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CURRENT CONCEPTS IN WOUND CARE

CURRENT CONCEPTS IN WOUND CARE. Tim Brandys MD FRCSC. OUTLINE:. Moist Wound Healing Acute vs. Chronic Wound Wound Bed Prep Pressure Ulcers Leg Ulcers Dressing Selection Cases. Moist Wound Healing:. George Winter 1960’s Advantages: -inc.rate reepithelialization

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CURRENT CONCEPTS IN WOUND CARE

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  1. CURRENT CONCEPTS IN WOUND CARE Tim Brandys MD FRCSC

  2. OUTLINE: • Moist Wound Healing • Acute vs. Chronic Wound • Wound Bed Prep • Pressure Ulcers • Leg Ulcers • Dressing Selection • Cases

  3. Moist Wound Healing: • George Winter 1960’s Advantages: -inc.rate reepithelialization -inc. production collagen -inc. angiogenesis -allows autolytic debridement -Decrease pain -Dry dressings peel off healing layers -accelerates healing 50% vs.air dry

  4. Acute vs. Chronic wound Healing:

  5. Acute Wound Healing: • Orderly sequence Repair • 4 Phases: Hemostasis,Inflammation,Proliferation, Maturation. • Each Phase=Cell Type dominate • Hemostasis=Plt.,Inflamm.=Neutrophil, Prolif.=Fibroblast,Maturation • All regulated by growth factors,cytokines,&chemokines

  6. Chronic Wound: • Stuck in the Inflammatory Phase,defective remodeling of ECM,fail to reepithelialize.

  7. CHRONIC WOUND • Usual Molecular & Cellular processes disrupted • Neutrophils dominate: release MMP’s in excess-digest extracellular matrix • Leaky capillaries- release excess Fibronectin binds & inactivates growth factors

  8. Chronic Wound: • Fibroblasts become senescent fail to respond to normal wound healing signals • Neutrophils continue to stimulated (by systemic or local factors) and wound is left in a viscous circle of inflammation. • Other Chronic wounds are stuck in the proliferative phase again due to unresponsive cells

  9. Wound Bed Prep

  10. Wound Bed Prep.: Goal: Convert the Chronic wound into an Acute wound and allow normal healing to take place.

  11. Wound Bed Prep.:Three Pronged Attack 1. Debridement 2. Decrease Bacterial Burden 3. Manage wound Exudate

  12. Debridement: Purpose: 1. To remove “Necrotic Burden”and restore acute wound healing. 2. To allow proper wound assessment.

  13. Surgical Debridement: Advantages: • Remove large amounts necrotic tissue fast. • Allows bone, tissue cultures • Leaves healthy vasc. Bed Disadvantages: • Painful • Can remove too much

  14. Enzymatic Debridement: Collagenase selectively digests collagen types 1 & 3 in necrotic tissue Advantages: Easy,Not painful Disadvantage: Slow

  15. Increased bacterial burden Infected Contaminated Colonized Decrease Bacterial Load: • All Chronic wounds sit somewhere along a bacterial continuum.

  16. Infection: Risk = Bacterial x Virulence Infection Burden Microorganism Host Resistance

  17. Infection Concepts: • Host Resistance : Immunocompromised, Malnutrition • Bacterial Burden: >10 5th microbes/g • Biofilm: Microcolonies of Bacteria secrete protective glycocalyx

  18. Manage Wound Exudate: Chronic Wound Exudate : Inhibits: Proliferation Fibroblasts,Keratinocytes,Endothelial cells Contains MMP’s,Serine Proteases Fibrinogen &Fibrin bind and inactivate growth factors

  19. Hospital Wounds:

  20. Pressure Ulcers:

  21. Leg Ulcers:

  22. Dressing Selection: THERE IS NO UNIVERSAL WOUND DRESSING THE DRESSING MUST FIT THE WOUND DRESSINGS MUST BE REASSESED FOR EACH PHASE OF WOUND HEALING

  23. INFECTED Antimicrobial: ACTICOAT: Ionized silver Broad spec. MRSA/VRE IODOSORB: Cadexomer Iodine Broad spec. Decr. Foul odour Absorbent Dressing Selection:

  24. LOW EXUDATE HYROGEL: Moist env. Autolysis Decrease pain Dressing Selection:

  25. ESCHAR,SLOUGH ENZYMATIC DEBRIDEMENT: Collagenase-selective Digestion types 1 and 3 collagen in necrotic tissue Dressing Selection:

  26. LIGHT EXUDATE HYDROCOLLOID: Duoderm Wound granulating Dressing Selection:

  27. Moderate to heavy exudate FOAM: Allevyn Hydrophillic polyurethane foam Absorbs up to 4 days Dessing Selection:

  28. Moderate to Heavy Exudate ALGINATES -Seaweed -Turns to gel -Moist Wound Environment -Hemostatic -Can be drying Dressing Selection:

  29. Moderate to Heavy Exudate HYDROFIBER AQUACEL -Turns into gel -Moist wound Environment Dressing Selection:

  30. VENOUS ULCER COMPRESSION BANDAGE Profore-4 layer compression ABI >.8 Dressing Selection:

  31. LARGE WOUND CAVITY 1.Allevyn Cavity 2.THE VAC Sponge with suction unit -stimulates angiogenesis,causes wound contraction Dressing Selection:

  32. CASES

  33. CASE 1: 70 yo smoker admitted with pancreatitis to the ICU.Required prolonged stay on the ventilator.Physical exam reveals absent pedal pulses and a painful necrotic left heel ulcer. What do you do now?

  34. CASE 2: 40 yo male paraplegic admitted to medicine with UTI .Develops a large ischial ulcer while in hospital.Surgery is consulted. WHAT DO YOU DO NOW?

  35. Case 3 : Otherwise healthy 35 yo female suffers lacerations to right leg during accident with farming equipment.Transferred to plastic surgery after failure to heal wounds in peripheral hospital. WHAT DO YOU DO KNOW?

  36. CASE 4: 50 yo diabetic male is referred to the orthopedic surgeon with a non healing ulcer over the plantar surface 1st metatarsal head left foot. WHAT DO YOU DO NOW?

  37. CASE 5: 65 yo female comes to the Vasc.Surg clinic with a large left ankle ulcer.It is painless and has a lot of exudate.The ulcer has failed to heal despite wet to dry saline dressings. What Do You Do Now ?

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