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Czy da się wygoić owrzodzenie stopy w ZSC w 56 dni? Case study i zdjęcia

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Terapia owrzodzeń i ran trudno gojących się wymaga regularnego postępowania terapeutycznego, zgodnego ze strategią TIME. Bardzo istotne dla sukcesu terapii jest stosowanie opatrunków specjalistycznych oraz preparatów, które zapewnią optymalne środowisko gojenia oraz kontrolę obciążenia mikrobiologicznego, infekcji oraz stanu zapalnego.

Opis przypadku dzięki uprzejmości mgr Magdaleny Mróz

Podologia i Leczenie Ran – eMMed – Magdalena Mróz

Opis przypadku

Kobieta w wieku 75 lat, stopa cukrzycowa neuropatyczna, prawa, po amputacji palucha. Przetoka pomiędzy podeszwą stopy w okolicy 4. głowy kości śródstopia a przestrzenią między 4. a 5. paliczkiem. Obecny wyciek treści surowiczo-krwistej. Rana na podeszwie stopy o średnicy 1,5 cm. Łożysko rany z ziarniną. Obrzęk grzbietowej części stopy. ABI kończyny prawej 1.

23.09.2020 r. Stan rany przed rozpoczęciem leczenia.

Postępowanie terapeutyczne – strategia TIME

Terapia owrzodzeń i ran trudno gojących się wymaga regularnego postępowania terapeutycznego, zgodnego z strategią TIME. Podstawą terapii są następujące procedury: regularne oczyszczanie łożyska rany (etap T – Tissue debridement), kontrola obciążenia mikrobiologicznego, infekcji i zapalenia (etap I – Infection and inflammation control), zarządzanie raną w optymalnie wilgotnym środowisku (etap M – Moisture balance) oraz pielęgnacja brzegów rany i wspieranie procesu naskórkowania, czyli etap E (Edges, epidermization).

W opisanym przypadku w ramach strategii TIME w pielęgnacji rany wdrożono następujące działania:

Etap T – przeprowadzono łyżeczkowanie przetoki, usunięto hiperkeratozy z podeszwy stopy, przetokę przepłukano preparatem Granudacyn®.

Etap I – zastosowano płukanie rany bezpiecznym produktem o szerokim spektrum działania bójczego Granudacyn®. Produktu nie trzeba wypłukiwać z rany. Jako sączek do przetoki zastosowano Exufiber® Ag+– opatrunek z siarczanem srebra, który następnie zabezpieczano pianką poliuretanową z siarczanem srebra i węglem aktywowanym (Mepilex® Ag).

Etap M – odpowiednio dobrany opatrunek  Exufiber® Ag+ pozwolił prawidłowo zarządzić wilgotnym środowiskiem rany. Włókna alkoholu poliwinylowego wykazują wysoką chłonność i mają zdolność zatrzymania wysięku, dzięki czemu tkanki w przetoce oraz na podeszwie nie były wyeksponowane na działanie wydzieliny. Warstwa kontaktowa z miękkiego silikonu Safetac zmniejsza ryzyko maceracji do minimum.

Etap E – usunięto hiperkeratozy z brzegów rany. Skórę wokół natłuszczano za pomocą maści Epaderm®.

Całość mocowano za pomocą bandaża mocującego. Zmiana opatrunku następowała co 2-3 dni.

Postępy w leczeniu

Przetokę płukano preparatem Granudacyn®. Jako sączek do przetoki stosowano opatrunek Exufiber® Ag+, który następnie zabezpieczano opatrunkiem wtórnym Mepilex® Ag. Całość mocowano bandażem. Zmiana opatrunku następowała co 2-3 dni.

Po trzech tygodniach terapii uzyskano wyraźne zmniejszenie średnicy rany na podeszwie stopy: z 1,5 cm do 0,8 cm średnicy (ok. 50%). Minimalna ilość treści surowiczej. Brak obrzęku stopy. Ziarnina czysta w dnie.

Stan rany po trzech tygodniach terapii.

Podczas wizyty kontrolnej w dniu 17.11.2020 r. stwierdzono całkowite wygojenie przetoki. Zarówno wlot, jak i wylot przetoki zostały całkowicie objęte naskórkiem. Pacjentce przekazano zalecenia końcowe w ramach profilaktyki ZSC.

Stan rany w dniu 17.11.2020 r.

Efekt terapii na wagę złota

W terapii ran z cechami infekcji szczególnie ważnym aspektem jest płukanie rany za pomocą bezpiecznego produktu o działaniu przeciwdrobnoustrojowym. Takim produktem jest np. roztwór Granudacyn®. Równie istotne jest stosowanie opatrunków specjalistycznych o właściwościach antybakteryjnych, które pomogą zwalczyć infekcję oraz kontrolować obciążenie mikrobiologiczne w łożysku rany. Takimi właściwościami charakteryzuje się żelujący opatrunek włóknisty Exufiber® Ag+. Dzięki zawartości siarczanu srebra opatrunek wykazuje działanie bójcze wobec bakterii Gram-ujemnych i Gram-dodatnich, w tym również szczepów opornych na antybiotyki, już po 30 minutach od aplikacji. Działanie bójcze utrzymuje się nawet do 7 dni. Opatrunek Exufiber® Ag+ jest zalecany przez międzynarodowe grupy eksperckie jako element postępowania przeciwbiofilmowego, uzupełniającego strategię TIME.

Opatrunek specjalistyczny stosowany w leczeniu ran trudno gojących się powinien ponadto charakteryzować się wysoką absorpcją i retencją, co ograniczy ryzyko przesiąkania wysięku przez opatrunek i maceracji tkanek. Jest to niezwykle ważne w czasach ograniczonego dostępu pacjentów do specjalisty. Właściwości te również wykazuje opatrunek Exufiber® Ag+. Cechuje go spójna struktura, dzięki której opatrunek można łatwo wyjąć w jednym kawałku nawet z głębokiej przetoki. Co więcej, opatrunek ten wykazuje potwierdzone w badaniach in vitro właściwości przekazywania wysięku do opatrunku wtórnego.

W opisanym przypadku dzięki zastosowaniu roztworu Granudacyn® oraz opatrunków Exufiber® Ag+ i Mepilex® Ag infekcja została opanowana po 33 dniach terapii i uzyskano pełne wygojenie rany.

Wnioski

Terapia owrzodzeń w czasach pandemii może być utrudniona ze względu na rzadsze wizyty pacjentów w gabinecie chirurgicznym. Dlatego też poza edukacją pacjenta i jego opiekunów niezwykle ważne jest stosowanie w terapii bezpiecznych i skutecznych rozwiązań: produktów do płukania ran Granudacyn® oraz specjalistycznych opatrunków z siarczanem srebra, takich jak Exufiber® Ag+, których stosowanie daje efekty na wagę złota.

Źródła:

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