Why is this Wound Not Healing? June 8, Aimee Garcia, MD, CWS, FACCWS Mary Litchford, PhD, RDN, LDN

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1 Why is this Wound Not Healing? June 8, 2017 Aimee Garcia, MD, CWS, FACCWS Mary Litchford, PhD, RDN, LDN 2017 National Pressure Ulcer Advisory Panel NPUAP Mission The National Pressure Ulcer Advisory Panel (NPUAP) is the nation s leading scientific expert in pressure injury prevention and treatment. Our goal is to insure improved patient health, and to advance public policy, education and research. npuap.org 2017 National Pressure Ulcer Advisory Panel 1

2 Reduced Price for the International Guideline! NPUAP in collaboration with the European Pressure Ulcer Advisory Panel (EPUAP) and the Pan Pacific Pressure Injury Alliance (PPPIA) has worked to develop a pressure injury prevention and treatment the Clinical Practice Guideline and Quick Reference Guide. The price of these books have recently been reduced. Purchase your copy today at National Pressure Ulcer Advisory Panel npuap.org NPUAP Monograph Released in November 2012, the 254-page, 24 chapter monograph, Pressure Ulcers: Prevalence, Incidence and Implications for the Future was authored by 27 experts from NPUAP and invited authorities and edited by NPUAP Alumna Dr. Barbara Pieper. The monograph focuses on pressure ulcer rates from all clinical settings and populations; rates in special populations; a review of pressure ulcer prevention programs; and a discussion of the state of pressure ulcers in America over the last decade. Purchase the monograph today at E-version $49 Individual Chapters $19 npuap.org 2017 National Pressure Ulcer Advisory Panel 2

3 NEW Educational Slide Sets Pressure Injury Definition and Stages Prevention of Pressure Injury Treatment of Pressure Injury Each downloadable slide set includes presentations, speaker notes and handouts Purchase the slide sets today at npuap.org 2017 National Pressure Ulcer Advisory Panel National Pressure Ulcer Advisory Panel 3

4 THANK YOU to the following companies that have provided support for this webinar! Acelity American Medical Technologies ArjoHuntligh Coloplast Dabir Surfaces HoverTech International Leaf Healthcare Medline The NPUAP webinar commercial supporters did not have any input regarding the content of this presentation. THANK YOU to the following companies that have provided support for this webinar! Molnlycke Permobil Position Health Select Medical Sizewise Span America Stryker Tamarack Habilitation Technologies Wellsense The NPUAP webinar commercial supporters did not have any input regarding the content of this presentation. 4

5 Faculty Disclosure Aimee Garcia, MD, CWS, FACCWS No disclosures Past President, NPUAP Mary Litchford, PhD, RDN, LDN President CASE Software & Books Author of: Nutrition Focused Physical Assessment: Making Clinical Connections; Laboratory Assessment of Nutritional Status: Bridging Theory & Practice Nutrition & Pressure Injuries: Putting New Guidelines into Practice Common Denominators of Declining Nutritional Status Consultant for Prosynthesis Labs Speaker s Bureau Abbott Labs Speaker s Bureau Nestle Nutrition President National Pressure Ulcer Advisory Panel 2016 National Pressure Ulcer Advisory Panel Planning Committee Disclosures Jeffrey Levine, MD Mary Litchford, PhD, RD, LDN Sally O Neill, PhD Mary Sieggreen, MSN, CNS, NP, CVN The planning committee members have listed no financial interest/arrangements that would be considered a conflict of interest National Pressure Ulcer Advisory Panel 5

6 Objectives Understand the factors that might impact wound healing Identify what work-up is required to assess a non-healing wound Discuss the nutrition recommendations for pressure injury treatment in a chronic wound. Non-healing wound A non-healing or chronic wound is defined as a wound that does not improve after four weeks or does not heal in eight weeks. Many factors can impact wound healing 6

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8 Factors that Impact Wound Healing Medications Immobility Radiation Therapy/Chemotherapy Arterial / Venous Insufficiency Diabetes & Other Chronic Medical Diseases Aging Smoking Infection Nutrition Medications Any medication that impacts the inflammatory phase NSAIDS Steroids Immunosuppressive medications 8

9 PRESSURE POINTS Factors that impact wound healing Radiation Therapy/Chemotherapy Arterial / Venous Insufficiency Diabetes & Other Chronic Medical Diseases 9

10 Normal Changes in Elderly Skin Decreased blood flow to skin Decreased elastin Flattening of the rete ridges Loss of subcutaneous fat Decreased dermal-epidermal turnover (Blackwell Science, Inc. Gilchrest BA. Histologic changes in aging normal skin. Journal of American Geriatrics Society 1982;30:139.) 10

11 Smoking Nicotine Carbon Monoxide Hydrogen cyanide Effects last for 1 hour after smoking Bacterial Burden Negative Impact on Wound Healing Prolongs the inflammatory stage Induces additional tissue destruction Delays collagen synthesis Prevents epithelialization 11

12 Sibbald RG, Woo K, Ayello EA. Adv Skin Wound Care 2006;19: Levels of Bacterial Burden Contamination Bacteria in a wound Colonization Bacteria are replicating Host remains in control Usually polymicrobial Surrounding skin External environment Endogenous sources Landis SJ. Adv Skin Wound Care 2008;21:

13 Landis SJ. Adv Skin Wound Care 2008;21: Levels of Bacterial Burden Critical Colonization wounds with more than 100,000 organisms/gram will not heal Suspect bacterial burden if a clean wound shows no improvement after 14 DAYS of topical therapy Infection Invasion of the soft tissues 13

14 Probability of Host Infection P (Infection) = Bacterial burden x Virulence Host resistance Landis SJ. Adv Skin Wound Care 2008;21: Wound Cultures Traditional swab culture detects only surface bacterial colonization/contamination may not reflect the invasive organism causing infection Quantitative Wound Culture recommended for determining infection documents bacterial burden identifies bacteria actually invading wound tissue 14

15 Quantitative Analysis Superficial Swab Z swab Levine technique Needle aspiration Punch Biopsy Tissue sample Z swab Swabs using the Z-stroke entail rotating the swab between the fingers as the wound is swabbed from margin to margin in a 10 point zig-zag fashion. 15

16 Levine technique The Levine Technique consists of rotating the swab over a 1 cm square area with enough pressure to express fluid from within the wound tissue The Levine Technique is best used when in the wound is first cleaned and there is no necrotic tissue or eschar Tissue hypoxia Inhibition of oxidative burst activity in polymorphonuclear leukocytes intracellular production of antimicrobial metabolites Reduced leukocyte killing capacity Fecal contamination contains high numbers of anaerobes Hohn DC et al. Surg Forum 1976; 27:

17 Complications Osteomyelitis Fistulas Carcinoma Sepsis Osteomyelitis Can occur in 1/3 rd of pressure ulcers Osteomyelitis most common in: Pelvis Femoral head Ischial bones Calcaneus If bone is visible or palpable, likelihood of osteomyelitis is >90% 17

18 Osteomyelitis Work up Plain x-rays Lab analysis ESR, CRP Bone scans MRI Biopsy 2011 National Pressure Ulcer Advisory Panel Fistulas Abnormal passage between two epithelialized surfaces that connect one viscera to another or to the body surface %20attachment.pdf 18

19 Fistulas Management goals: Management and free drainage of exudate Protection of surrounding skin Prevention of infection Removal of necrosis or slough Promotion of granulation from the base of the wound Sinus Tracts Discharging, blind-ended track that extends from the surface of the skin to an underlying abscess/cavity. May be caused by infection, liquefaction or a foreign body %20attachment.pdf 19

20 Sinus Tracts Management goals: Allow cleansing and draining Do not plug Protection of surrounding skin Prevention of infection Removal of necrosis or slough Promotion of granulation from the base of the wound Carcinoma in Pressure Ulcers Marjolin s ulcer Most commonly found in burn wounds and osteomyelitis Most common type: squamous cell carcinoma Other types: Basal cell Melanoma Fibrosarcoma Angiosarcoma Osteosarcoma Others 20

21 Occurrence Most malignancies in pressure ulcers occur in the sacral or iliac areas Rich lymphatic drainage to the pelvic region Higher rates of metastasis Little support for chemo; Radiation can be effective for palliation Marjolin s Ulcer Occurs in 1.7% of chronic wounds Incidence of SCCa in pressure ulcers is 0.5% Very aggressive Metastatic rate in pressure ulcers is 60% Burns (38%) Osteo (14%) Biopsy if wound present for >6 months 21

22 Prognosis Factors affecting prognosis Tumor type Location Rate of metastasis Survival rates 65-75% in 3 years 35-50% if metastatic disease present SIRS Defined as a systemic response to infection Criteria: Fever of more than 38 C (100.4 F) or less than 36 C (96.8 F) Heart rate of more than 90 beats per minute Respiratory rate of more than 20 breaths per minute or arterial carbon dioxide tension (PaCO 2 ) of less than 32 mm Hg Abnormal white blood cell count (>12,000/µL or < 4,000/µL or >10% immature [band] forms) 22

23 SIRS Non-specific Can be caused by multiple conditions: Infection Ischemia Trauma Inflammation Combination of above Sepsis Bacteremia Not always related to SIRS or sepsis Sepsis Systemic response to infection SIRS + infection Associated with: Hypoperfusion Organ dysfunction Hypotension 23

24 Nutrition Mary Litchford, PhD, RDN, LDN 2017 National Pressure Ulcer Advisory Panel Does Nutrition Really Make a Difference? Two observations: 1. Healing is a matter of time, but sometimes also a matter of opportunity. 2. Let food be thy medicine and medicine be thy food. Hippocrates Image from Dreamtime Photos 48 24

25 Undernutrition-Malnutrition Continuum Too tired to shop or cook Too tired to eat Limited food budget Illness Injury or surgery Loss of reserves Poor dietary intake Increased nutrient needs 49 Food intake Weight loss Fat stores Muscle mass Physical strength Undernutrition & malnutrition Impaired nutrient transport Organ function Food-Meds Issues Adapted from: Litchford, M. Nutr Clin Prac. Aug : NPUAP-EPUAP & Pan Pacific Pressure Injury Alliance (PPPIA) CPG Nutrition Recommendations Nutrition screening Nutrition assessment Care planning Energy intake Protein intake Hydration Vitamins and minerals Image by Dreamtime 50 25

26 Reassess Energy Requirements Provide 30 to 35 kcalories/kg body weight for adults with a pressure ulcer who are assessed as being at risk of malnutrition. Adjust energy intake based on weight change or level of obesity. Adults who are under weight, or who have had significant unintended weight loss, may need additional energy intake NPUAP-EPUAP & Pan Pacific Pressure Injury Alliance (PPPIA) CPG 51 CSB, 2016 Reassess Energy Requirements: Action Plan 1.Collect more data on actual food intake over 2-4 days 2.Determine amount and quality of protein eaten per meal 3.Recheck height & weight 4.Assess for chewing & swallowing problems 5.Reassess need for therapeutic diets Image by Dreamtime 52 26

27 Reassess Hydration Status Provide and encourage adequate daily fluid intake for hydration for an individual assessed to be at risk of or with a pressure ulcer. This must be consistent with the individual s comorbid conditions and goals. Monitor individuals for s and sx of dehydration, including change in weight, skin turgor, urine output, serum Na, and/or calculated serum osmolality NPUAP-EPUAP & Pan Pacific Pressure Injury Alliance (PPPIA) CPG Images from Dreamtime Photos 53 Reassess Water Requirements: Action Plan 1. Collect more data on actual intake water over 2-4 days 2. NFPA for s/s dehydration 3. Recheck weight history 4. Assess for swallowing problems 5. Assess need for thickened liquids if ordered Image by Dreamtime 54 27

28 Reassess Protein Requirements Offer 1.25 to 1.5 gms protein/kg body weight daily for adults with an existing pressure ulcer and who are assessed to be at risk of malnutrition when compatible with goals of care, and reassess as condition changes. Provide adequate protein for positive nitrogen balance for adults with a pressure ulcer NPUAP-EPUAP & Pan Pacific Pressure Injury Alliance (PPPIA) CPG Images from Dreamtime Photos 55 Reassess Protein Requirements: Action Plan 1. Collect more data on actual protein intake over 2-4 days 2. Determine amount and quality of protein eaten per meal 3. Assess for chewing & swallowing problems 4. Reassess need for therapeutic diets Image by Dreamtime 56 28

29 PRO gm 6/5/2017 Incomplete Protein Protein Protein Sources are Not Nutritionally Equal Complete 57 Food For Thought Which menu promotes tissue synthesis? Menu 1 (no B, light L, heavy S) Menu 2 (equal at each meal) Menu 3 (light B, light L, heavy S) No difference in outcomes Protein Distribution at Meals Breakfast Lunch Dinner Meal Menu 1 Menu 2 Menu

30 Leucine Triggers Tissue Synthesis Mg leucine per gm protein120 Leucine ( mg/gm PRO) Source Protein in Dietary Supplements per Selected Manufacturers' Websites & USDA Nutrient Analysis Database 59 Options when Intake is Insufficient Offer high calorie, high protein nutritional supplements in addition to the usual diet to adults with nutritional risk and pressure ulcer risk if nutritional requirements cannot be achieved by dietary intake. Supplement with high protein, arginine, and micronutrients for adults with a pressure ulcer Category/Stage III or IV or multiple pressure ulcers when nutritional requirements cannot be met with traditional high calorie and protein supplements NPUAP-EPUAP & Pan Pacific Pressure Injury Alliance (PPPIA) CPG Images from Dreamtime Photos 60 30

31 New Nutrition Prescription: Action Plan Image by Dreamtime 1. Address each problem: 2. Small appetite: use fortified foods 3. Insufficient protein intake: 30 gm protein meal, supplements 4. Chewing/swallowing problems: consistency modified diet 5. Fatigue: mealtime assistant 61 References 1. Posthauer ME, Banks M, Dorner B, et al. The role of nutrition for pressure ulcer management: National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, and Pan Pacific Pressure Injury Alliance white paper. Adv Skin Wound Care 2015 Apr;28(4):175-88; quiz Accessed June 10, Litchford, MD. Counteracting the Trajectory of Frailty and Sarcopenia in Older Adults. Nutr Clin Prac. Aug : Litchford M, Dorner B, Posthauer ME. Malnutrition as a precursor of pressure ulcers. Wound 2014;3(1): Accessed June 10, Evidence-based recommendations for optimal dietary protein intake in older people: a position paper from the PORT-AGE study group. J Am Med Dir Assoc 2013;14(8): Accessed June 10, National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and treatment of pressure ulcers: clinical practice guideline. Haesler E, ed. Cambridge Media: Osborne Park, Western Australia. 6. Dorner B, Friedrich EK, Posthauer ME; American Dietetic Association. Position of the American Dietetic Association: individualized nutrition approaches for older adults in health care communities. J Am Diet Assoc 2010;110: Lim SL, Ong KC, Chan YH, et al. Malnutrition and its impact on cost of hospitalization, length of stay, readmission and 3-year mortality. Clin Nutr 2012;31(3): Accessed June 10, Rojer AG, Kruizenga HM, Trappenburg MC, et al. The prevalence of malnutrition according to the new ESPEN definition in four diverse populations. Clin Nutr 2015;35(3): Accessed June 20,

32 References 9. White J, Guenter P, Jensen G, et al.; Academy of Nutrition and Dietetics Malnutrition Work Group; A.S.P.E.N. Malnutrition Task Force; A.S.P.E.N. Board of Directors. Consensus statement of the Academy of Nutrition and Dietetics/American Society of Parenteral and Enteral Nutrition: characteristics recommended for the identification and documentation of adult malnutrition (undernutrition). J Acad Nutr Diet 2012:112(5): Accessed June 20, Edsberg L, Langemo D, Baharestani M, et al. Unavoidable pressure injury: state of the science and consensus outcomes. J Wound Ostomy Continence Nurs 2014 Jul-Aug;41(4): van Anholt RD, Sobotka L, Meijer EP, et al. Specific nutritional support accelerates pressure ulcer healing and reduces wound care intensity in non-malnourished patients. Nutrition 2010;26(9): Accessed June 10, Cereda E, Klersy C, Serioli M, et al.; Oligo Element Sore Trial Study Group. A nutritional formula enriched with arginine, zinc, and antioxidants for the healing of pressure ulcers: a randomized, controlled trial. Ann Intern Med 2015;162(3): CE Test Information To earn the 1.0 CE credit for today s webinar please visit the link below. This information will also be ed out to webinar registrants ONE HOUR after the conclusion of the webinar. _1ChUkJSaolcDrGl 32