Mimo że na rynku dostępnych jest wiele opatrunków specjalistycznych, dostosowanych do różnych rodzajów ran, to wielu pacjentów, a także klinicystów, nadal stosuje gazę do zaopatrywania ran. Tymczasem w wielu przypadkach może to zaburzać gojenie. O tym, kiedy gazę można stosować na rany, mówi w rozmowie z FLR mgr Jolanta Dynarska, pielęgniarka, specjalistka w leczeniu ran.
Karolina Rybkowska, Forum Leczenia Ran: Czy tradycyjna gaza może być samodzielnym opatrunkiem na ranę?
Jolanta Dynarska: – Owszem, tradycyjna gaza może być samodzielnym opatrunkiem na ranę, jednak nie w każdym przypadku. Gazy możemy użyć, jeśli brakuje w danym momencie opatrunków specjalistycznych. W możliwie najkrótszym czasie należy ją jednak zmienić na właściwy opatrunek specjalistyczny, dopasowany do stanu danej rany. W przypadku ran ostrych, jeśli musimy wykonać opatrunek uciskowy, użycie gazy jest sposobem na powstrzymanie krwotoku, choć i tu, w mojej ocenie, gaza nie jest najlepszym rozwiązaniem. Gazę stosować powinniśmy jedynie w przypadkach zabezpieczenia dodatkowego na opatrunki specjalistyczne, dedykowane konkretnej sytuacji w ranie.
Kiedy zatem gaza jest bezpieczna w leczeniu ran? Jakim zastosowaniom może służyć?
– W swojej praktyce stosuję gazę podczas każdej wizyty pacjenta. Używam jej do oczyszczania wszelkich zabrudzeń z samej rany i okolicy wokół niej. Poza tym materiał ten podczas debridementu doskonale redukuje ilość urobku, który uda mi się oddzielić od łożyska rany. Gaza służy mi również do oczyszczania moich narzędzi i w końcu do antyseptyki, gdyż zawsze podczas nakładania płynu antyseptycznego wyścielam dość dokładnie dno rany, uwzględniając przy tym wszelkie kieszenie i tunele. Gaza z antyseptykiem wyścielająca ranę w formie przymoczka jest na stan dzisiejszej wiedzy dobrym materiałem, gdyż utrzymuje antyseptyk, a wyciągając ją z rany, można zobaczyć również luźne elementy urobku, które przyczepiły się do niej.
Kiedy nie należy stosować gazy w procesie opatrywania ran?
– Gazy nie można stosować w przypadku między innymi ran z wysiękiem. Tkanina, z której wykonana jest gaza, to splecione nitki materiału, które układają się tak, że tworzą oczka w swojej strukturze. Wysięk z rany przenika przez tę strukturę, wydostaje się poza ranę na zdrową skórę, którą może uszkodzić.
W przypadku wysięku o charakterze gęstej i ropnej wydzieliny dochodzi do obklejenia nitek gazy, a więc tworzy się warstwa, która skutecznie blokuje odpływ wydzieliny. Ponadto pod warstwą tą gromadzi się wciąż produkowany wysięk, który może zaburzać proces gojenia się rany. W procesie leczenia ran bardzo ważne jest zarządzanie wysiękiem, czyli umiejętność utrzymania jego ilości w ranie na takim poziomie, który będzie wspierał gojenie. Gaza uniemożliwia zachowanie tego mechanizmu.
Jakie są konsekwencje nieprawidłowego stosowania gazy na ranę?
– Gaza przywiera do otwartych struktur i powierzchni rany, więc podczas zmiany takiego opatrunku spowodujemy rozrywanie zdrowych tkanek i sprawimy dodatkowy ból pacjentowi. Gaza powoduje również utratę ciepła z rany, ponieważ jej struktury umożliwiają parowanie wysięku. Ponadto materiał ten może pozostawiać włókna w dnie rany, co z pewnością może indukować procesy zapalne. Gaza stosowana w postaci grubych kompresów może powodować ucisk i miejscowe niedokrwienie tkanek. Ponadto gaza nie zabezpiecza łożyska rany przed patogenami ze środowiska zewnętrznego, przez co drobnoustroje mają swobodny dostęp do rany, gdzie mogą się kolonizować.
Dlaczego pomimo dostępności wielu opatrunków specjalistycznych na rynku pacjenci nadal korzystają z tradycyjnej gazy na rany? Z czego to wynika?
– Oczywiście zdarzają się pacjenci, którym na pierwszej wizycie zdejmuję gaziki z ran. Z pewnością jest co najmniej kilka przyczyn stosowania tego materiału jako samodzielnego opatrunku, choć w mojej ocenie jedną z najistotniejszych wciąż pozostaje niska świadomość medyków w tym zakresie. W trakcie pierwszej wizyty pacjenta każdorazowo zbieram dokładny wywiad i analizuję dokumenty medyczne. Niestety często stwierdzam, że wiele działań i zleceń, z którymi przyszedł pacjent, jest niezgodnych z najnowszymi wytycznymi, popartymi badaniami.
Nadal panuje również przekonanie, że opatrunki specjalistyczne są drogie. Zdecydowanie są one jednak znacznie korzystniejsze dla pacjenta, ponieważ skracają czas leczenia, a nierzadko wręcz sprawiają, że całkowite wygojenie rany jest w ogóle możliwe, nawet w przypadku ran trudno gojących się.
W asortymencie opatrunków specjalistycznych dostępnych na naszym rynku znajdziemy takie, które są refundowane. Warto z tego korzystać, dlatego wypisuję swoim pacjentom recepty, by nie dochodziło do problemów ekonomicznych przy zakupie opatrunku. Ponadto, jeżeli walczymy np. o uratowanie nogi pacjenta przed amputacją, to odpowiednie narzędzia w postaci opatrunków specjalistycznych są koniecznością. Uważam, że nie ma ceny za zdrowie i życie ludzkie.
W jaki sposób nowoczesne opatrunki wspierają proces gojenia się ran w odróżnieniu od tradycyjnej gazy?
– Tradycyjna gaza i specjalistyczne opatrunki, cóż, mają się do siebie nijak. Nowoczesne opatrunki mają szerokie spektrum zastosowań w porównaniu do gazy: mogą uwodnić i rozpuścić martwicę, utrzymać wilgotne środowisko, ułatwić procesy autolizy, chronić ranę przed obniżeniem temperatury i przed środowiskiem zewnętrznym. Dzięki specjalistycznym technologiom, które wykorzystywane są w strukturach poszczególnych opatrunków, potrafią one wchłaniać wysięk z dna rany i nasączać się nim jedynie w swojej strukturze, przez co nie dochodzi do kontaktu szkodliwych składowych wysięku z samą raną czy też skórą wokół niej.
Ponadto opatrunki specjalistyczne wspierają angiogenezę i fibrynolizę, stymulują proces napływu do brzegów rany zdrowych komórek. Istnieją też opatrunki, które mają możliwość niszczenia biofilmu czy też uwalniania do niego substancji antyseptycznych. Opatrunki specjalistyczne mają właściwości zmiany ph na kwaśne w dnie rany, a także właściwości hemostatyczne z uwagi na obecność w składzie jonów wapnia, które wpływają na ciśnienie osmotyczne w kapilarach i przyspieszają proces krzepnięcia krwi.
W przypadku ran o intensywnym zapachu wykorzystuję opatrunki, które potrafią go zatrzymać, przez co poprawiają komfort pacjenta i pozwalają na zachowanie godności. Dodam, że dzisiejsze zdobycze nauki w zakresie technologii dają również możliwości wspierania zdrowej ziarniny w jej wzroście poprzez strukturę szkieletu opatrunku, po której wzrasta i którą wchłaniają tkanki pacjenta.
Podsumowując, gaza nie posiada żadnych z wyżej wymienionych możliwości, a jest ich naprawdę bardzo dużo. Wystarczy chcieć pomagać i korzystać z naukowych zdobyczy, tak naprawdę podanych w bardzo prosty sposób, czyli w postaci najnowszych wytycznych i rekomendacjach towarzystw naukowych.
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