Basis Bukti Terkini

Manajemen Luka Diabetik

Dr. Suriadi, RN, AWCS, CHb

Chairman of International Affair: The Muhammadityah Institute of
Nursing - Pontianak
Independent Practice: PKU Muhammadiyah Kitamura Wound Clinic
The Head of Nurse Education Program, Faculty of Medicine, The
University of Tanjung Pura-Pontianak
Prevalensi

Komplikasi diabetes: Infeksi, Perlukaan

dan atau gangren.

Di USA, 45% -83% dari 120.000 pasien di

amputasi dengan kasus Diabetes (Baranoski, S
& Ayello, E.A, 2002).

Amputasi; 15 - 46 kali > pasien yang

bukan diabetes (Reiber, 1995 dan Lavery, 1996).
Tiga faktor penyebab utama ：neuropati,
buruknya sirkulasi dan menurunnya
resistensi terhadap infeksi.
Cont…

 Penyebab utama amputasi adalah perlukaan

pada kaki
 Negara berkembang : 1 dari 6 klien diabetes
akan mengalami luka di kaki
 Statistik pada negara berkembang: buruk
 Masalah kaki menyebabkan paling sering
masuk RS
 Masalah di kaki 15% - 40% di negara
berkembang
sumber : Diabetes & foot care – the facts. Jan 2006 – Diabetes NZ
Manajemen Luka Diebetik

Evidence Based
 Vibration therapy accelerates healing of
Diabetic Foot Ulcer patients

Design
– Prospective randomized control trial was used
Subjects
– Patients with DFU (Neuropathic Ulcer grade II)
Intervention
– Vibration was applied for 15 minutes three times a day
Outcome
– Healing rate and healing period
Analysis
– Kaplan–Meier curves were used to assess the time from the start
of study treatment to the time of reporting of healing events

Sitty S, Elly Nurahmah, Suriadi, 2013

 Results
Healing Rate (n=80)
Variables Experimental Control Group P
Group (n= 40) (n = 40)

Healed Time .002

25% Percentiles, (day, SE) 13 (2.58) 25 (3.42)
50% Percentiles, (day, SE) 15 (7.00) 34 (4.83)
75% Percentiles, (day, SE) 27 (2.51) 56 (5.71)

Relative change per day,

Mean (SD), %/day
Area 6.41 (3.65) 2.72 (1.31) .003

Delta 0.07 (0.36) 0.03 (0.13) .003

The Wilcoxon for continuous variables and Fisher Exact Test for
categorical variables were used.
COMPARISON OF HEALING RATE DURING THE STUDY PERIOD (n=80)

Kaplan-Meier survival estimates, by GROUP

1.00
0.75
0.50
0.25
0.00

0 20 40 60 80
analysis time
GROUP = control GROUP = experiment

A significant difference between the 2 groups confirmed by the log-rank test

(P = .002)
 Comparison of Nitric Oxide between two groups (n=80)

*Pre *Post
Groups intervention intervention P-value #Delta

Control 1,12 (0,19-4,84) 0,86 (0,36-2,60) 0,065 -0,29 ((-4,16)- 2,60)

Intervention 0,92 (0,03-2,97) 2,91 (0,96-6,60) <0,001 1,39 (0,10-6,60)

P-Value 0,502 <0,001 <0,001

*)median (min-mak), Wilcoxon test, # Mann-Whitney test

There was significant difference between pre & post

intervention of NO values for both.
 Application for the DFU patients

Use in clinical setting

The Comparative Study on Stress And No Stress Toward Acceleration
of Wound Healing in DFU Patients

• Design : Comparative study

• Samples : Quota sampling

• Procedures :
1. Identified patients stress and no stress using DASS
42 (Depression Anxiety and Stress Scale).

2. Analysis cortisol serum using COBAS ELEXYCE 411

Rangga Saputra & suriadi .2014 ( STIK Muhammdiyah)

 RESULT
Comparison of the reduction wound area and cortisol level with &
no stress DFU patients (N=13)

Stress No Stress
Parameters Statistic P. Value
Mean (SD) n=7 Mean (SD) n=6

Reduction of Wound % 88.02±44.39 261.59±123.36 t = 3.253 0.008

Cortisol serum level 18.03±6.56 8.71±1.90 t = -3.608 0.004

There was significant difference between two groups (p = < 0.05).

This study postulated that patients who had stress showed high cortisol levels
than patient without stress. Then patients no stress had faster in reduction of
wound area.
 PERBEDAAN EFEKTIFITAS PENCUCIAN LUKA ANTARA
PENGGUNAAN NACL 0,9% DENGAN AIR KANGEN PH 9,5
TERHADAP PENURUNAN JUMLAH BAKTERI PADA
PENDERITA DIABETIC FOOT ULCER DI KLINIK SPESIALIS
PERAWATAN LUKA KITAMURA KALIMANTAN BARAT

RIZAL MUSTAKIM & Suriadi,

2014

12
• Desain •Populasi
penelitia dan
n Quasi Populasi:
sampel
Experiment, Penderita
dengan Diabetic Foot
pendekatan Ulcer
Pre Post Sampel:
Nonequavale Cousative
n test. Sampling

Klinik
Spesialis
Desember Perawatan
20114 Luka Kitamura
Kalimantan
• Waktu Barat
Penelitia
n
 Hasil Responden Menurut Usia

No Umur Jumlah %

1 36- 45 tahun 5 25

2 46 - 55 tahun 7 35

3 56 - 65 tahun 8 40

Jumlah 20 100

14
 Perbedaan Jumlah Bakteri
Antarr Group
Variab Sebelum Sesudah t P Value
el Mean ± SD Mean ± SD

NaCl 13.552.000±8.575.634,476 9.868.000±7.503.991,234 1,24 ,246

1

pH 9,5 22.997.000±10.265.088,088 7.493.400±5.596.003,908 2,43 ,038

7

15
NaCl 0,9%

16
NaCl 0,9%

17
NaCl 0,9%

18
Air Kangen pH 9,5

19
Air Kangen pH 9,5

20
Air Kangen pH 9,5

21
 Kesimpulan
Pencucian luka dengan menggunakan NaCl 0,9%
didapatkan rata-rata mengalami penurunan jumlah
bakteri secara angka. Namun tidak berbeda
secara signifikan pada perhitungan uji statistik.
Pencucian luka dengan menggunakan Air Kangen
pH 9,5 didapatkan rata-rata mengalami penurunan
jumlah bakteri secara angka dan signifikan pada
perhitungan uji statistik.
Ada perbedaan efektivitas pencucian luka antara
penggunaan NaCl 0,9% dengan Air Kangen pH
9,5 terhadap peurunan jumlah bakteri..p =0,038.

22
 PENGARUH PENGGUNAAN ELECTRO
MUSCULAR STIMULATION (VEINOPLUS
ARTERIAL) TERHADAP PENYEMBUHAN
LUKA KAKI DIABETES

SUKARNI & SURIADI, 2014

Penelitian eksperimen murni dengan desain penelitian yang digunakan
adalah randomized clinical trial (RCT), pre dan post test kontrol group

Terdiri atas kelompok intervensi dan kontrol. Kelompok kontrol

menggunakan perawatan luka standar dan kelompok intervensi
menggunakan perawatan luka standar ditambah dengan EMS
 Perbedaan rata-rata
Kelompok n Rata-rata±SB (IK 95%) p

Intervensi 16 0.2113±0.16239
0.18188 (0.28102-0.08273) 0.010
Kontrol 16 0.0294±0.10649

Uji t tidak berpasangan

Uji t tidak berpasangan
 Perbedaan
Variabel n Rata-rata±SB IK 95% p
Rata-rata±SB

Sebelum 27.25±9.504
12.839-
16 8.813±7.556 0.000
18.44±7.211 4.786
Setelah

Uji t berpasangan
 Perbedaan
Variabel n Rata-rata±SB IK 95% p
Rata-rata±SB

Sebelum 27.63±8.951 Uji t berpasangan

16 16.875±8.007 21.142-12.608 0.000

Setelah 10.75±5.905

Uji Wilcoxon
 Perbedaan rata-rata
Variabel Kelompok n Rata-rata±SB p
(IK 95%)

Intervensi 16 27.63±8.951
Sebelum 0.375 (7.041-(-6.291)) 0.970
Kontrol 16 27.25±9.504

Intervensi 16 10.75±5.905
-7.688 (-2.929-(-
Setelah 0.003
12.446))
Kontrol 16 18.44±7.211
 FACTORS AFFECTING THE OCCURENCE
OF DIABETIC FOOT ULCER IN TYPE 2
DIABETES MELLITUS PATIENTS IN
“KITAMURA” SPECIALIST CLINIC OF
WOUND, STOMA, AND INCONTINENCE
CARE, PONTIANAK, 2014

Author : Adam Astrada, S. Kep

Suriadi, MSN, AWCS, PhD
Ns. Arina Nurfianti, M. Kep
 FACTORS AFFECTING THE OCCURENCE OF DIABETIC FOOT
ULCER IN TYPE 2 DIABETES MELLITUS PATIENTS IN
“KITAMURA” SPECIALIST CLINIC OF WOUND, STOMA, AND
INCONTINENCE CARE, PONTIANAK IN 2014

Diet Design: Cross-sectional

pattern approach
Medicati
on
Smoking Sampling method:
behaviour Accidental
Physical
DF activity
Follow-
Data collection:
Physical
U up
Foot care
examination
and Interview
(questionnaire)
Psychological
aspect
Social
Data analysis: SPSS 16.0
interaction
Spiritual Univariate,
aspect Bivariate(Chi-square), &
Race/ethnicity Multivariate (binary logistic
regression)
 Sample
Total: 88
respondents
DFU: 42 respondents Without DFU: 46 respondents

Inclusion criteria: Inclusion criteria:

• Age : 30 • Age : 30
– 69 y/o – 69 y/o
• Diagnose : • Diagnose :
type 2 DM + type 2 DM
DFU • Wound history : >120 days
• Wound history : ≤120 days

Exclusion criteria:
• Comorbidity involving ≥ 3
main organs
• Patients with mental illness,
conciousness alteration, or
cognitive problems.
 Instrument 2: Questionnaire
(face and construct validities, α Cronbach ≥ 0.6)
The Cancer Council Victoria: Food Frequency
Diet Questionnaire
Morisky 8-item Medication Adherence
pattern Medication
Questionnaire
Glover Nilsson Smoking Behavioral
Smoking Questionnaire
behaviour Global Physical Activity
Physical Questionnaire
DF activity
Follow-
Schmitt et al.
2013
Desalu et al,
U up
Foot care 2011
Self-Efficacy Assessment Tool and
Assessing Psychosocial Distress in
Psychological
Diabetes
aspect Interpersonal Support Evaluation List
Social
(short version)
interaction Multidimentional Measurement of
Spiritual
aspect Religiousness/Spirituality for Use in Health
Race/ethnicity Research
Included in demographic form
 Multivariate
Variabel p OR 95% CI
Smoking 0,007 0,110 0,22 – 0,542
behaviour
Foot care 0,028 5,566 1,202 –
25,783
Psychological 0,008 0,110 0,021 – 0,568
aspect
Social 0,018 7,807 1,419 –
interaction 42,960
Malays 0,001 0,029 0,004 – 0,225
Javanese 0,001 0,021 0,002 – 0,206
Trends:
• Diabetic patients with less social interaction and lack of foot
care are 7 – 8 times and 5 – 6 times more prone to experience
DFU, respectively, after influenced by smoking, psychological
aspect, and ethnicity.
Translation of Evidence: wound
healing
Here is where the scientific evidence is
considered in the context of clinical
expertise and values, thus resulting in
clinical practice guidelines, best practices,
protocols, standards or clinical pathways.
KITAMURA WOUND CLINIC
Protocol for Diabetic Foot Ulcer
(Advanced wound care management)
Basic DM Management DFU Classification (1-IV)
Five Vilar of DM Management: BP, B. Glucose,
Diet, Activity, Health Education
Type of DFUs
Screening Diabetic Foot Assessment

Advanced wound care management

Physical /foot assessment

Mild tissue damage Wound type assessment Severe tissue damage

Thermography
Cleansing

Conservative Vibration 壊死組織の除去

Debridement
EMS
適切なドレッシング
Dressing: trad./modern

Assessment wound healing NPWT

Infection
DFU heal
Prevention of amputation
Detection of Skin Layers by
Ultrasound Device

10MHz
 Suspected DTI？
①

②
③

① Discontinuous ② ③
layer

Edema
 Evidence –Based Approach
in Clinical Practice

Best available Environment

research evidence and
organizational
Population context
characteristics, Decision
needs, values and
preferences Making
Resources,
including
practitioner
expertise
THANK YOU