Dm Gangren
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Pembimbing:
dr. M. Mahfudz Sp.PD
SMF ILMU PENYAKIT DALAM RSUD Jombang2014
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Nama : Ny. IstrianiUsia : 55 thJenis Kelamin : PerempuanPendidikan : SMPPekerjaan : Ibu rumah tanggaAgama : IslamSuku : JawaAlamat : Banjardowo, JombangTgl MRS : 03-02-2014No. RM : 21-04-75
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KU : Luka di kaki kananRPS : Luka di kaki kanan ± 1 minggu. Luka krn tertusuk
duri dan tdk sembuh2, makin lama makin melebar, nyeri (+), gatal (-), panas badan (-), nafsu makan menurun.
RPD : DM (+) 2th, HT (-)RPK : DM (-), HT (-)
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• KU: cukup GCS: 456• Vital Sign:
– T: 110/70 mmHg– N: 88x/mnt– t: 36,7oC– RR: 22x/mnt
• Kepala: A/I/C/D (-/-/-/-)• Leher: Pembesaran KGB (-)
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Thorax:Paru: Simetris, retraksi (-), ves/ves, Rh -/- Wh-/-Jantung: S1S2 tunggal, reguler, murmur (-), gallop (-)
Abdomen: Flat, supel, hepar/lien ttb, BU (+), nyeri tekan (-)Extremitas: Akral hangat, edema -/- ulkus pedis DStatus vaskular: palpasi A. tibialis anterior dextra dan
sinistra dbN, CRT dbN.
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• Hb: 11,9• Leukosit: 23.600• Hematokrit: 34,2• Eritrosit: 4.020.000• Trombosit: 318.000• GDA: high
• SGOT: 18• SGPT: 20• Kreatinin: 0,85• Urea: 28• Asam Urat: 4,28• HbsAg : -
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• Perempuan, 55 thn• Ulkus pedis dextra• Nafsu makan menurun• GDA high• Leukosit 23.600
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DM HiperglikemiaGangren Pedis Dextra
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DM Hiperglikemia + Gangren Pedis Dextra
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Laboratorium: GDP G2JPP LFT RFT UL Kultur bakteri
Radiologi:Foto pedis (D)
Konsul:Dokter Spesialis Bedah
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Non farmakologi:Rawat lukaDiet 3J (Jenis-Jumlah-Jadwal)
Farmakologi:RCI 3x12 unitInj Ceftriaxone 2x1Inj Metronidazole 3x1As mefenamat 3x500 mg (jika nyeri)
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• Keluhan• Vital sign• GDA• Komplikasi• Efek samping OAD
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• Konseling tentang kondisi px pd px dan keluarga• Diet rendah glukosa• Menjaga pola hidup dan pola makan• Menjaga kebersihan• Merawat luka dan ganti perban 3x sehari
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Diabetes Mellitus
DefinisiDiabetes Mellitus (DM) adalah penyakit endokrin yg ditandai dg hiperglikemia serta gangguan metabolisme karbohidrat, lemak, protein yg berhubungan dg defisiensi absolut atau relatif aktivitas dan atau sekresi insulin (studi WHO,1999)
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Diabetes Mellitus
DM merupakan penyakit metabolik yg bersifat herediter krn kurangnya insulin di dalam tubuh, baik insulin relatif atau insulin absolut, dg tanda-tanda hiperglikemia dan glukosuria, disertai gejala klinik akut.
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Klasifikasi DM
• DM tipe-1 krn proses autoimun atau idiopatik defisiensi insulin absolut.
• DM tipe-2 bervariasi mulai yg terutama dominan resistensi insulin dg defisiensi insulin defek sekresi insulin disertai resistensi insulin.
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Klasifikasi DM• DM tipe-3 (lain) defek genetik fungsi sel beta,
infeksi, defek genetik kerja insulin, endokrinopati, penyakit eksokrin pankreas, imunologi, krn obat atau zat kimia, sindrom genetik lain yg berkaitan dg DM.
• DM Gestasional timbul selama kehamilan.
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Diabetes tipe 2 (NIDDM)Diabetes tipe 2 (NIDDM)
• Jenis paling banyak ditemukan (>90%)• Jumlah insulin normal, mungkin lebih banyak
tetapi jumlah reseptor insulin pd permukaan sel berkurang.
• Dapat terjadi keadaan yg disebut resistensi insulin.
• Sel β pankreas berkurang 50-60%• Sel α meningkat
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Autoimun proses/idiopatik → destruksi sel beta → defisiensi insulin absolut → DM tipe 1 (IDDM)
Resistensi insulin/defisiensi insulin relatif → defek sekresi insulin → DM tipe 2 (NIDDM)
Defek genetik/endokrinopati/obat/infeksi → gangguan fungsi sel beta dan kerja insulin → DM tipe lain
Toleransi terhadap KH → waktu hamil → kadar glukosa darah meningkat → DM gestasional
Patofisiologi DM
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Gejala-gejala
• Rasa haus berlebihan• Sering BAK• Rasa lapar berlebihan• Pandangan kabur• Kesemutan• Luka yg lama sembuh• Penurunan berat badan yg tidak jelas sebabnya
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PERKENI, 2011
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PENATALAKSANAAN
• Obat antidiabetes terdiri dari 2 golongan:– Insulin– Obat Hipoglikemik Oral (OHO)
• Tujuan pemberian insulin dlm pengobatan:– Menstimuli pemakaian glukosa dan asam
amino oleh sel-sel tubuh– Menstimuli konversi glukosa dan asam amino
menjadi glikogen, protein dan lemak.
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Oral Antidiabetics
• Sulfonylureas • Meglitinide• Biguanid • Glitazone• Alpha-glucosidase inhibitor
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Mekanisme kerja OAD
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Insulin
• Made in beta cells of the pancreas• Moves glucose into cells (thus acts like growth
hormone in a way)• Moves potassium into cells (can buy time in
emergencies)
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Insulin
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Types of insulin
• Regular insulins• Insulin analogs• Pre-mixed insulin
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Insulin preparations
• Rapid acting (lispro, asparte)
• Short acting (regular)• Intermediate acting
(NPH)• Long acting
– Ultralente– [Glargine/Lantus]
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KOMPLIKASI DM (PERKENI, 2011)
A. Komplikasi Akut: 1. Hipoglikemia 2. Ketoasidosis Diabetik (KAD) 3. Koma Hiperosmoler Non Ketotik (KHONK)
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B. Komplikasi Kronik: 1. Makroangiopati 2. Mikroangiopati 3. Neuropati 4. Komplikasi mekanisme kombinasi - Kardiopati (PJK, kardiomiopati) - Rentan Infeksi (TBC, ISK, ginggivitis) - Kaki diabetik - Disfungsi ereksi
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Komplikasi Kronik DM
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ATHEROSCLEROSIS
NormalFatty
StreakFibrousPlaque
Athero-scleroticPlaque
PlaqueRupture/Fissure &
Thrombosis
Clinically Silent
Increasing AgeIncreasing Age
AnginaTransient Ischemic Attack
Claudication / POAD
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PD TUNGKAI
• Trias yaitu:- Iskemia- Neuropati- Infeksi
• Tanda makroangiopati dapat dideteksi dg hilangnya denyut atau melemahnya denyut pd: a.dorsalis pedis, a.tibialis, dan a.poplitea.
• Manifestasi campuran: selulitis atau gangren diabetik, gangguan pulsasi a.dorsalis pedis dan diabetik retinopati.
• Prognosis kurang baik.
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Jenis Gangren
1.Gangren kering• Sakit pd daerah lesi.• Lesi menjadi pucat, kebiruan, berbercak ungu
lama-kelamaan menjadi hitam.• Tidak teraba denyut nadi (tdk selalu)• Bila diraba terasa kering dan dingin.• Pinggirnya berbatas tegas.• Nyeri lama-kelamaan berkurang gangren lepas
dari jaringan yg utuh.
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cont..
2.Gangren basah• Bengkak pd daerah lesi.• Lesi berwarna merah menjadi hijau kemudian
menjadi kehitaman.• Dingin, lunak, basah.• Ada jaringan nekrose yg berbau busuk tapi bisa
juga tanpa bau sama sekali.
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Stadium “Fontaine”
1. Asimptomatik/gejala tdk khas2. Klaudikasio intermitten3. Nyeri saat istirahat4. Manifestasi kerusakan jaringan krn anoreksia
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Stadium “Wagner”
0. Kulit utuh tp ada kelainan bentuk kaki krn neuropati
1. Tukak superficial2. Tukak lebih dalam3. Tukak dalam dg abses dg kemungkinan selulitis
dan/atau osteomyelitis4. Gangren jari5. Gangren kaki
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Penatalaksanaan
1.Gangren kering• Bed rest.• Kontrol kadar gula darah dg diet, OAD, insulin.• Amputasi utk mencegah perluasan gangren,
namun indikasi harus jelas.• Perbaiki sirkulasi utk mengatasi/mencegah
angiopati dg obat antiplatelet agregasi (aspirin, dipyridamol, pentoxyvilin).
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cont..
2.Gangren basah• Bed rest.• Kontrol kadar gula darah dg diet, OAD, insulin.• Debridement.• Kompres air hangat.• Beri antibiotik topikal.• Beri antibiotik sistemik sesuai kultur atau antibiotik
spektrum luas.• Beri pyridoxine atau neurotropik lain.• Perbaiki sirkulasi utk mengatasi/mencegah angiopati dg obat
antiplatelet agregasi (aspirin, dipyridamol, pentoxyvilin).
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Indikasi amputasi
• Febris terus-menerus.• Regulasi DM sulit dicapai (kadar gula darah >
300)• Osteomyelitis pd gambaran radiologi.• Selulitis cenderung ke atas.• Infeksi pd gangren yg menyebabkan KU
memburuk.• Faal ginjal semakin menurun.
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TERIMA KASIH