wound healing AND ITS COMPLICATIONS.pptx

WOUND HEALING AND COMPLICATIONS

1. WOUND HEALING AND ITS COMPLIACTIONS Presented by: Dr. Sourav Panda DNB JR 1 Max Superspecialty Hospital, Saket, New Delhi

2. Wound Healing Defined as response of the host tissue to injury to restore the mechanical integrity and to restore the barrier to fluid lossand infection and to re establish normal blood and lymphatic flow patterns is known as wound healing.

3. Phases of wound healing Haemostasis Inflammatory phase (3 to 5 days) Proliferative phase (starts from D3, lasts for 2-4 weeks) Remodelling phase.(starts after 2-4weeks, lasts for years)

4. Haemostasis Response of the host tissue to stop hemorrhage and restore normal blood flow. Injury to blood vessels Local Vasoconstriction Formation of primary platelet plug Coagulation cascade

5. Inflammation Starts soon after the injury and lasts for 3 – 5 days. Predominant cells: Initially Neutrophil, Later Monocytes (Macrophages). Release of chemicals as a result of platelet activation Bradykinin, C3a C5a, Histamines and leukotrienes. Neutrophils help in wound decontamination Macrophages aid in wound debridement.

6. Proliferation Starts around day3, lasts for 2-4 weeks. Predominant cells: Fibroblasts. Angiogenesis, Collagen deposition, Re- epithilialisation . Multiple growth factors: PDGF, VEGF, EGF, TGF-b Formation of granulation tissue and production of ECM. Myofibroblasts: Wound contraction.

7. Remodelling Starts by 2-3 weeks and lasts for 1 to 2 years. Further Crosslinking of collagen Conversion of collagen type 3 to type1 (4:1) Regression of capillaries. Increase in wound strength

8. Local factors affecting wound healing Oxygenation Infection/ Prolonged Inflammation Foreign body Hydration of the wound Wound Characteristics

9. Systemic factors affecting wound healing Age and Gender Systemic Diseases Diabetes Obesity Nutrition Alcohol and Smoking Drugs: Glucocorticoids, Adriamycin.

10. Complications of wound healing Keloid Grow beyond the borders of the original wound margin. Rarely regress with time Common in darkly pigmented skins (Africans/ Asians) Genetic susceptibility (multigenetic disposition) Defective apoptosis and increased TGF-b Not preventable Proliferative scars characterized by excessive net collagen deposition. Hypertrophic scar Raised scars within the margin of the original wound. Regresses spontaneously with time. Increased tension in the wound acts as a stimulus for activation of fibroblasts and increased collagen deposition. Preventable Tension relief Hydration and occlusion of wounds

11. Treatment of Keloids First line: Silicones sheets with pressure therapy + intralesional triamcinolone. Intralesional 5FU, Bleomycin and Verapamil can be used as 2 nd line medical treatment Refractory cases after 12 months: Surgical excision (High recurrence rate of 50 to 100%) Immediate post operative brachytherapy with iridium-192 reduces recurrence rates. Internal cryotherapy: reduction in scar volume without recurrence Imiquimod (TLR-7 agonist)

12. Classification of surgical wounds Type1: Clean wound Uninfected No brak in sterile technique No inflammation is encountered Respi / GI/Genital/ uninfected urinary tract is not entered Primary closure.

13. Clean Contaminated wound Respi / GI/ Genital/ Urinary tract is entered under controlled conditions and without unusual contamination. Specifically surgeries of Billiary tract, appendix, oropharynx, vagina are included in this category. No evidence of infection.

14. Contaminated Open traumatic wounds<4h Surgeries with major breaks in sterile technique Gross spillage from the GI tract Incision with acute non purulent inflammation

15. Dirty/ Infected Old open traumatic wounds>4h Surgeries for perforated viscera The organism causing post op infection were present in the surgical field before the procedure.

16. Risk of SSI in surgical wounds Type w/o Abx prophylaxis with abx prophylaxis Clean 2% 1% Clean contaminated 10% 3% Contaminated 20% 6% Dirty 40% 7%

17. SSI Signs of infection at the site of surgery that occurs Within 30 days of surgery or Within 1 year of surgery with an implant in situ. Types of SSI Superficial Incisional Deep incisional Organ or body space

18. Southampton Wound Grading system Grade 0: Normal Healing Grade 1: Mild brusing / Erythema. Grade 2: Erythema + Other signs of inflammation. Grade 3: Clear/ Serosanguinous discharge Grade 4: Pus discharge Grade 5: Deep wound infection with anatomical separation or hematoma requiring aspiration

19. Asepsis Wound score Criterion points A Additional Treatment Antibiotics for wound infection Drainage of pus under LA Debridement of wound under GA 10 5 10 S Serous discharge 0-5 E Erythema 0-5 P Pus discharge 0-10 S Separation of deep tissues 0-10 I Isolation of bacteria from the wound 10 S Stay in hospital >14days 5

20. Interpretaion 0 to 10 Satisfactory Healing 11 to 20 Disturbance of healing 21 to 30 Minor wound infection 31 to 40 Moderate wound infection >40 Severe wound infection