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Leczenie rany urazowej podudzia z ubytkiem skórnym – case study i zdjęcia

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Rany powstałe w wyniku złamań i innych urazów narażone są często na trudności w gojeniu i powikłania. Dr n. med. Krzysztof Karaś w rozmowie z Forum Leczenia Ran przedstawia przypadek pacjentki, u której trudno gojąca się rana powstała w następstwie złamania rzepki. Dzięki zastosowaniu specjalistycznych opatrunków uzyskano wygojenie rany, a pacjentka mogła zakończyć leczenie w poradni.

Opis przypadku

59-letnia pacjentka została przekierowana z poradni ortopedycznej do poradni chirurgicznej z powodu źle gojącej się rany podudzia lewego. W wywiadzie: hospitalizacja na oddziale ortopedii i operacja z powodu złamania rzepki. Do urazu doszło 14 dni przed wizytą pacjentki w poradni. Uraz powstał w mechanizmie upadku.

W wywiadzie lekarskim stwierdzono choroby współistniejące w postaci nadciśnienia tętniczego oraz nikotynizmu.

Charakterystyka rany

Rana obejmująca przednią powierzchnię podudzia lewego, pokryta strupem w 1/5, w 4/5 skóra wysuszona, niedokrwiony płat skórny, pod którym znajdował się wysięk surowiczo-ropny – brak zdjęcia początkowego. Niewielki stan zapalny ograniczony do brzegów rany. Pacjentka przyjmowała antybiotyk – zgodny z zaleceniami poszpitalnymi. Widoczny obrzęk pooperacyjny. Chora przyjechała na wózku inwalidzkim z założoną ortezą kolanową – chodzi, zaczyna rehabilitację. W wywiadzie nie zgłoszono zaburzeń neurologicznych.

Leczenie początkowe

Początkowe postępowanie w poradni objęło następujące czynności: zmiany martwicze, w tym niedokrwiony płat skórny, zostały wycięte. Głębsze warstwy rany oczyszczono ze zdewitalizowanej tkanki oraz zmian ropnych. Ranę zdezynfekowano i przemyto oraz zastosowano przymoczki z płynu antyseptycznego. Na ranę zastosowano połączenie opatrunków AQUACEL® Ag+ Extra™ oraz AQUACEL® Foam. Ponadto zastosowano terapię kompresyjną w postaci bandażowania kończyny opaskami elastycznymi od palców do uda.

Dalszy przebieg leczenia

Wizyty kontrolne odbywały się w przyszpitalnej poradni co 7 dni. W pierwszych dwóch tygodniach leczenia (21.10-02.11) obserwowano znaczny wysięk surowiczy z rany. Na wizytach kontrolnych rana była poddawana oczyszczaniu, wycinaniu zdewitalizowanej tkanki oraz dezynfekcji płynem antyseptycznym. Stosowano opatrunki AQUACEL® Ag+ Extra™ oraz AQUACEL® Foam (17,5 cm x 17,5 cm). Zmiany opatrunków następowały co 2-3 dni.

26.10.2020 r. Rana przed oczyszczeniem.

Rana po oczyszczeniu.

02.11.2020 r. Rana przed oczyszczeniem.

Rana po oczyszczeniu.

Po 4 tygodniach leczenia (23.11) zaobserwowano znaczną redukcję wysięku surowiczego. Na wizycie kontrolnej rana ponownie została oczyszczona i wyłyżeczkowana. Wycięto zdewitalizowaną tkankę i zdezynfekowano ranę płynem antyseptycznym. Nadal stosowano opatrunki AQUACEL® Ag+ Extra™ oraz AQUACEL® Foam. Opatrunki były zmieniane co 3 dni.

23.11.2020 r. Rana po oczyszczeniu.

Po 5 tygodniach leczenia (07.12) zaobserwowano znaczne zmniejszenie powierzchni rany bez cech infekcji, a także widoczne naskórkowanie brzeżne. Rana została oczyszczona z włóknika i zdezynfekowana płynem antyseptycznym. Na ranę stosowano opatrunek AQUACEL ® Ag Foam, zmieniany w odstępach 3-dniowych.

07.12.2020 r. Rana przed oczyszczeniem.

Po dwóch miesiącach terapii zaobserwowano gojenie rany. W centralnej części pozostała niewielka ziarninująca rana. Nie stwierdzono wysięku. Rana została poddana oczyszczeniu i wycięciu nadmiaru naskórka oraz zdezynfekowana płynem antyseptycznym. Na ranę nadal stosowano opatrunek AQUACEL ® Ag Foam, zmieniany co 5 dni. Na tym etapie zakończono leczenie w poradni.

21.12.2020 r. Rana przed oczyszczeniem.

Leczenie trwało od 21.10.2020 r. do 21.12.2020 r. W ciągu całego okresu leczenia w poradni opatrunki były zmieniane 21 razy.

Wnioski z leczenia

Jak wskazuje dr n. med. Krzysztof Karaś, skuteczna terapia trudno gojących się owrzodzeń wymaga uwzględnienia wielu czynników, w tym przede wszystkim odpowiednio dobranych do właściwości rany specjalistycznych opatrunków oraz celowanej antybiotykoterapii. Aby uzyskać wygojenie, rana powinna być regularnie oczyszczana. Należy również zadbać o odpowiednią higienę rany. Istotne jest także leczenie wspomagające w postaci kompresjoterapii. Jak tłumaczy ekspert, bandażowanie kończyny usuwa wysięk z tkanki podskórnej, co powoduje odtworzenie prawidłowej struktury skóry i tkanki podskórnej, umożliwiając ich „zlepienie”, a w konsekwencji wygojenie rany.

Ekspert podkreśla również, że odpowiedni dobór opatrunków jest kluczowy dla skuteczności leczenia. W omawianym przypadku ze względu na obfity wysięk oraz zanieczyszczenie rany najlepszym wyborem było połączenie opatrunków AQUACEL® Ag+ Extra™ i AQUACEL® Foam. Opatrunki te zapewniły holistyczną opiekę nad raną i odpowiadały na wszystkie problemy terapeutyczne.

Jak wyjaśnia dr n. med. Krzysztof Karaś, AQUACEL® Ag+ Extra™ to opatrunek zawierający srebro jonowe, który wykazuje skuteczne działanie przeciwdrobnoustrojowe, a jednocześnie stwarza korzystne środowisko gojenia. Opatrunek sekwestruje drobnoustroje i zatrzymuje je w swojej strukturze, co zapobiega nadkażaniu. Dzięki zastosowaniu w opatrunku technologii Więcej niż srebro™ opatrunek skutecznie przerywa strukturę biofilmu i zapobiega jego odnawianiu.

Dzięki technologii Hydrofiber® opatrunek AQUACEL® Foam wykazuje natomiast właściwości chłonne. Opatrunek skutecznie wchłania nadmiar wysięku i zapobiega wydostawaniu się wydzieliny poza łożysko rany. Dzięki temu zapobiega maceracji, uszkodzeniom i podrażnieniom skóry wokół rany i jednocześnie niweluje nieprzyjemny zapach. W omawianym przypadku opatrunek zapobiegł wydostawaniu się wysięku poza ranę nawet pomimo ucisku ortezy oraz znacznej ilości wydzieliny z rany.

Zastosowanie opatrunków AQUACEL® Ag+ Extra™ oraz AQUACEL® Foam w połączeniu pozwoliło na zmniejszenie częstotliwości zmiany opatrunków, a w konsekwencji na zmniejszenie kosztów leczenia i poprawę jakości życia pacjentki.

Jak podkreśla dr n. med. Krzysztof Karaś, zestawienie opatrunków AQUACEL® Ag+ Extra™ i AQUACEL® Foam może być stosowane zarówno na rany płytkie, takie jak np. owrzodzenia lub oparzenia, jak i na rany głębokie, w tym penetrujące w głąb tkanki odleżyny i rany napowięziowe pooperacyjne. Jak podkreśla ekspert, leczenie tymi opatrunkami daje w wielu przypadkach bardzo dobre rezultaty.

Artykuł powstał we współpracy z firmą ConvaTec.

Dr n. med. Krzysztof Karaś – specjalista w dziedzinie chirurgii ogólnej. Na co dzień pracuje na Oddziale Chirurgii w Szpitalu Pomnik Chrztu Polski w Gnieźnie.

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