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Odleżyna typu TB-TTI – rana poprzedzająca zgon pacjenta. Wywiad z ekspertką

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Odleżyna typu TB-TTI to drugi obok odleżyny Kennedy typ ran występujących u pacjentów w stanie agonalnym. Mgr Anna Wójcik, pielęgniarka specjalizująca się w leczeniu ran, w rozmowie z FLR wyjaśnia, jakie są czynniki powstania tego rodzaju rany, czym się ona charakteryzuje oraz jak przebiega leczenie.

Marta Bogucka, ForumLeczeniaRan.pl: U pacjentów z jakich grup może wystąpić odleżyna typu TB-TTI?

Mgr Anna Wójcik: Odleżyny typu TB-TTI (ang. Trombley-Brennan terminal tissue injuries), podobnie jak odleżyny KTU (ang. Kennedy Terminal Ulcer), występują u chorych w stanie terminalno-agonalnym, u których organizm jest na etapie wyniszczenia (kacheksji). Pojawienie się tego rodzaju rany jest wynikiem rozpoczęcia procesu umierania.

Jaka jest patogeneza tego rodzaju ran?

Odleżyny typu TB-TTI są skutkiem postępującej niewydolności wielonarządowej, która prowadzi do gromadzenia metabolitów i substancji toksycznych. Substancje te nie mogą być dostatecznie eliminowane przez układy krwionośny, wydalniczy i oddechowy.

Do powstania tego rodzaju ran predysponuje również starczy wiek, ponieważ wiążą się z tym zmiany w strukturze skóry: ulega ona ścieńczeniu, zanika tkanka podskórna, zmniejsza się elastyczność skóry. Występują również zaburzenia świadomości i wynikający z nich deficyt samoopieki.

Odleżyny poprzedzające śmierć pacjenta powstają na skutek innego mechanizmu niż „standardowe” odleżyny. Nie muszą być związane z urazem ciśnieniowym. W przypadku zwykłej odleżyny po wdrożeniu elementów profilaktyki często widoczna jest poprawa kondycji skóry. Odleżyny typu TB-TTI i Kennedy nie wykazują natomiast poprawy pomimo zastosowania działań leczniczych.

Należy podkreślić, że powstanie tego rodzaju ran nie jest wynikiem zaniedbania ze strony personelu medycznego lub opiekunów osoby chorej. Są one skutkiem procesu umierania. Z tego względu część ekspertów określa je jako odleżyny nie do uniknięcia, mając na uwadze, że im dłużej trwa proces umierania, tym ryzyko wystąpienia tego rodzaju ran jest wyższe.

Czym charakteryzuje się obraz kliniczny odleżyn typu TB-TTI i Kennedy?

Cechą charakterystyczną odleżyn typu TB-TTI i Kennedy jest ich nagły rozwój. Zgon pacjenta następuje w ciągu zaledwie godzin lub dni od czasu pojawienia się zmian.

Odleżyny tego rodzaju przyjmują początkowo postać różowych lub fioletowych przebarwień przypominających siniaki (podminowanie skóry). Mogą mieć kształt skrzydeł motyla lub wydłużonych pręg zlokalizowanych na kończynach dolnych lub na brzuchu. Cechą odróżniającą odleżyny typu TB-TTI od odleżyn Kennedy jest to, że nie występuje w ich przypadku piorunująca progresja. Skóra pozostaje nienaruszona i nie dochodzi do głębszej degradacji tkanek. Zwiększa się natomiast powierzchnia zmian chorobowych.

W jakich obszarach ciała może się rozwinąć odleżyna typu TB-TTI?

Odleżyna typu TB- TTI powstaje najczęściej w okolicy żeber, wyrostków kolczystych kręgów, łokci oraz podudzi. Co istotne, mogą się rozwinąć w obszarze ciała, który nie ulega żadnemu naciskowi. Ze względu na specyficzną lokalizację działania związane z raną są ograniczone. Zarządzanie raną polega w tym przypadku na możliwie jak najdłuższym utrzymaniu martwiczego, niezakażonego strupa (z wykorzystaniem opatrunków na bazie PVP–I), który stanowi barierę przed infekcją i odsłonięciem wrażliwych struktur anatomicznych. W przypadku wycieku ropnej treści ranę należy zdrenować i oczyścić według wybranego protokołu.

Czy leczenie tego rodzaju ran przebiega według standardowych protokołów przewidzianych dla ran trudno gojących się? Czy możliwe jest ich wyleczenie?

Ze względu na zwolnione procesy metaboliczne oraz upośledzoną perfuzję tkankową spowodowaną krańcową niewydolnością krążenia, która wpływa na niedotlenienie tkanek, odleżyny typu TB-TTI i Kennedy określa się jako rany nie do wyleczenia.

Rekomendowanym działaniem jest wdrażanie protokołu zgodnego z akronimem SPECIAL, w którym ograniczamy się do zarządzania raną, poprawy jakości życia pacjenta oraz zapewnienia możliwie najwyższej jakości opieki. Akronim SPECIAL obejmuje następujące działania:

S – stabilizacja rany,

P – zapobieganie nowym ranom,

E– eliminacja nieprzyjemnego zapachu,

C– kontrola bólu,

I – profilaktyka infekcji,

A– stosowanie opatrunków aktywnych,

L – zmniejszenie częstości zmiany opatrunków.

Czy w przypadku tego rodzaju ran zasadne jest stosowanie zasad profilaktyki przeciwodleżynowej? Czy odleżyny typu TB-TTI są możliwe do uniknięcia?

Występowanie odleżyn poprzedzających śmierć pacjenta jest częste. Oceniam to zarówno na podstawie analizy literatury, jak i własnych doświadczeń z praktyki klinicznej.

Zmniejszenie ryzyka wystąpienia tego rodzaju ran jest możliwe, jeżeli działania prewencyjne zostaną wdrożone przez personel medyczny w okresie preterminalnym. Dotyczy to głównie utrzymania prawidłowego stanu odżywienia i nawodnienia, kontroli funkcji nerek i kondycji skóry, działań fizjoterapeutycznych, odciążenia, pielęgnacji skóry.

Jakie znaczenie mają te działania dla prewencji ran?

Posiłki o niskiej jakości odżywczej oraz ograniczenia ruchu spowodowane niekontrolowanym bólem przewlekłym lub stanem zapalnym predysponują do utraty masy mięśniowej, co z kolei zwiększa ryzyko wystąpienia ran.

Dlatego tak istotne jest, by odpowiednio wcześnie wdrożyć procedury profilaktyczne, a następnie prowadzić ukierunkowane, indywidualne postępowanie pielęgnacyjne, zgodne z rekomendacjami towarzystw naukowych. Istotna jest również edukacja rodziny i opiekunów pacjenta, ponieważ wpływa ona na poprawę jakości życia chorego w okresie terminalnym.

mgr pielęgniarstwa Anna Wójcik
Uniwersytet Rzeszowski, Instytut Nauk o Zdrowiu
Poradnia Leczenia Ran Szpital Specjalistyczny Podkarpacki Ośrodek Onkologiczny w Brzozowie

konsultacja: dr hab. n. o zdr. Dariusz Bazaliński, spec. pielęgniarstwa chirurgicznego i ratunkowego, prof. Uniwersytetu Rzeszowskiego w Kolegium Nauk Medycznych

Bibliografia:

  1. Kennedy KL. Kennedy Terminal Ulcer. In: Milne C, Corbett L, Dubec D, eds. Wound, Ostomy and Continence Nursing Secrets. Philadelphia, PA: Hanley & Belfus, Inc; 2003:198–199.
  2. Trombley K, Brennan MR, Thomas L, Kline M. Prelude to death or practice failure? Trombley-Brennan terminal tissue injuries. Am J Hosp Palliat Care. 2012; 29(7):541-545
  3. Bazaliński D, Szymańska P, Szewczyk TM. Odleżyny pięt w świetle wytycznych światowych (EPUAP/NPIAP) i doświadczeń własnych. Przegląd piśmiennictwa. Leczenie Ran 2020; 17 (4): 185–193;
  4. Alvarez OM, Kalinski C, Nusbaum J, Hernandez L, Pappous E, Kyriannis C, Parker R, Chrzanowski G, Comfort CP. Incorporating wound healing strategies to improve palliation (symptom management) in patients with chronic wounds. J Palliat Med 2007; 10 (5): 1161–1189.;
  5. Szymańska P., Wójcik A., Bazaliński D. Leppert W.: Zarządzanie raną w obrębie pięt jako element całościowej opieki nad chorym u kresu życia – przegląd literatury i doświadczenia własne. Medycyna Paliatywna. 2021; (13) 3; 112-123

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