Point-of-care in Wound Healing

APLIKASI KLINIS TEKNOLOGI

WOUND BLOTTING, ULTRASONOGRAFI DAN TERMOGRAFI

Adam Astrada, MHS, RN, CNS

PhD candidate

Department of Wound Care Management

Graduate School of Medicine
The University of Tokyo
Disclaimer

Pemateri dan materi yang disampaikan tidak memiliki hubungan

maupun ketertarikan finansial dengan sponsor maupun terhadap
produk yang ditampilkan dalam webinar ini
Objectives

• Memahami peran biofilm dalam penyembuhan luka

• Memahami prinsip teknologi wound blotting sebagai alat
deteksi biofilm yang objektif
• Mengenal dan memahami prinsip dan peran
ultrasonografi sebagai alat penunjang dalam perawatan
dan prognosis penyembuhan luka
• Mengenal dan memahami prinsip dan peran termografi
sebagai alat penunjang dalam prognosis perawatan luka
 Mengapa luka menjadi kronik?
Luka kronik: luka yang menggalami kegagalan dalam melalui proses normal
penyembuhan sesuai dengan urutan dan waktu yang ditentukan (Frykberk, 2015)
Karakter umum: peningkatan proinflmatory sitokin, protease, reactive oxygen
species, sel scenesens, infeksi menetap/berulang, dan defisiensi sel punca (Frykberk, 2015)

78% luka kronik memiliki biofilm (Malone, 2017)

Biofilm mencegah sel imun untuk

memusnahkan bakteri menyebabkan
infeksi berulang dan luka menjadi
kronik
Ilustrasi: Adam Astrada (Percival et al., 2015; Römling et al., 2012; Vyas et al., 2016)

(1) Robert G. Frykberg and Jaminelli Banks.Advances in Wound Care.Sep 2015.560-582.http://doi.org/10.1089/wound.2015.0635

(2) Malone M, Bjarnsholt T, Mcbain AJ, James G, Stoodley P, Leaper D, et al. The prevalence of biofilms in chronic wounds: a systematic review and meta-analysis of published data. J Wound Care. 2017;26(1):20–
5.
(3) Percival SL, Vuotto C, Donelli G, Lipsky BA. Biofilms and wounds: An identification algorithm and potential treatment options. Adv wound care. 2015;4(7):389–97
(4) Römling U, Balsalobre C. Biofilm infections, their resilience to therapy and innovative treatment strategies. J Intern Med. 2012;272(6):541–61.
(5) Vyas KS, Wong LK. Detection of Biofilm in Wounds as an Early Indicator for Risk for Tissue Infection and Wound Chronicity. Ann Plast Surg. 2016;76(1):127–31.
Infeksi dan biofilm

Critical
Contamination Colonization Infection
colonization
Free floating growth Biofilm (Phillips et al., 2008)

Infection starts
from here
 Kekeliruan umum
mengenai biofilm

• Bisa dilihat dengan mata

telanjang (bahkan hanyan dengan
ketebalan100 μm?)

• Berbentuk seperti “film”

transparan

(Metcalf, 2014)
Ilustrasi: Adam Astrada

Distribusi biofilm dalam jaringan luka

Metcalf DG, Bowler PG, Hurlow J. A clinical algorithm for wound biofilm identification. J Wound Care. 2014;23(1):137–42.
 “Gold standard” in biofilm detection: microscopic
observation

Kelemahan:
• Invasif ➔ memerlukan biopsi
• Prosedur yang kompleks
• Memakan biaya banyak

Medeteksi hanya bagian kecil

dari woundbed luka yang luas (Hurlow et. al., 2016)

Wu, Yuank-Kun et al. Biofilms in chronic wounds: Pathogenesis and Diagnosis. Trends in Biotechnology. 2019;37(5):505-517. https://doi.org/10.1016/j.tibtech.2018.10.011
Hurlow, J et al. Clinical investigation of biofilm in non-healing wounds by high resolution microscopy techniques. J Wound Care; 2016: 25. Sup 9.
Wound blotting
Konsep dan terapannya
Prinsip wound blotting
Membran

Wound bed

Deteksi biofilm dapat dilakukan secara non-invasif, mudah and cepat

hanya dalam 2 menit
Predictive validity wound blotting dalam peningkatan jaringan slough (Nakagami, 2017)

Luka decubitus tampak bersih Biofilm (+) Luka satu minggu kemudian

Nakagami, G et al. Biofilm detection by wound blotting can predict slough development in pressure ulcers: A prospective observational study. Wound Repair and
regeneration. 2017; 25(1): 131-138. DOI:10.1111/wrr.12505
 Validitas teknologi wound blotting: in vivo Table 1A. Biofilm identification by histological analysis
and wound blotting with ruthenium red staining
Table 2A. Pressure ulcer patient characte
Patient characteristics (n = 9)
Biofilm histological analysis Female 5
Deteksi biofilm melalui
Ruthenium Red wound blotting di
+ - Total Age, years 61
permukaan
+
luka
8 0 8 Disease*
Wound
blotting Neurology 4
- 1 1 2
Deteksi biofilm melalui
Total
ektraksi
9
utuh 1wound10bed Urology 4
Respiratory 3
melalui native polyacrylamide gel electrophoresis
Oncology 3
Table 1B. Biofilm identification by histological analysis
and wound blotting with alcian blue staining Others

Biofilm histological analysis *multiple comorbidities. n (%), mean (standar

Alcian Blue Table 2B. Wound characteristics
+ - Total
Wound characteristics (n = 17)
Wound + 9 1 10
Wound size, cm2 13.5
blotting - 0 0 0
DESIGN-R® score 24
Total 9 1 10 Wound location (n = 10)
Trochanter
Coccyx

Sensitivity: 100% Leg

Others

r = 0.67 (p = 0.036)
n (%), median (interquartile range)

Astrada, A., Nakagami, G., Minematsu T., Goto T,. Kitamura A., Mugita Y., Sanada H. Concurrent validity of biofilm detection by wound blotting on
chronic wounds. Journal of Wound Care. 2020. (In press)
 Validitas teknologi wound blotting: clinical sample
dari Pressue Ulcer Round di UTokyo Hospital

12
Native PAGE Intensity

10
Meski wound blotting mendeteksi biofilm
hanya pada permukaan luka, wound blotting
8
r = 0.77
mampu menunjukkan keberadaan umum
6
(p = 0.001)
4

2
biofilm yang terdistribusi di seluruh jaringan luka
0
0 20 40 60 80 100
Alcian Blue Blotting Intensity (☓105)

Astrada, A., Nakagami, G., Minematsu T., Goto T,. Kitamura A., Mugita Y., Sanada H. Concurrent validity of biofilm detection by wound blotting on
chronic wounds. Journal of Wound Care. 2020. (In press)
Impact Factor
2018: 13.578
 Penerapan wound blotting di lingkup klinis
Biofilm-based wound care system:
ultrasonic debridement + wound blotting evaluation Vs Standard care
(n: 13)
(n: 52)
Desain penelitian: retrospective cohort
Lokasi: University of Tokyo Hospital

Adjusted HR: 4.5

(95% CI: 1.3 – 15.0, p: 0.015)

Mori, Y et al. Effectiveness of biofilm-based wound care system on wound healing in chronic wounds. Wound Repair and Regeneration. 2019; 27: 540-547.
DOI:10.1111/wrr.12738
Penerapan wound blotting di lingkup klinis

Wound blotting staining kit

dari Saraya Corp.
Ringkasan

• Keberadaan biofilm menybabkan infeksi yang menetap

dan berulang pada luka kronis
• Biofilm merupakan struktur microskopis yang tidak dapat
dilihat dengan mata telanjang ➔ memerlukan
pemeriksaan di laboratorium
• Wound blotting merupakan alat deteksi biofilm yang
objektif dan sudah divalidasi
• Wound blotting dapat digunakan untuk mengevaluasi
keberhasilan dalam membersihkan luka
Ultrasonografi dalam
perawatan luka
Konsep dan terapannya
 Point-of-care ultrasonography (POCUS)
Ultrasound dapat digunakan sebagai alat skrining untuk mendeteksi
jaringan di bawah kulit, terutama pada luka tertutup

Keunggulan ultrasound:
1. Non-invasif
2. Non-ionizing
3. Dapat digunakan berulang-ulang
4. Biaya habis pakai yang minim
5. Portable (tanpa atau minim instalasi khusus)
6. Dapat digunakan oleh perawat luka sebagai alat
penunjang perawatan (secara legal?)
SonoSite M-Turbo, Fujifilm
 Alat ultrasound yang diperlukan

Wireless Handheld type

Clarius Mobile Health
Tablet type https://www.24x7mag.com/medical-equipment/imaging-
equipment/ultrasound/clarius-mobile-health-releases-pocket-sized-
Sonosite IVIZ (Fujifilm) ultrasound-device/

Laptop type
SonoSite M-Turbo, Fujifilm

Untuk wound care, gunakan Linear Probe

https://www.probomedical.com/shop/brand/sonosite-brand/edge-ii/sonosite-hfl38xi-for-sale/
 Konsep ultrasonografi (simplified)

(Yabunaka, 2019)

(Yabunaka, 2019)

真田弘美、藪中幸一、野村岳志. 看護のエコー.株式会社照林社.(2019). ISBN978-4-7965-2462-9

 Kegunaan ultrasound dalam perawatan luka

Memebedakan abses dan selulitis

dengan akurasi dan presisi yang tinggi

Systematic review oleh Subramaniam (2016)

Screening 3.203 referensi ➔ 6 observational studies (n: 800)
(4 pediatrik dan 2 dewasa)

Sensitivity: 97% (95% CI: 94% - 98%)

dan specificity: 83% (95% CI: 75% - 88%)

Subramaniam, et al. Point-of-care ultrasound for diagnosis of abscess in skin and soft tissue infections. Academic Emergency Medicine. 2016; 23(11):1298-1306.
doi: 10.1111/acem.13049
 Kegunaan ultrasound dalam perawatan luka
Systematic review dan meta-analysis oleh Gottlieb et al, 2020
14 studi (n: 2.656)

Pada pasien pediatrik

Sensitivity: 89.9% (81.8% - 94.6%)
Specificity: 79.9% (71.5% - 86.3%)

Pada pasien kasus abses “clinically

unclear”
Sensitivity: 91.9% (CI: 77.5% - 97.4%)
Specificity: 76.9% (CI: 65.3 – 85.5%)

Gottlieb, M et al. Point-of-care ultrasonography for the diagnosis of skin and soft tissue abscess: A systematic review and meta-analysis. Annals of Emergency Medicine. 2020;
76(1): 67 – 77. https://doi.org/10.1016/j.annemergmed.2020.01.004
6 case studies
Penerapan ultrasonografi di lingkup klinis
Case 1
Age/sex: 32/F

Duration of DM: 5 years

DM medication: none
Wound duration: 13 days
Wound cause: food
allergy?

Pus was aspirated by a (Astrada, 2020) (Astrada, 2020)

vocational nurse with
syringe 2 days prior
coming to the clinic. Px
complains pain and
difficulty to sleep 2 – 3
days.

Examination: tenderness
on plantar and dorsal
right hand
Permission: Adam Astrada, 2020 (unpublished data) (Astrada, 2020) (Astrada, 2020)
 (Astrada, 2020)

(Astrada, 2020)
Permission: Adam Astrada, 2020
(unpublished data)
 Diagnosis
My judgement:
• Diagnosis: cellulitis without
abscess/discharge
• Plan: No needs to explore/incise the
wound, oral broad spectrum
antibiotic treatment

Responsible nurse:
• Made 3.7 cm incision with local
anesthesia

Result:
No evidence of discharge (Astrada, 2020) (Astrada, 2020)

Conclusion: unnecessary procedure

(incision)

Permission: Adam Astrada, 2020 Sebelum eksplorasi Setelah eksplorasi

(unpublished data)
 Case 2

61-year-old male complained pain and swollen foot

since last night (1 day) with unknown cause.
Tenderness form foot extending to popliteal
Random blood glucose: >>500 mg/dL (over device
detection range)
Undiagnosed diabetes mellitus

Complete blood count

WBC: 16,400 (3.5k – 10.0k)
RBC: 3,510,000 (3,800k –
(Astrada, 2020)
5,800k)
Hb: 8.4 g/dL (11.0 – 16.5)
HCT: 24.8% (35.0 – 50.0)
PLT: 218,000 (150k – 390k)

Permission: Adam Astrada, 2020

(unpublished data) (Astrada, 2020)
(Astrada, 2020)
(Astrada, 2020) (Astrada, 2020) (Astrada, 2020) (Astrada, 2020)
 (Astrada, 2020)

(Astrada, 2020)

Permission: Adam Astrada, 2020

(unpublished data)
 (Astrada, 2020)

(Astrada, 2020)

Permission: Adam Astrada, 2020

(unpublished data)
 (Astrada, 2020)

(Astrada, 2020)

Permission: Adam Astrada, 2020

(unpublished data)
 (Astrada, 2020)

(Astrada, 2020)

Permission: Adam Astrada, 2020

(unpublished data)
 (Astrada, 2020)

(Astrada, 2020)

Permission: Adam Astrada, 2020

(unpublished data)
Diagnosis
(Astrada, 2020)

My judgement:
• Strong edema
• No discharge
• No deep necrotic tissue
• Incise blister only

Responsible nurse:
• Suspected abscess
(Astrada, 2020)
• Surgical debridement including blister and heel pad
Permission: Adam Astrada, 2020
(unpublished data)
Result
(Astrada, 2020)
• No discharge
• No necrotic
tissue
• Unnecessary
surgical
procedure

(Astrada, 2020)

Permission: Adam Astrada, 2020

(unpublished data)
Case 3

Female 47 years old

Wound history: 2-week-old furuncle
Blood pressure: 104/58 mmHg (Astrada, 2020)
Pain advances to olecranon

Molar
Random blood glucose: 282 mg/dL
Alb: 2.1 g/dL (3.8 – 5.1)
BUN: 28 mg/dL (10 – 50)
Creatinine: 1 mg/dL (0.5 – 0.9)

Complete blood count

WBC: 12,400 (3.5k – 10.0k)
RBC: 4,040,000 (3,800k – 5,800k)
Hb: 10.0 g/dL (11.0 – 16.5)
HCT: 31.2% (35.0 – 50.0)
PLT: 437,000 (150k – 390k) (Astrada, 2020)

Permission: Adam Astrada, 2020 (unpublished data)

Diagnosis
My judgement:
• abscess extending to
white arrow
(Astrada, 2020)
• Incision extents to yellow
arrow
Responsible nurse:
• Agreed to incise with
yellow arrow

Permission: Adam Astrada, 2020 (unpublished data)

 After
exploration
Result:
Heavy pus (Astrada, 2020)
Immense pain regardless local
anesthesia (lidocaine)

(Astrada, 2020)
(Astrada, 2020)

Permission: Adam Astrada, 2020 (unpublished data)

 Left foot Right foot
Case 4
Age/sex: 62 years old/F

Duration of DM : 4 years (Astrada, 2020) (Astrada, 2020)

Wound duration : 11 weeks
Wound cause : Bullous
Blood pressure : 131/58
ABPI right foot : 1.15
Laboratory work-up
WBC : 9,600 (3.5k – 10.0k)
RBC : 2,550,00 (3,800k – 5,800k)
PLT : 746,000 (150k – 390k)
Hb : 5 g/dL (11 – 16)

(Astrada, 2020)

Lokasi nyeri

Pain was caused by prolonged positioning on that

Permission: Adam Astrada, 2020
(unpublished data)
side to find a comfortable position during rest
 (Astrada, 2020)

Left foot

(Astrada, 2020)

Permission: Adam Astrada, 2020

(unpublished data)
Diagnosis

My judgement
• Deep tissue injury, extents along side the lateral side of foot,
possibly develops 3 – 7 days later.

(Astrada, 2020)

(Astrada, 2020)
(Astrada, 2020)

Permission: Adam Astrada, 2020 (unpublished data)

Seminggu kemudian
Before After
exploration exploration
Seminggu kemudian

(Astrada, 2020) (Astrada, 2020) (Astrada, 2020)

(Astrada, 2020)

Permission: Adam Astrada, 2020 (unpublished data)

Case 5

Male/mid 60s

Diabetic
Femoral (longitudinal) 21 Sept 2018
Femoral (transverse) 21 Sept 2018
Longitudinal swiping
Ultrasound dan osteomyelitis

1 in 4 people with diabetes may experience chronic foot ulceration in their lifetime (Geraghty & LaPorta, 2019)

A simple ulceration can to progress to a deeper tissue such as adipose and muscle
tissue and bones

Courtesy: https://thoracickey.com/drainage-and-debridement-of-foot-infections/

20% those wounds involved bone which had 23 times more risk to develop osteomyelitis (Lavery,
2009)

1. Geraghty T, LaPorta G. Current health and economic burden of chronic diabetic osteomyelitis. Expert Rev Pharmacoeconomics Outcomes Res 2019;19:279–286. doi: 10.1080/14737167.2019.1567337
2. Lavery LA, Peters EJ, Armstrong DG, Wendel CS, Murdoch DP, Lipsky BA. Risk factors for developing osteomyelitis in patients with diabetic foot wounds. Diabetes Res Clin Pract 2009;83:347–352. doi:
10.1016/j.diabres.2008.11.030
 Osteomyelitis is associated with higher risk of major
amputation in DFUs and accounts to more than 20% of
moderate infections and
50% – 60% of severe infections
(Pemayun, 2015; Lázaro-Martínez, 2017)

1 in 2 of who underwent amputation Healing and ambulatory rates were 100%

might die in the next three years in non-ischemic diabetic foot osteomyelitis
(Geraghty & LaPorta, 2019) (Fujii, 2016)

Therefore, diabetic foot ulcer osteomyelitis is highly curable!

1. Pemayun TGD, Naibaho RM, Novitasari D, Amin N, Minuljo TT. Risk factors for lower extremity amputation in patients with diabetic foot ulcers: a hospital-based
case–control study. Diabet Foot Ankle 2015;6:29629. doi: 10.3402/dfa.v6.29629
2. Lázaro-Martínez J L, Tardáguila-García A, García-Klepzig JL. Diagnostic and therapeutic update on diabetic foot osteomyelitis. Endocrinol Diabetes Nutr
2017;64:100–108. doi: 10.1016/j.endinu.2016.10.008
3. Fujii M, Terashi H, Yokono K. Surgical treatment strategy for diabetic forefoot osteomyelitis. Wound Repair Regen 2016;24:447–453. doi: 10.1111/wrr.12418
 The International Working Group on the Diabetic Foot
(IWGDF) suggested clinicians to use a combination of
clinical, radiographic and laboratory findings for the
diagnosis of diabetic osteomyelitis (Meyr, 2018; Berendt, 2008)

Bone biopsy is considered as the “gold standard”

to diagnose osteomyelitis

Drawbacks in bone biopsy:

1. Ambiguity, of what to observe: histological
or microbiologic analysis
2. Lack of standardization: instrumentation,
sampling and handling
Pfannenstein R.R., Hyllengren S.B., Boffeli T.J. (2015)
3. Invasiveness Bone Biopsy Techniques. In: Boffeli T. (eds)
Osteomyelitis of the Foot and Ankle. Springer, Cham

Magnetic resonance imaging (MRI) or at least plain x-ray are the diagnostic tool of
choice for osteomyelitis along with clinical observation (Hayden, 2015; Beaman, 2017)

However, those examinations require costly instrumentation and processes

Astrada, A et al. Ultrasonographic Features of Diabetic Foot Osteomyelitis: A Case Series. Health Science Reports. 2020 (under review)
Astrada, A et al. Ultrasonographic Features of Diabetic Foot Osteomyelitis: A Case Series. Health Science Reports. 2020 (under review)
 Sepadankah?

• Memiliki akurasi diagnostik yang tinggi ➔ memperbaiki care

plan manajemen luka di 10% kasus (Gattlieb, 2020)
• Secara keseluruhan, dapat memangkas biaya medis (studi
Harvard Business School dan Harvard Medical School) sebanyak USD2,826.31
(IDR 40.6 jt) per pasien (Schaik, 2018)
• Secara keseluruhan, aman digunakan bahkan oleh
generalis dan dapat mempercepat diagnosis (systematic review)
(Sorensen & Hunskaar, 2019)

1. Gottlieb, M et al. Point-of-care ultrasonography for the diagnosis of skin and soft tissue abscess: A systematic review and meta-analysis. Annals of Emergency Medicine. 2020; 76(1): 67 – 77.
https://doi.org/10.1016/j.annemergmed.2020.01.004
2. Schaik, GWWV; Schaik, KDV; Murphy, MC. Point-of-care ultrasonography (POCUS) in a community emergency department: an analysis of decision making and cost savings associated
with POCUS. American Institute of Ultrasound in Medicine. 2018; 38:2133 – 2140. doi:10.1002/jum.14910
3. Sorensen, B & Hunskaar, S. Point-of-care ultrasound in primary care: a systematic review of generalist performed point-of-care ultrasound in unselected populations. The Ultrasound Jurnal.
2019; 11(31). https://doi.org/10.1186/s13089-019-0145-4
Rangkuman:
potensi terapan dalam wound care
• Membedakan abses dan selulitis dengan akurat
• Mendeteksi deep tissue injury ➔ prediksi pressure ulcer
• Mendeteksi gangguan vaskuler
• Skrining osteomyelitis
Termografi
Konsep dan potensi terapannya
 Konsep

• Kulit manusia memiliki kemampuan emisi mendekati black

body ➔ kemampuan gelombang panas hampir sempurna,
sesuai dengan temperature yang sebenarnya (Sanchez-Marin, 2009)
• Penggunaan dengan kamera termograf dapat mendeteksi
perbedaan suhu sebesar 0.1 ℃ (palpasi 2 ℃) ➔ lebih
objektif dan sensitif

Sanchez-Marin, Calixto-Carrera, and Villaseñor-Mora: Novel approach to assess the emissivity of the human skin. Journal of Biomedical Optics. 2009; 14(2).
Alat yang digunakan

FLirOne Gen-1 iPhone type

https://www.flir.com/support/products/
flir-one-gen-1#Overview
FLirOne Gen-3 iPhone type
Thermo Tracer TH7800N https://www.flir.com/products/flir-one-gen-
3/
http://www.infrared.avio.co.jp/en/products/ir-thermo/lineup/th7800n/index.html
 Screening osteomyelitis
Pasien dengan diabetic foot (n: 20)
Lokasi: Diabetic Foot Clinic, University of Tokyo Hospital
Gold standard: MRI
“Ankle Pattern” ➔ osteomyelitis
(sensitivity: 100%, negative predictive
value: 71.4%. p: 0.011)
(Oe, 2013)

Oe, M et al. Screening for osteomyelitis using ultrasonography in patients with diabetic foot. Ulcers. 2013. http://dx.doi.org/10.1155/2013/284294
 Prognosis wound healing
Luka decubitus derajat 1 atau II denga
wound bed dengan suhu lebih tinggi
dari peri-wound 6.85 kali lebih berisiko
stagnant atau memburuk (Nakagami, 2011)

Luka kaki diabetik dengan wound bed

yang memiliki suhu lebih rendah dari
periwound menunjukkan proses
penyembuhan (Astrada, 2019)

1. Nakagami, G et al. Combination of ultrasonographic and thermographic assessments for predicting partial-thickness pressure ulcer healing. Wounds. 2011 Sep; 23(9):285 –
292.
2. Astrada, A et al. Successful treatment od a diabetic foot ulcer with exposed bone using Trigona honey: a case study. Journal of Wound Care. 2019; 28(Supp12).
https://doi.org/10.12968/jowc.2019.28.Sup12.S4
Rangkuman keseluruhan

• Wound blotting dapat digunakan sebagai alat yang

objektif dan tervalidasi dalam mendeteksi biofilm,
terutama pada luka kronik terbuka
• Ultrasonography dapat membantu membedakan abses
dan selulitis, memprediski luka tekan akibat deep tissue
injury, mendeteksi masalah vaskular, serta sebagai alat
screening diabetic osteomyelitis
• Termografi dapat digunakan untuk memprediksi prognosis
penyembuhan luka dan sebagai alat skrining osteomyelitis
For permission, please address to
Adam Astrada
aastrada-tky@g.ecc.u-tokyo.ac.jp