Myths & facts ofWOUND Care Graphics & Research:; Mansoor Khan (M.B.B.S)Plastic & Reconstructive Surgery Hayatabad Medical Complex, Peshawar.
“ Discontinuity of the skin,mucous membrane or tissuecaused by physical, chemical or biological insult
Changing trends in theclassifcation…?
ACUTE Recent woundwhich has yet to progressthrough the sequentialstages of healingCHRONIC Wound thathas arrested in one of thewound healing stagesusually inflammatory phase
SIMPLE WOUND those wounds which arereadily managed by local wound care/contraction, direct closure, skin grafting, local tissurerearrangment.COMPLEX WOUND these are large woundsrequiring tissue distant from wound site i.e. regional,distal transposition or microvascular composite tissuetransferPROBLEM WOUND Those wounds which failsto achieve closure with the above methods or recurresdue to local or systemic causes.
Location, size, depth, exposedstructures, level of contamination, necrosis, level of exudation, granulation,
Standardized serial digital photography
Portable Digitizer for Wound Monitoring
Full blood count,serum albumen, blood glucoselevel and HbA1c, CRP and ESR, ABPI,
Transcutaneousoxygen pressure (tcPO2)
Causative factors ofproblem wounds….?
AgeIschemia Bacterial Infection PROBLEM WOUND
Accelerated senescence, diminishedproduction of growth factors, collagen,matrix, decreased ability to survive AGEhypoxic stress,Aging is irreversible: optimization of the systemicparameters & supplementation is the solution
ISCHEMIA Damage to the small vessels in the wound leads to hypoxia of the woundrelative to the normal tissue(25mmHg vs 40mmHg), this hypoxia becomes chronic due to peri-wound fibrosis in problem wounds.
ISCHEMIAReduction of peripheralvascular resistance
ISCHEMIAWarmth: Vasodilates thevessels
BACTERIABacterial inoculum & virality,presence of foreign bodies,determines the severity of thewoundBacteria: Set up free radiclesenvironment, secrets toxins &proteases----bystander damage
BACTERIANever forget to use topicalantibiotics ‘cuase peri-woundfibrosis restricts the the deliveryof systemic antibiotics Indications for antibiotics: Venousstasis ulcers, lymphangitis, cellulitis, critical colonization of the wound, infection (straw color oozing, pain),
Debridement : without debridement wound isexposed to cytotoxic stressors & competeswith the bacteria for scarce oxygen & nutritionresources, debridement reduces the bioburdenand help ensure healing
Eschar : should be excised: Many surgeons stillconsider it as a biological dressing & believesin healing under eschar. Proteinaceous escharacts as meal for bacteria.
Enzymatic wound debridement
Autolytic debridement: throughthe action of the leukocytes i.e.hydrocollides
Pressurized water jetmachamical debrider(VersaJet)
Adjuvents in management….?
NEGATIVE PRESSURE WOUND THERAPY Tremendous adjuvent for wound closure Mechanism: relieves edema, removes deletriousPrecautions: the enzymes, exudates, basponge should not be cterial load, cyclicalplaced on normal compression &skin, use of optimal relaxation stimulatesnegative pressure of mechanotransductive125mmHg pathway of growth factors.
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
DRESSINGSGoals: to clean the wound, creat moist healingenvironment to facilitate cell migration &prevent dessicationParadigm shift: from moist to dry dressing tomoist dressing.
CHOICE OF DRESSING IS BASED ON QUANTITY OF EXUDATEHydrogel/films/composite dressings: ;used forlight exudating woundsHydrocollides are used for moderatequantities of exudation.Alginates/foams/NPWT: usefull for heavyexudation.
GauzeAdvantages: Traditional first choice used formoist to dry dressing, low materialexpense, easily availble, excellent as surgicalbandage for uncomplicated.Dis advantages: moist to dry dressings aretraumatizing as gauze is non-selectivedebrider causing significant bystanderdamage, leaves behind fine microfibers whichare irritants and source of infection.Impregnated gauze with petrolium, iodinatedcompounds for moist dressing is availablehaving comparable results with the moderndressings.
Semiocclusive DressingsUnpermeable to fluids to keep moistenvironment, permit of gas molecules.To cover freshly closed incisions, skingraft donor site. Should not be used forcontaminated wounds .
Hydrogel dressing:Autolytic debridement by rehydratingthe wound and facilitat healing. Usedin wound with small amount ofeschar and predisposed todessication, infected wounds, requiresecondary dressing on top of it.
Foam dressingHighly absorptive and acts like a wickmaking it useful in highly exudativewounds.
Alginates useful inwounds with significantexudated fluids, they canabsorb fluids 20 times theirdry weight, not to be used onnonexudative wounds as theywill dry up the wound. If usedfor dry wound they should behydrated with saline prior toapplication
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
Antimicrobial dressingsMost benefical agent is Silver, broad spectrumantimicrobial agent including VRE, MRSA.
Cadexomer iodineSlow release iodine for cosistentbactericidal levels without thewound cell damaging effects seenwith pyodine-iodine products
Management of simple& complex wounds….??
Thorough wound wash Debridement of the necrosed margins, conservatively on the face, Layered closure to obliteration the dead spaceNo skin stiches untill skin margins are <2mm apart by applying intradermal suturesUse of fine monofilament sutures with carefull handling of the skin margins.
Timely removal of the sutures, andapplication of the scar modification measurements ensures a fine scare…..
Elective surgery patients areadvised to refrain from strenousactivity for at least 6 weeks
Management ofproblem wound…?
Decreases angiogenesis, collagen deposition, cellularproliferation, prone to infectionPatients should receive Vit-A (25000IU/day PO or200000 IU topically TDS)Goal should be to maintain a clean wound withminimal bacterial colonization
IrradiatedwoundsProgressive endarteritisobliterans, microvasculardamag, fibrotic changesleading to ischemia, prone toinfection.Needs very carefulldebridement, antimicrobialmoist dressing whilepromoting autolysis are idealfor these wounds.Hyperbaric oxygen therapyand growth factors are alsouseful adjuvents. Usuallyneeds flap coverage.
PressuresoresPatients are usuallymalnourished andnutritional uplift isnecessory in thesepatients along withthe administration ofgrowth hormones oranabolic steroids(oxandrolone) tocounteract thecatabolic s state of thepatients
Pressure soresThey needs thorough multiple sessions of debridements andultimately 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.
PressuresoresThe spasm of thepatients should berelieved non-surgically(benzodiazipins,dantrolen e.t.c.) orsurgically.Use of pressurerelieving devices arehelpful in healingand preventingrecurrence.
Diabetic woundsCombination of microangiopathic, neuropathic andpressure necrosis ulcers. Thorough serial debridement , glucose control, pressureoffloading, revascularization, nerve decompressioncombination is required.
Venous stasis ulcersCompression therapy is the main stay of theapy i.e.graduated compression stockings (30-40mmHgpressure), contraindicated when ABPI is <0.7 andshloud be used with causion in 0.7-0.9.Supplementary dressing depending upon theamount of exudate is used. When edema subsidesthen the wounds are closed & compression therapycontiued post-op for several weeks.Ulcers resistant to compression therapy shouldundergo venous insufficiency studies. Thesuperficial/perforators insufficiency is the idicationfor vascular surgery.