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Suppl.1
Vol.1
2012.
WOUNDS
Journal
1st CONGRESS
OF TREATMENT CHRONIC WOUNDS
WITH INTERNATIONAL PARTICIPATION
CHRONIC WOUNDS, CURRENT THERAPY-ANSWERS
Best Western Hotel M, Belgrade
November 23-24. 2012.
Octenidin
bazirani
antiseptici
za sve starosne strukture
Plus za
najbolje performanse
Content
3
Content
4
Editorial
5
Introduction
6
The chronic wound: general, clinical and diagnostic aspect
Z. Janjic, D. Momcilovic, J. Nikolic, M. Marinkovic
6
Microbiology of chronic wounds: the role of systemic antimicrobials in the treatment
Brkić S.
6
Dermo-epidermal skin substitute
Elia Ricci
7
Neurological aspects of chronic wounds
Jovanovic Zagorka
7
Burns in Neonates
Rytis Rimdeika, MD, PhD
8
The wounds in vascular surgery
Nenad Ilijevski, Predrag Matić, Đorđe Radak
8
Chronic venous ulceration- trend growth mixed ulceration
Javorka Delic
8
Surgical Treatment of Chronic Venous Insufficiency and Venous Leg Ulcers
Dragan J. Milic, MD, PhD, FACS
9
Hemodynamic controversies over “in-flow” perforator veins in the etiology of chronic venous ulcers. Our experience in EVLA performing
Petar Dragić MD
9
Indication and different materials for compression therapy for venous leg ulcers
Nada Kecelj Leskovec, MD, PhD,
10
Treatment of chronic wounds using modern supportive covering
Sandra Marinović Kulišić, Jasna Lipozenčić
10
Hard to heal chronic wounds – the role of lymphoedema
Tanja Planinšek Ručigaj
10
Treatment of Venous Leg Ulcers with Reducing Terminal Reflux and EVLA.
Andrej Šikovec, MD, MSc, Avelana Vein
10
Decubital ulceration - general aspects and risk factors
Dubravko Huljev
11
Prevention and treatment of pressure ulcers
Simon Pandjaitan, Saša Milićević
11
Application of topical negative pressure in healing wounds
Sasa Borovic, Biljana Polic, Mirjana Nesovic
11
Conservative and active surgical treatment of pressure ulcers
Saša Milićević, Nenad Stepić, Simon Pandjaitan
12
Necrotizing fasciitis, acute disease of contemporary man
Z.Janjic, J.Nikolic, M.Marinkovic, N.Djermanov
12
Surgical treatment of Complications Dystrophic Epidermolysis Bullosa
Rytis Rimdeika, MD, PhD
12
Chronic wounds in dermatology: new possibilitas of the treatment
Jasmina Begic
13
Madura foot as cause of chronic wounds
Radovanovic S, Delic J.
13
Tissue guided regeneration with allogeneic platelet gel, autologous cancellous bone graft and resorbtive collagene membrane
Igor Frangez, Ciril Triller, Dragica Maja Smrke
13
Debrisoft - or how to simply do the wound debriman
Borisav Mandić, Tijana Đurić, Marina Dišović
14
Calciphylaxis
C. Triller, D. Huljev, D.M. Smrke
14
Application of iron preparations and recombinant human erythropoietin is a prerequisite for faster healing of chronic wounds in
the cardiovascular surgery in anemic persons
Branko Čalija
14
Development Center for treatment of chronic wounds in the BH Heart Center Tuzla
Softie M., Banjanovic B., Jahic M., S. Rajkovic
15
Reconstructive treatment of diabetic foot
Jelena Jeremic, Cedomir Vucetic
15
Vacuum Assisted Wound Closure in Vascular Surgery – Experience of Clinic for Vascular and Endovascular Surgery of the Serbian
Clinical Centre
Marko Dragas, Igor Koncar, Lazar Davidovic
16
Organization of a specialized multidisciplinary Wound Center for Chronic Wound Management in Copenhagen
Finn Gottrup
16
Organization of the Center of Chronic Wounds - Management in the Asklepios-Klinik-Hamburg-Harburg
Dr. Harald Daum
16
Comprehensive treatment in the treatment of burns
Nenad Stepić
17
Organisation of the Center for chronic wounds management- our experiences
Aleksandar Gajić,
17
Presentation of the Swiss Wound Care Association (SAfW)
Dr. Sebastian Probst
17
Intravenous Iron Administration For Acute and Chronic Wound Healing in Anemic Patients
Branko Calija
18
Endovenous laser ablation veins in treatment of vsm, and prevention of recurrent venous ulcer
Dario Jocić
18
Debrisoft-or how to simply do the wound debriman
Borisav Mandić, Tijana Đurić, Marina Dišović
18
Mesotherapy in dermatocosmetology and regulation of reparative processes of the skin
Nevenka Dokmanovic
19
Chronic wounds on postoperative cut – present cases
Dijana Lukic, Gordana Kanjevac, Javorka Delic
19
Injuries In Children
Sara Rowan
19
The Role of Nurse in Treatment of Chronic Wounds
Anke Bültemann
20
Pressure ulcer-indicator for bad nursing care
Kanjuh Ž.,Lazarević A., Dragin A.
21
2 CONGRESS OF TREATMENT CHRONIC WOUNDS 2014, BELGRADE, SERBIA
nd
Content
— Wounds 3
Chronic wounds, with their presence, complexity of appearance and healing, certainly are a great proffesional challenge. Various great resources
need to be engaged and there are, also, significant costs. The existence of
associations for wound healing, specialized professional magazine and
professional meetings is an actual need. Following world’s professional and
scientific streams, Serbian experts, through collaboration, tend to give a
greater contribution in solving the daily problems of chronic wounds.
This issue of magazine (suplement) appears in time of I Congress of Serbian
Wound Healing Association with international participation, having intentions to complete this meeting.
WOUNDS
Suppl.1 Vol.1
2012.
Publisher:
Serbian Wound Healing Society
Heroja Milana Tepića 1, Belgrade
The need for congress about wound healing with international participation comes from enviable success in achieving high professional and
organisational level. There is a dynaimic development in this area, so the
doctors and medical stuff who do the chronic wound healing have plenty of
possibilities in prevention and healing of chronic wounds. There is, also, an
increasing number of these patients. But, existing procedures often do not
give expectant results, the haealing is long and multidisciplinary. Congress
is a professional meeting where professional achievements in various
areas can be presented and evaluated. This Congress is, also, the result of
collaboration and support of European Wound Management Association .
Serbian Association is one of the oldest European associations for chronic
wound healing. This meeting gathers eminent experts from Europe and
Serbia, pharmaceutical industry, our doctors and nurses who do the healing
of chronic wounds. Professional improvement is a need and also a duty. In
our estimation, there are between 60000 and 80000 patients with chronic
wounds in Serbia and this is a huge economic, healthy and social problem.
Congress gives an opportunity for education, experience exchanging,
for presentation of Serbian Helth System and puts Serbia together with
European countries, which have high- level organization and systematic approach in healing of chronic wounds. Congress is an opportunity for direct
meetings and communication of participants, which will enable greater
cooperation and exchange of knowledge and experience in aim of improving chronic wounds healing and patients’ welfare.
Editor- on-Chief:
Prof dr Čedomir Vučetić
Magazine Wounds publishes significant number of abstracts, in aim of introducing this works to as many professionals as possible on this congress.
There is a constant need for improving praxis, knowledge and experience
in chronic wound healing. Magazine Wounds tends to give the experts in
this area an opportunity to present results in healing of chronic wounds.
Hoping that our efforts will be useful to experts, patients and society, we
are inviting you for collaboration in aim of a more successful work.
Finn Gottrup
Ellia Rici
Marco Romanelli
Dubravko Huljev
Rytis Rimdejka
Zita Kiš Dadara
Sebastijan Probst
Sara Rowan
Editor- on-Chief
Prof dr Čedomir Vučetić
4 Wounds
Design, layout and printing:
Dina Dizajn d.o.o.
Kneza od Semberije 5a, Belgrade
Members of the editorial board
Javorka Delić
Mirjana Dragašević
Branko Čalija
Željko Kanjuh
Saša Borović
Simon Panđaitan
Zlata Janjić
Milan Matić
Zagorka Jovanović
Jelena Jeremić
Nenad Ilijevski
Srećko Bosić
Members of the foreign editorial board
Prim. dr Javorka Delić, specialist of dermatology and
angiology
In formation of chronic wounds participate more causes
(multifactoriality), so they should be familiarize beacouse
“Hidden wounds are difficult to heal” (Hippocrates). This
can be achieved through teamwork (multidisciplinarity,
interdisciplinary), continuing professional education,
using the latest advances in diagnosis and treatment,
exchanging of knowledge and experience, which is the
goal of the Congress. Using modern methods of treatment
it shortens the healing time by 50%, it improves vitality of
patients and reduce medical costs. In therapy is applied
individual and holistic (comorbidities) principles. There are
always the most important clinical parameters and good
listening patients as active participants in the treatment,
beacouse “Patients are our best teachers”(Hippocrates).
Prof. dr Čedomir Vučetić, specialist in orthopedic
surgery and traumatology
Surgical treatment of chronic wounds is present in
various types and causes of the condition, as wounds, as
complications. Appropriate consideration of when and
how to surgically treat, and the availability of this type of
treatment is a continuing need in improving treatment.
Surgery is, often, necessary in the prevention of chronic
wounds and subsequent complications.
Avaliable
are very simple procedure, applicable in all situations
(debridement), but also the most complex reconstructive
surgery procedures (microsurgery).
Finn Gotrup, Vascular surgeon
Non-healing wounds are a significant problem for health
care systems all over the world. In the industrialized world,
almost 1-1½% of the population has a problem wound
at any one time and accounts for 2-4% of the health care
budget-a figure which is likely to rise with an increasingly
elderly and diabetic population (1-3)
WOUNDS
— Wounds 5
The chronic wound: general, clinical and
diagnostic aspect
Z. Janjic, D. Momcilovic, J. Nikolic, M. Marinkovic,
Clinic of plastic and reconstructive surgery, Clinical center of Vojvodina,
Medical faculty, University of Novi Sad, Novi Sad, Serbia.
Background: Chronic Wounds (CrW) are defined as wound that not
healed after three months. ChW have also been defined as wounds do
not decrease in size by 30% in three weeks or by 50% in 4-5 weeks with
optimal surgical management. The authors to consider, in according to
literature data and self experience, to give the up to date general, clinical
and diagnostic aspect recommendations in doctrine of CrW.
Methods: This is descriptive, retrospective and comparative study of
general characteristics, possibility of diagnostic and treatment of CrW in
according on contemporary literature and self experience of surgeons from
Clinic of plastic and reconstructive surgery, Clinical center of Vojvodina from
Novi Sad, to found in 1964 year.
Results: In the past 40 year’s human population advancing in age,
increasing in weight with the resultant comorbididities, an increase in the
number of patients with ChW. Although the causes of ChW are numerous
like diabetic, arterial, venous, and pressure sores, elderly and poor mobility
constitute the majority of ChW. Infection is common problem in ChW, usually resulting in nonhealing and significant patient morbidity end mortality. The different diagnostic procedures are present in CrW now, while the
surgical postulate is like that before. The most changes on the historical
view were on local wound treatment in depending on socio-economic
status of single person and society.
Conclusions: The authors of this study to have an opinion that avoid
CrW are impossible but we to be able to reduce them with prophylactic
treatment of acute wound in risk group of patients. The most important will
be the education and coordination of patient, his or her family as well as
medical and support staff. In according to experience of health care system
over the world and in Serbia, the optimal way to improve prophylaxis and
treatment of patients with ChW will be to create an independent multidisciplinary wound-healing center and has outpatient clinic as well as an
inpatient word.
Key words: Chronic wounds, diagnostic, treatment
Microbiology of chronic wounds: the role of
systemic antimicrobials in the treatment
Brkić S.
Clinical center Vojvodina, Clinic for infectious diseases, Serbia
Aims: The place and role of systemic antimicrobials in the treatment of
chronic wounds, the choice and duration of treatment are the one of the
most contraversional facts in complexicity of chronic wounds care. Worldwide literature show that over 60% of patients received minimaly once cure
of systemic antimicrobials.
Methods: Overview of new literature and guidelines with short
retrospective study on the Clinic for Infectious Diseases, KCV, according to
antimicrobial treatment of decubital ulcers with suspicion for moderate to
severe infection.
Results: In 2 years od observation (2010,2011) on The Clinic for Infectious Diseases we treated 81 patient, average age of 59,92 godine (60%
6 Wounds
—
The chronic wound: general, clinical and diagnostic aspect
≥65y.) with decubital ulcers and clinical diagnosis od potential local and/
or systemic infection. Patients had been admitted with decubital ulcers
or developed it during hospitalization. Statistically significant number of
patients had neurological or osteomuscular disorders and 20% had minimally two or more co-morbidities. Significant number of patients expresed
also laboratory signs of local infection (54%), following others with lab.
findings for systemic infection (20%), and 26% patients didn’t have any
lab. findings for infection at all, but also received antimicrobial treatment.
68% smears taken from wounds were positive with polymicrobial cultures
(gram negative bacteria).
Conclusions: Systemic antimicrobials are indicated only in moderate
to severe local infections (cellulitis, limfangitis, abscesses, osteomyelitis)
and systemic complications (sepssis). In the presence of febrile state, for
introduction of systemic antimicorbials laboratory findigs for infection are
usefull and for systemic complication it is necessery that patients fullfaying the criteria for SIRS. Extensive use of systemic antimicrobials increase
development of resistance and expose patients to other side effects.
Key words: chronc wounds, systemic antimicrobials
Dermo-epidermal skin substitute
Elia Ricci
Difficult Wound Healing Unit, St Lucas’ Clinic,
Pecetto Torinese, ITALY
The new development of Bioengineering made available to the operators
a new category of products that promote tissue repair in chronic and acute
wounds. Currently the indications of use are not well defined, the first
documents are being drafted, but have found nothing in the operators,
many supporters. an international consensus document published in 2011
defines three different types of extracellular matrices: biological, synthetic
and composite. These materials are used as temporary coverings, their role
is in the resumption of reparative processes, this takes place through the
provision of a structure which, colonized by autologous tissues, allows
the rapid filling of loss of substance. Also these tissues have the ability to
inactivate MMPs, some authors have suggested this as real action of the
scaffolds (table 1). There is a big push from Industries in terms of research
of new products and in positioning it on the market, it is not simple classify
all heads available. Should also consider the different regulations in force
between nations and continents. In table 2 is reported a list of products
available with the classification of J W T. The most evident advantage of this
type of treatment is the reduction of aggressiveness of surgical treatment.
This feature allows to extend to patients, not otherwise candidates for
traditional surgery, the access to the operating room. even in the absence of
trial extended and controlled, it is easy to predict that this type of technology will be more and more widely applied in the near future.
Chronic wounds contain high levels of MMPs which can:
* Degrade the ECM and growth factors
* Increase inflammatory response
* Reduce cell responsiveness in the wound
* Delay wound healing
↓
Treat using an acellular matrix that closely resembles
native ECM. This may act as a scaffold for:
* MMPs to bind to and break down collagen in the product
* Epithelial cells, fibroblasts and vascular endothelial cells to
migrate into and proliferate
* Reduced levels of MMPs to be released back into wound
as collagen matrix breaks down, rebalancing protease and
growth factor levels in the wound
↓
Enhanced wound healing environment, where matrix
has been replaced by new collagen with remodelling
of ECM
Neurological aspects of chronic wounds
Jovanovic Zagorka
Clinic of Neurology Clinical Center of Serbia, School of Medicine,
University of Belgrade, Serbia.
The role of the nervous system is important in maintaining of trophic,
tone and skin perfusion. which participate in The structure of the central
and peripheral nervous system, especially the autonomic nervous system
participate in these functions. In a number of neurological diseases there
are the disorders of motor function, autonomic control of sensitivity and
vascular systems, which are particularly pronounced for difficult moving
patients. Immobility associated with chronic pressure on the skin leads to
chronic wounds. These diseases are stroke, Parkinsonism and Parkinson’s
syndrome, motor neuron disease, multiple sclerosis, myelitis, spinal cord
injury, polyradiculoneuritis, polyneuropathies et al. Dementia and depression contribute to the development of chronic wounds.
Type
SUB TYPE
BRAND NAME
Non cellularized dermal substitute
Bi layer
Integra
Hyalomatrix PA
Pelnac
Renoskin
Single layer
Alloderm
Epiflex
Ez derm
Gammagraft
Glyaderm
Integra single layer
Matriderm
Surederm
The prevalence of chronic wounds due to pressure (pressure ulcers)varies in
different studies from 12% to 27% of nonselected patients. The selection
of patients in relation of pathology showed the highest number of severe
pressure ulcers (classification by European pressure ulcer advisory panel) in
surgical patients (12%), geriatric (8%) and neurological patients (2%) after
7 days of hospital admission. The structure analysis of neurologic disease
with pressure ulcers showed one examination of 592 neurological patients,
of which 16 had decubitus on admission: 2 with motor neuron disease, 5
with Parkinson’s disease and 9 with other neurological diseases. In another
study of older patients the most common risk for pressure ulcers was the
previous stroke (60% patients). The study of risk for pressure ulcers in
patients in intensive care showed the highest risk in patients who have had
a stroke (OR = 1.96), followed by trauma (OR = 1.83) and cognitive decline
(OR = 1.26). In patients with spinal cord trauma, pressure ulcers occured in
30% - 40% of cases, with the recurrence after surgical treatment in 17.3%
of patients.
Living cells /
Cells products
Dermagraft
Dermagen
In neurological practice, trigeminlni trophic ulcer can be seen, as a result
of damage to the central or peripheral trigeminal system, with anesthesia,
paresthesia and persistent or recurrent skin ulcers.
Advanced
biological skin
repair therapy
Apligraft
Table 1: Role of acellular matrix in wound Healing (HardingK W Int 2011)
Human fibroblast derived dermal
substitutes
KERATINOCYTES COLTURE
Epicel
Epibase
Recell
Laserskin
HELPS FIBROBLAST GROWTH
Biobrane
Graftygen derma
Oasis
Unite
HELPS EPIDERMAL GROWTH
Supratel
Veloderm/graftigen
epidermis
In diabetic senso-motor polyneuropathy, the chronic wounds are
categorized as neuropathic in 50% of patients, ischemic in 15% and neuroischemic in 35%. There is a loss of perception of pain in the feet, which
along with other internal and external biomechanical factors, are leading
to chronic wounds.
Prevention should be started early, in the form of daily skin care, avoiding
pressure, good nutrition, optima physical and mental activity. Early treatment with medication includes nutritional resources, antibiotic preparations, growth factors and extracellular matrix products, using pulsed
electromagnetic fields, and surgery at the end.
Burns in Neonates
Table2: Classification of bioengineering tissues
BIBLIOGRAPHY:
·
Harding K., Kirsner R, Lee D, Mulder G, Serena T. “Acellular matrices for the treatment of
wounds”
Wounds International 2011.
·
VVAA “Bioengineered Alternative Tissue” J Wound Tecn 4, 2009
Rytis Rimdeika, MD, PhD
Lithuanian University of Health Sciences,
University Hospital Kauno Klinikos
Although burns in neonates are rare they still occur incidentally. The immaturity of skin renders infants susceptible to burns of various etiologies:
following relatively brief exposure to disinfectants, phototherapy lamps
and blankets, adhesive dressings, etc. Burns in neonates have major
implications in terms of morbidity. Author will give an overview of various
Neurological aspects of chronic wounds
— Wounds 7
etiologic factors of burns in neonates and will illustrate the presentation
with own clinical experience based on treatment of eleven patients.
First clinical case is on treatment of preterm neonate twins who sustained
burn injuries on the warming blankets in 30 December 2001. Major full
thickness burn injuries were diagnosed with a 15 and 20 % TBSA respectively. Patients were treated by eschar excisions and wound split skin
grafting with an allograft overlay (sandwich technique). Ten year follow-up
is presented. Other cases represent chemical burns in nine infants caused
by solution of benzalkonium chloride. This disinfectant often used for the
skin antisepsis prior to injections, punctures and surgical procedures in
hospitals, with no restriction to use or obstetric practice. Nine infants (5
females and 4 males) were gestated normally in regional hospital on 10th
-11th December, 2009. During 24 hours after gestation skin was wiped with
benzalkonium chloride prior to puncture of vein or for hygienic purposes.
Inflammation of wiped zones was followed by blistering and ulceration.
Affected areas included scalp, neck, armpits, thorax, abdomen, groins.
All infants were transferred to University Hospital immediately . 2-15 %
TBSA chemical burn injuries were diagnosed. Two of them sustained 15 %
TBSA injuries complicated by infection. In University Hospital wounds were
debrided and dressed with advanced dressings. Two sustaining 15 % TBSA
burn injuries had wound debridement under general anesthesia. For these
infants hydrophilic base antiseptic creams were used and wounds were
dressed by non-occlusive dressings.
Author concludes that the cases highlight the importance of having a clear
policy for nursing in every neonatal unit and measures to avoid errors by
vigilant checking of all medication and technical devices.
The wounds in vascular surgery
Nenad Ilijevski, Predrag Matić, Đorđe Radak
Institut of Cardiovasculare Disease, Institut “Dedinje”, Belgrade,Serbia
Chronic venous ulcerationtrend growth mixed ulceration
Javorka Delic
City Institute for Dermatology, Belgrade Serbia
Chronic venous ulceration (CMA) is the most common, is 65% of all ulcers of
vascular etiology (46%-75%, Wells 2004; Korber 2008; Control study 2006;
Delic 2004, 2008; Debus 2009).
In recent years, the distribution of the CMA increased tendency of mixed
ulceration, i.e. association of CMA with peripheral artery disease, diabetes,
vasculitis, lymph edema, trauma. Mixed CMA represent 10-22% of all ulcers
(Schultz, Debus, Delic, Control).
The primary objective of the study was the incidence of mixed CMA,
secondary clinical presentation, time of healing, complications, treatment
methods. In the study 91 patients - 60 women, average years (59 yr.), 31
men (56 years). CMA (post thrombotic) is present in 59 (65%) showed
mixed ulceration in 32 (35%) patients.
Average healing time of mixed CMA is 6 months, with complications (infections, cellulites, pain, bleeding), change in localization to the front and side
of the lower leg and foot, and more than 5 co morbidities and risk factors.
Arterial-venous ulcers, affect the choice of compression therapy (CT), when
the ABI below 0.8, when the ABI below 0.6 KT is not recommended, as
the ulcer is treated artery. Mixed ulcers are difficult healing ulcers, treated
with combined therapy (CB, HBO, NDT, laser stimulative, grafts, surgery,
hospitalization), and the treatment of multiple expensive compared to
“pure” venous ulceration.
The tendency of increasing mixed CMA explains the increase of the population over 70 years, an increase in cardiovascular, neurological diseases,
injuries, and the application of standardized diagnostics.
The wounds on legs were often the reason for thi patient ,s visit to vascular
surgeon. The treatment of the wounds is the burden for health system .The
most of them are vascular etiology,vhronic and reccurence. The wounds can
be the consequences of the disease of arterial or veins systems, or theirs
combinations. Also, the patients with chronic wounds have the risk factor
for the amputation of the extremities.
Because clinical and localization of mixed CMA is often defined as atypical.
Initial survey of patients with CMA includes Color Doppler, ABI, co morbidities control, i.e. a holistic approach, enabling accurate diagnosis and
treatment.
The examinations presented that the prevalence of chronic wounds ,aproximatelly 1% (adult populations) and that 80% of the wounds were veins
eiology.
Surgical Treatment of Chronic Venous
Insufficiency and Venous Leg Ulcers
Conservative method for tretament is consisted –the realisation adequate
conditions for wounds healing , dressings ,but the operative method for
wounds therapy is also very importante. The operative treatment is presented by debridment , arterial revascularisation and operation on vains
systems on extremities.
Key words: wounds, arterial, veins, therapy
Key words: venous ulcers, Ulcus mixtum
Dragan J. Milic, MD, PhD, FACS
Clinic for Vascular Surgery, Clinical Centre Nis, Serbia
Background: Chronic Venous Insufficiency and Venous Leg Ulcers
(VLU) are a major health problem because of their high prevalence and
associated high cost of care. The cost of venous leg ulcers is estimated to be
$1 billion per year in the United States, and the average cost for one patient
over a lifetime exceeds $40 000 because the natural history of this disorder
is slow healing and high recurrence rate. It is estimated that 0.3% of entire
population in Western European countries has an active venous ulcer.
Etiopathology: Ambulatory venous hypertension is a key factor in
the development of chronic venous insufficiency and venous ulcers. Basically there are two possible mechanisms involved in the development of
venous hypertension:
1) venous reflux which could be axial or segmental, deep or superficial;
and/or 2) venous obstruction.
8 Wounds
—
The wounds in vascular surgery
Surgical treatment: In the treatment of Venous Leg Ulcers main
postulate is to correct underlying venous lesion. The role of surgery is to
reduce venous reflux, hasten healing, and prevent ulcer recurrence. Surgical
options for treatment of venous insufficiency include ablation of the saphenous vein; interruption of the perforating veins with subfascial endoscopic
surgery, laser or radiofrequency ablation or sclerotherapy; treatment of
iliac vein obstruction with PTA and stenting; and removal of incompetent
superficial veins with phlebectomy, stripping, sclerotherapy, or laser and
radiofrequency therapy, skin grafting....There is no evidence demonstrating
the superiority of surgery over compression treatment in the healing of
venous ulcers, but ESCHAR study clearly demonstrated that surgery reduces
the rate of recurrences compared to compression therapy.
Conclusion: For venous leg ulcers surgical management should be
considered in order to correct underlying venous lesion. Although more
research is needed regarding the comparative efficacy of various surgical
approaches, options include debridement; human skin grafting; and
surgery for venous insufficiency, which is associated with a reduced rate of
ulcer recurrence and may be helpful for severe or refractory cases. Artificial
skin grafting with human skin equivalent may be effective when used with
compression therapy, but there are concerns regarding infection transmission.
Hemodynamic controversies over
“in-flow” perforator veins in the
etiology of chr onic venous ulcers.
Our experience in EVLA performing
Results: The success of laser procedure is based upon the main trunk occlussion of superficial venous system and absence of flow in control duplex
check-up. Subjectively, patients feel the reduction of pressure and gradual
disappearance of symptoms immediately after the first intervention. In
all the treated patients there occurred the healing of chronic venous ulcer
during a follow-up period lasting for a few weeks up to several months post
intervention.
Conclusion: In-flow preforator veins represent closing part of the
course of superficial venous insufficiency, i.e. the entering point of reflux
into deep venous system. In most cases we speak of Cockett’s preforator
veins, but frequently they can also be other preforator veins. Their hemodynamic importance in conditions of venous ulcer presence in an isloated
venous insufficiency of superficial venous system is a minor one. By solving
the problem of insufficiency of superficial venous system we also solve
the problem of preforator veins, therefore their further treatment is not
necessary for ulcer healing. Contrary to in-flow, out-flow perforators are
connected to insufficiency of deep venous system (usually as a consequence
of secondary insufficiency of deep venous system), therefore for ulcer healing their treatment is necessary.
Indication and different materials for
compression therapy for venous leg ulcers
Nada Kecelj Leskovec, MD, PhD, Department of Dermatovenereology,
University Medical Centre Ljubljana, Slovenia
Petar Dragić MD
Jelica Malešev MD
Introduction: The causes of the occurrence of chronic venous ulcers
are the following hemodynamic changes:
• Insufficiency of superficial venous system and
• Insufficiency of deep venous system with consequential occurrence of
“out-flow” perforators.
Aim: To point at the fact that hemodynamic importance of in-flow
perforators in the occurrence of venous ulcers in an isolated insufficiency of
superficial venous system is a minor one and also frequently overestimated
by physicians dealing with the issue.
Method: Last decade brought some important novelties in the field of
venous diseases treatment, therefore contemporary phlebology currently
has an array of minimally invesive methods.
Since 2008 until present day, we treated by laser 47 patients with venous
ulcres occurred due to insufficiency of superficial venous system. We have
not treated ulcers of other etiology so far. We used duplex scan to exclude
DVT, insufficiency and post-thrombotic syndrom of deep veins and artherial
insufficiency...
Chronic venous ulcers of our patients were treated by a combined therapy:
• endovenous laser ablation of insufficient superficial venous system with or
without adjuvant procedures, e.g. the application of Aethoxisclerola foam
and/or microphlebectomy,
Aim: The aims of compression therapy are to accelerate vein, lymph and
microcirculation flow and therefore to reduce chronic nonbacterial inflammation and oedema of the limb and to improve venous ulcer healing.
Methods: According to the degree of extensibility, short-stretch (extensibility 10% to 100%) and long-stretch (extensibility >100%) compression
materials are distinguished. The former generate very high sub-bandage
pressures during exercise due to contraction of muscles and stiffness of
the material (passive compression) and maintain low pressures during
rest due to their low elasticity. By contrast, long-stretch bandages exert
moderately high pressures, which are almost the same at rest and during
walking and are unaffected by changes in calf circumference, e.g. due to a
decrease in oedema (active compression). Stiffness tells us how pressures
under the bandage change during walking. It can be expressed with the
static stiffness index (SSI), which is the difference in pressure between
active standing and lying.
Results: In the first phase of compression therapy in a calf with venous
ulcer, erythema and oedema we advise short stretch bandages or very stiff
compression systems. After the reduction of limb oedema, improvement of
skin changes and healed venous ulcer, the maintain phase of compression
therapy is proceeded with long stretch compression bandages or stockings.
Conclusions: Compression therapy is indicated in all stages of CVI.
Short-stretch compression systems are suitable for advanced forms of the
disease associated with cutaneous changes and ulceration. Long-stretch
compression bandages and stockings are recommended for maintain
therapy.
• transcutaneous laser iradiation and
• elastic compression.
Hemodynamic controversies over “in-flow” perforator veins in the etiology of chronic venous ulcers. Our experience in EVLA performing
— Wounds 9
Treatment of chronic wounds using modern
supportive covering
Sandra Marinović Kulišić, Jasna Lipozenčić
The goal: Treatment with modern supportive covering is today the
most effective and pharmacoeconomic justified. The main role of a
supportive lining provide optimum physical and chemical conditions for
wound healing, and today their role is becoming ever more demanding,
in terms of prevention of the development of infection control exudate,
painful atraumatic bent down and eventually “cost benefit” compared to
conventional treatment.
Method: The modern concept of treatment today includes general and
local treatment. General measures are aimed at correcting any associated
diseases and conditions that hinder the healing process and that local treatment consists of cleaning the wound and removal of pus, necrotic layers,
and to encourage the process of granulation and epithelialization.
supportive covering are divided into:
- covering that help with autolytic processes in the wound: gels, alginates
- coverings that accelerate granulation with creating moist, warm
environment and absorbing excess secretions (hydrocolloids, hidrofiber,
hidrocapilar and silicone coverings)
- coverings that accelerate epithelization: membrane, acrylic, lining with
collagen, cellulose hidrobalans coverings, films and nets
- covering which affect on infection: the addition of silver linings and coal,
iodine, and poliheksanida medical honey.
Results: Of the 1750 patients in 2011 with chronic wounds, 980 were
venous ulcers, 215 ischemic ulcers and 565 ulcers of various etiology
(vasculitis, polyarteritis nodosa, calciphylaxis, necrobiosis lipoidica). Treatment was carried out with modern supportive liner, and it was measured
by assessing the status of the wound, chronic wound classification (previously made Biopsy specimen for microbiological treatment of ulcers and
histopathological analysis) and Doppler veins and arteries of the lower
extremities.
Conclusion: The modern supportive covering are an integral part of
care for patients with wounds of various origins. In keeping with the indications and proper application, along with an individualized approach each
patient, we can achieve faster, better, and better treatment for wounds.
Hard to heal chronic wounds – the role of
lymphoedema
Tanja Planinšek Ručigaj
Lymphoedema of lower limb presents as persistent and progressive swelling of the leg. In many patients venous and lymphatic insufficiency coexist.
Even more, at many patients with chronic wounds venous etiology, the
significance of lymphatic failure has not been recognized. The presence of
lymphoedema influence on ulcers healing and in the other way, the chronic
venous ulceratios will also damage local lymphatics and that will increasing
the potential for develop and worsening the lymphoedema. In later second
and third stage of lymphoedema, where the oedema is very big, the skin
is stretched and fragile so the risk of appearence of ulcers is biger. We can
find the chronic oedema at 35-55 % of patients with leg ulcerations. When
the lymph drainage is compromised, the fluid will accumulates and remains
10 Wounds
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Treatment of chronic wounds using modern supportive covering
proteins will influence on proliferation of macrofages. The inflammatory
responce will efect on fibroblasts and collagen fibres. All of those process
cause the skin problems and risk of infections and ulcerations.
At our study, where patients with lymphoedema and patients with
lymphoedeama and chronic venous insufficiency, both group with ulcers,
were inclouded, we find, that in group with mixed aethiology of ulcers, the
healing rate is lower versus healing rate at ulcers only lymphatic ethiology.
Treatment of Venous Leg Ulcers with Reducing
Terminal Reflux and EVLA.
Andrej Šikovec, MD, MSc
Avelana Vein
Center Otočec, Slovenia
Aim: Venous leg ulcer is the end stage result of chronic venous
insufficiency. About 1% of mainly elder population is affected by this
condition. The changes that are the result of high venous pressure cause the
inflammation cascade that ends up in hypoxia and necrosis of the tissue.
A compression therapy and care of ulcer remain the pillars of the therapy
but reducing the superficial venous reflux may boost the healing process.
The immediate distal vein reflux abolishing relives symptoms and improves
the condition to that stage that endovenous thermal therapy of superficial
reflux is feasible.
Method: After the duplex scan we started immediately with ultrasound
guided foam therapy of the venous network around the ulcer with 1%
Aethoxysclerol foam. After some weeks we continued the treatment with
endovascular laser ablation of the refluxing trunk vein and perforators if
feasible.
Results: In 2 years we have treated 12 leg ulcer in this way and we
achieved healing of all ulcers in 2 month period.
Conclusions: Immediate reducing of terminal vein reflux boost the
healing process of the venous ulcer. In this way the infection and inflammation are reduced and the symptoms are relived. So the endovenous laser
ablation of safenous vein and perforator can be safely performed in short
time period.
Key words: venous leg ulcer, terminal venous flow reduction, EVLA
Decubital ulceration - general aspects and risk
factors
Dubravko Huljev
Decubitus is a significant phenomenon, especially in the elderly years,
which is constantly growing and it is one of the most common complications of poorly moving people. This is an important gerontology public
health problem that also represent big health and economic problems
for the patient, his environment, and the facility in which it is located.
Decubitus (Latin decumbere = lying) is a condition that occurs due to tissue
ischemia or circulatory in some area of the body, caused by a stronger and
longer-lasting pressure on a certain part of the body (most commonly over
bony promination) lying or sitting. It occurs in patients who are immobile or
hardly moving, and in which it does not perform adequate.
The most important risk factor for decubitus is patients immobility, (general
bad condition, paralysis, injury or illness that is requiring bed rest or use a
wheelchair, coma, recovery after major surgery). Additional factors that
influence the development of decubitus are age, contractures, loss of feeling, malnutrition, inadequate hydration, urinary and fecal incontinence,
bacterial contamination, and so on. Prevalence in hospitalized patients,
depending on the severity of the disease and the department, is ranging
from 3.5% up to 69%. In home care that range is from 2.6% to 24%.
There are three main mechanisms for formation decubitus, and they are
pressure, shear and friction. Pressure is the most important factor in the
development of decubitus. If the external pressure is higher than the capillary pressure, then arises occlusion of blood vessels. Capillaries are closed
when the pressure rises above 32 mm Hg. Shearing occurs when the patient
slides on the surface. Shear forces result in damage to the blood vessels,
with resultant cessation of circulation. Friction is a force that occurs when
two surfaces slide over one another (eg, between the skin of patients and
sheets). On that way occurs a superficial skin abrasions. Clinically we distinguish 4 stages decubitus. I stage - erythema with edema. It occurs after a
few hours and disappears when the pressure is removed. II stage - bubbles
in the affected region or partial lack of skin. III stage - with the entire loss
of necrosis of skin and subcutaneous tissue to the fascia and muscle, with
or without undermined parts. Stage IV - ulcer affects the muscles, tendons
and bones.
The most common location is the sacrum, gluteal region, pertrohanterna
region, heel and back. Bottom of decubitus is often deep necrosis that often
extends all the way to the bone, which can be affected by infection (osteomyelitis). The edges are often undermined, secretion is often purulent, and
the surrounding skin is often atrophic with marked signs of cellulitis.
There are often complications, but the most common of these are:
infections, cellulitis, sepsis, osteomyelitis, malignant transformation ulcer
(Marjolin ulcer).
Prevention and treatment of pressure ulcers
Simon Pandjaitan1, Saša Milićević2
Plastic surgery office Pandja and Maraš,
2
Military Medical Academy, Clinic for plastic surgery and burns,
Belgrade, Serbia
1
Objectives: Pressure ulcer is a disease that occurs as a result of poor
care. Decubital ulcerations caused by action of the continuous pressure on
a particular part of the body which lead to interruption of the circulation in
the superficial layers of the skin and soft tissues. The aim of this paper is to
present the prevention of pressure ulcers occurrence, and to show the ways
of pressure ulcers treatment.
Methods: Pressure ulcer prevention methods are: prolonged pressure
release - turning the patient at regular time intervals, the use of different
types of mattresses (for better distribution of the pressure), the use of
bridges in the positioning of patients, as well as various types of splint
joints. In addition, it can also be used Clinitron bed with constant pumping
hot air. Conservative and surgical methods could be applied in the treatment
of pressure ulcers. Non surgical methods are: improved nutritional status,
treatment of infection and adequate care. Surgical treatment includes
application of split skin and local flaps in the definitive coverage of defects
of the skin caused by pressure sores covering ulceration.
Results: The paper gives a schematic view of prevention, the presentation looks mattress and advantages of using bridges. Application of surgical
methods in the treatment of pressure ulcers is presented with clinical cases,
with a final postoperative result.
Conclusion: Prevention of pressure ulcers is a key factor in care of
patients with chronic illnesses. The treatment of pressure ulcers requires
a good estimate for the application of the appropriate methods that will
promptly lead to the complete coverage of defects of the skin cover.
Keywords: pressure sores ulcers, prevention, treatment
Application of topical negative pressure in
healing wounds
Sasa Borovic, Biljana Polic, Mirjana Nesovic
Introduction: Deep sternal infections and mediastinitis are the worst
forms of surgical site infection after cardio surgery operations.This paper
presents the results of use of topical negative pressure in patients with
postoperative mediastinitis
Methods: Retrospective study that analyze the results of treatment of
10 patients using topical negative pressure in mediastinitis after cardiosurgery operation. Patients were treated in the period from march 2010.
until may 2012. in Institute of Cardiovascular diseases “Dedinje.” We used
Renasys (Smith & Nephew) and V.A.C (KCI) apparatus.
Results: Of 10 patients, 5 (50%) were female. The average age of
treated patients was 66 years (range 56 to 79). On average, 22 days passed
from cardiosurgery operation to the diagnosis of infection and the start of
treatment (interval ranged from 9 to 60).Topical negative pressure is used
on average 37 days (range 18 to 120). After treatment, the wound in 5
(50%) patients were sewn without reconstruction technique, in 4 (40%)
were used reconstructive procedures, and at 1 (10%) patient wound is
not closed. At 7 (70%) patients the treatment was successful, and of that
number 4 was without recurrence, and at 3 patienst were recurrent, and
that was locally treated until healing. In 3 (30%) patients there was a death
that was associated with infection of surgical site.
Conclusion: By using of topical negative pressure are achieved a
good results, hospitalization time is much shorten and material costs are
reduced.
Conservative and active surgical treatment of
pressure ulcers
Saša Milićević1, Nenad Stepić1, Simon Pandjaitan2
Military Medical Academy, Clinic for plastic surgery and burns,
2
Plastic surgery office Pandja and Maraš,
Belgrade, Serbia
1
Objectives: Defects of the skin covering in pressure ulcers usually cover
using active surgical approach, use of split skin graft or local flaps. The aim
of this paper is to present comparative characteristics of the conservative
and active surgical treatment.
Methods: In application of active surgical treatment, it is necessary
preoperative conditioning of patients for specific positioning, as well as
evaluation and assessment of the general state of health for the upcoming
surgery. In patients who do not accept an active surgical treatment, method
of choice is conservative treatment, with the implementation of prevention,
adequate antibiotic therapy and positioning. This paper describes the
characteristics of both approaches.
Results: Conservative treatment is a less invasive approach, which
is characterized with debridement and necrectomy, with the use of
appropriate medications for local treatment and wound dressing for the
Prevention and treatment of pressure ulcers
— Wounds 11
treatment of chronic wounds. Conservative treatment often requires more
active during treatment. Active surgical treatment is a method that is often
characterized by active short time of treatment, but that depends on the
general condition of the patient, postoperative course, and the need for
more intervention, depending on the localization of pressure ulcers and
surgical wounds healing time.
Conclusion: The decision regarding the application of certain methods
of treatment of patients with decubitus depends on the characteristics of
pressure ulcers, and general condition of the patient and his or her willingness to accept the most appropriate method of treatment which will in a
short period of time to give better results.
Keywords: pressure sores ulcers, conservative treatment, active surgical treatment
Necrotizing fasciitis, acute disease of
contemporary man
Z.Janjic, J.Nikolic, M.Marinkovic, N.Djermanov,
Clinic of Plastic and reconstructive surgery, Clinical center of Vojvodina,
Medical faculty, University of Novi Sad, Novi Sad, Serbia
Background: Necrotizing fasciitis (NF) was in the past an uncommon,
progressive infection of the superficial fascia and soft tissue with thrombosis
of skin vessels, associated with ischemia and necroses of all tissue and with
high possibility of death. The correct epidemiological data was unknown
because of the other admit diagnosis on surgical department (cellulitis,
abscessus, phlegmons). The aim of this study was to represent debridement
as the surgical procedures the most important for treatment NF patients
with recommendation for the rest therapy for this life-threatening disease.
Methods: Authors to reviewed the retrospective, one year clinical
study, with statistical analysis of data and photodocumentad patients with
NF treated in Emergency Center and Clinic of Plastic and Reconstructive
Surgery, Clinical Center of Vojvodina from Novi Sad (Serbia).
Results: A total of 46 patients with NF underwent surgery for one year,
which is the 30% more than in our last study from 2006 year. The most
common diagnosis for admitted patients was phlegmons (21 patients\ 45,
65%), while NF was admitted diagnosis for 14 patients (30, 43%). Except
for that diagnosis, patients were hospitalized as abscessus or as cellulitis.
The more common were male patients (78%) with localization on the lower
extremity (39%). The acute course of disease was the most diagnosticated
(50%) with sepsis (68%), as the most common complication in postoperative course of disease. Unfortunate, five patients (10, 86%) were to die due
NF.
Conclusions: NF is a serious life-threatening infection of soft tissue.
The incidence of this disease is growing. The early diagnosis and the fast
and aggressive surgical excision of all necrotic tissue (the majority of patients required repeated debridement) with parenteral antibiotics therapy
and systemic support to be in the recent time imperative for successful
treatment of NF.
Key words: Necrotizing fasciitis, debridement, diagnosis, treatment.
12 Wounds
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Necrotizing fasciitis, acute disease of contemporary man
Surgical treatment of Complications
Dystrophic Epidermolysis Bullosa
Rytis Rimdeika, MD, PhD
Lithuanian University of Health Sciences,
University Hospital Kauno Klinikos
The term Epidermolysis Bullosa (EB) refers a group of disorders best
characterized by blister formation as the result of skin fragility. Clinical
manifestations range widely, from localized blistering of the limbs to
generalized blistering of the skin and oral cavity, and injuries to multiple
internal organs. EB subtypes are known to arise from mutations within the
genes encoding for several different proteins, each of which is intimately
involved in the maintenance of adhesion of the keratinocyte to the underlying dermis or structural keratinocyte stability. EB is best diagnosed and
subclassified by the collective findings obtained via detailed personal and
family history, in concert with the results of various laboratory findings. All
types and subtypes of EB are rare; the overall incidence and prevalence of
the disease is approximately 50 per one million live births and 9 per one
million population. Out of these 92 percent are cases referred to EB Simplex
and 5 percent of referred to Dystrophic EB. Optimal patient management
requires a multidisciplinary approach, and involves the injury prevention of
susceptible tissues, use of advanced wound dressings, nutritional support,
and adequate medical or surgical interventions to correct whenever possible the extracutaneous complications. Prognosis varies considerably and
is based on both EB subtype and the overall health of the patient.
The hands and foots due to intensive use during normal daily activity are
especially exposed to blistering, with secondary scarring leading to pseudosyndactily, adduction contracture of the thumb, and flexion or extension
contracture of the fingers. The standard surgical approach for the correction
of these deformities is based on the degloving of affected limb, combined
blunt-to-sharp release of pseudosyndactily and contractures, skin grafting
of the secondary wounds.
Author will give a short overview on classification, etiology, epidemiology,
diagnostics of various subtypes of EB, as well as personal approach to surgical techniques of dissolving syndactily and contractures, intraoperative
splinting of separated fingers, wound management after the surgical
release of deformations and post op nursing. Author conclude that an individual surgical attitude, along with an adequate intra and post-operative
rehabilitation, ensures a good restoration of function and a satisfying delay
of inevitable recurrence.
Chronic wounds in dermatology: new
possibilitas of the treatment
Jasmina Begic
Dermatovenerology Clinic, Clinical Center University Sarajevo
Bosnia and Herzegovina
Introduction: The incidence of the skin and soft tissue infection
(SSTIs) has increased due the to the ageing of the general population,
the increased number of critically ill patients, the increased number of
immunocompromised patients (HIV infection, cancer, immunosuppressive
therapy) and recent emergence of multi-drug resistant pathogens. Unusual
number of nonhealing wounds, noticed in the people with autoimmune
disorders.One of the reasons at the autoimmune disorders is that they may
have low-grade vasculitis-inflammation affecting the small blood vessels
in the skin. People with normal skin is heavily colonized by bacterial flora.
Normal flora of skin is classified on the resident flora, transient flora and
transient or temporary residents. The infection may arise as primary infections in minor superficial breaks in the skin or as secondary infections of
preexisting dermatosis. Carriers of S.aureus and GAS are at increased risk
for pyodermas and skin and soft tissue infection (SSTIs).
Aim: Aim is to present new possibilitas of the treatment patients with skin
and soft tissue infections (SSTIs).
Methods: Three contemporary problems conforming the clinical
evaluation of patients with skin infection are diagnosis, severity of infections and pathogen-specific antibiotic resistence. In the six months we
made at patients with inflammatory dermatoses, bullous disease, ulcers,
dermatopphytosis and bites,microbiological tests, microbiological swab
and the culture techniques , the amount leucocytes in the complete blood
count, CRP and local clinical symptoms of infections( induration, erythema,
warmth and pain).RESULTS: during the six months most frequently isolated
bacteria were S.aureus, Pseudomonas aeruginosa, MRSA( in the nose at
the skin). At the patients with SSTIs accompanied by signs and symptoms
of systemic toxicity we sow at the patients with bullous disease and the
patients with immunosuppressive therapy, and they treated with systemic,
topic and supplemetary therapy.Patients without this symptoms were
treated with topic and supplementary therapy. Like supplementary therapy
we used Bioptron polarized light (480-3400nm).
Conclusion: In the case of skin and soft tissue infections (SSTIs) we
treated patients with systemic, topic and Bioptron polarized light (4803400nm) and we reduce infection, reduce time of hospitalization and
antibiotic therapy.
Madura foot as cause of chronic wounds
Radovanovic S1, Delic J.2
Nyangabgwe Referral Hospital, Francistown, Botswana
2
City Institute for Dermatology, Belgrade, Serbia
1
Madura foot is rare cause for chronic wounds formation and in endemic
areas it offenly remains unrecognized. This disease is morphological entity,
etiologically there can be eumicetoms which are evoked by pathogen fungi
or actinomicity caused by microaerophyl actinomicity.
Clinically, there is trio: 1. Tumefaction 2. Fistulas (and fistula scars) 3. Colored
“grains” in escudat-agregation of the cause. Disease is asymptomatically in
good condition even at very destructive neglected changes.
We had two patients with actinomicity and results of their therapies which
consists of two 5 week treatments with mix of antibiotics and antimicotics.
For correct therapy it is essentially important to make difference between
eumicetoms and actinomicetom, histological and microbiological.
Key words: Madura foot, micetom, atypical chronic wounds
Tissue guided regeneration with allogeneic
platelet gel, autologous cancellous bone graft
and resorbtive collagene membrane
Igor Frangez1, Ciril Triller2, Dragica Maja Smrke2
University clinical centre Ljubljana, Department of Traumatology 1
and Department of Surgical Infections 2, Ljubljana, Slovenia.
Background: Chronic osteitis is a serious complication in open fractures. Therapy is usually long and demanding. It is one of the most difficult
complications in open fracture treatment and appears in about 20 % of
cases. Approach must be multidisciplinary with surgical basis. At the end
of the infect erradication there is often a large bone defect. Tissue guided
regeneration with allogeneic platelet gel, autologous cancellous bone graft
and resorbtive collagene membrane is one of the possibilities how to bridge
bone defect.
Case report: 26 years old male sustained open fracture of distal cruris
with steel wire. He was urgently operated – necrectomy of bone and soft
tissue, revision of wound and external fixation was performed. We replaced
external fixator with intramedulary nail. After 6 weeks we covered wound
with Tiersch transplant. Four months later he came with clinical sign of
infection on distal part of the cruris and chronic osteitis was diagnosed.
Intramedulary nail was replaced with external fixator, radical necrectomy
of bone and soft tissue was performed, VAC was changed every three days.
Antibiotic therapy was adjusted to antibiogram. In two months osteitis was
healed and soft tissue defect was grafted with surralis and one month later
we performed tissue guided regeneration with allogenic platelet gel and
autologous cancellous bone graft and resorbtive collagene membrane.
The essential idea of this therapy was to combine the healing capacities of
platelet-derived growth factors and osteogenic stem cells and the modeling
capacity of the gel. After operation we performed photobiomodulation
with LED (light emitting diode) of the operated area to enhance healing
potential. After 4 months the graft was incorporated, the bone defect was
fully bridged and full weight-bearing capacity was achieved.
Conclusion: Our case presents the example, where tissue guided
regeneration with allogenic platelet gel, autologous cancelous bone graft,
collagene resorbtive membrane in addition with photobiomodulation with
LED can improve and shorten treatment outcome.
Debrisoft - or how to simply do the wound
debriman
Borisav Mandić, Tijana Đurić, Marina Dišović
Health centre “Dr Ristić” Novi Beograd, Srbija
Aim: Demonstration of fast and easy wound debridman by Debrisoft
utilization. It is an active system which removes debris, necrotivc tissue,
fybrin sediments, escudat and even hyperceratotic sediments on the edge
of the wound. It is provided by milions of polyester microfybrin fibers in the
Debrisoft.
It simultaneously allows the newformed granulated tissue and epithel to
remain unharmed. Debrisoft is ised at vein ulcus, decubitus, diabet foot,
acut wounds and postoperative wound that heal secondary.
Methods: We have analized efect of Debrisoft use at hard-to-heal
vein ulcuses in which treatment of interactive compresses is also used. We
have presented several cases in which Debrisoft was used for its efficeancy
Madura foot as cause of chronic wounds
— Wounds 13
in entirelly painless wound debridman after which speed of healing was
accelerated.
Results: Single use of Debrisoft in 2-4 min. period provided very good
result in removal of debris, necrotic tissue of fibrin sediments. For similar
effect by classic methods it was needed 3-7 days!
In some cases, particulary with thick necrotic particle, parts of the dead
tissue have to be removed by invasive methods (surgery) and after that
treat with Debrisoft.
Conclusion: Debridman is neccessary treatment which enables healing of chronic wounds. By Debrisoft use, it is accomplished fast, east and
effectivly. Also, the whole procedure is very comfortable for the patient
since it is completely painless.
Key words: Debrisoft, debridman, painless
Calciphylaxis
C. TRILLER¹, D. HULJEV², D.M. SMRKE¹
¹ University Medical Centre Ljubljana, Slovenia, Division of Surgery,
Department of surgical Infections
² Sveti Duh University Hospital, University Department of Surgery,
Centre for Plastic and Reconstructive Surgery, Zagreb, Croatia
Calciphylaxis is a form of extra-skeletal calcification characterized by
calcium deposites in arterial tunica media and vascular thrombosis, which
leads to tissue ischaemia including skin ischaemia with consequential skin
necrosis. Necroses may also develop in the subcutaneous adipose tissue and
skeletal muscle. The cause of this disorder remains unknown. It was first
described by Bryant and White as early as 1989 in association with uremia,
and the syndrome remained clinicaly inadequately recognizable until
1976. Then, Gipstein and coworkers described the disorder in more detail,
followed ba a great number of calciphylaxis case reports since then, including data on morbidity and therapeutic dilemmas. Calciphylaxis has been
reported in association with renal insufficiency treated by hemodialysis,
hepatic cirrhosis, diabetes mellitus, obesity, Mb. Crohn and some other
sistemic diseases like cholangiocarcinoma, lupus erithematodes and carcinoma of breast. The authors present the clinical procedure of identifying
and treating major ulcerations on both legs in a patient with polymorbidity
and recognized calciphylaxis wich caused skin necroses with consequential
chronic leg ulcers.
Key words: calciphylaxis, calcific uremic arteriolopathy, renal insufficiency, hemodialysis
Application of iron preparations and
recombinant human erythropoietin is a
prerequisite for faster healing of chronic
wounds in the cardiovascular surgery in
anemic persons
Branko Čalija
Institute for Cardiovascular Diseases Dedinje, Belgrade, Serbia
Introduction: Treatment of chronic ulceration of the skin lower
extremities resulting from various diseases and pathological changes in
modern medicine requires a large investment, patience and persistence for
both patients and health care professionals. It is well known that within
the European Union, the USA, Canada and Australia for the treatment of
14 Wounds
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Calciphylaxis
chronic wounds spends about 2% of the planned budget to treat population. Unfortunately in Serbia the concept of code list of medical services and
treatment of chronic wounds there.
As in most cases, patients with early chronic anemia and a wound healing process is even more difficult and complicated. This is indicated by
numerous data in the literature and our experience over the last twenty
years gained in the transfusion management of patients undergoing heart
surgery, arteries and aorta.
When the concentration of hemoglobin in the circulation of patients was
lower than 100 g / L healing of chronic wounds or ulcers on the extremities
was slow and difficult due to the lack of peripheral oxygenation. Anemia in
most cases is caused by iron deficiency or a consequence of chronic diseases
(diabetes, insufficient renal function, systemic disease, malignancy), or is
caused by the inflammatory cytokines on progenitor cells of the erythrocyte
lineage.
Method: Repeated infusions of iron supplements (Ferri sucrose, 1 mg
vials contains100 Fe3 +), in the interval of 3-4 weeks (total of 1000 mg),
raises the level of Hb 30%, compared to baseline (≤100 g / L). When the iron
infusion combined with subcutaneous application of recombinant human
erythropoietin (repo), erythropoiesis is significantly faster, and the level of
Hb in the circulation increases by 40% and maintained for longer. Usually it
is applied to 10 000 IU of alpha or beta repo, or 100 mcg of darbepoetin alfa
once a week, a total of 30 000 IU or 300 mcg of darbepoetin alpha.
Results:Following the introduction of strategies to correct preoperative
anemia hypochromic iron supplementation and repo, the need for allogeneic red blood cell transfusions in Institute for Cardiovascular Diseases
Dedinje was reduced from year to year. Durable are reduced postoperative
complications that include chronic wounds and sternum and lower extremities (the place extirpation of vein grafts).
Conclusion: Treatment of anemia in pre, peri and postoperative iron
supplementation and r-EPO in cardiovascular surgery in addition to medical
and has also economic importance.
Development Center for treatment of chronic
wounds in the BH Heart Center Tuzla
Softic M., Banjanovic B., Jahic M., S. Rajkovic
Special Hospital BH Heart Center Tuzla
Introduction: The Center for treatment of chronic wounds was organized in early May 2012 as part of the BH Heart Center Tuzla. In daily contact
with patients, we had a growing influx of patients with problems and
severe complications occurred as a result of chronic venous insufficiency,
arterial occlusive disease, or diabetes mellitus. Practically there were no
institutions where these patients receive adequate assistance. This was the
reason why we accepted the cooperation and under the supervision of colleagues from Germany and Austria, launched a project of the Center for the
treatment of chronic wounds. Identificran space within our facility, which
consists of two clinics and outpatient clinic with 5 beds. The team is trained
and is composed of four doctors and six nurses. Center currently operates as
the day hospital. In future hospitalization of these patients. During the first
six months in our clinic were examined over 70 patients. After presenting
our protocol for treatment in our institution, 38 patients consented.
Patients and Methods: 38 patients consented to be treated in our institution by protokolu.18 patients (47.36%) had a chronic wound as a result of
chronic venous insufficiency, in 7 patients (18.42%), the wound was the
result of Diabetes mellitus , 4 patients (10.5%) due to arterial occlusive
disease, vasculitis, allergic etiology was verified in 3 patients (7.9%),
Rheumatiod arthritis in 1 patient (2.63%), as the primary cause of injury
was verified in 2 patients (5.26%), and peripheral neuropahtia as a result of
previous surgery for a variety of foot deformities in 3 patients (7.8%). After
the first examination, and treatment of vascular clinic patients is explained
mode and Approximate length of treatment. Procjelini we found that 90
days period when we should expect the first results of treatment.
Results: 13 patients (34.2%) had less than 6 treatments at our institution, which was expected. In 25 patients, the treatment is carried out
according to the protocol for a period of 90 days. In 7 patients with chronic
venous ulcer healing was observed, the remaining 4 patients with diabetic
foot were recorded at one healing, and in the remaining three patients, a
drastic reduction in the wound and infection control, two of the remaining
patient in whom verificran arterial ulcer in one noted healing after surgery
(FP bypass), another patient had suggested surgery, a patient with rheumatoid arthritis are still being treated in our institution, in three patients
with polineuropathiom improvement is noted with infection control but are
still on treatment.
Conclusion: From our past experience has proven that the launch of
the Centre and the treatment of these patients by the principle of moist
wound care was fully justified and appropriate. Moist wound care patients
were well tolerated. Hidrobalansni system, without the addition of analgesics was responsible for the high potential of reducing pain. Antimicrobial
substances in addition to some of the bandages were effective in the treatment of wounds at risk of infection and infected rana.Upotreba products
that contain collagen has led to faster healing of wounds due to improved
mikroprokrvlejnosti tissue. The establishment of the modern center for
the treatment of chronic wounds, except the use of the latest methods of
treatment, we started with the formation of a unified database, create the
specific information on the wounds, which will help in the statistical analysis and evaluation, and objective decision about the treatment strategy.
Reconstructive treatment of diabetic foot
Jelena Jeremic, Cedomir Vucetic
Clinic for Orthopaedic Surgery and Traumatology,
Clinical Centre of Serbia, Belgrade
Faculty of Medicine, University of Belgrade
Clinic for Plastic and Reconstructive Surgery, Belgrade
Introduction: Surgical treatment, which aims to save disturbed
anatomical integrity and function, is reconstructive. If it is necessary to do
the amputation of bigger or smaller anatomical part, if the way of doing
it aims to save as much as possible, avoiding the radical procedures, using
specific surgical procedures- it is, also, a reconstructive treatment.
Pouprose: We are showing surgical techniques and possibilities of
reconstructive treatment in diabetic foot.
Method: Patients with diabetic foot were treated operatively when there
was a deformity which had led to ulcers or to further local complications.
The patients with ulcers and gangrene on toes and part of the foot were,
also, treated operatively. The surgical reconstructive treatment is classified
as preventive and reconstructive in cases of developed clinical picture. Preventing complications development, necrosis, gangrene, infection caused
by surgical interventions is named as preventive reconstructive treatment.
It included deformity correction, pressure distribution, improving the
circulation of the operated part. Preventive reconstructive treatment aims
to correct anatomical relations and function. Reconstructive treatment at
developed clinical picture of diabetic foot included covering of skin deffects,
resection of bones and joints, saving the foot integrity. With these operative
procedures we are trying to save the anatomical integrity and function.
Results: Healing in earlier levels of changing was simplier and with
greater chances for success (shorter time of operative wound healing,
avoiding or delaying further unwanted changes on foot, better function
and better esthetic result).
Conclusion: Reconstructive surgical treatment has two important
parts, preventive and reconstructive treatment at developed clinical picture
of diabetic foot. Surgical correction of deformities which lead to ulcers appearance gives better results than non- operative treatment. Reconstructive
procedures give less disability, provide functionality and better quality of
life.
Vacuum Assisted Wound Closure in Vascular
Surgery – Experience of Clinic for Vascular and
Endovascular Surgery of the Serbian Clinical
Centre
Marko Dragas1,2, Igor Koncar1,2, Lazar Davidovic1,2
1
Clinic for Vascular and Endovascular Surgery
of the Serbian Clinical Centre
2
Medical Faculty, University of Belgrade
Vacuum assisted closure (VAC – KCI) has been increasingly used in the Western Europe and USA clinical practice since 15 years ago. Serbian National
Agency for Drugs and Medical Devices registered this method in 2009. Advantages of this method are faster wound healing, wound approximation
and cost effects related to the wound and patient with wound care. There
are not enough publications regarding usage of this method in vascular
surgery. Of most importance are groin incisions due to the wound dehiscence, lymphatic fistula or infections in 5% to 10% of patients following
vascular procedures. These complications may be limb- or life-threatening,
especially for early, deep wound infections. Also, cost effects in developed
country are not automatically transmitted to developing countries due to
the huge difference in procedure and hospital costs.
In order to explore potential of this method in vascular surgery and to test
cost effects in a developing country Clinic for Vascular and Endovascular
Surgery of the Serbian Clinical Centre organized clinical trial supporting by
Lavifarm ad. Representative of KCI for Serbia.
Aim of the trial was to compare treatment and cost effects of VAC and
conventional wound treatment that was already used in the local clinical
practice for decades.
Material and Methods. All patients with wound infection and
dehiscence operated at the Clinic for Vascular and Endovascular Surgery
of the Serbian Clinical Centre in the period from January 2011 – January
2012 were included in the trial. Primary endpoint of the study was wound
closure, while secondary endpoints were duration of hospitalization,
number of weekly wound dressings, costs of wound care, working time of
medical nurse dedicated to the care of this patient related to the complicated wound. Patients were divided in several groups in order to be easier
to compare and interpret results. 1. Wound with exposed synthetic vascular
implant (25%), 2. Infected or dehisced laparotomy wound (13%) 3 Wound
after foot amputation (29%) 4. Wound after major limb amputation (21%)
5. Fasciotomy wound (13%)
All data of patients treated with VAC therapy, except data related to
dehisced laparotomy wound, were compared with the conventionally
treated wound. There was successful wound suture during hospitalisation in
84% of patients. Among complication we recorded recurrence of infection
(4%), bleeding (4%), limb ambutation (4%) and death (4%). There was
Reconstructive treatment of diabetic foot
— Wounds 15
significant difference between the conventional method in hospitalization
length, costs of wound care, nursing necessary time and costs of wound
care.
Vacuum assisted wound closure is effective method for care of complicated
wounds in vascular surgery. Wound infection with exposed synthetic grafts
might be solvable with this method, however greater number of patients is
necessary to confirm that or to define subgroups of patients that are good
responders to this therapy. Cost effectiveness ov VAC therapy is applicable in
a developing countries scenario.
4.
5.
6.
7.
Organization of a specialized multidisciplinary
Wound Center for Chronic Wound Management
in Copenhagen
Finn Gottrup
Professor of Surgery, MD, DMSci.
Copenhagen Wound Healing Center
Department of Dermatology
Bispebjerg Hospital, Copenhagen, Denmark
Objective: To improve prophylaxis, diagnostics and treatment of wound
patients. This is achieved during establishment of a multi-professional
organization in the primary as well as in the secondary health care sector.
Methods: Such a multi-professional organization in the health care
sector should consist of hospital centres and smaller units in the primary
health care sector. Collaboration models between the hospital and community sector should be developed and standardized treatment protocols and
patient guidelines should be carried out. Evidence for improved quality of
treatment and care and a standardized educational program for all involved
types of staff should be accomplished.
Results: Such a model has been established in Denmark. Clinically the
organizational model consists of two hospitals units with own staff and inbeds: Copenhagen Wound Healing Center (since1996) and University Center
of Wound Healing (since 2003).
The referral policy has been simplified and centralized. Treatment plans
including diagnostics, treatment and prevention have bee optimized.
Different types of educational services, basic and clinical research and
prevention programs have been established. A national education program
of 6 months for nurses has been achieved and a 2 year education for medical
doctor and a national accepted wound expert area called “Clinical Wound
Healing” have been worked out. For generation of evidences a PC database
on patients with DFU primarily for research use has been worked out.
Conclusion: Development of organizational models including databases, systemic evaluation of quality of care and outcome measures may in
the future give us the ideal and optimal method of organization of wound
care delivering. Education and development evidence are vital parts of this
development.
References:
1.
Gottrup F et al. A new concept of a multidisciplinary wound healing center and a national expert function of wound healing. Arch Surg. 2001;136:765-72
2.
Gottrup F. Organization of wound healing services: the Danish experience and the importance of surgery. Wound Repair Regen. 2003; 11: 452-7.
3.
Gottrup F. Optimizing wound treatment through health care structuring and professional education. Wound Rep Reg 2004; 12:129-133
16 Wounds
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Gottrup F. A specialised wound healing center concept: importance of a multidisciplinary department structure and surgical treatment facilities in the treatment of chronic
wounds. Am J Surg 2004; 187:38-43S
Gottrup F. Management of the Diabetic Foot: Surgical and Organisational Aspects. Horm
Metab Res, 2005;37, Supplement 1:69-75
Gottrup F. Education and organization in wound healing and care. In: Shukla VK, Mani
R, Teot L, Pradhan S, eds. Management of wound healing. Jaypee, New Delhi. 2007, pp.
241-256.
Gottrup F, Apelqvist J. Present and new techniques and devices in the treatment of DFU:
a critical review of evidence. Diabetes Metab Res Rev. 2012; 28 Suppl 1:64-71
Organization of the Center of
Chronic Wounds - Management in the
Asklepios-Klinik-Hamburg-Harburg
Dr. Harald Daum et al.
History: The WundCentrum Harburg was founded in 1999. It is part of
the Department of Vascular- and Endovascular Surgery. We started our
work out of the interest to optimize the outcome of our patients with arterial caused gangrene and necrosis, but more and more we fixed our focus
of all kind of chronic wounds. In 2011 we became certificated as the first
woundcenter in Germany.
Organization: Our Woundcenter is integrated in an outpatient clinik
within our hospital. There are three specialized wound-nurses working in
the Woundcenter on a regular base. In addition to that at least one surgeon
is attending. They are working close together with the angiologist in our
team, so we get vascular duplex whenever it is necessary.
Advantages: In our Woundcenter we concentrate all patients with
complex dressings and can prove new methods. This leads to more
competence and helps to spare money. Furthermore we get a lot of new
patients for the hospital for vascular reconstructions, which is a big deal for
our hospital economists. Every nurse in education has to pass through this
ward. Every patient is listed in a standardized wound-documentation with
digital photo-documentation. This gives us the chance of a retrospective
follow-up, if it is of interest.
So the centralization of patients with chronic wounds helps to improve the
quality of treatment and has economic benefits.
Comprehensive treatment in the treatment of
burns
Nenad Stepić
Military Medical Academy, Clinic for Plastic Surgery and Burns,
Belgrade, Serbia
Objectives: The burns are thermal damage to the body, characterized
by local and systemic changes. The aim of this paper is to present the
methods of modern treatment of burns.
Methods: Treatment of burned patients in specialized institutions
consists of resuscitation of burned patient, monitoring, general treatment
of burns, and local surgical treatment. Upon admission to the hospital, burn
depth and surface and assessment of vital signs are evaluated, and presence of associated trauma, urinary and central venous catheters are placed,
and nasogastric tube, wound smear and blood for laboratory analysis are
Organization of a specialized multidisciplinary Wound Center for Chronic Wound Management in Copenhagen
used, heart and lung X-ray and ECG are done, resuscitation and monitoring
is going on, general therapy is administered and local treatment of burned
surfaces is started. Depending on the patient general condition and on the
burned surfaces localization, treatment is applied in a multidisciplinary
approach. After burned surfaces demarcation, definitive evaluation of the
depth and surface is done, based on which a decision is made on how to further local treatment, using the conservative and active surgical approach.
Results: This paper presents an algorithm of treatment from hospital
admission until the final results, with the wording of replacement fluid,
local and active surgical treatment is carried out at the Military Medical
Academy. Clinical cases are presented with an analysis of the primary assessment, course of treatment and final results.
Conclusion: Treatment of burned patients is a complex process that
often requires a multidisciplinary approach, and the success of the treatment depends on adequate assessment and implementation of optimal
methods.
Keywords: burns, treatment, modern approach
Dr. Sebastian Probst
The aim of this presentation is to demonstrate strategies how the Swiss
Wound Care Association (SAfW) (Swiss German section and Swiss French
section) promotes modern wound care within Switzerland to patients, their
caregivers, nurses and medical doctors (MD’s). This is done through educational coursesthat vary from a basic wound course to a Master in Advanced
Studies (MAS) in wound care and the establishment of interdisciplinary
education of specialised wound care nurses and MDs. Additionally the SAfW
promotes scientific projects in this area with a grant. Thedevelopment and
implementation of education of wound care specialist’s education as well
as the wound care projects within Switzerland are a mainstay of the SAfW
and will be presented.
Intravenous Iron Administration For Acute and
Chronic Wound Healing in Anemic Patients
Organisation of the Center for chronic wounds
management- our experiences
Aleksandar Gajić,
Center for hyperbaric oxygen chambre ant chronic wounds
management. Department for physical medicine and
rehabilitation ” Dr Miroslav Zotovic”, Banjaluka, Republika Srpska,
Bosna and Hercegovina
Aim: the presentation of the organisation and results of the Center for
chronic wounds management.
Materials and methods: Hyperbaric oxygen therapy we have
since 2005 ,on department for vascular rehabilitation.Later, The Center was
formed as special unit for hyperbaric oxygen(HBO) and other modality of
the teratment. In Center worked 3 doctors and 12 nurses; the doctor and
nurse is one team for wounds management. Also, we have many consultants –endocrinologyst ,psychiatryst,and others(multidiciplinary method.
) In Center we have Hospital department (21 beds) and 2 department
for wound dressings and current diagnostic support (tpO2 and LDP). For
now,we have terated aproximatelly 3000 patients. The most of them
were treated (85%) about diabetic foot. All patients were terated by
complex, therapy,paralel more kind of the therapy . 90% of all patients
were treated by HBO. Results : The control parameters for wound s
healing were: discrease of the surface of the wounds,the appearance of
the granulation tissue, start of epithelasition ,discrease oedema and pain.
At 86% of all patients we realised very good results ,at 8% of all cases
treated by operative interventions and at 5% of all patients there arent any
changes. Consclusion : The organisation of the Center for chronic wounds
is very importante , because the chronic wounds are medical and also,
socio-economic problem.
Key words: Chronic wound, organisation
Presentation of the Swiss Wound Care
Association (SAfW).
Branko Calija
Dedinje Cardiovascular Institute, Belgrade, Serbia
Healing of an open wound, be it from a surgical procedure plays a crucial
part in recovery and health. The most common complication is infection,
which often affects compromised and elderly patients. An open, festering
wound becomes a breeding ground for bacteria and other microbes. The infection can spread to the bloodstream and cause sepsis, a serious and often
fatal condition. Without the proper amount of iron, wound would starve off
oxygen and not complete the steps of healing as oxygen plays a vital role in
the repair and making of new, healthy tissue. Iron deficiency anemia may
be a result of chronic blood loss, acute blood loss, malabsorption of iron or a
deficient diet. Laboratory tests to diagnose iron deficiency anemia include
low hemoglobin and hematocrit, low mean corpuscular volume (MCV),
low serum iron, low ferritin and elevated total iron binding capacity (TIBC).
Iron’s primary job involves carrying oxygen-rich hemoglobin to the cells and
tissues of the body. Wound-healing takes many steps and involves diverse
components. It generally occurs in three stages, the inflammatory phase in
which wound healing begins; the proliferative phase in which cells begin to
cover the wound; and the maturation phase in which scar tissue is formed.
A cascade of events occurs to allow for these processes. Because iron’s
responsibility involves getting oxygen via the hemoglobin to the wound
site, it plays an important role in healing. Healing could not take place
without oxygen. Management of Anemia. Anemia, is not only is a major risk
factor for transfusion, but it is also an independent predictor of morbidity
and mortality, and patients should be monitored throughout their course
of care. Management of anemia consists of treating the underlying cause
and use of hematinic agents to rapidly restore hemoglobin levels to normal.
Choice of agents should be guided by the etiology of the anemia as well as
the patient’s condition and available time prior to surgery; commonly used
agents include iron (oral or intravenous preparations), folic acid, vitamin
B12, and erythropoiesis stimulating agents (ESAs). ESAs are highly effective
in increasing hemoglobin levels and they can produce the equivalent of
one unit of blood per week of treatment. Intravenous iron preparations are
available with various formulations (i.e. iron sucrose, and iron gluconate)
each with specific characteristics to treat iron deficiency anemia. Given the
concerns associated with ESAs mentioned above, the role of intravenous
iron has become even more important as the primary therapy for anemia.
Organisation of the Center for chronic wounds management- our experiences
— Wounds 17
Additionally, evidence indicates that intravenous iron with or without ESA
therapy can reduce blood transfusions in surgical patients.
Endovenous laser ablation veins in treatment
of vsm, and prevention of recurrent venous
ulcer
Dario Jocić
Introduction: Ligature, crosektomy and vein stripping was a standard
in treatment of venous insufficiency and varicose veins. Since the beginning
of the twentieth century endovenous thermal ablation has become, in
the Western world, the most common method of treating varicose veins
disease.
Methodology: The study included 45 patients operated between
1.10.2011. to 01.09.2012. 31person of that were female, average age 47.2
years. All patients were symptomatic, 14 patients were in stage C2, C3 in
18, 7 in C4, C5 in 4, and 2 patients had active venous ulcer. All patients
were operated Nd-YAG 1064-nm laser, in terms of tumescent anesthesia.
In the postoperative period, the patients were prescribed wearing elastic
stockings 3-4 weeks after surgery. Patients were monitored, first, seventh
postoperative day, month after surgery and after six months.
Results: In 11 patients was made endovenous laser ablation veins in
both legs, in 5 patients was made ablation VSM, ITA small veins and in 3
patients was made endovenous and laser ablation of perforating veins. In
the postoperative period, there was no deep vein thrombosis, infection or
bleeding. Ultrasonographic screening examination one month after surgery
in all patients was registered successful thermal ablation of the treated
veins. The patients from the C5 and C6 groups during the study period, has
no been recurrence of the ulcer.
Conclusion: Endovenous laser thermal ablation VSM, ITA vein shows
excellent postoperative results. In period of the development of minimally
invasive surgery, this method has taken its place. The method is successful in
alleviating the symptoms, treatment and prevention of varicose syndrome
recurrence of venous ulcers.
Key words: laser ablation endovenous veins, venous ulcers, varicose
veins.
Debrisoft-or how to simply do the wound
debriman
Borisav Mandić¹, Tijana Đurić¹,Marina Dišović¹
¹Health centre “Dr Ristić” Novi Beograd, Srbija
Aim: Demonstration of fast and easy wound debridman by Debrisoft
utilization. It is an active system which removes debris, necrotivc tissue,
fybrin sediments, escudat and even hyperceratotic sediments on the edge
of the wound. It is provided by milions of polyester microfybrin fibers in the
Debrisoft.
It simultaneously allows the newformed granulated tissue and epithel to
remain unharmed. Debrisoft is ised at vein ulcus, decubitus, diabet foot,
acut wounds and postoperative wound that heal secondary.
Methods: We have analized efect of Debrisoft use at hard-to-heal
vein ulcuses in which treatment of interactive compresses is also used. We
have presented several cases in which Debrisoft was used for its efficeancy
18 Wounds
—
in entirelly painless wound debridman after which speed of healing was
accelerated.
Results: Single use of Debrisoft in 2-4 min. period provided very good
result in removal of debris, necrotic tissue of fibrin sediments. For similar
effect by classic methods it was needed 3-7 days!
In some cases, particulary with thick necrotic particle, parts of the dead
tissue have to be removed by invasive methods (surgery) and after that
treat with Debrisoft.
Conclusion: Debridman is neccessary treatment which enables healing of chronic wounds. By Debrisoft use, it is accomplished fast, east and
effectivly. Also, the whole procedure is very comfortable for the patient
since it is completely painless.
Key words: Debrisoft, debridman, painless
Mesotherapy in dermatocosmetology and
regulation of reparative processes of the skin
Nevenka Dokmanovic
Mesotherapy also known as intradermal therapy was created in 1952,
thanks to Dr. Michel Pistor, and it was initially used in rheumatology and
traumatology. It represent intradermal injection application method in a
very small dosages, locoregional, with the goal of healing on the expance of
effects of medications and effect of biostimulation active points and zones
reflexogenic skin.
Indications in deramtocosmetology are numerous: Dermatological
disorders (acne, seborrhea, scleroderma, eczema, trophic ulcers, hyperpigmentation), rosacea, xanthelasma, cellulite, aging skin, hair diseases, scars,
stretchs. Mesotherapy treatment gives a positive result at the expence of
the effect of needle skin (intermittent effect), on specific pharmacological
effects (pharmacological effect) and on reflex action and neurohumoralnog
to distant organs and systems.
Among dermatocosmetologist appeared a guestion appropriate to use
intradermal injections surface to accelerate the reparative process in skin
damage and reduced its pace of regeneration, which develops during
aging. Consequently, it has been made a research of stimulation of skin
reparation by glycosaminoglycans (GAG), through intradermal injection.
The main positive effects of glycosaminoglycans are: normalization of collagen synthesis, stimulation of fibroblast proliferation, stimulation of the
trophic tissues, active antioxidant protection, normalization of blood wall,
antiplatelet activity. The research was conducted on rats, genous Wistar.
The tested animals were divided into groups. In first group was studied
the normal course of reparative processes without additional stimulation.
In second group were rats whose reparative processes were stimulated by
intrabdominal application GAG.In third group, stimulation of reparative
processes are performed by intradermal injections of GAG about skin defect
to a depth of 2 mm. The aim of this study was to evaluate the regeneration
of skin and systemic reactions of the body in various ways applications
products.
The results of exeperiment research shows that the drug glycosaminoglycan has a stimulatory effects on wound healing in all ways of application.
Intradermal GAG applications has led to a more active process of reparation.
Keywords: Mesotherapy,glycosaminoglycan, reparations
Endovenous laser ablation veins in treatment of vsm, and prevention of recurrent venous ulcer
Chronic wounds on postoperative cut –
present cases
Injuries In Children
Sara Rowan
Florence Italy
Dijana Lukic, Gordana Kanjevac, Javorka Delic
Most chronic wounds on department of the peripheral circulation The
City Institute of Dermatology are venous and venous – diabetic,that are
significantly increasing.Postoperative wounds , is our patients are usually
in place phlebectomy ( for coronary by – pass ) and after tumor surgery
(higrom,lipoma), other less frequently after surgery.
Aim of presentation is to present patient with chronic wounds to cut operating
First patient.72 years,males, on both sides phlebectomy.Operating on both
sides of the cut ,in the region ankle, ulcers 4/6 cm on the inside, filled with
witish solid content,theswelling and cellulitis surrounding tissue.Ulceration
last month of operation.In the smear:Staphyl.aureus.Treatment of enzymatic debridement,systemic antibiotic therapy for cellulitis.Transparent
polyurethane coverings.Healing in the two months. Risk factors: diabetes.
Despite the diversity of injuries occurring in various paediatric populations,
treatment principles for wound healing and especially for infection are
similar in both adult and paediatric cases.
Three distinct milestones may be noted in terms of wound healing in the
last 30 years:
1.The introduction and use of moist wound healing (MWH). The research
carried out on the benefits of MWH improved our understanding of the
optimal wound microenvironment.
2. The creation of slow release antimicrobials such as silver dressings which
allow us to prevent complications such as infection or treat them faster.
3. The third milestone is the use of NWPT in wound healing. NWPT can
provide temporary wound cover following thorough debridement and
before definitive closure in trauma injuries. It can reduce complexity of
reconstruction, preparing the wound bed for flaps or skin grafts following
debridement and can reduce oedema and control exudate.
Dressing problems in children with injuries may involve size of dressings,
conformability, durability, trauma upon removal and pain.
The aims of the latest technological advances in wound healing have been
to achieve improvements with respect to:
photo 1 , photo 2 (wounds incurred after phlebectomy )
Second patient:35 years,females,wound on in the cut after surgery higrom,
the right leg ankle,at the outside,3/4cm.Last two months.Wound was
entirely filled, with adherent whitish masses,extremely painful.Smear:
Citrobacter spp.Treatment:enzymatic debridement ,then silicone gel to
stimulate healing.Four weeks after the treatment wound 1/ 0.5 cm completely granular,without secretion.Risk factors: obesity, cutis laxa.
• trauma upon dressing removal
• healing time
• bacterial barrier
• exudate control
• pain
• scarring
The treatment of wounds has advanced vastly over the years, aided along
the way by improved understanding of the physiology of wound healing.
Symptomatic of the advance is the fact that educational programs on these
subjects are more readily available today.
Examples of cases studies of children with trauma, burns and congenital
malformation wounds treated in various countries will be presented.
photo 1, photo 2 (wounds incurred after operations higrom)
Risk factors for wound postoperative cut on the immune and nutritional status of the patiente,surgical technique,local microbiological
conditions the state of the periheral circulation , ways of dressing.
Also,diabetes,anemia,obesity (F.Gottrup,Preventio of surgical site infection,2008).Task of nurse to encourage patients , to establish a relationship
of trust in health care professionals and provide support in the treatment.
Keywords: chronic wounds, postoperative cut
The Role of Nurse in Treatment of Chronic
Wounds
Anke Bültemann
Wundcentrum Harburg, Asklepiosklinikum Hamburg-Harburg
Tissue viability nurses have divers tasks in a specialised wound care center. I
am presenting my tasks in my institution.
Treatment: The diagnostic and treatment of the cause of a chronic
wound is preliminary. Nurses percieve important information by use of their
senses. These are filtered and passed on tothe physician. With the necessary
perception of the human being at eyes’ heigth and enough confidence the
nurse becomes the patient’s representative and attains accesstohisor her
experiences and needs concerning woundc are.
Chronic wounds on postoperative cut – present cases
— Wounds 19
Due to specialisation nurses may perform debridement techniques such
as ultrasound assisted wound cleaning. sterile filter showering or electrotherapy. New products can be tested and rated, user observation studies
accompanied.
Standards: Awound centeradjoinedto a hospital can help to unify the
woundt herapy and adjust standards such asthe „Wundfibel“, the WoundWatch (www.wunduhr.de), a uniform wound and photo documentation.
Structure: So called „multipliers“ optimise wound care within the
hospital. These arenurses, instructed in wound care with a close contac to
the wound center due to regular internal trainee ships and case discussions
External Network: In order to avoid the „revolving door
effect“between hospitals and the outpatient sector, an interprofessional
and interdisziplinary network needs to beset up. Regular conferences such
as „ICW Arbeitsgruppen“ are comunication platforms be tweenthe sectors.
Physicaltherapists, podologists, lymphatictherapeuts, nutrititional consultants should not beforgotten.
Pressure ulcer-indicator for bad nursing care
Kanjuh Ž.1Lazarević A.2 Dragin A.1
Clinic for rehabilitation “Dr Miroslav Zotović”Belgrade.1
College of nursing Belgrade2
Introduction and aim: Pressure ulcer has serious implications
for patient, prolonged hospitalization and has major economic effect on a
„health troth“ and patient. Traditionally, preassure sores ulcer is considered
as a phenomenon that should be avoided and as a reflection of quality of
nursing care. The aim of the paper is determined systematic review outlines
the major risk factors and measures of prevention to the overall health of
patient.
Methodology: Using key words „pressure ulcer”, „bedsore” „risk factor”, „prevention”, „nursing” was carried out searching PubMed database.
The research included papers which printed on English and Serbian
language during the period of 1991-2011 year.
Results: Most pressure ulcers can be prevented by keeping in mind the
fact that the ratio of the pressure-time most critical factor for its development. It has been shown that the lower the pressure acting for a long time
may be crucial for the development of pressure ulcer than higher pressure
for shorter duration. Also, prevention of pressure ulcer can not be seen in
isolation to the overall treatment of patient. For example, a strict regime of
change in patient position for 2 hours can reduce the occurrence of pressure
ulcer, but also impairs the patient’s peace and healing to an unacceptable
degree, especially in the ICU, if it lasts longer. Contrary, technical aids such
as a bed or mattress antidecubital with variable pressures in some places,
reducing the need for manual turning of patients, increase the potential impact of immobility, increased isolation and sensory limitations. In any case,
both approaches to prevention should be gradually revised and adapted to
prevent the patient’s overall condition.
Conclusion: A holistic approach that accepts the risk factors and
managed, purposeful stance than that seeks to minimize risk, absolute end,
which can reduce the quality of care.
Key words: pressure ulcer, risk factor, nursing care.
20 Wounds
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Pressure ulcer-indicator for bad nursing care
2nd CONGRESS OF TREATMENT CHRONIC WOUNDS 2014,
BELGRADE, SERBIA
Dear coleagues,
We inform you that the second Congress will be held in year 2014, in Belgrade. We are confident that the next Congress will be an excellent opportunity
for the presentation of new findings and results of treatment, for exchanging experiences and socializing with colleagues from other countries.
Prim. dr Javorka Delić, president
Serbian Wound Healing Society
www.lecenjerana.com
2nd CONGRESS OF TREATMENT CHRONIC WOUNDS 2014, BELGRADE, SERBIA
— Wounds 21
22 Wounds
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2nd CONGRESS OF TREATMENT CHRONIC WOUNDS 2014,
BELGRADE, SERBIA
Tosama_A5letak_2str SRB_TISK.pdf
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