1. Surgical dressings
Dr. Sujith Thampy
S4 Unit

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

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

10. Safety of use

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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.

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

28. 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

29. 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

30. 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.

31. 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

32. 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

33. 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

34. 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

35. 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.

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

37. Mode of Action

38. 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

39. 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.

40. 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

41. 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

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

43. THANK U
& BYE………
TO MEET AGAIN