2012 kevinsextonmay2 bc wound healing

8/13/2019 2012 KevinSextonMay2 BC Wound Healing

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Wound Healing:

A Practical Approach

Kevin Sexton

Bonus Conference 5/2/12


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Goals

1) To list the phases of wound healing and have

a basic understanding of each.

1) List the types of wound closure and

components of the reconstructive triangle.

2) Be exposed to current wound

dressings/therapies.


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Why bother?

6.5 million chronic wounds in the US

4 Main Types

Pressure sores

Diabetic ulcers ($38 billion dollars in 2007)

Venous stasis ulcers

Arterial insufficiency

Americans are getting olderMUSTOE T. Understanding chronic wounds: a unifying hypothesis on their pathogenesis and

implications for therapy. The American Journal of Surgery 2004;187(5):S65S70.

Driver VR, Fabbi M, Lavery LA, Gibbons G. The costs of diabetic foot: the economic case for

the limb salvage team. J Vasc Surg 2010;52(3 Suppl):17S22S.


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Wound Classification

Acute

< 3 months old

Chronic

> 3 months old

Problem with inflammation


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All may occur

simultaneously

Individual Processes

May Overlap

Sabiston Textbook of Surgery; ISBN-13:978-0721604091


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What are the primary cells

responsible for each wound

healing phase?


7/40Sabiston Textbook of Surgery; ISBN-13:978-0721604091

Myofibroblast


8/40Sabiston Textbook of Surgery; ISBN-13:978-0721604091


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How strong is the wound?

1 Week3%

3 Weeks30%

12 Weeks

80% 16 Weeks80%

What are you going to tell yourpatients about activity?



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Wound Closure

Primary First intention

Immediate Closure

Suturing, skin graft placement, flap closure, etc

Secondary Wound is allowed to close spontaneously

Highly contaminated wounds

Tertiary Delayed primary closure

Control infectionWound Closure



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Flaps / Grafts

MicrosurgeryTissue Expansion

The Reconstructive Triangle


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Wound Care

3 Healing Gestures

Washing the wound

Making Plasters Topicals to aid in wound healing

Bandaging the wound

A brief history of wound healing. Yardley, PA: Oxford Clinical Communications; 1998.

Carved into a stone tablet dated 2200 BC


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Modern Wound Therapy

Prepare the wound bed

Minimize hypoxia

Minimize bacterial content

Create a warm, damp occluded environment

Maximizes epithelialization

Minimizes pain

Disrupt the environment as little as possible

Minimize the impact of comorbidities


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Oxygen Delivery

Wound ischemia is detrimental to all

processes

Initial factor for chronic wounds

Relative hypoxia more common

Initially stimulates fibroblast proliferation and

angiogenesis

Higher oxygen tension is required thereafter

IMPEDIMENTS TO WOUND HEALING/STADELMANN ET AL. THE AMERICAN JOURNAL OF SURGERY VOLUME 176 (Suppl 2A) AUGUST 1998


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Relative Hypoxia

PaO2 of 30-40 mm Hg of O2

No fibroblast replication

Collagen production severely limited

Hunt TK, Hussain Z. Wound microenvironment. In: Cohen IK, Diegelmann, RF, Lindblad WJ, (eds)Wound Healing Biochemical & Clinical Aspects. Philadelphia: W.B. Saunders Company; 1992:27481.


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Treatment Options

Angioplasty

Bypass

Minimize comorbidities Stop Smoking

Therapy for heart failure


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Blood Transfusions

If relative hypoxemia is bad, then a low hemoglobin

concentration must impair wound healing.

Actually, if compensatory mechanisms maintained

(cardiac output, adequate pulmonary gas exchange,

and normalizing lactate) then the data is equivocal.

Peacock EE Jr. Wound Repair, 3rd ed. Philadelphia: W.B. Saunders Co., 1984.

Bains JW, Crawford DT, Ketchum AS. Effect of chronic anemia on wound tensile strength: correlation with blood volume,

total red cell volume, and proteins.Ann Surg. 1966;164:243.

Heughan C, Grislis G, Hunt TK. The effects of anemia on wound healing. Ann Surg. 1974;179:163.

Jonsson K, Jensen JA, Goodson WH 3rd, et al. Tissue oxygenation, anemia, and perfusion in relation to wound healing in

surgical patients.Ann Surg. 1991;214:605 613.


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Infection

Health is not sterility.

Number of organisms present per gram of

tissue

10 5organisms/gram tissue

> chances of wound closure 20%

< 94 % chance of closure

Robson MC. Infection in the surgical patient: an imbalance in the normal equilibrium. Clin Plast Surg. 1979;6:493503.

Robson MC, Krizek TK, Heggers JP. Biology of surgical infection. In: Ravitch MM (ed.). Current Problems in Surgery. Chicago:

Yearbook Medical Publishers, 1973:1 62.

Krizek TK, Robson MC, Kho E. Bacterial growth and skin graft survival. Surg Forum. 1967;18:518 519.


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Treatment Options

Debridement

Presence of foreign debris reduces number of

bacteria to cause a wound infection by a factor of

10,000 Elek SD. Experimental staphylococcal infections in the skin ofman.Ann NY Acad Sci. 1956;65:85.

AntibioticsSystemic antibiotic are ineffective unless there are

systemic symptoms

Topical antibiotics deliver high concentrations of

drug where they are most effective.Robson MC, Edstrom LE, Krizek TJ, et al. The efficacy of systemic antibiotics

in the treatment of granulating wounds.J Surg Res. 1974;16:299 306.


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Dressings Qualities

Protect wound from bacteria and foreign

material

Absorb exudate

Prevent heat and fluid loss

Provide compression

Minimize edema and dead space Be nonadherent to limit wound disruption

Be aesthetically attractive


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Occlusive Dressings

Winter Experiment

Rate of epithelialization doubled in wounds

that were covered in occlusive dressing

Winter GD. Formation of the scab and the rate of epithelialization of

superficial wounds of the skin in the young domestic pig. Nature

1962;193:2934.

O l i


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Occlusion Damp, mildly acidic environment

Epidermal migration, angiogenesis, connective

tissue synthesis

Relatively lower oxygen tension

Stimulates angiogenesis

Good initially, bad if persists

Granulation stimulated by cytokines

Preserved if wound environment occluded

Bolton L, Pirone L, Chen J, et al. Dressings effects on wound healing. Wounds 1990;2:12634.

Varghese MC, Balin AK, Carter M, et al. Local environment of chronic wounds under synthetic dressings. Arch Dermatol

1986;122:527.

Hunt TK, Zederfdeld B, Goldstick TK. Oxygen and healing. Am J Surg 1969;118:5215.

Knighton DR, Silver IA, Hunt TK. Regulation of wound-healing angiogenesis-effect of oxygen gradients and inspired oxygen

concentration. Surgery 1981;90:26270.

Alvarez OM, Mertz PM, Eaglstein WH. The effect of occlusive dressings on collagen synthesis and reepithelialization in

superficial wounds. J Surg Res 1983;35:1428.

Alvarez O, Rozint J, Wiseman D. Moist environment: matching the dressing to the wound. Wounds 1989;1:3551.


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Occlusion is Better than Sliced Bread.

Barnett A, Berkowitz RL, Mills R, et al. Comparison of synthetic adhesive moisture vapor permeable andfine mesh gauze dressings for split-thickness skin graft donor sites. Am J Surg 1983;145:3 7981.


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There are no perfect dressings.

Infected wounds

Need non-occlusive dressing

Heavily Exudative wounds

Need absorbent dressing

Necrotic Wounds

Need debriding dressings


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But there are a lot of choices

Lionelli GT, Lawrence WT. Wound Dressings.

Surg Clin N Am. 2003 Volume 83. pages

617-38.


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Nonadherent Fabrics

Hydrophobic

More Occlusive

Xeroform

3% Bismuth tribromophenatein petroleum

Limited antimicrobial activity

Staphylococcus aureus

Escherichia Coli

Vaseline Gauze

Telfa

Hydrophilic

Facilitate drainage of fluid

into overlying layers

Adaptic

Fine mesh gauze


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Absorptive Dressings

Gauze

Wide-Mesh

Kerlix

Sticks to wounds Debridement

Overwrap

Wick moisture

Foam Dressings

Hydrophobic, polyurethane

foam sheets

Allevyn Mepilex

Biopatch

Absorbent

Nonadherent


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Occlusive Dressings

Non-Biologic

Films

Hydrocolloids

Alginates Hydrogels

Biologic

Allograft

Alloderm

Xenograft Strattice

Amnion

Skin Substitutes

IntegraBenefits of Both: insulation

moisture retention

mechanical barrier


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Films

Tegaderm

Op-Site

Waterproof Allow Gas

Transmission

Oxygen

Carbon Dioxide

Water Vapor

Nonabsorptive

Leak

Need to have intact skin

surrounding wound


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Hydrocolloids

Hydrocolloid matrix

Gelatin, pectin, carboxymethylcellulose

Wafers, Pastes, Powders

Duoderm

Water contact leads to swelling and gel

formation


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Alginates

Based on alginic acid (seaweed) derivatives

Exudative wounds

Forms gel with water contact

Must change when begins to bleed

Sorbsan


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Antibacterial Solutions Acetic Acid

gram - coverage, Pseudomonas

0.5% concentration for effect

0.25% killed 100% of fibroblasts in vitro

Slows wound epithelialization Decreased PMN function

Dakins (bleach)

Non-descriminant killer Wounds slower to epithelialize and neovascularize

Lineaweaver W, Howard R, Soucy D, et al. Topical antimicrobial toxicity. Arch Surg 1985;120:26770.

Lineaweaver W, McMorris S, Soucy D, et al. Cellular and bacterial toxicities of topical antimicrobials. Plast Reconstr Surg

1985;75:3946.

Dakins HD. The antiseptic action of hypochlorites: the ancient history of the new antiseptic. BMJ 1915;2:80910.

Kozol RA, Gillies C, Elgebaly SA. Effects of sodium hypochlorite (Dakins Solution) oncells of the wound module. Arch Surg

1988;123:4203.


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Iodine Containing Solutions

Kills bacteria

For the most part, studies show betadine does

not promote good wound healing and impairs

wound strength.

Kjolseth D, Frank JM, Barker JH, et al. Comparison of the effects of commonly used

wound agents on epithelialization and neovascularization. J Am Coll Surg 1994;179: 305

12.

Stahl-Bayliss CM, Grandy RP, Fitzmartin RD, et al. The comparative efficacy and safety of

5% povidone-iodine for topical antisepsis. Ostomy Wound Manage 1990;31:409.

Cooper ML, Laer JA, Hansbrough JF. The cytotoxic effects of commonly used topical

antimicrobial agents on human fibroblasts and keratinocytes. J Trauma 1991;31: 77584.

Kramer SA. Effect of povidone-iodine on wound healing: a review. J Vasc Nurs

1999;17:1723.

Sundberg J, Meller R. A retrospective review of the use of cadexomer iodine in thetreatment of chronic wounds. Wounds 1997;9:6886.


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Silver Dressings

Broad antibacterial spectrum Silver sulfadiazine (1960s)

Antibacterial, antifungal, antiviral

Neutropenia

Sulfamylon (first used during WW II) Can penetrate eschar

Inhibits carbonic anhydrase (metabolic acidosis)

Both kill fibroblasts in culture, however they increase

epithelialization and neovascularization in partialthickness wounds.

Acticoat- only have to change every 3 days


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Silver References Moyer CA, Brentano L, Gravens DL, et al. Treatment of large human burns with 0.5% silver nitrate

solution. Arch Surg 1965;90:81267. Bellinger CG, Conway H. Effects of silver nitrate and sulfamylon on epithelial regeneration. Plast

Reconstr Surg 1970;45:5825.

Moncrief JA, Lindberg RB, Switzer WE, et al. Use of topical antibacterial therapy in the treatment ofthe burn wound. Arch Surg 1966;92:55865.

Kucan JO, Smoot EC. Five percent mafenide acetate solution in the treatment of thermal injuries. JBurn Care Rehabil 1993;14:15863.

Ballin JC. Evaluation of a new topical agent for burn therapy: Silver sulfadiazine (Silvadene). JAMA1974;230:11845. 50] Fox CL. Topical therapy and the development of silver sulfadiazine. Surg.Gynecol Obstet

1983;157:828.

Klasen HJ. A historical review of the use of silver in the treatment of burns. II. Renewed interest forsilver. Burns 2000;26:1318.

McCauley RL, Li YY, Poole B, et al. Differential inhibition of human basal keratinocyte growth tosilver sulfadiazine and mafenide acetate. J Surg Res 1992;52:27685.

Geronemus RG, Mertz PM, Eaglstein WH. Wound healing: the effects of topical antimicrobialagents. Arch Dermatol 1979;115:13114.

Tredget EE, Shankowsky HA, Groenveld A, et al. A matched-pair, randomized study evaluating theefficacy and safety of Acticoat silver-coated dressing for the treatment of burn wounds. J Burn CareRehabil 1998;19:5317.


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Antibacterial Ointments

Gram Positives

Bacitracin, Mupirocin

Gram Negatives

Neomycin, Polymyxin B

Antibacterial effect for 12 hours

Little benefit to epithelialized wounds


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Vacuum Therapy Increased Granulation Tissue

Increased Wound Blood Flow

Increased Angiogenesis

Decreases healing time Increased Bacterial Load in wound

Argenta LC, Morykwas MJ: Vacuum-assisted closure: A new method for wound control and treatment:

Clinical experience.Ann Plast Surg 1997; 38:563-576.discussion 577

Joseph E, Hamori CA, Bergman S, et al: A prospective randomized trial of vacuum-assisted closure versus

standard therapy of chronic nonhealing wounds. Wounds 2000; 12:60-67.

Timmers MS, Le Cessie S, Banwell P, et al: The effects of varying degrees of pressure delivered by negative-pressure wound therapy on skin perfusion.Ann Plast Surg 2005; 55:665-671.

Chen SZ, Li J, Li XY, et al: Effects of vacuum-assisted closure on wound microcirculation: An experimental

study.Asian J Surg 2005; 28:211-217. Weed T, Ratliff C, Drake DB: Quantifying bacterial bioburden during

negative pressure wound therapy: Does the wound VAC enhance bacterial clearance?.Ann Plast Surg 2004;

52:276-279.discussion 279-280

Obdeijn MC, de Lange MY, Lichtendahl DH, et al: Vacuum-assisted closure in the treatment of

poststernotomy mediastinitis.Ann Thorac Surg 1999; 68:2358-2360.

Defranzo AJ, Argenta LC, Marks MW, et al: The use of vacuum-assisted closure therapy for the treatment of

lower extremity wounds with exposed bone. Plast Reconstr Surg 2001; 108:1184-1191.


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