dr tongson - treatment and healing of chronic wounds
TRANSCRIPT
Treatment and Healing
Chronic Wounds
Dr. Luinio S. Tongson, FPCS, CWS, MSPH
Wound Care Conference
Singapore
Chronic Wounds
• Wound that does not heal in an orderly
set of stages and in a predictable amount
of time the way most wounds do
• Do not heal within three months(1)
• Often remain in the inflammatory stage for
too long.(2)
1.Mustoe T (March 17–18, 2005). "Dermal ulcer healing: Advances in understanding". Paris, France: EUROCONFERENCES.2.Snyder RJ (2005). "Treatment of nonhealing ulcers with allografts".Clin.Dermatol. 23 (4): 388–95.
Classification
• Majority (1,2)
– Venous ulcers
– Diabetic ulcer
– Pressure ulcers
• Others
– Radiation poisoning
– Ischemia (2)
1. Moreo K. "Understanding and overcoming the challenges of effective case
management for patients with chronic wounds". Case Manager 16 (2): 62–3, 67.
2. Mustoe T. "Understanding chronic wounds: a unifying hypothesis on their
pathogenesis and implications for therapy". Am. J. Surg. 187 (5A): 65S–70S.
Primary Intention
Secondary Intention
Tertiary Intention
Barriers to healing
Exudate Necrosis
Micro-
organisms
Cellular
dysfunctionBiochemical
imbalance
Chronic
contents
Excess
Eschar –
black/dry
Slough –
yellow/wet
Number
Pathoge-
necity
Host
resistance
Wrong
phenotype
Defective
receptors
???
Incorrect
cytokine
expression
Excessive
protease
production
Incomplete
cascades?
Delayed healing Non-healing
“Think WHOLE not HOLE”
Systemic
Factors• Chemotherapy
• Gene damage
• Steroids
Chronic
Wound
Metabolic Factors• Diabetes mellitus
• Renal failure
Nutritional Factors• Proteins
• Minerals
• Vitamins
Local Factors• Pressure
• Infection
• Necrotic tissue
• Dessication
• Chronic exudate
Local Factors that Impede
Wound Healing
• Inadequate blood supply
• Increased skin tension
• Poor surgical apposition
• Wound dehiscence
• Poor venous drainage
• Presence of foreign body &/or reactions
• Infection
• Excess local mobility.
Grey, J., Enoch, S., Harding, K. ABC of wound healing
Wound assessment BMJ. 2006 February 4; 332(7536): 285–288.
Systemic Factors that Impede
Wound Healing
• Advancing age
• Obesity
• Smoking
• Malnutrition
• Systemic malignancy
• Chemotherapy
• Radiotherapy
• Immunosupresive drugs
• Inherited neutrophil and macrophage disorder.
Grey, J., Enoch, S., Harding, K. ABC of wound healing
Wound assessment BMJ. 2006 February 4; 332(7536): 285–288.
Laboratory Investigation
.
Grey, J., Enoch, S., Harding, K. ABC of wound healing
Wound assessment BMJ. 2006 February 4; 332(7536): 285–288.
Treatment Plan
• Review of the
patient's medical
record focusing on
the chronic disease
baseline norms for
the patient.
Broderick ,N,, Understanding chronic wound healing . The Nurse Practitioner:
The American Journal of Primary Health Care. Oct 2009 Vol 34 Num 10 , pp 16 - 22
Treatment Plan
• Review the patient's
current medications to
evaluate if any of the
medications will
inhibit wound healing
Broderick ,N,, Understanding chronic wound healing . The Nurse Practitioner:
The American Journal of Primary Health Care. Oct 2009 Vol 34 Num 10 , pp 16 - 22
Medication that Impair
Wound Healing
• Corticosteroids
• Antiplatelet
• Nonsteroidal anti-inflammatory drugs
• Cytotoxic medications
• Nicotine
• Anticoagulants
• Immunosuppressives
• Anti-RA medications
• VasoconstrictorsBroderick ,N,, Understanding chronic wound healing . The
Nurse Practitioner: The American Journal of Primary Health
Care. Oct 2009 Vol 34 Num 10 , pp 16 - 22
Medication that Enhance
Wound Healing
• Pentoxifylline
• Prostaglandins
• Growth factors
• Sex hormones
• Retinoids
• Phenytoin
• Vitamins A and C
• Zinc
Broderick ,N,, Understanding chronic wound healing . The
Nurse Practitioner: The American Journal of Primary Health
Care. Oct 2009 Vol 34 Num 10 , pp 16 - 22
Treatment Plan
• Basic nutritional assessment would
include body mass index.
• Any indications of malnutrition
– Assessment to include lab tests, a food diary,
or at a minimum, assessment of intake for the
past 24 hours.
• Protein severe illness or large wounds
is 1 to 1.5 g/kg.
. Evans E. Nutritional assessment in chronic wound care
. J Wound Ostomy Continence Nurs. 2005; 32 (5): 317-320.
Treatment Plan
• Nutritional issues become more of a challenge
for the elderly due to decreased appetite.
• Encourage patients to increase their
consumption of proteins and to consume an
appropriate amount of calories.
• Patients with CRF add more challenge to
ensure nutritional intake meets the required
calorie count.
Broderick ,N,, Understanding chronic wound healing . The Nurse Practitioner:
The American Journal of Primary Health Care. Oct 2009 Vol 34 Num 10 , pp 16 - 22
Treatment Plan
• Assessment tool
• Monofilament
– Patients with diabetes
are at risk for
neuropathic changes
as early as 7 years
into the disease which
puts them at risk for
foot ulcers and early
amputation.
Falanga V, Brem H, Ennis WJ, Wolcott R, Gould L, Ayello EA.,. et al.
Maintenance debridement in the treatment of difficult-to-heal chronic wounds.
OWM Supplement. 2008; 1-15
Treatment Plan
• Vascular assessment:
Venous insufficiency VS
Peripheral Arterial
Disease
Broderick ,N,, Understanding chronic wound healing . The Nurse Practitioner:
The American Journal of Primary Health Care. Oct 2009 Vol 34 Num 10 , pp 16 - 22
Slide CVC VS PAD
Treatment Plan: TIME
• Moist wound healing is the gold standard
for wound care.1
• Dry wounds increase the chance of
infection, increases pain, and allows for
poor scar formation.1,2
• Proper dressing choices.
1. JonesV, Harding K. Moist wound healing optimizing the wound environment.
In: Chronic Wound Care: A Clinical Source Book for Healthcare Professionals.
4th ed. Mavern, PA: HMP Communications; 2007: 199-204. [Context Link]
2. Bolton L. Operational definition of moist wound healing. J Wound Ostomy
Continence Nurs. 2007;34 (1):23-29
Treatment Plan: TIME
• Wound assessment
– Cause of the wound
– Drainage
– Wound base appearance
– Periwound skin
– Pain related to the wound and dressing
changes
Broderick ,N,, Understanding chronic wound healing . The Nurse Practitioner:
The American Journal of Primary Health Care. Oct 2009 Vol 34 Num 10 , pp 16 - 22
Treatment Plan
• Evaluation of the patient's level of pain.
– Does the patient only have pain with dressing
changes or is it chronically present in the
wound site area.
• Research: new dressing that contains
ibuprofen* for those patients who are
unable, to take oral pain medications.
• Decreasing dressing changes can reduce
pain. . Gray M. Context for WOC practice. J Wound
Ostomy Continence Nurs. 2009: 36(1):11-13.
Treatment Plan
• Wound bed preparation is central to the
healing process.
• Removal of tissue that is colonized with
biofilm is an essential component of
continuous wound management.
• Debridement is an avenue used to "jump-
start" the wound healing process in a
stalled wound.
Falanga V, Brem H, Ennis WJ, Wolcott R, Gould L, Ayello EA.,. et al. Maintenance debridement in
the treatment of difficult-to-heal chronic wounds. OWM Supplement. 2008; 1-15.
Pathologic Process of
Chronic Wound
• Prolonged inflammatory phase
• Cellular senescence
• Deficiency of growth factor receptor sites
• No initial bleeding event to trigger cascade
• Higher level of proteases
Broderick ,N,, Understanding chronic wound healing . The Nurse Practitioner:
The American Journal of Primary Health Care. Oct 2009 Vol 34 Num 10 , pp 16 - 22
National Clinical Guidelines for Foot Care
– National Electronic Library for Health
• Modern Dressing
– Alginate, foam, hydrogel, hydrocolloid dressing
• 9 Randomized trials
• 2 Controlled trials
• Newer dressing or gels VS gauze dressing
– Moist dressing suggest improved performance over gauze
– Small trial does not provide an adequate evidence base
– Choice of different dressing depend on the type or stage of wound, personal experience, availability of dressing, patient preference and the site of wound
Advance Wound Care Modalities
Growth factor therapyGrowth factors under study
• Vascular endothelial growth factor (VEGF)
• Fibroblast growth factor(FGF)
• Keratinocyte growth factor (KGF)
Advance Wound Care Modalities
Extracellular matrices (Non living)
• Dermal regeneration template (Integra™)
• Allogenic dermal matrix (AlloDerm™)
• Matrix of human dermal fibroblast (TransCyte™)
• Porcine small intestine submucosa (Oasis™)
Negative Pressure Therapy
• Removes edema and
chronic exudate
• Reduces bacterial
colonization
• Enhances formation of
new blood vessels
• Increases cellular
proliferation
• Improves wound
oxygenation Niezgoda JA, Schibly B. Negative-pressure wound therapy (VAC).In: The Wound Management Manual, pp 65-71,edited by B Lee, McGraw-Hill, New York, 2005.
Hyperbaric Oxygen Therapy
• Medicare and Medicaid coverage for HBO:
Wagner grade 3 or
higher that failed
standard wound care
therapy.
• A large multicenterrandomized clinical trial is needed to properly
• test the efficacy of this expensive modality Wunderlich RP, Peters EJ, Lavery LA. Systemic hyperbaric
oxygen therapy: lower-extremity wound healing and the diabetic foot. Diabetes Care 23:1551-1555, 2000.
Bio-engineered Tissue • Randomised 12-week trial of 208 patients
– Bilayered construct comprising living fibroblasts
and keratinocytes from neonatal foreskin
– Complete wound closure in 56% of patients VS
38% in controls.
– Active group had ↓ incidence of osteomyelitis and
amputation 1
• 12-week randomised study with living
foreskin fibroblasts in a vicryl mesh– Complete wound closure of neuropathic foot
ulcers: 30% active group VS 18% control group. 2
Veves A, Falanga V, Armstrong DG, Sabolinski ML. Graftskin, a human skin equivalent, is effective in the management of noninfected neuropathic diabetic foot ulcers: a prospective randomized multicenter clinical trial. Diabetes Care 2001; 24: 290–95. 63 Marston WA, Hanft J, Norwood P, Pollak R. The efficacy and safety of Dermagraft in improving the healing of chronic diabetic foot ulcers: results of a prospective randomized trial. Diabetes Care 2003; 26: 1701–05.
Modified Wagner Classification
of Diabetic Foot
Grade O Skin intact, may have bony deformities or pre-ulcerative lesions
Grade I Localized superficial ulcer
Grade IIA Deep ulcer to tendon, bone, ligament, joint
Grade IIB Same as above, plus infection/cellulitis
Grade IIIA Deep abscess with or without cellulitis
Grade IIIB Osteomyelitis with or without cellulitis
Grade IV Gangrene of toes or forefoot
Grade V Gangrene of whole foot
Wagner FW Jr. The diabetic foot. Orthopedics 1987;10:163-72.
Wagner Grade 0
• Action
• Foot Care
Education
Wagner Grade 1
• Action
• Freedom from weight
bearing
• Local wound care
• Antibiotics for cellulitis
Common Methods to
“Off-Load” the Foot• Non Weight Bearing
– Bed rest
– Wheel chair
– Crutch assisted gait• Mechanical Off loading
– Total contact cast
– Felted foam
– “Half shoes”
– Therapeutic shoes
– Custom splints
– Removable cast walkers
Wagner Grade 2
• Action
• Bed rest
• Glycemic control
• Wound cultures
• Antibiotics
• Foot x-ray
• +/- Doppler studies
• Debridement if indicated
Wagner Grade 3
• Action
• Bed rest
• Glycemic control
• Hospitalization
• Wound culture
• Parenteral antibiotic
• Debridement
• +/- Bypass surgery
• Amputation if indicated
Wagner Grade 4
• Action• Bed rest
• Glycemic control
• Admit to hospital
• Wound culture
• Parenteral antibiotic
• Debridement
• +/- Bypass surgery
• Amputation if indicated
Indication for Amputation
• Primary Amputation
– Unreconstructable arterial occlusive disease
– Necrosis of significant areas of weight bearing
portion of the foot
– Fixed, unremediable flexion contracture of the
leg
– Very limited life expectancy because of co-
morbid conditions
Treatment of CLI, Journal of Vascular Surgery,
S 267-268; Jan 2000
Indication for Amputation
• Secondary amputation
– Unreconstructable vascular disease
– Persistent infection despite aggressive
vascular reconstruction
Treatment of CLI, Journal of Vascular Surgery,
S 267-268; Jan 2000
Amputation
If unavoidable, aim for the
most distal amputation
that will heal and return
the patient to optimal
function.
ADA Consensus Development Conference, 1999
Wagner Grade 5
• Action
• Same as Grade 4
• Major
Amputation
Indication for Major Amputation
in Diabetic Foot
Absolute
•Life threatening sepsis
• Massive foot necrosis
• Wagner 5 lesion
Indications for Amputation
Relative
• Strong behavioral overtones
– Major non-compliance
• Significant neuropathy
• Economics
What is a pressure ulcer?
• Defined as:
an area of localised damage to the skin and
underlying tissue caused by pressure, shear,
friction and/or a combination of theseEuropean Pressure Ulcer Advisory Panel EPUAP (2003)
• “bed sores”, “pressure damage”, “pressure
injuries” and “decubitus ulcers”
How does that ulcer form?
Decubitus ulcer
Pressure
Impaired blood flow
Decreased oxygen delivery
Local tissue injury
Necrosis
“At Risk” of Pressure Ulcer
• Anyone with limited mobility
– Generally poor health or weakness
– Paralysis
– Injury or illness that requires bed
rest or wheelchair use
– Recovery after surgery
– Sedation
– Coma
The doctor of the future will give no
medicine, but will interest her or his
patients in the care of the human
frame, in a proper diet, and in the
cause and PREVENTION of
disease.
Thomas Edison
Pressure Prevention
Risk Assessment upon admission
Admission interventions for each selected risk factor
Admit & daily skin exams documented for at-risk population
Quality
Improvement/
Monitor Program
RiskEarly
Care Plan
Daily skin
check
Pressure Ulcer Prevention
Risk Factors of Pressure Ulcers
Pressure
Shearing
Friction
Level of mobility
Sensory impairment
Continence
Level of consciousness
Acute, chronic and
terminal illness
• Comorbidity
• Posture
• Cognition,
psychological
status
• Previous pressure
damage
• Extremes of age
• Nutrition and
hydration status
• Moisture to the skin
Role of A Nurse
Pressure Ulcer
Cost Effective
Quality and Safety Care
Better Care
Outcome
Improve and Best
Practice
Preventive Interventions
Feedback
Risk Assessment upon admission
Admission treatment order based on current standards or product guidelines
Weekly assessments
Quality
Improvement/
Monitor Program
Admit
assessment
Treatment
plan
Weekly
re-assess
Pressure Ulcer Treatment
Key priorities for implementation
• Patients with a grade 1−2 pressure
ulcer should:
−as a minimum provision be placed
on a high specification foam
mattress/cushion, and
−be closely observed for skin
changes
Key priorities for implementation
• Patients with grade 3−4 pressure ulcers
should:
− as a minimum provision be placed on a
high specification foam mattress with an
alternating pressure overlay, or
− a sophisticated continuous low pressure
system
− the optimum wound healing environment
should be created by using modern
dressings
Management of Ulcers
• Wound Care
– debridement
– wound cleansing
– dressings
– adjuvant therapies
• Pressure reduction
• Risk factors addressed
– Continence care
– Nutritional improvement
– Mobility
• Consider operative repair
Referral to surgeon
Depending on:
• Failure of previous conservative management interventions
• Level of risk
• Previous positive effect of surgical techniques
• Patient preference
• Ulcer assessment
• General skin assessment
6 Treatment Principles
• Pressure relieve
• Debridement
• Infection
• Wet dressing
• Risk factors
• Surgery
Seiler W.O.; Stahelin H.B.: Decubitus ulcers: treatment through
therapeutic principles. Geriatrics 1985 40: 30-44 (1985).
Surgical Treatment
Three principles:
Excisional debridement of the ulcer
Partial of complete ostectomy to reduce the bony prominence
Closure of the wound
Musculocutaneous flaps: excellent blood supply, provision of bulky padding, against infection
Fasciocutaneous flaps: adequate blood supply, durable coverage, minimal functional deformity
66
If wounds do not heal
Indentifying factors
that impair wound healing
It's a motivating concept!
Ref: Zederfeldt B.: Factor influencing wound healing; in Sundel B.W., Symposium on wound
healing (Mölndal Sweden, Lindgren,A.Söner A.B. 1980)
Venous
REFLUX
Venous ulcers
• Inspect
• Clean/debride
• Measure
Venous ulcers
Venous ulcers
Venous ulcers
C0 C1 C2 C3 C4 C5 C6
Life Style Changes
Sclerotherapy
Compression
Topical
Surgery
Medications