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Wound Care: From then to now


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Wound Care: From then to now

  1. 1. Wound Care:From then to now
  2. 2. Objectives Discuss changes in theories of treatment in wound care and implications to current wound care practice. Review good wound care practice and implications as related to regulatory changes. Review types of wound debridement. Discuss list indications and contraindications for wound dressings.
  3. 3. Evolution of wound care dressings… 1948: “Experiments with occlusive dressings of a new plastic” by JP Bull  Discussed properties of a nylon derivative film  Water vapor permeability made it suitable for wound dressings  Also noted that the presence of a variety of organisms was reduced or disappeared
  4. 4. Evolution of wound care dressings… 1963 (Hinman): “Effects of air exposure and occlusion of experimental human skin wounds”  Useda sterile polyethylene film in artificially made wounds on health adult male volunteers  Wounds were either occluded or allowed to heal open to air  Results:Wounds healing under moist conditions healed 50% faster than wounds open to air Winters, CD Nature 1962
  5. 5. Where we’re going…Traditional dressings:• Gauze, lint and fiber products• Hydrocolloids Look how far we’ve come!!!
  6. 6. Wet to Dry Gauze: Why not?
  7. 7. Disadvantages of wet to dry: AHRQ Pressure Ulcer Guidelines  Wet-to-dry implies gauze is applied moist and removed when dry.Problems?  W/D gauze dressings as a form of mechanical debridement are “non-selective” and,  …are rarely applied correctly  …may cause pain on removal  …may be more costly in terms of labor and supplies  …may cause maceration of skin surrounding the wound  …may release airborne organisms (cross contamination)
  8. 8. What else??? Moistening gauze that is adhered  Primary objective is lost Gauze fibers can be left in wound Moist wound healing is an industry standard: known to improve healing rate  Winter’s research (1960’s) • Moist wounds healed 2x as fast as wounds allowed to dry
  9. 9. What else???  Inconsistency with application  Moisture levels vary with clinicians  Wet to moist may dry out and become wet to dry  Drying gauze has a cooling effect on tissue  Gauze: 77-81 degrees in wound bed  Films/foams: 91-95 degrees in wound bed vasoconstriction, hypoxia, impairment of phagocytic efficiencyOvington, L Hanging Wet to Dry Out to Dry. Home HelathCare Nurse. 2001; 19(8), 477-483
  10. 10. There’s more?  Gauze dressings present no bacterial barrier  Lawrence (1994): 64 layers of dry gauze allowed bacterial penetration  Hutchison (1989,1993): Moistened gauze presents less barrier  Hutchison (1990): Review of 3047 wounds showed the following infection rate: • 2.6% for those dressed with moisture- retentive dressings • 7.1% for those dressed with gauzeOvington, L Hanging Wet to Dry Out to Dry. Home HelathCare Nurse. 2001; 19(8), 477-483
  11. 11. Cost of Wound Care Cost of dry gauze and ancillary supplies  $.47 per dressing change Cost of hydrocolloid and ancillary supplies  $6.15 per dressing change Daily Cost (dressing cost + clinician cost)  Dry gauze $12.26  Hydrocolloid $3.55
  12. 12. How should we select dressings? Autolytic Fillers PrimaryHydrating Non-adhesive Active Absorbing Secondary Enzymatic
  13. 13. Wound Management Priorities Reduce or eliminate causative factors Provide systemic support for healing Apply appropriate topical therapy  Debride - remove necrotic tissue  Identify and eliminate infection  Fill dead space - lightly  Absorb excess exudate  Maintain moist wound surface  Open closed wound edges  Protect from trauma and pain  Insulate
  14. 14. Selecting Dressings○ Keeps the wound bed moist ○ Prevents both maceration & desiccation ○ Offers good Moisture Vapor Transmission Rate○ Minimizes peri-wound maceration○ Protects the peri-wound skin○ Eliminates dead space○ Assures packing will stay in place○ Minimizes pain○ Assures stable environment○ Provides thermal insulation○ Always consider caregiver time
  15. 15. Ideal Primary DressingsNeed to be compatible with the wound: May be hydrating or absorptive Promote/maintain moist, healing environment Provide for “breathability” (MVTR) Provide insulation Impermeable to microrganisms  minimize contamination from outside Atraumatic to the wound/periwound area Cost effective
  16. 16. Ideal Secondary DressingsNeed to be compatible with the wound: Absorb exudate Provide moisture to wound Promote autolysis (debridement) May be used in infected wounds Be atraumatic to wound/periwound  Minimize adherence  Minimize movement  Minimize stripping Cost effective
  17. 17. Foams Benefits:  Bordered and un-bordered  Provide a moist environment  High absorbency  Conformable, may be cut to size  Thermal insulation  No residue  MVTR  No adherence to wound bed
  18. 18. Foams Indications:  Superficial and full thickness wounds  Skin grafts, donor sites, burns, skin tears  Under compression for LE ulcers Contraindications:  Dry wounds Examples: Mepilex (Border), Allevyn (Plus Adhesive), Polymem, Biatain
  19. 19. Films Benefits:  Provide a moist environment  Enable autolytic debridement  Provide protection from extraneous forces (microbes, friction, shear, chemicals)  High MVTR  Conformable
  20. 20. Films Indications:  Minor injuries (abrasions)  Post-op dressing over sutures  IV sites Contraindications:  High exudate wounds  Fragile skin Examples: Tegaderm, Opsite
  21. 21. Alginates/Hydrofibers Benefits:  Provide a moist environment  High absorptive capacity  Conformable/cuttable (rope or sheet form)  Provide hemostasis  No adherence to moist wound bed
  22. 22. Alginates/Hydrofibers Indications:  Highly exuding wounds  Infected wounds (change daily) Contraindications:  Dry wounds or wound with eschar Aquacel, Melgisorb, Seasorb, Kaltostat
  23. 23. Hydrogels Benefits:  Promote a moist environment  Donate moisture to dry wounds  Aid in autolytic debridement (rehydrate/soften necrotic tissue)
  24. 24. Hydrogels Indications:  Drywounds  Wounds with slough wounds  Wounds with eschar  Over tissues and tendons to prevent drying Contraindications:  High exudate wounds Examples: Solosite, Woun’ Dress, SkinTegrity
  25. 25. Silicone Chemically inert, adverse effects rare Designed to be removed without trauma or pain Protect friable or newly healed tissue from injury Less trauma to periwound Examples: Mepilex, Allevyn Gentle
  26. 26. Enzymatic Debriders January 1, 2008 DESI drug changes Medicare Part D: Reimbursement  Limitedfor products which contain papain/urea/chlorophyllin complex sodium What does that mean??  Increased cost to the patient
  27. 27. Enzymatic DebridersAlternatives Uses chemicals to break-down and digest necrotic tissue Must know mechanism of action to be effective Examples: Hypertonic saline, Enzymes, Honey
  28. 28. Antimicrobials Bact er i oci dal :  Si l ver  Honey  Cadexom er i odi ne Bact er i ost at i c:  M hyl ene Bl ue and Gent i an Vi ol et et  Xer of or m
  29. 29. Silver Antimicrobial action through (+) silver ion Effective when in contact with wound fluid Consider:  Kill rate AND sustained release rate  Testing Methods: Simulated wound fluid, saline Delivery methods: foams, gels, alginates, hydrofibers, creams  (SSD - approved for burns, only)
  30. 30. How does silver work?Bacteria elimination: 3 ways• Cell wall rupture• Prevents respiration or nutrient processing• Disturbs replicationConclusion:• Silver resistance unlikely silver secondary to 3 mechanisms• No cases of bacterial resistance to silver in vivo.
  31. 31. Antiseptics (+) Destroy or inhibit growth of microorganisms  Efficacyon intact skin widely known and accepted (+) Resistance significantly less than antibiotics (-) In vitro cytotoxicity to cells of healing  AHRQ: Caution against use  NPUAP/EPUAP: Limited use to control bacterial bioburden
  32. 32. Antiseptics Hydrogen peroxide Acetic acid  Effective against Pseudomonas aeruginosa Diguanides (Chlorhexidine) Sodium hypochlorite (Dakin’s)  Notrecommended unless suitable are unavailable Povidone Iodine
  33. 33. CollagenUsually Type I bovine or avian or type IIIporcine collagen Benefits:  May accelerate wound healing  Slight absorption  May be used with topical agents Examples: Biostep, Fibracol, Puracol
  34. 34. Collagen Indications:  Partial & full thickness wounds  Minimal to moderate drainage Contraindications:  Eschar covered  Full thickness burns  Sensitivity to contents
  35. 35. Bioengineered ProductsGrowth Factor Preparations Regranex® PDGF preparation in a hydrogelSingle-Layered Tissue Dermagraft® Human fibroblasts on matrix meshBilayered Tissue Apligraf® Human fibroblasts and keratinocytes in a bovine collagen matrix.
  36. 36. Bioengineered ProductsProcessed Tissue Primatrix® Acellular collagen dermis (fetal bovine origin) Oasis® Acellular bovine graft (Bovine Small Intestinal Submucosa)
  37. 37.  Who makes it?  Organogenesis, Inc What is it?  Dermal layer: human fibroblasts from neonatal foreskin in a bovine Type I collagen matrix  Epidermal layer: human keratinocytes What does it do?  Accelerates wound repair by secreting important cells and proteins (GF and cytokines) Indications: Venous Leg Ulcers and DM Foot Ulcers
  38. 38.  Who makes it?  Advanced BioHealing, Inc What is it?  Human fibroblast (neonatal foreskin) derived dermal substitute  Contains fibroblasts, ECM and bioabsorbable scaffold How does it work?  Assists in the restoration of the dermal bed  Fibroblasts proliferate to fill the interstices of the scaffold and secrete human dermal collagen, matrix proteins, GF, and cytokines to create a 3-dimensional human dermal substitue Indications: Full thickness DM > 6 wks duration without tendon, muscle, joint capsule or bone exposure
  39. 39. Graft Jacket Who makes it?  Wright Medical Technology, Inc What is it?  Donated human skin  Removed the dermal and epidermal cells but preserved bioactive components (proteins, blood vessel channels) and structure What does it do?  A 3-dimensional scaffold to support the body’s own natural repair process of cellular repopulation and vascularization  Supports regeneration of host tissue Indications: DM
  40. 40.  Who makes it?  Healthpoint, Ltd What is it?  Extracellular matrix composed of porcine small intestinal submucosa (SIS) How does it work?  Provides a matrix for tissue repair  Placed onto wound, cells/nutrients from adjacent tissues invade the matrix, capillary growth ensues  New tissue formation by the body itself Indications: Partial and full thickness wounds, PrU, Venous ulcers, chronic vascular ulcers, DM, traumatic wounds, draining wounds, surgical wounds
  41. 41. In Conclusion Determine wound cause and address Establish plan of care that includes dressings that will address principles of moist wound healing Assure pain is addressed  Through pharmacologic and non- pharmacologic methods