Dr. B.J.

Bismedi, SpBP
CWC 2014
Solution For Better Wound Healing
 “Nasib Sebuah Luka
Yang Sulit Sembuh”
Akibat:
Trauma Mayor (Bencana) ,
Trauma Minor + Penyulit/penyakit
Tatalaksana:
Penilaian dan Pengkajian
Pembersihan dan Perawatan
Penutupan dan Rekonstruksi
Rehabilitasi dan Remodeling
 Definisi

WBP: Manajemen Luka dengan tujuan

mengakselerasi penyembuhan luka (endogenous
healing) atau untuk memfasilitasi terapi yang efektif
dan terukur.
(Falanga, 2000; Schultz et al, 2003)

WBP harus dipertimbangan sebagai pendekatan

terbaik untuk semua luka, khususnya luka kronis
yang sulit sembuh.
 Penyembuhan Luka
W
o Normal healing
u
n
d
t
e
n
s
I Delayed healing
l • trauma
e
• infection
s • poor nutrition
t
r
e
n Impaired healing
g • diabetes
t • radiation
h
• steroids

Time
INTERNATIONAL TRAINING
DEPARTMENT 5
 Definisi
“WBP : the science of open wound management
and dressing selection” #SEVC2013

Vs

“WBP is about treating the whole patient,

not just the hole in the patient,”
(Dr.R.Gary Sibbald #aswc2013)

“Wound Bed Preparation itu artinya bukan nyiapin tempat

tidur buat luka ya...#yesriver
@afauzinasution
Penyebab Luka Sulit/Tidak Sembuh
Didn’t Heal
Systemic Factors

• Chemotherapy
• Gene damage
• Steroids

• Diabetes Nutritional
Metabolic
factors mellitus Chronic • Protein
• Minerals factors
• Renal failure
Wound • Vitamins

• Pressure
• Infection
• Necrosis
• Desiccation
• Chronic exudate
 Psychosocial barriers
 Local
Family factors, financial, etc Factors
7
 Penilaian/
MEASURE Pasien

Diagnosis Luka

Preparasi bed luka

Kontrol bakteri Pengelolaan jaringan non vital Pengelolaan eksudat

Antibiotik Debridement Produk Absorbtif

Moist Wound Healing

Luka telah terpreparasi

Penutupan luka

SEKUNDER PRIMER Graft Flap

Luka ‘sembuh’

Falanga V, 2001
AIMS

 Menghilangkan faktor yang menghambat

penyembuhan luka
 Mempersiapkan luka dengan secara maximal
untuk dapat dilanjutkan Terapi Penutupan
Luka dengan advance product dan atau
dilakukan Rekonstruksi secara Bedah
Tatalaksana Luka – Rekonstruksi Defek
 Anak Tangga Rekonstruksi
PRINCIPLES = TIME
Framework terms Application to
practice

Tissue management Removal of

T nonviable tissue
Inflammation and Control of bacterial
I infection control load / burden
Moisture balance Management and
M control of exudates
Epithelial Promotion of a
E advancement / edge healthy wound edge
DEBRIDEMENT

CLEANSING
Antimicrobial

Modern
DRESSING

Dressing
Bandage
Fisioterapi

Re-assesmet
Rekonstruksi
Bedah
 PRINSIP T.I.M.E
 Setelah melakukan Kajian Luka ;
 “WOUND CARE” dilanjutkan dengan WBP:
 DEBRIDEMENT
 CLEANSING
 DRESSING (Modern)
 Undressing
 Bandage
 Posisi, Fisioterapi
 Algoritma Luka Sembuh
Bersih – Jahit / Sembuh
Luka Akut Terkontaminasi WBP
Primer
, Trauma Minor
Kotor WBP + Jahit Primer Tertunda
Luka dengan Terkontaminasi, Dressing
Penyulit TraumaMayor
Rekontruksi Luka
Tutup Defek – Skin
Necrotizing Soft Radical Graft / Flap (Sembuh
Luka Kronis Tissue Infection Debridement Primer)

Nekrotik
Debridement
WBP + (Modern) Dressing
Bedah

Slough Insisi-Drainase
EDGE,Epitelisasi Spontan /
Sembuh sekunder /
Infeksi Secondary Intention
Source: http://www.ewma.org
Removal of nonviable tissue
 TISSUE MANAGEMENT
for tissue: non-viable or
Necrosis:
deficient
‘The morphological changes indicative of cell death
caused by progressive enzymatic degradation.’

Debridement:
‘The removal of necrotic material
from the surface of a wound.’
Factors affecting necrosis
formation
 Poor blood supply
 Infection

 Ischaemia
 Trauma
Dry Necrotic Tissue
 Eschar
 Black
 Hard, dry, dead
tissue
 Colonised by
bacteria
Wet Necrotic Tissue
 Slough
 Yellow or cream
colour
 Soft, wet dead
tissue

 Denatured matrix
and cell debris
impair healing
 Clinical Action 
DEBRIDEMENT
 Debridement (episodic or
continuous)
 autolytic,
 sharp surgical,
 enzymatic,
 mechanical or
 biological
DEBRIDEMENT

• Membuang jaringan mati

• Membuang material asing

• Membersihkan jaringan yang terkontaminasi

• Mempertahankan struktur penting semaksimal

mungkin
 Surgical Debridement

Sharp debridement

Skalpel, gunting, kuret + irigasi

Paling cepat dan efektif

Komplikasi: Perdarahan +Nyeri; pembiusan

– toleransi operasi
 AUTOLYTIC DEBRIDEMENT

Invivo Enzymes Self Digest

Devitalized Tissue
Gelatinase
Kolagenase
Stromelisin

Membutuhkan suasana lembab / MOIST

 Penutup luka
 Hydrocolloid, Transparent film, Hydrogel

Falanga V, 2000; 2001

 Autolytic Debridement

The body’s natural process of debridement

- Proses Alami
- Enzym Proteolytic dari sel sel secara selektif
melisiskan jaringan nekrotik
- Difasilitasi oleh lingkungan luka yang MOIST
- Peran Modern Dressing
Suasana MOIST

Rawat luka tertutup rapat,

luka jadi panas?

Bagaimana dengan aplikasi

kasa lembab? = Moist ?
 MECHANICAL DEBRIDEMENT
Gauze debridement
Wet to dry dressing

Gauze + saline  kering

Jaringan mati terbuang saat mengganti balut

Debridement Balutan
= Cleansing cara Swabing

NYERI....
Falanga V, 2000; 2001
 MECHANICAL DEBRIDEMENT

Debridement Pinset

Nyeri

Debridement Mekanik Modern

Dengan tekanan, pulsatil; Pressure Irigation

Nyeri <<<
Falanga V, 2000; 2001
BIOLOGICAL DEBRIDEMENT
MAGGOT DEBRIDEMENT THERAPY

Larva therapy
Larva Phaenicica sericata (green blow fly)

Biomechanical debridement

Sejak 1932
Sukses untuk abses, luka bakar, selulitis, gangren,
ulkus, osteomielitis dan mastoiditis

Thomas S, 2005
 Chemical Debridement

• CHEMICAL AGENTS
• Hydrogen peroxide (H2O2)
• EUSOL (Edinburgh University Solution of Lime)
• Salicylic acid
• Malic acid
• Benzoic acid
• Hypochlorites

• Tidak Selektif, Nyeri  Dihindari

• H2O2; Dipakai sebagai Cleansing 

kontaminasi kuman anaerob
Tissue Management  Viable wound Base
Debridement mix Surgical + Autolytic
Control of bacterial load / burden
I nfection
 Sukses tidaknya penutupan luka tergantung ada
tidaknya infeksi

 Infeksi luka ditentukan keseimbangan daya tahan luka

& jumlah mikroorganisme

 < 104 /gram tissue  Infeksi 6%

 > 104/gram tissue  Infeksi 89%
 > 105/gram tissue  Gagal =INFEKSI
 I nfection
High bacteria, cause
inflammatory cytokines <<
proteases <<
growth factor activity >>
healing environment >>

Teh BT, 1979

 Action

 Anti microbial sistemik dan topikal

 Cleansing
 Dressing
 EXUDATE MANAGEMENT DRESSING

 Protease inhibitor
 Growth factor
 Manajemen Exudat Modern

 Direct : mechanical vacum

 VAC Therapy, Curavac
CLEANSING

 Showering
 Scrubbing
 Swabbing
 Bathing
Wound Cleansing

1 Remove debris 4 Avoid

and exudate  Cetrimide
2 Cleanse  Chlorhexidine
surrounding skin  Hydrogen Peroxide
 Chlorine
3 Recommended
 Povidone Iodine
 Saline
 Dyes
 Sterile Water
 Benzoic, Malic and
 Prontosan
Salicylic Acid
 Cleansing Konvensional
 Luka Tertutup / minor
 Swabbing; usap ,
mengepel,
 Prosedur a dan antiseptik
Dilakukan saat Ganti Balutan
Cleansing harus efektif
Tidak perlu terlalu sering
Potensi low temperature
 Modern Dressing
 Luka terbuka / mayor /
kavitas / eksudatif
 Swabbing; usap- pel
 Swabbing ; kompres,
gulung, berulang-ulang,
 Kasa fluffy, peras,
absorben, meliputi
seluruh permukaan luka
 Showering.
 (mirip debridement
mekanikal, wet to dry
gauze)
Management and control of exudates
 Apply Moisture Balancing Dressing
 KONSEP MOIST WOUND DRESSING
LUKA LUKA
BASAH / MOIST KERING/
INFEKSI NEKROTIK

AQUACEL
DuoDERM CGF •DuoDERM Gel
AQUACEL Ag (infeksi)
DuoDERM Extra •DuoDERM Paste
KALTOSTAT
Thin
CARBO Flex (berbau)

Menjaga
kelembaban

Memberi kelembaban
Absorb exudates & debridement & debridemen
autolisis autolosis
 Matching Colour and Product

 Black………………….. cleansing dressing, autolytic debride

 Green…………………. antimicrobial dressing

 Wet yellow…………. antimicrobial dressing

 Dry yellow…………. rehydrating dressing

 Red……………………… protect

 Hypergranulation. antimicrobial dressing

 Pink……………………. protect.

45
MOIST WOUND
ENVIROMENT
PENYEMBUHAN LUKA DALAM SUASANA MOIST
Promotion of a healthy wound edge
Re-Assessment / Re- Evaluate
Outcome : Advancing Edge of Wound
vs Non Advancing or Undermined
Action : Re-Assess

Pertimbangkan untuk terapi

korektif atau Rekontruksi
 Luka Trauma Mayor, Necrotic
-Undermining
  

 Necrotic  Debridement  WBP  Skin grafting

 Luka ‘Ulkus’ DM
Dorsum pedis
Ulkus post
debridement
Luka dalam Full
thickness-berongga
Dasar Luka
sloughing tendon-
granulasi
Tatalaksana
WBP  epitelisasi
spontan
 Luka Nekrotik Pedis DM

Tatalaksana
 Cleansing
 Debridement
 Sembuh Primer dg
Skingrafting
Luka Undermining/Cavitas
pasca Debridement + WBP