Presentation on theme: "Enzymatic Debridement"— Presentation transcript:
1Enzymatic Debridement Collagenase (Santyl)Digests necrotic collagenSpecific and selective for denatured collagenEffective when used for long periods of timeMaintenance debridementTends to be a slow acting drug
2Collagenase Considerations Cost Slow acting Deactivated when combined with heavy metalsSilver:Loses 50% of it’s efficacy when combined with silver.Can be combined with polysporin powder: good when you’re worried about localized infection.
3Autolytic Debridement Autolysis:Natural degradation of devitalized tissue using endogenous enzymesMoisture retentive or moisture donating dressingOcclusive dressingEschar and slough are liquefied by rehydration and activity of lysosomes
4Autolytic Debridement Indications:Wounds with necrotic tissue**No infection (you’re creating a Petri dish)Wounds with dry eschar particularly benefitCross hatching eschar facilitatesConsiderationsIt’s grossIt stinksIf biofilm gets too aggressive, it means an infection is starting to grow No Autolytic debridement!
5Autolytic Debridement ContraindicationsDry gangrenePoor circulatory supportNot enough lysozomes to make the debridement work but it won’t cause any harm.Infection
6Autolytic Debridement AdvantagesNon-invasiveSelectiveDoes not disrupt healthy tissueEasy: leave on hours, rinse wound with saline and apply another.PainlessStays on for hours before you change it.
7Autolytic Debridement DisadvantagesSLOWPotential to grow bacteriaCan macerate surrounding skinWatch for sensitivity to adhesive
8Biological Debridement Maggot Therapy!Biosurgical debridement, Larval Debridement TherapyRoleDebridement (maggots secret collagenase and eat liquefied tissue)Disinfection (secretions that maggots give off having antimicrobial properties)Promotes wound healing (Maybe???)
9Biological Debridement Initial research published in 1929But remain widely unused/unpopular“Ick” factorCostSlowRemoval and disposal questionsStudies limitedDFU 33% slough – traditional, 0% - maggotsVI cost effective compared to hydrogel
10Biological Debridement Sterile, medical grade maggots placed in woundCovered with dressingAllows oxygen exchangeContains maggotsHydrocolloid most commonly useddressingIn place 1-4 days, make sure you get them ALL out!
11Sharp Debridement Most widely used – particularly by PT Scalpel, forceps, scissors (blunt to cut dressings, or sharp to remove tissue), curette (least popular tool)
12Sharp Debridement Research supports: 2009 retrospective study DFU, VI Frequent debriders (>2x/12 wks) vs Infrequent debriders (<2x/12wks)241 woundsFrequent debriders showed a greater decrease in surface area of woundFrequent debriders had better median healing ratesResearch SUPPORTS sharp debridement!!!!
13Sharp Debridement Research support: 2009 study of DFU Growth factors alone vs growth factors with debridementGrowth factor plus debridement healed faster
14Sharp Debridement Advantages Fast Method of choice for thick, adherent or large amounts of slough, escharMethod of choice in presence of infectionIf sepsis, surgeon will perform debridement, not PT!SelectiveCan be combined with many techniquesInexpensive, but questionable reimbursementEvery 20 square cm $25
15Sharp Debridement Considerations Pain Anticoagulants/bleeding disorder Blood lossSilver nitrate to stop bleedingEnough blood flow?Potential for infectionKnow your anatomy!Comfort level
16Sharp Debridement Modified Sterile Technique Sterile gloves Sterile equipmentSterile fieldNOTE: 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!!!
17Sharp 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 sterileFlush with salineDispose of material properly
18Sharp Debridement Tips: Hold scalpel like a pencil The blade is sharp! Cut parallel to the surfaceParticularly along edgesIf you aren’t sure – don’t do itIf 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!
21Negative Pressure Wound Therapy NPWTSuction applied to wound via open-celled foam spongeFoam secured with vapor permeable drapeSuction attached to canister to collect excess drainage
22Negative Pressure Wound Therapy BenefitsEdema reductionIncrease perfusion distance = blood flow increaseIncrease perfusion31% to wound bed, 15% to periwoundStimulates granulation tissue formationMicrodeformationRemoval of exudate? Bacterial colonizationIncreased angiogenesisPerfusion distance: how far the nutrients go out from the wound bed.
23Negative Pressure Wound Therapy Suction mmHg150 mmHg is common for abdominal wounds50-75mmHg for feetLower pressure on distal woundsContinuous or intermittentIntermittent over graft sites or distal foot wounds with poor circulationCommonly use continuousClean application bedside, sterile application in ORLots of sponsored researchIncreased speed of healing negates costCost of vac is $ per day
25Negative Pressure Wound Therapy IndicationsAny type of woundSize minimum2.5cm in one directionEnough room to place a sponge
26Negative Pressure Wound Therapy ConsiderationsCostCarry aroundChange 2-3x/weekCan Pt self fix?Can be combines with some other productsSilver is most commonInfection
27Negative Pressure Wound Therapy ContraindicationsMalignancy in woundUntreated osteomyelitisFistulas/tracts – do you know where they end?Bleeding: stop bleeding before using suctionKnow your anatomy!No blood vessels, nerve endings, anastamosis, most organsCan put a vac over exposed bowel (seen a lot with compartment syndrome of the abdomen)
28Negative Pressure Wound Therapy How to applyIMPORTANT!!!! Count the number of foam pieces that you use so you make sure to remove ALL of them!!!!
29Hyperbaric OxygenInhaled 100% oxygen delivered to patient in enclosed environment pressurized to >1.4ATATypically ATAEasily transported via RBC and hemoglobinGoal is to increase aerobic cellular metabolismGrowing 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
30Hyperbaric Oxygen0.3 volume percent of oxygen is dissolved in plasma at sea level (1 ATA) breathing RA6.9 volume percent of oxygen is dissolved in plasma at 3 ATA breathing 100% O2Increased volume percent = increased diffusion radius = more O2 gets to the tissuesWhen tissues have more oxygen, they heal faster!
31Hyperbaric Oxygen So what? Re-establish normal cellular metabolism Promote angiogenesisIncrease granulation tissue formationDebate: Salvage marginal tissue?Decrease tissue edemaMeet increased demand of tissue
32Hyperbaric Oxygen Indications Refractory osteomyelitis: (osteomyelitis that has been treated for 30 days with antibiotics but has not responded.)Acute traumatic ischemic injury/Crush InjuryCompromised skin grafts and muscle flapsNecrotizing fasciitisGas gangreneLife threatening. Get to surgeon to Debride or amputate immediately!!!Others:CO poisoning, smoke inhalation, decompression sickness, arterial gas emboli, cyanide poisoning
33Hyperbaric Oxygen Contraindications Strongly consider Untreated pneumothoraxStrongly considerFever (signs of septic infection)ClaustrophobiaCOPD, CHFHigh FiO2 (don’t give them MORE oxygen as it may supress their respiratory drive)ChemotherapyIt 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 weekMust be prescribed by physician and MD must be on site while performing
34Skin Grafting Performed by MD or PA Should be considered with healthy wound beds that are failing to healAdequate blood supplyAbility to tolerateToo much wound exudate is a problemWill flood out the graft and it won’t takeGraft or flap will not survive if blood supply is inadequate.
35Skin Grafting Autograft Allograft From Pt’s own tissue (thigh or buttocks)Full thickness (rare to take)Partial thickness (most common)AllograftCreated from same species (cadaver graft)Done in OR, usually a hospitalization
36Skin Grafting Xenograft Performed in office Multiple applications Created from different species (animal origin)Oasis Wound MatrixDry product (long shelf life)Performed in officeMultiple applications
37Skin Grafting Bioengineered Tissue Apligraf, Dermagraft Living bilayered skin substituteEpidermal layer formed by human keratinocytesDermal layer composed of human fibroblasts in bovine collagen matrixContains matrix proteins and expresses cytokinesBut no melanocytes, macrophages, lymphocytes, blood vessels, hair follicles or sweat glandsNever looks like normal skin!Short shelf life, very expensive, have to be kept at a certain temperature
38Skin Grafting Bioengineered Tissue Full thickness wounds without exposed structuresNon-infected VI with compressionUsed in conjuncture with good wound careDebridementNon-infectedGood blood supply** KEYWithout this, the graft won’t takeOff-loading and compression
39Muscle Flap Flap surgery Musculocutaneous when need to fill depth Skin grafts on the other hand are superficialProvides rich vascular tissueMay also require skin graftingUsually gluteus maximusIf successful, muscle atrophies, but blood supply remains to feed skinSuccess rate is 50%
40Muscle Flap Surgical debridement IV antibiotics x6-8 weeks Ensure no osteomyelitisNPWT to maintain health of wound edgesSurgical procedure + hospitalizationAir fluidized bed x6-8 weeks-non-weight bearingBed is filled with sand that is constantly circulated to reduce pressure areas. Very expensive! And HEAVY
41Muscle 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 patientsFunction can be compromised in ambulatory patients
42Total Contact Casting Diabetic Foot Ulcer – gold standard GOAL: Need to offload the foot for healing to occurMost patients are neuropathicCan protect foot from further traumaCan’t feel if it isn’t a good fitBest if can eliminate 2/3 of weight bearing time
43Total Contact Casting Benefits Decreases plantar pressures by increasing weight bearing over entire lower legRedistribute pressurePrevent traumaReduce edemaImmobilize joints and soft tissueHelpful to prevent shear forces
44Total Contact Casting Considerations Gold standard, but only 45% of wound clinics perform some sort of offloadingIf you do it wrong – can seriously harmNo room for absorptionNo where for the fluid to go so it can cause maceration to the whole area!Close follow-up neededBy patient-time consumingBy clinicianRisk of infection!
45Total Contact Casting How performed Ulcer covered with gauze Cotton b/w toesStockinette applied¼ thick felt along malleoli and ant tibiaFoam padding around toesPlaster shell moldedWalking heel can be attachedFinished with fiberglass roll around plasterMUST 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!
46Total 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.
47Total Contact Casting Alternatives Cam walker Off the shelf Better than nothingNeuropathic Walker (aka: bivalve boot)Custom moldedOptional rocker soleEasily removed by patientPositive and negative attributePoor compliance
48Unna’s BootHeavy gauze impregnated with Calamine lotion, zinc oxide paste, glycerin, gelatinApply lotion to skinStart applying wrapStart at metatarsal heads50% overlapNo stretchCircular slightly angled wrap (no figure 8 wrap, not beneficial for edema)Stop ~1 inch below knee
49Unna’s Boot Application Stays on 5-10 days Takes ~1 hour to dryCan cover with kerlix and ace wrapNot very firmStays on 5-10 daysRemoves easily with scissors
50Unna’s Boot Indications Benefits Most commonly used for Venous Insufficiency woundsBenefitsMandatory complianceWill moisturize skinPassive edema control
51Unna’s Boot Considerations Heavily draining wounds Maceration Neuropathic patientsBalance-can throw off gait patternInfection which can start without notice because it’s on for 5-10 daysComplianceDry?Contact dermatitisPoor fit with fluctuating edemaPut on for 5-10 days
52Becaplermin Regranex Gel Platelet derived growth factor Indications Lower extremity diabetic neuropathic ulcers extending into subcutaneous tissue and beyondAdequate blood supplyLots of off label use
53Becaplermin Should be combined with: 15 gram tube ($600-$800) Good wound careSharp debridementMust have contact with receptorsInfection control15 gram tube ($600-$800)Must be refrigeratedCannot get heated AT ALL!!!Diabetic patients are always at increased risk for developing infection!
54Becaplermin Contraindications Known hypersensitivity Necrotic Tissue: growth factors won’t be exposed to appropriate tissuesInfectionNeoplasm at the siteBlack Box Warning (but NOT pulled from the market)>3 tubes = increased incidence of cancer**No specific typeFDA Black Box Warning
55Pressure Ulcer Prevention A big part of what we do – unique perspectivePressure ulcerCan develop anywhereParticularly boney prominencesIschial tuberositySacrumGreater trochanterVertebraeScapulaHead/faceEtc, Etc, Etc
56Pressure Ulcer Prevention 4 main causes of pressure ulcersPressureShearFrictionMoisture
57Pressure Ulcer Prevention IntensityDurationTissue tolerance: health of overall skin in relation to the pressure it can tolerateHave to do pressure relief!
58Pressure Ulcer Prevention PositioningTurns at minimum every two hoursSpecific to the patientIf poor skin quality or lots of bony prominences, they will need to be turned more often!OffloadingOcciput, heels, elbowsWear schedules for splints, bracesFrequent skin checks!!!!Caution with different skin tonesThe darker the skin tone, the harder it is to pick up little changes in the wound
59Pressure Ulcer Prevention Positioning30 degree side turnHOB <30 degreesNO DONUTS!Mattress replacementGroup 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
60Pressure Ulcer Prevention PositioningIn sitting – weight shift every 15 minutesPeople naturally weight shift every 7-8 minsCushionsBut be careful…Avoid sitting >1 hour if existing ulcer
61Pressure Ulcer Prevention ShearInterplay of gravity and frictionShearing forces stretch blood vessels, decreasing amount of pressure needed to occlude themDeep fascia levels over bony prominencesLeads to underminingIf shear is occurring, you develop pressure ulcers MUCH faster!
62Pressure Ulcer Prevention FrictionSignificant factor in pressure ulcer developmentWorks with shear to create woundsFriction alone = blisterFriction + Shear = much bigger problemCreates huge pressure ulcers.Draw sheets – but be carefulPull the patient up too high, then raise the HOB to lower them down…this is where the problem occurs!
63Pressure Ulcer Prevention MoistureMicroclimate of the skinGreatly alters resiliency of epidermisIncontinence Associate Dermatitis (IAD) vs Pressure UlcerIADDiaper rashSkin protectant (zinc oxide, barrier cream)Management of incontinence
64Pressure Ulcer Prevention NutritionMalnutrition is a significant risk factorMalnutrition is a significant factor in wound healing (patient must have an adequate amount of protein for proper wound healing)Catabolic vs AnabolicTests for malnutritionAlbumin: 20 day look at protein intakeSensitive to hydration, kidney/liver functionPre-Albumin: short half lifeProtein intake hours, effected by kidney failure NOT hydrationHistory