Wound Healing

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Wound Healing

  1. 1. WOUND Myths & facts of Care Graphics & Research:; Mansoor Khan (M.B.B.S) Plastic & Reconstructive Surgery Hayatabad Medical Complex, Peshawar.
  2. 2. Discontinuity of the skin, mucous membrane or tissue caused by physical, chemical or biological insult ” “
  3. 3. Changing trends in the classifcation…?
  4. 4. ACUTE Recent wound which has yet to progress through the sequential stages of healing CHRONIC Wound that has arrested in one of the wound healing stages usually inflammatory phase
  5. 5. Acute vs Chronic Wounds
  6. 6. SIMPLE WOUND those wounds which are readily managed by local wound care /contraction, direct closure, skin grafting, local tissure rearrangment. COMPLEX WOUND these are large wounds requiring tissue distant from wound site i.e. regional, distal transposition or microvascular composite tissue transfer PROBLEM WOUND Those wounds which fails to achieve closure with the above methods or recurres due to local or systemic causes.
  7. 7. Clinical History, examination & investigations….?
  8. 8. Mechanism of trauma, duration, pain, discharge . Co-morbidities (DM, HTN e.t.c.), radiotherapy
  9. 9. Location, size, depth, exposed structures, level of contamination, necrosis, level of exudation, granulation,
  10. 10. Visitrak Grid
  11. 11. Visitrak Grid
  12. 12. Standardized serial digital photography
  13. 13. Portable Digitizer for Wound Monitoring
  14. 14. Full blood count, serum albumen, blood glucose level and HbA1c, CRP and ESR, ABPI,
  15. 15. Transcutaneous oxygen pressure (tcPO2)
  16. 16. Causative factors of problem wounds….?
  17. 17. PROBLEM WOUND Bacterial Infection Ischemia Age
  18. 18. Accelerated senescence, diminished production of growth factors, collagen, matrix, decreased ability to survive hypoxic stress, Aging is irreversible: optimization of the systemic parameters & supplementation is the solution AGE
  19. 19. Damage to the small vessels in the wound leads to hypoxia of the wound relative to the normal tissue (25mmHg vs 40mmHg), this hypoxia becomes chronic due to peri- wound fibrosis in problem wounds. ISCHEMIA
  20. 20. Reduction of edema ISCHEMIA
  21. 21. Offloading: Reduction of pressure reduces ischemia. ISCHEMIA
  22. 22. Reduction of peripheral vascular resistance ISCHEMIA
  23. 23. Warmth: Vasodilates the vessels ISCHEMIA
  24. 24. ISCHEMIA
  25. 25. Hydration: Improves circulation ISCHEMIA
  26. 26. Bacterial inoculum & virality, presence of foreign bodies, determines the severity of the wound Bacteria: Set up free radicles environment, secrets toxins & proteases----bystander damage BACTERIA
  27. 27. Indications for antibiotics: Venous stasis ulcers, lymphangitis, cellulitis, critical colonization of the wound, infection (straw color oozing, pain), BACTERIA Never forget to use topical antibiotics ‘cuase peri-wound fibrosis restricts the the delivery of systemic antibiotics
  28. 28. Management (debridement)….?
  29. 29. Debridement : without debridement wound is exposed to cytotoxic stressors & competes with the bacteria for scarce oxygen & nutrition resources, debridement reduces the bioburden and help ensure healing
  30. 30. Post-debridement
  31. 31. Eschar : should be excised: Many surgeons still consider it as a biological dressing & believes in healing under eschar. Proteinaceous eschar acts as meal for bacteria.
  32. 32. Enzymatic wound debridement
  33. 33. Autolytic debridement: through the action of the leukocytes i.e. hydrocollides
  34. 34. Pressurized water jet machamical debrider (VersaJet)
  35. 35. Adjuvents in management….?
  36. 36. NEGATIVE PRESSURE WOUND THERAPY Tremendous adjuvent for wound closure Mechanism: relieves edema, removes deletrious enzymes, exudates, bacterial load, cyclical compression & relaxation stimulates mechanotransductive pathway of growth factors. Precautions: the sponge should not be placed on normal skin, use of optimal negative pressure of 125mmHg
  37. 37. Indications: lymphatic leak, venous stasis ulcers, diabetic wounds, sternal wounds, orthopedic wounds, abdominal wounds Contraindications: malignancy, ischemic wounds, inadequately debrided & badly infected wounds, exposed vessels, patients on anticoagulants
  38. 38. Hyperbaric oxygen therapy 100% oxygen at 2-3 ATA raises the dissolved oxygen level from 0.3% to 7% in plasma which increases 4-5 times oxygen delivery to the wound
  39. 39. DRESSINGS Goals: to clean the wound, creat moist healing environment to facilitate cell migration & prevent dessication Paradigm shift: from moist to dry dressing to moist dressing.
  40. 40. Hydrogel/films/composite dressings: ;used for light exudating wounds Hydrocollides are used for moderate quantities of exudation. Alginates/foams/NPWT: usefull for heavy exudation. CHOICE OF DRESSING IS BASED ON QUANTITY OF EXUDATE
  41. 41. Gauze Advantages: Traditional first choice used for moist to dry dressing, low material expense, easily availble, excellent as surgical bandage for uncomplicated. Dis advantages: moist to dry dressings are traumatizing as gauze is non-selective debrider causing significant bystander damage, leaves behind fine microfibers which are irritants and source of infection. Impregnated gauze with petrolium, iodinated compounds for moist dressing is available having comparable results with the modern dressings.
  42. 42. Semiocclusive Dressings Unpermeable to fluids to keep moist environment, permit of gas molecules. To cover freshly closed incisions, skin graft donor site. Should not be used for contaminated wounds .
  43. 43. Hydrogel dressing: Autolytic debridement by rehydrating the wound and facilitat healing. Used in wound with small amount of eschar and predisposed to dessication, infected wounds, require secondary dressing on top of it.
  44. 44. Foam dressing Highly absorptive and acts like a wick making it useful in highly exudative wounds.
  45. 45. Alginates useful in wounds with significant exudated fluids, they can absorb fluids 20 times their dry weight, not to be used on nonexudative wounds as they will dry up the wound. If used for dry wound they should be hydrated with saline prior to application
  46. 46. Pyodine iodine & Chlorhexadine damages the normal cells, fibroblasts and growth factors as well, so newer antimicrobial agents containing dressings are favoured i.e. silver and cadexomer iodine
  47. 47. Antimicrobial dressings Most benefical agent is Silver, broad spectrum antimicrobial agent including VRE, MRSA.
  48. 48. Cadexomer iodine Slow release iodine for cosistent bactericidal levels without the wound cell damaging effects seen with pyodine-iodine products
  49. 49. Management of simple & complex wounds….??
  50. 50.  Thorough wound wash  Debridement of the necrosed margins, conservatively on the face, Layered closure to obliteration the dead space No skin stiches untill skin margins are <2mm apart by applying intradermal sutures Use of fine monofilament sutures with carefull handling of the skin margins.
  51. 51. Timely removal of the sutures, and application of the scar modification measurements ensures a fine scare…..
  52. 52. Elective surgery patients are advised to refrain from strenous activity for at least 6 weeks
  53. 53. Management of problem wound…?
  54. 54. Decreases angiogenesis, collagen deposition, cellular proliferation, prone to infection Patients should receive Vit-A (25000IU/day PO or 200000 IU topically TDS) Goal should be to maintain a clean wound with minimal bacterial colonization
  55. 55. Irradiated wounds Progressive endarteritis obliterans, microvascular damag, fibrotic changes leading to ischemia, prone to infection. Needs very carefull debridement, antimicrobial moist dressing while promoting autolysis are ideal for these wounds. Hyperbaric oxygen therapy and growth factors are also useful adjuvents. Usually needs flap coverage.
  56. 56. Pressure sores Patients are usually malnourished and nutritional uplift is necessory in these patients along with the administration of growth hormones or anabolic steroids (oxandrolone) to counteract the catabolic s state of the patients
  57. 57. Pressure sores They needs thorough multiple sessions of debridements and ultimately fasciocutaneous or musculocutaneous flape coverage. Frustrating part is its high recurrence rates. Film drssings are ideal for stage I & II to keep the moist environment. While for stage III & IV more absorptive dressings (hydrogel, hydrocollides, foams and alginates) are required depending on the exudatation level.
  58. 58. Pressure sores The spasm of the patients should be relieved non- surgically (benzodiazipins, dantrolen e.t.c.) or surgically. Use of pressure relieving devices are helpful in healing and preventing recurrence.
  59. 59. Diabetic wounds Combination of microangiopathic, neuropathic and pressure necrosis ulcers. Thorough serial debridement , glucose control, pressure offloading, revascularization, nerve decompression combination is required.
  60. 60. Venous stasis ulcers Compression therapy is the main stay of theapy i.e. graduated compression stockings (30-40mmHg pressure), contraindicated when ABPI is <0.7 and shloud be used with causion in 0.7-0.9. Supplementary dressing depending upon the amount of exudate is used. When edema subsides then the wounds are closed & compression therapy contiued post-op for several weeks. Ulcers resistant to compression therapy should undergo venous insufficiency studies. The superficial/perforators insufficiency is the idication for vascular surgery.

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