

4

6

8

10

7 Ju

12

14

2010 2030

Populasi DM di Indonesia2013 2035

Country Millions Country Millions

China 98.4 China 142.7

India 65.1 India 109.0

USA 24.4 USA 29.7

Brazil 11.9 Brazil 19.2

Russian 10.9 Mexico 15.7

Mexico 8.7 Indonesia 14.1Indonesia 8.5 Egypt 13.1

Germany 7.6 Pakistan 12.8

Egypt 7.5 Turkey 11.8

Japan 7.2 Russian 11.1

Prevalensi DM yang tidak terdiagnosa cukup tinggi sebesar 4.1 %

Prevalence Acute and Chronic Wound

85.1

0

14.8

0

34.6

19.2

38.4

7.6

Sembuh Rujuk Drop out Meninggal

Summary Outcome in Wound Care Setting2013

Luka Akut Luka Kronis

26

1512

118 8

7

3 3 31 1 1

Prevalensi Acute and Chronic Wound in Home Care Setting

Saldy Yusuf., Sukmawati.,Mayumi Okuwa.,Junko Sugama. Development Enterostomal Therapy Nurse Outpatient Wound Clinic In Indonesia: A Retrospective Descriptive Study. 2013. Wound Research and Practice. 21(1):41-47

DFUs is major wound problems in clinical setting in Indonesia High number of Drop Out Patients

Prevalence DFUs in Indonesia• Prevalence of risks (neuropathy and angiopathy) in Hospital

Setting 55.4% (95% CI: 53.7-57.0%)(Yusuf et al., 2015).

• Prevalence of DFUs:– Hospital 12% (95% CI: 10.3-13.6%)

(Yusuf et al., 2015).

– Home care 26%(Yusuf et al., 2013).

• One year observation; healing (64.7%), recurrence (17.6%),dead (11.8%), unheal (5.9%)

(Baharia et al., 2014)

1. Yusuf, S., Okuwa, M., Irwan, M., Rassa, S., Laitung, B., Thalib, A., … Sugama, J. (2015). Prevalence and risk factor diabetic foot ulcers: A cross sectional study among DM type 2 in eastern Indonesia. OWM Journal.

2. Yusuf, S., Kasim, S., Okuwa, M., & Sugama, J. (2013). Development of an enterostomal therapy nurse outpatient wound clinic in Indonesia : a retrospective descriptive study. Wound Practice and Research, 21(1), 41–47.

3. Baharia Laitung, Muhammad Irwan, Saiful Rassa, Sukmawati, Saldy Yusuf. One year recurrence incidence and risk factors of diabetic footulcer in Makassar, eastern Indonesia (pre eliminary study). 1st WOC Scientific Meeting, Yogyakarta 2014. 5

DFU status on 1st admission

INFECTIONS ODOUR

CALLUSMASERASIEDEMA

UNDERMININGNECROTIC

POST AMPUTASI

Saldy Yusuf (2013) Current Status of Diabetic Foot Ulcers in Makasar, Indonesia. Baruga AP. Pettarani, 9Desember 2013

7

DFU presence in one way

11. WGDF, “Pathophysiology of foot ulceration Pathophysiology of foot ulceration,” 2012.

DIABETES MELLITUS

Neuropathy Angiopathy

PRE ULCER

DIABETIC FOOT ULCER

AMPUTATION

Dry Skin Corn Callus Tinea Pedis

PRE ULCERS: SKIN PROBLEMS

Onychocriptosis Onychodistrofi Onychogriposis Onychomycosis

PRE ULCERS: NAIL PROBLEMSPRE ULCERS: DEFORMITY PROBLEMSHallux VagusBunionHammer Toe

PRESENCE DIABETIC FOOT ULCER

Amputation

Golden Assessment

ABI dan TBIMONOFILAMENT TEST

ANGIOPATHYNEUROPATHY

8

Its not widely available in health care facilities

Alternative?

Foot palpatianIpswich Test

ANGIOPATHYNEUROPATHY

Diabetic Foot Check Up

How about its validity and reliabity?

Alternative Assessment

10

Palpasi Nadi Dorsalis Pedisdan Posterior Tibialis

Ipswich Test

• Sensitivity (66.7-100%)• Spesifisity (80.0-94.6%)

(Sulasti, Yusuf, Jafar, & Syam, 2017)

• Reliability between nurses (Cohen's Kappa = 0.724-0.909)

(Sulasti, Yusuf, Jafar, & Syam, 2017)

• Sensitivity (25-100%)• Spesificity (97.5-100%)

(Desri, Yusuf, Jafar, & Syam, 2017).

Validity and Reliability

Considerable to be valid and reliable as alternative assessment

Risk Category for DFUs

RESIKO 0

RESIKO 1 RESIKO 2A RESIKO 2B RESIKO 3BRESIKO 3A

No Neuropathy No Deformity No IschemicNo History of UlcerNo History of amputation

Neuropathy + Deformitas + PAOD + History of + History of ulcers amputation

Avery, D. A. C. L., Lavery, L. A., Peters, E. J. G., Williams, J. R., Murdoch, D. P., Hudson, A., & LAvery, D. C. (2008). Reevaluating the Way We Classify the International Working Group on the Diabetic Foot. Diabetes care, 31, 154–156. doi:10.2337/dc07-1302.Abbreviations

Eligible: 259

Analysis:249 (inpatient 14)

Drop Out: 10

Group 0:90 (36.1%)

12

Our findings

Group 1:14(5.6%)

Group 2A: 64 (25.7%)

Group 2B: 34 (13.7%)

Group 3A: 14 (5.6 %)

Group 3B: 3 (1.2%)

No DFU: 219 DFU:30

Yusuf, S., Okuwa, M., Irwan, M., et al (2016). Prevalence and Risk Factor of Diabetic Foot Ulcers in a Regional Hospital , Eastern Indonesia. Open Journal of Nursing, 6, 1–10.

Advanced Assessment:Mobile Infra Red Thermography

Identification neuropathy

2008(Bharara,

Viswanathan, & Cobb, 2008a and

2008b)

2009(Nishide et al., 2009)

(Roback, Johansson, & Starkhammar, 2009)

Identification Inflammation & sign

for foot diseaseDiagnosis

neuropathy

2012(Balbinot, Canani,

Robinson, Achaval, & Zaro, 2012)

IdentificationPlantar pattern

2011(Nagase et al., 2011)

2014(Yavuz et al., 2014)

Evaluation peakshear stress

HistoryMilestone application infra red thermography in diabetic foot

Saldy Yusuf: Identification Clinical Features Diabetic Foot Ulcers Using Non-Contact Thermography Based On Mobile Phone: A Case Series. WCET 2016 Conference, Cape Town, South Africa; 03/2016

Mobile Thermography as advanced assessment

Courtesy: Griya Afiat Makassar

Our FindingsThermography Features Clinical Features

Dorsal

Plantar

Clinical features showed necrotic area along side dorsal forefoot to medial, However thermography findings identified “cold pattern” at all fingers and forefoot area.

Yusuf, S., Sukmawati, K., & Laitung, B. (2016). Identification Clinical Features Diabetic Foot Ulcers Using Non Contact Thermography Based on Mobile Phone: A Case Series. In WCET 21st Biennial Congress.

Sandi, Selina, et al (2017)

Screening for risk

17

Our study will investigate infra red thermography based iPhone as early screening tool in community setting

Butterly Pattern Asymmetrically Pattern

Thermography: Pressure Ulcer

Thermography dapat digunakan untuk memprediksi terbentuknya “undermining” pada luka decubitus (Yusuf, S., et al 2016)

We noted some advantages:• Less expensive amazon(US $217.99).• Real time support time serial observation.• Non contact no contamination.• 2 Dimension imaging advanced analysis.• Pocket size Useful in various setting.• Attach to smartphone easy to capture,

saving, sending, uploading and printing.

Advantages

Wound Care:Wound Bed Preparation and TIME

20

TIME CONCEPT

European Wound Management Association (EWMA). Position Document: Wound Bed Preparation in Practice. London: MEP Ltd, 2004

EWMA merekomendasikan:1. Debridement secara berkala dan radikal.2. Inspeksi dan kontrol bakteri.3. Moisture balance untuk mencegah maserasi.

Moura, L. I. F., Dias, A. M. a, Carvalho, E., & de Sousa, H. C. (2013). Recent advances on thedevelopment of wound dressings for diabetic foot ulcer treatment--a review. ActaBiomaterialia, 9(7), 7093–114. doi:10.1016/j.actbio.2013.03.033

MOISTURE BALANCEPemilihan Balutan yang Tepat

Proses Perawatan

European Wound Management Association (EWMA). Position Document: Wound Bed Preparation in Practice. London: MEP Ltd, 2004

Cleaning Debridement Dressing

24

METODE DESKRIPSI KEUNTUNGAN KERUGIANMechanical Menggunakan kasa basah-

kering atau irigasi cairanmembersihkan bantalan luka dari kontaminasi bakteri.

Non selektif, sehingga jaringan sehat juga dapat terganggu, dapat menimbulkan nyeri..

Sharp-sequential bedside

Menggunakan scalpel atau gunting jaringan

Metode debridement yang paling cepat.

Perdarahan merupakan efek merugikan.

Biosurgeri Menggunakan belatung

kurang lebih 5-8/cm2

Belatung mensekresikan enzim yang merangsang granulasi.

Belatung steril tidak tersedia di semua unit pelayanan kesehatan.

Autolitycmenciptakan lingkungan lembab.

Contoh: Hydrogel

Menggunakan balutan yang Selektif sehingga tidakmengganggu jaringan yang sehat.

Sifatnya kerjanya lambat, kurang tepat untuk nekrotik yang luas dan melekat kuat.

Enzymatic Menggunakan preparat

enzim

Bersifat selektif, karena hanya bekerja pada jaringan nekrotik

Sifatnya yang lambat dibanding terapi conservative,.

Bates-Jensen, Barbara.M., MacLean, Catherine.H. (2007)

Metode Debridement

Pencucian LukaAda beberapa tekhnik pencucian luka:1. Menggosok (Swabbing),2. Mengguyur (Showering), Dan3. Merendam (Bathing)

namun tidak ada perbedaan yang signifikan diantara tekhniktersebut (Moore & Cowman, 2005).

Manfaat pencucian luka

26Makoto Oe, et al 2014., unpublished data

Patient ID 1 2 3 4 5

Wound location Sole (Right)5th toe(Left)

2nd Toe-dorsum (Right)

2nd Toe-sole

(Right)

Dorsum(Left)

Age (yrs.) 49 49 60 60 56

Gender Male

Duration of DM(yrs.) 14 14 6 6 13

Neuropathy NeuropathyABI 1.18 1.18 0.85 0.85 0.65Bacteria count (bedfore cleansing) 6.33x106 9.78x105 3.47x106 6.68x106 6.74x107

Bacteria count (aftercleansing)

1.34x106 3.38x105 1.89x107 1.23x107 1.56x106

0 day 5 day 7 day 11 day 14 day

5 day 14 day0 day 2 day

2 day HoneyIndonesiangroup

Control group7 day 11 day

0 day 2 day 5 day 7 day 11 day 14 dayManuka Honey group

Madu sebagai alternatif

Haryanto, Urai, T., Mukai, K., Suriadi, Sugama, J., & Nakatani, T. (2012). effectiveness of Indoensian Honey on the Aceleration of Cutaneous WOund Healing: An Experimental Study in Mice. WOUNDS, 24(4), 110–119.

2

1.8

1.6

1.4

1.2

1

0.8

0.6

0.4

0.2

00 1 2 3 4 5 9 10 11 12 13 14

Control

Indo

Manuka

Rat

ioof

area

sto

orig

inal

area

s

per group .Ratio of the wound area. Value was expressed Mean±SD. n = 6 ANOVA; Tukey-Kramer (** p < 0.01)

6 7 8

Days after wounding

** ** ****

NS

Madu sebagai alternatif

Haryanto, Urai, T., Mukai, K., Suriadi, Sugama, J., & Nakatani, T. (2012). effectiveness of Indoensian Honey on the Aceleration of Cutaneous WOund Healing: An Experimental Study in Mice. WOUNDS, 24(4), 110–119.

Case Series

29

5 Okt 20132 Okt 201327 Sept 2013

23 Sept 201320 Sept 2013

Kanan (Ada/absent)

Monofilament Absent

Pin Prick Absent

Palpasi

Dorsalis Pedis Absent

Posterior Tibialis Absent

ABPI

Dorsalis Pedis 1.1

Posterior Tibialis 0.6

Case 1: Callus

Case 1: DFU Wagner IV

Case 2: Abscess

6 Sept 201526 Agustus 201523Agustus 2015

13 Oktober 201521 September 201516 September 2015

LAPORAN KASUSLuka Kaki Diabetic Wagner IIIdi Klinik Griya Afiat Makassar

Saldy Yusuf, PhD.,ETN1,2.,Baharia Laitung, S.Kep1., Sukmawati, S.Kep1.

1Griya Afiat Makassar, Wound Care and Home Care Clinic, Makassar, Indonesia.2Chroni Wound Department, Kanazawa University Japan.

21 Januari 201420 Januari 2014 25 Januari 2014

29 Januari 2014 31 Januari 2014 7 February 2014

19 February 2014 23 February 201413 February 2014

PROSES PERAWATAN

26 February 2014 11 Maret 20141 Maret 2014

14 Maret 2014 24 Maret 201419 Maret 2014

28 Maret 2014 10 April 20142 April 2014

PROSES PERAWATAN

LAJU PENYEMBUHAN

20 Januari 2014 19 February 2014 11 Maret 2014 10 April 2014

Skor awal BBJ 48 , Skor akhir BBJ 13, laju penyembuhan 35/82 hari = 0.42/hari

Baharia., Sukmawati., Saldy Yusuf (2014) Case Report: Honey Impregnated wound dressing in DFU Wagner III. Data on file.

Baharia., Sukmawati., Saldy Yusuf (2014) Case Report: Honey Impregnated wound dressing in DFU Wagner III. Data on file.

Efektifitas waktu:• Lama perawatan : 82 hari.• Frekuensi perawatan : 23 kali.• Rata rata pergantian balutan : 4 hari.• Rata-rata waktu perawatan: 30-60 menit.Efektifitas dressing:• Tidak nyeri.• Bau terkontrol.• Balutan tidak lepas.Efektifitas hasil:• Sembuh tanpa komplikasi.• Sembuh tanpa amputasi (minor atau mayor).

EFEKTIFITAS

LAPORAN KASUSDiabetic Ulcer Non Foot

di Klinik Griya Afiat Makassar

Saldy Yusuf, PhD.,ETN1,2.Baharia Laitung, S.Kep1., Sukmawati, S.Kep1.,

1Griya Afiat Makassar, Wound Care and Home Care Clinic, Makassar, Indonesia.2Chroni Wound Department, Kanazawa University Japan.

Healing Progress

26 JULY 2014 31 JULY 2014 2 AGUSTUS 2014 7 AGUSTUS 2014

11 AGUSTUS 2014 18 AGUSTUS 201423 SEP 2014 28 OKT 2014

Wound phase

Dressing

Primary Secondary Tertiary Periwound Care

Inflamation • Hydro L• Epitel Salf• Metco

• Cutisorb • Hypafix • Metco/Zinc

Exudate • Madu • Foam Cavity

• Cutisorb

• Hypafix • Metco

Granulasi • Madu • AlCutisor b

• Alginate

• Hypafix • Metco

Epitel • Film

Wound care

Graphic 1: Wound Healing Progress

27 2934

39 40 40

30 30 29 2925 24

1815 13

10

5

0

15

20

25

30

35

40

45

1 2 3 4 5 11 12 13 14 156 7 8 9 10

Wound Care Series

Wound Healing Progress (BBJ Score)

Duration of care 95 days, Frequency of wound care 15 times,Baseline BBJ 27, Outcome BBJ 13:Wound Care Interval = 6.3 Days

Wound healing progress= 0.14 BBJ score/days

Kesimpulan• Di Indonesia Prevalensi DFU cukup tinggi.• Ipswich test dan palpasi nadi dorsalis pedis-

posterior pedialis dpt digunakan untuk identifikasi resiko.

• Perawatan DFU berorientasi pada penyebabdan status luks.

• Wound bed preparation dalam manajemen DFU dapat menekan biaya dan mengefektifkan waktu perawatan.

Spesialis Perawatan LukaJl. Syekh Yusuf V/3 MakssarHp: 0812 418 418 00

TERIMA KASIH

GRIYA AFIATMAKASSAR