Wound Management. E. Foy White-Chu, MD, CWSP
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1 Wound Management E. Foy White-Chu, MD, CWSP
2 E. Foy White-Chu, MD, CWSP Assistant Professor, OHSU Wound Medical Director, VAPORHCS
3 List the Four Principles of Wound Bed Preparation Determine safe debridement strategies depending upon the underlying conditions Identify appropriate moisture retentive dressings dependent upon the wound bed environment
4 Tissue Infection/Inflammation Moisture Balance Edge of Wound Leaper DJ, Schultz G, Carville K, et al. Extending the TIME concept: what have we learned in the past 10 years? Int Wound Journ 2012: 9 (Suppl 2): 1-19
5 Location: Be specific Measure: Longest Length by Widest Width at 90 degrees o Measure same manner each time Periwound: Induration?, Erythema?, Skin condition? Edge: TIME Wound Bed: TIME Drainage: None, Small, Moderate, Large o Do not throw the dressing in the trash (yet) o Ask when the dressing was last changed o Inquire about the NPWT cannister change
6 Sacrum Coccyx Ischium
7 Tissue Characteristics Granulation Tissue Necrotic Eschar Necrotic Slough Biofilm AKA : that yellow stuff
8 Slide courtesy of Dr. Lisa Gould/WHS
9 Sharp Debridement for: Necrotic, Non-viable tissue o Eschar o Slough o Multiple organism-related Biofilm o Debris o That Yellow Stuff GET RID OF IT!
10 JAMA Dermatol. 2013;149(9): doi: /jamadermatol Slide Courtesy of Dr. Lisa Gould/WHS
11 Autolytic o Slowest, least painful o Hydrogels, hydrocolloids, films Enzymatic o Faster than autolytic, but requires daily dressing changes Biological o Most selective o In place for 1-4 days o Palliative Care Option o Patient/Staff may Object o Must be 100% offloaded
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13 - Inflammation - Matrix metalloproteinases (MMPs) - Protease inhibitors - Surface growth factors Eming et al, J Invest Derm, 2007
14 Contamination/ Colonization Critical colonization/ Infection
15 Definition: Communities of bacteria that attach to one another and interact synergistically. Quorum Sensing Cultures not helpful Render antibiotics useless Treatment = Reduce burden + prevent it coming back! James GA et al. Wound Repair Regen 2008 Black CE et al. Surg Clin N Am 2010
16 Silver-impregnated products o Anything with Ag Cadexomer Iodine Medical-Grade Honey Bacteriostatic Dressings (Gentian Violet) PHMB Impregnated Gauze DACC containing product (class of its own) Avoid the use of topical antibiotics o If you can take it systemically, don t put it on topically Lee Am J Clin Dermatol Panuncialman. Clinics in Plastic Surgery 2007 Reddy JAMA 2008
17 Wet wound = o Damaged, macerated edge o Biofilm development Too wet/ infected Dry wound = o Eschar formation Too dry/ sterile Choose a dressing that is NOT bulky, NOT painful, NOT changed often
18 Products that Wet It o Hydrogel o Hydrocolloid o Vaseline/oil based products Products that Dry It o Alginate o Hydrofiber o Foam o Extra-absorbent dressings
19 Manages Drainage Reduces Wound Edema Reduces Bioburden o Loosens slough and necrosis o *Must have less than 20% necrotic tissue in wound* Increases Perfusion Promotes Wound Contraction Leaper DJ, et al. International Wound Journal 2012
20 Know what to look for when it s done wrong!
21 Wound Venous Leg Ulcer Neuropathic Foot Ulcer Prognostication Tool Size 10cm 2 PLUS Duration 12 months = 78% chance of not healing in 3 months Size >2cm 2 PLUS Duration > 2 months PLUS Deep ulcer with abscess/osteo = 79% chance of not healing in 5 months Margolis J Amer Med 2003 Margolis Wound Repair Regen 2004
22 Erythema Hyperkeratotic Maceration Rolled Edge/Epibole Epithelialization
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27 Eliminate Odor What causes the odor? Possible Treatments Anaerobes Cleansing Dakin s 0.25% Air-tight secondary dressing charcoal dressings Topical metronidazole Gel (0.75%) Contains ALCOHOL Cream (1%) Silver, cadexomer iodine dressings Oil of peppermint, kitty litter and coffee grounds?? Beware the malodorous hydrocolloid! Kalinski Wounds 2005 McDonald Journal of Palliative Medicine 2006 Alvarez J of Pall Med 2012
28 Pharmacologic: o Opiates premedicate with oral 30 minutes before or IV immediately before each dressing change o Topical lidocaine 4% solution o Local Wound Care: Atraumatic dressings Protect periwound skin Adjunctive Therapies: o Heat/Cold compresses o Distraction Therapy (music, relaxation techniques) ALLOW THE PATIENT TO BE IN CONTROL Allow individual to call time out Woo et al. Curr Opin Supp Pall Care 2013
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Chronic Wound Care ASPS #1: Use of wound surface culture technique in patients with chronic skin ulcers (overuse measure) This measure may be used as an Accountability measure Clinical Performance Measure