Dr.hilman.revisi Kaki Dm26

8/10/2019 Dr.hilman.revisi Kaki Dm26

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Bedah Vaskuler Bedah Vaskuler



Strategi dalam menghadapi pasienStrategi dalam menghadapi pasien

Kelainan Vaskuler Kelainan Vaskuler

Kelainan Vaskuler mengenai :Kelainan Vaskuler mengenai :- Sistem arteriSistem arteri- Sistem venaSistem vena- Sistem limfeSistem limfe



KelainanKelainan

ArteriArteri VenaVena Limfe Limfe“Six Ps”- Pulseless- Painful

- Pale- Paraesthesia- Paralysis- Perishing cld



Keluhan :

Akut : nyeri ! ke"iruan

dingin

Krnis : nyeri

ulkus

gangren

dingin



P#$%P&#$AL VAS'(LA$ )%S#AS#SP#$%P&#$AL VAS'(LA$ )%S#AS#S

Bedah Vaskuler *K(%+$S(P,-'.Bedah Vaskuler *K(%+$S(P,-'.



• /$0.B0A,1%%/%S 0BL%/#$A,S/$0.B0A,1%%/%S 0BL%/#$A,S

2Buerger )isease32Buerger )isease3

• '0.PL%'A/%0, 0* ).'0.PL%'A/%0, 0* ).

• A/&#$0S'L#$0S%SA/&#$0S'L#$0S%S

KAK% )%AB#/%KKAK% )%AB#/%K

- Kelainan endkrinKelainan endkrin

- Kelainan vaskuler Kelainan vaskuler

- Kelainan syaraf Kelainan syaraf



KAKI DIABETIK KAKI DIABETIK



• Kmplikasi : %nsidens amputasi 45 2K3Kmplikasi : %nsidens amputasi 45 2K3

Penurunan angka amputasi nn ).Penurunan angka amputasi nn ).

4665466578 978 9

888888;8 9;8 9

$S'. : 4667 ! 4665 : < ;5=5 9$S'. : 4667 ! 4665 : < ;5=5 9

258 9 dari 48>888 nn trauma3258 9 dari 48>888 nn trauma3

4665 ! 888 : 487 rang4665 ! 888 : 487 rang

Pasien /rauma :Pasien /rauma :

274+487 rang x 488 93 ? 78 9274+487 rang x 488 93 ? 78 9

Pasien ). :Pasien ). :

2@+487 rang x 488 93 ? @8 92@+487 rang x 488 93 ? @8 9

• Lama PeraatanLama Peraatan

• Biaya 2'st &spital3Biaya 2'st &spital3

• 1ii1ii

• $eha"ilitasi : - pst amputasi muscle exercise$eha"ilitasi : - pst amputasi muscle exercise



Jumlah Kasus Pasien Diabetes Mellitus Jumlah Kasus Pasien Diabetes Mellitus(Amputasi)(Amputasi)

Jumlah Kasus PasienTrauma

Tahun 2001 - 2004Tahun 2001 - 2004Tahun 2001 -2004

!"M - Ja#arta!"M - Ja#arta !"M - Ja#arta

$amaBulan

Tahun2001

Tahun2002

Tahun200%

Tahun2004

$amaBulan

Tahun2001

Tahun2002

Tahun200%

Tahun2004

Januari 1 % 4 % Januari 0 1 0 2

&ebruari 0 1 4 0 &ebruari 2 0 2 2

Maret % % ' Maret 1 1 1 %

April 0 0 * April 1 2 1 %

Mei 0 1 1 2 Mei 0 0 1 %

Juni 0 1 % Juni 0 2 0 '

Juli 1 1 1 2 Juli 0 0 0 1

A+ustus 0 1 2 A+ustus 0 1 2 0

!eptember

2 % 1 !eptember

0 0 % 2

,#tber 1 4 4 % ,#tber 2 0 2

$pember

0 4 4 1 $pember

0 0 1 0

Desember 1 1 % Desember

0 0 ' %

Jumlah . 2 % 4% Jumlah ' 22 2

Ttal 11' Ttal '2

Pasien DM / 11'1* ran+ 100 3'



K0.PL%KAS% :K0.PL%KAS% :

CC .akr Vaskuler :.akr Vaskuler : - 0tak- 0tak Dantung Dantung



- Perier- Perier



55 Mi#r 6as#uler /Mi#r 6as#uler /

- Mata- Mata

+in7al+in7al



Syaraf Syaraf

,eurpati



Pasien datang dengan keluhanPasien datang dengan keluhan

EE ,yeri :,yeri :

- Pegal- Pegal

- Klaudikati %ntermiten- Klaudikati %ntermiten

- $estpain- $estpain

EE %nfeksi :%nfeksi :

- Selulitis- Selulitis - A"ses - A"ses



-(lserasi(lserasi

- 1angren- 1angren



Anamnesis :

F $asa nyeri di"etis

klaudikati intermiten

F /rauma 2luka3 selulitis

F Luka G sukar sem"uhF 1angren



PEMERIKSAAN FISIK :PEMERIKSAAN FISIK :

Abdomen : masa (aneurisma)Abdomen : masa (aneurisma)

Inspeksi :Inspeksi :

permukaan kulitpermukaan kulit bulu kakibulu kaki

kukukuku

ulkus (neuroiskemik), gangrenulkus (neuroiskemik), gangren lokasi lukalokasi luka



Inspeksi

Palpasi :- Perabaan kulit

- Pulsasi sistem vaskular

- ABI (Ankle Brachial Index) ABI >

!ab"rat"rium

- #ula $arah

- %aal hati

- A&re&asi tr"mb"sit



PALPAS% :PALPAS% : H suhu kulitH suhu kulit

H capillary refill testH capillary refill test

P(LSAS% : prximal ! distalP(LSAS% : prximal ! distal

,ilai :,ilai :• nrmal ! a"sennrmal ! a"sen

• kekuatankekuatan



PalpasiPalpasi



P#.#$%KSAA, P#,(,DA,1P#.#$%KSAA, P#,(,DA,1

)arah :)arah : H rutin= faal hepar= ureum= creatininH rutin= faal hepar= ureum= creatinin

H agregasi trm"sitH agregasi trm"sit

,n %nvasif :,n %nvasif :

H *t plsH *t pls

HH Laser fluksimetriLaser fluksimetri

H (S1 )ppler H (S1 )ppler

H '/ AngigrafiH '/ Angigrafi

H .$AH .$A



%nvasif : Arterigrafi%nvasif : Arterigrafi H direkH direk

indirekindirek

H hasil :H hasil : - knvensinal- knvensinal

- )SA 2)igital Su"tractin Angigraphy3- )SA 2)igital Su"tractin Angigraphy3



A,KL# B$A'&%AL %,)#I 2AB%3

• Per"edaan tekanan sistlik a>ankle dengan a>"rachial

F %ndikasi : setiap ada kelainan+gangguan

vaskular perifer 2anggta gerak3

F /ehnik



B#)A& :B#)A& :

$aan Lkal$aan Lkal• %nsisi :%nsisi :

- drainase- drainase

- simple- simple - multiple- multiple



,ekrtmi ! )e"ridement,ekrtmi ! )e"ridement



e#nstru#sie#nstru#si

9as#ular9as#ular



AmputasiAmputasi



Pr"tesePr"tese



Penurunan faktr resik :Penurunan faktr resik :- merkk- merkk

- hipertensi- hipertensi

- hiperlipidemia- hiperlipidemia

- riayat keluarga- riayat keluarga

- edukasi :- edukasi : ke"ersihan kakike"ersihan kaki



Kasus emergensiKasus emergensi

FF Ascending infectinAscending infectin

- %nsisi- %nsisi - Amputasi- Amputasi

/+Suprtif+Alternatif /+Suprtif+Alternatif - &iper"arik- &iper"arik

- 0n 2xygen therapy3- 0n 2xygen therapy3



/rans Atlantic %nter Sciety

'nsensus 1rup 2/AS'3

SP%/S ? Impured Sensation

= Impured Tissue Perfusion

= %nfection

= Amount /issue Loss

= Size



%<%< &a#tr pre8ipsisi ;&a#tr pre8ipsisi ;

- i@a?at DM- i@a?at DM

- >ipertensi- >ipertensi

- Mer## - Mer##

- >?perlipi8emia- >?perlipi8emia



The 8iabeti= t s?n8rme en=mpasses aThe 8iabeti= t s?n8rme en=mpasses a

number pathl+ies in=lu8in+ /number pathl+ies in=lu8in+ /

- 8iabeti= neurpath?- 8iabeti= neurpath?

- peripheral 9as=ular 8isease- peripheral 9as=ular 8isease

- "har=t neurarthrpath?- "har=t neurarthrpath?- t ul=eratin- t ul=eratin

- stem?elitis- stem?elitis

- amputatin- amputatin



4he aeti"l"&y "f f""t ulcerati"n : 4he aeti"l"&y "f f""t ulcerati"n :

Purely neur"pathic : 56 7 - 8/ 70 m"re recentPurely neur"pathic : 56 7 - 8/ 70 m"re recent 98 798 7

Purely ischemicPurely ischemic : / 7 : / 7 0 70 7

;ixed neur"ischemic : <6 7 - 56 7;ixed neur"ischemic : <6 7 - 56 7 6<09 76<09 7

multidisciplinary f""t clinicsmultidisciplinary f""t clinics

i = f h l i l



$irect e=ect "f hyper&lycaemia "n neur"nal$irect e=ect "f hyper&lycaemia "n neur"nal

metab"lismmetab"lism

Abn"rmalities in nitric "xide metab"lismAbn"rmalities in nitric "xide metab"lism perineuralperineuralvas"c"nstricti"n nerve dama&evas"c"nstricti"n nerve dama&e

$istal sens"ry p"lyneur"pathy is the m"st imp"rtant type$istal sens"ry p"lyneur"pathy is the m"st imp"rtant type Aut"n"mic neur"pathy reducesAut"n"mic neur"pathy reduces

- s*eatin& (skin)- s*eatin& (skin)

- "pen A3 Shunt- "pen A3 Shunt bl""d ?"*bl""d ?"* Aut"n"mic neur"pathyAut"n"mic neur"pathy

- instrinsic muscle "f the f""t- instrinsic muscle "f the f""t

- altered f""t sh"pe- altered f""t sh"pe

cl"ved t"e pr"minent metatarsal headscl"ved t"e pr"minent metatarsal heads @eur"pathy is resp"sible f"r a hi&h pr"p"rti"n @eur"pathy is resp"sible f"r a hi&h pr"p"rti"n

- vascular disease- vascular disease

- infecti"n- infecti"n%""t ulcerati"n



4he distributi"n "f vascular disease in the l"*er 4he distributi"n "f vascular disease in the l"*erlimb is th"u&ht t" be di=erent in diabetic0 m"relimb is th"u&ht t" be di=erent in diabetic0 m"refreuent inv"lvement "f vessels bel"* the kneefreuent inv"lvement "f vessels bel"* the knee: <29 had intra p"pliteal (< x n"n diabetic: <29 had intra p"pliteal (< x n"n diabeticdisease)disease)

- $"ppler : *ave f"rm as l"ss "f the n"rmal$"ppler : *ave f"rm as l"ss "f the n"rmal

triphasictriphasic

- 4ranscutane"us "xy&en tensi"n 4ranscutane"us "xy&en tensi"n

accurately re?ects skin "xy&enati"naccurately re?ects skin "xy&enati"n an ulcer *ill heal level f"r amputati"nan ulcer *ill heal level f"r amputati"n

Arteri"&raphyArteri"&raphy &"ld standar&"ld standar



Bi"mechanical aspectsBi"mechanical aspects

' !imited 1"int m"bility is a further c"ntributin&!imited 1"int m"bility is a further c"ntributin&fact"r t" elevated plantar pr"cessuresfact"r t" elevated plantar pr"cessures

' +hr"nic hyper&lycamia results in #lyc"sylati"n "f+hr"nic hyper&lycamia results in #lyc"sylati"n "f

pr"teins and *hen c"lla&en is inv"lve thepr"teins and *hen c"lla&en is inv"lve the

c"lla&en bundles bec"me thickened and cr"ss c"lla&en bundles bec"me thickened and cr"ss linkedlinked thick0 thi&ht0 *axy skin0 restricti"n "fthick0 thi&ht0 *axy skin0 restricti"n "f

1"int m"rement 1"int m"rement

alters the mechanics "f *alkin& and isalters the mechanics "f *alkin& and is

str"u&hy ass"ciated *ith hi&h plantar pr"ssurestr"u&hy ass"ciated *ith hi&h plantar pr"ssure



Sp"ntane"us ulcerati"n c"mbinati"n "fSp"ntane"us ulcerati"n c"mbinati"n "f

trauma and neur"pathy0 unsersitivitytrauma and neur"pathy0 unsersitivity tissuetissue

dama&edama&e

lcerati"nlcerati"n

@eur"pathy causes atr"phy "f the intrinsic@eur"pathy causes atr"phy "f the intrinsic

muscle "f the f""t (pred"minanthy plantarmuscle "f the f""t (pred"minanthy plantar?ex"n "f the t"es) alterin& the ?ex"r2extens"r?ex"n "f the t"es) alterin& the ?ex"r2extens"r

balance at the metatars"phalan&eal 1"intsbalance at the metatars"phalan&eal 1"ints

neur"pathy

hi&h f""t pressures

Dr.hilman.revisi Kaki Dm26

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