2 Objectives Stages of Wound Healing Fungating Lesions overview Types of wound + dressing suggestionsPressure Sores – common areas and treatment pathwayFistulae overviewSummary
3 Stages of Wound Healing HaemostasisClotting cascadeInflammatoryBacteria and debris phagocytosed and removedRelease of factors causing migration + proliferationProliferativeAngiogenesis, collagen deposition, granulation tissue formation, epithelialisation, wound contractionRemodellingCollagen remodelled and realigned along tension lines and unneeded cells removed by apoptosis
5 Wound Healing – Primary Intention “Involves epidermis and dermis without total penetration of dermis healing by process of epithelialization”When wound edges are brought together so that they are adjacent to each other (re-approximated)Minimizes scarringMost surgical woundsWound closure is performed with sutures (stitches), staples, or adhesive tapeExamples: well-repaired lacerations,well reduced bone fractures,healing after flap surgery
7 Wound Healing – Secondary Intention The wound is allowed to granulateGranulation results in a broader scarHealing process can be slow due to presence of drainage from infectionWound care must be performed daily to encourage wound debris removal to allow for granulation tissue formationSurgeon may pack the wound with a gauze or use a drainage systemexamples:gingivectomy,gingivoplasty,tooth extraction sockets, poorly reduced fractures.
8 Wound Healing – Tertiary Intention (Delayed primary closure or secondary suture):The wound is initially cleaned, debrided and observed, typically 4 or 5 days before closure.The wound is purposely left openexamples:healing of wounds by use of tissue grafts.
17 Skin TearOccurs when friction + shearing forces cause tissue layers to slide across each other breaking blood vesselsCaused by sliding patients in bed,agitated patients moving in bed, removal of adhesive dressings
18 Skin Tear Management Remove dressings using “lateral pull” technique Mepitel dressing + dry gauzeChange Mepitel every 5-7 daysChange gauze when saturated
20 Wet Wound with Granulating Tissue AimsMinimise dressing changesRelieve the pressure that caused the ulcerIf increasing exudate then consider infectionMaximise nutrition and hydrationSuggested dressing – AquacelPlace sheets in wound bed and cover with dry dressingCover dressing depends on wetnessDaily – Gauze; 2-3/7 – Alldress, 3-5/7 – Allevyn/MepilexMultiple layers of aquacel can minimise dressing changesChange Aquacel when it has turned into a gel
22 CellulitisLocal infection of dermis and subcutaneous tissue characterised by spreading redness, pain and swelling.Monitor demarcation by marking and dating the skinConsider systemic/topical antibioticsUse Mepitel on wound bed to reduce surface painChange every 7/7 or PRN
24 Sacral Ulcer Remove/prevent pressure on area Observe for infection If problems with incontinence – consider barrier cream i.e. CavilonSacral Shaped Tegasorb – dressing of choice
25 Applying a Sacral dressing Fold sacral dressing in halfPinch the fold to form a crease "Bookmarking"Peel off the entire backingInsert "bookmark" into the patient's fold, above the rectum and secure the dressing up the middleSecure the dressing out the sides using the heat of your hand and slight pressure to help it adhereSlowly peel away the border while securing the tegaderm with your fingers
29 Wound with Yellow Slough Stage X as wound bed cannot be visualisedPain management with dressing changes2 options of treatment:Option 1 - cut silver dressing, such as Acticoat to fit into the wound bed and moisten with sterile water. Cover with a light dressing (gauze and tape or “island dressing” such as Alldress). Ensure daily that Acticoat dressing is moist. Change Acticoat 3/7.Option 2 - Spread a thin layer of Iodosorb on a gauze and place in wound bed.Cover with island dressing (such as Alldress) or foam. Change dressing q 3 days, when Iodasorb changes to a creamy colour.(NB) make sure patient doesn’t have thryroid issues—Iodosorb has iodine & contraindicated if thyroid condition or breast-feeding mother).
31 Diabetic/Neuropathic Ulcer Most common on plantar aspect of foot,heels and over metatarsal headsDry,warm, cracked, fissured skin, thickened nailsUsually no oedema/exudateCauses – peripheral neuropathy,arterial insufficiency, poor microvascular circulation, inadequate blood glucose controlTreatment – debridement plus mepilex/Allevyn + Intrasite gel
32 Pressure SoresSeveral factors that increase risk of developing a pressure sore:Mobility problemsPoor nutritionUnderlying health conditionAge >70 yrsUrinary &/or bowel incontinenceSerious mental health conditions
36 FistulaeAbnormal communication between 2 hollow organs or between a hollow organ and the skinAetiologyAnastomotic leaksTrauma - often iatrogenic post surgeryInflammatory bowel diseaseMalignancyRadiotherapy
37 Fistulae Types Rectovaginal/Rectovesical fistulas Conservative/SurgicalEnterocutaneous fistulasSimpleSingle orifice with intact abdominal wallMultipleMultiple orifices in abdominal wallDisruptedFistula caused by dehiscence or surgical wound/scar
38 Imaging Important to determine anatomy of fistula Fistulography will define tractSmall bowel or barium enema will define state of intestine or distal obstructionUS and CT will define abscess cavities
42 Management of Fistulae Usually conservative management - at least initially - consisting of:Skin protectionUpper GI contents are very corrosiveCorrection of fluid and electrolyte lossRequire careful fluid balance & restoration of blood volumeCorrection of acid-base imbalanceH2 Antagonist, proton pump inhibitor to reduce gastric secretionsSomatostatin analogues (e.g. Octreotide) to reduce GI and pancreatic secretions
43 Management of Fistulae Tissue viability reviewNutritional supportRestrict oral intake and possibly an nasogastric tubeMalnutrition corrected with either parenteral or enteral nutritionTotal parenteral nutrition given via Dacron-cuffed tunneled feeding lineRadiological screening to ensure tube in correct siteEnteral nutrition can be given distal to fistulaControl of sepsisAbscess cavities should be drainedAntibiotics
44 Enterocutaneous fistulas will not close if: There is total discontinuity of bowel endsThere is distal obstructionChronic abscess cavity exists around the site of the leakMucocutaneous continuity has occurred
45 Fistulas are less likely to close if: They arise from disease intestine (e.g. Crohn's Disease)They are end fistulaeThe patient is malnourishedThey are internal fistulas
46 60% will close in one month once sepsis has been controlled with conservative treatment Mortality associated with fistula is still at least 10%Surgery should be considered if fistula does not close by days
47 Summary Fully assess area and cleanse thoroughly Use appropriate dressing – if in doubt askTreat malodourBe aware need of ongoing psychological support
49 ReferencesSymptom Management in Advanced Cancer; (2009) Twycross, Wilcock, Toller.Blowers A L Irving M. Enterocutaneous fistulas. Surgery 1992; 10.2: 27 – 31Dubrick S J, Maharaj A R, McKelvey A A. Artificial nutritional support in patients with gastrointestinal fistulas. World J Surg 1999; 23: Mcintyre P B. Management of enterocutaneous fistulas: a review of 132 cases. Br J Surg 1984; 71: