הכנת מיטת הפצע עם אנזים אלגינוג'ל בטיפול בפצעי לחץ

קלינאים נתקלים בפצעים מסוגים שונים על בסיס יום יומי, כולל פצעים כירורגיים וטראומטיים, פצעים אונקולוגיים, פצעי הקרנה, פצעי רגל סוכרתיים, כיבים ורידיים, ומספר גדול של פצעי לחץ.

למרות מאמצים רבים שמטפלים משקיעים על בסיס יומי למניעת פצעי לחץ, הם בכל זאת מופיעים בשכיחות של 7%-9% (דרגות 1-4 – 4%, דרגות 2-4 – 5%) בבת החולים האוניברסיטאי של לובן שבבלגיה, הכולל  1,800 מיטות. כשליש מאותם פצעים מגיעים ממחלקות אחרות מחוץ לבית החולים.

במקרים רבים ניתן לטפל בפצעי הלחץ באופן שמרני, אך הקליניקאים נתקלים גם במספר גדול של כיבי לחץ שמצריכים התערבות כירורגית. הכנה יסודית של מיטת הפצע היא לפיכך, חיונית לטיפול באותם פצעים.

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'The goal of wound bed preparation is to stimulate granulation tissue, prepare the wound for surgical closure or to achieve wound closure’
Hospital of Leuven, a Belgian facility with 1,800 beds. About one-third of these wounds come from other departments outside of the hospital.
In many cases, these decubitus wounds can be treated conservatively, but clinicians also regularly see a large number of pressure ulcers that require comprehensive surgical debridement or flap surgery. Thorough wound bed preparation is thus essential for treating these wounds.
WOUND BED PREPARATION
Wound bed preparation focuses on debridement, bacterial balance, management of wound exudate and the overall health status of the patient (Sibbald et al, 2000). The goal of wound bed preparation is to stimulate granulation tissue, to prepare the wound for surgical closure or to achieve closure of the wound (Schultz et al, 2005).
In order to optimise wound bed preparation for these decubitus wounds, negative pressure wound therapy (NPWT) is often used after surgical debridement, although enzyme alginogels also have an important added value here. Enzyme alginogels combine the benefits of a gel, an alginate, and antibacterial enzymes. They address each of the four components that underpin wound bed preparation described in the TIME (tissue, infection, moisture, edge) framework (Beele et al, 2011). They clean the wound and carry out continuous debridement of the wound bed through their alginate content, breaking down necrotic tissue through hydration and autolysis.
The lysed necrotic tissue and the excess of wound exudate, including bacteria, are then absorbed into the product's structure. They restore bacterial balance and incorporate a unique, broad spectrum of antibacterial enzymes that are effective against a range of clinical isolates, including Methicillin-resistant Staphylococcus aureus (MRSA) (Desmet, 2009), without destroying the host skin cells essential for wound healing.
Enzyme alginogels also create a moist wound healing environment, while ensuring that the wound edges are protected (Beele et al, 2001).

CASE REPORTS
Case 1
The first case is a 72-year-old obese woman with type II diabetes, arterial hypertension and chronic kidney failure. The reason for admission was pneumonia, respiratory distress and multiple organ failure. She developed a category 4 sacral pressure ulcer due to bad overall health.
In mid-July, the wound care nurse originally encountered a superficial decubitus wound that was reddish-yellow in colour and had little exudate.
The initial treatment consisted of the necessary preventive measures, thorough

wound cleaning and disinfection and treatment with an enzyme alginogel (Figure 1).

The wound evolved relatively favourably, but two weeks later, a small cavity was discovered, for which a superficial debridement was performed. When the necessary surgical debridement was performed one week later, the wound care nurse was confronted with a very large cavity, a deep, reddish-yellow, category four decubitus wound with undermined wound edges and excess exudate.

The purpose of wound care was to prepare this wound for flap surgery as soon as possible. To this end, NPWT was initially started, which had to be abandoned rather quickly due to unexpected haemorrhaging.

On August 26, the patient was restarted on an enzyme alginogel. The wound still had a red wound base that was slightly granulated, but fibrin was present. The wound edges were still undermined and the wound was strongly exudative and

infected with Staphylococcus aureus (Figure 2).

Three weeks later, in mid-September, the wound had evolved favourably. The team noticed a red, granulating wound base with limited fibrin tissue.

The wound edges were still undermined. The wound was still strongly exudative, but did not exhibit any signs of infection. The patient's condition was slightly more stable in the meantime, but she was still insufficiently stable to undergo a major procedure, such as flap surgery. In consultation with the plastic surgeon, the decision was made to continue with the conservative treatment (Figure 3).

When the wound was evaluated one month later, the authors saw that it had become a great deal smaller.

This was due to the properties of the enzyme alginogel, continuous wound debridement, antimicrobial activity, maintenance of a moist-healing environment and protection of the wound edges and epithelial cells. The wound edges had become whole and solid and much less undermined. The wound bed had evolved into a red, granulating wound without signs of infection and with a moderate amount of exudate.

Given the enormous change in the wound, a decision was made in consultation with the plastic surgeon to continue to

treat the wound conservatively and not to have the patient undergo surgery for the time being.

When the wound was examined one month later, the authors noticed that the wound had become even smaller, measuring 3.5cm x 2cm, with a red, granulating wound bed and a moderate amount of exudate. In the meantime, the patient was ready to be discharged and cared for at home (Figure 4).

When the patient returned for a follow- up visit in mid-December (after about five months), the wound was almost fully healed.

Figure 4: Wound at 17/11/10. TIME- related symptoms: red granulated wound bottom (T); no signs of infection (I); moderate exudate (M); solid wound edges (E).
Figure 3: Wound at 14/09/10. TIME- related symptoms: red granulated wound bottom (T); no signs of infection (I); strong exudate (M); undermined wound edges (E).
Figure 1: Wound at 20/07/10. TIME- related symptoms: red-yellow wound bottom (T); no signs of infection (I); moderate exudate (M); red, irregular wound edges (E).
Figure 2: Wound at 26/08/10. TIME- related symptoms: red-yellow wound bottom after extensive debridement (T); large infection risk (I); strong exudate (M); very deep wound with undermined wound edges (E).

References

Beele H, Durante C, Kerihuel J-C, et al (2011) Expert consensus of a new enzyme alginogel.

Wounds Int 3(2): 1-9

Desmet K (2009) Pre-clinical evaluation of a new antimicrobial enzyme for the control of wound bioburden. Wounds 21(3): 65-73

Falanga V (2000) Classifications for wound bed preperation and stimulation of chronic wounds. Wound Repair Regen 8: 347-52

Schultz GS, Sibbald RG, Falanga V, et al (2005) Wound bed preperation: a systematic approach to wound management. Wound Repair Regen 13(4supp): 1S-11S

Sibbald RG, Williamson D, Orsted HL, et al (2000) Preparing the wound bed : debride­ment, bacterial balance and moisture balance.

Ostomy Wound Manage 46: 14-35

White R (2006) Flaminal: a novel approach to wound


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