1131108 - 外科敷料之新進展-國軍高雄總醫院整形外科 吳爭融 主任.pdf
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日期：113年11月8日 主題：外科敷料之新進展 講師：國軍高雄總醫院整形外科 吳爭融 主任
![Epithelial Electric Potential Difference
(transepithelial potential (TEP))
上皮層膜電位差
Fig. 4. Electric signals are an overriding guidance
cue for directional cell migration inwound healing.
(A) Electric fields guide migration of corneal
epithelial cells. Reversal of the
polarity of an applied electric field (150mV/mm)
reverses the direction of migration. The cell before
exposure to the field (0 h), is flattened and
rounded. After 1 h of exposure to
an electric field with the indicated polarity, the
cellmoves toward the negative pole. Then the field
is reversed and further 6 h later, the cellmoves to
the right. After a further 8 h
with reversed polarity again the cell has reversed
its direction andmoves inthe direction of the
newcathode. (B) In monolayerwound healing,
cellsmigrate directionally into the
wound.Whenan electric field is appliedwith
polarity against the default healing direction
(upper panel), that is against contact inhibition
release,wound void, population pressure,
mechanical forces at thewound edge, and chemical
gradients, the cells migrate away fromthewounds,
resulting inwound enlargement toward the
cathode at the right.
The cellsdoso ignoring other directional signals.
Quantitative analysisdemonstratedthat the
overriding effect happens between the field
strengthof 25–50mV/mm(from[23]).
video:
http://www.nature.com/nature/journal/v442/n71
01/extref/nature04925-s2.mov.
Electrical fields in wound healing—An overriding signal that directs
cell migration Seminars in Cell & Developmental Biology 20 (2009) 674–682](https://image.slidesharecdn.com/1131108-241108073545-5dd984ba/85/1131108-pdf-79-320.jpg)
1131108 - 外科敷料之新進展-國軍高雄總醫院整形外科 吳爭融 主任.pdf
- 2. 議程 Introduction of KAFGH Wound Management Concept Wound healing and wound hygiene Role of different Dressing Choose the Mr. Right
- 3. 人員現況 醫師人力 外科部 主任：謝尚卿 (M88碩士/講師) (三總受訓) 整形外科主任：吳爭融 (M98碩士進修中) (義大受訓) 美容外科主任：王啟宇 (M101學士/講師) (三總受訓) 整形外科主治：楊智凱 (M105學士) (高醫受訓) 整形外訓醫師：張景涵 (M112學士) (高榮受訓) 護理師人力 專科護理師一員：鍾瑞芳 高壓氧技術員暨美容中心護理師四員： 林筠茹、許娟瑛、林慧如、 籃佳雯
- 5. 指標性重建 -2 0 2 4 6 8 10 12 14 16 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 年度 顯微重建手術 斷指再接手術 游離皮瓣手術(skin/muscle/bone) 線性(游離皮瓣手術(skin/muscle/bone)) 105 106 107 108 109 110 111 112 顏面骨折重建 28 43 35 28 35 19 30 22 0 5 10 15 20 25 30 35 40 45 50 顏面骨折重建
- 7. 規劃新設燙傷中心 10床加護 6床一般 在 此 輸 入 副 標 題
- 12. Wound Healing
- 14. Factors prevent from healing progressing
- 16. M E I T
- 17. Evolving thenotionofWoundHygiene 常見傷口組織類型 壞死組織 傷口床組織和細胞缺血 造成的，也可能因感染 而出現。 黑色/棕色，具 有硬/乾/像皮革或柔軟/ 濕，可以牢固或鬆散地 附著在傷口床上。 腐肉 傷口床上的黃色/白色物 質。 可能出現在傷口表 面的厚斑塊或薄層。 肉芽組織（健康） 外觀呈鮮紅色和鵝卵 石狀，應濕潤有光澤。 上皮化 外觀無光澤，淡粉色 /白色，非常脆弱。 在部分厚度的傷口中， 上皮的小島會形成毛 囊等結構。 黑 黃 紅 粉
- 18. 21
- 19. Biofilm Delays Wound Healing ? 生物膜延遲傷口癒合 ? 產生持續但輕微的炎症反應 ? 損害肉芽組織和上皮形成 ? 嗜中性白血球聚集在生物膜周圍，但不能穿透和殺死生物膜相關微生物2 ? 1. Metcalf DG, Bowler PG. Burns Trauma. 2013 Jun 18;1(1):5-12. 2. Zhao et al. Adv Wound Care. 2013. 7:289-299. Biofilm Neutrophils P. aeruginosa biofilm (12 days post injury) No-biofilm Control Epithelial Gap
- 20. Biofilm比你想像的要勤奮努力 Masako, Journal of Dermatologic Science June 2005 破億囉 23
- 21. 群聚感應 （Quorum sensing） Nature Reviews Microbiology Koo, H. et al., (2017). Targeting microbial biofilms: current and prospective therapeutic strategies. Nature Reviews Microbiology, 15 (12), pp.740–755 Koo, H. et al., (2017). Targeting microbial biofilms: current and prospective therapeutic strategies. Nature Reviews Microbiology, 15 (12), pp.740–755 Extracellular Polymeric Substances (EPS)
- 22. Biofilm is Associated with Wound Chronicity Chronic infection Acute infection Hall-Stoodley L, et al. FEMS Immunol Med Microbiol. 2012 Jul;65(2):127-45. ? 使用抗生素治療局部或全身性感染 後, 一旦停藥,會又再復發 ? 具有抗生素治療失敗病史或是持續 性發生感染 ? 傷口有大量滲出液 ? 新生肉芽組織品質差 ? 表面具易移除不透明薄膜 ? 就算是高度懷疑已感染但即便是培 養也是陰性反應 25
- 23. Wound Hygiene 傷口衛生 A set of four steps that should be carried out at every dressing change until the wound has fully healed 清潔 清創 修剪 敷料 傷口護理的概念，促進困難癒合傷口之癒合
- 24. Moisture Dry Wet
- 25. Moisture
- 26. Exudate in different wounds
- 27. MMP roles
- 29. 护理人力短缺
- 31. Dressing and Wound Care Pain ---只有傷過痛過的人才會懂---
- 32. Ideal Wound Dressing Turner’s criteria: 1. It should be non-adherent to wound bed. 2. It should be impermeable to bacteria. 3. It should maintain moist wound environment. 4. It should be absorbent. 5. It should be non toxic, non allergenic. 6. It should require minimal change of dressings. 7. It should be cost-effective with long self-life. 8. It should be easy to apply and remove.
- 33. Selection of Appropriate Wound Dressing for Various Wounds Shi et al. Clinical Selection of Wound Dressing March 2020 | Volume 8 | Article 182
- 34. ? Hydrogel ? Hydrocolloid ? HydroClean ? Foam ? Superabsorbent ? NPWT ? Alginate/ Hydrofiber ? Foam ? Alginate/Hydrofiber ? NPWT ? Collagen based ? Hydrogel ? Hydrocolloid ? Collagen based ? Film
- 35. Hydrogel ? Moisturizing ? Remove necrotic tissue ? Fit to dead space ? Need 2nd dressing
- 36. Hydrogel ? 69 y/o, Woman , DM, Burn injury , poor wound healing for one month Rx: Duoderm gel +Foam
- 37. Hydrogel ? Moisturizing ? Mild compression
- 38. Hydrocolloid ? Hydrogel mixed with synthetic rubber and sticky materials ? Moderate exudate absorption ? Low adhesive, less pain ? Provide moisture environment
- 39. Hydrocolloid
- 41. ? Superabsorbent polyacrylate (SAP) wound dressing+ PHMB + Ringer’s solution ? Soften necrotic tissue/ slough ? Donate moisture and absorb exudate ? Effective method for promoting autolytic debridement, wound cleansing, wound progression to healing Hydro- Responsive
- 42. HydroClean
- 43. HydroClean
- 44. HydroClean
- 45. Alginate/Hydrofiber ? Excellent exudate absorption ? Hydrofiber: Lock in technique ? Can cut, fit to shape ? Easy apply and remove
- 46. Hydrofiber
- 47. Hydrofiber + Ag+
- 48. Aquacel Ag+ Extra Post OP 8 days 2nd dressing change Aquacel Ag plus Post OP 19 days 3rd dressing change Aquacel Ag plus Post OP 4 days 1st dressing change Aquacel Ag plus 58 y/o M Scald burn , 2nd degree , 3% TBSA
- 49. Aquacel Ag+ Extra Melanoma for 2 yrs Bleeding , pain, turbid discharge Refuse Surgical Tx Biopsy, AgNO3 ablation Aquacel Ag wound dressing Repeat AgNO3 ablation Aquacel Ag wound dressing 4 month later , F/U monthly 2 month later post op , than loss follow Marginal wide excision tumor with thumb preservation Aquacel Ag plus dressing 2 weeks later , 8 month later , post loss follow 3 months Pain , bleeding 83 y/o M Melanoma on thumb, right W/C: pseudomonas a.
- 50. Chitosan antibacterial mechanism of chitosan ? Moderate exudate absorb ? Antibacterial ? Hemostasis ? Electric chemotasis
- 51. Hydrocolloid + Hydrofiber ? Moderate to high exudate absorption ? Adhesive ? Provide moisture environment
- 52. Foam ?Low to high exudate ?Moist wound environment ?Reduce over/hyper-granulation ?Provide environment for epithelial maturation ?Acute or Chronic wounds
- 53. Foam 1month 1week 2months Case Left: 66y/o woman, MVC, residual skin defect, right leg Case Right: 31 y/o female military officer , 3rd degree contact burn, right leg
- 54. Foam 2months Case Left: 68 y/o woman , STSG donor site Case Right: post surgical wound on thumbs c 5 days
- 55. Foam + Silicone ? Water proof ? Reduce pain when remove ? Promote wound epithelialization
- 56. Foam +Ibuprofen ? ibuprofen concentration: 0· 5 mg/cm2 ? 10cmx10cm→50mg, released between 1 and 7 days ? maximum daily oral dose of 1200 mg ibuprofen-releasing foam dressing and silver dressing on infected leg ulcers Split-Thickness Donor Sites Markl, Peter, Prantl, Lukas, MD, PhD, et al. Management of Split-Thickness Donor Sites With Synthetic Wound Dressings: Results of a Comparative Clinical Study. Ann Plast Surg. 2010;65(5):490-496.
- 57. Superabsorbent 2months ? Highly exudate management ? Non-adherent
- 58. Superabsorbent 2months 5 days Case Left: 21 y/o man , major trauma, sacral pressure sore Case Right: 14 y/o boy, scald burn , 2nd degree , Superabsorbent
- 59. Negative Pressure ? Moderate to High exudate ? Decrease in wound edema ? Drawing the wound edges together ? Microdeformations of the wound surface ? Increase angiogenesis, granulation tissue formation
- 61. Negative Pressure ---AbThera 3M AbThera Advance Open Abdomen Dressing
- 64. Collagen Skin substitutes ? Hemostasis ? Moist wound ? Temporary coverage ? Reduce pain ? Promote wound healing ? Reduce scar
- 65. Biobrane
- 66. Collagen
- 67. Collagen 42y/o F,IV extravasation wound for one month 5 days post Deb 5 days 20 days 2 months Pliable
- 68. Collagen 2weeks 4weeks 2.5months 25 y/o lady, MVC, deep abrasion wounds with tendon exposure Collagen + PRP
- 69. Collagen 40 y/o, M, DM, Crushing injury 17th day 72th day
- 70. Collagen 60 y/o, F, DM, Crushing injury with hematoma and skin necrosis 17th day 72th day 12x10cm
- 71. Collagen 60 y/o, F, DM, Crushing injury with hematoma and skin necrosis 17th day 72th day 12x10cm 5weeks 5x3cm 3.5months 4 months
- 72. Case : 56 y/o DM foot, smoker, toe amputation and fasciotomy Collagen + Aquacel Ag+ extra 1 week 6months Collagen
- 73. Case : 56 y/o DM foot, smoker, toe amputation and fasciotomy Collagen + Aquacel Ag+ extra 1 week 6months Collagen
- 74. NovoSorb? BTM ( biodegradable polyurethane) Synthetic Skin substitutes ? Easy to store at room temperature ? Avoids cross-species immune rejection or disease transmission ? Circumvents cultural or ethical concerns to animal-derived products ? Allow integration of vascular tissue into the foam dermal component to create a neodermis ? Reduce wound contraction
- 76. Synthetic Skin substitutes 52y/o F , open fracture of tibia and fibula, type I s/p ORIF with soft tissue necrosis and infection 4months 8 months
- 77. Synthetic Skin substitutes 19 y/o M , MVC, Crushin injury with soft tissue necrosis and tendon exposure
- 78. Electric Modulator --- Procellera Ag Zn ? Microcell batteries of silver and zinc, activated by a moist environment ? Stimulate wound healing and provide antimicrobial protection
- 79. Epithelial Electric Potential Difference (transepithelial potential (TEP)) 上皮層膜電位差 Fig. 4. Electric signals are an overriding guidance cue for directional cell migration inwound healing. (A) Electric fields guide migration of corneal epithelial cells. Reversal of the polarity of an applied electric field (150mV/mm) reverses the direction of migration. The cell before exposure to the field (0 h), is flattened and rounded. After 1 h of exposure to an electric field with the indicated polarity, the cellmoves toward the negative pole. Then the field is reversed and further 6 h later, the cellmoves to the right. After a further 8 h with reversed polarity again the cell has reversed its direction andmoves inthe direction of the newcathode. (B) In monolayerwound healing, cellsmigrate directionally into the wound.Whenan electric field is appliedwith polarity against the default healing direction (upper panel), that is against contact inhibition release,wound void, population pressure, mechanical forces at thewound edge, and chemical gradients, the cells migrate away fromthewounds, resulting inwound enlargement toward the cathode at the right. The cellsdoso ignoring other directional signals. Quantitative analysisdemonstratedthat the overriding effect happens between the field strengthof 25–50mV/mm(from[23]). video: http://www.nature.com/nature/journal/v442/n71 01/extref/nature04925-s2.mov. Electrical fields in wound healing—An overriding signal that directs cell migration Seminars in Cell & Developmental Biology 20 (2009) 674–682
- 80. Electric Modulator 1 week 3 week 1.5 months Crushing injury with open dislocation of 1st toe and skin defect
- 81. Immune Modulator 含1.25%到手香萃取物 (PA-F4, 0.25%)與積雪草 萃取物(S1, 1%)乳膏外觀 為黃綠色至淡綠色，供局 部使用 Seed of Glycine Max(L.) Merr. Extract & Aqua (大豆萃取液) ) 86.25 % 衛部藥製字第060827號 新加坡藥證證號SIN16683P 馬來西亞藥證證號MAL23076025B 2023/08/01 健保給付 衛部醫器製字第006946號
- 83. Fespixon 4.5 months 63y/o man , DM(HbA1c 6.6; Alb: 3.2), Foot ulcer infection Aquacel Ag Plus+ Foam ; Combine with HBOT(10sessions)/ offloading shoes
- 84. Fespixon 4.5 months 69y/o man , DM(HbA1c 6.6; Alb: 3.2), PAOD with toe gangrene infection Aquacel Ag Plus , Combine with HBOT(10sessions) 10 months
- 85. Case : 70 y/o woman, scooter , senile skin degloving 含金屬銀 有效抗菌 不含凡士 林、石蠟 含三酸甘 油酯 Senile Skin Tear
- 86. Case : 72 y/o woman, falling down, senile skin degloving Senile Skin Tear
- 89. Choose Mr. Right
- 90. Choose Mr. Right
- 91. The Future
- 92. Take Home Massage 1. Wound hygiene concept 2. Wound balance concept 3. Choosing the right dressing