Current concept in Wound care

current availabe methods in wound care

1. Current Trends in Wound Management By Dr. Lawal Gbenga D. Registrar, Surgery Dept. Nha 4 th December 2017 Supervised by Dr. O. Oikeh .

2. “the primary goal of wound care is not the technical repair of the wound; it is providing optimal conditions for the natural reparative processes of the wound to proceed” – Richard L. Lammers

3. OUTLINE Introduction: Definitions, History Anatomy of a wound Aetiology of wounds Classification of wounds Wound healing: phases factors affecting healing Wound management: principles plastic surgeon’s consult? history and examination wound bed preparation closure dressing cover pharmacologic therapy / other modalities adjuncts special wounds Future trends Conclusion

4. INTRODUCTION D EFINITIONS Wound : refers to a disruption of normal tissue architecture Wound healing: a physiologic process that leads to restoration of both anatomic integrity & functional ability of damaged tissue . Wound bed: Uppermost viable layer of wound; may be covered with slough or eschar Wound bed preparation (WBP) is a systematic approach to wound management which involves identifying and removing barriers to healing

5. INTRODUCTION HISTORY 2000 B.C - Egyptians. Spiritual methods (incantations) & physical methods (application of poultice-like materials to the wound ) 1550 B.C: Ebers Papyrus - Concoctions containing honey, lint & grease for wound Rx 120 - 201 A.D: Galen - Wound moisture aids healing (epithelialization ) 1818–1865: Ignaz Philipp - handwashing in puerperal sepsis . 1865: Lister – P henolic acid antisepsis 1876: Robert Wood Johnson – iodoform gauze 1960-70s: polymeric dressing

6. Anatomy – parts of a wound Wound edge Wound corner Surface of the wound Base of the wound Cross section of a simple wound Skin surface Subcutaneus tissue Superficial fascia Muscle layer Base of the wound Wound edge Surface of the wound Wound cavity

7. WOUND AETIOLOGY Mechanical force Abra sion wound Puncured wound Laceration wound Crush wound Avulsion wound Bite wound Gun s hot wound T hermal – Heat, Cold Vascular compromise (arterial, venous, lymphatic or mixed ) Chemical acid, alkali Radiation Neoplasm Connective tissue disorders / Degenerative diseases Metabolic disease – diabetes mellitus

8. CLASSIFICATION OF WOUND Closed VS Open Closed: contusion/bruise Open: Abrasion, Puncture, Laceration, Penetrating wound, Perforating wound, Avulsion wound Tidy VS Untidy Simple VS Complex Acute VS Chronic Level of contamination: clean, clean-contaminated, contaminated, dirty

9. Phases of Wound healing 1. Hemostasis- I nflammation - vasoconstriction - fibrin clot formation - proinflammatory c y tokines and growth factors releas ed - infiltration PMNs, macrophages 2. Granulation /P roliferation - fibroblast migration - collagen deposition - angiogensis - granulation tissue formation - epithelisation 3. Remodelling - regression of many capillaries - physical contraction – myofibroblasts - collagen degeneration - epitheli azation

10. Phases of Wound healing Hemostasis-inflammation Granulation-proliferation Remodelling

11. Role of growth factors in wound healing

12. Chronic Wounds Chronic wounds are wounds which have “failed to proceed through an orderly and timely process to produce anatomic and functional integrity” Characteristics: Increased inflammatory cytokines Altered fibroblast phenotype Abnormalities growth factors Increased proteases Altered keratinocyte function Senescent cells (increased number)

13. Factors affecting wound healing Local Ischemia / Hypoxia Infection Foreign body Edema Ionizing radiation infection ischemia foreign bodies edema/ elevated tissue pressure Impaired healing Systemic Age Nutrition Stress Anaemia Diseases / Immunocompromis e d conditions Drugs Medication S moking Connective tissue disorders / Genetic diseases

14. Wound Management GOALS of wound care – Facilitate hemostasis Decrease tissue loss Promote wound healing Minimize scar formation Key components 1. Cause(s) of the wound : treatable? 2. Patient centred concerns: pain; factors that can influence healing? adherence to the treatment? 3 . Local wound factors: Think ‘DIME ’ - need for Debridement? - an undiagnosed infection? - how is the edge doing?

15. Wound Management Need for Plastic surgeon consultation a ) the acute wound where the final appearance may be the principal concern b ) the wound in a patient whose medical status and/or mode of injury predisposes her to wound healing difficulties and the threat of a problem wound c ) the established chronic wound refractory to past interventions . Generally Tarsal plate or lacrimal duct Open fracture or joint space Extensive facial wounds Associated with amputation Associated with loss of function Involves tendons or nerves Involves significant loss of epidermis Any wound that you are uncertain abouts

16. Wound Management : Principles Resuscitation Management of immediate life-threatening injuries H istory and Wound evaluation Wound bed preparation Optimize blood flow/Reduce edema Use appropriate dressings Use pharmacologic therapy Close wounds Optimize systemic parameters

17. Wound Management Tetanus status Allergies Medications Comorbidities Previous scar formation Social history History Age Occupation/functional requirement Symptoms Event/Mechanism of injury Contamination/Potential for foreign body Care given

18. Wound Examination GENERAL EXAMINATION Site Size and depth Shape Edge, Tunneling,Undermining Wound bed – Base, floor, colour , discharge Neurovascular function Tendon function Underlying structures Wound contamination / Foreign bodies DONOR SITE AVAILABILITY

19. Applied Wound Management - Colour Continuum BLACK BLACK-YELLOW YELLOW YELLOW-RED RED RED-PINK PINK (Necrotic) (slough) (granulation) (epithelization)

20. Wound Management INVESTIGATIONS General Patient Fitness – PCV , EUCr , LFT, Total protein and Albumin Investigate Local Wound Condition – wound biopsy M/C/S, wound biopsy for histology Establish A Diagnosis – doppler USS, angiography Assess Involvement Of Underlying Structures – X ray , Ultrasound Investigate Comorbid Conditions - genotype, FBS / Hb A1c,

21. Wound Bed Preparation A. Anesthesia – Topical, Local, Regional Block B. Cleaning/ Irrigation - Use normal saline - High pressure / Large syringe (60mL ) attached to a 14-gauge

22. Wound Bed Preparation C. Debridement Removes foreign matter & devitalized tissue Creates sharp wound edge Excision with elliptical shape Respect skin lines

23. Wound Bed Preparation D. Infection All chronic wounds contain bacteria and the presence of bacteria obtained from a surface swab does not define infection . Critical to wound healing is whether bacterial balance is achieved (contamination or colonisation) or bacterial damage (infection ).

24. Wound Bed Preparation E. Moisture balance Appropriate moisture is required to facilitate the action of growth factors, cytokines, and migration of cells including fibroblasts and keratinocytes Excessive moisture - cause damage to the surrounding skin - maceration & skin breakdown Inadequate moisture - impede cellular activities and promote eschar formation resulting in poor wound healing.

25. Wound Bed Preparation Edge A 20 to 40% reduction in two and four weeks respectively, is likely to be a reliable predictor of healing . A wound edge that is not migrating after appropriate wound bed preparation and healing is stalled, then advanced therapies should be considered . rule out other causes and co-factors . Consider other wound related outcomes such as: reduced pain reduced bacterial load, reduced dressing changes or an improved quality of life.

26. Wound Dressings ensures moist wound condition - absorb exudates - protects w ound - protects knots

27. Negative Pressure Wound Therapy(NPWT)/Vacuum Assisted Closure (VAC) - expeditiously prepare a wound bed for surgical closure by tertiary intent . - most wounds will heal optimally with a pressure of 75 - 125 mm Hg Mechanisms of action - visible contraction which occurs when negative pressure is applied - Provides direct and complete wound bed contact - Removes exudate - Reduces edema - Promotes granulation tissue formation by facilitating cell migration and proliferation

28. Negative Pressure Wound Therapy(NPWT )/ Vacuum Assisted Closure ( VAC Indications: – Large wounds – Cavities – Large amount of exudate Contraindications: - malignancy - ischemia - inadequately debrided wounds

29. Hyperbaric Oxygen Therapy (HBO) • use of 100% O2 saturation at 2 - 3 ATM raises the dissolved oxygen saturation in plasma from 0.3 % to nearly 7 % • Mechanism: - Stimulates angiogenesis and fibroblast migration - enhances neutrophil and antibiotic killing action - suppresses alpha toxin production in gas gangrene • No benefit: - those with a normal environmental perfusion - those with ischemic limbs

30. Wound closure • Key – wound edge eversion • “Approximate, don’t strangulate” • Anticipate wound edema Options : Primary: for primary wound management ALWAYS : thoracic cavity, abdominal wall or dura mater injury NEVER: war/blast injury, inflammation, contamination, foreign body, bite, gun shot , deep punctured wound Delayed primary (3-8 days ): for contaminated wound Secondary: - Early secondary wound closure (2 weeks) - after inflammation, necrosis – proliferation - Late secondary wound closure (4-6 weeks) - greater defect – plastic surgery

31. Wound closure Other devices in wound closure • Staples – Quick, poor aesthetic result – where scar is less of an issue (hairy scalp ) • Adhesives – Dermabond – clean, sharp edges, clean nonmobile areas, laceration less than 4 cm in length • Tape – Steri -strips – superficial, straight laceration under little tension

32. Wound Cover CHOICE OF WOUND COVER – graft, flap, skin substitutes PRIORITISATION Preserve Life Preserve Function Cosmesis Availability

33. Wound Cover Skin substitutes Concept of skin substitutes interacts with wound to improve the rate and quality of healing. Regenerative wound healing is the ultimate goal

34. Characteristics o f an Ideal Skin Substitute

35. Available Biologic And Synthetic Skin Substitutes Naturally occurring tissues - Cutaneous allografts - Cutaneous xenografts - Amniotic membranes . Synthetic bilaminate collagen based composite   Biobrane    TransCyte    Integra Dermagraft Collagen based dermal analogs - Deepithelized allograft - Alloderm Culture-derived tissue - Bilayer human tissue ( Apligraf ) - Cultured autologous keratinocytes - Fibroblast seeded dermal analogs - Collagen-glycosaminoglycan matrix - Epithelial seeded dermal analog

36. Wound Healing Properties of Amniotic Membrane The amniotic membrane: contains a significant number of cytokines and essential growth factors provides a matrix for migration and proliferation of cells is non-immunogenic has antibacterial properties provides a biological barrier Readily available at C-Section deliveries

37. Dermagraft living allogenic dermal fibroblasts grown on a degradable scaffold

38. TransCyte (ECM matrix generated by allogenic human dermal fibroblasts serves as a matrix for neodermis generation ORCEL: Composite cultured skin. Fibroblasts, keratinocytes seeded on opposite sides of bilayered matrix of bovine collagen

39. Wound Cover Grafts & Flaps • Radiation wounds require flaps. • Chronic non healing ulcers. • Extensive areas of ulceration. • Major soft tissue loss.

40. Adjuvant Treatments: Antibiotics Analgesics Tetanus prophylaxis Nutrition – vit A, Vit C, Zinc R educe edema – elevation (avoid in arterial disease) Rest/Positioning Physiotherapy Rehabilitation

41. Pharmacological agents - Recombinant cytokines & growth factors: accelerate healing Topical GF: PDGF ( becaplermin ) , TGF- β 3 , platelet derived- EGF , Platelet derived angiogenesis factors, G-CSF. Useful in the proliferative phase . - beta-Glucan stimulates the macrophage activity and promotes rapid wound healing

42. Special wounds Wound Care In Patients Pressure Sore • Debridements • Dressings • air-fluidized beds, air mattresses, air flotation and water flotation devices, and low air-loss beds • Should be aggressively nourished and receive vitamin supplementation. • administration of growth hormone or anabolic steroids .

43. Special wounds Wound Care in Patients with Diabetes • components of pressure necrosis, functional microangiopathy , and neuropathy. • Selective debridement, control of glucose levels, pressure offloading. • Revascularization • use of growth factors Wound Care in Patients with Venous Ulcers • Compression therapy is essential for venous stasis ulcers (use of stockings, elastic wraps, and multilayer wraps) • ideally the pressures exerted should be between 30 and 40 mm Hg • continued for several weeks following successful closure of the wound • contraindicated in patients with an ABI <0.7

44. Special wounds Wound Care in Patients with irradiated skin or chronic steroid use • These cause progressive endarteritis obliterans microvascular damage, along with fibrotic interstitial changes • results in a wound marked by ischemia, and prone to infection Managemen t: serial debridement, antimicrobial dressings, growth factors, hyperbaric oxygen therapy, microvascular free flap . • Patients on steroids should receive vitamin A (25,000 IU daily by mouth or 200,000 IU topically t.i.d )

45. FUTURE TRENDS Continued research in - uses of gene therapy for inducing healing are promising; amplifying function of growth factor genes - stem cell research - fetal wound healing

46. Conclusion Wound healing is a complex process that involves an interplay between the patient and the environment Timely and adequate intervention in the management of chronic wounds will prevent further tissue loss and reduce burden of the disease In the future, genetic and stem cell engineering will help eliminate the burden of chronic wounds

47. REFERENCE Bryant, R. A., & Nix, D. P. (2012). Acute and chronic wounds: Current management concepts . St Louis, MO :Elsevier Mosby. Emory University WOCNEC (2012). Skin and wound module. Atlanta , GA :Emory Universit Thomas Mustoe , Understanding chronic wounds: a unifying hypothesis on their pathogenesis and implications for therapy. The American Journal of Surgery 187 ( Suppl to May 2004) 65S–70S Orsted HL, David K, Forest- Lalande L, Mégie MF. Basic Principles of wound healing. Wound Care Canada. 2011; 9(2 ): 4-12. Stuart E, Joseph E.G, Keith G. H, ABC of wound healing : Recent advances and emerging treatments Singer AJ, Clark RA. Cutaneous wound healing.N Engl J Med 1999;341:738-46. x Harding KG, Sibbald RG, Woo KY, Ayello E. Wound Care : Wound bed preparation: DIM before DIME. Wound Healing Southern Africa 2008;1(1): 29-34 The Compendium of Wound Care Dressings in Malaysia , Volume 2 , Harikrishna K.R Nair https ://www.advancedtissue.com/top-types-wound-debridement/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4930235/ https://www.advancedtissue.com/honey-can-help-wound-healing/