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kaki diabetic=diabetic foot
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Kaki Diabetes
Diabetic Foot • A diabetic foot is a foot that exhibits any pathology that results directly
from diabetes mellitus or any long-term (or "chronic") complication of diabetes mellitus.[1]
• Presence of several characteristic diabetic foot pathologies is called diabetic foot syndrome. These are thus umbrella terms.
• The most serious foot complications in diabetes are:[2]• Diabetic foot ulceration. It occurs in 15% of all patients with
diabetes and precedes 84% of all diabetes-related lower leg amputations.[3]
• Diabetic foot infections• Neuropathic osteoarthropathy of the foot[
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DiabeticRetinopathyLeading causeof blindnessin adults1,2
DiabeticNephropathy
Leading cause of end-stage renal disease3,4
CardiovascularDisease
Stroke2- to 4-fold increase in cardiovascular mortality and stroke5
DiabeticNeuropathy
8/10 individuals with diabetes die from CV events6
Type 2 Diabetes is Associated with Serious Complications
1UK Prospective Diabetes Study Group. Diabetes Res 1990; 13:1–11. 2Fong DS, et al. Diabetes Care 2003; 26 (Suppl. 1):S99–S102. 3The Hypertension in Diabetes Study Group. J Hypertens 1993; 11:309–317. 4Molitch ME, et al. Diabetes Care 2003; 26 (Suppl. 1):S94–S98. 5Kannel WB, et al. Am Heart J 1990; 120:672–676.
6Gray RP & Yudkin JS. Cardiovascular disease in diabetes mellitus. In Textbook of Diabetes 2nd Edition, 1997. Blackwell Sciences. 7King’s Fund. Counting the cost. The real impact of non-insulin dependent diabetes. London: British Diabetic Association, 1996. 8Mayfield JA, et al. Diabetes Care 2003; 26 (Suppl. 1):S78–S79.
Diabetic Foot
Microangiopathy Macroangiopathy
Patogenesis Kaki diabetes
Why does acute DFU be chronic• Hyperglycemia and insulin resistance• Impaired oxygenisasion• Reduce macro and micricirculation• Pheriperal neuropathy• Wound pressure/ weingt bearing• Edema, pain• Oxidative stress• Malnutrition , mineral and vitamin• Infections, MMPs• GF retardation• Decrease hyaluronoic acid• compliance
Patofisiologi Luka Kaki Diabetes
Kaki Diabetik: Faktor-Faktor Risiko
Periferal neuropati: sensorik (>>), motorik, otonom
Perubahan biomekanik kaki
Peningkatan pressure pada telapak kaki
Deformitas tulang/biomekanik
Penyakit pembuluh darah tepi (PAD)
Riwayat ulkus atau amputasi
Kelainan kuku yang berat
ADA, Standard of Medical Care in Diabetes 2008
Neuropati Perifer
Neuropati motorikKelemahan otot intrinsik
Perubahan ekstensi dan fleksi
Penonjolan kaput tulang
Deformitas kaki (Biomekanik )
Peningkatan distribusi tekanan
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Stratification of NeuropatiUlcer
High
Low
High-risk foot clinicIntensive foot education and podiatry
Neuropathy, previous amputation or ulcer
Peripheral vascular diseaseUnable to feel monofilamentNeuropathy, no previous amputation or ulcer
No neuropathy
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Peripheral Arterial Disease ( PAD )
• Is a condition characterized by atherosclerotic occlusive disease of the lower extremities
• as a major risk factor for lower extremities amputation
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Penyakit Pembuluh Darah Perifer
Makrovascular
Mikrovaskular
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Makrosirkulasi
NormalFatty
StreakFibrousPlaque
Athero-scleroticPlaque
PlaqueRupture/Fissure &
Thrombosis
Clinically Silent
Increasing Age
Angina, TIA`s, PAD
Ischemic Stroke
Myocardial Infarction
Critical Leg Ischemia
Cardiovascular Death
Mikrosirkulasi • Fungsi nutrisi : 15 %• Fungsi termoregulasi
melalui endotel - prostaglandin - prostacycline - endotheline, - nitrid oxide ( NO )
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ANGIOPATIHiperglikem
iaSorbitol pathwayGlucose autoxidationAGE formation
Oxidative stress Antioxidants
Hypercoagulability:
Fibrinolysis
platelet reactivity
coagulability
Endothelial dysfunction:
NO
Endothelin 1
Prostacyclin
Thromboxan
leukocyte adhesion
lipid peroxidation
foam cell formation
TNF a
Komplikasi pembuluh darah
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Risk Factors of PAD in Diabetic(UKPDS)
1. Hyperglycemia 2. Eleveted systolic blood pressure 3. Low HDL cholesterol 4. Smoking 5.Cardiovascular disease
Fig: Arterial anastomosis around the ankle joint. The foot is supplied by the Dorsalis pedis, Posterior tibial and peroneal arteries. There is good Communication between these important vessels through the collateral arteries.
AB C
A. Dorsalis pedis artery B. Posterior tibial artery C. Peroneal artery
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Measurement of the Ankle–Brachial Index (ABI).
Survival probability curves derived from Kaplan-Meier analysis of percentages of patients remaining alive (or deceased from noncardiac causes) in two groups of subjects defined by baseline ABI (P < 0.0001, log-rank test). In each case, censored data points are indicated by crosses
Hubungan antara ABI dengan Risiko Kematian
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Biomekanika kaki
• Gaya yang mempengaruhi kaki saat berdiri/ berjalan
• Dipengaruhi oleh berat badan• Keadaan dinamik
• Kaki normal distribusi merata pada seluruh permukaan kaki
• Deformitas : distribusi tidak merata• Resiko timbulnya kalus atau luka
Intrinsic – biomechanical
Wagner’s classification • Grade-0 High risk foot and no ulceration.
• Grade -1 Superficial Ulcer.• Grade -2 Deep Ulcer ( cellulitis )• Grade -3 Osteomylitis with Ulcer or abscess.• Grade -4 Gangrenous Patches. Partial foot gangrene.• Grade -5 Gangrene of entire foot
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Bagaimana bisa terjadi luka ?Peningkatan tekanan pada telapak kaki
Iskemia jaringan kaki saat menapak
Gangguan mikrosirkulasi, aliran lymp, transport jaringan interstisial
Recovery tekanan O2 transcutaneus menurun
Recovery jaringan elastik menurun
Tekanan pada telapak kaki
Dipengaruh oleh : - gaya gesekan ( friction )
- gaya tekanan ( pressure )
Pengukuran tekanan telapak kaki
Perubahan biomekanik yang mempengaruhi tekanan pada kaki
Faktor intrinsik Faktor ekstrinsikPenonjolan tulang Sepatu tidak cocok
Gangguan mobilisasi gerak sendi
Berjalan tanpa alas kaki
Kerusakan pada sendi Jatuh/kecelakaan
Kalus Benda asing dalam sepatu
Perubahan struktur jaringan Aktivitas fisik
Riwayat operasi kaki
Neuro-osteoarthropatic joint
Deformitas (1)
Halux valgusHammer toesClaw toes
Pes Cavus
Deformitas pasca amputasi (4)
Pasca amputasi/operasi
Ketebalan jaringan
Bentuk deformitas
Derajat deformitas
Elastisitas jaringan
Mobilisasi sendi
Tekanan pada telapak kaki dipengaruhi oleh :
Most foot problems are preventable
Most foot problems are preventable through early identification & prompt
treatment by skilled health professionals
Holistic Management of Diabetic Foot Ulcer
Wound control
Metabolic control
Infection control
Vascular control
Mechanic control
Education control
Internatonal Working Group on the Diabetic Foot, 2007
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Kesimpulan
• Kaki diabetik merupakan salah satu komplikas kronis diabetes
• Patofisiologisnya sangat komplek• Lambat pada proses penyembuhan, risiko ulkus
menjadi kronis dan angka amputasi tinggi• Management harus holistik dan melibatkan berbagai
disiplin ilmu lainnya• Sebagian besar ulkus atau luka pada kaki diabetes
dapat dicegah dengan melakukan deteksi dini dan pencegahan pada kaki dengan faktor risiko
Terima Kasih
References• ^ [1] [2] Boulton in Diabetes, 30;36 2002^ • Frykberg RG, Armstrong DG, Giurini J, et al. (2000). "Diabetic foot
disorders: a clinical practice guideline. American College of Foot and Ankle Surgeons". J Foot Ankle Surg 39 (5 Suppl): S1–60. PMID 11280471.^
• Brem Harold, Tomic-Canic Marjana (2007). "Cellular and Molecular basis of wound healing in diabetes". JCI 117 (5): 1219–1222. doi:10.1172/JCI32169. PMC 1857239. PMID 17476353.^
• Arad Y, Fonseca V, Peters A, Vinik A (2011). "Beyond the Monofilament for the Insensate Diabetic Foot: A systematic review of randomized trials to prevent the occurrence of plantar foot ulcers in patients with diabetes". Diabetes Care 34 (4): 1041–6. doi:10.2337/dc10-1666. PMC 3064020. PMID 21447666.
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