7395165 dm dan komplikasitg

8/4/2019 7395165 DM Dan Komplikasitg

1/81

DIABETES DAN KOMPLIKASI

Dr. Zaharita bt BujangKlinik Kesihatan Pekan NenasPontian


2/81

SUDAH BERSEDIA NAKDENGAR CERAMAH ?


3/81

Sunday Star-26th March 2006


4/81


5/81

DIABETES MELITUS

Penyakit yang tinggi morbiditi dan mortaliti

Komplikasi diabetes

* Retinopathy : 14.6% NIDDM > 40 thn

* Nephropathy : 10% selepas 25 thn DM

* Neurologi : 50% selepas 50 thn


6/81

Risiko co-morbiditi

CVS 2-4

Stroke 5X

Amputasi 27.7X

Impotence 1/3 lelakidiabetes


7/81

PATHOGENESIS

Hyperglycaemia

Increased hepatic

glucose production Decreased

muscle glucose

uptake

Impaired insulin secretion


8/81

DIAGNOSIS

Pemeriksaan darah

- FBS , RBS , MGTT

Gejala gejala diabetes


9/81

DIAGNOSTIC CRITERIA FOR DIABETES(75 G ORAL GLUCOSE TOLERANCE TEST)

Fasting PlasmaGlucose (mmol/l)

< 6.1 Normal

> 6.1 - < 7.0 Impaired Fasting Glucose

> 7.0 Diabetes

2 hour PlasmaGlucose (mmol/l)

< 7.8 Normal

> 7.8 - < 11.1 Impaired GlucoseTolerance

> 11.1 Diabetes


10/81

JENIS-JENIS

PENYAKIT DIABETES


11/81

JENIS-JENIS PENYAKIT DIABETES

PRIMARY SECONDARY

Type 1

(IDDM)

Type 2

(NIDDM)


12/81

TYPE 1 VS TYPE 2

Younger: Age< 30 yrs Lean HLA DR3 or DR4

Autoimune disease. Present of Islet cell

antibodies. Insulin deficiency. May devel. Ketoacidosis. Always need insulin. Dissapearance of C-

peptide.

Older onset Overweight No HLA links

No immune disturbance Insulin resistance. Partial insulin def. May devel. Hyperosmolar

state. 50% need insulin after

many years. C- peptide persist.


13/81


14/81

COULD DIABETES PREVENTED?????

Lifestyle modification; Weight loss >5%.

Reduce fat and increase dietary fibre .

Exercise > 30 min daily.

?? Lifestyle modification could prevent diabetesalmost 100%.

Prof J. Toumiletho Univ. Helsinki


15/81


16/81

EDUCATION ON DIABETES

A common chronic disorder

Chronic hyperglycaemia

Currently no known cure BUT can becontrolled for a healthy & productive life

Symptoms: Polyuria, polydipsia, tiredness,

lethargy, wt loss 50% not aware they are diabetic

Majority are asymptomatic


17/81

Causes of Death AmongPeople With Diabetes

Ischemic heart disease

Other heart disease

Diabetes (acute complications)

Cancer

Cerebrovascular disease

Pneumonia/influenza

All other causes

40

15

13

13

10

4

5

CAUSES % of Deaths

Geiss LS et al. In: Diabetes in America. 2nd ed.1995:233-257.


18/81


19/81

KOMPLIKASIDIABETES


20/81

CAD, PVDCVA

Dyslipidemia

Hypertension

Smoking

microvascular macrovascular

Genetics


21/81

KOMPLIKASI DIABETES

AKUT KRONIK


22/81

KOMPLIKASI

AKUT

Hiperglisemia Koma

(Gula terlalu tinggi)

Hipoglisemia Koma

(Gula terlalu rendah)

Tanda amaran

Terlalu dahaga

Kencing banyakLetih

Lemah

Rasa mengantuk

Tanda amaran

Rasa lapar

Sakit kepalaKetar tangan

Berdebar

Berpeluh

Tingkahlaku agresif


23/81

KOMPLIKASI

KRONIK

Rosak

Salurdarah kecil

Rosak

Salurdarah besar

Mata

Buah pinggang

Saraf

Jantung

Salur darah anggota

Kaki diabetes


24/81

DIABETIC COMPLICATIONS

RETINOPATHY

NEPHROPATHYNEUROPATHY

DIABETIC FOOT

CARDIOVASCULAR DISEASE


25/81

MATA

Mudah dapat katarak ( selaput mata )

Glaukoma

Retinopathy


26/81


27/81


28/81


29/81

Cataracts of the crystalline lens with opacification, as shown here, are more frequent in persons

with diabetes mellitus.


30/81

Glaucoma with marked cupping of the optic disk is seen on funduscopic examination. The

incidence of glaucoma is higher in the diabetic population.


31/81


32/81

Diabetic retinopathy is shown here on funduscopic examination.


33/81

Proliferative diabetic retinopathy on funduscopic examination is shown here. This is a particularly

serious complication in diabetics that can lead to blindness.


34/81


35/81


36/81


RETINOPATHY

NEPHROPATHY

NEUROPATHY

DIABETIC FOOT



37/81

Diabetic Nephropathy-Natural History


38/81

Screening for Diabetic Nephropathy


39/81

DARAH TINGGI


40/81


41/81


42/81


43/81


RETINOPATHY

NEPHROPATHY

NEUROPATHY

DIABETIC FOOT


TREATMENT


44/81

SARAF

Kehilangan rasa pada anggota kaki

Saraf Autonomik-

Tekanan darah rendah bila bangun - pening

Kembung perut

Impotence

Mononeuropati


45/81

Diabetic neuropathy

Pemeriksaan neurologi

Diagnosis

Ada gejala

Touch and pin prick

Vibration sense

Position sense

Ankle jerk

Muscle wasting

Autonomic neuropathy

Diabetic control

Treat pain/parassthesia

footcare


46/81

TYPES OF NEUROPATHY

PERIPHERAL NEUROPATHY

- Distal Symmetrical Polyneuropathy- Mononeuritis ( Amyotrophy )

- Painful Neuropathy ( Acute )

AUTONOMIC NEUROPATHY- Gastroperesis, ED, Diabetic Diarrhoea

Neuropathic Bladder, etc


47/81

NEUROPATHY

PERIPHERAL NEUROPATHY

SYMPTOMATICSANTIEPILEPTICS :

Clonoazepam, Gabapentin, Carbamazipine

TRICYCLICS :

Amitriptyline, Imipramine

OTHERS :

Pentoxifylline, TENS, Acupuncture

TREATMENT


48/81

AUTONOMIC DYSFUNCTION

SEXUAL DYSFUNCTION

GASTROPERESIS

TREATMENT


49/81

SEXUAL DYSFUNCTION

SEXUAL DYSFUCTION

NEUROLOGICASSESSMENT

VASCULARASSESSMENT

HORMONALASSESSMENT

PIHORMONALNON HORMONAL

I/CAVERNOSALINJ

VACUUM

PENILEPROTHESIS

TREATMENT


50/81


RETINOPATHY

NEPHROPATHY

NEUROPATHY

DIABETIC FOOT



51/81

DIABETIC FOOT

NEUROPATHYPERIPHERAL

AUTONOMICULCERINFECTIONGANGRANEW OUND DEBRID

ANTIBIOTICSAVOID WT BEARING

REVASCULAR SURGERYANTIPLATELETPENTOXYFYLINEAMPUTATION

PVD

DM

PREVENTION

OPTIMAL GLYCEMIAGOOD FOOT CAREFOOT EVALUATIONPODIATRIC VISIT

TREATMENT


52/81

DIABETIC FOOT

Screening

Pemeriksaan kaki

6 -12 M

DM control

Specific intensive care

Emphasize self care


53/81

Foot Ulcers and Amputations &DM

>50% of lower limb amputations in the US

Foot ulcers occur in 15% of diabetes

patients over a lifetime Cost of diabetes-related amputation:

$27,000

National Diabetes Fact Sheet. November 1, 1997:1-8.

Reiber GE et al. In: Diabetes in America. 2nd ed. 1995:409-428.


54/81

DIABETIC FOOT

Foot problem ( esp. infection )

Major reason for hospitalization

Leading cause of nontraumatic footamputation.

Disorder of foot in Diabetic patient;

a) peripheral neuropathy

b) Ischemia


55/81

DIABETIC FOOT

Common presentation:

a) Infection

b) Gangrene c) Skin ulcers

d) Neuropathic joint disorder ( Charcot

fracture).


56/81

PATHOPHYSIOLOGY

MULTIFACTORIAL:

a) Diabetic neuropathy

b) Vascular disease c) Susceptibility to infection

d) Trauma

All these predispose the diabetic foot toulcerations.


57/81

WHY ALL THE FUSS ABOUTFOOT IN DIABETES MELLITUS?

Although the various system failuresassociated with DM are more lifethreatening, it is noted that diabetic foot

ulcer is more emotional and moredisabling


58/81

Risiko amputasi 15X lebihtinggi untuk pesakit diabetes

berbanding dengan oranglain.


59/81

EVALUATION OF ULCERS

Evidence of infection in adjacent softtissue.

Probe involvement of deeper

structures, tendons, bone and joint.


60/81

WAGNER CLASSIFICATION

Stage 0 - Pressure area on the foot aggravated byfootwear

Stage 1 - Superficial ulcer

Stage 2 - Full-thickness ulcer.

Stage 3 - Full-thickness ulcer with abscess or

osteomyelitis

Stage 4 - Infected area with local gangrene ( forefoot )

Stage 5 - Extensive gangrene, foot and leg


61/81


62/81

RISK STATUS CLASSIFICATION

1) Normal sensation with no deformity.

2) Normal sensation with deformity.

3) Insensitivity without deformity.4) Ischemia without deformity.

5) Complicated:

combination insensitivity/ ischemia/deformity; Charcot joint, previousulceration, ulceration.


63/81

TREATMENT

GRADE 0 skin intact, bony deformity,foot at risk.

Proper foot wear with padding.

Patient education.

Surgical correction of claw toes &prominent PIP joint.


64/81

TREATMENT

GRADE 1 superficial ulcers.

Outpatient dressing changes. Total contact cast.

Antibiotics.


65/81

TREATMENT

GRADE 2 Deep ulcers

Hospitilazation. Wound debridement/ aggressive.

Wound care and IV antibiotics.

Goal to correct to Grade 1 ulcer.


66/81

TREATMENT

GRADE 3 Abscess and osteomylitis

Emergency drainage. Wound left open for daily dressing till

definite closure.

IV antibiotic

If failed, amputation.


67/81

TREATMENT

GRADE 4 - Gangrene of toes/ forefoot

AMPUTATION


68/81

TREATMENT

GRADE 5 - whole foot gangrene

AMPUTATION


69/81

Foot ulcer


70/81

Foot ulcer


71/81


RETINOPATHY

NEPHROPATHYNEUROPATHY

DIABETIC FOOT



72/81

PENYAKIT MACROVASCULAR

80% KEMATIAN DIABETES ADALAHBERKAITAN DENGAN PENYAKIT

CARDIOVASKULARANTARANYA-

* CORONARY ARTERY DISEASE

*CEREBROVASCULAR STROKE* PERIPHERAL VASCULAR DISEASE

PENGURUSAN KOMPLIKASI


73/81

PENGURUSAN KOMPLIKASIMACROVASCULAR

SARINGAN CARDIOVASCULAR

YEARLY / GEJALA

SEJARAH ANGINA , CLAUDICATION

STROKE

CHECK BP

CAROTID BRUIT

PERPHERAL PULSE

ECG , CXR, STRESS TEST

ECHO


74/81

Kardiovaskular

Untuk mengurangkan komplikasimakrovaskular ,selain hyperglisemia

semua faktor risiko harus dirawat Merokok , dyslipidemia , kawal HPT, ubah

gaya hidup


75/81

CV DISEASE & DIABETES

SILENTISCHAEMIA

AMI

ANGINA

CARDIOMYOPATHY

INSULINRESISTANCE

HT

VASCULARDYSFUNCTION

HYPER

GLYCAEMIA

DYSLIPID-AEMIA

CLOTTING ABNSMOKING

OBESE


76/81

CV COMPLICATIONS

CORONARY ARTERY DISEASE

-ASYMPTOMATIC SUDDEN DEATH

PERIPHERAL ARTERY DISEASE

CEREBROVASCULAR DISEASE

CHD mortality according to


77/81

CHD mortality according todegree of glucose tolerance

1.4

2.7

3.2

0

1

2

3

4

Normal glucose

tolerance (n = 6055)

IGT (n = 690) Newly diagnosed

+ known diabetes

(n = 293)

AnnualCHD

mortality

per1000

persons

Adapted from Eschwege E et al. Horm Metab Res Suppl1985; 15: 41

6.


78/81

CORONARY ARTERY DISEASE

TREATMENT

MEDICALINVASIVE/SURGICAL

PREVENTION


79/81

MEDICAL TREATMENT

THROMBOLYTIC THERAPY

ANTIPLATELET

BETA BLOCKERACE INHIBITOR

TIGHT GLYCAEMIC CONTROL

CORRECT CVS RISK FACTORS


80/81

INVASIVE/SURGICAL

PERCUTANEOUS CORONARYINTERVENTION ( PCI )

ANGIOPLASTY +/- STENTING

SURGICAL BYPASS ( CABG )

HIGH RATE OF RESTENOSIS IN ANGIOPLASTY

USE OF IIa/IIIb Platelet Inhibitor prevent restenosis

post stenting ( EPISTENT Study )


81/81

SEKIAN TERIMAKASIH

ATAS PERHATIAN ANDA.

7395165 dm dan komplikasitg

Documents