chronic wound management – choice of dressing material? · suprasorb x + phmb polihexanide (phmb)...
TRANSCRIPT
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Chronic wound management – Choice of dressing material?
Tsang Ka-kit NC O&T
QEH
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Modern wound product Moist wound dressing method
Hydrogel, enzymatic cream
Advanced dressing product
Alignate, hydrofibre Anti-microbial dressing material
Before we start to apply any dressing material, something we should consider ………
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Clinical approach of wound management
Analyze the factors causing delay wound healing
State the objective of management
Use appropriate method or product to achieve the objective
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Clinical approach of wound management
Factors affecting wound healing
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General factors Age
Nutritional status Oral intake Serum albumin Total protein
Immune status Autoimmune disease Infection
Circulation insufficiency Venous ulcer vs DM ulcer/ arterial ulcer
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General factors Co-morbidity
Diabetes Gouty
Medication Steriod
Psychosocial status of patient
Environmental factor Temperature
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Local factors What is the reason for non-healing or
deterioration? Moisture balance Bacterial loading (heavy colonization) Infection Over-granulation Foreign body Non-viable tissue Nature of tissue exposed on wound bed Chronic inflammation
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Local factors What is the reason for non-healing or
deterioration? Skin tension eg. wound over joint area Pressure & friction eg. foot deformity, ischial sore,
protrude coccynx Micro-circulation Edematous of surrounding tissue Crust & scab
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Clinical signs of delay wound healing
General signs Infectious markers
ESR, CRP
WBC, neutrophil count
Haemoglobin
Local signs Color and consistency of exudate
Local sign and symptom of infection Smooth wound edge
Thicken skin edge
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Clinical approach of wound management
Objective of management Wound healing Prevention of deterioration / inactivation
Conservative vs surgical management Prepare for the next step of medical or surgical
intervention Wound bed preparation
Moisture balance
Bacterial loading control
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Case scenario 1
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Poor distal circulation ESRF
DM
Distal circulation compromise
Successful rate of wound healing at distal region decreased
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Poor distal circulation Objective of
management: Inactivation &
prevention of deterioration
Method: Povodine-iodine daily
with light gauze covering
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Case scenario 2
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Co-morbidity F/75
H’x of SSS on pacemaker with long term warfarin
Bleeding tendency
AF on amiodarone
Pleural effusion
Bed bound with general edematous
• dry eschar • fluctuate -ve • skin temp -ve
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Co-morbidity Objective of management:
Inactivation & prevention of deterioration
Method: light gauze covering and free
heel to avoid pressure
Povidone-iodine daily and observe for any systemic & localized infection
Beware of silent infection
• dry eschar • fluctuate -ve • skin temp -ve
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Case scenario 3
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Immune status F/ 27
RA
Repeated foot & leg ulcer
Latent unhealed ulcer for several months
On long-term oral steroid drugs
Dry & fragile skin
Prone to have skin maceration problem
Pain +++ve
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Immune status Objective &
actions Promote wound
healing by moist wound method & anti-inflammatory dressing
Moisture balance to prevent maceration
Skin care of intact skin with cleansing & skin moisturizer
Dry & fragile skin
Prone to have skin maceration problem
Pain +++ve
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Immune status Objective & actions
Check for pressure point and callosity
Excise the corn before walking exercise
Refer P&O for in-sole
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Case scenario 4
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Anatomical factor
Minimal soft tissue on the lateral malleolus
Underlying structure with fascia and bone
Reluctant to perform aggressive debridement
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Anatomical factor F/ 89
DM, PVD
Rt foot chronic ulcer on lateral malleolus
3 x 2.5 cm
Slough with no granulation
Scanty pus
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Anatomical factor Dressing method
Off-loading Extra care is needed on
sharp debridement Minimal debridement
with pure collagen dressing
Enzymatic debridement is another choice
2 months later
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Case scenario 6
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Nature of tissue exposed Fascia / tendon exposed
Treatment approach Is the tendon / fascia
healthy? Any slough or necrotic
tissue on the surface Paratenon exist
Function of the tendon ADL of patient
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Nature of tissue exposed Objective of
management Tendon cannot
preserve
Keep soft tissue moist for skin graft
Preserve or not ??
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Dressing materials
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Moisture balance Moist wound healing product
e.g. Hydrogel
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Moisture balance Hydrogel
More than 90% of water content
Colorless, transparent gel commonly comprising polymers and preservatives
Suitable for rehydration and autolytic debridement
Beware of bacterial loading especially on those with poor distal circulation and joint space exposure
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Moisture balance Paste
Little water content than hydrogel e.g. Iruxol mono cream
collagenase
Enzymatic debridement
Not for eschar
Remove the slough, leaving the wound bed ready for healing
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Moisture balance Exudate absorption
e.g. Foam
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Moisture balance
Foam (cont’d) Adsorbent dressing
Polyurethane foam wafers which absorb fluid into their matrix
Different commercial products have different speed of absorption and evaporation power
Can be adhesive or non-adhesive Mild pressure relieving property on local
area
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Control bacterial loading
Antimicrobial dressing
Beware that dressing does not have enough penetration to treat deep wound infection
Need to rule out any deep wound infection or osteomyelitis before use X-ray
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Control bacterial loading Silver dressing
Aquacel Ag (~1 ppm), Biatain silver, Polymen silver, Acticoat(~100 ppm), Urgotul with SSD
Silver concentration from 1 to 100 ppm Different form of silver including metallic silver, ionic
silver, nano-crystalline silver
Useful in chronic DM foot ulcer which usually have colonization
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Control bacterial loading Silver dressing & repeated conservative
sharp debridement
week 0
week 2
week 4
week 10
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Control bacterial loading Suprasorb X + PHMB
Suprasorb X Cellulose of hydro-balance dressing
Can absorb or donate moisture
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Control bacterial loading Suprasorb X + PHMB
Polihexanide (PHMB) Interfere with bacterial cell metabolism
Prohibit the cell’s ability to absorb nutrients and dispose waste product
Able to kill MRSA or VRE
No known cytotoxicity or resistance
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Molecular pathophysiology Cellular and molecular aberrations
prolong inflammatory phase impaired granulation formation Up-regulation of matrix
metalloproteinases (MMPs), cytokines and several destructive enzymes
destroy extra-cellular matrix (ECM)
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Molecular pathophysiology " Healing wound vs chronic ulcer
(Schultz & Mast, 1999)
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Combined dressing
Silver impregnated collagen Anti-inflammatory action Control bacterial loading and promote
wound healing simultaneously In vitro tests demonstrate that PRISMA
Matrix allows wound healing and kill bacteria at the same time
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Promote wound healing
Medical Manuka honey honey gel honey tulle
honey with alginate
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Promote wound healing Medical Manuka honey (cont’d)
Anti-bacterial function
pH 3.2 – 4.5 Kill micro-organism due to acidic nature
Super-saturated sugar solution
Draw water from micro-organisms by osmotic effect
Water drawing effect inhibits the growth of most species of bacteria
Moisturize wound bed
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Promote wound healing Medical Manuka honey (cont’d)
Anti-bacterial function (cont’d)
Methylglyoxal Unique Manuka factor (UMF)
Anti-bacterial property
Anti-inflammatory function Flavonoids
inhibit the formation of free radicals
decrease the excessive activity of collagenase and elastase since these enzymes can cause premature degradation of collagen and growth factors in chronic wounds
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Promote wound healing Medical Manuka honey (cont’d)
Advantage:
Moist wound bed through osmosis especially for relatively dry DM foot ulcer
Dis-advantage:
Frequency of dressing needs to be increase to counteract the dilution effect
A little bit messy because of oozing when compared with other modern wound dressing material
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Medical honey dressing
week 0 week 2 week 5 week 10 week 12
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Advancement of medical technology
Negative Pressure Wound Therapy
(NPWT)
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NPWT Negative pressure wound therapy (NPWT) =
Vacuum-assisted Closure (VAC) Developed since 1993 Expose wound bed to negative pressure by closed
system
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NPWT
Approach Debride dead tissue thoroughly Apply NWPT 80-175 mmHg
Change every 2-3 days Apply until wound bed covered or filled with
granulation tissue
Skin graft / flap coverage / other dressing materials
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NPWT
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NPWT Function
Drainage of wound exudate Decrease bacterial loading
Improve local circulation and angiogenesis Stimulate granulation and epithelization Decrease the number of surgeries required
As an adjunctive therapy to simplify the complexity of surgery afterwards
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Advancement of medical technology
Artificial skin
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Biological artificial skin Dermagraft®
It can be used when patient does not want or is not suitable for autograft
Biological dressing which extracted from the foreskin of infant
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Biological artificial skin Apply every week which can reduce the need of
skin graft in the operation theatre
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Future trend Diagnostic tool development
Check for any abnormality in mirco-environment
biochemical of wound fluid e.g. wound check
Target on the biochemistry / molecular pathology
Anti-inflammatory dressing
Drug development
e.g. doxycycline, immunoglobulin
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Bring home message Consider general and local factors affecting wound
healing
Estimates the probability of wound healing based on different factors
Set objective of management
Correlate the clinical sign to wound healing physiology & molecular pathophysiology
Use appropriate dressing product/ device to achieve the goal
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Thank you !!