The 13th ANNUAL EUROPEAN PRESSURE ULCER ADVISORY PANEL MEETING

Reported by: Haryanto

 Photo 1. Saat Presentasi

 Photo 2. Saat Konferensi

 Photo 3. Latar tempat Konferensi berlangsung

 Photo 4. Latar tempat Konferensi berlangsung

Photo 5. Saat Presentasi

A "European Pressure Advisory Panel ulcer (EPUAP)" has been created to lead and support all European countries in the efforts to Prevent and treat pressure ulcers. In this year EPUAP scheduled meeting, held in Birmingham, United Kingdom (UK) . This meeting was an annual event where the meeting of experts in the field of injury. I attended the meeting which was held this year at the University of Birmingham, Birmingham, UK for 3 days starting on 1-3 September 2010. My journey started from Kanazawa City to Tokyo. Through the Narita Airport, Tokyo I headed to Birmingham via Zurich (Sweden). At this meeting I represented the University of Kanazawa, Japan. The  meeting held  the second of largest city in the UK that still maintain the culture and the authenticity of European style. It could be seen with still many ancient buildings of European style. At the meeting this year, Its theme was ‘Flourishing of Science to support Prevention and Healing of Pressure Ulcers'. These meetings were very important because as a media for experts to exchange ideas and discuss the results of research and issues emerging at this time which aims to prevent and treat pressure ulcers. The meeting was attended by approximately 250 participants from 20 countries including Japan. Activities of this meeting in for a few sessions include free paper presentation which is presented from 122 publishers from several countries, the symposium sessions about Pressure ulcers Prevention: simplifying the science and practice and the Important, The Heel: a model to understanding the pressure ulcers, and malnutrition and pressure ulcers: adequate nutritional strategy for improve patient outcomes and Consensus Statements for a New Paradigm on Staging of Pressure Ulcers: Your Input is Needed. , A workshop session with the title "a living educational tool", a poster session by displaying a variety of research results with the number of 42 posters, oral and poster presentations were presented 19 presenters from various countries, the last session was student paper competition that was divided into two sessions , the first session featuring presenters from the UK,  Japan and Denmark and the second session from UK  and England. At this first session I presented  our of  research of  result  with theme  was  "Effectiveness of Indonesia Honey Toward on Wound Healing: An Experimental study in mice (Pilot Study)", by  Haryanto.
               In this presentation, I was given 30 minutes including presentation and question and answer. There are three hot issues discussed at this meeting related to pressure ulcers including  1) Introducing the process of consensus documentation: from prevalence and incidence to pressure, shear, friction and microclimate in context 2) Microclimate in context: optimising skin conditions. This presentation discusses the potential effects microclimate changes in skin and soft tissue.
At the end of this activity has also been agreed for next year's 2011 meeting on August 31 to September 2 in Oporto, Portugal with the theme of ulcer Pressure Research Achievements Translated to Clinical Guidelines.

TIP PRAKTIS: Manajemen Pencegahan Pressure Ulcer (1)

Haryanto, S.Kep, Ners, MSN, ETN

STIK Muhammadiyah Pontianak

email: gibyanto@yahoo.com.au

Gambar: Luka sudah mulai ada granulasi

Manajemen pressure ulcer membutuhkann pendekatan

kolaborasi antara pasien dan tim kesehatan. Di dalam

mengidentifikasi factor resiko dan mengevaluasi tindakan

pencegahan serta manajemen perawatan luka haruslah

sinergis antara semua pihak baik dari pasien, perawat dan

tenaga kesehatan lainnya. Pengetahuan yang cukup

tentang manajemen pencegahan dan perawatan pressure

ulcer merupakan dasar untuk mendapatkan hasil yang

maksimal.

Dibawah ini ada beberapa tip pencegahan pressure ulcer:

1. Tentukan dan atasi pennyebab kerusakan

2. Berikan pendidikan kesehatan kepada pasien tentang

    factor resiko dan pencegahan pressure ulcer

3. Tingkatkan aktivitas dan mobilisasi pada pasien

4. Anjurkan untuk berhenti merokok atau tidak merokok

5. Tingkatkan status nutrisi

6. Hygienis Kulit:

·      Pertahankan pH kulit

·      Bersihkan dan lindungi dari keringat dan cairan tubuh 

       lainnya (feses, air kemih)

·      Pertahankan kelembaban kulit secara teratur

7. Manajemen inkontinensia

8. Perubahan posisi secara teratur

9. Gunakan alat proteksi dan pakaian yang tepat

10.Gunakan alat yang tepat saat memindahkan pasien

11.Pemilihan support surface yang tepat

Sumber: Carville K. Wound Care; Manual.3^rd edition 1998.

Silver Chain Foundation. Australia

KILAS RISET: Pressure Gradient and Subsurface Shear Stress on the Neuropathic Forefoot

Supriadi 

STIK Muhammadiyah Pontianak

Introduction

Stresses within the neuropathic foot’s tissues can be estimated by pressure distributions and may provide information regarding the potential for skin breakdown.

Foot ulceration is a common and costly problem in people with diabetes mellitus (DM) and peripheral neuropathy (PN).

High peak plantar pressure coupled with a lack of protective sensation from sensory PN is a known contributing factor to the development of these plantar foot ulcers (Caselli et al., 2002; Pitei et al., 1999; Veves et al., 1992). 

As people with DMPN and high peak plantar pressure walk, the soft tissues of their feet are subjected to repetitive stresses which have been associated with the location of skin breakdown (Boulton et al., 1983).

The peak pressure gradient is defined as the spatial change in plantar pressure around the location of the peak plantar pressure (Mueller et al., 2005). 

This peak pressure gradient is associated with peak plantar pressure in the forefoot of people with DMPN and a history of a foot ulcer (r = 0.59), but peak pressure gradient appears to provide additional information as an indicator of plantar skin injury (Mueller et al., 2005).

More recently, Zou et al. described the peak maximum shear stress within the subsurface soft tissues of the foot (Zou et al., 2007). 

The maximum shear stress plays a key role in the mechanical failure criteria (Hills et al., 1993) and may predict tissue trauma and breakdown by estimating internal stresses. Finite element models of the foot have been used to predict stresses within the neuropathic foot (Actis et al., 2004; Chen et al., 2001; Gefen, 2003, Goske).

The purposes:

Determine the magnitude of peak plantar pressure, pressure time integral, peak pressure gradient, and peak maximum shear stress and determine the association of these variables with one another.

Research design and methods:

Sample: 16 healthy people without DMPN (CON), 16 people with DMPN and no history of skin breakdown and 22 individual with DMPN + U.

Device: 
Sensation was tested using the 5.07 Semmes Weinstein monofilaments and a Bio-Thesiometer (Bio Medical Instrument, Newbury, OH). All subjects were unable to sense the 5.07 Semmes Weinstein monofilament on at least two sites on the plantar foot as described elsewhere Sensation also was quantified with a Bio-Thesiometer. 

Plantar pressure assessment: Plantar pressures were collected during walking using F-scan system (Tekscan, Boston, MA).  Each F-scan sensor contains 960 sensing locations or pixels. Each pixel is 5.08 X 5.08 mm.

Determination of plantar pressure variables: The PPP and PPG were determined using custom software. The PPG then was determine in a define area (3 X 3 F-scan sensor pixels (231.2 mm²)) around the PPP by calculating the highest changes in pressure (PG) from one node (half pixel apart) to the next according to rows and columns and by diagonal.

Determining the PMSS; 3-D, principal, and shear stresses were first calculated for the subsurface tissues. The maximum shear stress was then calculated in the forefoot at 8 different depths from 0 to 10 mm, and the peak maximum shear stress was identified as the greatest maximum shear stress value (Zou et al., 2007).

Statistical analysis:

One-way analysis of variance with post-hoc t-tests with Bonferroni correction were used to test for differences between the three groups for age, body mass index, glycated hemoglobin, VPT, and each of the pressure variables in the forefoot (PPP, PTI, PPG, PMSS, and depth of PMSS).

Pearson correlation coefficients were used to examine the association of these pressure variables with one another for all 54 subjects. Criterion for significance was set at p = 0.05.

Results:

The PPP (p < 0.05), PPG (p < 0.0009), PMSS (p < 0.05), and Depth of PMSS (p < 0.0006) were different between groups. Post-hoc testing revealed differences between CON and DMPN+U groups for PPP (increase of 26.1% relative to CON, p <0.03), PPG (increase of 88.3% relative to CON, p <0.0004), PMSS (increase of 28.6% relative to CON, p < 0.02), and depth of PMSS (decrease of 25.4% relative to CON, p < 0.0002). 
CON and DMPN groups for depth of PMSS (decrease of 13.0% relative to CON, p < 0.03). DMPN and DMPN+U groups for PPG (increase of 44% relative to DMPN, p < 0.02). No differences were noted for PTI. A strong association was noted for: PMSS and PPP (r = 0.97; p < 0.0001), PMSS and PPG (r = 0.79; p < 0.0001), PPG and PPP (r = 0.84; p < 0.0001), and depth of PMSS and PPG (r = -0.56; p < 0.0001) A relatively lower association was noted for depth of PMSS and PPP (r = -0.27; p = 0.05).

Kesimpulannya:   
Hasil penelitian ini memberikan dukungan lebih lanjut bagi pentingnya  menentukan puncak tekanan gradien dan puncak tegangan geser maksimum ketika menilai pasien dengan DMPN dan puncak tekanan plantar  yang tinggi.

Referensi:
Lott, Donovan.J. et al. Pressure Gradient and Subsurface Shear Stress on the Neuropathic Forefoot Journal of Clini. Biomech. 2008: 23 (3): 342–348.

BASIC SCIENCES: PRESSURE ULCERS, PERMASALAHAN DI MULAI DI DEFINISI

 Saldy Yusuf, S.Kep.Ns.ETN

saldy_yusuf@yahoo.com

PENDAHULUAN

Pressure ulcer merupakan masalah kesehatan yang serius, dan terjadi tidak hanya di negara berkembang tapi juga di negara-negara maju. Di Belanda manajemen pressure ulcer menyerap $ 362 juta sampai $ 2.8 milyar atau 1% dari dana kesehatan nasional. Di Inggris Perawatan pressure ulcer menyerap 180 juta-321 juta poundsterling atau 0.4-0.8 % dari dana kesehatan nasional. Permasalahan seputar decubitus tidak hanya berkaitan dengan tingginya angka morbiditas, mortalitas dan biaya yang membebani institusi kesehatan namun tingginya insidens dan prevalensi decubitus. Bahkan dalam 25 tahun terakhir insidens dan prevalensi decubitus relatif stagnan, hal ini menunjukkan bahwa modalitas pencegahan sejauh ini belum menunjukkan hasil yang maksimal. Dengan kata lain benang merah penyebab decubitus belum terjawab!

FAKTOR PENYEBAB

Hingga saat ini tercatat lebih dari 200 faktor resiko yang berkontibusi dalam perkembangan luka decubitus dan pressure merupakan faktor yang dianggap paling berperan. Landis (1930) menemukan bahwa tekanan sebesar 32 mmHg dapat menyebabkan sumbatan total pembuluh darah, sayangnya angka ini sering digunakan sebagai nilai acuan untuk perkembangan luka decubitus. Hal ini tentunya sangat keliru sebab sebab angka ini berasal dari riset yang dilakukan pada kapiler jari-jari yang secara anatomis jelas berbeda dengan daerah sacrum ataupun daerah beresiko lainnya.

Fakta yang menarik adalah bahwa dibutuhkan tekanan yang sangat tinggi untuk menyebabkan decubitus, sebaliknya tekanan yang rendah berasosiasi dengan friction sudah cukup untuk menyebabkan pressure ulcers. Adapun coefficient of friction (CoF) sangat dipengaruhi oleh kelebihan kelembaban antara pasien dan permukaan tempat tidur.

PERMASALAHAN BERAWAL DARI DEFINISI

Permasalahan decubitus sebenarnya dimulai dari inkonsistensi penggunaan istilah (nomenclature inconsistency). Hal ini membuat pressure ulcers seolah-olah seperti penyakit tanpa definisi. Menurut Campbell (2010) mencatat ada begitu banyak istilah yang sering digunakan berkaitan dengan decubitus:

pressure ulcer, decubitus ulcer, bedsore, bed-sore, pressure sore, tissue necrosis, decubiti (grammatically incorrect) or decubitus, trophic ulcer, chronic ulcer, decubitus omniosus/acutus/chronicus, erythema gangraenosum, cuticular necrosis, and skin ulcer

Dari istilah tersebuit diatas penggunaan istilah bedsore/bed-sore merupakan istilah yang paling banyak digunakan, disusul oleh penggunaan pressure ulcer, pressure sore, decubitus ulcer dan yang terakhir decubiti.

Meskipun pressure diyakini sebagai penyebab utama, namun penggunaan decubitus ulcer nampaknya lebih netral untuk mencakup semua kemungkinan faktor penyebab termasuk faktor tekanan, shearing, dan friction. Kotnerr (2009) menambahkan bahwa untuk penggunaan di klinis maka ada dua alternatif terminology yang dapat digunakan yaitu superficial ulcers yang umumnya disebabkan oleh friction dan deep ulcer yang lebih dominan disebabkan oleh pressure. Oleh karena superficial ulcers dapat dikategorikan ke kategoi I dan II, maka dengan demikian deep ulcer dapat dikategorikan ke dalam kategori III dan IV dari definisi NPUAP dan EPUAP. Selain itu penggunaan istilah Pressure ulcer (atau luka tekan) telah menjebak kita pada pemahaman bahwa pressure (tekanan) merupakan penyebab pressure ulcer yang membuat kita mengabaikan kemungkinan faktor lain.

PENUTUP

Penggunaan istilah pressure ulcer telah menjebak kita pada pemahaman bahwa decuitus semata-mata disebabkan oleh pressure atau tekanan. Penggunaan istilah decubitus lebih dapat diterima sebab bersifat netral dan dapat mencakup faktor-faktor resiko lainnya. Pemahaman akan patomekanisme penyebab decubitus tentunya akan menentukan ke mana arah modalitas intervensi pencegahan dan perawatan.

REFERENCES:

1.  Kottner, Jan., Balzer, katrin., Dassen, Theo., Heinze, sarah. Pressure Ulcers: A Critical Review of Definitions and Classifications Ostomy Wound Management. 2009;55(9):22–29

2.   International guidelines.Pressure ulcer prevention: prevalence and incidence in context. A consensus document.London: MEP Ltd, 2009.

3.  Hillan, EM., Fraser, AK. Pressure sores: a desease without definitions Clinical Effectiveness in Nursing. 1998; 2: 103 105

4.  Landis, E. Microcirculation studies of capillary blood pressure in human skin. Heart 1930;15:209-228

5.  Yusuf, Saldy.Betulkah pressure ulcer disebabkan oleh pressure? http://saldyusuf.blogspot.com/2010/07/betulkah-pressure-ulcer-disebabkan-oleh.html%20accessed%2026%20Januari%202011.

6.  Campbell, Caren., Charles, Lawrence. The decubitus ulcer: Facts and controversies .Clinics in Dermatology. 2010;28:527–532

KILAS RISET: APAKAH NUTRITIONAL MARKERS DALAM CAIRAN LUKA DAPAT MEREFLEKSIKAN STATUS PRESSURE ULCER?

Haryanto, S.Kep, Ners, MSN, ETN

Sekolah Tinggi Ilmu Keperawatan Muhammadiyah Pontianak

gibyanto@yahoo.com.au

Evaluasi karakteristik cairan luka untuk pengkajian pressure ulcer di klinik membutuhkan pertimbangan tenaga ahli. Shinji Izaka et al dalam studinya dengan menggunakan metode crosssectional memfokuskan untuk menginvestigasi nutritional marker pada cairan luka sebagai alat yang objektif untuk merefleksikan status pressure ulcer  berdasarkan fase penyembuhan, infeksi dan granulasi khususnya nilai serum.

Sampel yang digunakan berjumlah 28 pasien dengan 32 luka full thickness pressure ulcer. Nilai albumin, total protein, glukosa dan zinc yang didapat dari cairan luka diukur. Pada status pressure ulcer , fase penyembuhan dan infeksi dievaluasi berdasarkan tanda-tanda klinik dan derajat pembentukan jaringan granulasi ditentukan berdasarkan konsentrasi hydroxyproline.

Berdasarkan studi ini, Shinji mengatakan rasio cairan luka/serum secara signifikan lebih rendah selama fase inflammasi daripada fase proliferasi (p50.020). Cairan pada luka infeksi mengandung glukosa kurang dari (0.3–1.0 mmol/L) dari pada luka yang tidak terinfeksi (5.0–7.6 mmol/L).

Ada hubungan negative antara rasio cairan luka/serum untuk glukosa dengan nilai hydroxyproline pada fase proliferasi (r5_0.73, p50.007), kecuali nilai zinc pada cairan luka menunjukkan hubungan positif (r50.61, p50.028).

Dari hasil studi ini, Shinji mengatakan bahwa penentuan nutritional markers pada cairan luka khususnya rasio cairan luka.serum kemungkinan dapat berguna untuk mengevaluasi status lokal Pressure Ulcer.

Sumber:

Iizaka. S et al., Do nutritional markers in wound fluid reflect pressure ulcer

status? Wound Rep Reg (2010) 18: 31–37