Basics of Modern Wound Management

Transcription

1 EAHP Workshop Wounds, Paris 13. and Innovative approaches to wound care Basics of Modern Wound Management Prof. Dr. Matthias Augustin Director, Institute for Health Services Research in Dermatology and Nursing (IVDP) and Comprehensive Wound Center (CWC) University Medical Center Hamburg-Eppendorf Institute for Health Services Research In Dermatology and Nursing Comprehensive Wound Center German Center for Health Care Research (Cvderm) Chair for Health Economics Clinical Research Unit 1

2 No disclosure of interest related to this presentation Topics today Basics of Modern Wound Management 1. Wound entities 2. Wound healing and wound stages 3. Guideline-compliant Therapies 4. Standards in diagnostics 5. Standards in treatment 6. The innovation pipelines 2

3 Wound entities Which wounds? Wound man Source: Heidelberger Handschriften 14. and 16. Century Wound entities Acute wounds Normal wound healing Healing within 1-3 weeks e.g. traumatic wounds, surgical wounds Delayed wound healing Healing within 4-6 weeks e.g. infected surgical wounds 3

4 Wound entities Chronic wounds Stagnation of wound healing No signs of healing for > 6 weeks Pathology of tissue Example 55 y/o female patient Type I Diabetes for 20 ys. Non-healing leg wound for about 6 months Cause: deep inflammation of the skin Wound entities Chronic wounds Community ulcers in the Metropolitan area of Hamburg (n=502) Min Max Mean SD Disease duration (yrs.) 8,9 8, Open wound (yrs.) 2,5 6,

5 Chronic wounds Most frequent chronic wounds 1. Ulcus cruris (Leg ulcer) 2. Decubitus (pressure ulcer) 3. (Diabetic) foot ulcer Augustin M, Debus ES (Hrsg.): Moderne Wundversorgung Band 2. Betaverlag Bonn 2011 Chronic wounds Similarities? Diabetische Wunden A: Charcot-Fuß, Ulcus Mittelfuß Stadium III A, B: Ulcus Vorfuß Stadium II A, C: Wagner Stadium II B, D: Malum perforans Vorfuß und Großzehe Stadium II A. Druckgeschwüre. A: Dekubitus II B gluteal, B: Fersengeschwür II B, C: Dekubitus II B, D: Dekubitus sakral bei WS-Fixateur 1. Mean age >70 yrs. 2. Multimorbidity 3. Multiple etiologies 4. High patient burden 5. High economic burden Chronisch venöse Unterschenkelgeschwüre. Typische Befunde: Hämosiderineinlagerungen und Dermatosklerose der Umgebungshaut, geschlängelte Venen am Fußrand (Bild A, B), Ödem im Bereich des Unterschenkels/Fußes (Bild C), Mazeration der Umgebungshaut durch starkes Exsudat um die Wunde. Augustin M, Debus ES (Hrsg.): Moderne Wundversorgung Band 2. Betaverlag Bonn

6 Chronic wounds Pathogenesis? Leg ulcers Diabetic foot ulcers Pressure ulcers Chronic wound = Ulcus Chronic wounds Pathogenesis Leg ulcers Venous disease Arterial disease Skin inflammation Infections Tumors Tissue damage Diabetic foot ulcers Neuropathy Angiopathy Musculo-sceletal dysfunction Tissue damage Pressure ulcers Chronic pressure Lack of movement Lack of off-load Tissue damage 6

7 Chronic wounds Pathogenesis of chronic wounds Vaskulitisch Vasculitis 2% Sonstige Others 3% Unklar Unknown 9% Gemischt/ Ischemic, mixed arteriell 23% Venous insufficiency Venös 63% Augustin M et al., Wound Repair Regen 2011 What is specific about a chronic wound? 7

8 What is specific about a chronic wound? What is specific about a chronic wound? Therapeutic approach Individual management Kausal + symptomatic Phase-specific Combined treatments Interdisciplinary Interprofessional Augustin M, Debus ES (Hrsg.): Moderne Wundversorgung Band 2. Betaverlag Bonn

9 Can wound treatment be standardized? Can wound treatment be standardized? Who performs the dressing changes in leg ulcers? (n=502) Dressing VW durch Sonstige Others change in the community by... Family Familie 1% 2% Ehepartner 8,5% Partner of patient Home Pflege-cardienst service 34% Doctor Arzt 24% Patient Selbst self 30% 9

10 Topics today Basics of Modern Wound Management 1. Wound entities 2. Wound healing and wound stages 3. Needs in Wound Management 4. Guideline-compliant Therapies 5. Standards in diagnostics 6. Standards in treatment 7. The innovation pipelines Wound healing in chronic wounds Healing phases Exsudation Phase Granulation Phase Epithelization 10

11 Wound healing in chronic wounds Treament end points Healed tissue readiness-to-graft Granulation induction Wound Cleaning Debridement 100% Wound healing Infection control - Exsudate control - Pain control Necrosis - Fibrin - Granulation - Epithelization Augustin M, Blome C, et al: Benefit evaluation in the therapy of chronic wounds from the patients' perspective-development and validation of a new method. Wound Repair Regen. Topics today Basics of Modern Wound Management 1. Wound entities 2. Wound healing and wound stages 3. Guideline-compliant Therapies 4. Standards in diagnostics 5. Standards in treatment 6. The innovation pipelines 11

12 Are there any standards in the treatment of chronic wounds? International Guidelines on leg ulcers SIGN-Guideline, Scotland 1998 Canadian Guideline (Ontario) 2004 Irish Guideline 2002 New Zealand Guideline

13 International Guidelines on pressure ulcers International Guidelines on chronic wounds 13

14 International Guidelines on chronic wounds Use of guidelines How can the guideline recommendations be - standardized - measured - appraised? Quality indicators for chronic wound management The 20 most important quality indicators of good wound treatment practice in leg ulcer (German Delphi Panel, 2006) I. History 1. Diligent anamnesis 2. History of pain II. Diagnostics 3. Accurate wound status 4. Wound size 5. Pain level 6. Vascular status 7. ABPI 8. Bacteriology 9. Biopsies 10. Allergy diagnostics III. Treatment 11. Compression treatment 12. Vascular surgery, if indic. 13. Wound debridement 14. Pain treatment, general 15. Pain treatment at dressing 16. Moist wound healing 17. Antiseptics for infection IV. Prevention 18. Aftercare 19. Compliance 20. Patient information Augustin M, et al.: Quality-of-care in chronic leg ulcer in the community introduction of quality indicators and a scoring system. Dermatology: 222(4):321-9,

15 Topics today Basics of Modern Wound Management 1. Wound entities 2. Wound healing and wound stages 3. Guideline-compliant Therapies 4. Standards in diagnostics 5. Standards in treatment 6. The innovation pipelines Chronic wounds general investigations Clinical approach according to guidelines: Accurate medical history Clinical findings Technical diagnostics Laboratory adapted to clinical situation! 15

16 Diagnosis + interdisciplinary approach! Female patient K.M., born 1937 Admission to intensive care unit: Admission diagnosis: Chronic venous ulcer Clinical findings Diagnosis + interdisciplinary approach! Female patient K.M., born 1937 Admission to intensive care unit: Diagnosis: Severe leukocytoclastic vasculitis Acute kidney failure Clinical findings

17 Chronic wounds clinical investigation Wound control: TIME scheme Tissue Standard Infection or inflammation Moisture imbalance Edge EWMA position paper 2004 Chronic wounds clinical investigation Tissue Infection or inflammation Moisture imbalance Fibrin 40% Edge necrosis 40% Epithel 15% Granulation 5% 17

18 Chronic wounds technical investigations Obligatory investigations Doppler-/Duplex Venous system Ankle-brachial pressure index Functional diagnostics, e.g. photoplethysmography Standard Standard Gallenkemper 2001, Partsch 2002, DGP guideline 2004 (B) Chronic wounds Laboratory investigations Biopsy and histopathology Important, if unknown etiology Standard unusual ulcer morphology long-lasting ulcer: exclude malignancy Guideline DGP 2004 (A) 18

19 Chronic wounds Follow-up diagnostics Ulcer planimetry and photo documentation Standard digital wound documentation Pain score Standard 10 cm visual-analogue scale Guideline DGP 2004 (A/A) Topics today Basics of Modern Wound Management 1. Wound entities 2. Wound healing and wound stages 3. Guideline-compliant Therapies 4. Standards in diagnostics 5. Standards in treatment 6. The innovation pipelines 19

20 Appropriate therapy = causal + symptomatic therapy Treatment of chronic wounds 1. Local therapy 2. Systemic therapy 3. Surgery Wound dressings * Growth factors Protease inhibitors Local antiseptics * 4. Physical therapies Local anesthetics * Enzyme therapeutics * 5. Other treatments Sugar, Honey * (*=System. Review) (A=recommendation LL) Biologic wound debridement (maggots) A 20

21 Phase-adapted therapy of chronic wounds Amount of exsudate necrosis - fibrin - granulation - epithelization Phase-adapted therapy of chronic wounds Amount of exsudate necrosis - fibrin - granulation - epithelization 21

22 CWC Comprehensive Wound Center - UKE Universitäres Wundzentrum Phase-adapted therapy of chronic wounds Amount of exsudate Vacuum treatment Charcoal dressings Alginates / Hyaluroic acid derivates Foams Hydrocolloids Biosurgery Hydrogels Skin grafts Growth factors Films necrosis - fibrin - granulation - epithelization Wound dressings 1. Topical therapy Reduction of wound dressing material portfolio at the University Medical Center of Hamburg Year Products (n=) Cost savings 2011: 1, : ,000 22

23 Attention: Woundburger Film Active Coal Foam Hydrogel Alginate Illustration by Sellmer 2013 Attention: Woundburger Costs: about 40 Euro per dressing Illustration by Sellmer

24 Do we only need one dressing? Reality of health care 20 chronic wounds in practice 06./ indication for 12 different wound dressings Do we only need one dressing? 12 differentiation criteria for the choice of dressing Wound type Severity Localization Pain status Surrounding tissue Wound edges Wound condition Wound odor Exsudation Perfusion status Infection status Comorbidity Decision factors for wound dressing and further wound therapy Predictors of healing outcomes 24

25 Anti-microbial therapy 1. Topical therapy Antiseptics 1 esp. Octenidine, Polihexanide, PVP-iodine Ag-Preparations Standard Local anesthetics SR: 3 studies, pain reduction with LA cream significantly effective (Briggs 1999) Standard 1 DGP guideline 2012 (A) 1 Consensus recommendation for the selection of wound antiseptics, ZfW 3/04 In total > 20 RCTs 1. Topical therapy First growth factors used in clinical trials PDGF Platelet derived growth factor TGF-beta Transforming growth factor-beta TGF-alpha Transforming growth factor-alpha FGF Fibroblast growth factor (acidic, basic) KGFs Keratinocyte growth factors EGF Epidermal growth factor IGF-1 Insulin-like growth factor-1 VEGF Vascular Endothelial Growth Factor F. XIII Factor XIII 25

26 1. Topical therapy Factor XIII in Ulcus cruris weekly follow-ups New technology: Platelet Rich Fibrin (PRF) Rationale: Centrifuged autologous thrombocyte concentrate from venous blood in fibrin matrix; enriched concentration of growth factors 26

27 PRF applications DFU: 2 visits in 2 wks Treatment of chronic wounds 1. Local therapies 2. Systemic therapies 3. Surgery Pentoxyphyllin * Zinc * Prostaglandin E1 Cumarin Fibrinolytics 4. Physical therapies Diuretics 5. Other treatments Flavonoids, Saponines Antibiotics 27

28 2. Systemic therapy Pentoxyphyllin SR: 9 studies, 572 Pat. Evidence compared to placebo, especially if combined with compression treatment (Jull 2002) Oral Zinc in CVI and UCM SR: 6 studies, weak evidence for patients with low serum zinc, otherwise not (Wilkinson 2002) Treatment of chronic wounds 1. Local therapy 2. Systemic therapy 3. Surgery Vein surgery * Surgery of fascia 4. Physical therapies 5. Other treatments Sclerotherapy Surgical debridement * Shave therapy Split skin and mesh graft, reverdins * Lobe transposition Allogenic or autologous transplantations * Synthetic skin equivalents 28

29 3. Surgical treatment of chronic wounds Function of surgical interventions 1. Early wound healing phases: Removal of necroses and sludge ( Debridement ) 2. Advanced wound healing phase: When well granulated = ready to graft: Skin grafting 3. After healing (or in parallel): Treatment of underlying conditions e.g. dissection of insufficient veins, arterial interventions Debridement Surgical Debridement Standard 29

30 Debridement Ultrasound Debridement Dermatology 2011;222: DOI: / Received: November 1, 2010 Accepted after revision: February 16, 2011 Published online: April 5, 2011 Efficacy, Tolerability and Patient Benefit of Ultrasound-Assisted Wound Treatment versus Surgical Debridement: A Randomized Clinical Study Katharina Herberger Nadine Franzke Christine Blome Matthias Augustin Nathalie Kirsten Center for Dermatological Research, Comprehensive Wound Center, Institute for Health Services Research in Dermatology and Nursing, University Clinics of Hamburg, Hamburg, Germany Herberger K et al., Dermatology 2011 Debridement Biosurgery: Maggot therapy (Lucilia sericata) Fly (Imago) Eggs 30

31 Debridement Biosurgery: Maggot therapy (Lucilia sericata) Quick Debridement Debridement Biosurgery: Maggot therapy (Lucilia sericata) Maggots before/after 72 h of wound incubation 31

32 3. Surgical treatment of chronic wounds Mesh-graft Reverdin Punch Graft 3. Tissue engineering of chronic wounds Transplantation of autologous Keratinocytes 32

33 3. Tissue engineering of chronic wounds Transplantation of autologous Keratinocytes 66 Jy/o Patient Ulcus cruris since > 20 yrs Non-healing acute ulcer for 3 yrs. Before Tx. / after 3 months Treatment of chronic wounds 1. Local therapy 2. Systemic therapy 3. Surgery 4. Physical therapies 5. Other treatments Medical compression therapy * (A) Intermittent apparative compression * (A) Vacuum therapy * (A) Ultrasound therapy * (A) Laser therapy * (B) Electro stimulation * (A) Physiotherapy, walking training (A) Lymph therapy (A) Medical baths 33

34 4. Physical therapies Medical compression treatment Standard Essential in venous leg ulcer! Cave: - ABPI not below Polyneuropathy - Quality of application! DGP-Guideline 2004 (A) Evidence of compression treatment Cullum N et al., The Cochrane Library, 2 (2002) 34

35 4. Physical therapies Topical negative pressure treatment (TNP) DGP-Guideline 2004 (A), DDG-Guideline 2004 (B) 4. Physical therapies Electrostimulation SR: 12 studies, extensive experimental work 1) Gardner, S. E. et al, The Effect of Electrical Stimulation on Chronic Wound Healing: A Meta-Analysis. Wound Repair and Regeneration 1999; Vol 7, S ) McCaig C. D. et al, Controlling cell behavior electrically: current views and future potential, Physiol Rev 2005; 85:

36 Stimulation of VEGF secretion in eletrical field (EF) VEGF Zhao et al J Cell Sci January 26; 117(Pt 3): Clinical effects of electrostimulation on chronic wounds Granulation, Epithelization (range: 0=no to 5=complete) ITT analysis (n=95) PP analysis (n=45) 4,5 4, ,5 3, ,5 2 1,5 Granulation Epithelization 2,5 2 1,5 Granulation Epithelization 1 1 0,5 0, ,5 T1 T2 T3-0,5 T1 T2 T3 Granulation: 2.7 x increase Epithelization: 17.0 x increase Herberger K, Debus ES, Larena A, Blome C, Augustin M: Effectiveness, Tolerability, and Safety of Electrical Stimulation of Wounds With an Electrical Stimulation Device.. Wounds: 24 (4): 76 84,

37 5. Other treatments Nutrition Standard Check nutritional status in any chronic wound! If necessary, diet consultation EPUAP-Guideline 2004 (B) 5. Other treatments Pain treatment Frequently underestimated! Standard More pain Less pain Leg ulcer Burn injury 1 Infected wound Pressure ulcer Cut wound Pediatric wound Diabetic foot ulcer 37

38 Do costs matter? 1) Therapeutic Innovations 1.1) Established (=in routine use; partially evidence-based) NPWT (VAC, Avance, etc.) Electrostimulation (WoundEL) Tissue engineering (autologous Keratinocytes, stem cells) Cell-based therapies Growth factors (PDGF/ Becaplermin) Biosurgery 2) Diagnostic Innovations intellligent wound dressings Biomarkers Pharmacogenomics 3) Innovations in Wound Management Telemedical Wound Care Wound Networks 1.2) Procedures in development Further growth factors) P-Stim (retroauricular vagal stimulation) PRF - Platelet-rich Fibrin Tissue engineering (stem cells) FA ArthroCare: Shave and Koagulate Bacteriophages Plasma therapy Microspheres Local hyperbaric oxygenation Molecular biologic and genetic procedures 38

39 Early investment pays Evidence for: TNP, hydroactive wound dressings electrostimulation, autologous KC, skin grafts, wound healing factors? Augustin M, Vanscheidt W. Chronic venous leg ulcers: the future of cell-based therapies. Lancet ;380(9846):953-5 Early intervention pays Benefits of early intervention in wound treatment PASI Wound Score Frühe Early Early Intervention Late Intervention Späte Late Intervention M on. Augustin M: Gesundheitsökonomische Aspekte der Wundversorgung. In: Augustin M, Debus S (Edts.): Moderne Wundversorgung. mhp Verlag

40 Early Early intervention intervention pays pays Benefits of early intervention in wound treatment PASI Wound Score Frühe Early Range of higher costs Späte Late Intervention M on. Augustin M: Gesundheitsökonomische Aspekte der Wundversorgung. In: Augustin M, Debus S (Edts.): Moderne Wundversorgung. mhp Verlag 2009 Next presentation: Innovations in wound treatment Growth factors 40

41 Thank you! 41