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War on WoundsLINDSAY HESTER, FNP

UNIVERSITY SURGICAL ASSOCIATES

VASCULAR SURGERY

LINDSAY.HESTER@UNIVERSITYSURGICAL.COM

No DisclosuresNot an advertisementNo financial ties

Cost of Wounds

Medicare Spending per

beneficiary 2014

Arterial $9-13K

Chronic $1-5K

DFU $1-11K

Pressure Ulcer $4-21K

Surgical $3-14K

Venous $1-2KAnnual Medicare Spending

ALL Wound Types

$28-$31-$96 BILLION (1)

15% Medicare beneficiaries

8.2 million patients

one type of wound

The Wound Care Market

Global Advanced Wound Care Market estimation

for 2022: $13-19 Billion

Engineered Skin Substitute Market $600 million 2017, estimated $1.39 billion by 2026 (Finance Industry News-April 2018)

Largest: Chronic wound market

Diabetic foot ulcer

Wound Basics

Key Ingredients to fight wounds

For Healing

• Vascularized

• Free of devitalized tissues

• Clear of infection

• Moist… exceptions to come

Dressing

• Eliminate dead space

• Control exudate

• Prevent bacterial overgrowth

• Proper fluid balance

In General

• Cost-efficient

• Manageable for ptsupport

• Location appropriate

• Antibiotics?

• (3)

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Four Stages of Normal Wound Healing

Wound Healing

Angiogenesis: formation new blood vesselsinitiated by platelets

← ↓

Chronic Wounds arrest in one stage-↓ typically inflammation

(2)

How to heal the

wound???

1ST - KNOW THE TYPE OF

WOUND YOU ARE DEALING

WITH!

& 2ND HOW BAD IS IT?!

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Grading: University of Texas (5)

Grade

Grade 0 Pre or post ulcerative

Grade 1 Full thickness ulcer not

involving tendon, capsule

or bone

Grade 2 Tendon capsular

involvement without bone

palp

Grade 3 Probes to bone

Stage

A Noninfected

B Infected

C Ischemic

D Infected and ischemic

Diabetic Wound

Treatment Options

Revascularization

Debridement

Dressing: clean moist and free excess fluids

Extensive open wounds…negative pressure wound therapy

Skin Grafts & Skin Substitutes

Hyperbaric Oxygen Therapy

Pressure reduction with mechanical offloading

Successful: 40-50% wound reduction four weeks

(5)

Non-invasive Assessments

Revascularization Needed?

ABIs DM: misleading, falsely elevated values

▪ Gen population <0.5 WH unlikely

Toe Pressure normal 60mHg

▪ Non DM >30mmHg WH

▪ DM >45- 55mmHg WH

TBI normal 0.7-0.8

TcPO2 Foot level 60mmHg, ~50mmHg for DM

▪ 20-30mmHg predictive of chronic WH complications

SPP: >30mmHg required for WH

Compression stocking contraindicated ABI <0.5 (10)

Revascularization

Longitudinal study 564 of DFU and severe limb ischemia (2009)

Angioplasty 75%

▪ 8.2% amputation rate

Bypass 21%

▪ 21.2% amputation rate

No intervention possible 5%

▪ 59.2%amputation rate (7)

Debridement

Must have adequate blood supply

Devitalized, infected tissue

Chronic Wound: serial debridement

Allows for specialized wound care products

➢ Sharp-appropriate anesthetic

➢ Bedside Grade1 Stage A

➢ Surgical infection or Grade 2-3 Stage A

➢ Irrigation

➢ Autolytic: uses body’s own wound fluid: hydrogel sheet, semipermeable foam, hydrocolloid

➢ Enzymatic: collagenase $ (3)

Dressings

Infectious Moisture Balance

Silver Alginates

Iodine hydrocolloids

Honey Films

Methylene Blue

Negative Pressure Wound Vac

Extensive open wounds following debridement

Randomized control trail 342pts (2008)- improved full resolution closure achieved when used(11).

Contraindications

▪ *Exposed organs, blood vessels, vascular grafts= tissue erosion-white sponge

▪ Devitalized tissue

▪ Ongoing infection

▪ ? ischemic wound-REVASCULARIZE

Maintenance of this device (5)

Growth Factors

Tissue GF promote cellular proliferation and angiogenesis

= improved ulcer healing

UpToDate systematic review of 28 trails and 11 different GT

▪ Quality of trails low, bias high

UpToDate meta-analysis of 12 trials any GF vs placebo or no GF showed significant increase in complete wound healing-mostly platelet derived & recombinant human platelet derived

Platelet derived GF as a gel preparation is approved by FDA for adjunctive therapy for DFU

▪ While effective- high cost, concern increased mortality secondary to malignancy when treated with three or more tubes(5)

Hyperbaric Oxygen Therapy

Increase tissue oxygen levels, fibroblast proliferation, angiogenesis, augments neutrophil bactericidal activity= wound healing

Pressurized chamber at 2-3 times the normal atmospheric pressure while breathing in 100%pure oxygen↑ O2 dissolved in plasma

Who can do it? monitor TcPO2 at RA then at 100% O2

▪ >100mmHg potential benefit from HBOT (9)

Questionable studies

▪ Longitudinal cohort 6259 patient DMFU with adequate arterial perfusion with HBO did not achieve better wound healing or decrease amputation likelihood (13.)

▪ 70pt trail with ischemic foot ulcer: HBO amputation rate 9%, control 33% (9)

HBOT Cost

$150-$350 per session: average $10K for total therapy sessions

$100 clinic v $1K and up in hospital setting

Medicare B Coverage: Diabetic wounds of the lower extremities if all of these apply:

▪ Type 1 or Type 2 diabetes and have a lower extremity wound that’s due to diabetes.

▪ Wound classified as Wagner grade III or higher.

▪ Failed an adequate course of standard wound therapy.

▪ Still pay 20% of the Medicare-approved amount (6)

Osteomyelitis

With or without evidence of local soft tissue infection

Supporting findings

▪ Visible bone or ability to probe to bone

▪ Ulcer >2cm

▪ Ulceration duration longer than one to two weeks

▪ ESR >70mm/h

▪ “Sausage toe”

XrayMRI

Antibiotics? Vs Source Control(12)

Infection and Antibiotics?

Polymicrobial 5-7organisms (12)

Severe: cellulitis, fever, hemodynamic instability, purulent drainage:

▪ broad spectrum, adjust based on C&S results

Mild- Moderate:

▪ systemic aerobic gram +cocci coverage

Hx of MRSA or high local rates:

▪ empiric ABX targeting MRSA (5)

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Infected or clean?

Dressing Goal?

Adjunct therapy?

Assessment finding?

Debridement?

Dressing consideration?

Vascular status?

Wound Products?

Better or worse?

Infection protection?

A B

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Type of

wound?

Toe

Considerations

Don’t lose the war

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Index of References

1.) Nussbaum, S.,Carter, M., Fife, C., DaVanzo,J., Haught, R., Nusgart,M.,Cartwright, D. (2018). An economic evaluation of the impact, cost, and Medicare policy implications of chronic nonhealing wounds. Value in Health, 21(1), 27-32.

2.) Lam, G., Fontaine, R., Ross,F., Kimmel, H., Kimmel, M., Chiu, E. (2017). Hyperbaric oxygen therapy: Exploring the clinical evidence. Advances in Skin and Wound Care. 30(4), 181-190.

3.) Armstrong, D., Meyr, A. (2018). Basic principles of wound management. In:UpToDate.

4.) https://woundeducators.com/wound-debridement-techniques-1-autolytic-debridement/

5.)Armstrong, D., McCulloch, D., Asla, R. (2018). Management of Diabetic Foot Ulcers. In:UpToDate

6.) https://www.medicare.gov/coverage/hyperbaric-oxygen-therapy.html

Index of References pg 2

7.)Faglia E, Clerici G, Clerissi J, Gabrielli L, Losa S, Mantero M, Caminiti M, Curci V, Quarantiello A, Lupattelli T, Morabito A. (2009). Long-term prognosis of diabetic patients with critical limb ischemia: a population-based cohort study. Diabetes Care. 32(5):822.

8.) www.shieldhealthcare.com/community/wp-content/uploads/2015/07/Stages-of-Healing_image.jpg

9.) Mechem, C., Manaker, S.(2018).Hyperbaric oxygen therapy. IN: UpToDate

10.) Mitchell, R. (2018). Noninvasive diagnosis of arterial disease. In: UpToDate.

11.) Walter, B., Ayala, P., Lantis, J. (2008). Comparison of negative pressure wound therapy using vacuum-assisted closure with advanced moist wound therapy in the treatment of diabetic foot ulcers: a multicenter randomized controlled trial. Diabetes Care.31(4):631

12.) Weintrob, A., Sexton, D. (2018). Clinical manifestations, diagnosis, and management of diabetic infections of the lower extremities. In:UpToDate.

13.) Margolis, D. J., Gupta, J., Hoffstad, O., Papdopoulos, M., Glick, H. A., Thom, S. R., & Mitra, N. (2013). Lack of effectiveness of hyperbaric oxygen therapy for the treatment of diabetic foot ulcer and the prevention of amputation: a cohort study. Diabetes Care, 36(7), 1961-1966. doi:10.2337/dc12-2160