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Palliative Wound Care

Palliative Wound Care. Frank D. Ferris, MD Rosene D. Pirrello, RPh San Diego Hospice & Palliative Care University of California San Diego School of Medicine / School of Pharmacy. Objectives. Describe approaches to the management of Healable Non-healable

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Palliative Wound Care

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  1. PalliativeWound Care Frank D. Ferris, MD Rosene D. Pirrello, RPh San Diego Hospice & Palliative Care University of California San Diego School of Medicine / School of Pharmacy

  2. Objectives • Describe approaches to the management of • Healable • Non-healable • Discuss issues faced by patients and families who are “wounded” Wounds

  3. Slides / Resources • www.cpsonline.info • Presentations • Wound Care • Chronic Wound Care, 4rd Edition.Krasner DL, Sibbald, Rodeheaver • Wound, Ostomy and Continence Nursing Secrets • Ostomy and Wound Management

  4. How Many Wounds at SDHPC? • Over last year 25 % ( 1,029 of 4,048 patients ) • In a single day ( May 25, 2007 ) 33 % ( 200 of 767 )

  5. Type of Wounds at SDHPC • Pressure – 50% • Malignant – 30% • Venous / edematous – 15% • Arterial – 5% • Diabetic – few

  6. Pathophysiology • Pressure • Malignant • Venous / edematous • Arterial • Diabetic

  7. Assess • Wound • Type, cause • Bacterial burden • Context • Underlying illness(es), prognosis • Nutritional status • Person • Symptoms • Woundedness

  8. Size: L – W – D Tunneling Color Odor Exudate Serous Serosanguineous Purulent Necrotic Tissue Slough Eschar Surrounding Tissues Assess the Wound

  9. Pressure Ulcer Staging . . . • Stage I – persistent changes in a defined area of intact skin related to pressure • Red, blue or purple hues • Stage II – partial thickness skin loss • Epidermis and / or dermis

  10. . . . Pressure Ulcer Staging • Stage III – full thickness skin loss • damage or necrosis of subcutaneous tissue • not through underlying fascia • Stage IV – full thickness skin loss • extensive damage or necrosis of muscles, bone or supporting structures • Undermining • Sinus tracts

  11. Goals of Care . . . • Treat – wound, underlying disease • Non-healing – stability,  progression • Healing – moist interactive wound healing • Bacterial Burden • Symptoms • Exudate • Pain • Odor • Bleeding

  12. . . . Goals of Care • Prevent • Skin integrity • Pressure • Edema • Promote • Body image • Psychic distress – patient, caregivers

  13. Management Strategies Healable Non-healable Moist interactive dressings Fluid balance Bacterial balance

  14. Wound Care is Multifactorial TissuePerfusion Fluids,Nutrition Eschar,Slough,Exudate BacterialBurden GrowthStimulants

  15. Margaret . . . • 68 year old woman • Metastatic lung Ca • Spinal cord compression, paraplegia • Cared for at home • Nutrition good • Loving family

  16. . . . Margaret • Stage X, R heel ulcer • eschar • 4 x 6 cm • Stage III, sacral ulcer • 5 x 8 cm • Goal: healing

  17. Debridement The single most important parameter for reducing the level of bacterial contamination in the chronic wound is the removal of devitalized tissue Rodeheaver GT. in Chronic Wound Care, 3rd. Edition, 2001

  18. Ensure Adequate Blood Supply ABI (Ankle Brachial Index) > 0.5 Palpable dorsalis pedis / posterior tibial 80 mmHg Toe Pressure 30–50 mmHg Transcutaneous 02 > 30 mmHg

  19. Debridement • Surgery fastest, eg, scalpel, curette, scissors • Aggressive • Non-aggressive • Autolytic (dressings) • Enzymes • Collagenase • Papain • Mechanical, eg, hydrotherapy

  20. EMLA,* Eutectic Mixture of Local Anesthetics • Lidocaine 2.5% / prilocaine 2.5% cream • Liquid when cold, solid at room temp. • Apply thick coat, “icing on a cake” • Leave on 30-60 minutes • Need complete seal eg, plastic wrap, transparent film (adhesive) *Approved for use on open wounds in Canada / Europe, but not US FDA

  21. Local Anesthetics LidocaineAmide - less allergy Topical Quick onset of action Injectable < 200 mg / dose + Epinephrine  bleeding Onset 10-15 min Max action 30-60 min Risk of tachycardia Benzocaine (ester) is a topical sensitizer

  22. Cleansing • Hydrogen peroxide • Sodium hypochlorite eg, Hygeol, Dakin's • Povidone iodine eg, Betadine • Aniline dyes eg, Neutral Red, Crystal Violet • Aluminum salts eg, Burow’s Solution These agents will delay healing and decrease bacterial burden

  23. Cleansing • Saline – preserved vs. unpreserved • Stove-top saline • 10 ml / 2 tsp salt in 1 liter / quart water • Boil 3 - 20 minutes • Water – tap vs. sterile • Cleansers • Skin – bacteriocidal • Wound – less toxic

  24. Cleansing Technique • Rinse • Cleanse • Irrigate • Pressure < 15 psi • 18-20 angiocatheter + 30–60 cc syringe

  25. Moist Interactive Healing Guideline 1. Use a dressing that will keep the ulcer bed continuously moist. Wet-to-dry dressings should only be used for debridement and are not considered continuously moist saline dressings Strength of evidence: Amore than one random controlled trial Ovington L. Ostomy / Wound Management1999; 45 (Suppl. 1A): 94S-106S

  26. Moist Interactive Healing • Increased cellular function • Facilitate autolytic debridement • Lower infection rates • Decreased pain

  27. Moist Interactive Healing Guideline 2. Use clinical judgment to select a type of moist wound dressing suitable for an ulcer. Studies of different types of moist wound dressings showed no differences in pressure ulcer healing outcomes Strength of evidence: Amore than one random controlled trial Ovington L. Ostomy / Wound Management1999; 45 (Suppl. 1A): 945-1065

  28. Types of Dressings

  29. Foams Absorbency ++++ Wear time 1 to 7 days Comments * Need moisture from the wound * May macerate surrounding skin

  30. Calcium Alginates Absorbency +++ Wear time 12 to 48 hours Comments * Hemostasis * Can be used in infected wounds * Rope - wicks vertically * Wafer - wicks laterally

  31. Hydrogels Absorbency ++ Wear Time 12 to 72 hours Comments * Lattice - saline propylene glycol hydrocolloid * Good autolytic debridement * Amorphous & sheet forms

  32. Hydrocolloids Absorbency + Wear Time 2 to 7 days Comments * Not vascular insufficiency / infection * Must have seal * Good autolytic debridement Components: * Hydrophilic - gelatin, pectin * Hydrophobic - cellulose * Adhesive - can cause allergy

  33. Transparent Films Absorbency 0 Wear Time 1 to 7 days Comments * Adhesive forms may damage surrounding skin * Cannot have leakage channels * Best re-epithelialization / protection

  34. Gauze Cotton mesh • Kerlix • 4x4’s Synthetic • Kling • Conform Hypertonic / Absorbing • Mesalt

  35. Non-adherent Non-impregnated • Adaptic • Telfa • Soft silicones Impregnated • Vaseline gauze • Xeroform

  36. Dressings Summary

  37. Dressing Layers • Directly on wound surface

  38. . . . Margaret • Stage X, R heel ulcer • eschar • 4 x 6 cm • Stage III, sacral ulcer • 5 x 8 cm • Goal: healing

  39. Fill dead space Moisture balance Non-toxic to cells Bacterial balance Pain control Minimize pressure Not saline-soaked gauze Vaseline covered gauze Alginates Dressings for Packing

  40. Dressings in Resource-poor Settings “ Must Have ” • Non-stick Vaseline gauze • Hydrogel • Alginate • Foam

  41. Prevention . . .

  42. Risk Assessment Braden Pressure Ulcer Risk Assessment Sensory perception Moisture Activity Mobility Nutrition Friction / shear 3 4 1 2

  43. Pressure Relief Assessment • Risks • High pressure - short period • Low pressure - long period • Definitions • Pressure relief = Reducing interface pressure below capillary closing pressure • Pressure reduction = Reducing interface pressure, but not necessarily below the level required to close capillaries

  44. Reduce Shear, Friction • General • head of bed less than 30° • foot board or elevate knee • protect elbows (pajama tops) • protect heels (protective boots) • Dressings • transparent film • hydrocolloid • Bedpan • apply thin powder film to bedpan

  45. Pressure Relief: Surfaces / Positioning Beds Group 1 – Pressure relief mattress Group 2 – Low air loss Group 3 – Air fluidized

  46. Pressure Relief: Surfaces / Positioning Positioning - q 2 hours - weight shift q 15-30 min x 5 seconds - side position at 30º angle - pillow under calves when on back Avoid external sources of pressure, eg, wrinkled sheets, inflated air rings

  47. Management Strategies Healable Non-healable Moist interactive dressings Topical antiseptics Fluid balance Bacterial balance Dry surface Bacterial balance

  48. Non-healable • Stability,  progression •  bacterial burden, odor •  exudate •  pain •  bleeding •  body image •  caregiver gifting

  49. John • 62 year old man • 18-month Hx malignant melanoma • Now metastatic • Tumour didn’t respond to chemotherapy, radiation therapy • Declined to participate in clinical trials • Pain well controlled

  50. Bacterial Burden • Anaerobes • Metronidazole • Silver sulfadiazine • Tissue depth • Topical • Systemic • Alginate dressings

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