Thursday, August 26, 2010

Honey-Based Dressings and Wound Care: An Option for Care in the United States

Honey-Based Dressings and Wound Care: An Option for Care in the United States
Barbara Pieper Journal of Wound, Ostomy and Continence Nursing
January/February 2009
Volume 36 Number 1
Pages 60 - 66

Honey-based wound dressings have been used worldwide since ancient times. A honey product received US Federal Drug Administration approval in 2007, making this dressing an option for wound care. Honey has been found to exert anti-inflammatory and antibacterial effects without antibiotic resistance, promote moist wound healing, and facilitate debridement. However, it may cause a stinging pain. As is true of any wound dressing, its use must be carefully selected and monitored. Continued research is needed to add to its evidence base. This article provides a summary of the current evidence base for the use of honey and a review of its therapeutic effects and discusses implications for WOC nursing practice.
Referenced in ancient medical writings of Egypt, Greece, and parts of India, honey is considered to be the oldest wound dressing.1,2 In 2007, the US Food and Drug Administration gave clearance to market a honey-based wound dressing product (Medihoney, Derma Sciences, Toronto, Ontario, Canada).3 The product uses active Manuka honey (Leptospermum scoparium), derived from tea plants, and Leptospermum polygalifolium, known as the jelly bush.4 Manuka is the name of the floral source of the honey L scoparium.1 This article summarizes the current evidence base for the use of honey, its therapeutic effects, and implications for WOC nursing practice.
Composition of Honey
Honey consists of multiple components derived from plants and bees during the maturation processes. It is a product obtained from bees of the genera Apis and Meliponinae.5 Bees collect nectar from flowers; nectar has a sugar content ranging from 5% to 60%. The resulting compound is composed of sucrose, glucose, and fructose.6 Nectar is processed by bees and deposited in the wax cells of the hive. The water content of honey is reduced to 17% by evaporation from the warmth of the hive and fanning of bees. The bees also add enzymes to the honey including invertase (which converts sucrose into glucose and fructose) and glucose oxidase (which oxidizes glucose and produces gluconic acid). Production of gluconic acid lowers honey's pH and contributes to hydrogen peroxide production.6 The resulting compound is converted to glucose and fructose, and the glucose is converted to gluconic acid and hydrogen peroxide by glucose oxidase. Culinary honeys undergo heat treatment, which destroys the enzyme responsible for producing hydrogen peroxide. In contrast, honey used for wound care does not undergo heat treatment. Instead, it is sterilized by [gamma]-radiation, thus retaining its biologic activity.1 The resulting honey is a supersaturated solution whose pH ranges from 3.2 to 4.2.1,6
Therapeutic Effects of Honey Dressings
WOC nurses should be knowledgeable of the therapeutic effects of a dressing when selecting it for wound care. This section reviews the anti-inflammatory and antimicrobial effects of honey, its ability to support moist wound healing, debride the wound bed, and control odor, and its effects on scar formation.
Anti-inflammatory Effects
Excessive inflammation can prevent healing or cause further tissue damage by increasing reactive oxygen species or free radicals.2 Honey has been shown to reduce both acute and chronic inflammation.7 Although the mechanism for the anti-inflammatory action of honey is not entirely understood,1 multiple effects have been reported. For example, histological studies of biopsy specimens show a reduced number of inflammatory cells when exposed to honey.2,8 Honey has also been shown to modulate the activity of immunocompetent cells such as monocytes in the wound.1 In addition, honey may stimulate peripheral blood B and T lymphocytes in cell culture and activate phagocytes from the blood.2,8 Honey has been reported to stimulate monocytes in cell culture to release cytokines tumor necrosis factor-1, interleukin (IL)-1, and IL-6, which act as intermediates in the immune response.2 Honey also supplies glucose that is critical for the “respiratory burst” in macrophages needed to generate hydrogen peroxide, and it provides substrates for glycolysis for energy production in macrophages.2
The potential benefits of honey's anti-inflammatory effect include alleviation of the pain associated with inflammation. A reduction in edema provides other positive effects. The pressure from edema restricts the blood flow of oxygen and nutrients, which leukocytes need to fight infection and fibroblasts need for connective tissue synthesis.2,8 Thus, reducing edema not only alleviates associated pain but also improves microcirculation and increases the availability of dissolved oxygen and nutrients needed for tissue repair and regeneration.
The anti-inflammatory effects of honey reduce hypertrophic scarring during the maturation phase of wound healing.2 The free radicals formed when excessive or prolonged inflammation is present stimulate the fibroblasts that produce the collagen fibers of a scar. The anti-inflammatory effects of honey reduce formation of reactive oxygen species, thus decreasing the fibroblast and collagen production needed to create a hypertrophic scar.
Antibacterial Effects
Honey has a broad spectrum of bactericidal and bacteriostatic activities.1,2 Although the antibacterial effects of honey have long been known,2 there is currently increased interest in these properties, partly due to the emergence of antibiotic-resistant strains of microorganisms. Medical honey has not been observed to foster bacterial resistance.9,10 Instead, honey is hypothesized to inhibit bacterial growth primarily due to its high osmolarity.2,10,11 However, some researchers contend that this effect is lost once the wound drainage dilutes the honey. Other factors thought to contribute to the antibacterial effects of honey are the phytochemicals in the nectar collected by the bees. This has been demonstrated for honey from the Leptospermum species from Australia and New Zealand. The antibacterial activity of honey may vary as many as 100-fold based on the type of honey and how it was processed.2,10 Producers have a registered trademark (UMF—Unique Manuka Factor) to measure the antibacterial potency of honey.12 The higher the number, the more potent the honey's antibacterial activity. The highest rating is 18.12
Other antibacterial effects of honey are associated with its acidic pH (range, 3.2–4.5), which may prevent biofilm formation and cross-contamination.4 Honey's ability to prevent cross-contamination is linked to its high osmolarity; it draws fluids into the wound, resulting in a viscous solution that provides a protective barrier against cross-infection.1
Hydrogen peroxide, produced in honey by the enzyme glucose oxidase, is an important source of honey's antibacterial activity.13 The amount of hydrogen peroxide in a wound varies over time, based on rates of production, destruction, and dilution by exudate. The hydrogen peroxide produced by honey is not cytotoxic. The amount produced is 1,000 times lower than a hydrogen peroxide 3% solution rinse.1,2,7 This low concentration of hydrogen peroxide may act as a “messenger” in promoting healing, and it may stimulate both fibroblasts and epithelial cells.1
Research has shown that honey exerts antibacterial activity against clinical isolates of Staphylococcus aureus, methicillin-resistant S aureus, vancomycin-resistant enterococci, [beta]-hemolytic streptococci, and vancomycin-sensitive enterococci.2,9–11,14,15 Examples of microorganisms that honey may inhibit are given in Table 1. Lusby and colleagues 16 reported that only Serratia marcescens and Candida albicans were not inhibited by honey. However, as noted earlier, the precise mechanisms that account for these antimicrobial effects are not entirely understood. It is known that honey's antibacterial activity acts much more slowly than traditional antiseptics that decrease bacterial counts within minutes.9 Honey also differs from other antiseptics because it retains its bactericidal activity in vitro even after dilution.11,14,15 Researchers are seeking to more clearly understand honey's antimicrobial activity because it persists irrespective of bacterial resistance to antibiotics. The clinical relevance of this is apparent as clinicians continue to grapple with the growing problem of antimicrobial resistance.

TABLE 1. Examples of Microorganisms Against Which Honey Is Effectivea
Gethin 17 examined bacteriologic findings associated with the use of Manuka honey. She noted (1) a small number of clinical trials but a multitude of case reports and observational reports, (2) a lack of research rigor, and (3) a paucity of trials on the use of topical honey in wound management of people with diabetes. Based on this review, Gethin concluded that honey may help reduce bacterial burden, but its floral source should be specified in all studies because it profoundly influences honey's effectiveness as an antibacterial agent.
Debridement Properties
Honey may facilitate wound debridement through several mechanisms. It enables the autolytic action of tissue proteases.2 Because of its strong osmotic action, honey pulls lymph fluid from the wound tissues to add moisture needed for autolytic debridement. The osmotic action washes the wound base from beneath, removing debris and painlessly lifting off slough and necrotic tissue.2,8 The production of hydrogen peroxide may also contribute to debridement.1 Matrix metalloproteases of connective tissue and neutrophil serine proteases may be activated by hydrogen peroxide.2 Although high protease activity is strongly associated with impaired wound healing, this has not been shown to be the case with honey, possibly because the anti-inflammatory effect of honey tempers this situation.2 Honey may provide a more comfortable and cost-effective method of debridement than mechanical or surgical excision.2
Odor Control Properties
Decreased wound odor has been reported when honey dressings were used to treat abscesses, diabetic foot ulcers, leg ulcers, and fungating wounds.1 Honey reduces wound odor via 2 mechanisms. First, malodor is attributed to the presence of anaerobic bacteria such as Bacteroides spp, Peptostreptococcus spp, and Prevotella spp. Honey exerts antibacterial action in vivo and in vitro against these anaerobes, reducing their presence in the wound bed and subsequent ability to produce odor. Second, honey provides glucose as an alternative to the amino acids created when serum and dead cells are metabolized by bacteria.18 As a result, lactic acid is produced as compared to the malodorous ammonia, amines, and sulfur compounds typically formed by the metabolism of amino acids from decomposed serum and tissue proteins when honey is not present.1,2,8,18
Wound Healing Effects
Honey has been reported to promote wound healing through several mechanisms. It promotes a moist wound environment by drawing lymph into the wound through osmosis and preventing the dressing from adhering to the wound bed.18 In addition, the levulose and fructose contained in honey may improve local nutrition and promote epithelialization.1,2 The acidic nature of honey provides an optimal environment for fibroblast activity.1 Molan 2 noted that honey (1) stimulates angiogenesis, thus increasing oxygen and nutrients to the wound and promoting healthy granulation tissue; (2) hastens epithelialization, possibly decreasing the need of skin grafting; and (3) stimulates collagen synthesis and improves tensile strength.
Honey's effect on wound healing has been examined with various wound types (Table 2). Gunes and Eser 18 completed a randomized clinical trial comparing honey dressing (n = 15) versus an ethoxy-diaminoacridine plus nitrofurazone dressing (n = 11) on pressure ulcer healing. The investigators were not blinded to treatment group. Wounds were traced and evaluated with the Pressure Ulcer Scale for Healing tool. Both groups had decreased scores over the course of the study, but the honey group had 4 times the rate of healing of the control group.

TABLE 2. Types of Wounds for Which Honey Dressings Have Been Useda
Gethin and Cowman 19 examined healing of leg ulcers with Manuka honey in an 8-patient case series. Mean reduction in wound area across all wounds was 54.8% over the 4-week period. This improvement, in part, might have been attributable to renewed interest and compliance in wound care. Dunford and Hanano 20 examined the effects of honey for the treatment of venous leg ulcers that had not healed after 12 weeks of compression therapy. This prospective, nonrandomized study reported on 40 patients from 4 centers. Thirteen patients (32.5%) dropped from the study primarily because of an increased stinging ulcer pain (n = 6, 15%), deterioration in health (n = 3), and deterioration in the ulcer condition (n = 2). Overall, pain levels decreased in 50% of participants, wound odor decreased in 24 patients, wound area decreased significantly, and 7 ulcers healed.
Ahmed and colleagues 21 examined the use of honey dressings with 21 patients with chronic wounds, 23 with complicated surgical wounds, and 16 with acute traumatic wounds. Treatment lasted for 1 to 28 weeks; all wounds had failed previous treatments. All but one patient (who dropped due to pain) completed the study, and 57 of 59 patients (96.6%) achieved healing of their wounds. During treatment, they noted decreased edema and wound exudate, enhanced debridement, decreased odor, and advanced epithelialization. No allergic reactions occurred. Stephen-Haynes 22 evaluated a Manuka-impregnated dressing on 20 patients with nonhealing wounds. She reported that the honey dressing was easy to apply (65%), was easy to remove (75%), stayed in place (85%), improved the wound bed (80%), and was comfortable (65%).
Honey has been used on damaged skin associated with radiation therapy for cancer. Moolenaar and colleagues 23 initiated a prospective randomized controlled study in Caucasian women who received radiotherapy to the breast or the thoracic wall and developed grade 3 radiation-induced dermatitis. In 21 women, 24 skin reactions were evaluated: 12 were treated with a honey dressing and 12 with paraffin dressings. No statistically significant difference in time to healing and closure was found when treatments were compared. However, subjects managed with the honey dressing had a trend toward less pain, itching, and irritation. Neither treatment resulted in relevant side effects.
Topical honey has also been examined in the management of radiation-induced mucositis for head and neck cancers.24 Twenty patients received the radiation therapy alone and 20 received 20 mL of pure honey applied to the mucosa 15 minutes pretreatment, 15 minutes posttreatment, and 6 hours postradiation therapy. The honey-treated patients had a significant reduction in symptomatic grade 3/4 mucositis and had either no change or a positive change in body weight.
Subrahmanyam 25 randomly assigned 50 burn patients to early tangential excision and skin grafting (n = 25) versus honey treatment (n = 25). The honey-treated group had less blood volume replaced. After 3 months, the graft group had significantly better functional and cosmetic results than the honey-treated group. In fact, 3 of the honey-treated patients had significant contractures. The authors concluded that early tangential excision and skin grafting was superior to topical honey treatment.25
Misirlioglu and colleagues 26 compared honey- impregnated gauze with 3 other dressings (hydrocolloid, paraffin gauze, and saline-soaked gauze) on split-thickness, skin-graft donor sites. Eighty-eight patients' grafts were treated half with the honey-based dressing and half with 1 of the other 3 dressings. The honey-treated sites showed a faster epithelialization time and lower pain compared to the paraffin and saline-soaked dressings. However, these differences did not persist when the honey dressing was compared to the hydrocolloid dressing. They concluded that the honey dressing was safe and could be an alternative dressing for split-thickness, skin-graft donor sites.26
Systematic Reviews of Wound Healing
The results of 3 systematic reviews illustrate existing evidence pertaining to the effectiveness of honey dressings in chronic wound healing. Fox 27 searched 5 databases, literature from companies, and the Internet. She identified 6 studies that examined the use of honey in wound management for adults with chronic wounds. None were randomized controlled trials or comparative studies of honey treatment versus usual treatment. All were found to have major design flaws. Despite this paucity of research-based evidence, 5 of the 6 articles described honey as a superior treatment option, thus creating a dilemma for clinicians who are questioned by patients about the use of a honey dressing. Fox 27 concluded that there is a paucity of high-quality literature related to the use of topical honey in adults with chronic wounds and recommended caution in the use of honey-based dressings. Moore and colleagues 28 reported a systematic review of 7 nonblinded, randomized controlled trials that used honey as a wound dressing for superficial burns (n = 6) and infected postoperative wounds (n = 1). All of the studies compared honey to other active therapies, but the alternative interventions included atypical treatments such as potato peelings and amniotic membrane. The main outcomes of the studies were healing time and infection rate. In all of the studies, honey was associated with a shorter healing time, eradication of infection, decreased use of antibiotics, and decreased hospitalization. Nevertheless, since 6 of the studies were done by the same researcher, Moore and colleagues 28 suggest caution when interpreting these findings. In contrast, Molan 29 analyzed research from 17 randomized controlled trials with 1,965 participants, 5 clinical trials involving 95 participants, and 16 trials on 533 wounds on experimental animals. He concluded that honey could promote wound healing when other dressings have failed.29 He also noted that trials examining the efficacy of honey dressings were rarely blinded because the odor of honey is easily recognizable to both investigators and subjects.
Scar Formation
Topham 30 reported scarless healing when honey was used in some cavity wounds. He suggested 3 potential mechanisms resulting in this outcome: (1) saccharides at the wound surface may encourage the production of hyaluronic acid from glucose, which simultaneously suppresses the formation of fiber-forming collagens; (2) glucose at the wound bed creates an environment that enables wound-healing proteoglycans to exert their effects without producing excessive quantities of collagens; and (3) the mechanism by which sugar attaches to collagen may change its structure.
Use of Honey in Children
Honey dressings have also been used in children. Simon and colleagues 31 described 16 wound care situations in 14 patients with impaired wound healing due to the toxicity of chemotherapy and radiation therapy, persistent or intermittent immunosuppression, malnutrition from nausea, vomiting, or mucositis, or infection. Honey was found to be a nonadherent dressing. One child experienced local pain, resulting in discontinuation of the honey dressings. Although measurement methods were not presented, the authors reported a high acceptance by patients and their families that positively impacted patient satisfaction. Vardi and coworkers 32 described 9 neonates who had undergone major operations and presented with chronic open wounds that failed to heal with conventional treatment after 14 days. The conventional treatment included systemic antibiotics, cleaning the wound twice daily, and applying an ointment. Swab cultures were taken daily. Conventional treatment failure was defined as after 14 days of systemic antibiotics and local treatment, the wound was still open, oozing pus, and swab cultures were positive. The honey-based dressing resulted in improved wound healing in all neonates after 5 days of treatment, and all of the wounds closed within 21 days. Systemic adverse events (ie, hyperglycemia, electrolyte imbalance, or significant irritation of surrounding tissue) did not occur. Okeniyi and colleagues 33 examined healing of 43 incised pyomyositis abscess wounds with honey in 32 Nigerian children. The most common cause of this infection was S aureus, which was attributed to the hot and humid tropical climate, poor hygiene, and malnutrition. All children received antibiotics, but the hospital length of stay was shorter and wounds healed faster in the honey-treated group. No wound required secondary wound closure and no side effects were seen in either group.
Bell 6 reviewed the literature from 1996 to 2006 and 2 studies using honey for treating wounds or skin damage in children. One study evaluated the use of honey for treatment of wound infections in neonates 32 and the other reported honey for treatment of diaper dermatitis. The second study that Bell summarized combined honey with beeswax and olive oil in the treatment of 12 infants with incontinence-associated dermatitis. A swab culture for C albicans was taken before therapy and at the end of treatment. Rash severity was rated on a 5-point scale. The honey mixture was applied to the affected areas 4 times per day for a maximum of 7 days. By day 7, 10 of the 12 infants had mild or no incontinence-associated dermatitis. Based on these studies, Bell 6 concluded that the evidence of using honey was interesting, but evidence supporting its use in infants and neonates is weak and recommended that randomized controlled clinical trials with sufficient power should be completed to provide more definitive data. Weaknesses in the available evidence included variability in honey preparations, small sample sizes in the 2 studies identified, and absence of cultures for subjects in the dermatitis study.
Although microbes cannot grow in honey, Clostridium botulinum spores are a theoretical concern in raw products meant for infants. Specifically, the gastric environment in infants is less acidic, and it may provide less effective protection against Clostridium spores than the gastric lumen of an adult. Nevertheless, C botulinum has not been reported yet with honey dressings.6
Clinical Considerations
WOC nurses should make decisions about the use of honey dressings based on current best evidence and research-based knowledge of principles of topical wound care (Table 3). This process begins with an assessment of wound type. White 8 identified the use of honey for (1) chronic wounds such as leg ulcers and pressure ulcers, (2) wounds with delayed healing and local infection, (3) acute wounds such as burns and locally infected wounds without cellulitis, and (4) wound bed preparation for grafting. Honey also may be used as a compassionate treatment option for patients whose care has failed other treatments.9

TABLE 3. Considerations for Honey-Based Dressingsa
The type of honey dressing product should match the wound type. Honey gel/ointment may be applied directly to the wound or an appropriate dressing placed on the wound. The gel/ointment is covered with an occlusive dressing so as to maintain a moist environment to keep the preparation from drying out on the wound bed.8 A practical challenge associated with the use of a liquid/gel honey application is ensuring that it remains in place on vertical wounds such as leg ulcers or abdominal wounds.9,34 If the honey-based product is not available in this format, soaking an alginate dressing with honey and covering with a gauze layer followed by a transparent dressing may help maintain contact with the wound. The alginate honey dressing is especially attractive because it has been found to be malleable, easy to apply, nonadherent to the wound base, and less painful on removal.12
The frequency of dressing change needs to be based on the amount of drainage. If the outer dressing becomes moist with exudate, it must be removed to prevent contamination and maceration of periwound skin. As the drainage decreases, the dressing can be left on for longer periods (4–7 days), thus decreasing the frequency of dressing changes.12 Strike-through of the honey dressing should be avoided because it leaves a sticky residue on affected surfaces.34 A heavy flow of drainage that washes honey to the outer surface may also allow the dressing to stick to the wound, necessitating more frequent dressing changes.35 If a nonadherent dressing is used on the wound base, it should be sufficiently porous to allow components of the honey to diffuse to the wound.35
Relative and absolute contraindications for using a honey dressing also must be considered. These include the following: (1) using a honey product that is not indicated for wound care; (2) sensitivity to bee venom/stings or honey; (3) dry, necrotic wounds; (4) dressings that cannot be changed within a specific time; (5) wounds requiring surgical debridement; and (6) following incision and drainage of an abscess.31,36 Although Stephen-Haynes 22 noted that dressings made from animal products have the potential to provoke an immune reaction, Simon and colleagues 31 observed that no reports of anaphylaxis have ever been associated with the use of honey products for wound care. In addition, since honey is a potential source of glucose absorption, patients with diabetes may be at a slightly greater risk of hyperglycemia.22
Although honey has antibacterial properties, systemic antibiotics may still be needed. For example, this is true of oncology patients with profound neutropenia 31 and any situation in which there is invasive infection, including those with cellulitis.
Some patients experience pain associated with the use of honey dressings. Transient stinging reported as pain may occur for around an hour after its application.8 Blaser and associates 9 reported that 1 of 7 patients stopped treatment due to severe pain, but the pain in this case was later found to be related to opioid resistance. The cause of the transient pain often seen with the use of honey dressings is not fully understood, but it may be related to its osmotic effect (ie, drawing fluid from the wound) or its acidic pH.9 Honey-associated wound pain can be treated with an analgesic or a more dilute honey preparation.8 In some patients, the use of a gel preparation that contains wax ester and ethoxylated oil has been found effective.9
As with any topical therapy, the WOC nurse must assess the effectiveness of a honey-based dressing. Anderson 36 identified key questions to be used when assessing outcomes of a honey dressing:
1. Is there a reduction in redness and swelling in terms of inflammation indicating positive changes in the wound? Has the infection resolved?
2. What is the person's pain description? Has it increased or decreased with the honey dressing? Is it pain the person is willing to tolerate with the dressing?
3. What is the condition of the surrounding skin and is it improving?
4. Is the number of dressing changes decreasing over time? (If dressing frequency is not decreasing, the honey may not be effective due to the amount of drainage and the amount of honey may need to be increased.)
5. Is there a reduction in necrotic tissue?
6. What are the patient's and the clinician's rating of wound odor and is it decreasing?
7. Considering the wound and other dressings, is it cost-effective?
Honey dressing products have been used worldwide for many years, and a honey-based dressing is not available in the United States. A review of existing research reveals increasing evidence regarding the efficacy of honey-based products for healing selected chronic wounds. Honey has been used with adults and children and on acute and chronic wounds. It exerts an antibacterial effect without the risk of antibiotic resistance. Some patients report pain reduction, but stinging or increased pain has also been reported. As with any wound care treatment, prospective randomized controlled studies are needed to provide a more robust and informative evidence base concerning its use in wound care.
The authors have no significant interest, financial or otherwise, in any company that might have an interest in the publication of this educational activity.
[check mark] Honey wound care products have a long historical use worldwide and have been recently approved by the Food and Drug Administration in the United States.
[check mark] Honey-based dressings should be considered with other wound dressings in patient care decisions. WOC nurses should be aware of recommendations for not using these products such as an allergy to honey or bee products.
[check mark] Honey dressings have anti-inflammatory and antibacterial effects. They promote moist wound healing and facilitate debridement. They may cause a stinging pain in some patients.
[check mark] Only honey products approved for wound care should be used.
[check mark] Clinician/patient/family teaching on the proper use of this product is critical.
[check mark] Evaluation of the outcomes of a honey-based dressing should be done as it is done for other dressings.

Manajemen Luka

Manajemen Luka
Dr. Theo Rompas
Bagian Bedah Rumah Sakit Dian Harapan

Kehidupan manusia normal dibatasi pada rentang fungsi yang terbatas. Tubuh akan beradaptasi (menyesuaikan diri) secara fisiologis maupun morfologis apabila terjadi beban fisiologis maupun stimulus (rangsangan) patologis. Jika batas adaptasi ini terlampaui maka dapat terjadi perlukaan (cedera). Pada tingkat tertentu dapat terjadi pemulihan sampai normal atau mendekati normal. Namun , bila stimulusnya berat akan terjadi kerusakan irreversible. Misalnya pada rangsangan panas, mulai dari sengatan matahari, siraman air panas (luka bakar ketebalan sebagian), ataupun luka bakar berat sampai terjadi karbonisasi (seluruh kulit, bahkan lemak dan otot ikut terbakar).
Definisi luka adalah hilangnya atau rusaknya sebagian jaringan tubuh. Keadaan ini dapat dapat diakibatkan trauma benda tajam atau tumpul, perubahan suhu, listrik maupun kimiawi. Berdasarkan penyebab tersebut beserta mekanismenya dapat terjadi luka tertutup maupun luka terbuka seperti luka lecet, memar, luka robek, luka iris, luka tusuk, luka bakar maupun luka kombinasi.
Proses penyembuhan luka ini telah dijelaskan pada berbagai catatan sejarah. Pada saat itu telah dipahami benar bahwa setiap benda asing dan jaringan mati harus dikeluarkan dari luka, pembersihan luka dapat mencegah infeksi dan pus terlokulisasi (menumpuk) harus dialirkan (drainage). Larutan-larutan khusus seperti madu telah dikenal dapat mengurangi proses pernanahan pada luka. Sedangkan pada luka-luka primer dijahit dengan mempergunakan rambut ataupun rahang dari serangga. Pada abad XVI Pare (ahli bedah Prancis) memperhatikan bagaimana kerusakan jaringan sebagai akibat tindakan para dokter pada jaman itu, misalnya aplikasi minyak ternyata menghambat proses penyembuhan luka, bahkan dapat menyebabkan sepsis. Pernyataannya yang sangat terkenal dan tetap dingat setiap dokter saat ini adalah, “do not put anything in a wound you would not put in your own eyes”. Pada perkembangan selanjutnya, seperti pemahaman tentang bakteri dan tindakan-tindakan atraumatik pada luka dapat mengurangi kejadian sepsis maupun kematian. Saat ini tindakan asepsis, penggunaan antiseptik dan antimikroba merupakan era baru dalam perawatan luka
Pada awal abad XX, kontrol nyeri, pengertian tentang pemberian cairan infus dan cairan pengganti darah lainnya dan penggunaan antibiotika merupakan kontributor utama dalam perawatan luka, saat itu proses penyembuhan yang abnormal belum mendapat perhatian. Kini dengan makin dipahami mekanisme biologi perbaikan jaringan (tissue repair) sampai tingkat biokimia dan molekular, kembali terjadi perobahan dalam konsep perawatan luka. Bahkan dengan adanya observasi pada beberapa mamalia bahwa proses penyembuhan luka bukan sekedar penyembuhan/perbaikan (repair) tapi suatu “regeneration”, suatu penyembuhan luka tanpa bekas scar atau fibrosis. Saat ini sementara berkembang penelitian-penelitian dan usaha bagaimana proses penyembuhan luka pada manusia bersifat regenerasi (“Fetal Wound Repair”)

Klasifikasi Luka
Luka dapat diklasifikasi dalam dua kategori utama: akut dan kronis. Luka akut adalah luka dimana proses reparasi (repair) tahapan “normal” dengan hasil penyembuhan tetap mempertahankan fungsi maupun anatomis. Biasanya luka jenis ini terjadi pada orang yang kondisi kesehatan baik, dimana luka dapat ditutup primer atau ditutup primer tertunda. Luka kronis adalah luka yang gagal sembuh sesuai waktunya, dimana hasil penyembuhannya disertai kehilangan fungsi maupun gangguan anatomis. Biasanya pada pasien-pasien dengan penyakit kronis seperti diabetik ulcer, venous statis ulcer dan pressure ulcer.

Fase Penyembuhan Luka
Sejak adanya perlukaan/trauma, proses penyembuhan luka telah dimulai berupa proses peradangan (inflamasi), pertumbuhan (proliferasi) dan pembentukan kembali (remodelling). Pemahaman tahapan mekanisme proses penyembuhan ini sangat erat dengan tindakan terapi yang dibuat maupun berbagai variasi penutupan luka.

Fase inflamasi
Fase inflamasi berlangsung sejak terjadinya luka sampai kira-kira hari kelima. Pembuluh darah yang terputus pada luka akan menyebabkan pendarahan dan tubuh akan berusaha menghentikannya dengan vasokon-striksi, pengerutan ujung pembuluh yang putus (retraksi), dan reaksi hemostasis. Hemostasis terjadi karena trombosit yang keluar dari pembuluh darah saling melengket, dan bersama jala fibrin yang terbentuk, membekukan darah yang keluar dari pembuluh darah. Sementara itu, terjadi reaksi inflamasi.
Sel mast dalam jaringan ikat menghasilkan serotonin dan histamine yang meningkatkan permeabilitas kapiler sehingga terjadi eksudasi, penyebukan sel radang, disertai vasodilatasi setempat yang menyebabkan udem dan pembengkakan. Tanda dan gejala klinis reaksi radang menjadi jelas yang berupa warna kemerahan karena kapiler melebar (rubor), rasa hangat (kalor), nyeri (dolor), dan pembengkakan (tumor).

Aktivitas seluler yang terjadi adalah pergerakan leukosit menembus dinding pembuluh darah (diapedesis) menuju luka karena daya kemotaksis. Leukosit mengeluarkan enzim hidrolitik yang membantu mencerna bakteri dan kotoran luka. Limfosit yang monosit yang kemudian muncul ikut menghancurkan dan memakan kotoran luka dan bakteri. Fase ini disebut juga fase lamban karena reaksi pembentukan kolagen baru sedikit dan luka hanya dipertautkan oleh fibrin yang amat lemah.

Fase Proliferasi
Fase proliferasi disebut juga fase fibroplasia karena yang menonjol adalah proses proliferasi fibroblast. Fase ini berlangsung dari akhir fase inflamasi sampai kira-kira akhir minggu ketiga. Fibroblast berasal dari sel mesenkim yang belum berdiferensiasi, menghasilkan mukopolisakarida, asam aminogisin, dan prolin yang merupakan bahan dasar kolagen serat yang akan mempertautkan tepi luka.
Pada fase ini, serat-serat dibentuk dan dihancurkan kembali untuk penyesuaian diri dari tegangan pada luka yang cenderung mengerut. Sifat ini, bersama dengan sifat kontraktil miofibroblast, menyebabkan tarikan pada tepi luka. Pada akhir fase ini, kekuatan regangan luka mencapai 25% jaringan normal. Nantinya, dalam proses penyudahan, kekuatan serat kolagen bertambah karena ikatan intramolekul dan antarmolekul.

Pada fase fiboplasia ini, luka dipenuhi sel radang, fibroblast, dan kolagen, membentuk jaringan berwarna kemerahan dengan permukaan yang berbenjol halus yang disebut jaringan granulasi. Epitel tepi luka yang terdiri atas sel basal terlepas dari dasarnya dan berpindah mengisi permukaan luka. Tempatnya kemudian diisi oleh sel baru yang terbentuk dari proses mitosis. Proses migrasi hanya terjadi ke arah yang lebih rendah atau datar. Proses ini baru berhenti setelah epitel saling menyentuh dan menutup seluruh permukaan luka. Dengan tertutupnya permukaan luka, proses fibroplasia dengan pembentukan jaringan graanulasi juga akan berhenti dan mulailah proses pematangan dalam fase penyudahan (remodeling).
Fase penyudahan (remodeling)

Pada fase ini terjadi proses pematangan yang terdiri atas penyerapan kembali jaringan yang berlebih, pengerutan sesuai dangan gaya gravitasi, dan akhirnya perupaan kembali jaringan yang baru terbentuk. Fase ini dapat berlangsung berbulan-bulan dan dinyatakan berakhir kalau semua tanda radang sudah lenyap. Tubuh berusaha menormalkan kembali semua yang menjadi abnormal karena proses penyembuhan. Udem dan sel radang diserap, sel muda menjadi matang, kapiler baru menutup dan diserap kembali, kolagen yang berlebih diserap dan sisanya mengerut sesuai dengan regangan yang ada.

Selama proses ini dihasilkan jaringan parut yang pucat, tipis, dan lemas, serta mudah digerakkan dari dasar. Terlihat pengerutan maksimal pada luka. Pada akhir fase ini, perupaaan luka kulit mampu menahan regangan kira-kira 80% kemampuan kulit normal. Hal ini tercapai kira-kira 3/6 bulan setelah penyembuhan. Perupaan luka tulang (patah tulang) memerlukan waktu satu tahun atau lebih untuk membentuk jaringan yang normal secara histology atau secara bentuk.

Tipe Penutupan Luka
Penyembuhan luka kulit tanpa pertolongan dari luar seperti yang telah diterangkan tadi, berjalan secara alami.luka akan terisi jaringan granulasi dan kemudian ditutup jaringan epitel. Penyembuhan ini disebut penyembuhan sekunder atau sanatio per secundam intentionem. Cara ini biasanya makan waktu cukup lama dan meninggalkan parut yang kurang baik, terutama kalau lukanya menganga lebar.

Jenis penyembuhan yang lain adalah penyembuhan primer atau sanatio per primam intentionem, yang terjadi bila luka segera diusahakan bertaut, biasanya dengan bantuan jahitan. Parut yang terjadi biasanya lebih halus dan kecil.

Namun, penjahitan luka tidak dapat langsung dilakukan pada luka yang terkontaminasi berat dan /atau tidak berbatas tegas. Luka yang compang-camping seperti luka tembak, sering meninggalkan jaringan yang tidak dapat hidup yang pada pemeriksaan pertama sukar dikenal. Keadaan ini diperkirakan akan menyebabkan infeksi bila luka langsung dijahit. Luka yang demikian sebaiknya dibersihkan dan dieksisi (debrideman) dahulu dan kemudian dibiarkan selama 4-7 hari. Baru selanjutnya dijahit dan akan sembuh secara primer. Cara ini umumnya disebut penyembuhan primer tertunda. Terjadinya infeksi pada luka pascaeksisi umumnya terjadi karena eksisi luka tidak cukup luas dan teliti.

Jika, setelah dilakukan debrideman,luka langsung dijahit, dapat diharapkan terjadi penyembuhan primer.
Pada manusia, penyembuhan luka dengan cara reorganisasi dan regenerasi jaringan hanya terjadi pada epidermis, hati, dan tulang yang dapat menyembuh alami tanpa meniggalkan bekas. Organ lain, termasuk kulit, mengalami penyembuhan secara epimorfosis, artinya jaringan yang rusak diganti oleh jaringan ikat yang tidak sama dengan jaringan semula.

Gangguan Proses Penyembuhan Luka
Penyembuhan luka dapat terganggu oleh penyebab dari dalam tubuh sendiri (endogen) atau oleh penyebab dari luar tubuh(eksogen).
Penyebab endogen terpenting adalah gangguan koagulasi yang disebut koagulopati dan gangguan system imun. Semua gangguan pembekuan darah akan menghambat penyembuhan luka sebab hemostasis merupakan titik tolak dan dasar fase inflamasi gangguan system imum akan menghambat dan mengubah reaksi tubuh terhadapluka, kematin jaringan, dan kontaminasi. Bila system daya tahan tubuh, baik seluler maupun humoral terganggu, pembersihan kontaminan dan jaringan mati serta penahanan infeksi tidak berjalan baik.
Gangguan system imun dapat terjadi pada infeksi virus, terutama HIV, keganasan tahap lanjut, penyakit menahun berat seperti tuberkulosis, hipoksia setempat, seperti ditemukan pada arterioskleoisis, diabetes melitus, morbus Raynaud, morbus Burger, kelainan pendarahan (hemangioma, fistel arteriovena), atau fibrosis. System imun juga dipengaruhi oleh gizi kurang akibat kelaparan, malabsorbsi, juga oleh kekurangan asam amino esensial, mineral, maupun vitamin, serta oleh gangguan dalam metabolisme makanan, misalnya pada penyakit hati. Selain itu, fungsi system imun ditekan oleh keadaan umum yang kurang baik,seperti pada usia lanjut dan penyakit kronis.
Penyebab eksogen meliputi penyinaran sinar ionisasi yang akan mengganggu mitosis dan merusak sel dengan akibat dini maupun lanjut. Pemberian sitostatik, obat penekan reaksi imun, misalnya setelah transplantasi organ, dan koatekosteroid juga akan mempengaruhi penyembuhan luka. Pengaruh setempat, seperti infeksi, hematom, benda asing, serta jaringan mati seperti sekuester dan nekrosis, termasuk penggunaan bahan-bahan topikal apakah larutan kompres, kream, salep antibiotika dan desinfektan yang sangat sitotoksik (mematikan sel) adalah sangat menghambat penyembuhan luka.
Bila luka atau ulkus (borok) tidak kunjung sembuh,harus dilakukan pemeriksaan kembali dengan memperhatikan fase penyembuhan luka untuk menentukan sebab gangguan. Lakukan anamnese lengkap dilanjutkan dengan pemeriksaan fisik,radiologi, biakan, dan kalau perlu lakukan biopsi histologik/patologik serta pemeriksaan serologik.

Tindakan Perawatan luka
Pertama-tama dilakukan pemeriksaan secara teliti untuk memastikan apakah ada perdarahan yang harus dihentikan. Kemudian, tentukan jenis trauma, tajam atau tumpul, luasnya kematian jaringan, banyaknya kontaminasi, dan berat ringannya luka. Luka trauma berat memerlukan penanganan segera, dengan memperhatikan kondisi yang mengancam jiwa maupun mengancam terjadinya amputasi.
Prinsip utama perawatan luka adalah mengoptimalkan proses penyembuhan secara normal, bukan mempercepat. Sampai saat ini belum ada bahan/obat yang terbukti secara klinis dapat mempercepat proses penyembuhan. Proses penyembuhan adalah “nature of law”. Dengan demikian setiap tindakan, pemberian obat-obatan maupun bahan aplikasi lokal (wound dressings) pada luka harus dipastikan tidak bersifat sitotoksik
Tindakan dilakukan dengan anastesia setempat atau umum, tergantung berat dan letak luka, serta keadaan penderita. Luka dan sekitarnya dicuci dengan air dan didesinfeksi dengan antiseptik/desinfektan. Bahan yang dapat dipakai ialah larutan yodium povidon 1% dan larutan klorheksidin ½%. Larutan yodium 3% atau alcohol 70% hanya digunakan untuk membersihkan kulit di sekitar luka. Kemudian, daerah sekitar lapangan kerja ditutup dengan kain steril dan secara steril dilakukan kembali pembersihan luka dari kontaminasi secara mekanis, misalnya pembangunan jaringan mati dengan gunting atau pisau (debrideman) dan dibersihkan dengan bilasan, guyuran, atau semprotan cairan isotonis misalnya NaCL. Irigasi ini sangat berguna melarutkan dan mengurangi jumlah kuman Eksisi luka dan irigasi yang baik dapat mencegah infeksi. Akhirnya, dilakukan penjahitan dengan rapi. Bila diperkirakan akan terbentuk atau dikeluarkan cairan yang berlebihan, perlu dibuat pengaliran (drain bukan untuk darah). Luka ditutup dengan bahan yang dapat mencegah lengketnya kasa, misalnya kasa yang mengandung vaselin, atau suatu bahan yang netral dan tidak bersifat sitotoksik, ditambah dengan kasa penyerap dan dibalut (jika perlu pergunakan pembalut elastis).

“wound Dressings”
Sampai saat ini sangat beragam bahan-bahan yang dipergunakan dalam penutupan luka. Mulai dari jenis plesternya sampai jenis kasa maupun kandungan bahan aktif dalam kasa yang kontak dengan luka. Bahan yang paling murah dan benar adalah kasa steril saja. Syarat suatu bahan penutup luka adalah:
Tidak sitotoksik
Tidak nyeri saat pergantian kasa
Bersifat protektif
Tidak berbau
Membantu proses penyembuhan (menjaga kelembaban kulit)
Murah dan mudah didapat.
Suatu prinsip penting dalam merawat luka adalah jangan menambah kerusakan dengan aplikasi bahan-bahan yang bersifat sitotoksik.

Pada tahap awal dapat terjadi hematom pada luka. Keadaan ini harus dicegah dengan mengerjakan hemostasis secara teliti. Hematom yang mengganggu atau terlalu besar sebaiknya dibuka dan dikelurkan. Seroma adalah penumpukan cairan luka lapangan bedah. Jika seroma mengganggu atau terlalu besar, dapat dilakukan pungsi. Jika seroma kambuh, sebaiknya dibuka dan dipasang penyalir. Infeksi luka terjadi jika luka yang terkontaminasi dijahit tanpa pembilasan dan eksisi yang memadai. Pada keadaan demikian, luka harus dibuka kembali, dibiarkan terbuka dan penderita diberi antibiotik sesuai dengan hasil biakan dari cairan luka atau nanah.
Penyulit lanjut dapat berupa keloid dan jaringan parut hipertrofik yang timbul karena reaksi serat kolagen yang berlebihan dalam proses penyembuhan luka. Serat kolagen di sini teranyam teratur. Keloid yang tumbuh berlebihan melampaui batas luka, sering disertai gatal dan cenderung kambuh bila dilakukan intervensi bedah.
Parut hipertrofik hanya berupa parut luka yang menonjol, nodular, dan kemerahan, yang menimbulkan rasa gatal dan kadang-kadang nyeri. Parut hipertrofik akan menyusut pada fase akhir penyembuhan luka setelah sekitar satu tahun, sedangkan keloid justru tumbuh.
Keloid dapat ditemukan di seluruh permukaan tubuh. Tempat yang sering biasanya, kulit dada, di wajah, sternum, pinggang, daerah rahang bawah, leher, telinga, dan dahi. Keloid agak jarang dilihat di bagian tengah wajah, pada mata, cuping hidung, atau mulut.
Pengobatan keloid pada umumnya tidak memuaskan, biasanya dilakukan penyuntikan kortikosteroid intrakeloid, bebat tekan, radiasi ringan dan salep steroid atau beberapa jenis salep yang terbukti secara klinis mis ®madecassol (2 kali sehari selama 3-6 bulan) atau ®mederma jelly. Untuk mencegah terjadinya keloid, sebaiknya pembedahan dilakukan secara halus, diberikan bebat tekan dan dihindari kemungkinan timbulnya komplikasi pada proses penyembuhan luka.
Kontraktur jaringan parut di bekas luka atau bekas operasi kadang sangat mencolok, terutama di wajah, leher, dan tangan. Kontraktur dapat mengakibatkan cacat berat dan gangguan gerak pada sendi, misalnya pada luka bakar.

Perawatan Masa Depan
Saat ini dalam penelitian suatu usaha proses penyembuhan merupakan suatu proses regenerasi seperti diamati pada fetus hewan, dimana luka intrauterin yang sembuh sama sekali tidak disertai adanya scar (fibrosis). Saat ini yang mulai dipakai sebagai bahan penutup luka adalah golongan enzim seperti hyaluronic acid, kolagenase sampai growth faktor untuk luka-luka kronis.

Schwatz, Principles of Surgery
Norton, Surgery-Basic Science and Clinical Evidence
Hamilton Bailey, Emergency Surgery

Cara Perawatan Luka Modern

Selamat Datang.
Dahulu dan mungkin sampai sekarang ini perawatan luka masih banyak yang menerapkan cara yang kurang tepat. Penggunaan Povidon Iodine, Salep luka, Rivanol masih banyak digunakan, baik dari kalangan medis sendiri seperti dokter dan perawat maupun masyarakat umum. Anda ingin tahu? Bagus!!!