Surgical dressings Dr. Sujith Thampy S4 Unit

History Until the early 1980s, only a few wound care products were available apart from traditional dressings (eg: gauze-based products), paste (eg: zinc paste) & bandages

The first modern wound dressings introduced during mid 1980s combined 2 main characteristics moisture keeping &absorbing or moisture keeping & antibacterial In mid 1990s,it expanded into well-recognized groups of products, such as vapor-permeable adhesive films, hydrogels, hydrocolloids, alginates & synthetic foams In second half of 1990s, combination products & engineered skin substitutes were developed. Currently, the global tendency demonstrates in decreasing no of product categories & making the market more transparent Lot of research-on the basis of physiology

An ideal wound dressing should….. Protect from external forces & contamination Protection against drying & loss of body water & electrolytes Discourage infection Provide thermal insulation Reduce odour Be easy to apply Be cost and resource effective

Phase-adapted functions Early phase-cleaning Every wound contains variable amount of dirt debris & bacteria along with exudate, which hinder wound healing both mechanically & biologically, & increase risk of infection. Dressings should support & speed up cleaning of excessive exudates

Granulation phase Adequate regulation of wound moisture is important requirement for formation of granulation tissue It should absorb excessive secretions ,prevent drying of wound & delivers moisture when it is needed. It`s atraumatic character (not adhering to the wound) ensure that the rest of wound is maintained

Epithelialisation Mature granulation tissue & a moist sliding surface for migration epithelial cells If excessive secretions epithelial cells will swim away, if too dry a scab will hinder epithelialisation Cell stripping during dressing change can be prevented by using atraumatic materials

Requirements of wound dressings Absorbency - capacity of dressing to remove secretion due to capillary effect & hold it in its material Wound friendliness- shouldn`t adhere to wound even after prolonged term use & allow a less painful removal- can be achieved by impregnating dressing with ointments, gels& other hydrophobic materials

Gas permeability Continuous gas exchange helps in the regulation of concentration of O2 & pH and thereby helps in the cellular processes

Safety of use

Methods of wound dressings Dry dressings Limited indications - as a part of first aid - for wounds that heal with primary intension - for burns Moist dressings Natural skin

Dry gauze - Made up of dry cotton; soft, highly absorbent, pliable, highly permeable to air & strong For initial treatment of acute, dirty, highly secreting wounds & sutured wounds healing by primary intention As they stick to wound; ointments or moistening should be done in the granulation and epithelialisation phase

Non woven swabs Simliar to gauze, rapidly absorbent pliable But not so strong & will adhere to wound also Can be used for fixation of tracheostomies , tubes, drains & cannulas

Combined absorbent dressings Combination of absorbent materials in layers-demonstrate good absorbency Secretions are well distributed & drawn away from the wound & held in the depth of the absorbent core

Soft foam dressings Double layer poly urethane foam Open pore underside is in contact with wound & absorb all the exudates Ensure rapid & intense cleaning of dirty wound In granulation phase it acts as matrix for formation of new tissue & stimulates the formation of granulation mechanically Denser top layer act as a barrier to secondary infection & prevent fluid loss

Moist dressings Moist wound treatment -standard treatment for all wounds under going 20 healing Especially in c/c wounds Scientific basis by research of Winter in1962 “In the old days we only had to know saline and gauze” Foam Ointment dressings Antimicrobials Enzymatic Debridement Hydrocolloid Hydrogel Calcium alginate

Hydrocolloid Highly absorbent gel (polyurethane) Oxygen and water vapour permeable Allows for autolytic debridement Indications: Venous ulcers, pressure ulcers, diabetic ulcers, 1st and 2nd degree burns Can stay in place for 72 hours

Hydrogel Absorbs 5 times own weight Facilitates autolytic debridement Hydrophilic polysaccharide particles Facilitates autolytic debridement Delivered in many forms Amorphous gel, Sheets, Strands Indications: Mildly exuding wounds, clean wounds , partial thickness wounds Can stay in place for 24 hours

Calcium alginate Mannuronic acid fibers- Seaweed Forms a hydrophilic gel Comes as- Sheets, tubes, loose fibers packs Absorbs up to 30 times weight Maintains a moist wound environment. Indications: Wounds with large amount of drainage Can stay in place 24 to 72 hrs

Foam Hydrocellular foam, waterproof outer layer Highly absorbent (20 times weight) Non-adherent to wound Allows for autolytic debridement and gaseous exchange Indications: Highly exudative wound requiring a non-stick surface (e.g. venous stasis) Can be left in place for 72 to 96 hours

Ointment dressings Open weave cotton textile or non woven material is impregnated with ointment Do not absorb or do not adhere to wound Absorbent dressing is needed above the ointment dressing to absorb secretions

Enzymatic Debridement Removes: Senescent fibroblasts Necrotic tissue harboring bacteria Indications: A wound with lot of fibrinous exudate, other necrotic material or slough Papain (Papaya) – digestant of nonviable protein Denatures nonviable protein Apply directly to wound

Antimicrobials Indications: Infected wounds, wounds with bacterial counts greater than 105 Bacterial count greater than this decrease wound healing rates Bacterial proteases degrade growth factors Therapeutic concentration at the site of the wound Acticoat- Nanocrystalline silver coating on polyethylene mesh

Natural skin Autologous grafts large surface wounds, burns. transplantation of the patient's own skin from an adjacent undamaged area definitive coverage of burned skin with good quality of healed skin. Acellular Dermal Replacement For deep wounds-loss of dermis Tissue-derived or manufactured products which provide temporary wound closure Incorporate and promote generation of a neodermis which support epidermal tissue. Require autograft later

Natural skin Allogenic skin graft Cadaveric skin Preservation can be done by freeze-drying, glutaraldehyde fixation, or glycerolization. To provide sufficient cadaver skin instantly accessible for the patient with a burns- skin banks in European countries

Natural skin Xenogenic grafts application of non-human tissue to wounds. unlimited availability under well-controlled conditions still makes animal skin a favorable wound covering. Porcine skin- most common- high similarity to human skin Sterility is an essential concern- Ionizing radiation- most suitable method Coupled with freeze-drying- decrease the antigenic properties & increase its potential to inhibit bacterial growth.

Innovations in Wound Management Biosurgery (Larval Therapy) Laser therapy MySkin Growth inducing factors Hyaluronic acid dressing Tenderwet VAC therapy Multi-Layer Compression System

Biosurgery (Larval Therapy) Lucilia sericata (greenbottles) Phaenicia sericata (green blow fly) Debride wounds by dissolving the dead & infected tissue Disinfect wound by killing bacteria Stimulate wound healing. Removes slough and malodor Special dressing technique Sterile breed of larvae Allergic reaction Ethical issues Research

Laser therapy Biostimulation or photobiostimulation application of low-power monochromatic and coherent light Increase the speed, quality and tensile strength of tissue repair, resolve inflammation and provide pain relief Responses of cells occur due to changes in photoacceptor molecules such as porphyrin. Needs expert handling Costly & Time-consuming

MySkin Cultured autologous epidermal substitute Contains living cells expanded from the tissue of individual patients. (only their own cells) Comprises a layer of keratinocytes (epidermal cells) on a polymer-like coating which facilitates the transfer of cells into the wound where they can initiate healing. Use silicone substrate layer to support cell delivery, wound coverage and allow exudate management. Treatment of burns, ulcers and other nonhealing wounds.

Method Thin biopsy of skin is taken from the thigh area -in sterile saline solution-treated with a digestive enzyme overnight-next day keratinocytes are isolated from the dermal/epidermal junction, multiplied in cell culture and stored in liquid nitrogen Three days before dressings, keratinocytes are thawed and cultured on a silicone disc, transfer keratinocytes from the dressing to the wound bed and promote re-epithelialization…(four days) -after standard dressing

Growth promoting factors Proteins that direct biological processes Chronic wound deficient Platelet-Derived Growth Factors (pdGF) Activates endothelial cells and fibroblasts Stimulates vascular proliferation, migration, new blood vessel formation Recruits smooth muscle cells and pericytes to stabilize newly formed vessels

Growth promoting factors Oxidized Regenerated Cellulose (ORC)/Collagen Modulates protease activity Growth factor remains active Growth factors delivered back to wound over time Modifies hostile proteolytic environment of chronic wound

Hyaluronic acid dressing Vapor-permeable films Industrially manufactured and purified hyaluronic acid. Indicated for use on diabetic foot ulcers and venous leg ulcers Hyalograft 3D and Laserskin (HYAFF-11) Composed of a benzyl ester derivative of hyaluronic acid May be used as membranes for direct wound dressing or as scaffolds for the cultivation of fibroblasts and keratinocytes for transplantation. Hyalofill

Xelma Extracellular matrix protein- amelogenin, a thickening agent propylene glycol alginate (PGA) and water. Temporarily replaces the damaged extracellular matrix protein for cell attachment. Favours wound healing by restoring vital cell functions Treatment of hard-to-heal ulcers, primarily venous leg ulcers, use with standard compression therapy of non-infected wounds.

Tenderwet Extremely effective dressing for chronic, infected and non infected during cleaning & start of granulation phase Allows continous irrigation of wound

Mode of Action

Multi-Layer Compression System For management of venous leg ulcers and related conditions Used on patient`s ankle Provides sustained graduated compression from the ankle to below the knee 3 layers

Multi-Layer Compression System THIRD LAYER- Cohesive compression bandage delivers additional pressure. SECOND LAYER-Compression bandage gives visual cue to aid proper application. Bandage is printed with a rectangular pattern that turns to a square when correct level of stretch is achieved. FIRST LAYER-Padding is made of cotton.

VAC therapy Application of topical negative sub-atmospheric pressure across the surface of the wound Evacuates excess exudate Kills anaerobic bacteria Controls odour Mechanically pulls edges of wounds together

Indications Chronic non-healing wounds: Pressure ulcers Venous/arterial ulcers Diabetic ulcers Sub-acute non-healing wounds Dehisced surgical wounds Acute and traumatic wounds Meshed flaps and grafts Graft and flap donor sites Others like burns; snake and spider bites

Closing thoughts What we do is just conventional old method of dressing we have to improve & the world is also finding a lot more……

THANK U & BYE……… TO MEET AGAIN