penatalaksanaan luka

DR. dr. Hardisiswo, SpBP-RE (K)

Pit IDI Bogor, 31 Oktober 2015

Divisi Bedah Plastik, Dept BedahFK Unpad/ RS Hasan Sadikin

Bandung

Wound

disruption of the normal anatomical relationships of tissues as a result of injury.

surgical incision

trauma

Wound Type

Wound Problem

Infection

Delayed healing

Septic wound

Scar: hypertrophic scar,

keloid

Chronic wound

Delayed healing

Infection

Septic wound

Intractable wound/unhealing

wound

All Wound problems can

occur

Acute wound

Chronic wound

Non healing

wound

Luka

Akut Kronis

≥ 6 minggu

Wound Classification

Wound

Chronic

Acute

skin loss

vulnus

escoriatum

vulnus laceratum

vulnus punctum

vulnus scissum

skin avulsion/ deglovingeschar

slough

infection

granulation

Process of Wound Healing

Luka Akut

Bersih

Kontaminasi

Kotor

Infeksi

Daerah luka akut yang

berisiko terhadap fungsi

Mengenai pembuluh darah besar

Saraf-saraf penting: N.VII, plexus brachialis, dst.

Tendon-tendon

Organ-organ = mata, hati, jantung, dsb

Duktus/saluran kelenjar – Stenson

Luka akut berisiko infeksi

Luka ≥ 6 jam

Luka kontaminasi/kotor

Terjadi di tempat yang kotor

Luka dalam dan benda kontaminan/kotor (paku/bambu/besi)

Luka akut berisiko keloid/parut

hipertrofik

Luka laserasi dalam

Luka laserasi kotor

Luka compang-camping

Luka tegang (skin loss) – tension

Luka akut jadi kronis

Penanganan luka akut

Primary survey – life threatening

Secondary survey – manajemen luka

Manajemen luka akut

Membuat luka menjadi bersih

Mengurangi/mencegah risiko infeksi

Mencegah menjadi luka kronis

Mengurangi/mencegah parut buruk

(keloid/hypertrophic scar)

Tujuan

Good wound

management

Debridement

Wound toilet

Good surgery

technique

Good Healing

aesthetic&

functional

Simple

Laceration

Complex

wound

Wound toilet / Debridement

Wound toilet – luka kecil dan bersih

Debridement – membuang semua kotoran pada luka, jaringan mati dan membuat luka jadi bersih dan siap ditutup

Irrigation & Debridement

Debridement – excision of all devitalized, contaminated &

Foreign bodies

If Possible, Vital structures including nerves, blood vessels,

tendons and bones shouldn’t be debribed.

Irrigation with NaCL

Mechanical debridement (sharp& blunt)

Gauze debridement

Chemical debridement

Trusler AP. Surgical Techniques and Wound Management. In Brown DL. Michigan Manual of

Plastic Surgery. Lippincott Wiliams& Wilkins.Philadelphia. 2007

Defect Closure

Need Meticulous surgical technique

Good approximation SOLVE the puzzle

Suture material

Tissue handling

Subcutaneous suture

AVOID TENSION

Cutaneous suture — eversion

Langer Line

Penutupan luka

Dijahit

Primer

Tersier

Graft – STSG & FTSG

Tidak dijahit

Sekunder

Dirawat terbuka

Post Operative Care

Dressing

Clean, Moist, Pressure

Suture removal within 5 - 7 days (face)

Silicone sheet

Avoid sunlight

Cream / Ointment for scar

Wound dressing

Syarat

Bersih

Menyerap / hidrofil

Lembab

Efek pressure (menekan)

Antibiotik

Modern wound dressing

Acute Wound

Vulnus

Excoriatum

Vulnus

Laceratum

Acute Wound

Vulnus

Scissum

Acute Wound

Skin Avulsion Gun Shot wound

Acute Wound

Skin Degloving

Pre – Post Operative

Pre – Post Operative

Management of Skin Avulsion

Test vitality

Distal to

proximal

HarvestingSuture the

vital flap +

graft

Chronic wound

All chronic wounds begin as acute wounds but fail to progress

through the normal healing process and become locked in an

extended inflammatory phase.

External

Inflamation

Inducer

wounding

Acute

inflammatio

n

Chronic

inflammatio

n

Proliferatio

n

Remodelin

g

Chronic wound

growth factors,

cytokines, and

proteases all play

important roles in

wound healing process

alterations in one or more

components of these

factors may account for

the impaired healing in

chronic wounds.

Sucessful wound healing requires a

balance between protease and

inhibitor levels in order to bring

controled synthesis and

degradation of extracelular matrix

component

In Chronic Wounds Inflamatory phase

Management

Asses the WoundAcute wound — The problem is easy to resolve

Cronic Wound

?Nonhealing wound

Wound by Its Colour

Chronicwound

Venous Ulcer

Venous

ulcer

Blood Stasis

Chronic

Inflamation

Chronicwound

Diabetic Foot

Gangrene DM

Diabetic

Ulcer

Chronicwound

Management Chronic Wound

Management

Chronic Wound

Bed Preparation

Antibiotic

Status nutrition

Local

care

Systemic care

1. Broad spectrum

empiric

2. Kultur & resistency

Albumin > 2.5 g/dl1. Elastic verband

(celulitis, venous ulcer)

2. Mobilisastion

(pressure sores)

1. Glucose control

2. stop smoking

3. Cancer Therapy

Debridement

Dressing

Wound-bed preparation

Paradigm

TIME Principles of wound bed

preparation

Tissue non-viable or deficient

Infection or Inflammation

Moisture imbalance

Edge of wound —non-advancing or

undermining

TIME Principles of wound bed

preparation

Tissue non-viable or deficient

Patofisiologi

• Matriks yang

dipenuhi debris

menghambat

penyembuhan

luka

Sikap

• Debridement

(berkala atau

kontinyu)

Hasil yang

diharapkan

• restorasi luka

(fungsi ECM

baik)

• luka lebih

sehat

TIME Principles of wound bed

preparation

Patofisiologi

• Jumlah

baketeri

banyak

• Fase inflamasi

memanjang

Sikap

• Menghilangkan

fokus infeksi

dengan

antibiotik

topikal/sistemik

Hasil yang

diharapkan

• berkurangnya

bakteri dan

proses

inflamasi

Infection or Inflammation

Infected Ulcer

Infected

Ulcer

Chronicwound

TIME Principles of wound bed

preparation

Patofisiologi

• luka yang kering

memperlambat

epitelisasi

• Luka yang basah

menyebabkan

maserasi pada tepi

luka

Sikap

• dressing yang

melembabkan luka

• menggunakan

NPWT atau vakum

Hasil yang

diharapkan

• keseimbangan

kelembaban luka

tercapai

Moisture imbalance

TIME Principles of wound bed

preparation

Patofisiologi

• tidak ada migrasi

sel-sel keratinosit

• gangguan pada

ECM

• aktifitas protease

tinggi

Sikap

• menilai ulang

penyebab

(assessment)

• debridement

• skin graft

Hasil yang

diharapkan

• tepi luka yang

mengecil

(mendekat)

Edge of wound —non-advancing or

undermining

Banyak penawaran produk wound dressing

AI KARTIKAPressure sores grade IV

Pre Operation

Chronicwound

AI KARTIKAPost Operation

Debridement &

Wound care

Chronicwound

Post close defek

Chronicwound

2. ♂,32 TH, Chronic Ulcer + Anemia Gravis,

Post Debridement I

AFTER DEBRIDEMENT

Week 3 post op, edema

Pre – Post Operative

Pre – Post Operative

Pre – Post Operative

Conclusion

Penilaian luka

jenis

bentuk

lokasi

Penyakit komorbid

Pengetahuan anatomi

Luka akut atau kronis membutuhkan wound toilet atau

debridement

Goal: menghasilkan jaringan parut yang baik secara estetik dan

fungsi

LUKA KRONIK

LUKA AKUT

SEMBUH

•SLOUGH•BAKTERI•BIOFILM•ESCHAR

•PUS

DebridementAntibiotikdressing

DebridementAntibiotikdressing

•Bersih• granulasi sehat•Vaskularisasi ↑