Effective Wound Healing: Getting Back to the Basics Bill Richlen PT, WCC, DWC
What Is Happening Currently? There is a lack of education in current wound care principles and evidence-based practice We have always done it this way Institutions where one would expect expertise in wound healing are not truly experts
What Is Happening Currently? Loving wound care, being a wound center, or being called the wound care doesn t mean they are truly experts. When all you have is a hammer, everything looks like a nail
What Is Happening Currently? eems to be an over-reliance on advanced therapies NPWT used on necrotic wounds? HBOT in pts who are notably malnourished
o What Are The Basics? Remove or Treat the Cause Moist Wound Therapy Remove necrotic tissue and epibole Manage the bioburden Nutrition Tissue perfusion
Remove/Treat the Cause Pressure Effective turning and repositioning upport surfaces Venous Insufficiency Graduated compression therapy Massage Increase mobility
Remove/Treat the Cause Arterial Disease Re-establish sufficient blood flow ART Assist device Mixed Arterial/Venous Re-establish sufficient blood flow Edema management
Remove/Treat the Cause Diabetes Blood sugar control Offloading TCC is gold standard Footwear PT, podiatry and orthotist working together to determine best types of footwear
Moist Wound Therapy Current principle for healing 1962 Dr. George Winter 1972 DT Rovee TEWL study
Moist Wound Therapy Why so important? Natural environment of living cells Enhanced autolysis Increased angiogenesis Increased reepithelialization Decreased Pain
What Are The Basics? Moisture levels can affect tissue temperature Cellular function optimal at normal body temp imple dressing change can drop temp enough to require 4 hours to resume healing Result is vasoconstriction, decreased oxygen, increased risk of infection and impaired enzyme and cell function
Moist Wound Therapy Exude Managaement Exudate has several roles Flushes away debris Carrier medium Lubricant
Moist Wound Therapy Exude Management Ideal level is scant to minimal Moderate to High levels Risk of maceration Chronic wound exudate can have higher levels of proteolytic enzymes Choose dressings or treatments that remove excess yet keep wound moist
Moist Wound Therapy Exudate Management Insufficient levels Leads to dry wound beds and cell death Causes: prolonged exposure, inappropriate topical products, and poor blood flow Choose product that add moisture or prevent loss
Debride Necrotic Tissue Necrotic Burden Growth medium for bacteria Endotoxins that impede healing Prevent wound contraction, granulation and epithelialization
Debride Necrotic Tissue Necrotic Burden Removal essential using appropriate and effective debridement options A number of advanced therapies require minimal necrosis present before implementation
Debride Necrotic Tissue elective Debridement Methods Autolytic: Body s own way of cleaning up the wound; promote moist wound Enzymatic: Collagenase antyl is only option Biological/Bio-urgical: use of medical grade larva to clean wound
Debride Necrotic Tissue Non-elective Debridement Methods Mechanical: crubbing, Irrigation, Pulsed lavage, whirlpool harp: Fastest method using scalpels, curettes, scissors to remove necrotic tissue; can be performed by MD, NP, PA, PT, PTA, OT and Nurses
Remove Epibole Epibole Commonly known as rolled or curled edges Prevention via scrubbing Treatment via surgical excision or chemical cauterization
Manage the Bioburden Bioburden All wounds are contaminated Goal is a host manageable bioburden Compete for oxygen and/or nutrition Release waste products/toxins
Manage the Bioburden igns/ymptoms of high bacteria Increased/purulent drainage Edema Induration Heat Friable granulation Foul odor Delayed healing Erythema Pain
Manage the Bioburden 4 distinct categories Contamination Colonization Critical Colonization 1-2 signs or symptoms Infection 3 or more signs or symptoms
Manage the Bioburden Proper and effective wound cleansing tudy showed that more than 50% of wounds cleaned with normal saline showed increased bioburden Use methods that effectively remove bacteria and debris
Manage the Bioburden Antimicrobial Products Cleansers, gels, and dressings that contain things like sodium hypochlorite, silver and cadexomer iodine Topical antispetics and antiboitics are for infected wounds and should be limited to 2 wks in duration
Manage the Bioburden Antimicrobial Products Not all created equal and therefore may not produce results Do your due diligence Time kill studies? Where was product tested? Under what conditions was it tested? FDA clearance or approval as an antimicrobial? Does your silver play nice with N?
Nutrition According to studies 85% Nursing Home patients are malnourished Under-managed and misunderstood Need proper levels of nutrients in all phases igns of malnutrition Low BMI Unintended weight loss Muscle wasting Low energy Poor skin turgor
Nutrition Run the appropriate labs Albumin At Risk Level <3.5gm/dL Pre-Albumin At Risk Level <16mg/dL Transferin At Risk Level <200mg/dL
Nutrition Run the appropriate labs Normal values do not mean pt is getting enough protein to HEAL! Be sure to recheck to ensure interventions are working
Nutrition Daily Nutrition Requirements Protein: 1.2 1.5 gm/kg Unique in that it contains nitrogen Positive Nitrogen Balance in order to grow new tissue = Anabolism Negative Nitrogen Balance = Catabolism
Nutrition Daily Nutrition Requirements Carbs: will vary with pts depending on activity levels and diabetes Necessary to spare protein from being used for energy Closely monitor glucose levels in diabetics
Nutrition Daily Nutrition Requirements Fats Cell membrane development and inflammatory response Good source of energy Good alternative energy source for diabetics
Nutrition Daily Nutrition Requirements Calories: 30-35 kcals/kg Protein = 4 cal/gm Carbs = 4 cal/gm Fat = 9 cal/gm Total grams of protein and calories CONUMED needs to be calculated daily to ensure needs are met
Nutrition Daily Nutrition Requirements Fluids: 30ml/kg bodyweight or 1500ml per day Additional fluids is draining wound, emesis and diarrhea Add 500ml/day if using airfluidized therapy
Nutrition Daily Nutrition Requirements Use multivitamin/mineral supplement if deficiencies No studies show improved healing with extra Vit C and zinc supplement if levels are normal
Nutrition Nutritional trategies 5-6 small meals per day Favorite foods Easy to chew and swallow Fortified foods Nutritional supplements with medications Pro tat AWC Juven Arginaid Extra
Tissue Perfusion/Blood Flow Oxygen is required in all phases of wound healing Arterial disease and edema (venous and lymphedema) can compromise flow Pulmonary disease and dehydration can lead to wound hypoxia Identify cause and treat
o Where Do Adjunctive Therapies Fit in Picture? Once you have effectively managed all the basics with standards means Adjunctive therapies can help manage some of the basics, however if one of the basics is not being addressed, the ROI may not be cost effective
Closing Thoughts Chronic wounds pose many challenges to clinicians Most disciplines do not receive advanced wound training as a part of their initial degree curriculum Ensure basics are being managed first eek consultation from wound care specialists: WCC, CWOCN, CW, CWP, CWCA, DWC
KEEP CALM HEAL THOE WOUND!
Thank You