The document discusses wound bed preparation for chronic wounds. It outlines the 4 stages of wound healing and local, regional, and systemic causes of non-healing ulcers. Key aspects of wound bed preparation include debridement to remove necrotic tissue and slough through methods like surgical, biological, autolytic, or enzymatic. Maintaining appropriate moisture, controlling infection, and addressing any underlying causes are also important for wound healing. The goal of wound bed preparation is to create an environment suitable for granulation and re-epithelialization.

1. Wound Bed
Preparation
Dr Joel Arudchelvam
MBBS (COL), MD (SUR). MRCS (ENG), FCSSL
Consultant Vascular and Transplant Surgeon,
Senior lecturer, department of Surgery, faculty of medicine, University of
Colombo.
South Asian Regional Conference of Dermatology 2023

2. Chronic wounds
A wound does not show signs of healing by 3
months*
Halim AS, Khoo TL, Saad AZ. Wound bed preparation from a clinical perspective. Indian J Plast Surg. 2012 May;45(2):193-202. doi:
10.4103/0970-0358.101277. PMID: 23162216; PMCID: PMC3495367.

3. Wound healing
4 stages
o Haematoma formation
o Inflammation/ debridment
o Proliferation /granulation formation
o Remodelling / maturation

8. Causes for non-healing ulcers
o Local causes
o Regional causes
o Systemic causes

9. Causes for non-healing ulcers
Local causes
o Presence of
necrotic tissue,
slough
o Ongoing infection
/ osteomyelitis
o
o Biofilm

10. Necrotic Tissue / slough
o Acts as a nidus for
Bacteria
o Bacteria
o Produce
metalloproteinases
o Compete for oxygen,
nutrients

12. Osteomyelitis

13. Causes for non-healing
ulcers
Regional causes
o Venous
o Arterial (ischemiac)
o Neuropathic

14. Causes for non-healing ulcers
Systemic causes
o Diseases- diabetes mellitus, CKD,
immunodeficiency, etc.
o Drugs- immunosuppressive, cytotoxic
o Nutritional deficiencies- hypo-albuminaemia,
anaemia, vitamin and mineral deficiencies

15. Treatment for chronic ulcers
o Local
o Regional
o Systemic

16. Wound bed preparation
o Process of making the wound base is
suitable for future granulation and
epithelialisation
o TIME concept - introduced in 2000
o TIME component
o Tissue management
o Inflammation / infection control
o Moisture balance
o Epithelial (edge)

17. Treatment for chronic
ulcers
Local
Wound toilet / Debridement
o Process of removal of slough, dead
tissue and draining pus.
o Following a wound toilet the wound
base is made suitable for future
granulation and epithelialisation.

18. Wound debridement types
o Surgical
o Biological methods
o Autolytic
o Enzymatic

19. Wound debridement types
o Surgical method
o Fastest method
o Allows the accurate assessment extent of the wound

20. Biological debridement
o Green bottle fly larvae (Lucila serricata)
o Consume necrotic tissue / slough
o Efficient against MRSA and beta haemolytic
streptococcus

21. Autolytic debridement
o Necrotic tissue is removed by endogenous
enzymes or phagocytic cells
o Slow
o Risk of infection

22. Enzymatic debridement
Uses enzymes
o Collagenase
o Papain

23. Treatment for chronic
ulcers
Regional causes
o Arterial (ischemic)-
revascularization

24. Treatment for chronic
ulcers
Regional causes
o Venous - Strapping
o i.e. multilayer compression

25. Treatment for chronic
ulcers
Regional causes
o Neuropathic- off loading

26. Treatment for chronic
ulcers
Systemic causes
o Correct anaemia, vitamin deficiency and other
nutritional deficiencies
o Optimization of underlying comorbidities

27. Bacterial balance
o Colonization, critical colonization and infection
o Critical colonization - presence of replicating
microorganisms causing tissue damage
o Clinical
o Change in the colour of the wound
o Friable and unhealthy granulation tissue
o Abnormal odour
o Increased exudate
o Pain

28. Critical Colonisation

29. Biofilm
o Bacteria with polysaccharide cover
o Resistant of antimicrobials
o Results in intermittent release of bacteria
and wound infection
o Delayed healing

30. Biofilm

31. Infection

32. Role of antibiotics in
chronic wounds
o indicated in patients with evidence of local or
systemic infection
o Topical antibiotics / antiseptics/ silver – for
critical colonisation / biofilm
o No place for log term antibiotics for chronic
wounds

33. Silver Dressings
o Antimicrobial to reduce bio burden of wound
through slow release of silver ion into the
wound
o e.g. Acticoat, Biatin Ag, Atruman Ag

34. Moisture balance
o Maintaining moisture needed for;
o Re-epithelization
o Action of growth factors, cytokines
o For the growth of proliferating cells e.g fibroblasts
o Excessive moisture - counter productive
o Highly exudative wound
o Absorptive dressings e.g foam, hydrocolloid
o Negative pressure wound therapy
o Dry wounds
o Gel Dressings
o Poly urethane Film dressings

35. Gel
Hydro colloid Film
Foam

36. Vacuum assisted closure VAC

37. Vacuum assisted closure VAC
o Macrostrain - reduction in size that occurs when
negative pressure is applied.
o Draws wound edges together
o Removes exudate
o Microstrain - micro deformation at the cellular level
o Reduces edema
o Promotes granulation

38. Epithelial advancement
o Proliferatinng skin cells will not migrate over
necrotic tissue, biofilm, slough and callosity
o Should be removed by debridement
o Control of infection

40. Avoid in chronic wounds
o Iodine (Betadine)
o Hydrogen peroxide
o Other toxic agents

41. Avoid
o Do not apply gauze bandage
tightly around limbs, digits –
causes ischaemia
o Use – plaster , crepe instead

42. Thank You