Optimizing Wound Care Outcomes: Pre and Post Procedure Protocols. Srinivas Iyengar MD, FACC Bradenton Cardiology Center
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1 Optimizing Wound Care Outcomes: Pre and Post Procedure Protocols Srinivas Iyengar MD, FACC Bradenton Cardiology Center
2 No relevant financial disclosures
3 Define the problem! Prior to any therapeutic intervention, identify etiology Comprehensive approach is mandatory to optimize wound care outcomes Systemic evaluation/treatment based on ulceration/wound
4 Treat the patient, not just the ulcer Identify modifiable risk factors Have appropriate specialists manage specific issues Thorough communication with patient and patient s family integral to improving outcomes as well as keeping expectations realistic
5 Multi-specialty Approach Diabetes, smoking- PCP, endocrinology LE arterial/venous ulcerations: Podiatry, surgery Vascular inflow/outflow: Vascular surgery, Cardiology, Radiology Infection: PCP, Infectious Disease Nutrition: Home Health, Nutritionists
6 Wound Care Centers Best case scenario to combine all specialties under one roof If not possible, collaboration and communication between specialists is a must Again, emphasis has to be made on a systemic approach, not just local wound care
7 Identify etiology Surgical wounds Venous ulcers Arterial ulcers Diabetic ulcers Pressure ulcers Mixed ulcers
8
9 Healing Outcomes Healable Wounds: goal is for closure with functional integrity Maintenance wounds: Slow healing, goal is for patient independence w/o further progression Non-healable wounds: Prevent progression to other areas/systemic, pain control, amputation
10
11 Site specific protocol Irrigation of wound bed Topical antiseptics (i.e. pre-treatment with chlorhexidine) Debridement- sharp, enzymatic, maggot tx Wound closure- suture Scar management- sunscreen, massage
12 Hyberbaric Oxygen Therapy Diabetic foot wounds- significantly reduce the risk of major amputation and improve healing Mandibular osteoradionecrosis- help close fistula tracts, decrease amount of exposed bone,obtain complete closure Peripheral nerves- improvement in functional recovery following microsurgical repair
13 Pre-endovascular arterial intervention protocol Absolutely must have thorough arterial exam performed Rule-out other etiologies prior to performing endovascular procedure (i.e. venous, pressure) Quality abdominal and LE arterial performed to define complete inflow ABIs AND TBIs Cannot emphasize enough importance of risk factor modification
14 Pre-protocol If U/S is sub-optimal, obtain abd/pelvis/le run-off CTA Identify any renal/iodine issues PRIOR to procedure (as well as for CTA) Discuss with surgical colleagues about alternative therapies if warranted
15 Peri-procedural issues Discuss with wound care team about possible use of anti-platelet agents (i.e. plavix) and concerns with debridement May plan local procedure immediately after or before debridement depending upon blood loss expectation/tissue depth/surgical concerns Watch-out for groin complications!!
16 Post-procedure Protocol Patient should have f/u with wound care specialist within 1 week of endovascular procedure and weekly thereafter until wound closure ABIs +/- LE arterial U/S to be repeated in one month, f/u by repeat study at six months Timing of repeat studies variable as rate of healing/progression will often dictate individual approach
17 Post-procedure outcomes Important to realize limitation of PTA/atherectomy/stents for long-term cure of LE arterial disease Patient may have wound/ulcer closure but ultimately may have re-stenosis of target vessel (especially infra-popliteal arteries) Key is to MODIFY life-style issues so patient does not have recurrence of ulcerations (i.e. adjustment of foot-wear, avoidance of walking barefoot, diabetes control)
18 Summary: Pre Pre: Risk factor modification, comprehensive approach, target lesion etiology/identification, appropriate pre-procedure testing (i.e. ABIs) Nutrition, infectious diseases, metabolic issues to be identified STOP SMOKING!!
19 Summary: Peri Discussion about possible long-term usage of anti-platelet medications with both patient and wound care team Maintenance of close wound care f/u and antibiotic tx (if pt receiving outpatient therapy) Nutritional/social support
20 Summary: Post Immediate f/u with wound care team within the week Repeat vascular testing as deemed appropriate Additional endovascular procedures as needed (i.e. contralateral limb for bilateral ulcerations)
21 It takes a village to raise a child it takes a team to heal an ulcer!
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