Laporan Kasus ULKUS DIABETIKUM
Disusun Oleh : dr. dr. Patrick Patri ck Gianny Gia nny Warouw
Pembimbing : dr. Alexander . M. Sina!a
P"#G"AM I$TE"$SIP "UMA SAKIT UMUM DAE"A "ATU A%I PUT"I B#TU$G KABUPATE$ PE$A%AM PASE" UTA"A &'()
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LEMBA" PE$GESAA$
LAPORAN KASUS DOKTER INTERNSHIP
ULKUS DIABETIKUM
Yang dipersiapan dan disusun !leh dr" Pa#ri$ %iann& 'ar!u(
Telah dia)uan* di!resi* diba$aan dan din&a#aan #elah memenuhi s&ara# lap!ran in#ernship"
Pena)am* +, N!-ember +./0 D!#er Pendamping In#ernship RSUD Ra#u A)i Pu#ri 1!#ung*
dr. Alexander . M. Sina!a
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BAB I PE$DAULUA$
Diabe#es melli#us 2D34 adalah sua#u sindr!m linis elainan me#ab!li &ang di#andai dengan adan&a hipergliemia &ang disebaban !leh de5e seresi insulin* de5e er)a insulin* a#au eduan&a" Pada pen&andang D3 dapa# #er)adi !mpliasi pada semua #inga# sel dan semua #inga#an ana#!mi" 3ani5es#asi !mpliasi r!ni dapa# #er)adi pada #inga# mir!-asular 2re#in!pa#i diabe#i* ne5r!pa#i diabe#i* neur!pa#i diabe#i* dan ardi!mi!pa#i4 ardi!mi!pa#i4 maupun mar!-asular mar!-asular 2s#r!e* pen&ai# )an#ung !r!ner* peripheral !r!ner* peripheral vascular disease4" disease4" K!mpliasi lain dari D3 dapa# dapa# berupa berupa eren#an eren#anan an berlebih berlebih #erhadap #erhadap in5esi in5esi aiba# aiba# mudahn&a mudahn&a #er)adi in5esi saluran emih* #uberul!sis paru* dan in5esi ai* &ang emudian dapa# berembang men)adi ulus6gangren diabe#i" Kai diabe#i adalah segala ben#u elainan &ang #er)adi pada ai &ang dise diseba bab ban an
!leh !leh
diab diabe# e#es es
mell melli# i#us us""
7a# 7a#!r !r
u#am u#amaa
&ang &ang
mempe empeng ngar aruh uhii
#erben#un&a #erben#un&a ai diabe#i merupaan !mbinasi neur!pa#i !#!n!m dan neur!pa#i s!ma#i* insu5isiensi insu5isiensi -asuler -asuler** ser#a in5esi" Penderi#a Penderi#a ai diabe#i &ang masu rumah sai# umumn&a disebaban disebaban !leh #rauma #rauma e$il &ang #ida #ida dirasaan !leh penderi#a"
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BAB II TI$%AUA$ PUSTAKA
&.( De*ini+i
Ulus Ulus ai ai diabe# diabe#ia ia adala adalah h ai ai denga dengan n diabe# diabe#es es meli meli#us #us &ang &ang menga mengala lami mi perubahan
pa#!l!gis
aiba#
in5esi*
ulserasi
&ang
berhubungan
dengan
abn!rmali#as neur!l!gis*pen&ai# -asular peri5er dengan dera)a# ber-ariasi* dan a#au !mpliasi me#ab!li dari diabe#es pada e#remi#as ba(ah" Pre-alensi ulus diabe#i pada p!pulasi diabe#es adalah 89/. lebih sering #er)adi pada pasien usia lan)u#" Sebagian besar 2;.90.4 ulus aan sembuh sendiri* /.9/, aan #e#ap a#i5* ,9+, aan berahir pada ampu#asidalam urun (a#u ;9/0 bulan dari e-aluasi per#ama
&.& E,ide-iolo!i
Kai diabe#i merupaan salah sa#u !mpliasi r!ni D3 &ang paling di#au#i" Hasil pengel!laan ai diabe#i sering menge$e(aan* bai bagi d!#er pengel!la maupun pen&andang D3 dan eluargan&a" Seringali ai diabe#i berahir dengan e$a$a#an dan ema#ian" Sampai saa# ini* di Ind!nesia ai diabe diabe#i #i masih masih merup merupaa aan n masala masalah h &ang &ang rumi# rumi# dan #ida #ida #ere #erel! l!la la dengan dengan masimal* arena selain urangn&a mina# un#u mendalami masalah ai diabe#i* e#ida#ahuan mas&araa# mengenai ai diabe#i )uga masih sanga# men&!l!" Sebagai #ambahan* masalah bia&a peng!ba#an &ang besar &ang #ida #er)angau !leh mas&araa# pada umumn&a )uga menambah pelin&a masalah ai diabe#i" Di RSUP RSUPN N dr" dr"
aan meninggal = #ahun pas$a ampu#asi"
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Ada ban&a ban&a 5a#!r 5a#!r &ang berpenga berpengaruh ruh dalam dalam #er)adi #er)adin&a n&a ai diabe#i diabe#i"" Se$ara umum 5a#!r95a#!r #ersebu# dapa# dibagi men)adi:
7a#!r predisp!sisi 7a#! 7a#!rr &ang &ang mempe mempenga ngaruh ruhii da&a da&a #ahan #ahan )ari )aringa ngan n #erha #erhadap dap #rauma #rauma seper# seper#ii elaina elainan n mar!-a mar!-asul suler er dan mir!-a mir!-asul suler er** )enis )enis elamin elamin** mer!!* mer!!* dan neur!pa#i !#!n!m" 7a#!r 7a#!r &ang mening meninga# a#an an emung emunginan inan #erena #erena #rauma #rauma seper#i seper#i neur!pa# neur!pa#ii m!#!ri* neur!pa#i sens!ri* limited joint mobility* mobility* dan !mpliasi D3 &ang lain 2seper#i ma#a abur4"
7a#!r presipi#asi
Perluaan di uli# 2)amur4"
Trauma"
Teanan berepan)angan pada #umi# saa# berbaring lama"
7a#!r &ang memperlamba# pen&embuhan lua
Dera)a# lua"
Pera(a#an lua"
Pengendalian adar gula darah"
&./ Pato*i+iolo!i
Ter)adin&a masalah ai dia(ali adan&a hipergliemia pada pen&andang D3 &ang men&ebaban elainan neur!pa#i dan elainan pada pembuluh darah" Neur!pa#i* bai neur!pa#i sens!ri maupun m!#!ri dan au#!n!mi aan meng menga aib iba# a#a an n berb berbag agai ai peru peruba baha han n pada pada uli uli## dan dan !#!# !#!#** &ang &ang emu emudi dian an men&eba men&ebaban ban #er)adin #er)adin&a &a perubaha perubahan n dis#ribu dis#ribusi si #eanan #eanan pada #elapa #elapa ai dan selan)u#n&a aan mempermudah #er)adin&a ulus" Adan&a eren#anan #erhadap in5esi men&ebaban in5esi mudah mereba men)adi in5esi &ang luas" 7a#!r aliran darah &ang urang )uga aan lebih lan)u# menambah rumi#n&a pengel!laan ai diabe#i" (. 0a+kul +kulo o,at ,ati
Pada Pada
buluh buluh darah* darah* aiba# aiba# !mpli !mplias asii D3 #er)a #er)adi di e#id e#idar ara# a#
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permuaan lapisan dalam ar#eri ar# eri sehingga sehing ga aliran alir an lamelar berubah men)adi #urbulen &ang beraiba# pada mudahn&a #erben#u #r!mbus" Pada s#adium lan)u# seluruh lumen ar#eri aan #ersumba# dan manaala aliran !la#eral #ida $uup* aan #er)adi isemia dan bahan gangren &ang luas" 3ani5es 3ani5es#asi #asi angi!pa# angi!pa#ii pada pembulu pembuluh h darah darah penderi# penderi#aa D3 an#ara an#ara lain berupa pen&empi#an dan pen&umba#an pembuluh darah peri5er &ang #eru#ama sering #er)adi pada #ungai ba(ah" Pada penderi#a muda* pembuluh darah &ang paling a(al mengalami angi!pa#i adalah ar#eri #ibialis" Kelainan ar#eri aiba# diabe#es )uga sering mengenai bagian dis#al dari ar#eri 5em!ralis pr!5unda* ar#eri p!pli#ea* ar#eri #ibialis dan ar#eri digi#alis pedis" Aiba#n&a Aiba#n& a per5usi )aringan dis#al dari dari #unga #ungaii men) men)adi adi urang urang bai bai dan #imbul #imbul ulus ulus &ang &ang emudi emudian an dapa# dapa# berembang men)adi ner!sis6gangren &ang sanga# suli# dia#asi dan #ida )arang memerluan ampu#asi" Perubahan -is!si#as darah dan 5ungsi #r!mb!si#* penebalan membrana basalis ser#a penurunan pr!dusi pr!s#asilin 2-as!dila#!r dan anti anti platel platelet et aggregating agent 4 aan mema$u #erben#un&a mir!#r!mbus dan pen&umba#an mir!-asuler" Peris#i(a ini mengaiba#an #imbuln&a isemia !rgan dan6a#au )aringan &ang bersangu#an* bers angu#an* #ermasu serabu# sera bu# sara5 peri5ern&a" peri5ern& a" Hipergliemia r!ni dapa# men&ebaban -asul!pa#i berupa dis5ungsi end!#el melalui berbagai meanisme an#ara lain:
Hipergliemia Hipergliemia r!ni men&ebaban gli!silasi n!n en?ima#i dari pr!#ein dan mar! mar!m! m!le leul ul seper seper#i #i DNA* DNA* &ang &ang aan aan menga mengai iba# ba#an an peruba perubaha han n si5a# si5a# an#igeni dari pr!#ein dan DNA" Keadaan ini aan men&ebaban perubahan
#eanan in#ra-asular aiba# gangguan eseimbangan NO dan pr!s#aglandin" Hiper Hipergli gliem emia ia menin meninga ga# #an an a#i a#i-as -asii PK< PK< in#ra in#rasel selula ularr sehin sehingga gga aan aan
men&ebaban gangguan NADPH pool NADPH pool &ang &ang aan menghamba# pr!dusi NO" O-eresp O-erespresi resi growth factors factors meninga#an pr!li5erasi sel end!#el dan !#!#
p!l!s pembuluh darah dara h sehingga aan #er)adi #er)a di ne!-asularisasi" ne!-asularis asi" Hipergliemia aan meninga#an sin#esis diacylglycerol 2DA%4 2DA%4 melalui )alur gli!li#i" Peninga#an adar DA% aan meninga#an a#i-i#as PK<" 1ai DA% maupun PK< berperan dalam mem!dulasi #er)adin&a -as!!ns#risi"
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Sel Sel end! end!#e #ell sang sanga# a# pea pea #erh #erhad adap ap peng pengar aruh uh s#re s#ress !si !sida da#i #i5" 5" Kead Keadaa aan n hipergliemia aan meninga#an #endensi un#u #er)adin&a s#res !sida#i5 dan peninga#an oxidized oxidized lipopro lipoprotein tein** #eru#ama small dense LDL-cholesterol 2oxidized LDL4 LDL4 &ang lebih bersi5a# a#er!geni" Di samping i#u peninga#an adar adar asam lema bebas bebas dan eadaan eadaan hipergl hipergliem iemia ia dapa# dapa# mening meninga#a a#an n
!sidasi 5!s5!lipid dan pr!#ein" Hipergl Hipergliem iemia ia aan diser#a diser#aii dengan dengan #endensi #endensi pr!#r!mb pr!#r!mb!#i !#i dan agregasi agregasi pla#ele#" Keadaan ini berhubungan dengan beberapa 5a#!r an#ara lain penurunan
pr!dusi
NO
dan
penurunan
a#i-i#as
5ibrin!li#i
aiba#
peninga#an adar PAI9/" Di samping i#u* pada pad a D3 #ipe + #er)adi peninga#an p eninga#an a#i-i#a a#i-i#ass !agulas !agulasii aiba# aiba# pengaruh pengaruh berbagai berbagai 5a#!r 5a#!r seper#i seper#i pemben# pemben#uan uan 2A%Es4 dan penurunan sin#esis heparin advanced glycosylation end products products 2A%Es4
sul5a#" 'alaupun alaupun #ida #ida ada hubungan hubungan langsung langsung an#ara an#ara a#i-asi a#i-asi !agula !agulasi si dengan dengan dis5 dis5un ungs gsii
end! end!#e #el* l*
namu namun n
a#i a#i-a -asi si
!ag !agul ulas asii
&ang &ang
beru berula lang ng
dapa dapa##
men&ebaban s#imulasi &ang berlebihan dari sel9sel end!#el sehingga aan #er)adi dis5ungsi end!#el" Pr!ses angi!pa#i men&ebaban sumba#an ar#eri &ang berlangsung se$ara r!ni hingga menimbulan ge)ala lini &ang menuru# 7!n#aine dibagi men)adi s#adium sebagai beriu#: I" rasa ram6ebal* II" claudicatio intermitten* intermitten* III" resting III" resting pain* pain* I@" isemia6in5ar dan6a#au gangren" &. $euro,ati %angguan mir!sirulasi mir!sirulasi dan neur!pa#i pun&a hubungan &ang era# dengan pa#!genesis ai diabe#i" Neur!pa#i diabe#i pada 5ase a(al men&erang sara5 halus #eru#ama di u)ung9u)ung ai" Hal ini disebu# sebagai 5en!mena dying back *
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bahan gangren" Neur!pa#i diabe#i disebaban !leh gangguan )alur p!li!l 2glu!sa s!rb s!rbi# i#!l !l
5ru#!sa 5ru#!sa44 aiba# aiba# eurang eurangan an insulin insulin"" Pada )aringan )aringan sara5* sara5* #er)adi #er)adi
penimbunan s!rbi#!l dan 5ru#!sa ser#a penurunan adar mi!in!si#!l &ang meni menimb mbul ula an n neur neur!p !pa# a#i" i" Peru Peruba baha han n bi! bi!im imia ia dala dalam m )ari )aring ngan an sara sara55 aan aan mengganggu egia#an me#ab!li sel9sel S$h(ann dan men&ebaban hilangn&a as!n" Ke$epa#an !ndusi m!#!ri aan berurang pada #ahap dini per)alanan neur!pa#i" Selan)u#n&a #imbul n&eri* pares#esia* berurangn&a sensasi ge#ar dan pr!pri!sep#i* dan gangguan m!#!ri &ang diser#ai hilangn&a re5les9re5les #end!n dalam* elemahan !#!#* dan a#r!5i" Neur!pa#i Neur!pa#i dapa# men&erang sara59sara5 peri5er 2m!n!neur!pa#i dan p!lineur!pa#i4* sara59sara5 ranial* a#au sis#em sara5 !#!n! !#!n!m" m" Terser erserang angn&a n&a sis#e sis#em m sara5 sara5 !#!n!m !#!n!m dapa# dapa# diser# diser#ai ai diare diare n!#ur n!#urnal nal** e#erlamba#an e#erlamba#an peng!s!ngan lambung dengan gas#r!paresis* gas#r!paresis* hip!#ensi p!s#ural* p!s#ural* dan imp!#ensi" Pasien dengan neur!pa#i !#!n!m diabe#i dapa# menderi#a in5ar mi!ardial au# #anpa n&eri" Pasien ini )uga dapa# ehilangan resp!ns a#e!lamin #erhadap hip!gliemia dan #ida men&adari reasi9reasi hip!gliemia" a4 Neur!pa#i m!#!ri
Kerusaan Kerusaan sara5 m!#!ri aan men&ebaban a#r!5i !#!#9!#!# in#rinsi &ang menim menimbul bulan an elem elemaha ahan n pada pada ai ai dan dan e#er e#erba# ba#asa asan n gera gera sendi sendi aiba# aiba# aumulasi !lagen di ba(ah dermis hingga #er)adi eauan periar#iuler" De5!rmi# De5!rmi#as as aiba# aiba# a#r!5i a#r!5i !#!# dan e#erba e#erba#asa #asan n gera gera sendi sendi men&ebab men&ebaban an perubahan eseimbangan pada sendi ai* perubahan $ara ber)alan* dan menim menimbul bulan an #i#i #i#i #umpu #umpu baru baru pada pada #elap #elapa a ai ai ser#a ser#a berai beraiba ba## pada pada mudahn&a #erben#u #erben#u alus &ang #ebal 2claw 2claw foot 4" 4" Seiring dengan berlan)u#n&a
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2=4 2=4
Ter)a er)adi di 5ra 5ra#u #urr dan dan !la !laps ps pers persen endi dian an""
284 284
Timbul mbul uls ulsera erasi plan#a an#arris pe pedis dis"
b4 Neur!pa#i sens!ri
Kehilan Kehilangan gan 5ungsi 5ungsi sens!ri sens!ri men&ebab men&ebaban an penderi penderi#a #a ehilang ehilangan an da&a e(asp e(aspada adaan an pr!#e pr!#esi si ai ai #erha #erhadap dap rangs rangsan angan gan dari dari luar luar"" Nila Nilaii amban ambang g pr!#esi dari ai di#en#uan !leh n!rmal #idan&a 5ungsi sara5 sens!ris ai" Pada Pada eada eadaan an n!rma n!rmall sensa sensasi si &ang &ang di#eri di#erima ma menim menimbul bulan an re5l re5les es un#u un#u meninga#an reasi per#ahanan dan menghindaran diri dari rangsangan &ang men&ai#an dengan $ara mengubah p!sisi ai un#u men$egah #er)adin&a erusaan &ang lebih besar" Sebagian impuls aan di#erusan e !#a dan di sini sin&al di!lah emudian resp!n diirim melalui sara5 m!#!ri" Pada penderi#a D3 &ang #elah mengalami neur!pa#i peri5er sara5 sens!ri 2arena 2arena gangguan gangguan pengan#a pengan#aran ran impuls4 impuls4** pasien pasien #ida #ida merasa merasaan an dan #ida #ida men&adari adan&a #rauma e$il namun sering" Pasien #ida merasaan adan&a #eanan &ang besar pada #elapa ai" Semuan&a baru die#ahui se#elah #imbul in5esi* ner!sis* a#au ulus &ang sudah #ahap lan)u# dan dapa# membaha&aan eselama#an pasien" 1erbagai ma$am meanisme #er)adin&a lua dapa# #er)adi pada pasien D3* seper#i: + 2/4 Teanan eanan rendah rendah #e#api #erus menerus dan berelan berelan)u# )u#an an 2lua 2lua pada #umi# arena lama berbaring* deubi#us4" 2+4 Teanan #inggi dalam (a#u (a#u pende 2lua* #er#usu )arum6pau4" )arum6pau4" 2=4 Teanan sedang berulang berulang ali 2pada #empa# #empa# de5!rmi#as de5!rmi#as pada ai4" $4 Neur!pa#i !#!n!m Pada ai diabe#i gangguan sara5 !#!n!m &ang berperan #eru#ama #eru#ama adalah
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men&eba men&ebaban ban #er)adi #er)adin&a n&a pin#as pin#as ar#eri!ar#eri!-en!s en!saa sehingga sehingga #er)adi #er)adi penuruna penurunan n nu#risi )aringan &ang beraiba# pada perubahan !mp!sisi* 5ungsi* dan si5a# -is!elas#isi#as sehingga da&a #ahan )aringan luna dari ai aan menurun dengan aiba# mudah #er)adi ulus" . 1oku ku++ in* in*eek+i k+i
In5esi dimulai dimulai dari uli# ai dan dan dengan $epa# men&ebar men&ebar melalui )alur )alur musul!5asial" Selan)u#n&a in5esi men&erang apsul6sarung #end!n dan !#!#* bai pada ai maupun pada #ungai hingga #er)adi seluli#is" Kai diabe#i lasi biasan&a #imbul di a#as apu# me#a#arsal pada sisi plan#ar pedis" Sebelumn&a* di a#as l!asi #ersebu# #erdapa# alus &ang #ebal dan emudian men&ebar lebih dalam dan dapa# mengenai #ulang" Aiba#n&a Aiba#n&a #er)adi !s#e!mieli#is !s#e!mieli#is seunder" seunder" Sedangan Sedangan uman pen&ebab in5esi pada penderi#a diabe#es biasan&a mul#iba#erial &ai#u gram nega#i5* gram p!si#i5* dan anaer!b &ang beer)a se$ara sinergi" In5esi sering berlangsung agresi5 dan $epa# meluas ser#a mudah #erben#u gangren &ang selan)u#n&a merupaan an$aman hilangn&a ai" Di samping i#u* ,. dari asus ulus6gangren ulus6gangren diabe#es aan mengalami mengalami in5esi aiba# mun$uln&a lingungan gula darah &ang subur un#u berembangn&a ba#eri pa#!gen" ia adar gula darah #ida #er!n#r!l maa in5esi aan )adi lebih serius" Hal ini disebaban arena pada in5esi aan diseresi h!rm!n !n#ra insulin 2seper 2seper#i #i a#e! a#e!la lami min* n* !r#i !r#is!l s!l** h!m!n h!m!n per#um per#umbuh buhan an** dan dan gluag gluag!n4 !n4 &ang &ang men&ebaban men&ebaban meninga#n&a adar gula darah" Peninga#an Peninga#an adar gula darah )uga men&e men&ebab baban an gagal gagaln&a n&a 5ungs 5ungsii neu#r! neu#r!5i 5ill dan gangg ganggua uan n sis# sis#em em imun! imun!l!g l!gi" i" Sebagaimana Sebagaimana die#ahui* die#ahui* dalam melasanaan melasanaan 5ag!si#!sis sel P3N membu#uhan energi dari glu!sa es!gen un#u memper#ahanan a#i-i#asn&a" Dengan ban#uan
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S#age +: "igh +: "igh #isk !oot S#age =: $lcerated !oot S#age 8: %nfected 8: %nfected !oot S#age ,: ecrotic ,: ecrotic !oot S#age ;: $nsalvable !oot " B. Kla+i* Kla+i*ika ika+i +i Li7er, Li7er,ool ool Klasi5iasi primer: @asular Neur!pa#i Neur!isemi
Klasi5iasi seunder: Tua sederhana* #anpa !mpliasi Tua dengan !mpliasi" 8. Kla+i* Kla+i*ika ika+i +i Wa!n Wa!ner er 'agner .: Kuli# in#a6u#uh 'agner /: Tua super5isial super 5isial 'agner +: Tua dalam 2sampai #end!* #ulang4 'agner =: Tua dalam dengan in5esi 'agner 8: Tua dengan gangren #erl!alisasi 'agner ,: Tua dengan gangren luas seluruh ai" D. Klasi5iasi TeBas
Stadiu-
A
Tin!kat ' ( Tanpa #ua a Lua super5isial*
a #a u
p a s$ a
#ua* in#a6u#uh
B 8
#ida
uli# #end!n
sampai a#au
apsul sendi
&
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sam sampai a#au
apsul sendi
Lua
sampai
#ulang6sendi
9999999999999999999999999999Dengan In5esi9999999999999999999999999999 999999999999999999999999999Dengan Isemia999999999999999999999999999
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s#ru$#ures* 5as$ia* mus$le* !r #end!n
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In5e$#i!n (i#h s&s#emi$ mani5es#a#i!n: 7e-er* leu$!$!sis* shi5# #! #he le5# 3e#ab!li$ ins#abili#&
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," Radi$ adi$ul ular ar pain pain ;" Anh&dr!sis Ge:ala aki;at in+u*i+ien+i arteri ,eri*er
%e)ala &ang biasa dirasaan !leh pasien an#ara lain* n&eri isemi pada saa# is#iraha#* ulus &ang #ida sembuh" Rasa ram arau elelahan pada !#!#9!#!# besar pada salah sa#u a#au edua es#remi#as ba(ah &ang #imbul pada saa# ber)alan dalam )ara #er#en#u* &ang mengindiasian adan&a laudiasi! in#ermi##en" %e)ala ini ber#ambah pada saa# bera#i-i#as dan membai dengan is#iraha# selama beberapa meni#" Onse# dari laudiasi! dapa# #er)adi lebih dini apabila pasien sering ber)alan $epa# a#au menaii #angga" Rasa #ida n&aman* ram a#au elemahan pada be#is a#au ai sering #er)adi pada penderi#a ai diabe#is* diabe#is* arena $enderung #er)adi !lusi a#er!sler!sis a#er!sler!sis #ibi!per!neal" #ibi!per!neal" A#r!5i A#r!5i !#!#9 !#!# !#!# be#i be#iss mung mungi in n )uga )uga #er) #er)ad adi" i" %e)a %e)ala la9g 9ge) e)al alaa &ang &ang #imb #imbul ul pada pada paha paha** mengindiasian adan&a !lusi a!r#a ilia$a" N&eri pada saa# beris#iraha# )arang #er)adi pada penderi#a diabe#es" Pada beberapa asus* 5issure* ulus u lus a#au a #au uli# uli # pe$ah9pe$ah pe$ah 9pe$ah merupaan #anda a(al #elah #er)adin&a penurunan per5usi" Ke#ia penderi#a diabe#es da#ing dengan gangrene hal #ersebu# sering merupaan aiba# dari in5esi Pada pemerisaan 5isis* dapa# dilaua penilaia lasi5iasi lasi5iasi ai diabe#i
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Pen$ Pen$eg egah ahan an prim primer er ini ini )uga )uga meru merupa paa an n sua# sua#u u upa& upa&aa edu eduas asii epa epada da para para pen&andang D3 bai &ang belum #erena ai diabe#i* maupun penderi#a ai diabe#i un#u men$egah #imbuln&a lua lain pada uli#" Keadaan ai pen&andang D3 dig!l!ngan berdasarna risi! #er)adin&a dan risi! besarn&a masalah &ang mungin #imbul" Pengg!l!ngan ai diabe#i berdasaran risi! #er)adin&a masalah 27r&berg4 27r& berg4 &ai#u: &' Sensasi n!rmal #anpa de5!rmi#as (' Sensasi n!rmal dengan de5!rmi#as a#au #eanan plan#ar #inggi )' Insensi#i-i#as #anpa de5!rmi#as *' Isemia #anpa de5!rmi#as K!mbinasi6complicated +' K!mbinasi6complicated a4 K!mbin K!mbinasi asi insensi#i insensi#i-i#a -i#as* s* isemia* isemia* dan6a#au dan6a#au de5!rmi de5!rmi#as #as b4 Ri(a&a# adan&a #ua* de5!rmi#as de5!r mi#as
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weight-bearing dapa# dilauan an#ara lain dengan removable cast walker * total contant contant casting casting * temporary temporary shoes* shoes* felt padding * crutches* crutches* wheelchair * electric carts* carts* maupun cradled insoles" insoles" 1erbagai $ara surgial )uga dapa# dipaai un#u mengurangi #eanan pada lua* seper#i de!mpresi ulus6abses dengan insisi abses dan pr!sedur !resi bedah 2misaln&a !perasi un#u hammer toe* toe* metatarsal head resection* resection* ,chilles tendon lengthening * dan partial dan partial calcanectomy4" calcanectomy4" !. Woun" oun" cont contro rol l
Pera(a#an lua se)a per#ama ali pasien da#ang merupaan hal &ang harus dier)aan dengan bai dan #eli#i" E-aluasi lua harus dier)aan se$erma# mungin" Klasi5iasi ulus PEDIS dilauan se#elah debridement &ang &ang adeua#" Debridement &ang &ang bai dan adeua# aan sanga# memban#u mengurangi )aringan ner!#i &ang harus dieluaran #ubuh* dengan demiian aan sanga# mengurangi mengurangi pr!dusi $airan6pus $airan6pu s dari ulus6gangren" ulus6gangre n" 1erbagai #erapi #!pi$al dapa# diman5aa#an un#u mengurangi mir!ba pada lua* seper#i $airan $ airan salin sebagai pembersih lua* lu a* a#au i!dine en$er* en$e r* sen&a(a pera sebagai bagian dari dressing* dll" Demiian pula berbagai ber bagai $ara debridement n!n surgia surgiall dapa# dapa# diman5a diman5aa#a a#an n un#u un#u memper memper$epa $epa## pembersi pembersihan han )aringan )aringan
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an#ibi!# an#ibi!#i i harus harus diberia diberian n an#ibi!# an#ibi!#i i spe#rum spe#rum luas* luas* men$au men$aup p uman uman %ram %ram p!si#i5 dan nega#i5 2misaln&a 2misaln &a g!l!ngan g!l!nga n se5al!sp!rin4* se5al!sp!rin 4* di!mbinasian di!mbinasi an dengan !ba# &ang berman5aa# #erhadap uman anaer!b 2misaln&a me#r!nida?!l4" $. %ascu ascula larr cont contro rol l
Keadaan -asular &ang buru #en#u aan menghamba# esembuhan lua" 1erbaga 1erbagaii langah langah diagn!s# diagn!s#i i dan #erapi #erapi dapa# dapa# dier)a dier)aan an sesuai sesuai eadaan eadaan dan !ndisi pasien" Umumn&a elainan pembuluh darah peri5er dapa# dienali melalui berbagai $ara sederhana seper#i (arna dan suhu uli#* perabaan ar#eri d!rsalis pedis* ar#eri #ibialis p!s#eri!r* ar#eri p!pli#ea* dan ar#eri 5em!ralis* ser#a penguuran #eanan darah" da rah" Di samping sampin g i#u* saa# ini )uga #ersedia #ersed ia berbagai berbaga i 5asili#as mu#ahir un#u menge-aluasi eadaan pembuluh darah dengan $ara n!nin-asi5 maupun in-asi5 dan semiin-asi5* semiin-asi5* seper#i pemerisaan ankle brachial index* index * ankle pressure pressure* toe pressure* pressure* T$PO+* T$PO+* dan pemerisaan pemer isaan echo Doppler ser#a ser#a ar#eri!gra5i" Se#e Se#elah lah dila dilaua uan n diagn! diagn!sis sis eada eadaan an -asul -asular arn&a n&a** dapa# dapa# dilau dilauan an pengel!laan un#u elainan pembuluh darah peri5er dari sudu# -asular* &ai#u berupa:
3!di5iasi 7a#!r Risi!
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#indaan re-asularisasi* diperluan pemerisaan angi!gra5i un#u mendapa#an gambaran pembuluh darah &ang lebih )elas" Un#u !lusi &ang pan)ang dian)uran !perasi bedah pin#as #erbua" Un#u !lusi &ang pende dapa# dipiiran un#u pr!sedur end!-asular 2PT
i#u* i#u*
#era #erapi pi
hipe hiperb rbar ari i
dila dilap! p!r ran an
)uga )uga
berm berman an5a 5aa# a#
un#u un#u
memp memperb erbai aiii -asu -asula laris risas asii dan dan !sig !sigena enasi si )arin )aringan gan lua lua pada pada ai ai diabe# diabe#i i seba sebaga gaii #era #erapi pi adjuvant " 'alaupu alaupun n demii demiian an** masih masih ban&a ban&a enda endala la un#u un#u
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7a#!r 7a#!r edua edua adalah adalah lingun lingungan gan gula darah &ang subur un#u un#u peremb perembanga angan n ba#eri pa#!genF dan 5a#!r e#iga ialah arena adan&a pin#as ar#eri!-en!sa di subu#is &ang #erbua hingga aliran nu#rien #ida sampai e #empa# in5esi" Selai elain n e#i e#iga ga 5a# 5a#!r !r di a#as a#as** masih asih ban& ban&a a 5a# 5a#!r !r lain lain &ang &ang iu# iu# berpengaruh dalam #erben#un&a ai diabe#i" 'aspad)i men&a#aan bah(a 5a#! 5a#!rr pendid pendidia ian* n* s!si! s!si!e! e!n!m n!mi* i* dan dan gi?i gi?i )uga )uga pun&a pun&a andil andil $uup $uup besar besar"" Pendidi Pendidian an dan s!si!e! s!si!e!n!mi n!mi &ang rendah rendah #erai# #erai# dengan dengan penge#a penge#ahuan huan &ang ura urang ng meng mengen enai ai diab diabe# e#es es mell melli# i#us us dan dan pen$ pen$eg egah ahan an !mp !mpli lia asi sin& n&aa ser# ser#aa emampu emampuan an 5inansi 5inansial al aan mempeng mempengaruh aruhii pengel!l pengel!laan aan diabe#e diabe#ess melli#u melli#uss &ang dideri#a dideri#an&a" n&a" S#a#us S#a#us gi?i &ang rendah rendah memili memilii i e#erai e#erai#an #an dengan dengan rendahn& rendahn&aa resp!n imun sehingga mempermudah #er)adin&a in5esi"
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BAB II LAP#"A$ KASUS
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emerahan 2C4* nanah 2C4" Demam 2C4* ri(a&a# demam 2C4 adang dieluhan se)a pasein #erlua" Demam #ida #erlalu #inggi* perlangsungan hilang #imbul* #urun dengan pemberian para$e#am!l* menggigil 2C4* n&eri epala 2C4* pusing 294* Ri(a&a# sering pusing 2C4 se)a 8 bulan #erahir" 1a#u 2C4 han&a seseali* sesa 294* N&eri dada 294* ri(a&a# sesa dan n&eri dada sebelumn&a 294 3ual 294* 3un#ah 2C4 5reuensi /B isi sisa maanan* N&eri ulu ha#i 294* Ri(a&a# n&eri ulu ha#i 2C4 = hari S3RS* Na5su maan biasa* pasien sering merasa lapar mesi baru maan beberapa )am &ang lalu* pasien sering merasa lemah dan merasa $epa# haus" Penurunan 11 /. g dalam / bulan #erahir Pasien mengeluh sering ram* ga#al* ebas* dan merasa panas pada edua ai dan u)ung9u)ung )ari #angan* Pasien )uga mengau sering mengalami lua9
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Tanda @i#al
: 9 Teanan Darah
: /;.6/.. mmHg
9
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S#a#us %eneralis Pe-erik+aan
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Ke,ala Mata
ormocephali* ormocephali* rambu# hi#am* K!n)ung K!n)ung#i#i-aa anemis anemis 969* re5les $aha&a $aha&a langsung langsung C6C* C6C*
Telin!a
re5les $aha&a #ida langsung C6C* s$lera i#eri 969 ormotia* ormotia* liang #elinga lapang C6C* membran #impani
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Edema 96C
. PEME"IKSAA$ PE$U$%A$G Lab!ra#!rium pada #anggal /> O#!ber +./0 Pe-erik+aan EMAT#L#GI ;
a+il
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$ilai "u:ukan
/+ 9/, g6dL
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9 Gluko+a 9 Keton 9 Uro;ilino!en 9 Biliru;in 9 Dara= 9 0T8 . SE SEDI DIME ME$ $ 9 Leuko+it 9 Eritro+it
C Nega#i-e Nega#i-e Nega#i-e Nega#i-e Nega#i-e
Nega#i-e Nega#i-e Nega#i-e Nega#i-e Nega#i-e Nega#i-e
.9/. .9 /
/9, 6LP1 .9/ 6LP1
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La,oran Pe-;eda=an
Dilauan Dilauan = N!-ember +./0 puul /8"=. 'ITA 'ITA di ruang OK RSUD RAP1 PPU
Tindaan Operasi :
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