Vac. Ppt.pptx good ppt for vaccine dressing

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1. DIFFERENT TYPES OF WOUND MANAGEMENT,LOCAL ANTIBIOTIC DELIVERY SYSTEM,VAC APPLICATION PRESENTER:DR.A.LAKSHMAN(PGY1) MODERATOR:DR.M.AMBEDKAR

2. The  basic principles  for the  management of a wound are: Haemostasis Cleaning the wound Analgesia Skin closure Dressing

3. Haemostasis: Haemostasis  is the process that causes  bleeding to stop . In most wounds, haemostasis will be  spontaneous . In cases of  significant injury  or  laceration of vessels , steps may need to be taken to reduce bleeding and aid haemostasis . These include  pressure ,  elevation ,  tourniquet , or  suturing .

4. Cleaning the Wound: Wound cleaning  is important for  reducing infection  and  promoting healing . There are five aspects of wound cleaning: Disinfect  the skin around the wound with antiseptic Avoid getting alcohol or detergents inside the wound Decontaminate  the wound by manually removing any foreign bodies Debride  any devitalised tissue where possible Irrigate  the wound with saline If there is no obvious contamination present, low pressure irrigation is sufficient* (pouring normal saline from a sterile container carefully into the wound) Antibiotics  for high-risk wounds or signs of infection (follow local antibiotic guidelines) Risk factors for wound infection include foreign body present or heavily soiled wounds, bites (including human), puncture wounds, and open fractures *If the wound is clearly contaminated, it must be irrigated at high pressure to remove any visible debris present .

5. Analgesia: Analgesia  will allow for a humane and easier closure of the wound. Infiltration with a  local anaesthetic  is the most common form of analgesia used, with regular  systemic analgesia  (such as paracetamol) used as an adjunct. Skin Closure The aid in wound healing , the edges of the wound can be  manually opposed . There are three main methods of doing so: Skin adhesive strips are suitable if no risk factors for infection are present Tissue adhesive glue   can be used for small lacerations with easily opposable edges Sutures  are typically used for any laceration greater than 5cm, deep dermal wounds, or in locations that are prone to flexion, tension, or wetting.

6. Dressing the Wound and Follow-Up Correct dressing of the wound  will reduce infection and contamination. When applying a wound dressing to a non-infected laceration, the first layer should be  non-adherent  (such as a saline-soaked gauze), followed by an  absorbent materia l to attract any wound exudate, and finally  soft gauze tape  to secure the dressing in place. Following initial wound management,  advise patients  to: Seek medical attention for any  signs of infection Take  simple analgesia  (e.g. paracetamol) Keep the  wound dry  as much as possible. Any  sutures or adhesive strips  should be  removed 10-14 days  after initial would closure; tissue adhesive glue will naturally slough off after 1-2 weeks.  Remove dressings  at the same time as the sutures or adhesive strips.

7. WOUND BED PREPARATION It involves: -Removing dead tissue and slough-Debridement -Promote growth of granulation tissue -Avoid/controls infection -Promote epithelization It is used for treatment of chronic wounds by removing the barriers to healing.

8. MINOR WOUNDS- Wound is cleaned with saline thoroughly;then non stick dressing is placed.An incised wound is treated by primary suturing.In lacerated wound,wound edge is excised and then apposed by primary suturing without tension. HEAMATOMA- Ice packs wrapped in cloth is applied and kept for 15 minutes in every 2hrs for 24hrs;compression bandage;elevation of the part;ultrasound of the part and guided aspiration if persists;occasionally heamatoma is evacuated. CRUSHED OR DEVITALISED WOUND- There will be oedema and tension;all devitalised tissue is removed;oedema is allowed to subside for 2-6 days; Then delayed primary suturing is done.If it is a deep devitalised wound,after wound debridement it is allowed to granulate completely. Later if wound edges are closer,secondary suturing is done usually after 10 days using monofilament non absorbable suture.if thw wound is wider,it is covered with Split-Skin-Grafting(SSG).

9. MAJOR WOUNDS - Airway should be maintained.Bleeding should be controlled;Intravenous fluids should be started.They need proper management in operation theatre under GA after initial assessment of patient and the wound. - In a wound with tension,Fasciotomy is done to prevent development of compartment syndrome.Major vessels are sutured. Nerve with clean cut ends is sutured primarily using fine polypropylene suture.If nerve is crushed or cut ends are away or if there is difficulty in identifying cut ends,then marker stitches are placed at the site and later secondary suturing is done

10. PRINCIPLES OF WOUND SUTURING : Primary suturing should not be done if there is oedema/infection/devitalised tissue/ heamatoma Always associated injuries to deeper structures like vessels/nerves or tendons should be looked for before closure of the wound Wound should be widened by extending the incision wherever needed to have proper evaluation of deeper structures. Proper cleaning,asepsis,wound excision/debridement Any foreign body in the wound should be removed Skin closure if possible should be done without tension Proper aseptic precautions should be undertaken Antibiotic/Analgesics are needed Sutures are removed after 7 days.

11. DEBRIDEMENT Debridement is removal of dead,nonviable,necrotic tissue. METHODS: Surgical Debridement Mechanical Debridement-Physical removal of necrotic tissue with advance dressing techniques Chemical Debridement-Hydrogen Peroxide,N.S EUSOL(Edinburgh University Solution Of Lime)

12. Surgical Debridement It is done when there is an extensive amount of necrotic tissue It is efficient and causes minimal damage to surrounding tissue Minor bleeding following the procedure can release inflammatory mediators such as cytokines,that can assist the wound repair process Painful

13. Mechanical Debridement Physically removes the debris from the wound Ex: WET TO DRY DRESSINGS Simplest form and can cause mechanical separation of eschar from the wound bed once the dressing is removed and can cause patient discomfort and damage newly formed tissue. WOUND IRRIGATION Involves the use of a pressurized stream of water High pressure irrigation removes bacteria and necrotic debris from the wounds but could drive bacteria into soft tissue.

14. Antiseptics

15. POVIDONE IODINE: Compound of iodine and polyvinylpyrrolidone Effective antiseptic that does not impede wound healing Bactericidal against gram-positive and negative organisms No acquired bacterial resistance or cross-resistance Helps wound healing in a range of acute and chronic wounds.

16. VARIABLES THAT AFFECT THE BACTERIAL BURDEN OF A WOUND HOST FACTORS - Immuno suppression -Diabetes -Medication -Poor Vascularity

17. Stages of wound infection CONTAMINATION -Presence of non-replicating bacteria. -Normal condition in chronic wounds and does not impair healing. COLONIZATION -Presence of replicating bacteria without a host reaction -Does not contribute to impaired healing -Usually caused by skin commensals Ex.Staphylococcus epidermis,Corynebacterium Sp.

18. Management based on stage of chronic wound Remove debris Control infection Promote granulation tissue formation Promote epitheliasation Control wound discharge

19. Management based on stage of proliferation and remodelling Dressing optimal for formation of granulation tissue and epitheliasation . Manipulation of hydration and oxygen tension in wound Avoid drying /maceration Control infection Options include- VAC,antibiotic ointments

20. Moisture It is a rate limiting factor Most modern dressing products are interactive dressings as they absorb fluid from the wound and secrete substances to enhance wound healing. Moisture is important factor deciding rate of wound healing The moisture vapour transmission rate(MVTR) measures the moisture retentive property of a dressing. MVTR less than 840g/24hrs is desirable to maintain adequate moisture around wound surface. MVTR of gauze is 1200g/24hrs

21. Benefits of maintaining a moist wound environment: - Faster Healing -Autolysis of dead tissue -Reduce Infection -Prevent trauma to neo-epithelium -Reduce Pain -Fewer Dressing Changes

22. Occlusive Wound Dressing Refers to ability of the dressing to prevent transmission of gases and water vapour from wound to atmosphere Occlusion limits tissue drying and desiccation and prevent secondary damage. It maintains moist environment-promote faster epitheliazation of wound. Useful in case of minimal exudate in wound. In case of heavy exudate,maceration of wound will hamper the wound healing.

23. OPEN DRESSING -More Inflammation and necrosis in early stages -Dermis is more scarred in later stages -Dermal collagen synthesis is decreased -Epithelial cell migration is decreased OCCLUSIVE DRESSING -Less Inflammation and necrosis in early stages -Dermis is less scarred in later stages -Dermal collagen synthesis is increased -Epithelial cell margin is increased

24. Properties of Ideal Dressing Material Non Adherent Highly Absorbant High moisture vapour permeability Provide barrier to external contamination Easy to sterilize Easy to apply Hypoallergic Cost effective

25. Topical Antibiotic Ointments Impregnated with antiseptic agents(ionic silver or cadexomer iodine) Broad antimicrobial spectrum No toxicity to fibroblasts etc. Acticoat ionised silver coated polyethylene mesh Silver ions are maintained at sustained levels within the dressing,which provide an effective,long lasting antimicrobial barrier to bacterial penetration. Acticoat Dressings destroy microorganisms more quickly than conventional antimicrobial products,such as silver sulfadiazine or silver nitrate,megaheal .

26. Gauze Dressing Most commonly used Limited absorption capacity.Therefore more frequent dressing changes are needed. Cause cooling and drying of wound bed Cheapest,so can be used when frequent dressing changes are needed and large areas need dressing cover.

27. Wound Healing PRIMARY HEALING - It occurs in a clean incised wound or surgical wound.Wound edges are approximated with sutures.There is more epithelial regeneration than fibrosis.Wound heals rapidly with complete closure.Scar will be linear,smooth and supple. SECONDARY HEALING - It occurs in a wound with extensive soft tissue loss like in major trauma,burns and wound with sepsis.It heals slowly with fibrosis which leads into a wide scar,often hypertrophied and contracted and may lead to disability. - Reepitheliasation occurs from remaining dermal elements or wound margins

28. HEALING BY THIRD INTENTION(TERITIARY INTENTION) - After wound debridement and control of local infection,wound is closed with sutures or covered using skin graft.Primary contaminated or mixed tissue wounds heal by Teritiary Intention STAGES OF WOUND HEALING: Stage of haematoma and inflammation Stage of granulation tissue formation Stage of epithelisation Stage of scar formation and resorption Stage of maturation

29. Phases of Wound Healing Inflammatory Phase - It begins immediately after formation and lasts for 72 hours.There is initial arteriolar vasoconstriction,thrombus formation,platelet aggregation due to endothelial damage and release of ADP - Later vasodilatation and increased vascular permeability develops. - Here haemostasis,coagulation and chemotaxis occurs. -All these cause features of acute inflammation- rubor,calor,tumour,dolor and loss of function. Proliferative Phase - It begins from 3 rd day and lasts for 3-6wks.There will be formation of granulation tissue and repair of the wound.Granulation tissue contains fibroblasts,neocapillaries,collagen,fibronectin and hyaluronic acid.

30. Remodelling Phase - It begins at 6wks and lasts for 6 months to 1 or 2yrs. - There is maturation of collagen by cross linking and realignment of collagen fibres along the line of tension,which is responsible for tensile strength of the scar. -There is reduced wound vascularity.Fibroblast and myofibroblast activity causes wound contraction.Type III collagen is replaced by type I collagen causing maturation of the collagen. -Ratio of type I collagen to type III collagen becomes 4:1. - Scar strengths in 3% in 1wk;20% in 3wks;80% in 12 wks.Final matured scar is acellular and avascular and contains type I collagen

31. The 4 barriers of wound healing are: T -Tissue-dead or deficient-Assessment and debridement of non viable or foreign material on the surface of wound. I -Infection-Assessment of etiology of each wound,need for topical antiseptic and/or systemic antibiotic use to control infection and management of inappropriate inflammation unrelated to infection M -Moisture imbalance- Assesemnt of the aetiology and management of wound exudate. E -Edge-non advancing or undermining-Assessment of non-advancing or undermined wound edges Wound bed preparation is a method of preparing the chronic wound healing therapies to accept skin graft or flap for final wound closure.

32. Factors affecting wound healing LOCAL FACTORS Infection Presence of necrotic tissue and foreign body Poor blood supply Haematoma Venous or lymph stasis Tissue tension Recurrent trauma Mechanism and type-Incised/Lacerated/Crush/Avulsion

33. GENERAL FACTORS Age,Obesity,Smoking,Alcohol,Stress Malnutrition Vitamin Deficiency(Vit C,Vit A) Diabetes Malignancy HIV and Immunosuppressive diseases Steroids and Cytotoxic drugs

34. VAC/NPWT 1. Introduction Delayed wound healing particularly in difficult wounds and in elderly with co morbidities is a major concern. It leads to the pain, morbidity, prolonged treatment, and require major reconstructive surgery which imposes enormous social and financial burden. Vacuum-assisted closure (VAC) can be used as an alternative to the conventional methods of wound management. Use of negative pressure optimizes the wound for spontaneous healing or by lesser reconstructive options. The vacuum-assisted closure is a nonpharmacologic/non surgical means for modulating wound healing It was first proposed by Argenta and Morykwas in 1997. The application of vacuum reduces oedema, infection and increases local blood flow which promote healing. It is used as an adjunct or alternate to surgery for wide range of wounds with an aim to decrease morbidity, cost, duration of hospitalization and increase patient comfort.

35. Method of VAC application Wound is thoroughly debrided, irrigated with normal saline, adequate haemostasis is achieved and peri-wound skin is made dry. Sterile foams are used for dressing as they provide an even distribution of negative pressure over the whole wound bed. Two types of foam are commonly used , Black (Polyurethane ether, lighter, hydrophobic with a pore size of 400e600 mm) used for thoracic and abdominal cavity wounds. White (Polyvinyl alcohol, dense, hydrophilic with a pore size of 250 mm) used for superficial surface wounds. A fenestrated evacuation tube is fixed in the foam, which is connected to a vacuum pump. The wound is then sealed with an adhesive drape. Drapes should cover the foam and tubing and at least 3 x 5 cm of surrounding healthy tissue to ensure a watertight/airtight seal. The dressing is usually changed on 3rd day. The negative pressure mode can be either continuous or intermittent, ranging from 50 to 125 mmHg. Intermittent mode consists of a cycle of 5 min on and 2 min off phase. The pressure setting can be kept low (50e75 mmHg) particularly for painful chronic wounds. Higher pressures (150 mmHg plus) are used for large cavity and exudative wounds

36. Indications of VAC Diabetic foot ulcers, bed sores, skin graft fixation, Burns, crush injuries, sternal/abdominal wound dehiscence, fasciotomy wounds, extravasation wounds and animal bites/frostbite. Contraindications of VAC Malignant wound untreated osteomyelitis, fistulae to organs or body cavities, presence of necrotic tissue and those with exposed arteries/nerves/anastomotic site/organs. Relative contraindications include patients with blood dyscrasias, patients on anticoagulants or with actively bleeding wounds

37. During VAC therapy RED FLAG SIGNS include active or excessive bleeding, surrounding invasive sepsis, increased pain, signs of infection, such as fever, pus or foul-smelling drainage and allergic reaction to the adhesive. Complications: Failure of the VAC system (loss of seal, power failure, and blockage of the drainage system), wound infection, pain, bleeding, allergies to the adhesive drape, excoriation of the skin, restricted mobility, adherence of the tissues to the foam, lack of patient compliance and skin necrosis.

38. VAC causes wound contraction, stabilization of the wound environment, decreased edema with removal of wound exudates, and microdeformation of cells. These effects allow VAC to accelerate wound healing by virtue of increase blood flow; reduced bacterial load; and improved wound bed preparation for subsequent coverage. The compression of tissue by negative pressure causes tissue hypoxia due to decreases perfusion beneath the foam which stimulates angioneogenesis , and local vasodilatation due to release of nitric oxide. This occurs during the “suction off” periods of VAC therapy. Therefore intermittent mode of VAC is more effective as compared to continuous mode.

39. INTERMITTENT VS CONTINOUS VAC Intermittent negative pressure is recommended as it generates more blood flow during vacuum “off” phase. Studies have shown that rate of granulation tissue formation is twice with intermittent negative pressure compared with continuous negative pressure. (103% with intermittent Vs 63% with continuous). Air leak in the dressing should be avoided as it leads to continual flow of air over the wound surface leading to desiccation of tissue and formation of eschar. This eschar seals the wound with retained exudate and leads to worsening of the wound. The pressure in VAC dressing gradually reduces over 2 days therefore, dressings should be changed after 48 h. One word of caution the VAC therapy should not be terminated abruptly after one session as it may result in a rebound phenomenon and worsening of the wound. Therefore 2 to 3 sessions of VAC should always be planned.

40. Conclusion of VAC 1. VAC is a good alternative/adjunct to standard wound care especially for difficult wounds. 2. It reduces the extent of reconstructive procedures. 3. The optimum pressure setting is 125 mm of Hg. 4. Intermittent suction is better than continuous suction. 5. There are logistic benefits of VAC over conventional wound care methods.

41. LOCAL ANTIBIOTIC DELIVERY SYSTEM The primary reason for using these local antibiotic delivery vehicles is the ability to achieve very high local concentrations of antibiotics without associated systemic toxicity. In the typical infected wound environment, which frequently has zones of avascularity, the ability to achieve high levels of antibiotics in these otherwise inaccessible areas is highly desirable. Additional reasons for use of these delivery vehicles include the desire to treat remaining planktonic organisms and sessile organisms in biofilms more effectively with high concentrations of antibiotics. 

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