褥瘡に対するチーム医療と形成外科治療

A Team Approach and Plastic Surgical Treatment for Pressure Ulcers

はじめに

　形成外科に紹介される褥瘡患者の多くは，すでにいくつかの施設で保存的治療や外科的治療がなされており，難治化した状態での受診であることが多い．その治療や再発予防にあたっては，チーム医療が不可欠である．

　また，褥瘡および糖尿病や末梢動脈疾患などによる下肢の潰瘍など，いわゆる慢性創傷である難治性潰瘍の治療にあたっては，外傷や手術創などの急性創傷とは異なり，綿密な創傷管理が必要である．それには，刻々と変化する創面の状態を診断し，その都度最も適切な治療を行うことで創傷治癒を促すという，創床管理（wound bed preparation：WBP）の概念が重要である．2003年にSchultzらが提唱したTIMEコンセプトというWBPの実践方法は，理解しやすく臨床に即している^1）．

　本稿では，褥瘡治療において当院で行っているチーム治療について，さらに褥瘡治療の実際についてTIMEコンセプトを交えながら解説する．

Abstract : A refractory pressure ulcer should be treated not only by surgery but also with team medical care in order to avoid recurrence after the initial treatment. At our hospital, plastic surgeons are responsible for organizing the team care. As part of the team care strategy, physical therapists (PTs) and occupational therapists (OTs) provide education to improve the mobility of spinal-cord-injury patients, e.g., improving muscle strength of the upper extremities for adequate transfer and ability to perform wheelchair push ups. For elderly patients, nurses assess the risk of pressure ulcer development using the Braden's scale and set up a nutrition support team. Additionally, if patients have difficulty swallowing, a speech therapist treats the dysphagia. And PTs and OTs treat their impaired activities of daily living. Finally, medical social workers arrange home-health-care services when the patient returns to their home. The management of chronic wounds has progressed from merely assessing the status of the wound to understanding the underlying molecular and cellular abnormalities that prevent the wound from healing. The concept of wound bed preparation, TIME, has simultaneously evolved to provide a systematic approach to removing the barriers to natural healing and enhancing the effectiveness of advanced therapies. Wound bed preparation and the TIME framework are most likely to be successful when used alongside the wound bed preparation care cycle.