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Effect of Sea Cucumber Extract on Diabetic Foot ULcer

Article · March 2016

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Haryanto Haryanto
Muhammadiyah Institute of Nursing Sciences, Pontianak, Indonesia
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Effect of sea cucumber extract on diabetic foot
ulcers
The cost of treatment for patients with DFUs is very
expensive5, the periods of hospitalisation are longer and often
ends with amputation6-7. This condition requires appropriate
Ichsan Budiharto wound management to prevent infection, reduce necrotic
RN, MN, ET tissue, and improve the wound healing process.
General Hospital, Doctor Soedarso,
Modern dressing materials such as film, foam, non-adherent,
Pontianak
hydrogel, hydrocolloid and alginate 8 are currently being
Doctor Soedarso Street, Pontianak,
used. Unfortunately, the price is relatively expensive9, so an
78124, West Borneo, Indonesia
alternative dressing which is safe and cost-effective is needed.
Email: ichsanbudiharto@[Link]
Natural material is an alternative that can be used as a wound
care dressing. Natural alternatives can include: honey, aloe
vera, black seed, and sea cucumber extract. These natural
Emmy Hermiyanti Pranggono materials are less expensive and easier to obtain in many
Dr, SpPD KIC areas in Indonesia10.
Department Internist, Hasan Sadikin Sea cucumber is a natural material that is commonly known
Hospital, Bandung as trepang, beche-de-mer, or gamat. It has long been utilised
Pasarkaliki Street No. 190, Bandung, in the food and folk medicine systems of Asia and Middle
40161, West Java, Indonesia East communities11. It is abundant in regions of both Indonesia
Email: humprorshs@[Link] and Malaysia. Both in vitro and in vivo studies have shown
sea cucumber has several therapeutic properties including
anti-inflammatory 12,13, antibacterial and antimicrobial 13-15,
antioxidant 16,17, and wound healing 18,19. Nutritionally, sea
Titis Kurniawan cucumbers have valuable nutrients such as Vitamin A,
RN, MNS Vitamin B1 (thiamine), Vitamin B2 (riboflavin), Vitamin B3
Faculty of Nursing, University of (niacin), and minerals, such as calcium, magnesium, iron and
Padjajaran, Bandung, Indonesia zinc, and are high in protein20,21. Moreover, sea cucumbers
Raya Bandung Sumedang Street KM 21, have bioactive compounds that may have therapeutic effects
Jatinangor 45363 such as triterpene glycoside, enzyme, amyloses, fatty acid,
Email: t.kurniawan1981@[Link] and cytotoxin22, glycine, glutamic acid, arginine22, saponin23,
and glycosaminoglycans24.

Examination of the properties suggests that sea cucumber can

help with wound healing. In addition, there was no known
Haryanto* study using sea cucumber on DFUs in a clinical setting.
RN, MSN, ET The purpose of this study is to determine the effect of sea
The Institute of Nursing cucumber extract on wound healing for DFUs.
Muhammadiyah, Pontianak
Sei Raya Dalam Street No. 10, Pontianak METHODS
74124, West Borneo, Indonesia
This was a quasi-experimental study with one group pre
Email: gibyanto@[Link]
and post design. The study population consisted of 14 type
*Corresponding author II diabetic patients, male and female. They were consecutive
patients at the outpatient wound clinic at Doctor Soedarso,
Pontianak, a general hospital in Indonesia. This study was
BACKGROUND conducted from 26 March to 2 June 2014. Inclusion criteria
Diabetic foot ulcers (DFUs) are defined by the presence of were Ankle Brachial Index 0.9 to 1.2, blood sugar level 70–250
abnormal neurological injury, infection or vascular blood mg/dl, albumin level >3, DFU scale 2–4 (Wagner scale).
vessel damage1. A DFU is the main complication of diabetes Patients with infection and using corticosteroids were not
mellitus 2, which is linked to the presence of neuropathy, included. Patients who did not complete their treatment and
angiopathy and foot deformity, including pain and vascular with severe complaints during the wound care trial were
disorders3. As a result, DFUs may become necrotic, requiring eliminated from the study. The consent form was explained
the patient to have a foot or leg amputation. The prevalence in detail and so were the objectives of the study. The data
of persons with a DFU that have an amputation is as high as collection procedure and the results of this study were
85%1-2,4. reported in a manner that does not identify any individual.

WCET Journal Volume 36 Number 1 – January/March 2016

34
Table 1: Characteristics of participants (n=14)

Characteristics Categories F
Age (years) 49 (37–64)b
Gender Men 3 (21.4%)
Women 11 (78.6%)
Wound grade (Wagner scales)
Stadium 2 5 (35.7%)
Stadium 3 5 (35.7%)
Stadium 4 4 (28.6%)
ABI 0.95 (0.9–1.1)b
Blood sugar level 179.57±17.314
Albumin level 3.250±0.95*
Values are categories data (%), Mean ±SD* or Median (min-max)** where specified

In this study, we used sea cucumber (Stichopus hermanii), ranging from 0.9 to 1.1. Mean blood glucose level was
obtained from Sukadana region, West Borneo. Acetate 179.57±17.31 and mean serum albumin level was 3.250±0.95
acid was used to make an extract. Sea cucumber extract (Table 1).
was added into hydrogel preparations with a ratio of
250 mg: 1 ml. The total score of the LUMT wound assessment before
application of sea cucumber was 37.000 and after was 21.214
Examination of blood sugar and albumin levels, and ABI was (Table 2). There was significantly difference wound healing
carried out before and after the application of sea cucumber before and after sea cucumber application after 2 weeks
extract. The Leg Ulcer Measurement Tool (LUMT) was (p=0.001).
used for wound assessment to assess wound status on the
Of the 14 LUMT items, there were two items that showed no
foot 25. The LUMT has two parts but only part A, which
effect such as wound area and undermining. However, for
has 14 items evaluated by the researcher, was used for this
the other items there were significantly differences (Table
study. Every item has five wound assessments at two weeks
3). This included exudate type and amount, wound depth,
that were done by the researcher. This tool has shown 0.82
presence of necrotic tissue type and amount, presence of
validity and intrarater and interrater reliability of >0.75 and
granulation tissue, wound edge and viability, oedema type
high sensitivity25,26. For documentation, every wound was
and location, and presence of infection.
measured and photographed using a digital camera. Dressing
changes depended on the amount of exudate and wound During treatment there were no reported amputations or
condition. The follow-up period of treatment was two weeks. wound dressing irritation, and allergy. Before and after
wound examples are shown in Figures 1 and 2.
This research was approved by the Ethics Committee of the
Faculty of Nursing, University of Padjajaran, Bandung and
DISCUSSION
General Hospital, Doctor Soedarso, Pontianak.
In this study, we investigated the effect of sea cucumber
RESULTS extract on wound healing on DFUs. This study was the
first on DFUs, so comparison with previous results was not
Fourteen patients were included in the study; 3 male (21.4%) possible.
and 11 female (78.6%), with ages ranging from 37 to 64 years.
Wagner ’s grade II, III and IV ulcers were 35.7%, 35.7%, Previous research using sea cucumber found a higher
and 28.6% patients respectively. Mean ABI value was 0.95, percentage of wound contraction compared to the control27,28,

Table 2: Pre and post treatment using sea cucumber extract on diabetic foot ulcers (n=14)
Median
(min–max) Z p

Pre treatment 37.000 –3.299 0.001*

(19.00–51.00)
Post treatment 24.500
(00.00–39.00)
*p <0.005 (Wilcoxon test)

[Link]
35
Table 3: Comparing between before and after applied sea cucumber extract based on LUMT (n=14)

No. Items Before After Z p

1 Exudate type 3.00 (2.00–4.00) 2.00 (0.00–3.00) –3.442 0.001*

2. Amount 3.00 (2.00–4.00) 2.50 (0.00–3.00) –3.207 0.001*
3. Wound area 4.00 (2.00–4.00) 4.00 (0.00–4.00) –1.841 0.66
4. Depth 3.00 (2.00–4.00) 2.00 (0.00–4.00) –2.714 0.007*
5. Undermining 2.00 (0.00–4.00) 1.00 (0.00–4.00) –1.890 0.059
6. Necrotic type 2.00 (0.00–4.00) 1.00 (0.00–2.00) –3.017 0.003*
7. Necrotic type amount 2.50 (0.00–4.00) 0.50 (0.00–3.00) –3.108 0.002*
8. Granulation tissue type 3.00 (2.00–4.00) 1.00 (0.00–3.00) –3.384 0.001*
9 Amount granulation tissue 3.00 (1.00–4.00) 1.00 (0.00–3.00) –3.270 0.001*
10. Wound edge 3.00 (1.00–4.00) 1.50 (0.00–3.00) –3.384 0.001*
11. Wound edge viability 3.00 (1.00–3.00) 1.00 (0.00–2.00) –3.286 0.001*
12. Oedema type 2.00 (1.00–3.00) 1.00 (0.00–2.00) –3.071 0.002*
13. Oedema location 2.00 (1.00–3.00) 1.00 (0.00–2.00) –2.714 0.007*
14. Wound infection 3.00 (1.00–4.00) 1.00 (0.00–2.00) –3.126 0.002*

Value are median (min-max) *p <0.05 (Wilcoxon test)

enhanced wound contraction, stimulation of tissue in this study, sea cucumber extract had a positive effect on
regeneration, and regulation of pro-inflammatory cytokines wound healing, particularly DFUs. However, this study had
in burns29. However, animal models were used. some limitations such as: there was no control group; the
follow-up period was only two weeks; and it was a small
Other research examined the effect of sea cucumber extract
collagen as a bone substitute material for cytotoxicity, in sample size.
cultured fibroblast cells 30. This study found that the sea
cucumber extract collagen had no cytotoxic effect on CONCLUSION
fibroblast cell cultures. This agreed with work by Popov 31, In conclusion, the result of this study shown that sea
which found that collagen peptide had no toxic effect. In cucumber extract could be used as an alternative dressing.
addition, it was rapidly absorbed into the skin, and safe
No toxic effects were reported in this study. Furthermore, our
when was administered in the long term, so it can be used for
study showed that using sea cucumber significantly reduced
wound healing.
amputation and wound dressing irritation. However, further
In our study, there were differences between LUMT research is needed using larger samples, a control group and
assessment scores at baseline and at two weeks. Overall, a randomisation design in the clinical setting.

Figure 1: Wound before treatment with sea cucumber extract Figure 2: Wound after treatment with sea cucumber extract

WCET Journal Volume 36 Number 1 – January/March 2016

36
Pengaruh perawatan luka menggunakan ekstrak
teripang terhadap penyembuhan ulkus kaki
diabetik
Luka kaki diabetik didefinisikan luka dengan adanya METODOLOGI
ketidaknormalan neurologik, infeksi ataupun kerusakan Metodologi penelitian ini adalah dengan rancangan quasi
pembuluh darah vaskuler 1 Luka ini disebabkan karena eksperimen dengan one group pre and post design. Jumlah
komplikasi yang dari diabetes2 yang dihubungkan dengan
sampel 14 responden dengan DM tipe II. Responden
adanya neuropati, angiopati serta kelainan bentuk kaki
adalah pasien yang datang ke Poli luka RSUD Dr. Soedarso
termasuk nyeri dan gangguan pembuluh darah 3 Akibat
Pontianak. Penelitian ini dilaksanakan mulai 26 Maret
dari luka kaki diabetik akan terjadi nekrosis dan 85% pasien
sampai dengan 2 Juni 2014. Adapun yang menjadi kriteria
dengan luka kaki diabetik akan mengalami amputasi1-2,4.
inklusi sampel dalam penelitian ini adalah Ankle Brachial
Pasien dengan luka kaki diabetik juga membutuhkan Index normal (0,9–1,2), Gula darah terkontrol 70–250 mg/
biaya yang mahal5, masa rawat di rumah sakit yang lama dl, Albumin >3, Derajat luka kaki diabetik 2–4 menurut
bahkan seringkali diakhiri dengan amputasi 6,7. Kondisi klasifikasi Wagner. Pasien mengalami infeksi dan mendapat
ini membutuhkan manajemen perawatan luka yang tepat obat kortikosteroid tidak dilibatkan dalam penelitian. Pasien
untuk mencegah infeksi, mengurangi jaringan nekrosis, dan yang tidak tuntas dalam pengobatan dan memiliki keluhan
meningkatkan proses penyembuhan luka. serius selama penelitian akan di eliminasi dari penelitian.
Pernyataan kesediaan dan tujuan dari penelitian dijelaskan
Bahan balutan moderen seperti film dressing, foam dresing,
secara mendetail. Prosedur pengumpulan data dan hasil dari
non adherent dressing, hydrogels, hydrocolloid dan alginate saat
penelitian akan dilaporkan dengan menjaga kerahasiaan
ini telah banyak digunakan 8. Sayangnya, harga produk
pasien.
advance/ moderns dressing relatif mahal9, sehingga balutan
alternatif yang efektif, aman, serta murah sangat dibutuhkan.
BAHAN DAN ALAT
Bahan balutan (dressing) alami sebagai alternatif dapat
digunakan seperti madu, lidah buaya, jintan dan ekstrak Pada penelitian ini, kami menggunakan
gamat (teripang). Bahan alami tidak mahal dan lebih mudah
Teripang Stichopus hermanii yang diperoleh dari alam
didapat di berbagai wilayah Indonesia10.
sukadana yang telah dikeringkan. Bahan kimia yang
Teripang adalah bahan alami yang sering disebut gamat atau digunakan untuk melakukan ekstrak adalah Asam asetat.
timun laut. Teripang telah dikonsumsi sebagai makanan dan Ekstrak teripang ditambahkan dengan sediaan hidro gel
digunakan untuk pengobatan di Asia dan Timur Tengah11. dengan perbandingan 1 ml sediaan dilarutkan 250 mg
ekstrak teripang. Alat yang digunakan adalah Instrumen
Teripang banyak terdapat di Indonesia dan Malaysia. Hasil
Leg Ulcer Measurement Tool (LUMT) untuk memprediksi
penelitian baik in vitro maupun in vivo telah menunjukkan
penyembuhan luka. Instrumen ini mengambarkan
bahwa teripang mempunyai beberapa sifat terapeutik
perubahan status luka pada kaki (14). Pada penelitian ini
meliputi anti-inflamasi12,13, anti-bakteri and anti-mikroba13-15,
hanya menggunakan bagian A saja untuk pemeriksa/
anti-oksidan 16,17, dan penyembuhan luka 18,19. Berdasarkan
peneliti sedangkan pada bagian B (subjektifitas pasien) tidak
kandungan nutrisi, teripang mempunyai nilai nutrisi seperti
digunakan. Validitas dari LUMT adalah 0,82 dan reabilitas
Vitamin A, Vitamin B1 (thiamine), Vitamin B2 (riboflavin),
intrarater serta interrater >0,75 serta sensivitas yang tinggi25,26.
Vitamin B3 (niacin), dan mineral-mineral meliputi kalsium,
Pendokumentasian, setiap luka diukur dan diambil foto
magnesium, zat besi dan seng serta banyak mengandung
dengan menggunakan kamera digital. Penggantian balutan
protein20,21. Selain itu, teripang memiliki kandungan bioaktif
tergantung pada jumlah eksudat dan kondisi luka. Periode
yang mempunyai efek terapeutik yaitu triterpene glycoside,
perawatan dilakukan selama 2 minggu pada tiap responden.
enzim, amilose, asam lemak dan sitoksin22, glisin, asam
glutamat, arginin22, saponin23, and glycosaminoglycans24. Penelitian ini disetujui oleh Komite Etik Fakultas
Keperawatan Universitas Universitas Pajajaran, Bandung dan
Hasil penelitian terhadap kandungan teripang menunjukkan
RSUD Dr Soedarso Pontianak.
bahwa teripang dapat membantu penyembuhan luka. Selain
itu, tidak ada penelitian penggunaan teripang pada luka kaki
diabetik di tatanan klinik. Tujuan dari penelitian ini adalah HASIL
untuk menentukan efek teripang pada penyembuhan luka Total 14 responden di inklusi pada penelitian; 3 pria (21.4%)
kaki diabetik. dan 11 wanita (78.6%) dengan rentang usia dari 37-64 tahun.

[Link]
37
Derajat ulkus II, III dan IV menurut Wagner adalah masing- sampel yang lebih besar, menggunakan kelompok kontrol
masing 35.7%, 35.7% dan 28.6%. Nilai rata-rata ABI adalah dan rancangan randomisasi pada tatanan klinik.
0.95 dengan rentang dari 0.9-1.1. Nilai rata-rata gula darah
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Your host country — South Africa

Situated at the southern tip of Africa, South Africa is 1,233,404 km² in size and is edged on three sides by nearly 3000 km
of coastline, with the Indian Ocean to the east and the Atlantic Ocean to the west.
South Africa has a population of about 52 million and is a multilingual country with 11 official languages.
South Africa is in the southern hemisphere, so it is summer here when it’s winter in Europe and North America
(November to February), which makes it ideal for anyone wanting to escape the cold weather.
The country is strong on adventure, sport, nature and wildlife, and is a pioneer and global leader in responsible tourism.
[Link]

Your host city — Cape Town

Mother City of Africa, and the Western Cape, an area which is regarded as one of the most beautiful regions in the world.
The city is a rare cultural gem, resulting from the amalgamation of Indonesian, French, Dutch, British and German
settlers, the local Bushmen and other tribes from the north.
The impressive presence of Table Mountain, flanked by the legendary Devil’s Peak and historical Signal Hill, stands
proudly above the city.
A city of culture, built on a history that is reflected in the architecture, cuisine, music and dance. Together with a warm
summer temperature, beautiful, white sandy beaches and flanked by the magnificent winelands, Cape Town is one of the
top holiday destinations in the world.
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