#1
|
|||
|
|||
Àìáóëàòîðíîå âåäåíèå ðàí.
Ìîå èìõî: Ïîñëå òóàëåòà ðàíû - ñóõàÿ ìàðëåâàÿ ïîâÿçêà ôèêñèðîâàííàÿ ïëàñòûðåì íå â íàòÿã. Ò.å. öåíòð ïîâÿçêè, êîòîðûé íåïîñðåäñòâåííî íàä ðàíîé îòíîñèòåëüíî ñâîáîäíûé. Äàëåå èìååì ñòðóï è çàæèâëåíèå ïîä íèì.
P.S. Ïðè èñïîëüçîâàíèè ïëàñòûðÿ, ôèêñàöèÿ òèïà # - âûãîäíåé, ÷åì êðåñò.(òîæå èìõî) |
#3
|
|||
|
|||
Íå, äàâàéòå íå ìíîãî. õîòü è íàõðåñò.
Ïëàñòûðü, åñëè äåøåâ - àëëåðãåíåí. |
#4
|
||||
|
||||
Íó êàê ìîæåò îòêðûòàÿ ðàíêà íàãíàèâàòüñÿ? À ïåðåêèñòüþ, äóìàþ, íå ñòîèò...
__________________
ðóêó êú ñåìó ïðèëîæèëú Àëåêñàíäðú |
#6
|
|||
|
|||
Íàãíàèâàòüñÿ = èíôèöèðîâàòüñÿ, ñ ãíîéíî-ôèáðèíîçíûì íàë¸òîì, êîòîðûé âðåäèò ãðàíóëÿöèÿì, èìõî...
|
#7
|
||||
|
||||
 ýòîé æå òåìå Àíäðåé óæå ïèñàë îá ýòîì. Ïîçâîëüòå ýâèäåíñ íå èñêàòü è íå ïðèâîäèòü. Îí åñòü è ìíå ïîïàäàëñÿ. ×òî êàñàåòñÿ íàãíîåíèÿ, òî (ïîñêîëüêó íå ÿâëÿþñü ñïåöèàëèñòîì â ýòîé îáëàñòè) äëÿ ìåíÿ ýòî ãíîéíèê, ò.å. òîãäà, êîãäà íàäî âñêðûâàòü. "Ãäå ãíîé - òàì ðåæü"... Ìîæåò, êîíå÷íî, ÿ è íå ïðàâ.
__________________
ðóêó êú ñåìó ïðèëîæèëú Àëåêñàíäðú |
|
#8
|
||||
|
||||
Õî÷åòñÿ ýâèäåíñà ïðî ïåðåêèñü òî...óæ áîëüíî õîðîøî îíà ðàíó î÷èùàåò...òðóäíî ñìèðèòüñÿ ñ ìûñëüþ ÷òî åíòî âðåäíîå...
Íàãíîåíèå, êàê óæå ñêàçàë Âëàä - ýòî èíôèöèðîâàíèå ðàíû (îòêðûòîé) èëè ãåìàòîìû (çàêðûòîé), èëè åùå ÷åãî...  ïåðâîì ñëó÷àå - âñêðûâàòü íå íàäî, âî âòîðîì íàäî... Çû: ÿ ïîêà íà òåìó ïåðåêèñè ýâèäåíñîâ íå íàøëà, íàøëà òîëüêî òî, ÷òî âñÿ÷åñêèå äåòðèòû òêàíåâûå è íåêðîòè÷åñêèå ìàññû ïëîõî âëèÿþò íà çàæèâëåíèå ðàí (àìåðèêó îòêðûëà )à âîò êàê ðàç ïåðåêèñü è ïðèçâàíà âñå ýòî èç ðàíû óáèðàòü. |
#9
|
||||
|
||||
Íó íåêîãäà ìíå ñåé÷àñ ýâèäåíñ ïðî ïåðåêèñü èñêàòü... (à åñëè ÷åñòíî, òî íåîõîòà , Íó, íåàêòóàëüíî ýòî äëÿ ìåíÿ ñåé÷àñ, ÿ íå çàíèìàþñü ãíîéíîé õèðóðãèåé).  ëþáîì ñëó÷àå â ãàéäëàéíàõ ìíå âñòðå÷àëèñü ðåêîìåíäàöèè ïî î÷èùåíèþ ðàíû îò äåòðèòà è ïðî÷åãî "ìóñîðà" îáû÷íûì ôèçèîëîãè÷åñêèì ðàñòâîðîì, ò.å. ìåõàíè÷åñêîå "îòìûâàíèå".
Îïÿòü æå, èíôèöèðîâàíèå è íàãíîåíèå äëÿ ìåíÿ ïîíÿòèÿ ðàçíûå. Åùå ðàç âñïîìíþ àôîðèçì: "Ãäå ãíîé, òàì - ðåæü". Êîãäà ãåìàòîìà íàãíàèâàåòñÿ, îíà íàçûâàåòñÿ àáñöåäèðóþùåé (åñëè ìíå ïàìÿòü íå èçìåíÿåò) è ëå÷èòñÿ ïî âñåì ïðàâèëàì èñêóññòâà (òàê êàê ëå÷èòñÿ ãíîéíèê). À îòêðûòàÿ ðàíà, êàê ïðàâèëî, âñåãäà èíôèöèðîâàíà (à êàê èíà÷å, åñëè äàæå íà çäîðîâîé êîæå âñåãäà ïðèñóñòâóþò áàêòåðèè). Äðóãîé âîïðîñ, êîíêðåòíûé ñîñòàâ ôëîðû. Òåì íå ìåíåå, åñëè íåò êàêèõ-ëèáî ïðåäïîñûëîê (ñêàæåì, äèàáåòà, íàðóøåíèé êðîâîñíàáæåíèÿ - òðîôèêè, âåíîçíîé íåäîñòàòî÷íîñòè et cetera), òî îòêðûòàÿ ðàíà âñåãäà ñïîêîéíåíüêî "çÿòÿãèâàåòñÿ" âòîðè÷íûì íàòÿæåíèåì, âíå çàâèñèìîñòè îí íàëè÷èÿ/îòñóòñâèÿ "ãíîéíî-ôèáðèíîçíîãî" íàëåòà.
__________________
ðóêó êú ñåìó ïðèëîæèëú Àëåêñàíäðú |
#10
|
||||
|
||||
Î÷èùàåò-òî õîðîøî, íî ôèáðîáëàñòû è êåðàòîöèòû ïîñëå ýòîãî íåäîâîëüíû.
[Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] Ïîäîáíûõ èññëåäîâàíèé íåñêîëüêî, è íàéòè èõ äîñòàòî÷íî ïðîñòî. ×òî ïèøóò â Surgical wound healing and management (Informa HealthCare? New York-London, 2007) Various additives have been used in the irrigation solutions in an effort to eliminate the bacterial load of an open wound and optimize wound healing. Anglen has classified the various irrigation additives into three classes: antiseptics, antibiotics, and surfactants (32). Various antiseptics, such as povidone-iodine, chlorhexidine, and hydrogen peroxide, have been used in irrigation solutions as they offer a broad-spectrum activity against most of the bacteria, fungi, and viruses that colonize the wound. The efficacy of antiseptic solutions has been tested extensively and the relative results have been reported in several studies (47–50). Because of questionable capacity to reduce the infection rates of open fractures, potential toxicity to the cellular elements of bone (particularly osteoblasts and osteoclasts) and deleterious effect on wound healing, the use of antiseptic irrigation solutions is generally not recommended (32,51). Bacitracin, polymyxin, and neomycin have been used as antibiotic additives in irrigation solutions in an attempt to increase the bacteriostatic and bactericidal capacity of the irrigation solution and eliminate septic complications (52). Nevertheless, their clinical efficacy has not been proved unequivocally, and concerns regarding the cost of their use, serious, though rare, toxicity, and promotion of bacterial resistance limit their role in optimal open wound care (53). Examples of surfactants include liquid soap and benzalkonium chloride. The addition of detergents in irrigation solutions in the treatment of open wounds was once practiced by several surgeons (54,55). Their main advantages were attributed to the interference with the adherence of bacteria to surfaces and also to their capacity to emulsify and remove foreign material from the open wound (32). The introduction of antibiotics as an integral part of standard wound care has supplanted the use of the various soap solutions. Nevertheless, the observation that antibiotic irrigation solutions produce foaming led to the speculation that their efficacy may be attributed to a detergent-type action (51). This hypothesis has been tested experimentally, and it was found that soap solutions were more effective than antibiotic solutions in removing slime- producing staphylococcus from metallic surfaces (56,57). The efficacy of a sequential irrigation protocol consisting of benzalkonium chloride followed by castile soap and normal saline in reducing the rate of positive wound cultures has been tested experimentally (53,58). The results of these experimental studies indicated a potential therapeutic value of the sequential surfac- tant irrigation in treating infected orthopedic wounds, although further studies should be undertaken to clarify the exact role of the sequential irrigation protocol in clinical practice. At present, surfactant irrigation should be considered in highly contaminated wounds, particularly as first irrigation (32). Ñïèñîê ëèòåðàòóðû: 32. Anglen JO. Wound irrigation in musculoskeletal injury. J Am Acad Orthop Surg 2001; 9(4):219–226. 47. Kaysinger KK, Nicholson NC, Ramp WK, et al. Toxic effects of wound irrigation solutions on cultured tibiae and osteoblasts. J Orthop Trauma 1995; 9:303–311. 48. Lineaweaver W, McMorris S, Soucy D, et al. Cellular and bacterial toxicities of topical antimicrobials. Plast Reconstr Surg 1985; 75:394–396. 49. Rodeheaver G, Bellamy W, Kody M, et al. Bactericidal activity and toxicity of iodine-containing solutions in wounds. Arch Surg 1982; 117:181–186. 50. Rogers DM, Blouin GS, O’Leary JP. Povidone-iodine wound irrigation and wound sepsis. Surg Gynecol Obstet 1983; 157:426–430. 51. Anglen JO. Comparison of soap and antibiotic solutions for irrigation of lower-limb open fracture wounds. Aprospective, randomized study. J Bone Joint Surg Am 2005; 87:1415–1422. Åñëè çàòðàãèâàòü ìîþ ñïåöèàëüíîñòü, òî â èþëüñêì, ïî-ìîåìó, âûïóñêå JBJS(Am) îïóáëèêîâàíà ñòàòüÿ (ñåêöèÿ EBM), â êîòîðîé ïåðåêèñü "íå ðåêîìåíäîâàíà äëÿ îáðàáîòêè ïîñëåîïåðàöèîííîé ðàíû": The proper timing of dressing removal is also controver- sial. Studies of clean and clean-contaminated wounds showed no difference in infection rates according to whether the dressing was removed on the first postoperative day or at the After the dressing is removed, the time of suture removal wound may be cleaned with tap water or saline solution, but antiseptics such as hydrogen peroxide should be avoided. Showering may commence after wound epithelialization without an increased risk of infection. C äîêàçàòåëüñòâàìè â ñàìîì óâàæàåìîì òðàâìàòîëîãè÷åñêîì æóðíàëå, ïîâåðüòå íà ñëîâî, âñå â ïîðÿäêå, ñöûëêè íà ÐÊÈ èìåþòñÿ. Êîíå÷íî æå èìååòñÿ ââèäó ïåðâè÷íî çàêðûòàÿ ðàíà, íî â òîé æå ñòàòüå íåò íè ñëîâà ïðî ïåðåêèñü â ðàçäåëå "èððèãàöèÿ ðàíû", à òàì ïàëüìó ïåðâåíñòâà îïÿòü æå îòäàëè äåòåðãåíòàì (õëîðèä áåíçàëêîíèÿ, êàñòèëüñêîå ìûëî). Êðîìå òîãî, ïåðåêèñü ìîæåò è íàâðåäèòü ïåðâè÷íî çàêðûòîé ðàíå: [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] |
#11
|
||||
|
||||
Îñòàëîñü ðàçîáðàòüñÿ ñ ýâèäåíñàìè çåëåíêè è ôóêîðöèíà, íî ýòî áóäåò íåïðîñòî.
|
#12
|
|||
|
|||
Õî÷ó ïîïûòàòüñÿ ðåàáèëèòèðîâàòüñÿ è îäíîâðåìåííî îïðàâäàòü ôóêîðöèí ñ çåë¸íêîé. Ïðèìåíåíèå âîäíûõ àíòèñåïòèêîâ (ÿ òàê äëÿ ñåáÿ ïîíÿë, ÷òî ýòî ÅÁÌ) â àìáóëàòîðíûõ óñëîâèÿõ ïîäðàçóìåâàåò áîëüøîé ïðîöåíò ó÷àñòèÿ â ýòîì äåëà ñàìîãî ïàöèåíòà. Ò.å. íå õîäèòü æå åìó äâà ðàçà â äåíü â ïîëèêëèíèêó íà ïåðåâÿçêó, äà åù¸ è íî÷üþ ïåðåä ñíîì çâàòü õèðóðãà. À äëÿ ñàìîñòîÿòåëüíîãî ïðèìåíåíèÿ àíèëèíîâûå êðàñèòåëè ïîäõîäÿò ëó÷øå, ñïîñîáñòâóÿ îáðàçîâàíèþ êîðêè. Òåì ñàìûì ïðåïÿòñòâóÿ ðåèíôèöèðîâàíèþ ðàíû. Èìõî.
È åù¸ îäíî èìõî ïî çàìå÷àíèþ îò alexdr. Íåñîìíåííî "íàãíîåíèåì" ìîæíî íàçâàòü îáðàçîâàíèå ãíîéíîé ïîëîñòè. Èëè äàæå áåç ïîëîñòè - ôëåãìîíà. Áûâàåò, ê ïðèìåðó, ôëåãìîíà æåëóäêà... å¸ âñêðûâàòü êàê-òî, íå "ïðèêîëüíî" Ò.î. ÿ õî÷ó ñêàçàòü, ÷òî íåâçèðàÿ íà îáÿçàòåëüíóþ èíôèöèðîâàííîñòü îòêðûòîé ðàíû ñóùåñòâóþò ðàçëè÷íûå ôàçû ðàíåâîãî ïðîöåññà, êîðîòêî: ýêññóäàöèÿ (ãíîåîáðàçîâàíèå), ãðàíóëÿöèÿ, ýïèòåëèçàöèÿ. òàê âîò â êîíöå ôàçû ãðàíóëÿöèè è ýïèòåëèçàöèè ðàíó íàçâàòü ãíîéíîé ÿçûê íå ïîâîðà÷èâàåòñÿ (è ïî ñóòè îíà óñëîâíî ÷èñòàÿ â ýòîò ïåðèîä), ÷åãî íå ñêàæåøü î âðåìåíè àêòèâíîãî ãíîåòå÷åíèÿ. |
#13
|
||||
|
||||
Ññûëêè èíòåðåñíûå, ñïàñèáî, ïðèìåì ê ñâåäåíèþ.
Ïåðâûé ìîìåíò:  ïåðâîé ññûëêå èäåò ðå÷ü î ïîòåíöèàëüíîé òîêñè÷íîñòè ïåðåêèñè ê êëåòî÷íûì ýëåìåíòàì êîñòè (îñîáåííî osteoblasts è osteoclasts) è óïîìèíàíèå î âðåäíîì ýôôåêòå íà çàæèâëåíèå ðàíû. Ïî âòîðîé ññûëêå - ðàçãîâîð âîîáùå èäåò î øîâíîì ìàòåðèàëå. Èç âñåãî ýòîãî ÿ ïîíÿëà, ÷òî ïðèìåíåíèå ïåðåêèñè, ðàâíî êàê è äðóãèõ àíòèñåïòèêîâ íå ðåêîìåíäóåòñÿ â îðòîïåäèè è òðàâìàòîëîãèè è íåëüçÿ ëèòü ïåðåêèñü íà øîâíûé ìàòåðèàë. Åñëè ÿ ýòî ïîêàæó íà÷ìåäó - ìåíÿ ïîøëþò äàëåêî è íàäîëãî. Âòîðîé ìîìåíò: ×åì æåíùèíà, ïðè èíôèöèðîâàíèè âîò åå òàêîé âîò ðàíû ïóïêà äîìà ìîæåò îáðàáàòûâàòü âìåñòî ïåðåêèñè ñâîþ ðàíó? Øâîâ òàì íåò. Æèäêèì ìûëîì? Ïðî õëîðèä áåíçàëêîíèÿ îòäåëüíàÿ ïåñíÿ, â ñâîå âðåìÿ, êîãäà ÿ òîëüêî ïðèøëà íà ôîðóì, ÿ âûñêàçàëàñü â êîíñóëüòàöèè êàêîé-òî ïàöèåíòêå, ÷òî ÕÁ îáëàäàåò õîðîøèì àíòèñåïòè÷åñêèì ýôôåêòîì, â ñâÿçè ñ ÷åì, ñ ãîñïîäèíîì Ñòóäåíöîâûì âîçíèêëè ðàçíîãëàñèÿ, è îí äîñòàòî÷íî ìíîãî ññûëîê âûëîæèë â ýòîé òåìå, ÷òîáû îïðîâåðãíóü ìîå ìíåíèå. |
#14
|
||||
|
||||
Ìû íà äîì äà¸ì ïàöèåíòàì Intrasite Gel (ãåëü, ââîäèòñÿ â ðàíó, ñîäåðæèò êàðáîêñèìåòèë öåëëóëîçíûé ïîëèìåð, ïðîïèëåí ãëèêîëü è âîäó, ïîêðûâàåìûì Lyofoam (ïîëèóðåòàíîâàÿ ïåííàÿ ïîâÿçêà).
|
#15
|
|||
|
|||
Ê âîïðîñó èíôèöèðîâàíèÿ ðàí òàêîãî òèïà.
Îðèåíòèðîì äëÿ îòêðûòûõ ðàí, áóäåò ñëóæèòü: 1. ãèïåðåìèÿ êðàåâ 2. áîëåçíåííîñòü êðàåâ è ïðèëåæàùèõ òêàíåé 3. ïîâûøåíèå òåìïåðàòóðû 4. ãíîéíîå îòäåëÿåìîå èç ãëóáèíû (òóò ìîæíî äóìàòü î ñâèùå, ñàíèðîâàòü, ïðîâîäèòü êîíòðàñòíîå èññëåäîâàíèå, ñîçäàòü îòòîê, âûÿâèòü è óñòðàíèòü èñòî÷íèê èíôåêöèè) Ïðè 1,2,3 áåç 4 ìîæåò áûòü äîñòàòî÷íî íàçíà÷èòü à\á âíóòðü. Ïàöèåíòû ÷àñòî ïðèíèìàþò çà ãíîé - îáû÷íûé ôèáðèí. Àìáóëàòîðíîå âåäåíèå - ïðåäïî÷òèòåëüíåé (ìåíüøå âåðîÿòíîñòü ïðèñîåäèíåíèÿ âíóòðèáîëüíè÷íûõ çâåðåé). Ïåðåêèñü ïðåêðàñíî âûïîëíÿåò ìåõàíè÷åñêè îò÷èñòêó îò ìåëêîãî äåòðèòà, ãíîÿ îñîáåííî â "ãëóáîêèõ ìåñòàõ". Ïðèìåíåíèå äëÿ îòêðûòîé ðàíû, ñ äîñòóïíûì äíîì, íè ÷åì íå âûãîäíåé îáû÷íîé ÷èñòîé âîäû.  ñëó÷àå îòñòóòñòâèÿ óêàçàííûõ ïðèçíàêîâ, ÿ áû ðåêîìåíäîâàë ïàöèåíòêå ïîâÿçêó Cosmopor íåìåöêîé ôèðìû Hartman. Îíà íå ïðèëèïíåò ê ðàíå, ïðåêðàñíî äåðæèòñÿ (íó, äåñÿòü äíåé ñïîêîéíî, äàæå íà ïðîáëåìíûõ ìåñòàõ), ãèïîàëëåðãåííà, "äûøèò", è ïðåêðàñíî âûïîëíÿåò áàðüåðíóþ ôóíêöèþ..... Ñòîèòü íà òàêóþ ðàíêó ýòî óäîâîëüñòâèå áóäåò ðóáëåé 15-30. |