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Advances In Wound Care 2007 Rex Moulton-Barrett,MD.

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Presentation on theme: "Advances In Wound Care 2007 Rex Moulton-Barrett,MD."— Presentation transcript:

1 Advances In Wound Care 2007 Rex Moulton-Barrett,MD

2 Wound aspects Wound aspects o o Etiology o o Types: Acute/Chronic o o Patho-physiology o o Treatment:Pain Ulceration Edema Exudate

3 Components of Normal Wound Healing Coagulation process Coagulation process Inflammatory process Inflammatory process Migratory/ Proliferative process Migratory/ Proliferative process Remodeling process Remodeling process Injury: hours / days weeks A) Immediate to 2-5 days B) Hemostasis : Vasoconstriction, Platelet aggregation, Thromboplastin clot C) Inflammation: Vasodilation, Phagocytosis A) 2 days to 3 weeks B) Granulation: Fibroblasts lay collagen, Fills & new capillaries C) Contraction: Wound edges pull together to reduce defect D) Epithelialization: Crosses moist surface up to 3 cm A) 3 weeks to 2 years B) New collagen forms which increases tensile strength C) Scar tissue is only 80 percent as strong as original tissue

4 Degrades ECM impaired cell migration impaired connective tissue deposition Degrades growth factors Prolonged inflammation Stimulation of macrophage and neutrophils to wound bed Release of pro-inflammatory cytokines Production MMPs and TIMPs Chronic wound delayed healing TNF and IL-1 Repeated trauma Local tissue ischemia Necrotic tissue Heavy bacterial burden Tissue breakdown

5 Biochemical Differences Biochemical Differences Healing wounds Healing wounds cell mitosis cell mitosis pro-inflammatory pro-inflammatory cytokines cytokines Matrix metalloproteinases Matrix metalloproteinases Growth factors Growth factors Cells capable of Cells capable of responding to healing signals responding to healing signals Chronic wounds Chronic wounds mitogenic activity mitogenic activity pro-inflammatory pro-inflammatory cytokines cytokines MMPs MMPs Varied # growth Varied # growth factors factors Senescent cells Senescent cells

6 Wound Etiology Mechanical Arterial Venous Neuropathic Malignancy Vasculitic Metabolic Address the etiology Address the etiology

7 Types of Ulcers & Pathophysiology Diabetic: pressure(joint/bone)>neuropathic>ischemic>infective Diabetic: pressure(joint/bone)>neuropathic>ischemic>infective Venous Stasis: intercellular pressure>ischemia ( post-capillary ) Venous Stasis: intercellular pressure>ischemia ( post-capillary ) Arterial: ischemia ( pre-capillary ) Arterial: ischemia ( pre-capillary ) Pressure/Decubitus Sore: neuropathic>boney/joint pressure Pressure/Decubitus Sore: neuropathic>boney/joint pressure soft tissue infection is a secondary acute or chronic event soft tissue infection is a secondary acute or chronic event joint infection and or osteomyelitis chronic joint infection and or osteomyelitis chronic secondary amyloidosis chronic secondary amyloidosis chronic Marjolin Ulcer: squamous cell carcinoma or sarcoma >3 yrs Marjolin Ulcer: squamous cell carcinoma or sarcoma >3 yrs

8 Pressure Sore Staging National Pressure Ulcer Advisory Panel (NPUAP) Stage 1 Nonblanchable erythema intact skin, discoloration of the skin, warmth, edema, induration, or hardnes ulcer defined area of persistent redness in lightly pigmented skin, in darker skin tones, persistent red, blue, or purple hues. Stage 2 Partial thickness skin loss involving epidermis, dermis, or both. ulcer is superficial with abrasion, blister, or shallow crater. Stage 3 Full thickness skin loss subcutaneous tissue that may extend to, but not through, underlying fascia. ulcer may have deep crater or undermining adjacent tissue. Stage 4 Full thickness skin loss with, tissue necrosis, muscle, bone, or supporting structures (e.g., tendon, joint capsule) Undermining and sinus tracts

9 Diabetic Foot Ulcer Diabetic Foot Ulcer DM: 10 Million USA today DM: 10 Million USA today Immunopathy, vasculopathy, neuropathy,erythrocyte hemopathy Immunopathy, vasculopathy, neuropathy,erythrocyte hemopathy Misconception: small vessel disease Misconception: small vessel disease Multidisciplinary approach: podiatry, vascular, plastics, physical therapy Multidisciplinary approach: podiatry, vascular, plastics, physical therapy Neuropathy primary problem: small muscle contractures ( intrinsic minus ) Neuropathy primary problem: small muscle contractures ( intrinsic minus ) Secondary ligament and tendon glycosation leads to shortening Secondary ligament and tendon glycosation leads to shortening Secondary joint contracture: asensate pressure sore Secondary joint contracture: asensate pressure sore Treatment: restore balance and distribute load and protect surfaces Treatment: restore balance and distribute load and protect surfaces Examples: midfoot ulcer: remove underlying metaphysis (118,000 lb/sq) Examples: midfoot ulcer: remove underlying metaphysis (118,000 lb/sq) heel ulcer: Tendo achilles Z lengthening to 90 degrees heel ulcer: Tendo achilles Z lengthening to 90 degrees Cuboid dislocation and Charcot Foot: requires internal fixation Cuboid dislocation and Charcot Foot: requires internal fixation

10 Venous Stasis Ulcer Venous Stasis Ulcer Cause: intercellular & post-capillary stasis and edema Cause: intercellular & post-capillary stasis and edema Secondary causes: infection, dry wound, shearing forces Secondary causes: infection, dry wound, shearing forces Classic management: Zinc and compression Una Boot Classic management: Zinc and compression Una Boot Rule out concomitant arterial ischemia Rule out concomitant arterial ischemia Modern Work-up and treatment: Modern Work-up and treatment: –Duplex u/s and cultures –If significant venous reflux disease: end-venous ablation and venectomy –Local treatment is a 4 component weekly: silver dressing silver dressing 3 layer compression 3 layer compression With or without absorbent dressing With or without absorbent dressing

11 Venous Stasis Ulcers & Compression Circ-aid ( R:Allegra Medical ): Circ-aid ( R:Allegra Medical ): Nonelastic, latex-free, 40 mmHg compression therapy system Uses interlocking Velcro® bands Washable and reusable Circ-aid vrs Una Boot: 45% faster, 38% cheaper than Una Boot Circ-aid vrs Una Boot: 45% faster, 38% cheaper than Una Boot Cir-aid: less surface shear and focal compression than 30mmHg stockings Cir-aid: less surface shear and focal compression than 30mmHg stockings at 2 months 1/2 the edema remains a.c.t. similar stockings at 2 months 1/2 the edema remains a.c.t. similar stockings 67% of pts. With failed Una and stockings healed at 12 months 67% of pts. With failed Una and stockings healed at 12 months

12 Ischemic and Post - Radiation Ulcers Multidisciplinary approach Multidisciplinary approach Work-up arteriograms and duplex u/s digital toe pressures Work-up arteriograms and duplex u/s digital toe pressures Primary treatment: revascularize arterial Primary treatment: revascularize arterial Secondary infections, osteomyelitis benefit from hyperbaric oxygen providing arterial supply adequate, ie toe pressures helpful Secondary infections, osteomyelitis benefit from hyperbaric oxygen providing arterial supply adequate, ie toe pressures helpful

13 Assessment – Systemic Factors Age Age Body build Body build Stress Stress Nutrition Nutrition Medications Medications Tissue oxygenation Tissue oxygenation Concomitant disease Concomitant disease

14 Assessment – Local Factors Perfusion Perfusion Mechanical stressors Mechanical stressors Edema Edema Wound temperature Wound temperature Cytotoxic agents Cytotoxic agents Necrotic tissue Necrotic tissue Bacterial burden Bacterial burden Desiccation Desiccation Excess exudate Excess exudate

15 TIME Principles of Wound Bed Preparation Wound bed preparation accelerates healing T issue non viable or deficient I nfection or inflammation M oisture imbalance E dge of wound non advancing or undermined Defective matrix and cell debris High bacterial counts or prolonged inflammation Desiccation or excess fluid Non-migrating keratinocytes Non-responsive wound cells Debridement Antimicrobials Dressings compression Biological agents Adjunct Therapies Debridement Restore wound base and ECM proteins Low bacterial counts and controlled inflammation Restore cell migration, maceration avoided Stimulate keratinocyte migration

16 Suction Vac Suction Vac 0.15 mm pore, 125 mmHg suction: 0.15 mm pore, 125 mmHg suction: Increased angiogenesis, VEGF, nitric oxide? Increased angiogenesis, VEGF, nitric oxide? Increased vessels,granulation: up to 5xs Increased vessels,granulation: up to 5xs Decreased exudate, hypoxia Decreased exudate, hypoxia Dressing changes/2 days, but costly rental Dressing changes/2 days, but costly rental 76 in Jan 2005

17 KCI: Education KCI: Education See whp1.swf See whp1.swf

18 Debridement Debridement Why debride ? Why debride ? Enhanced wound assessment Enhanced wound assessment Decrease infection potential/extent Decrease infection potential/extent Increase granulation epithelialization Increase granulation epithelializationT What to debride ? What to debride ? Slough-moist yellow, tan Slough-moist yellow, tan or gray non-viable tissue or gray non-viable tissue Eschar-dry, leathery Eschar-dry, leathery Tissue

19 Debridement Methods Debridement Methods Surgical: excise Surgical: excise Mechanical: adherance,sheer, irrigate Mechanical: adherance,sheer, irrigate Autolytic: topical Autolytic: topical Enzymatic: topical Enzymatic: topical Biological: topical Biological: topical

20 Surgical Debridement Scalpel Scalpel Scissors Scissors Curet Curet Laser Laser Hydro-Scapel Hydro-Scapel U/S Hydro U/S Hydro Recommended for removal of thick, adherent eschar and devitalized tissue in large wounds

21 Mechanical Debridement Definition - The removal of foreign Definition - The removal of foreign material and dead or damaged tissue material and dead or damaged tissue by the use of physical forces. by the use of physical forces. Methods Methods Irrigation Irrigation Wet-to-dry dressings Wet-to-dry dressings Hydrotherapy: Whirlpool Hydrotherapy: Whirlpool Suction Vac Suction Vac

22 Mechanical Debridement Considerations Aggressive debridement Aggressive debridement Wet-to-dry dressing may be painful Wet-to-dry dressing may be painful Trauma to capillaries can cause bleeding Trauma to capillaries can cause bleeding Skin maceration may occur Skin maceration may occur Dressing changes may be time-consuming Dressing changes may be time-consuming

23 Autolytic Debridement Autolytic Debridement The process by which the wound bed utilizes phagocytic cells and proteolytic enzymes to remove debris The process by which the wound bed utilizes phagocytic cells and proteolytic enzymes to remove debris This process can be promoted and enhanced by maintaining a moist wound environment This process can be promoted and enhanced by maintaining a moist wound environment

24 Autolytic Debridement Considerations Less aggressive debridement Less aggressive debridement Slower than other methods Slower than other methods Easy to perform Easy to perform Little or no discomfort Little or no discomfort Performed in any setting Performed in any setting Contraindication: infection Contraindication: infection

25 Autolytic Debridement Autolytic Debridement

26 Enzymatic Debridement Enzymatic Debridement The use of topically applied chemical agents to stimulate the breakdown of necrotic tissue The use of topically applied chemical agents to stimulate the breakdown of necrotic tissue Common Topical Agents Common Topical Agents –Papain-Urea –Papain-Urea-Chlorophyllin –Collagenase

27 Enzymatic Debridement Enzymatic Debridement Collagenase Derived from Clostridium Hystoliticum Highly specific for peptide sequence found in collagen Less aggressive debridement Site of action – collagen fibers anchoring necrotic tissue to the wound bed 10 Harper (1972) 11 Boxer (1969) 12 Varma (1973 )

28 Enzymatic Debridement Enzymatic Debridement Papain-Urea Papain-Urea Proteolytic enzyme derived papaya 6 Proteolytic enzyme derived papaya 6 Urea is added as a denaturant 6 Urea is added as a denaturant 6 Site of action – cysteine residues on protein 8 Site of action – cysteine residues on protein 8 Inactive against collagen 6 Inactive against collagen 6 6 Falabella (1998) 8 Sherry and Fletcher (1962

29 Papain-Urea Mode of Action

30 Enzymatic Debridement Enzymatic Debridement Papain-Urea Chlorophyllin Papain-Urea Chlorophyllin Contains Papain, Urea and Sodium Copper Chlorophyllin Contains Papain, Urea and Sodium Copper Chlorophyllin Sodium copper chlorophyllin is a Chlorophyll derivative Sodium copper chlorophyllin is a Chlorophyll derivative –Anti-agglutinin –results in anti-Inflammatory action –Reduces odor 7 Morrison J, Casali J (1957)

31 Enzymatic Debridement Considerations Should be painless Should be painless Less traumatic than Less traumatic than surgical or mechanical surgical or mechanical debridement debridement Easy dressing change Easy dressing change Observe caution with Observe caution with infected wounds infected wounds *Agency for Healthcare Research and Quality (1994) Consider the use of enzymatic Consider the use of enzymatic debridement for individuals debridement for individuals who: who: –Cannot tolerate surgery –long-term-care facility –home care*

32 The right method is a clinical decision that requires judgment Autolytic, Collagenase, Papain-Urea-Chlorophyllin

33 Bacterial Balance Control mechanism Control mechanism Intact skin is a physical barrier Intact skin is a physical barrier pH is not conducive to bacterial growth pH is not conducive to bacterial growth Skin secretes fatty acids and antibacterial Skin secretes fatty acids and antibacterial polypeptides polypeptides Normal flora prevent pathogenic flora Normal flora prevent pathogenic flora from establishing from establishingI Infection or inflammation

34 Risk Factors for Infection Risk Factors for Infection Vascular disease Vascular disease Edema Edema Malnutrition Malnutrition Diabetes mellitus Diabetes mellitus Alcoholism Alcoholism Prior surgery or radiation Prior surgery or radiation Drugs e.g. corticosteroids Drugs e.g. corticosteroids Inherited immune defects Inherited immune defects Large wound area Large wound area Increased wound depth Increased wound depth Degree of chronicity Degree of chronicity Anatomic location (distal extremity, perineal) Anatomic location (distal extremity, perineal) Presence of foreign bodies Presence of foreign bodies Necrotic tissue Necrotic tissue Mechanism of injury Mechanism of injury Degree of contamination Degree of contamination Reduced perfusion Reduced perfusion Systemic Local

35 Bacterial Burden Bacterial Burden Contamination Infection Colonized Critically colonized Local Contamination - Infection continuum Systemic

36 13 Robson (1997) 14 Dow (2001) Bacterial Burden Bacterial Burden Tissue bacterial levels > 10 5 have consistently resulted in impaired healing causing: Tissue bacterial levels > 10 5 have consistently resulted in impaired healing causing: Metabolic load Metabolic load Produces endotoxins and proteases Produces endotoxins and proteases

37 Bacterial balance Host resistance Bacterial quantity and virulence 3 Sibbald et al (2000) 12 Dow (2001) Local perfusion immunosuppression Diabetes medications Adhesins cell capsules biofilms Antibiotic resistance

38 3 Rules for Topical Antimicrobial Agents Do not use antibiotics that are used systemically – ability to breed resistant organisms (topical gentamiycin, tobramycin) Do not use antibiotics that are used systemically – ability to breed resistant organisms (topical gentamiycin, tobramycin) Do not use agents that are common allergens (neomycin, gentamycin, amikacin, tobramycin, bacitracin, lanolin) Do not use agents that are common allergens (neomycin, gentamycin, amikacin, tobramycin, bacitracin, lanolin) Do not use agents that have high cellular toxicity in healable wounds (povidone iodine, chlorhexidine, hydrogen peroxide) Do not use agents that have high cellular toxicity in healable wounds (povidone iodine, chlorhexidine, hydrogen peroxide) 22 Sibbald 2003

39 Topical Antimicrobials: Silver Topical Antimicrobials: Silver Centuries of use Centuries of use Cytotoxicity associated with carriers not silver - ex. Silver nitrate, Silver sulfadiazine Cytotoxicity associated with carriers not silver - ex. Silver nitrate, Silver sulfadiazine Traditional delivery required repeated applications due to binding with chlorine and proteins Traditional delivery required repeated applications due to binding with chlorine and proteins New silver dressings allow for continued silver release in to the dressing - up to 7 days New silver dressings allow for continued silver release in to the dressing - up to 7 days 17 Demling and DeSanti (2001)

40 Why Silver for Wound Bed Preparation? Broad spectrum antimicrobial: yeasts, molds & Broad spectrum antimicrobial: yeasts, molds & bacteria, including MRSA bacteria, including MRSA Kills microbes on contact: inhibitiion cellular respiration Kills microbes on contact: inhibitiion cellular respiration denatures nucleic acids denatures nucleic acids alters cell membrane permeability alters cell membrane permeability Does not induce resistance: if used at adequate levels Does not induce resistance: if used at adequate levels Low mammalian cell toxicity Low mammalian cell toxicity Anti-inflammatory activity: delivery system dependent) Anti-inflammatory activity: delivery system dependent)

41 Nanocrystalline Silver Nanocrystalline Silver Decreased size of silver particles leads to increased proportion of surface atoms compared with internal atoms 15 Decreased size of silver particles leads to increased proportion of surface atoms compared with internal atoms 15\ It is believed that the nanocrystalline structure is responsible for the rapid and long lasting action 15 It is believed that the nanocrystalline structure is responsible for the rapid and long lasting action Demling and DeSanti (2001) Magnification of normal Silver Magnification of Nanocrystalline Silver (< 1 micron)

42 Evaluating Silver Products Evaluating Silver Products Minimum bactericidal concentration (MBC) - amount of antimicrobial agent Minimum bactericidal concentration (MBC) - amount of antimicrobial agent required to kill a given microbe required to kill a given microbe MBC is represented by a log reduction of 3 Stratton et al (1991) MBC is represented by a log reduction of 3 Stratton et al (1991) –The silver required varies from 5ppm ppm for clinically relevant microbes Yin et al (1999) & Hall (1987) –MBC of silver for MRSA = 60.5 ppm Calculated from Maple et al (1992)

43 Case Study Case Study Day 3650 Day 20 Day 3650 Day year old venous leg ulcers Treated: silver nanocrystal therapy 10 year old venous leg ulcers Treated: silver nanocrystal therapy previously treated: compression and SSD previously treated: compression and SSD

44 Topical Antimicrobials Cadexomer Iodine Iodine is a well known antimicrobial agent Iodine is a well known antimicrobial agent 0.9% iodine is carried in polysaccharide beads 0.9% iodine is carried in polysaccharide beads Provides sustained release iodine:non- cytotoxic concentration Provides sustained release iodine:non- cytotoxic concentration High rate of absorption from exudating ulcers High rate of absorption from exudating ulcers No documented cases of bacterial resistance No documented cases of bacterial resistance

45 Recommendations for Wound Bed Prep Thorough cleansing Thorough cleansing Debridement if needed Debridement if needed Exudate management Exudate management –Consider topical antimicrobials –Silver Cadexomer iodine gel dressing Systemic antibiotics Systemic antibiotics Critically colonized INFECTION Contaminated Colonized Impaired healing

46 Exudate Management Exudate Management 1960s: Moist Wound Environment Dr. George Winter 1960s: Moist Wound Environment Dr. George Winter –Improved Collagen synthesis & granulation tissue –Faster Cell migration and epithelial resurfacing –Prevention of scabs, crusts, and eschar M moisture

47 Moist Wound Environment Moist Wound Environment Additional benefits Additional benefits Faster healing Faster healing Capacity for autolysis Capacity for autolysis Decreased rates of infection Decreased rates of infection Reduced wound trauma Reduced wound trauma Decreased pain Decreased pain Fewer dressing changes Fewer dressing changes Cost effective Cost effective

48 Moisture Imbalance - Dry Moisture Imbalance - Dry Desiccation slows epithelial migration Desiccation slows epithelial migration Painful and uncomfortable for the patient Painful and uncomfortable for the patient Delays normal healing process Delays normal healing process Acts as a source of infection Acts as a source of infection Longer treatment time Longer treatment time Increased cost Increased cost

49 Moisture Imbalance - Wet Moisture Imbalance - Wet Maceration of peri-wound skin Maceration of peri-wound skin Chronic wound fluid issues Chronic wound fluid issues

50 Different from acute wound Different from acute wound Imbalance of growth factors and pro-inflammatory cytokines Imbalance of growth factors and pro-inflammatory cytokines Excessively high levels of proteases Excessively high levels of proteases Degrades ECM and selectively inhibits proliferating cells Degrades ECM and selectively inhibits proliferating cells 21 Enoch and Harding, 2003 Exudate from a Chronic Wound

51 Exudate Management Exudate Management Chronic wound fluid Breakdown of Necrotic tissue (debridement) Microbial management Compression Edema Bacterial burden Dressing selection

52 Chronic Wound Fluid - Edema Ankle-Brachial index & compression Ankle-Brachial index & compression < None Reduced High

53 Dressing Selection Factors Dressing Selection Factors Amount of exudate Amount of exudate Anatomical location Anatomical location Presence of dead space (depth, undermining, tunneling) Presence of dead space (depth, undermining, tunneling) Condition of surrounding skin Condition of surrounding skin Caregiver ability Caregiver ability Healable vs. non-healable wound Healable vs. non-healable wound Cost Cost

54 Small Amount of Exudate Small Amount of Exudate AB C D

55 Moderate Amount of Exudate

56 Large Amount of Exudate Large Amount of Exudate AB

57 Managing Moisture Imbalance Films Films Hydrogel Hydrogel Hydrocolloid Hydrocolloid Alginate Alginate Foams Foams Specialty Absorbent Specialty Absorbent Suction Vac Suction Vac Exudate amount Exudate amount None Small Moderate Large

58 Edge of Wound Non-advancing or Undermined Cells not capable of responding to healing Cells not capable of responding to healing signals signals Hyper-proliferation of epidermal cells Hyper-proliferation of epidermal cells occurs at the wound margins occurs at the wound margins Epidermis fails to migrate across the wound Epidermis fails to migrate across the woundE

59 Useful teaching resources Wound Care Information Network KCIhttp://www.kci1.com/products/vac/vac/index.asp Smith & Nephewhttp://wound.smith-nephew.com/us/Home.asp


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