RUMAH SAKIT UMUM

KARUNIA KASIH

dr. Panondang Panggabean, SpB

Jl. Raya Jatiwaringin No.133, Jatiwaringin, Kec. Pondok Gede, Kota Bekasi, Jawa Barat 17411
 Topics

1. Current status DFU in Indonesia

2. Risk Assessment
3. Wound care of DFU
4. Case series.

2
 PREVALENSI DIABETES MELLITUS
2013 2035
PREVALENCE DM IN INDONESIA1,3,4 Country
Populasi
Millions
MCountry
di Millions
1 D Indonesia
4China 98.4 China 142.7
12
7.00% 6% 1India 65.1 India
Juta
109.0
2
6.00% 5.7%
10
USA 24.4 USA 29.7
5.00% 7 Juta
8
4.00% Brazil 11.9 Brazil 19.2
Russian 10.9 Mexico 15.7
6
3.00% Mexico 8.7 Indonesia 14.1
2.00% 1.63% 4
Indonesia 8.5 Egypt 13.1
1.00% 2
Germany 7.6 Pakistan 12.8
0.00%
0
19831 20072 20303
2010 2030

Egypt 7.5 Turkey 11.8

Japan 7.2 Russian 11.1

Prevalensi DM yang tidak terdiagnosa cukup tinggi sebesar 4.1 %

1. Waspadji S, Ranakusuma A, Suyono S, Supartondo S, Sukaton U. Diabetes Mellitus in an Urban Population in Jakarta, Indonesia. Tohoku J exp Med. 1983;141:219-228.
2. Mihardja L, Delima, Siswoyo H, Ghani L, Soegondo S. Prevalence and determinants of diabetes mellitus and impaired glucose tolerance in Indonesia (a part of basic health
research/Riskesdas). Acta Med Indones. 2009;41(4):169-74.
3. Shaw, J.E., Sicree RA, Zimmet PZ. Global estimates of the prevalence of diabetes for 2010 and 2030. Diabetes Res Clin Pract. 2010;87(1):4-14.
4. Guariguata L, Whiting DR, Hambleton I, Beagley J, Linnenkamp U, Shaw JE. Global estimates of diabetes prevalence for 2013 and projections for 2035. Diabetes Res Clin Pract.
2014;103(2):137-149.
5. Pramono, L. a, Setiati, S., Soewondo, P., Subekti, I., Adisasmita, A., Kodim, N., & Sutrisna, B. (2010). Prevalence and predictors of undiagnosed diabetes mellitus in Indonesia. Acta
Medica Indonesiana, 42, 216–223. 3
 Prevalence Acute and Chronic Wound
Summary Outcome in Wound Care Setting
Prevalensi Acute and Chronic Wound 2013
in Home Care Setting Luka Akut Luka
85.1 Kronis
26

15
12 34.6 38.4
11
8 8
7 19.2
3 3 3 14.8
1 1 1 7.6
0 0

Sembuh Rujuk Drop out Meninggal

DFUs is major wound problems in

High number of Drop Out Patients
clinical setting in Indonesia

Saldy Yusuf., Sukmawati.,Mayumi Okuwa.,Junko Sugama. Development Enterostomal Therapy Nurse Outpatient Wound
Clinic In Indonesia: A Retrospective Descriptive Study. 2013. Wound Research and Practice. 21(1):41-47
 Prevalence DFUs in Indonesia
• Prevalence of risks (neuropathy and angiopathy) in Hospital
Setting 55.4% (95% CI: 53.7-57.0%)
(Yusuf et al., 2015).
• Prevalence of DFUs:
– Hospital 12% (95% CI: 10.3-13.6%)
(Yusuf et al., 2015).
– Home care 26%
(Yusuf et al., 2013).
• One year observation; healing (64.7%), recurrence (17.6%),
dead (11.8%), unheal (5.9%)
(Baharia et al., 2014)
1. Yusuf, S., Okuwa, M., Irwan, M., Rassa, S., Laitung, B., Thalib, A., … Sugama, J. (2015). Prevalence and risk factor diabetic foot ulcers:
A cross sectional study among DM type 2 in eastern Indonesia. OWM Journal.
2. Yusuf, S., Kasim, S., Okuwa, M., & Sugama, J. (2013). Development of an enterostomal therapy nurse outpatient wound clinic in
Indonesia : a retrospective descriptive study. Wound Practice and Research, 21(1), 41–47.
3. Baharia Laitung, Muhammad Irwan, Saiful Rassa, Sukmawati, Saldy Yusuf. One year recurrence incidence and risk factors of
diabetic foot ulcer in Makassar, eastern Indonesia (pre eliminary study). 1st WOC Scientific Meeting, Yogyakarta 2014. 5
 DFU status on 1st admission

NECROTIC INFECTIONS ODOUR UNDERMINING

EDEMA MASERASI CALLUS

POST AMPUTASI

Saldy Yusuf (2013) Current Status of Diabetic Foot Ulcers in Makasar, Indonesia. Baruga AP. Pettarani, 9
Desember 2013
 DFU presence in one way
DIABETES MELLITUS

Neuropathy Angiopathy
Onychocriptosi Bunion
s
Hammer Toe Hallux Vagus
PRE ULCERS: DEFORMITY PROBLEMS
PRE ULCER

PRESENCE DIABETIC FOOT ULCER

DIABETIC FOOT ULCER

Amputation AMPUTATION
11. WGDF, “Pathophysiology of foot ulceration Pathophysiology of foot ulceration,” 2012. 7
 Golden Assessment
NEUROPATHY ANGIOPATHY

MONOFILAMENT TEST ABI dan TBI

Its not widely available in health care facilities

Alternative?
8
 Alternative Assessment
NEUROPATHY ANGIOPATHY

Ipswich Test Foot palpatian

Diabetic Foot Check Up

How about its validity and reliabity?

 Validity and Reliability

Ipswich Test Palpasi Nadi Dorsalis

• Sensitivity (66.7-100%) Pedis dan Posterior
• Spesifisity (80.0-94.6%) Tibialis
(Sulasti, Yusuf, Jafar, & Syam, 2017)

• Reliability between nurses • Sensitivity (25-100%)

(Cohen's Kappa = 0.724-0.909) • Spesificity (97.5-100%)
(Sulasti, Yusuf, Jafar, & Syam, 2017)
(Desri, Yusuf, Jafar, & Syam, 2017).

Considerable to be valid and reliable as alternative assessment

10
 Risk Category for DFUs
No Neuropathy
No Deformity
No Ischemic
RESIKO 0
No History of
Ulcer
No History of
amputation

RESIKO 1 RESIKO 2A RESIKO 2B RESIKO 3A RESIKO 3B

Neuropathy + Deformitas
+ History of History
+ PAOD +
of ulcers amputation
Avery, D. A. C. L., Lavery, L. A., Peters, E. J. G., Williams, J. R., Murdoch, D. P., Hudson, A., & LAvery, D. C. (2008). Reevaluating the Way We Classify the
International Working Group on the Diabetic Foot. Diabetes care, 31, 154–156. doi:10.2337/dc07-1302.Abbreviations
 Our findings

Eligible: 259

Drop Out: 10

Analysis: 249 (inpatient 14)

No DFU: 219 DFU:30

Group 0: Group 1: Group 2A: Group 3B:

Group 2B: 34 Group 3A:
90 (36.1%) 14(5.6%) 64 (25.7%) 14 (5.6 %) 3 (1.2%)
(13.7%)

12
Yusuf, S., Okuwa, M., Irwan, M., et al (2016). Prevalence and Risk Factor of Diabetic Foot Ulcers in
a Regional Hospital , Eastern Indonesia. Open Journal of Nursing, 6, 1–10.
 Advanced Assessment:
Mobile Infra Red
Thermography
 History
Milestone application infra red thermography in diabetic foot

Identification
Inflammation & Diagnosis
sign for foot neuropathy
disease
Identification Identification Evaluation peak
neuropathy Plantar pattern shear stress

2008 2009 2011 2012 2014

(Bharara, (Nishide et al., 2009) (Nagase et al., 2011) (Balbinot, Canani, (Yavuz et al., 2014)
Viswanathan, & Robinson, Achaval,
Cobb, 2008a (Roback, Johansson,
& Zaro, 2012)
and 2008b) & Starkhammar, 2009)

Saldy Yusuf: Identification Clinical Features Diabetic Foot Ulcers Using Non-Contact Thermography Based On Mobile Phone: A
Case Series. WCET 2016 Conference, Cape Town, South Africa; 03/2016
 Mobile Thermography as advanced assessment

Courtesy: Griya Afiat Makassar

 Our Findings
Thermography Features Clinical Features

Dorsal

Plantar

Clinical features showed necrotic area along side dorsal forefoot to medial, However
thermography findings identified “cold pattern” at all fingers and forefoot area.
Yusuf, S., Sukmawati, K., & Laitung, B. (2016). Identification Clinical Features Diabetic Foot Ulcers Using Non
Contact Thermography Based on Mobile Phone: A Case Series. In WCET 21st Biennial Congress.
 Screening for risk

Butterly Pattern Asymmetrically Pattern

Our study will investigate infra red thermography based iPhone

as early screening tool in community setting
17
Sandi, Selina, et al (2017)
 Thermography: Pressure Ulcer

Thermography dapat digunakan untuk memprediksi terbentuknya

“undermining” pada luka decubitus (Yusuf, S., et al 2016)
 Advantages

We noted some advantages:

• Less expensive  amazon(US $217.99).
• Real time  support time serial observation.
• Non contact  no contamination.
• 2 Dimension imaging advanced analysis.
• Pocket size  Useful in various setting.
• Attach to smartphone  easy to capture,
saving, sending, uploading and printing.
 Wound Care:
Wound Bed Preparation and TIME

20
 TIME CONCEPT
EWMA merekomendasikan:
1. Debridement secara berkala dan radikal.
2. Inspeksi dan kontrol bakteri.
3. Moisture balance untuk mencegah maserasi.

European Wound Management Association (EWMA). Position Document: Wound Bed

Preparation in Practice. London: MEP Ltd, 2004
 MOISTURE BALANCE
Pemilihan Balutan yang Tepat

Moura, L. I. F., Dias, A. M. a, Carvalho, E., & de Sousa, H. C. (2013). Recent advances on the
development of wound dressings for diabetic foot ulcer treatment--a review. Acta Biomaterialia,
9(7), 7093–114. doi:10.1016/j.actbio.2013.03.033
 Proses Perawatan

Cleaning Debridement Dressing

European Wound Management Association (EWMA). Position Document: Wound Bed

Preparation in Practice. London: MEP Ltd, 2004
 Metode Debridement
METODE DESKRIPSI KEUNTUNGAN KERUGIAN
Mechanica Menggunakan kasa membersihkan bantalan Non selektif, sehingga
l basah- kering atau irigasi luka dari kontaminasi jaringan sehat juga
cairan bakteri. dapat terganggu, dapat
menimbulkan nyeri..
Sharp- Menggunakan scalpel atau Metode Perdarahan
sequential debridement gunting jaringan yang paling merupakan efek
bedside cepat. merugikan.
Biosurgeri Menggunakan Belatung Belatung steril tidak
belatung kurang lebih mensekresikan enzim tersedia di semua
5-8/cm2 yang merangsang unit pelayanan
granulasi. kesehatan.
Autolityc Menggunakan balutan Selektif sehingga Sifatnya kerjanya
yang menciptakan tidak mengganggu lambat, kurang tepat
lingkungan lembab. jaringan yang sehat. untuk nekrotik yang luas
Contoh: Hydrogel dan melekat kuat.

Enzymati Menggunakan Bersifat selektif, Sifatnya yang lambat

c preparat enzim karena hanya bekerja dibanding terapi
pada jaringan nekrotik conservative,.

Bates-Jensen, Barbara.M., MacLean, Catherine.H. (2007) 24

 Pencucian Luka
Ada beberapa tekhnik pencucian luka:
1. Menggosok (Swabbing),
2. Mengguyur (Showering), Dan
3. Merendam (Bathing)

namun tidak ada perbedaan yang signifikan diantara tekhnik

tersebut (Moore & Cowman, 2005).
 Manfaat pencucian luka
Patient ID 1 2 3 4 5
2nd Toe- 2nd Toe-
5th toe Dorsum
Wound location Sole (Right) dorsum sole
(Left) (Left)
(Right) (Right)
Age (yrs.) Gender 49 49 60 60 56
Duration of DM Male
(yrs.)
14 14 6 6 13
Neuropathy
ABI Neuropathy
1.18 1.18 0.85 0.85 0.65
Bacteria count
6.33x106 9.78x105 3.47x106 6.68x106 6.74x107
(bedfore cleansing)
Bacteria count (after
1.34x106 3.38x105 1.89x107 1.23x107 1.56x106
cleansing)

26
Makoto Oe, et al 2014., unpublished data
 Madu sebagai alternatif
0 day 2 day 5 day 7 day 11 day 14 day Indonesian Honey
group

0 day 2 day 5 day 7 day 11 14 day

day Manuka Honey
group

0 day 2 day 5 day 7 day 11 14 day

day Control
group

Haryanto, Urai, T., Mukai, K., Suriadi, Sugama, J., & Nakatani, T. (2012). effectiveness of Indoensian Honey on the
Aceleration of Cutaneous WOund Healing: An Experimental Study in Mice. WOUNDS, 24(4), 110–119.
 Madu sebagai alternatif
2
1.8
Control
1.6
Indo
1.4
Ratio of areas to original

Manuka
1.2 ** ** **
**
1
0.8 NS
0.6
0.4
areas

0.2
0
0 1 2 3 4 5 6 7 8 9 10 11 12 13
14
Days after
wounding
Ratio of the wound area. Value was expressed Mean±SD. n = 6 per group .
ANOVA; Tukey-Kramer (** p < 0.01)

Haryanto, Urai, T., Mukai, K., Suriadi, Sugama, J., & Nakatani, T. (2012). effectiveness of Indoensian Honey on the Aceleration of
Cutaneous WOund Healing: An Experimental Study in Mice. WOUNDS, 24(4), 110–119.
Case Series

29
 Case 1: Callus
Kanan
(Ada/absent)
Monofilament Absent
Pin Prick Absent
Palpasi
Dorsalis Pedis Absent
20 Sept 2013 23 Sept 2013 Posterior Tibialis Absent
ABPI
Dorsalis Pedis 1.1
Posterior Tibialis 0.6

27 Sept 2013 2 Okt 2013 5 Okt 2013

Case 1: DFU Wagner
IV
 Case 2:
Abscess

23Agustus 2015 26 Agustus 2015 6 Sept 2015

16 September 2015 21 September 2015 13 Oktober 2015

 LAPORAN KASUS
Luka Kaki Diabetic Wagner III
di Klinik Griya Afiat Makassar
Saldy Yusuf, PhD.,ETN1,2.,
Baharia Laitung, S.Kep1., Sukmawati, S.Kep1.

1 Griya Afiat Makassar, Wound Care and Home Care Clinic, Makassar, Indonesia.
2Chronic Wound Department, Kanazawa University Japan.
 PROSES PERAWATAN

20 Januari 2014 21 Januari 2014 25 Januari 2014

29 Januari 2014 31 Januari 2014 7 February 2014

13 February 2014 19 February 2014 23 February 2014

 PROSES PERAWATAN

26 February 2014 1 Maret 2014 11 Maret 2014

14 Maret 2014 19 Maret 2014 24 Maret 2014

28 Maret 2014 2 April 2014 10 April 2014

 LAJU PENYEMBUHAN

20 Januari 2014 19 February 2014 11 Maret 2014 10 April 2014

Skor awal BBJ 48 , Skor akhir BBJ 13, laju penyembuhan 35/82 hari = 0.42/hari

Baharia., Sukmawati., Saldy Yusuf (2014) Case Report: Honey Impregnated wound dressing in DFU Wagner III. Data on file.
 EFEKTIFITAS

Efektifitas waktu:
• Lama perawatan : 82 hari.
• Frekuensi perawatan : 23 kali.
• Rata rata pergantian balutan : 4 hari.
• Rata-rata waktu perawatan: 30-60 menit.
Efektifitas dressing:
• Tidak nyeri.
• Bau terkontrol.
• Balutan tidak lepas.
Efektifitas hasil:
• Sembuh tanpa komplikasi.
• Sembuh tanpa amputasi (minor atau mayor).

Baharia., Sukmawati., Saldy Yusuf (2014) Case Report: Honey Impregnated wound dressing in DFU Wagner III. Data on file.
 LAPORAN KASUS
Diabetic Ulcer Non Foot
di Klinik Griya Afiat Makassar

Saldy Yusuf, PhD.,ETN1,2.

Baharia Laitung, S.Kep1., Sukmawati, S.Kep1.,

1 Griya Afiat Makassar, Wound Care and Home Care Clinic, Makassar, Indonesia.
2Chronic Wound Department, Kanazawa University Japan.
 Healing Progress

26 JULY 2014 31 JULY 2014 2 AGUSTUS 2014 7 AGUSTUS 2014

23 SEP 2014 28 OKT 2014

11 AGUSTUS 2014 18 AGUSTUS 2014
 Wound
Wound care Dressing
phase
Primary Secondary Tertiary Periwound Care
Inflamation • Hydro L • Cutisorb • Hypafix • Metco/Zinc
• Epitel Salf
• Metco
Exudate • Madu • Foam • Hypafix • Metco
Cavity
• Cutisorb
Granulasi • Madu • AlCutisor b • Hypafix • Metco
• Alginate

Epitel • Film
 Graphic 1: Wound Healing Progress
Wound Healing Progress (BBJ
45 Score)
40
39 40 40
35
34
29 30 30 29 29
30 27
25 24
25

20 18
15 13
15

10

0
1 2 3 4 5 6 7 8 9 11 12 13 14 15
10

Wound Care Series

Duration of care 95 days, Frequency of wound care 15 times,

Baseline BBJ 27, Outcome BBJ 13:
 Wound Care Interval = 6.3 Days
 Wound healing progress= 0.14 BBJ score/days
 Kesimpulan
• Di Indonesia Prevalensi DFU cukup tinggi.
• Ipswich test dan palpasi nadi dorsalis pedis-
posterior pedialis dpt digunakan untuk
identifikasi resiko.
• Perawatan DFU berorientasi pada penyebab
dan status luks.
• Wound bed preparation dalam manajemen
DFU dapat menekan biaya dan mengefektifkan
waktu perawatan.
RUMAH SAKIT UMUM
KARUNIA KASIH
TERIMA KASIH