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Enzymatic Debridement Collagenase (Santyl) Digests necrotic collagen – Specific and selective for denatured collagen Effective when used for long periods.

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Presentation on theme: "Enzymatic Debridement Collagenase (Santyl) Digests necrotic collagen – Specific and selective for denatured collagen Effective when used for long periods."— 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

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

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 48- 72 hours, rinse wound with saline and apply another. – Painless

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

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

17 Sharp Debridement Things to remember Position patient and self comfortably! – This can take 60-90 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!

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

23 Negative Pressure Wound Therapy Suction 50-150 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 $150-200 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 –

29 Hyperbaric Oxygen Inhaled 100% oxygen delivered to patient in enclosed environment pressurized to >1.4ATA – Typically 2.4-3.0 ATA Easily transported via RBC and hemoglobin Goal is to increase aerobic cellular metabolism

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 – 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

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

35 Skin Grafting Autograft – 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 – 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!

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

41 Muscle Flap Muscle atrophies – 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

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

46 Total Contact Casting Alternatives – TCC-EZ Making TCC easier? –

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 – 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 – 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

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: – 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!!!

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 Pressure – 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)

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

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 48-72 hours, effected by kidney failure NOT hydration History

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