Primary Wound Management Current Concepts in Topical Therapy

Priority # 1: Correct Causative Factors Pressure/Shear: Support surface + repositioning guidelines Friction/Shear: Gentle skin care; minimal tape use; measures to prevent “scrubbing” Venous: Leg elevation + compression Arterial: Revascularization? Measures to optimize perfusion/protect limbs Neuropathy: offloading

Priority # 2: Systemic Support Measures to optimize perfusion – Pain control; warmth; edema control; oxygen if needed Must have sufficient blood flow to heal—if wound poorly perfused & revascularization not an option, consider HBOT

Systemic Support Nutritional Support – 30 – 35 cal/Kg/day – 1.2 – 1.5 gm protein/Kg/day (glutamine & l- arginine) – MVI – Zinc only if needed and only short-term – Consider oxandrolone for pt with significant wt loss who does not respond to standard therapy

Systemic Support Tight Glucose Control – Goal: Normoglycemia – Impact of glucose >180 – Implications: check glucose records each visit; constantly reinforce link between glucose levels and ability to heal

Systemic Support Measures to minimize effects of high-dose steroids: topical Vit A to wound bed (25,000 – 100,000 IU daily, depending on size of wound) Note limited research on this topic

Priority # 3: Principle-based Topical Therapy Goal: Promote wound healing by creating local environment that favors repair Inflammatory phase: wound cleanup (debridement and bacterial control) Proliferative phase: rebuilding (formation of granulation tissue to fill defect + new epithelium to resurface)

History of Wound Care Dominant Principles and Concepts – Limited knowledge re: wound healing – Primary focus: infection control Common Approaches – Gauze dressings with antiseptic solutions – Aggressive cleansing – Mgmt refractory wounds: “more of the same” vs. experimental agents

Shift to Moist Wd Healing Winter’s Research: 40% reduction in time to epithelialization with moist surface Subsequent studies: improved rates of healing full-thickness wounds; no increase in infection rates Gradual shift in focus: from preventing infection to creating favorable environment for repair

Principle-Based Topical Therapy Eliminate impediments: necrotic tissue, excess bioburden, wound exudate, closed wound edges Keep wound moist, insulated, and protected

Topical Therapy Acronym D = Debride necrotic tissue I = Identify and treat infection P = Pack dead space, lightly A = Absorb excess exudate M = Maintain moist wound surface O = Open wound edges P = Protect healing wound I = Insulate healing wound

Topical Therapy: Decision- Making Guidelines Wound Assessment: – Location – Dimensions and depth – Undermined/tunneled areas – Status of wound base: granulating? clean but not granulating? necrotic? – Exudate – Status of wound edges/surrounding tissue

Necrotic Wounds When to debride: --Anytime the goal is repair --Anytime the wound is infected

OASIS Assessment Challenges Open Wounds: – Granulating vs. clean but not granulating – Closed versus open wound edges Closed Incisions – Presence/absence of healing ridge – Epithelialization

Necrotic Wounds Debridement Options: – Surgical – Conservative sharp wound debridement – Enzymatic – Chemical – Autolytic

Infected Wounds Guiding Principle: must intervene when – there is invasive infection of soft tissue or bone or – the bacterial loads on the surface of the wound are sufficient to interfere with repair

Infected Wounds Wounds involving infection of soft tissue: – Clinical S/S: redness, heat, edema, pain, exudate – Treatment: systemic antibiotics (culture based if possible) Wounds involving osteomyelitis: – Clinical S/S: exposed bone; nonhealing tunnel – Treatment: systemic antibiotics

Infected Wounds: Culture guidelines: – Purpose: to determine infecting organism and antibiotics to which it is sensitive – Procedure: Wound biopsy (punch culture) OR Modified swab: flush with N/S swab 1 sq cm of viable tissue till exudate produced

Infected Wounds Wounds with sufficient bacterial load at wound surface to interfere with repair: – Clinical S/S: deterioration in quantity or quality of granulation tissue; persistent high volumes of exudate; pain – Treatment: topical agents to reduce bacterial loads (cleansers, sustained release iodine or silver dressings)

Infected Wounds Topical Agents for Bacterial Control – Necrotic wounds: consider Dakin’s – Technicare cleanser for wd with daily dsg changes (kills 99% of bacteria within 2 min): Caretech Labs – Sustained release iodine (Healthpoint) – Sustained release silver agents (Acticoat, Silvasorb, Aquacell Ag, Contreet, Actisorb)

Create/maintain open wound edges Cauterize with silver nitrate Refer for excision of wound edges

Dressing Selection Goals: – Wick and absorb exudate – Maintain moist wound surface – Provide bacterial barrier/protection against trauma – Insulate

Dressing Selection Assessment parameters: – Wound depth > 0.5 cm? – Tunnels or undermined areas present? – Volume of exudate?

Dressing Selection Classify wound: – Deep and wet: > 0.5 cm deep (or tunnels or undermining) + mod – lg amt exudate – Deep and dry: > 0.5 cm deep (or tunnels or undermining) + minimal or no exudate – Shallow and wet: < 0.5 cm deep (no tunnels or undermined areas) + mod – lg amt exudate – Shallow and dry: < 0.5 cm deep (no tunnels or undermined areas) + minimal or no exudate

Dressing Options Deep and wet: – Filler dressing: alginate rope or hydrofiber rope or damp gauze (least effective option); note Nugauze or Mesalt rope best for narrow tunnels – Cover dressing: adhesive foam; gauze + tape or transparent adhesive dressing (consider need for bacterial barrier—e.g., pt who is incontinent and has trunk wound)

Dressing Options Deep and dry: – Filler dressing: layer of wound gel + damp fluffed gauze; gel-soaked gauze – Cover dressing: gauze + transparent adhesive dressing (maintains hydration and provides bacterial barrier)

Dressing Options Shallow and wet – Alginate + foam or gauze – Hydrofiber + foam or gauze – Nonadherent contact layer + gauze – Adhesive foam alone

Dressing Options Shallow and dry – Solid gel (glycerine-based gels better for wounds with exudate) – Hydrocolloid – Nonadherent + wrap gauze (for wound on extremity) – Transparent adhesive dressing (if no exudate)

Refractory Wounds Definition: Wound that fails to show measurable progress for 2 consecutive weeks despite appropriate management Management: – Assure correction etiologic factors – Assure adequate systemic support – Assure clean protected wound bed – Consider use of active wound therapy

Active Wound Therapy Definition: Agent that actively stimulates the repair process Options: – Electrical Stimulation – Negative Pressure Wound Therapy – Growth Factors – Human Skin Equivalents

Summary Key goals: – Correct causative factors – Provide systemic support – Establish clean moist wound bed – Monitor for progress – Intervene for failure to progress!