Trough out the history different materials were used
as wound coverings - from the hot olive oil and wax in ancient times, membranes
and animal feces in Middle Ages, hemp and cotton in the 19th century, to the
linen fabric, gauze, viscose and paraffin in the early 20th century. Гиппократужезаметил, чтораназаживаетбыстрее, когдаонахранитсявовлажнойсреде, покрытаялистьями. Hippocrates had
already noticed that the wound healed faster when it was stored in a humid
environment, covered with leaves. Доконца 20 века, влеченииранприменялиметодлечения «подструпом». By the end of
the 20th century, used in the treatment of wounds treatment "under a
scab." описывалиметодывысушиванияраны, Davidson (1925) описалметодсприменениемдубильныхкислотдляобразованияструпа. Copeland
(1897), Sneve (1905), John (1910), Wallace (1947) described a method for drying
the wound; Davidson (1925) described a method of using tannic acid to form a
scab [1]. Концепциязаживленияранвовлажнойсредевозниклав 1962 году, когдаДжорджВинтеробнаружил, чтоэпителизацияпроисходитвдваразабыстреевовлажнойсреде. The concept of wound healing
in the moist environment appeared in 1962, when George Winter discovered that
epithelisation was happening twice faster in the moist environment. Однимизпервыхктосталлечитьранывовлажнойсреде, былтакжеиЛистер. Lister was also
one of the first who began to treat the wounds in the moist environment. МодифицированныеметодикивнедрялисьА.В. Modified
technique introduced A.V. Вишневским, М.И. Vishnevsky, M.I.
Кузиным. Kuzin. Внастоящеевремядостоверното, чтоналичиетеплойвлажнойраневойсредыдействуетположительнонапроцессрегенерациитканей. Currently it is
known that the presence of warm, moist wound environment affects positively on
the process of tissue regeneration [2]. Наибольшеераспространениеполучилиповязкисразличнымиэмульсиямиимазями. The most widely
used bandages with different emulsions and ointments. РаботамиА.В. The works ВишневскогоиА.А. A.V. Vishnevsky
and A.A. Вишневскогообоснованопатогенетическоедействиемасляно-бальзамическойэмульсии. Vishnevsky
justified pathogenetic effect of oil-balsamic emulsion. Присвежихожогахцелесообразноприменятьмасляно-бальзамическуюэмульсиюВишневскогоследующегосостава: жидкогодегтя 1,0; When fresh
burns it is advisable to apply oil-balsamic Vishnevsky’s emulsion following
composition: liquid tar 1.0; анестезинаиксероформапо 3,0; anestezina and
xeroform of 3.0; касторовогомасла 100,0. castor oil 100.0. Применяюттакжесинтомициновую, сульфидиновуюилистрептоциднуюэмульсии, фурациллиповуюмазь, рыбийжирипр. НекоторыехирургизакрываютобожженнуюповерхностьфибриннымипленкамиА.Н. Some surgeons
close the burned surface with fibrin films [3-5]. Принеосложненномтеченииожогавторойстепениперваяперевязканередкоявляетсяипоследней, т. к. еестараютсяпроизвестивсрокиполногозаживленияожога (через 8—12 дней). When it is uncomplicated
second-degree burn the dressings often the first and the last.Повторныеперевязкиприглубокихожогахпроизводятчерезкаждые 5—7 днейвзависимостиотпоказаний (промоканиеповязки, боливране, усилениелихорадки). Repeated dressings with deep burns make in every 5-7
days depending on the indication (soaking of bandages, pain in the wound,
increasing of fever). Каждуюповторнуюперевязкутакжеследуетначинатьсобщейилиместнойванныизтеплогослабогорастворамарганцовокислогокалия. Each
re-bandaging should also begin with general or local bath of warm weak solution
of potassium permanganate. Приобширныхожогахповторныеперевязкимогут, однако, вызватьзначительнуюболезненность. With extensive burns,
repeated dressings can, however, cause significant pain. Поэтомунередкоприходитсяпроизводитьихподнеглубокимнаркозом, применяядлянегозакисьазота. So, we often
have to produce them under a shallow anesthesia using nitrous oxide for it [6].
Наиболеесовершеннымметодомзакрытияраниожоговявляетсяаутодермопластика, котораяосуществляетсяв 80-90% случаевприхирургическомлечениипострадавшихсглубокимиожогами.
The most advanced method of closing wounds and burns
is autodermaplasty, which is carried out in 80-90% of cases in the surgical
treatment of patients with deep burns. Несмотрянаотлаженнуютехникувыполненияэтойоперации, совершенствованиеоборудованияиметодикведенияранвпослеоперационномпериоде, хирургинередкосталкиваютсясосложнениямиввиделизисатрансплантатовиихнеприживления. Although
well-adjusted technigue of performing this operation, the improvement of
equipment and methods for treatment of postoperative wounds, surgeons, often
face complications in the form of lysis of grafts without engraftment [7-10]. Обширныепоплощадиожоги, атакжеповторныеоперациипроводимыеданнымбольнымприводяткдефицитудонорскихресурсовкожи. Vast area of
burns and repeated operations carried out to these patients lead to a shortage
of donor skin resources. Однойизважныхпроблемсовременнойкомбустиологииявляетсяпоискэффективныхметодовхирургическоголечениябольныхсглубокимиожогамиболее 15-20% поверхноститела, прикоторыхпроведениепластическогозакрытияранзатрудненоиз-задефицитасобственныхдонорскихресурсов. One of the
important problems of modern combustiology is searching of effective methods
for surgical treatment of patients with deep burns over 15-20% of the body
surface, when plastic closing of wounds is difficult due to the shortage of
donor's own resources. Множественныеостаточныераныпослелеченияожогов IIIаб-IV степениявляютсяпоказаниемдляприменениясовременныхбиополимеров-заменителейкожи. Multiple
residual wounds after the treatment of burns IIIab-IV degree are an indication
for using of modern biopolymer-skin substitutes. Ожоги II-IIIA степенисоставляютбольшинствосредитермическихпораженийкожи, лечениекоторыхвосновномосуществляетсяконсервативнымиметодиками. Burns II-IIIa
degree makes the majority of thermal lesions whose treatment is mainly carried
out by conservative methods. ForУпациентовсожогами II-IIIa степенейнеобходимосоздаватьблагоприятныеусловиядляэпителизацииран, устранятьдискомфорт, вызванныйболезненностьюприперевязках, предотвращатьвлияниепатогенноймикрофлоры. patients with
burns II-IIIa degrees it is necessary to create favorable conditions for the
epithelialization of wounds, eliminate discomfort caused by soreness during
dressings, to prevent the impact of pathogenic organisms [11]. Тяжестьидлительностьлеченияпострадавшихотожоговыхпораженийставитзадачуразработкисредств, ускоряющихихэпителизацию. The severity
and duration of the treatment of people suffered from burn injuries puts the
task for developing medicine that accelerates their epithelialization. Однимизвариантовпроведенияместноголеченияожоговыхранвусловияхдефицитадонорскойкожиможетбытьиспользованиевременныхраневыхпокрытий, разработкаисовершенствованиекоторыхвнастоящеевремяостаетсячрезвычайноважнойнаучно-практическойзадачей. One of the
options for local treatment of burn wounds with a shortage of donor skin of
temporary wound coverings can be used the development and improvement of which
currently remains an extremely important scientific and practical task [12]. Вкомбустиологиираневыепокрытияиграютважнуюрольнаэтапеподготовкигранулирующихранкаутодермопластике, способствуютлучшемуприживлениюкожныхтрансплантатовислужатбарьероммеждуранойиокружающейсредой. In
combustiology wound coverings play an important role in the preparatory phase
granulating wounds to autodermoplasty, they contribute better engraftment of
skin grafts and serve as a barrier between the wound and the environment. Кромеожогов, проблемавосстановлениякожногопокровавозникаетприразличныхтравмах, трофическихязвахидругиххроническихдлительнонезаживающих, вялотекущихранах, возникающихнафонеатеросклероза, венознойнедостаточности, сахарногодиабета, заболеванийсоединительнойткани, лучевойболезни. In addition to
burns, the problem of recovery of the skin occurs at various injuries, trophic
ulcers and other chronic long healing, sluggish wounds arising in the
background of atherosclerosis, venous insufficiency, diabetes mellitus,
connective tissue disease and radiation sickness [13].
Схожиепроблемывозникаютиприаутоиммунныхнарушениях, приводящихклизисуэпидермисаислизистыхоболочек (болезньЛайелаидр.). Similar
problems arise in autoimmune disorders that lead to lysis of the epidermis and
mucous membranes (Lyell's disease). Сдревностилюдииспользовалиматериалыбиологическогопроисхождениядлявременногозакрытияраниожогов. Since ancient
times, people used materials of biological origin for the temporary closing of
wounds and burns. Внастоящеевремявкачествебиологическихраневыхпокрытийприменяютсяаллогенныеиксеногенныеткани, втомчиследонорскаяитрупнаякожа. Currently as
biological wound coverings are used allogeneic and xenogeneic tissue, including
donor and cadaver skin. Однакоприменениеданныхматериаловшироконераспространенноиз-завысокойстоимостипроизводства, проблемахэтическогохарактера, ограничениемдонорскихресурсов, отсутствиемотлаженнойсистемы «банковкожи», трудностейзаготовкииограничениемсроковхранения. However, the
use of these materials is not widely adopted because of the high cost of their
production, ethical issues, limited donor resources, a lack of well-functioning
system of «skin banks», difficulties of preparation and a limited period of
storage [14]. Поэтомупроблемапоискаэффективныхспособоввосстановлениябарьерамеждувнутреннейсредойорганизмаивнешнейсредойявляетсяактуальнойвсовременноймедицине. Therefore, the
problem of finding effective ways to restore the barrier between the internal
environment and the external environment of human body is relevant in modern
medicine. Синтетическиебиополимерыимеютпреимуществапередтрадиционнымиибиологическимираневымипокрытиями, таккаклишеныихнедостатков. Synthetic
biopolymers have advantages over traditional and biological wound dressing,
since have no their drawbacks. Традиционныеперевязочныематериалы, такиекакмарля, обладаютвыраженнымиадгезивнымисвойствами. Traditional
wound dressings, such as gauze, have strong adhesive qualities. Грануляционнаятканьспособнапрорастатьчерезкрупныеячейкиволокнистойповязки. Granulation
tissue can grow through the large cells of the fiber dressings. When you remove
stucking dressings, you damage the newly formed epithelium, granulation and
other underlying tissue with the occurrence of bleeding, which affects the
delay of wound healing and the possible increase in the degree of tissue
damage, which is particularly important with the border burns [15]. Just when fixing the gauze bandage on a limb
with a gauze bandage in terms of increasing reactive edema may develop
turnstile effect and development of ischemia. As a result of injuring to tissue
with stucking dressings, the regeneration processes are slowed down, there is a
risk of complications and chronic wound healing process. Also, these dressings
are painful, cause discomfort and patients often require pain relief. In
foreign literature, it is believed that the pain relief during dressing is a
sign negatively characterizes the approach in the treatment of wounds, in
particular due to the use of unmodern injuring dressings [16].
More and more scientists pay special attention to the
problem of pain during change dressing. Pain at changes of dressing affects
negatively the psychosomatic status of the patient, expressed in depression,
fear of dressings, insomnia, loss of appetite, inactivity, anxiety and loss of
independence. It was also found that regular pain nociception leads to
increasing cortisol production which has a negative effect on the immune system
and the production of cells growth factors and vasopressin compromising the
delivery of oxygen and nutrients to the wound. Particular attention is paid to
the quality of life of patients with wounds and is improvement, by noninvasive,
painless dressing and enabling accelerated tissue repair. In the development of
wound dressings becomes important concept of wound healing in a moist
environment. Hippocrates had already noticed that the wound heals faster when
it is stored in a humid environment, covered with leaves. By the end of the
20th century, the treatment of wounds «under a scab» has used. Copeland (1897),
Sneve (1905), John (1910) Wallace (1947) described methods for drying the wound;
Davidson (1925) described a method of using tannic acid to form a scab [17].
Bandage and cotton hitherto are used in the treatment
of wounds, including burns. These dressings have a certain degree of adsorption
capacity, but cannot maintain the moisture balance in the wound, leading to its
complete drying. But now it is available a large number of modern, interactive
wound dressings, the choice of which should be based not only on the size and
type of wounds, but also on the characteristics of exudate - the origin,
composition, volume and viscosity.
Exudate is a key component in all phases of wound
healing, delivering nutrients to the wound and creating favorable conditions
for migration and mitosis of epithelial cells, proliferation of granulation
tissue and fibroblast, migration of leukocytes, enhances local immunity and autolytic
wound cleansing. In the literature, there is an opinion about the importance of
exudate in galvanotaxis - maintenance of endogenous bioelectric fields that
affect the movement of cells.
To assess the degree of retention moisture on the
wound surface is used outside Water Vapor Transmission Rate (WVTR), reflecting
the rate of transmission of water from its surface, including through the
dressing. With average WVTR less 35gr/m2,
collagen synthesis is increased by 5%, the intensity of re-epithelization
increase by 30-50% (runs 2-5 times faster) in comparison with methods of
treatment of wounds. The rate of evaporation through the damaged skin is
0.5-2.2 ml / cm2 / h. The optimal
rate of evaporation through the wound covering is considered an indicator of
6-12 mg/cm2. Drying of the wound
leads to inhibition of keratinocyte proliferation, formation of eschar, which
consists of the dried exudate and cellular debris. It serves as a mechanical
barrier for migrating epithelial cells from the wound edges, and significantly
lengthens the healing of wounds [18].
If the depth of the damage is limited to the papillary
layer, dermal elements in the form of hair follicles and sebaceous glands,
which remained after the burn, die by dehydration, thereby depriving it the
possibility of healing by epithelialization insula.
Another problem in the treatment of wounds it is
plenty of fluid. It is important that wound dressings not only well absorbed,
but also well linked excess exudate. In complicated infections, a significant
degree and for the area and as a consequence - nonhealing wounds including
burn, with an increase of edema resulting from venous-lymphatic stasis,
inflammatory exudate loses its medicinal properties and it is often
overproduction. Exudate become aggressive to the surrounding tissue, can lead
to maceration of intact skin around the wound repair and inhibition of increase
in the depth and extent of tissue damage resulting from an excess of
inflammatory mediators and proteinases high level. In addition, an abundance of
unbound exudate, and the presence of dead tissue, do not pose a barrier to
infection and create a favorable climate for the growth of bacteria [19].
It is known that burn wound immediately after the
injury does not contain microorganismsas a result of their death along with the
diseased tissue. Shortly after the burn, the wound begins to proliferate the
bacteria (most S. aureus, S. epidermidis) are stored in the ducts of the sweat
glands and hair follicles in the damaged area of the skin surface after
burns. Wound infection contributes to chronic inflammation, delayed
collagenogenesis and fibrillogenesis, fewer mitotic fibroblasts slow down their
differentiation into mature form, inhibits cell proliferation, reduces the
migration of keratinocytes. There is evidence that wound infection increases
the likelihood of scarring can cause bacteremia and sepsis. What is important
is that the exudate impregnated dressings may be a reservoir of infection.
Also, these dressings often have an unpleasant odor sickened relatives and
caregivers and negatively affects the quality of life, leading to his
exclusion. Based on the above, the effective management of exudate is an
important clinical problem.
To modern wound dressings, non-invasive and having the
property used in the concept of moist wound healing include hydrocolloids,
hydrogels, alginates, calcium, film coatings and silicones.
In
the history of using different materials used as wound coverings - from the hot
olive oil and beeswax in ancient times, the membranes of animals and feces in
the Middle Ages, hemp and cotton fabrics in the 19th century, to the linen
cloth, gauze, rayon and paraffin in the early 20th century . Hippocrates
already noted that the wound heals faster when it is stored in a humid
environment, covered with leaves. By the end of the 20th century, it was used
in the treatment of wounds treatment "under a scab." Copeland (1897),
Sneve (1905), John (1910) Wallace (1947) described methods of drying the wound,
Davidson (1925) described a method of using tannic acids for the formation of a
scab. wound healing in a moist environment concept originated in 1962, when
George Winter discovered that epithelization occurs twice as fast in a moist
environment. One of the first who began to treat wounds in a moist environment,
was also the Lister. Modified technique introduced AV Vishnevsky, MI Kuzin [20].
Currently reliably that the presence of warm, moist wound environment acts
positively on tissue regeneration. The most widely used bandages with different
emulsions and ointments. AV Works Vishnevsky and AA Vishnevsky justified
pathogenetic effect of the oil-balsamic emulsion. When fresh burns advisable to
use oil-balsamic emulsion Vishnevsky following composition: liquid tar 1.0;
anestezina and xeroform at 3.0; castor oil 100.0. Applied also sintomitsinovoy,
sulfidinovuyu or streptotsidnoy emulsion furatsil lime cream, fish oil and so
on. Some surgeons close the burned surface of fibrin films AN Filatov. When
uncomplicated second-degree burn is often a first ligation and last, t. To. Try
to make it in time for complete healing of burns (8-12 days). Repeated
dressings for deep burns produce every 5-7 days depending on the indication
(soaking bandages, pain in the wound, increasing fever). Each re-dressing also
should begin with general or local bath of warm weak permanganate solution
kaliya.Pri extensive burns repeated dressings may, however, cause significant
morbidity. So often we have to produce them under a shallow anesthesia using
nitrous oxide for him.
The
most advanced method of closing wounds and burns is autodermoplasty, which is
carried out in 80-90% of cases in the surgical treatment of patients with deep
burns [21].
Despite the well-adjusted equipment perform this operation, improvement of
equipment and maintenance of healing techniques in the postoperative period,
surgeons often face complications in the form of lysis of grafts and their neprizhivleniya.
Vast areas of burns, as well as the repeated operations carried out according
to the patient lead to a shortage of donor skin resources. One of the important
problems of modern Combustiology is to find effective methods of surgical
treatment of patients with deep burns over 15-20% of the body surface, which is
holding a plastic closure of wounds is difficult due to the shortage of donor's
own resources. Multiple residual wound after treatment of burns IIIab-IV degree
is an indication for the use of advanced biopolymers skin substitutes. Burns
II-IIIA degree constitute the majority of thermal lesions whose treatment is
mainly carried out by conservative methods. Patients with burns II-IIIa degrees
is necessary to create favorable conditions for wound epithelialization,
eliminating the discomfort caused by painful at dressing changes, the effect of
preventing the pathogenic microflora. The severity and duration of the
treatment suffered from burn injuries poses the problem of development tools that
accelerate their epithelialization. One of the options for the local treatment
of burn wounds in a donor skin deficit may be the use of temporary wound
coverings, development and improvement of which currently remains an extremely
important scientific and practical problem. In Combustiology wound coverings
play an important role in preparation of granulating wounds to autodermoplasty,
contribute to a better engraftment of skin grafts, and serve as a barrier
between the wound and the environment. In addition to burns, the problem of
recovery of the skin occurs for various injuries, trophic ulcers and other
chronic dlitelnonezazhivayuschih, indolent wounds that occur on the background
of atherosclerosis, venous insufficiency, diabetes, connective tissue disease,
radiation sickness. Similar problems arise in autoimmune disorders that lead to
lysis of the epidermis and mucous membranes (Lyell's disease, and others.).
Since ancient times people have used materials of biological origin for the
temporary closure of wounds and burns. Currently, as a biological wound
coverings applied allogeneic and xenogeneic tissue, including cadaveric donor
and leather. However, the use of these materials are not widely popular because
of the high cost of production.
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