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Enzymatic Debridement

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Presentation on theme: "Enzymatic Debridement"— Presentation transcript:

1 Enzymatic Debridement
Collagenase (Santyl) Digests necrotic collagen Specific and selective for denatured collagen Effective when used for long periods of time Maintenance debridement Tends to be a slow acting drug

2 Collagenase Considerations Cost Slow acting
Deactivated when combined with heavy metals Silver:Loses 50% of it’s efficacy when combined with silver. Can be combined with polysporin powder: good when you’re worried about localized infection.

3 Autolytic Debridement
Autolysis: Natural degradation of devitalized tissue using endogenous enzymes Moisture retentive or moisture donating dressing Occlusive dressing Eschar and slough are liquefied by rehydration and activity of lysosomes

4 Autolytic Debridement
Indications: Wounds with necrotic tissue **No infection (you’re creating a Petri dish) Wounds with dry eschar particularly benefit Cross hatching eschar facilitates Considerations It’s gross It stinks If biofilm gets too aggressive, it means an infection is starting to grow No Autolytic debridement!

5 Autolytic Debridement
Contraindications Dry gangrene Poor circulatory support Not enough lysozomes to make the debridement work but it won’t cause any harm. Infection

6 Autolytic Debridement
Advantages Non-invasive Selective Does not disrupt healthy tissue Easy: leave on hours, rinse wound with saline and apply another. Painless Stays on for hours before you change it.

7 Autolytic Debridement
Disadvantages SLOW Potential to grow bacteria Can macerate surrounding skin Watch for sensitivity to adhesive

8 Biological Debridement
Maggot Therapy! Biosurgical debridement, Larval Debridement Therapy Role Debridement (maggots secret collagenase and eat liquefied tissue) Disinfection (secretions that maggots give off having antimicrobial properties) Promotes wound healing (Maybe???)

9 Biological Debridement
Initial research published in 1929 But remain widely unused/unpopular “Ick” factor Cost Slow Removal and disposal questions Studies limited DFU 33% slough – traditional, 0% - maggots VI cost effective compared to hydrogel

10 Biological Debridement
Sterile, medical grade maggots placed in wound Covered with dressing Allows oxygen exchange Contains maggots Hydrocolloid most commonly used dressing In place 1-4 days, make sure you get them ALL out!

11 Sharp Debridement Most widely used – particularly by PT
Scalpel, forceps, scissors (blunt to cut dressings, or sharp to remove tissue), curette (least popular tool)

12 Sharp Debridement Research supports: 2009 retrospective study DFU, VI
Frequent debriders (>2x/12 wks) vs Infrequent debriders (<2x/12wks) 241 wounds Frequent debriders showed a greater decrease in surface area of wound Frequent debriders had better median healing rates Research SUPPORTS sharp debridement!!!!

13 Sharp Debridement Research support: 2009 study of DFU
Growth factors alone vs growth factors with debridement Growth factor plus debridement healed faster

14 Sharp Debridement Advantages Fast
Method of choice for thick, adherent or large amounts of slough, eschar Method of choice in presence of infection If sepsis, surgeon will perform debridement, not PT! Selective Can be combined with many techniques Inexpensive, but questionable reimbursement Every 20 square cm $25

15 Sharp Debridement Considerations Pain Anticoagulants/bleeding disorder
Blood loss Silver nitrate to stop bleeding Enough blood flow? Potential for infection Know your anatomy! Comfort level

16 Sharp Debridement Modified Sterile Technique Sterile gloves
Sterile equipment Sterile field NOTE: Sterile gauze is individually packaged. Clean gauze is packaged in bulk in a single package. Any time you are setting something down, you need to set onto your sterile field. If you set down on a towel etc, you cannot use that tool again!!!

17 Sharp Debridement Things to remember
Position patient and self comfortably! This can take minutes in some cases! Wash hands! Explain the procedure (before bringing in equipment) ESPECIALLY the first time to reduce anxiety “only interested in removing dead/harmful tissue, some blood is ok because it means the circulation to the area is good but it is NOT our goal to make you bleed” Stay sterile Flush with saline Dispose of material properly

18 Sharp Debridement Tips: Hold scalpel like a pencil The blade is sharp!
Cut parallel to the surface Particularly along edges If you aren’t sure – don’t do it If not in use - have your safety on! Take a THIN layer off, you can always go back and remove more, but you cannot replace accidently removed tissue!

19 Debridement Before Debridement

20 Debridement After Debridement (1 hour later)

21 Negative Pressure Wound Therapy
NPWT Suction applied to wound via open-celled foam sponge Foam secured with vapor permeable drape Suction attached to canister to collect excess drainage

22 Negative Pressure Wound Therapy
Benefits Edema reduction Increase perfusion distance = blood flow increase Increase perfusion 31% to wound bed, 15% to periwound Stimulates granulation tissue formation Microdeformation Removal of exudate ? Bacterial colonization Increased angiogenesis Perfusion distance: how far the nutrients go out from the wound bed.

23 Negative Pressure Wound Therapy
Suction mmHg 150 mmHg is common for abdominal wounds 50-75mmHg for feet Lower pressure on distal wounds Continuous or intermittent Intermittent over graft sites or distal foot wounds with poor circulation Commonly use continuous Clean application bedside, sterile application in OR Lots of sponsored research Increased speed of healing negates cost Cost of vac is $ per day

24 Negative Pressure Wound Therapy
How it works:

25 Negative Pressure Wound Therapy
Indications Any type of wound Size minimum 2.5cm in one direction Enough room to place a sponge

26 Negative Pressure Wound Therapy
Considerations Cost Carry around Change 2-3x/week Can Pt self fix? Can be combines with some other products Silver is most common Infection

27 Negative Pressure Wound Therapy
Contraindications Malignancy in wound Untreated osteomyelitis Fistulas/tracts – do you know where they end? Bleeding: stop bleeding before using suction Know your anatomy! No blood vessels, nerve endings, anastamosis, most organs Can put a vac over exposed bowel (seen a lot with compartment syndrome of the abdomen)

28 Negative Pressure Wound Therapy
How to apply IMPORTANT!!!! Count the number of foam pieces that you use so you make sure to remove ALL of them!!!!

29 Hyperbaric Oxygen Inhaled 100% oxygen delivered to patient in enclosed environment pressurized to >1.4ATA Typically ATA Easily transported via RBC and hemoglobin Goal is to increase aerobic cellular metabolism Growing trend because it is a MONEY MAKER! 2 types of chambers: single placed clamber (right) or multiplaced chamber (Left) Multi-have to wear masks to breathe in 100% oxygen

30 Hyperbaric Oxygen 0.3 volume percent of oxygen is dissolved in plasma at sea level (1 ATA) breathing RA 6.9 volume percent of oxygen is dissolved in plasma at 3 ATA breathing 100% O2 Increased volume percent = increased diffusion radius = more O2 gets to the tissues When tissues have more oxygen, they heal faster!

31 Hyperbaric Oxygen So what? Re-establish normal cellular metabolism
Promote angiogenesis Increase granulation tissue formation Debate: Salvage marginal tissue? Decrease tissue edema Meet increased demand of tissue

32 Hyperbaric Oxygen Indications
Refractory osteomyelitis: (osteomyelitis that has been treated for 30 days with antibiotics but has not responded.) Acute traumatic ischemic injury/Crush Injury Compromised skin grafts and muscle flaps Necrotizing fasciitis Gas gangrene Life threatening. Get to surgeon to Debride or amputate immediately!!! Others: CO poisoning, smoke inhalation, decompression sickness, arterial gas emboli, cyanide poisoning

33 Hyperbaric Oxygen Contraindications Strongly consider
Untreated pneumothorax Strongly consider Fever (signs of septic infection) Claustrophobia COPD, CHF High FiO2 (don’t give them MORE oxygen as it may supress their respiratory drive) Chemotherapy It takes 5-7 minutes to decompress the chamber. It can cause Ben’s decompression Syndrome if not given adequate time to decompress. Full Drive 2-3 hours, 5-6 times a week Must be prescribed by physician and MD must be on site while performing

34 Skin Grafting Performed by MD or PA
Should be considered with healthy wound beds that are failing to heal Adequate blood supply Ability to tolerate Too much wound exudate is a problem Will flood out the graft and it won’t take Graft or flap will not survive if blood supply is inadequate.

35 Skin Grafting Autograft Allograft
From Pt’s own tissue (thigh or buttocks) Full thickness (rare to take) Partial thickness (most common) Allograft Created from same species (cadaver graft) Done in OR, usually a hospitalization

36 Skin Grafting Xenograft Performed in office Multiple applications
Created from different species (animal origin) Oasis Wound Matrix Dry product (long shelf life) Performed in office Multiple applications

37 Skin Grafting Bioengineered Tissue Apligraf, Dermagraft
Living bilayered skin substitute Epidermal layer formed by human keratinocytes Dermal layer composed of human fibroblasts in bovine collagen matrix Contains matrix proteins and expresses cytokines But no melanocytes, macrophages, lymphocytes, blood vessels, hair follicles or sweat glands Never looks like normal skin! Short shelf life, very expensive, have to be kept at a certain temperature

38 Skin Grafting Bioengineered Tissue
Full thickness wounds without exposed structures Non-infected VI with compression Used in conjuncture with good wound care Debridement Non-infected Good blood supply** KEY Without this, the graft won’t take Off-loading and compression

39 Muscle Flap Flap surgery Musculocutaneous when need to fill depth
Skin grafts on the other hand are superficial Provides rich vascular tissue May also require skin grafting Usually gluteus maximus If successful, muscle atrophies, but blood supply remains to feed skin Success rate is 50%

40 Muscle Flap Surgical debridement IV antibiotics x6-8 weeks
Ensure no osteomyelitis NPWT to maintain health of wound edges Surgical procedure + hospitalization Air fluidized bed x6-8 weeks-non-weight bearing Bed is filled with sand that is constantly circulated to reduce pressure areas. Very expensive! And HEAVY

41 Muscle Flap Muscle atrophies Who? NOT for cushioning
Pressure relief is necessary** But how did they get the wound in the first place? May have to do MORE pressure relief than before!!! Who? Usually SCI patients Function can be compromised in ambulatory patients

42 Total Contact Casting Diabetic Foot Ulcer – gold standard
GOAL: Need to offload the foot for healing to occur Most patients are neuropathic Can protect foot from further trauma Can’t feel if it isn’t a good fit Best if can eliminate 2/3 of weight bearing time

43 Total Contact Casting Benefits
Decreases plantar pressures by increasing weight bearing over entire lower leg Redistribute pressure Prevent trauma Reduce edema Immobilize joints and soft tissue Helpful to prevent shear forces

44 Total Contact Casting Considerations
Gold standard, but only 45% of wound clinics perform some sort of offloading If you do it wrong – can seriously harm No room for absorption No where for the fluid to go so it can cause maceration to the whole area! Close follow-up needed By patient-time consuming By clinician Risk of infection!

45 Total Contact Casting How performed Ulcer covered with gauze
Cotton b/w toes Stockinette applied ¼ thick felt along malleoli and ant tibia Foam padding around toes Plaster shell molded Walking heel can be attached Finished with fiberglass roll around plaster MUST use water between degrees! Cast hardens in 20 minutes! Cast is pretty wet when you apply it. There is a BIG RED line on the outside (make sure that it is straight!) Easiest to apply if patient is prone!

46 Total Contact Casting Alternatives TCC-EZ
Making TCC easier? Hard enough to walk on in 20 minutes (enough to get to the car/home) etc but pt needs to let harden for a couple of hours before doing any significant amount of walking.

47 Total Contact Casting Alternatives Cam walker Off the shelf
Better than nothing Neuropathic Walker (aka: bivalve boot) Custom molded Optional rocker sole Easily removed by patient Positive and negative attribute Poor compliance

48 Unna’s Boot Heavy gauze impregnated with Calamine lotion, zinc oxide paste, glycerin, gelatin Apply lotion to skin Start applying wrap Start at metatarsal heads 50% overlap No stretch Circular slightly angled wrap (no figure 8 wrap, not beneficial for edema) Stop ~1 inch below knee

49 Unna’s Boot Application Stays on 5-10 days
Takes ~1 hour to dry Can cover with kerlix and ace wrap Not very firm Stays on 5-10 days Removes easily with scissors

50 Unna’s Boot Indications Benefits
Most commonly used for Venous Insufficiency wounds Benefits Mandatory compliance Will moisturize skin Passive edema control

51 Unna’s Boot Considerations Heavily draining wounds Maceration
Neuropathic patients Balance-can throw off gait pattern Infection which can start without notice because it’s on for 5-10 days Compliance Dry? Contact dermatitis Poor fit with fluctuating edema Put on for 5-10 days

52 Becaplermin Regranex Gel Platelet derived growth factor Indications
Lower extremity diabetic neuropathic ulcers extending into subcutaneous tissue and beyond Adequate blood supply Lots of off label use

53 Becaplermin Should be combined with: 15 gram tube ($600-$800)
Good wound care Sharp debridement Must have contact with receptors Infection control 15 gram tube ($600-$800) Must be refrigerated Cannot get heated AT ALL!!! Diabetic patients are always at increased risk for developing infection!

54 Becaplermin Contraindications Known hypersensitivity
Necrotic Tissue: growth factors won’t be exposed to appropriate tissues Infection Neoplasm at the site Black Box Warning (but NOT pulled from the market) >3 tubes = increased incidence of cancer** No specific type FDA Black Box Warning

55 Pressure Ulcer Prevention
A big part of what we do – unique perspective Pressure ulcer Can develop anywhere Particularly boney prominences Ischial tuberosity Sacrum Greater trochanter Vertebrae Scapula Head/face Etc, Etc, Etc

56 Pressure Ulcer Prevention
4 main causes of pressure ulcers Pressure Shear Friction Moisture

57 Pressure Ulcer Prevention
Intensity Duration Tissue tolerance: health of overall skin in relation to the pressure it can tolerate Have to do pressure relief!

58 Pressure Ulcer Prevention
Positioning Turns at minimum every two hours Specific to the patient If poor skin quality or lots of bony prominences, they will need to be turned more often! Offloading Occiput, heels, elbows Wear schedules for splints, braces Frequent skin checks!!!! Caution with different skin tones The darker the skin tone, the harder it is to pick up little changes in the wound

59 Pressure Ulcer Prevention
Positioning 30 degree side turn HOB <30 degrees NO DONUTS! Mattress replacement Group 1 (static) Group 2 (dynamic) Group 3 (fluidized) less than 30 degrees (ventilator associated pneumonia if on a vent); greater than 30 degrees: increased pressure

60 Pressure Ulcer Prevention
Positioning In sitting – weight shift every 15 minutes People naturally weight shift every 7-8 mins Cushions But be careful… Avoid sitting >1 hour if existing ulcer

61 Pressure Ulcer Prevention
Shear Interplay of gravity and friction Shearing forces stretch blood vessels, decreasing amount of pressure needed to occlude them Deep fascia levels over bony prominences Leads to undermining If shear is occurring, you develop pressure ulcers MUCH faster!

62 Pressure Ulcer Prevention
Friction Significant factor in pressure ulcer development Works with shear to create wounds Friction alone = blister Friction + Shear = much bigger problem Creates huge pressure ulcers. Draw sheets – but be careful Pull the patient up too high, then raise the HOB to lower them down…this is where the problem occurs!

63 Pressure Ulcer Prevention
Moisture Microclimate of the skin Greatly alters resiliency of epidermis Incontinence Associate Dermatitis (IAD) vs Pressure Ulcer IAD Diaper rash Skin protectant (zinc oxide, barrier cream) Management of incontinence

64 Pressure Ulcer Prevention
Nutrition Malnutrition is a significant risk factor Malnutrition is a significant factor in wound healing (patient must have an adequate amount of protein for proper wound healing) Catabolic vs Anabolic Tests for malnutrition Albumin: 20 day look at protein intake Sensitive to hydration, kidney/liver function Pre-Albumin: short half life Protein intake hours, effected by kidney failure NOT hydration History

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