PENGENDALIAN PERKHIDMATAN PENYAKIT TIDAK BERJANGKIT (NCD) UNTUK PARAMEDIK

KEMENTERIAN KESIHATAN MALAYSIA

KULIAH 34

REHABILITASI : AMPUTASI KAKI

ANJURAN : BAHAGIAN PEMBANGUNAN KESIHATAN KELUARGA DAN BAHAGIAN KAWALAN PENYAKIT

Modul Latihan Pengendalian Perkhidmatan NCD Untuk Paramedik KKM

KANDUNGAN

o Patofisiologi amputasi kaki

o Pesakit berisiko amputasi kaki

o Klassifikasi dan diagnosa

o Rawatan dan rehabilitasi kes amputasi kaki (prinsip umum)

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PATOFISIOLOGI

Neuropati

‘Vasculopathy’ ‘Immunopathy’

DIABETIC TRIAD

3 komponen yang bertindak dalam pelbagai kombinasi

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Neuropati

Motor Sensori Autonomik

↓ nocicepsi

↓ Proprioception, Tidak mengetahui

posisi kaki A-V Shunt

Meningkatkan pengaliran

darah ke kaki

Vena kaki menimbul, Kaki panas

Kurang peluh

Kulit kering

Fisur dan kulit pecah

Otot dan kaki menjadi lemah

Ketidakseimbangan posisi badan

Kecacatan, tekanan dan koyak

Kecederaan

Tekanan kepada tulang, sendi dan plantar

Pembentukan callus

Jangkitan Luka

PATOFISIOLOGI NEUROPATI

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Penyakit Arteri Periferi

Artherosclerosis Penyempitan

dan penutupan lumen arteri

Iskemia kaki

Luka kaki Necrosis/ Gangren

Jangkitan

Plak arteroma

menyebab lumen

arteri menjadi sempit

PATOFISIOLOGI PENYAKIT ARTERI PERIFERI

Jari menjadi

gangren akibat

arterosclerosis

Modul Latihan Pengendalian Perkhidmatan NCD Untuk Paramedik KKM

Modul Latihan Perkhidmatan NCD Untuk Paramedik KKM

KAKI BERISIKO…. • Ischaemia

• Numbness

• Structural Deformities

• Callus and / or Corn

• Absence of Pedal Pulses

• A capillary refill time in excess of 3 secs

• Limb pain and / or parasthesia

• Intermittent Claudication

• History of Foot Ulcer

• Loss of sensation of light touch,sharp and blunt touch

AJM Boulton, H Connor, PR Cavanagh, The Foot in Diabetes, 2002

Pre-ulcer

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Modul Latihan Perkhidmatan NCD Untuk Paramedik KKM

Modul Latihan Perkhidmatan NCD Untuk Paramedik KKM

Diabetic Foot Ulcer

• Diabetic Foot Ulcer menyebabkan ‘Non-Traumatic Lower Extremity Amputation’ (LEA).

• 15% daripada Pesakit diabetes mengalami ulser kaki.

• Risiko LEA adalah 8 kali ganda di kalangan mereka yang pernah mendapat ulser kaki

• 25% daripada semua kemasukan pesakit diabetes ke wad adalah disebabkan ulser kaki diabetes

Modul Latihan Perkhidmatan NCD Untuk

Paramedik KKM

“Tragic “Rule of 50”

• 50% drp amputasi

• 50% drp pesakit

• 50% drp pesakit

Paras Transfemoral/ transtibial

amputasi kedua dlm 5 tahun

Meninggal dunia 5

tahun

Clinical Care of the Diabetic Foot, 2005

Modul Latihan Perkhidmatan NCD Untuk Paramedik KKM

Tragic “Rule of 15”

• 15% drp pesakit DM > Ulser kaki sepjg hidup

• 15% drp ulser kaki > Osteomyelitis

• 15% drp ulser kaki > Amputasi

Clinical Care of the Diabetic Foot, 2005

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Modul Latihan Perkhidmatan NCD Untuk Paramedik KKM

PENILAIAN

LUKA

Bhg tepi ulser

‘Assess for

undermining &

condition of

margin’

Saiz

Ukur saiz

Kedalaman

ulser

‘Wound bed’

Assess for:

necrotic and

granulation

tissue,

fibrin slough,

epithelium,

exudate,odor

Kulit sekeliling ulser

Penilaian: warna,

kelembapan, kelembutan

KLASSIFIKASI

• King’s College Foot Classification

• Wagner’s Classification

• University of Texas Classification

KING’S COLLEGE FOOT CLASSIFICATION

• Stage 1: The Normal Foot

• Stage 2: The High Risk Foot

• Stage 3: The Ulcerated Foot

• Stage 4: The Cellulitic Foot

• Stage 5: The Necrotic Foot

• Stage 6: Major Amputation

•Simple classification to use

•Specific management recommended for each stage

• No Risk Factor present: – Neuropathy – Ischemia – Deformity – Callus – Swelling

• One or More Risk Factors present:

• Neuropathy • Peripheral Vascular Disease • Deformity • Callus • Swelling

Stage 1: The Normal Foot

Stage 2: The High Risk Foot

• Skin breakdown and ulceration • No classification as each ulcer must be

assessed on its own merits • Differentiate between neuropathic and

neuroischemic • X-ray newly presenting ulcers for:

– Osteomyelitis – Foreign body – Gas – Charcot changes

• Microbiological control is lost and foot has become cellulitic

• Local infection • Spreading sepsis • Sloughing of soft tissue • Vascular compromise • Blue discolouration

Stage 3: The Ulcerated Foot

Stage 4: The Cellulitic Foot

Gangrene (necrosis)

Type: Dry, Wet

Pain is agonizing and cannot be controlled

Overwhelming infection

Extensive necrosis

Rare in neuropathic

Stage 5: The Necrotic Foot

Stage 6: Major Amputation

UJIAN

• Full Blood Count • Renal profile

• HbA1C (Glycosylated Haemoglobin) - indicator of diabetes control over last 3 months • Culture of wound

• X-rays of the foot and leg, ECG, CXR, Urine

Modul Latihan Perkhidmatan NCD Untuk

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Ankle Brachial Index (ABI)

Ankle systolic pressure measured using a cuff and a handheld continuous wave Doppler Ultra Sound Probe placed over pedal vessels (DP or TP = whichever is higher)

Ankle Systolic Pressure

Brachial Systolic Pressure

ABI: Normal 1 to 1.2

Ischaemia <0.8

Critical Ischaemia <0.5

Adapted from: Norman PE, Eikelboom JW, Hankey GJ. Peripheral arterial disease: prognostic significance and

prevention of atherothrombotic complications. Medical Journal of Australia 2004; 181:150-154. Figure 1, p.151

Ankle-Brachial Index

• Screening: 2004 ADA recommendation

– “Consider” at age 50 years and every 5 years

• Diagnosis:

– Claudication, absent DP/PT pulses, foot ulcer

• Limitations:

– Underestimates severity in calcified arteries

Diabetes Care. 2005;28:2206

Diabetes Care. 2004;27(Suppl 1):S15-S35

Interpretation of the ABI

Interpretation ABI

Normal 0.90-1.30

Mild obstruction 0.70-0.89

Moderate obstruction* 0.40-0.69

Severe obstruction* <0.40

Poorly compressible** >1.30

2° to medial calcification

*Poor ulcer healing with ABI < 0.50

**Further vascular evaluation needed

PRINCIPLES OF TREATMENT

• Debridement of necrotic tissue

• Wound care

• Reduction of plantar pressure (off-loading)

• Treatment of infection

• Vascular management of ischaemia

• Medical management of co morbidities

• Surgical management to reduce or remove bony prominences and / or improve soft tissue cover

• Reduce risk of recurrence

Debridement of necrotic tissues

Removal of all non-viable tissues and slough

• Surgical debridement

• Mechanical debridement (surgical debridement, wet-to-

dry dressings and high- pressure irrigation)

• Enzymatic debridement (topical proteolytic enzymes;

controversial)

• Autolytic debridement (naturally in healthy, moist wound

environment with adequate circulation)

Wound Care

• After debridement, the ulcer is covered to protect

it from trauma and contaminants.

• Moist wound environment will facilitate healing

• Wound size, depth, location, surface and

discharge

Reduction of plantar pressure (Off-loading)

Allow healing

The methods of off-loading include:

• Total non-weight bearing

• Total contact cast (gold standard for neuropathic foot)

• Foot cast or boots

• Removable walking braces with rocker bottom soles

• Total contact orthoses – custom walking braces

• Patellar tendon bearing braces

• Half shoe or wedge shoes

• Healing sandal – surgical shoe with molded insole

• Accommodative dressing: felt, foam, felted-foam, etc

• Shoe cutouts (toe box, medial, lateral or dorsal pressure points).

• Assistive devices: crutches, walker, cane, etc.

Charcot restraint orthotic walker (CROW)

Bottine shoe with a full-contact insole and a rocker bar

with an early pivot point

Depth-inlay soft leather

laced shoe with custom

accommodative pressure-

dissipating foot orthosis

Vascular Management of

Ischaemia

• Vascular reconstruction surgery

• Any clinically suspicious lower extremity

ischaemia should be fully investigated and

corrected before any definitive foot surgery

is contemplated

Surgical Management

• Chronic foot ulcers

– best treated surgically

– removal of infected bone or joints

– metatarsal head resections, partial calcanectomy,

exostectomy, sesamoidectomy and digital arthroplasty

• Structurally deformed foot

– correction of hammertoes, excision of exostoses, bunions

and tendo-achilles lengthening

• Gangrene and ulcers with OM

– Amputation

– goal of treatment is preservation of function, not just

preservation of tissue

– first step in rehabilitation

DIABETIC CHARCOT’S FOOT

• impairment of the efferent sensory input from joint receptors

• progressive destruction of foot architecture

– pathological fracture, joint dislocation and fragmentation of articular cartilage

• Assessment

– Clinical examination

• acute Charcot’s foot will have swelling, erythema, raised skin temperature, joint effusion and bone resorption in an insensate foot

• 75% of patient with Charcot’s foot have some degree of pain in an otherwise insensate foot, thus complicating diagnosis

• in the presence of a concomitant ulcer, Dx of OM may be difficult to rule out

AETIOLOGY • classically due to neuroarthropathy

• hypervascular diabetic limb

– ↑blood flow ↑osteoclastic activiti bone and joint destruction

• ischaemic intrinsic muscles alter loading dynamics of the foot joint instability

• Investigations

– plain X-ray : osteoarthropathy

– white cell count (WBC), ESR : rule out OM

– bone biopsy :

• most specific way of distinguishing between

osteomyelitis and osteoarthropathy.

• pathognomonic biopsy showing neuropathic

osteoarthropathy

• consists of multiple shards of bone and soft

tissue embedded in the deep layers of synovium

Neuropathic Charcot's joint

Osteomyelitis

Goals of Treatment

• interrupt destructive process

• maintain adequate alignment of midfoot and ankle

• early diagnosis

• prevent progression

• Treatment

– Acute stage: immobilization and rest

– Post-acute: protected weight bearing

• After 4-6 months, patients may resume using

their usual footwear

– Surgery : create a stable and plantigrade

foot

• commonly, exostectomies for prominent plantar

(rocker bottom) deformities

• Others: ankle fusion, tibiocalcaneal fusion,

isolated or multiple midfoot fusion and triple arthrodesis

WOUND MANAGEMENT

FACTORS AFFECTING WOUND HEALING

• Systemic

– Age

– Nutrition

– Trauma

– Metabolic diseases

– Immunosuppression

– Connective tissue disorders

– Smoking

– Stress

FACTORS AFFECTING WOUND HEALING

• Local

– Mechanical injury

– Infection

– Edema

– Ischemia//necrotic tissue

– Topical agents

– Ionizing radiation

– Low oxygen tension

– Foreign bodies

Factors that delay the wound healing process

Local Factors

• Continued pressure

• Desiccation and dehydration

• Infection or heavy colonization

• Necrosis

• Incontinence leading to maceration

• Lack of oxygen delivery to the tissues

Systemic Factors

• Old age

• Chronic diseases (e.g DM, anaemia)

• Malnutrition

• Vascular insufficiency

• Immunodefiency

• Smoking

• Stress

• Poor health

Topical Therapy: Principles

• Remove necrotic tissue and foreign bodies or particles

• Identify and eliminate infection

• Obliterate dead space

• Absorb excess exudate

• Maintain a moist wound surface

• Provide thermal insulation

• Protect the healing wound from trauma and bacterial invasion

Doughty, Acute and Chronic Wounds, 1992

Wound Care Product Selection: Other Considerations

• Is wound partial or full thickness?

• Is wound dry or draining?

• Is wound superficial or deep?

• Need to develop treatment protocols based on wound characteristics rather than wound type.

Types of Topical Wound Dressings

• Hydrocolloid dressings

• Hydrogel dressings

• Alginate dressings

• Hydrofiber dressings

• Transparent film dressings

• Foam dressings

• Absorption dressings

• Gauze dressings

• Biologic dressings

• Other

Rehabilitasi Kes Amputasi

• Perlu dimulakan secepat mungkin untuk memaksimumkan tahap pemulihan

• Physiotherapy dan Occupational Therapy yang berkaitan keperluan pesakit boleh menyumbang kepada pemulihan

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Tahap Amputasi dan Rehabilitasi

• Pesakit amputasi ringan boleh dirawat sebagai pesakit luar

• Pesakit tahap sederhana disarankan untuk menerima rawatan rehabilitasi di pusat atau unit rehabilitasi strok

• Pesakit strok tahap teruk disarankan untuk mendapat rawatan jangka panjang di pusat khas rehabilitasi strok.

Modul Latihan Perkhidmatan NCD Untuk Paramedik KKM

TAKE HOME MESSAGE

• Anggota kesihatan perlu mengetahui pesakit yang berisiko mendapat amputasi

• Anggota kesihatan perlu tahu mengesan komplikasi kaki di peringkat awal dan memberi rawatan ulser dan masalah kaki yang lain

• Pemeriksaan kaki perlu dibuat pada kedua-dua belah kaki, termasuk ‘stump’

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Paramedik KKM

SELAMATKAN KAKI PESAKIT ANDA DENGAN MEMBERIKAN RAWATAN

MASALAH-MASALAH KAKI DIABETIK YANG BETUL

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