Tata Laksana Luka (Diperbarui 2023)

#bedahplastikntt @robertusarian
arian9677@gmail.com @eanplastic
Tata Laksana
Luka
Robertus Arian Datusanantyo (EAN)
Plastic Surgeon - RSUD Prof. Dr. W. Z. Johannes
onlinestoresinger.com

Anatomi Kulit
www.gettyimages.com

3

4

Luka Akut dan
Kronis

Luka Akut vs Kronis
• Luka: terputusnya kontinuitas kulit.
• Penyembuhan luka: respon organisme secara
global terhadap adanya perlukaan.
• Luka akut: terjadi dalam 3-4 minggu.
• Luka kronis: terjadi lebih dari 4-6 minggu, tidak
sembuh, terlambat sembuh…
• Luka akut bisa menjadi kronis, dan penyembuhan
luka kronis dapat melalui fase “akut”
6

Asesmen Luka Akut
• Ukuran, bentuk, lokasi
• Waktu terjadi luka (onset)
• Laserasi, avulsi, atau kronis
• Debris, perdarahan, eksudat, pus, bau
• Exposed: tendon, vaskuler, saraf, otot,
sendi, tulang
• Benda asing: perlu X-ray?
7

Penyembuhan
Luka

Fase Penyembuhan Luka
• Fase Inflamasi
• Fase Proliferasi
– Fibrolasi
– Granulasi
– Kontraksi
– Epitelisasi
• Fase Remodelling
9

Fase Inﬂamasi 10
• Koagulasi
• Vasodilatasi
• Migrasi PMN dan
makrofag
• Peran growth
factor, sitokin,
dan kemokin.

Fase Proliferasi 11
• Keratinosit dan
fibroblas
• Migrasi sel
• Proliferasi
• Pembentukan
kapiler
• Sintesis ECM
• Epitel membentuk
epidermis

Fase Remodelling 12
Parut / scar
Keseimbangan
antara sintesis
ECM dan
degradasi oleh
protease.

Manajemen
Luka Akut

Manajemen Luka Akut (1)
• Irigasi & debridement: menyingkirkan jaringan
nekrosis dan koloni bakteri
• Jaringan nekrotik: menjadi fokus infeksi, memperpanjang
fase inflamasi, obstruksi mekanis kontraksi, dan mengganggu
reepitelisasi
• Autolitik: elastase, kolagenase, myeloperoksidase, hidrolase
asam, lisosom
• Tindakan debridement: mempercepat penyembuhan
• Ragu: tunggu demarkasi
14

• Bila kering:
– Timbul krusta keras
– Desikasi pada matriks kolagen
– Keratinosit di bawah krusta?
• Kondisi “moist” / lembab:
– Mendorong migrasi keratinosit dan pembentukan matriks
– Mendorong autolitik
– Mengurangi nyeri dan bengkak
– Mengurangi risiko infeksi dan fibrosis
– Secara kosmetik lebih baik.
15

• Debridement dan Irigasi jaringan non vital
• Bilas luka dan singkirkan tato traumatik
• Singkirkan semua benda asing
• Menjahit luka:
– Freshening tepi luka
– Hindari dead space, jahit lapis demi lapis
– Teknik atraumatik, perlakukan jaringan dengan lembut
– Hindari tension dalam penutupan luka
– Gunakan jahitan dalam dengan bijaksana
• Tunda penutupan luka dengan kontaminasi berat
16

Anestesi Lokal dan Blok
• Potensi, onset, durasi
• Penambahan adrenalin (epinefrin)
• Blok:
– Wrist, brachial, infraorbita, submental, supraorbita
• Inﬁltrasi:
– Intradermal, subkutan, campuran
• Dosis maksimal:
– Lidokain 5 mg/kgBB
– Lidokain + epinefrin 7 mg/kgBB
17

18

19

20

21

22

23

24
www.ethicon.com

25

26

27

Kesalahan Umum
• Tidak menyingkirkan debris, tidak
freshening tepi luka
• Bekas jahitan besar dan mengganggu
• Gagal menjahit sesuai posisi anatomis
sebelum luka
• Dead space
• Jahitan diambil tidak tepat waktu
28

Manajemen
Luka Kronis

• Beban: lama sembuh, mahal,
membebani sistem kesehatan
• Perawat: defisiensi pengetahuan
• Pasien: keterlibatan dan kepatuhan
pasien
• Dokter Layanan Primer: latar
belakang luka kronis dan alur pelayanan
pasien
30
Mengapa Luka Kronis?
(Jones, 2019; Atkin et.al., 2019)

31
Prevalensi luka
kronis di negara
maju bervariasi 1%
sd 2%
Rata-rata waktu sembuh
ulkus diabetikum stage
4: 190 hari
Diperlukan > 420 hari
untuk kesembuhan 90%
ulkus venosus
Diperlukan US$8041 (Rp
116 juta) untuk setiap
ulkus dekubitus yang
terjadi di RS
“Pasien yang tidak mengerti tujuan
perawatan luka menjadi tidak patuh
sehingga penyembuhan luka terganggu.”
(Atkin et. al., 2019)

32
1. Peripheral neuropathy (sensory, motor and
autonomic neuropathy)
A number of classification systems for DFU have
been developed, including PEDIS (perfusion, extent,
Fig 1. Risk factors for hard-to-heal wound formation. Note: the more factors a patient has, the more likely
the wound will not heal
Presentation of wound/lesion/ulcer
Yes
No Risk factors associated with hard-to-heal wounds
Obesity
Older age
Poor nutrition
Genetics
Smoking
Anaemia
Hypoxia
Comorbidities
Diabetes
Arterial disease
Venous disease
Neuropathy
Chronic inflammation
Lymphatic insufficiency
Oedema (if on lower limbs)
Immune suppression or disease
Cancer
Systemic medication
Radiation
Psychosocial
Patient adherence
Patient economic status
Demographic factors
Behavioural factors
Immobilisation
Healing
Pressure ulcer
Leg ulcer
Diabetic foot ulcers
Peripheral arterial disease
Risk of a hard-to-heal wound
Address underlying cause
Modify risk factors where possible
Maintenance care
When underlying cause and risk
factors cannot be sufficiently altered
to facilitate healing

33
Patofisiologi
Wound Healing
• Hemostasis –
Inflamasi
• Proliferasi
• Maturasi
• MMP - TIMP
Bioﬁlms
• 70%
• Kompleks
mikrobial dalam
extracelular
polymeric
substance
• Debridement –
Regrow
• Kultur?
Cell Senescence
• Fibroblas
• Pemendekan
telomer karena
mitosis
• Mengganggu
proliferasi
• Dipengaruhi
biofilms
(Jones, 2020a; Atkin et.al., 2019)

1. Asesmen holistik
2. Asesmen luka
3. Tentukan luaran dan rencana perawatan
4. Manajemen patologi dasar atau maintenance
care
5. Local wound care / maintenance
6. Tindak lanjut, reasesmen, pengukuran
7. Modifikasi, rujuk kalau perlu
8. Pendidikan pasien dan keluarga
9. Lepas rawat atau beralih ke maintenance
10. Pencatatan tiap episode
34
Tata Laksana
(Atkin et.al., 2019)
§ Intervensi dini
§ Asesmen dan diagnosis
akurat pasien & lukanya
§ Strategi manajemen
optimal pasien dan
lukanya
§ Nakes dengan
kompetensi tepat
§ Rujukan dini ke spesialis
Komponen Standar
Perawatan Efektif

• Wound extent: dimensi luka dan kedalaman
jaringan yang terlibat
• Wound attributes: petunjuk terhadap
penyebab, status, dan patoﬁsiologi luka
• Wound burden: relasi antara wound extent
dan wound attributes
• Wound severity: wound burden, host, dan
lingkungan
35
Asesmen Luka Kronis
(Lazarus et. al., 1994)

36
Tentukan Luaran
• Restorasi anatomis
• Restorasi fungsi
Luka Sembuh
• Luka sembuh tidak realistis
• Pasien kritis / end of life care
• Martabat, mengurangi risiko infeksi,
bau, eksudat, dan nyeri
Maintenance
• Luka sembuh tidak realistis
• Dikehendaki pasien
• Risiko komplikasi luka terbuka dapat
lebih besar daripada risiko amputasi
Amputasi
(Atkin et.al., 2019)

37
ABSTRACT
Our understanding of pressure injury etiology and development has grown in recent years through research, clinical expertise,
and global interdisciplinary expert collaboration. Therefore, the National Pressure Ulcer Advisory Panel (NPUAP) has revised the
Revised National Pressure Ulcer Advisory Panel Pressure
Injury Staging System
Revised Pressure Injury Staging System
Laura E. Edsberg ¿ Joyce M. Black ¿ Margaret Goldberg ¿ Laurie McNichol ¿ Lynn Moore ¿ Mary Sieggreen
J Wound Ostomy Continence Nurs. 2016;43(6):585-597.
Published by Lippincott Williams & Wilkins
Wound Care
Wound Care
PERSPECTIVE ARTICLE
Consensus guidelines for the identification and treatment
of biofilms in chronic nonhealing wounds
Gregory Schultz, PhD1
; Thomas Bjarnsholt, DMSc2,3
; Garth A. James, PhD4
; David J. Leaper, DSc5
;
Andrew J. McBain, PhD6
; Matthew Malone, MSc7,8
; Paul Stoodley, PhD9
; Theresa Swanson, MHSc10
;
Masahiro Tachi, MD11
; Randall D. Wolcott, MD12
; for the Global Wound Biofilm Expert Panel
1. Department of Obstetrics & Gynecology, Institute for Wound Research, University of Florida, Gainesville, Florida,
2. Department of Immunology and Microbiology, Costerton Biofilm Center, University of Copenhagen, Copenhagen, Denmark,
3. Department of Clinical Microbiology, Copenhagen University Hospital, Copenhagen, Denmark,
4. Center for Biofilm Engineering, Montana State University, Bozeman, Montana,
5. Clinical Sciences, University of Huddersfield, Huddersfield, United Kingdom,
6. Division of Pharmacy and Optometry, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester,
Manchester, United Kingdom,
7. Liverpool Hospital, South West Sydney LHD, Sydney, New South Wales, Australia,
8. LIVEDIAB, Ingham Institute of Applied Medical Research, Sydney, New South Wales, Australia,
9. Departments of Microbial Infection and Immunity, and Orthopaedics, Ohio State University, Columbus, Ohio,
10. Warrnambool Base Hospital, Warrnambool, Victoria, Australia,
11. Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, Tohoku University, Sendai, Japan, and
12. Southwest Regional Wound Center, Lubbock, Texas
Reprint requests:
Gregory Schultz, Department of Obstetrics
and Gynecology, Institute for Wound
Research, University of Florida, 1600
South West, Archer Road, Room M337F,
Gainesville, FL 32610-0294.
Tel: 352-273-7560;
Fax: 352-392-6994;
Email: schultzg@ufl.edu
Manuscript received: December 12, 2016
Accepted in final form: September 11,
2017
DOI:10.1111/wrr.12590
ABSTRACT
Background: Despite a growing consensus that biofilms contribute to a delay in
the healing of chronic wounds, conflicting evidence pertaining to their
identification and management can lead to uncertainty regarding treatment. This,
in part, has been driven by reliance on in vitro data or animal models, which may
not directly correlate to clinical evidence on the importance of biofilms. Limited
data presented in human studies have further contributed to the uncertainty.
Guidelines for care of chronic wounds with a focus on biofilms are needed to help
aid the identification and management of biofilms, providing a clinical focus to
support clinicians in improving patient care through evidence-based medicine.
Methods: A Global Wound Biofilm Expert Panel, comprising 10 clinicians and
researchers with expertise in laboratory and clinical aspects of biofilms, was
identified and convened. A modified Delphi process, based on published scientific
data and expert opinion, was used to develop consensus statements that could help
Guidelines
CHALLENGES
AND CURRENT
BEST PRACTICE
MANAGEMENT OF
PATIENTS WITH
VENOUS LEG ULCERS
A JOINT
DOCUMENT
Diabetic foot problems:
prevention and management
NICE guideline
Published: 26 August 2015
www.nice.org.uk/guidance/ng19
© NICE 2020. All rights reserved. Subject to Notice of rights (https://www.nice.org.uk/terms-and-conditions#notice-of-
rights). Last updated 11 October 2019

38
• Tissue Viability
T
• Infection / Inflammation
I
• Moisture Balance
M
• Wound Edge
E
• Repair / Regeneration
R
• Social- & Patient-Related Factors
S

• Observasi:
– jaringan mati
– Jaringan non-vital
• Debridement:
– Pilihan debridement
– Pertimbangan melakukan debridement
– Kapan tidak melakukan debridement
• Luaran: bed luka bersih
39
Tissue Viability
T

40
T Jaringan
nekrotik?
Pilihan
Debridement?

41
Debridement
T
Surgical Autolysis Chemical
Larval /
Biologic
Mecha-
nical

• Observasi:
– Inflamasi dan / atau infeksi
– Bioburden
• Pilihan terapi:
– Antimikroba / antibiotik
– Bacterial-binding dressing
– Terapi oksigen
– Surfaktan
– Keseimbangan MMP / TIMP
42
Infection / Inflammation
I

43
I
Infeksi

• Luaran:
– Inflamasi terkendali
– Infeksi terkendali
– Biofilm terkendali
44
Infection / Inflammation
I

• Observasi: keseimbangan kelembaban
(moisture) yang tidak tepat
• Pilihan terapi:
– NPWT
– Bebat tekan
– Absorben
• Luaran: Manajemen kelembaban
sehingga suasana luka konduktif untuk
penyembuhan
45
Moisture Balance
M

46
Absorben
Negative-Pressure Wound
Therapy

• Observasi:
– Tepi luka: rolled / epibole / callus
– Kemajuan tepi luka buruk
• Terapi:
– Debridement
– Pelindung tepi luka
– Wound filler (kolagen)
47
Wound Edge
E

48
perglycemia, which can potentially lead
to peripheral neuropathy and pathologi-
cal changes to plantar soft tissue, i.e.,
stiffening and loss of effective load distri-
bution across the contact surface of the
foot [16]. Chronically elevated blood
sugar levels lead to increased tendency to
thrombosis, disrupted blood flow, vaso-
constriction, and diminished antimicro-
bial defense. Thus, maintaining normo-
glycemic levels in diabetic patients is one
of the most important general preventive
measures.
Buckingham et al. [28] examined 375
patients with diabetes mellitus for sclero-
dermalike skin changes, limited joint
mobility, and vital capacity changes. In
190 patients, skin changes presented as
thickening, tightening, and a waxy qual-
ity of the skin. The severity of skin
changes was positively correlated with
duration of diabetes, patient age, severity
of joint contractures, and diabetic
ropathy and plantar pressures > 6 kg/cm2
Garrow et al. [33] compared special “pre-
ventive foot care (PFC) socks” (Legend
Care, Mullingar, County Weatmeath,
Ireland) with normal, commercially
available socks. PFC socks are designed
with an innovative dual-layer construc-
tion. Use of “PFC socks” in the study
achieved a significant increase in maxi-
mum foot contact area of around
8 % (p < 0.01) and a significant reduc-
tion in plantar pressure of about 9 %
(p < 0.01). Another study with17 patients
with high plantar pressures and 17 pa-
tients with plantar callus investigated the
effects of orthotics, cushion inlays, and
the combination of the two [34], and
showed that combination use yielded the
greatest reduction (about 63 %). A sig-
nificant reduction of plantar pressure
was found even 12 months after use of
orthotic devices was discontinued.
The importance of regular inspection of
38 Review Article Xerosis and callus formation:Key to diabetic foot syndrome
(Pavicic & Korting, 2006; Edsberg et. al., 2016; Jones, 2020b)
Fundamental care in practice I CLINICAL
to provide the optimal environment for
wound healing. However, the holistic
treatment should also be explained to
them and any questions they might
patient may have had compression in the
past and been unable to wear their shoes
Menna
Lloyd
Jones
Photo 2 shows maceration of surrounding skin; observe the unhealthy condition of the wound margin,which will need to be addressed in order to encourage
epithelialisation from the wound margins.Also,over 50% of the wound is covered with devitalised tissue,which will require debridement.

• Luaran:
– Berkurangnya ukuran luka
– Epitelisasi
49
Wound Edge
E

• Observasi:
– Terapi konservatif è luka menetap /
menutup sangat lambat
• Terapi:
– Amnion, perancah sel (cell scaffold), GF,
PRP, bioengineered substitute, stem cell,
ECM-based technologies
– NPWT
– Skin graft (autologous)
50
Repair / Regeneration
R

• Luaran:
– Penutupan luka
– Perbaikan jaringan
51
Repair / Regeneration
R

52
Social- & Patient-Related Factors
S
• Situasi Sosial
• Pemahaman Pasien
• Kepatuhan Pasien
• Pilihan Pasien
• Psikososial
• Pendidikan Pasien
• Pemahaman Sistem Belief
• Literasi Motivasional
• Mendengar Aktif
• Psikoedukasi
• Tujuan Pasien
• Pendidikan ke Keluarga
Pasien / Pemberi Layanan
Peran serta aktif pasien
dalam rencana perawatan
(Jones, 2020b; Atkin et. al., 2019)
§ Faktor psikososial
§ Faktor fisik dan
komorbiditas
§ Faktor ekstrinsik
Manajemen Faktor terkait
Pasien

Bacaan Lanjutan (1)
Atkin L, Bućko Z, Conde Montero E, Cutting K, Moﬀatt C, Probst A, Romanelli M, Schultz GS,
Tettelbach W. Implementing TIMERS: the race against hard-to-heal wounds. J Wound
Care 2019; 28(3 Suppl 3):S1–S49
Boyce DE, Shokrollahi K. Reconstructive surgery. BMJ. 2006;332(7543):710-712.
doi:10.1136/bmj.332.7543.710
Bhattacharya V. Management of soft tissue wounds of the face. Indian J Plast Surg.
2012;45(3):436-443. doi:10.4103/0970-0358.105936
Bullocks JM, et al., 2017, Plastic Surgery Emergencies: Principles and Techniques Second
Edition, Thieme Medical Publisher, Stuttgart
Edsberg LE, Black JM, Goldberg M, et al. Revised National Pressure Ulcer Advisory Panel
Pressure Injury Staging System. J Wound, Ostomy Cont Nurs. 2016;43(6):585–97.
Guyuron et. al. (Eds.), Plastic Surgery: Indications and Practice 1st Edition, Saunders
Jones ML. International consensus document. Implementing TIMERS: the race against hard-
to-heal wounds. Part 1. British Journal of Healthcare Assistants 2019; 13:12:578-579
53

Bacaan Lanjutan (2)
Kantor J, 2016, Atlas of Suturing Technique, McGraw-Hill Education, New York
McGreggor AD, McGreggor IA, 2000, Fundamental Technique of Plastic Surgery and Their
Surgical Application, Churchill Livingstone
Standring, 2005, Gray’s Anatomy 39ed, available at graysanatomyonline.com
Thorne et. al. (Eds.), 2014, Grabb and Smith’s Plastic Surgery 7th Edition, Lippincott Williams
& Wilkins, Philadelphia
Lazarus GS, Cooper DM, Knighton DR, Margolis DJ, Pecoraro RE, Rodeheaver G, Robson MC.
Definitions and guidelines for assessment of wounds and evaluation of healing. Arch
Dermatol. 1994 Apr;130(4):489-93.
Pavicic T, Korting HC. Xerosis and callus formation as a key to the diabetic foot syndrome:
dermatologic view of the problem and its management. J Dtsch Dermatol Ges. 2006
Nov;4(11):935-41.
54

dr. Robertus Arian D. (EAN), M.P.H.,M.Ked.Klin.,SpBP-RE
Dokter Spesialis Bedah Plastik Rekonstruksi & Estetik
RSUD Prof. Dr. W. Z. Johannes; RS St. Carolus Borromeus; RS Leona
WA: +62 818 04 245 382; Instagram: @eanplastic;
E-mail: arian9677@gmail.com; #bedahplastikntt;
Presentations: http://bit.ly/ean_slideshare
55

Tata Laksana Luka (Diperbarui 2023)

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Similar to Tata Laksana Luka (Diperbarui 2023)

Similar to Tata Laksana Luka (Diperbarui 2023) (20)

More from Robertus Arian Datusanantyo

More from Robertus Arian Datusanantyo (20)

Recently uploaded

Recently uploaded (20)

Tata Laksana Luka (Diperbarui 2023)