REFERATDiabetic Ulcer

definition

Diabetic ulcer is an open lesion on the surface of the skin due to angiopathy complications resulting in vascular insufficiency and neuropathy, which in further there is a lesion in patients which is often not perceived, and can progress to an infection caused by aerobic and anaerobic bacteria.

epidemiology

• Indonesia 15% of diabetic patient• Foot diabetic ulcer Most causes of

hospitalization by 80% to diabetic patient• mortality rate 32% • amputation 30%• diabetic patient with post amputation

14,3% will be die within a year and 37% will be die within 3 years

Etiology

The etiologies of diabetic ulceration include neuropathy, arterial disease, pressure, and foot deformity. Diabetic peripheral neuropathy, present in 60% of diabetic persons and 80% of diabetic persons with foot ulcers, confers the greatest risk of foot ulceration; microvascular disease and suboptimal glycemic control contribute.

classification

Risk factor Risk factors that can not be changed:1. age ≥ 60 years old2. Diabetic periods ≥ 10 tahun

The risk factors that can be changed (including habits and lifestyle):

1. neuropathy (sensory, motor, peripheral)2. Obesity3. Hypertension4. Uncontrolled Glycosylated hemoglobin (HbA1C)5. Uncontrolled blood glucose

6. Vascular insufficiency because of Atherosclerosis that caused by:

a) Uncontrolled total cholesterol levelb) Uncontrolled HDL levelc) Uncontrolled triglycerides7. Smoke8. Disobedience Diabetic Diet

Pathogenesis

• In patients with diabetes uncontrolled blood glucose levels are not controlled cancaus complications such as neuropathy,

• changes in nerve tissue is due to accumulation of sorbitol and fructose

• As a result axons started to dissapear, decreasing the speed of induction, paresthesia, decreased muscle reflex, muscle atrophy, excessive sweating, dry skin and numbness

• Ischemia is a condition where there is a lack of blood supply (oxygen deprivation) in the tissue.

• This is due to the process of macroangiopathy in blood vessels, decreased tissue circulation characterized by missing or reduced pulse in the dorsalis pedis artery, tibial and popliteal, foot atrophy, and cold toe tip.

• The disorder occurs subsequent to a tissue necrosis causing ulcers that usually starts from the foot or leg.

• Atherosclerosis is a condition in which the arteries thicken and narrow due to the buildup of fat on the inside of blood vessels.

• Thickened arteries in the legs can affect the muscles of the legs due to reduced blood supply, resulting in tingling, discomfort, and in the long term can lead to tissue death which will develop into a diabetic ulcer.

• Angiopathy process in patients with Diabetes mellitus is a narrowing and blockage of peripheral blood vessels, often occurs in the lower limbs, especially legs, as a result of reduced tissue perfusion to the distal part of the legs that can give rise to diabetic ulcers.

• High blood glucose levels can lead to thickening of the intima (hyperplasia of the arterial basal membrane) albumin could leak out of large blood vessels and capillaries which can disturb the distribution of blood to tissues and lead to tissue necrosis and diabetic ulcers.

• Erythrocytes in patients with uncontrolled diabetes will have an increase in HbA1C which causes erythrocyte deformability ineffective oxygen release in tissues, resulting in blockages that interfere with tissue circulation and lack of oxygen resulting in tissue death that subsequently give rise to diabetic ulcers.

• Increased levels of fibrinogen and increased platelet reactivity resulting in increased aggregation of red blood cells blood circulation becomes slow and facilitate the formation of thrombi in the blood vessel which would interfere with blood circulation.

• Inflammatory changes in the blood vessels, accumulation of fat in the lumen of blood vessels, as HDL concentrations are usually low.

• The existence other risk factor that increases susceptibility to atherosclerosis such as hypertension. Atheroscrelosis can cause decreased circulation to the foot tissue, causing necrosis and ulcer

Signs and symptoms of diabetic ulcers are:

• Frequent tingling• Leg pain at rest• diminished sensoric perception• Tissue damage (necrosis)• Decreased pulse of the dorsalis pedis, tibial

and popliteal arteries• Leg atrophy• dry skin

Examination in Diabetic Ulcer

Whean treating patient wit diabetic ulcer, there are a few steps that can be done to determine the wound status :1. Wound Asessment

a) Determine the wound location : this is useful as an indicator to what caused the wound, therefore minimizes the probability of the wound from occuring, by eliminating the cause of the wound.

b) Evaluate the grade of the wound : according to Wagner grading system for diabetic foot ulcer.

c) Wound colour : If the colour at the base of the wound is red, the thw wound is clean and is rich in vascularisation. If yellow, then the wound is infected, if it is black or dark coloured then the tissue is necrotic and avacular.

d) Wound shape and size : evaluate the wound size; length, width, and depthe) Vascular statusi. Subjective : is patient still sensitive to pain on

the wound area.ii. Objective : observe the skin colour, is it pale or

cyanotic distal to the wound. iii. Palpation :

1. Any changes in temperature especially on toe tip (becoming colder)

2. Palpate pulse beat distal to the wound, whether it is still palpable, or not tekanan nadi.

b. Ankle Brachial Index (ABI) The Ankle Brachial Index is a non invasive vascular screening test, to identify enlargement of blood vessels and peripheral vascular diseases, by comparing the systolic pressure on the ankle with brachial systolic pressure, in which central systolic pressure can be estimated. ABI is measured using continous wave Doppler, a sphygmomanometer, and a pressure cuff to measure the ankle and brachial systolic pressure. ABI has a high sensitivity an specifity in diagnosing arterial diseases of the lower extremity. ABI of less than 0.9 indicates an arterial disease of the lower extremity.

Indications of ABI

• Intermittent claudication • Diagnosing a patient suspected of a lower extremity

arterial disease with wound on the lower extremity• People over 70 years • People over 50 years with a history of smoking and

diabetes. • To evaluate the arterial flow of the lower extremity,

and to determine the process for compression therapy, or wound debridement.

• To determine the wound healing potential.

Contraindication of ABI

• Severe pain on the leg • Deep vein thrombosis• Severe pain linked to wound of the lower

extremity.

ABI Procedure

• Place the patient at a supine position for 20 minutes

• Make sure the toe area is not blocked or obstructed by clothing

• Cover the wound with cuff• Place the measurement cuff above the ankle• Doppler probe is placed in the anterior tibial

and dorsalis pedis arteries (with connecting gel) directions of probe is set to 450

• Press cuff until until pulse sound dissapears• Press cuff again to lower pressure until pulse sound

appears, this point is the ankle systolic pressure• Move cuff to arm of the same side• find the brachial pulse with doppler probe.• Press cuff until until pulse sound dissapears• Press cuff again to lower pressure until pulse sound

appears, this point is the brachial systolic pressure• Count the ABI by dividing the ankle systolic

pressure with the brachial systolic pressure.

ABI score Perfusion Status

>1.3 Elevated, incompressible vessels

>1.0 Normal

<0.9 Lower Extremity Arterial Disease

<0.6 to 0.8 Borderline

<0.5 Severe Ischemia

<0.4 Critical Ischemia, limb threatened

Treatment

a. correction of vascular abnormalitiesb. Improve circulationc. Manage the problems that arises (infections, necrosis)d. Foot care education. e. The provision of appropriate medications for infections (according to laboratory results) and eliminate symptoms and compklications of diabetes.f. Regular excercise to maintain an ideal body weightg. Stop smoking

h. Daily foot carei. Using the right footwearJ. Avoid repeated trauma, whether it is physical, chemical or thermalk. Avoid the use of vasoconstrictorsl. Regular check up to the doctor even after the foot ulcer have healed.

Debridement

One of the most important action in wound careDebridement is an action to dispose the necrotic tissue, callus and fibrotic tissue around 2-3 mm from the wound edges. Debridement increases the growth factors which helps the wound to heal. Frequent debridement methods are : Surgical, autolytic, chemical, and mechanical debridement

Debridement cont.

Surgical, autolytic, and chemical debridement only removes the necrotic tissues (selective debridement), while mechanical debridement removes both the necrotic tissue and healthy tissue around the wound (non-selective debridement)

Offloading

Is a reduction in pressure on the ulcer, diabetic ulcers usually occurs on lacations receiving high pressure, bed rest is the best way to reduce pressure.