Case Wounds Mark H. Meissner, MD University of Washington School of Medicine 65 yr old male physician Recurrent R medial malleolar ulcer over 5 years New R lateral malleolar ulcer Intermittently wearing stockings Past history 5 R knee reconstructions History of DVT treated with thrombolysis (1997) Multiple previous superficial venous procedures Endovenous laser ablation R GSV Multiple round of tributary & perforator foam sclerotherapy Exam 6 7 cm patch venous eczema R medial malleolus Lateral malleolar ulcer 1+ pretibial edema, No superficial varicosities Fundamentals of Ulcer Care Compression, compression, compression. Debridement Maintain a moist environment Primary wound dressings Secondary wound dressings Exclude correctable pathology Superficial reflux Proximal obstruction Compression and Ulcer Healing Cullum NA, Cochrane Reviews 2001 Compression (# healed) No Compression (# healed) Relative Risk (95% CI) Charles 19/27 6/23 2.70 (1.30-5.60) Eriksson 9/17 7/17 1.29 (0.62-2.65) Kitka 21/30 15/39 1.82 (1.15-2.89) Rubin 18/19 7/17 2.30 (1.29-4.10) Sikes 17/21 15/21 1.13 (0.81-1.59) Taylor 12/18 4/18 3.00 (1.19-7.56) 0.1 0.2 0.5 1 2 5 10 1
Wound Dressings Dressing Type Benefits Products Films Moisture Retaining Tegaderm HP Hydrogels / Hydrocolloids Alginates Foams Moisture Retaining Autolytic Debridement Promote Granulation Control Exudate Autolytic Debridement Control Bleeding Control Exudate Atraumatic Removal OpSite Flexigrid Carrasyn Hydrogel Curagel Tegasorb Duoderm CGF Algosteril Tegaderm Alginate Sorbsan Cutinova Allevyn Biatain Mepilex Antimicrobial Broad Spectrum Antimicrobial Acticoat Advanced Wound Care Matrices Growth Factors Protease Inactivation Angiogenesis Iosorb Appligraf Oasis Talymed Semi-Occlusive Dressings Palfreyman, BMJ 2007 Meta-analysis of 42 dressing trials (3001 patients) Time to complete ulcer healing Proportion of ulcers completely healed Hydrocolloid vs Low Adherent RR 1.0, 0.83-1.25 Hydrocolloid vs Foam RR 0.98, 0.79-1.22 Hydrodolloid vs Alginate RR 0.72, 0.48 1.69 Foam vs Low Adherent RR 1.35, 0.93 1.94 Foam vs Alginate RR 1.75, 0.79 3.88 Hydrogel vs Low Adherent RR 1.53, 0.96 2.42 Alginate vs Low Adherant RR 1.08, 0.86 1.36 0.5 1 2 5 Advanced Wound Care Matrices Hankin CS, JMCP 2012 Comparative analysis of randomized trials Apligraf (Bilayered skin substitute) Oasis (Porcine intestinal submucosa) Talymed (poly-n-acetyl glucosamine) n Wound Closure NNT p Apligraf 130 50.8% (24 wk) 6 (3 24) 0.02 Compression 110 39.8% (24 wk) Oasis 62 54.8% (12 wk) 5 (3 39).02 Compression 58 34.5% (12 wk) Talymed 22 86.4% (20 wk) 2 (2 8) 0.005 Compression 20 45.0% (20 wk) The Economics of Wound Care Kerstein MD, Dis Manage Health Outcomes 2001 Economic modeling based on 26 clinical trials Costs per ulcer healed over 12 weeks (n = 883) Compression in all patients Cost per dressing change ($) Dressings per week Average nursing costs ($) Cost / healed ulcer ($) Saline Gauze Hydrocolloid Apligraf 15.85 23.99 1234.38 4.0 (1.0 12.5) 1.6 (1.0 2.59) 1 558.73 227.37 138.23 2939 1873 15053 2
Limitations of Conventional Imaging Compression Syndromes Nonthrombotic Iliac Vein Lesions (NIVL) Raju & Neglen, J Vasc Surg 2006 Female: Male 4:1 Left: Right 3:1 3
What Is a Critical Venous Stenosis? Raju S, J Vasc Surg: Venous and Lym Dis 2014 Arterial concepts of critical stenosis do not apply Arterial Reduction if downstream pressure / flow Venous Elevation of upstream pressure Complex determinants of upstream venous pressure Inflow volume (rest vs exercise) Starling (intra-abdominal) pressures Outflow (left atrial) pressure Degree of stenosis What Is a Critical Venous Stenosis? Raju S, J Vasc Surg: Venous and Lym Dis 2014 Upstream pressure is determined by the dominant component (components are not additive) Effect of Intra-Abdominal Pressure 20 X 18 Wall Stent 4
Follow-Up Importance of compression emphasized Wound care returned to local vein doctor All ulcers healed at 8 weeks Conclusions Dressings account for only 13 25% of costs Cost effectiveness = The fewest nursing resources Rapid ulcer healing Infrequent dressing changes BUT Few clinical differences between dressings Semi-occlusive dressing Antimicrobial dressings Advanced wound care matrices Higher rates of wound healing (NNT 2 6) Higher costs Conclusions Strict trial entry criteria may not be generalizeable Patients with specific wound characteristics might benefit from specific dressings Ulcer size Degree of exudate Drainage Chronicity Most cost effective dressing MAY vary between pts The best approach is the one that minimizes the total number of dressing changes in the individual patient 5