Mgmt of Chronic wounds II

1. remove old dressings
2. assess wound
3. irrigate wound (prn)
4. debride/apply physical agent to wound (prn)
5. re-assess (prn)
6. apply new topical dressing with any topical medications
7. document procedure

1. manage the exudate/hydration (moist but not too wet)
2. remove necrotic tissue
3. prevent/reduce infection
4. prevent repeated trauma
5. good nutrition
6. optimize appropriate wound phase responses

1. failure to reverse the cause (repeated trauma, excessive bioburden d/t infection/biofilm)
2. poor perfusion/nutrition of oxygen
3. excessive or insufficient mediators of wound phase (inflammatory mediators, proteases, growth factors, cell types, etc.)

1. too dry
- add moisture

2. too wet
- wick it away

3. necrotic tissue present
- remove it

4. protect wound
- remove traumatic stimuli
- minimize risk of further injury

5. Infection present
- treat it
- do not seal a wound that is infected
- avoid over utilization of antibiotics

1. debridement
2. dressings
3. physical agents
4. education/pt. mgmt

1. primary- remove necrotic tissue
2. secondary- max. appropriate wound phase, moisture mgmt, infection ctrl.

primary- moisture mgmt

secondary- protect from trauma; treat/ctrl infection; remove necrotic tissue; good nutrition

primary- max wound phase

secondary- infection ctrl; good nutrition; remove necrotic tissue

primary- protect from trauma

secondary- good nutrition; moisture mgmt; infection ctrl

1. mechanical (sharp, blunt, etc.)
2. autolytic
3. enzymatic
4. biological debridement

1. sharp (scoring/cross hatching, "pick and snip" shaving)
2. blunt (other tools, gauze, forceps, etc.)
3. whirlpool
4. waterpik
5. pulsed lavage
6. low-frequency US (MIST)

1. occlusive dressings
2. semi-occlusive dressings

1. accuzyme
2. travase
3. elase
4. panofil
5. santyl (only one left on market?)

1. larval debridement (maggots)

1. non-selective, mechanical debridement
2. remove loosely adherent devitalized tissue
3. soften necrotic tissue
4. hydrate wound bed
5. promote moist wound healing
6. promote circulation (but won't cure)
7. soak adherent dressings off
8. decreases pain

1. contraindicated for Venous Statis wounds
- causes increased edema in dependent pos'n in warm environment resulting in vasodilation

2. contraindicated if granulation tissue is present
- whirlpool additives all have some degree of cytotoxicity (Hibiclens, bleach, chlorazene)

3. questionable use in cellulitis (systemic antibiotics=gold standard)

4. Risk of contamination of wounds (perineal area, cross-contamination if multiple wounds, patient to patient)

C- no studies ongoing found in current literature research

1. 97597- selective debridement ($45-51 per session)
- removal of devitalized tissue from wound(s), selective debridement, without anesthesia (ex- high pressure water jet, with/without suction, sharp selective debridement with scissors, scalpel and forceps), with or without topical application(s), wound assessment, and instruction(s) for ongoing care, may include whirlpool, per session: total surface area less than or equal to 20 sq. cm

2. 97598- selective debridement ($63-69 per session)
- total wound(s) surface area greater than 20 sq. cm

1. remove debris that supports bacteria and delays healing
2. use appropriate pressure
- safe psi= 4-15 psi (below 4 psi is ineffective)
- spray bottle=1.2 psi
- bulb syringe=2.0 psi
- piston irrigation syringe (60 mL) with catheter tip= 4.2 psi
- saline squeeze bottle (250 mL) with irrigation cap= 4.5 psi
- 35 mL syringe with 19 gauge needle= 8.0 psi
3. use appropriate solution
- normal saline
- avoid skin cleansers or antiseptic agents

1. aka Pulsavac (not wound-vac)
2. debridement and irrigation (paid under selective debridement code)
- ctrl amt of pressure to reduce trauma
- suction produces mechanical distortion of cell facilitating cellular division
- intermittent pressure increases circulation
- suction removes debris
- safe effective irrigation pressures range from 4-15 psi

C- some studies ongoing

1. debridement through cavitation and acoustic streaming
2. destruction of biofilms, bacteria, viruses and fungi
3. less painful then other mechanical or sharp debridement techniques

Types- MIST, Arobella, Soneca

Method:
1. non-contact and contact (curett-style soundhead)
2. frequency 25-40kHz
- low in comparison to US in clinic 1-3 MHz

1. primary (on wound bed) and secondary (over primary)

Dressing categories:
- hydrocolloid (autolytic)
- transparent (autolytic)
- foam dressings
- alginate dressings
- hydrogel dressing (autolytic)

3. continuum of occlusion and absorption

1. autolytic
2. absorbs moisture
3. occlusive
4. may need to change regularly (occasionally see a hydrocolloid powder placed in wound)
5. may be better to use in combination (hydrocolloid secondary/outside layer; alginate primary/inner layer; with a skin sealant surrounding wound)

1. autolytic
2. semi-occlusive
3. no-absorption (better used in dry, AI wounds)

1. absorb moisture (hydrophillic inside, hydrophobic outside)
2. however, you need to make sure you get all of it out of wound bed when changing
3. also need to add layers to properly fit wound
4. if the foam is non-adhesive, it requires a secondary dressing to keep it in place

1. maximum absorption
2. requires a secondary dressing to keep in place
3. react with serum and wound exudate to form a hydrophilic gel, providing a moist wound environment and may trap bacteria
4. highly permeable, non-occlusive

1. autolytic
2. non-occlusive
3. worry about abcess and allowing site for bacteria (poor bacterial barriers)
4. able to absorb min. amt. of fluid by swelling
5. available in sheets, amorphous gels, or impregnated gauzes
6. able to donate moisture to dry wounds (moisture retentive); reduce pressure
7. minimally adherent, requires secondary dressing

1. use occlusive dressing (hydrocolloid, etc.) to take advantage of wound fluid
- use dressing to seal in wound, allowing for wound to stay moist, and letting nature take its course
- autolytic approach

2. healthy wound fluid contains optimal ratios of endogenous chemicals (enzymes, cytokines, growth factors)

3. exudate highest during inflammatory phase and increases (may need more absorbant to address exudate rates)
- increased by infection and as necrotic tissue is being lysed

Balance moisture in wound base

1. manage exudates:
- absorptive dressing in wound bed (alginate, etc.)
- moisture barrier (skin sealant) on periwound, protecting from wound's moisture

2. Dry wound:
- moisture donating dressing in wound (hydrogel, etc.)
- moisture for periwound and surrounding skin

avoid maceration of surrounding skin

skin prep- alcohol based, prepares for adherence

skin barrier- emollient

skin sealer- polyuerthane layer; prevents moisture from reaching skin layer

op site, tegaderm- moisture barrier, to protect skin from tearing with dressing changes (push skin away from tape, not vice versa)

1. eliminate living organisms
2. have limited absorption (probably increased inflammation and increased exudate)
3. types:
- bacitracin (Cortisporin, Neosporin, Polysporin)
- Gentamicin (Garamycin)
- Metronidazole gel and cream (MetroGel, MetroCream, Noritate)
- Mupriocin
- Silver Sulfadiazine (Silvadene, SSD)

1. a common ingredient in many dressings PTs apply
2. silver is a potent, natural antibacterial agent
3. very little resistance to silver
4. however, you do not want to mix silver sulfadiazine (antibacterial dressing) with silver nitrate (used in burns that produced hypergranulation, causing a chemical burn to area)

1. prevent build up (slow release of silver or iodine dressings)
2. types of dressings:
- most can be available with silver
- cadexemer iodine
- aquacel Ag

1. silver
2. broad-spectrum antiseptic agents
3. (however, do not use with enyzmatic dressing (santyl) because it will interfere with enzyme process--- heavy metal inactivates enzyme; autogenic inhibitor)

1. broad-spectrum antiseptic agents
2. interaction with wound fluid causes release of silver

1. kills MRSA, VRE, fungi, but also kills fibroblasts and epithelial cells
2. be careful how you use (timing very important)

1. usually a narrow spectrum (antiseptics?)
2. types:
- nystatin (mycostatin)
- ketoconazol (Nizoral)
- Micoazole nitrate (Monistat-Derm)

Signs and symptoms:
1. no progress (not weeping, granulation present but no changes, etc.)-- may have biofilm
2. looks clean and healthy
3. looks anemic

mgmt:
1. frequent debridement
2. may be the best candidates for appropriate cytokine/GF therapies

1. only FDA approved GF for use in chronic wounds is Regranex (PDGF)
2. dosage important
3. timing is critical
- use when base is clear of necrosis (application in senescent wound)
- stop when satisfactory grnulation is present (can cause hypergranulation)