wound care: from then to now
TRANSCRIPT
Wound Care: From then to now
Objectives
Discuss changes in theories of treatment in wound care and implications to current wound care practice.
Review good wound care practice and implications as related to regulatory changes.
Review types of wound debridement. Discuss list indications and
contraindications for wound dressings.
Evolution of wound care dressings…
1948: “Experiments with occlusive dressings of a new plastic” by JP Bull
Discussed properties of a nylon derivative film
Water vapor permeability made it suitable for wound dressings
Also noted that the presence of a variety of organisms was reduced or disappeared
Evolution of wound care dressings…
1963 (Hinman): “Effects of air exposure and occlusion of experimental human skin wounds”Used a sterile polyethylene film in artificially
made wounds on health adult male volunteersWounds were either occluded or allowed to heal
open to airResults: Wounds healing under moist conditions
healed 50% faster than wounds open to air
Winters, CD Nature 1962
Where we’re going…
Traditional dressings:• Gauze, lint and fiber products• Hydrocolloids
Modern Moist Wound Dressings:• Foams• Films• Alginates/Hydrofibers• Collagen• Hydrogels• Topical Antimicrobials• Silicone
Look how far we’ve come!!!
Wet to Dry Gauze: Why not?
Disadvantages of wet to dry:
AHRQ Pressure Ulcer Guidelines Wet-to-dry implies gauze is applied moist and removed
when dry.
Problems? W/D gauze dressings as a form of mechanical debridement
are “non-selective” and, …are rarely applied correctly …may cause pain on removal …may be more costly in terms of labor and supplies …may cause maceration of skin surrounding the wound …may release airborne organisms (cross contamination)
What else???
Moistening gauze that is adhered
Primary objective is lost
Gauze fibers can be left in wound
Moist wound healing is an industry standard: known to improve healing rate
Winter’s research (1960’s)
• Moist wounds healed 2x as fast as wounds allowed to dry
What else???
Inconsistency with application Moisture levels vary with clinicians Wet to moist may dry out and become wet to dry
Drying gauze has a cooling effect on tissue Gauze: 77-81 degrees in wound bed Films/foams: 91-95 degrees in wound bed
vasoconstriction, hypoxia, impairment of phagocytic efficiency
Ovington, L Hanging Wet to Dry Out to Dry. Home HelathCare Nurse. 2001; 19(8), 477-483
There’s more?
Gauze dressings present no bacterial barrier
Lawrence (1994): 64 layers of dry gauze allowed bacterial penetration
Hutchison (1989,1993): Moistened gauze presents less barrier
Hutchison (1990): Review of 3047 wounds showed the following infection rate:
• 2.6% for those dressed with moisture-retentive dressings
• 7.1% for those dressed with gauze
Ovington, L Hanging Wet to Dry Out to Dry. Home HelathCare Nurse. 2001; 19(8), 477-483
Cost of Wound Care
Cost of dry gauze and ancillary supplies$.47 per dressing change
Cost of hydrocolloid and ancillary supplies
$6.15 per dressing change
Daily Cost (dressing cost + clinician cost)
Dry gauze $12.26
Hydrocolloid $3.55
Colwell et al, Decubitus 1993
How should we select dressings?
Hydrating
Absorbing
Fillers
Active
Secondary
Primary
Autolytic
Enzymatic
Non-adhesive
Wound Management Priorities
Reduce or eliminate causative factors Provide systemic support for healing Apply appropriate topical therapy
Debride - remove necrotic tissue Identify and eliminate infection Fill dead space - lightly Absorb excess exudate Maintain moist wound surface Open closed wound edges Protect from trauma and pain Insulate
Selecting Dressings
○ Keeps the wound bed moist ○Prevents both maceration & desiccation
○Offers good Moisture Vapor Transmission Rate
○ Minimizes peri-wound maceration
○ Protects the peri-wound skin
○ Eliminates dead space
○ Assures packing will stay in place
○ Minimizes pain
○ Assures stable environment
○ Provides thermal insulation
○ Always consider caregiver time
Ideal Primary Dressings
Need to be compatible with the wound:
May be hydrating or absorptive
Promote/maintain moist, healing environment
Provide for “breathability” (MVTR)
Provide insulation
Impermeable to microrganisms
minimize contamination from outside
Atraumatic to the wound/periwound area
Cost effective
Ideal Secondary Dressings
Need to be compatible with the wound: Absorb exudate Provide moisture to wound Promote autolysis (debridement) May be used in infected wounds Be atraumatic to wound/periwound
Minimize adherence Minimize movement Minimize stripping
Cost effective
Foams
Benefits:Bordered and un-borderedProvide a moist environmentHigh absorbencyConformable, may be cut to sizeThermal insulationNo residue MVTRNo adherence to wound bed
Foams
Indications:
Superficial and full thickness wounds
Skin grafts, donor sites, burns, skin tears
Under compression for LE ulcers
Contraindications:
Dry wounds
Examples: Mepilex (Border), Allevyn (Plus Adhesive), Polymem, Biatain
Films
Benefits:
Provide a moist environment
Enable autolytic debridement
Provide protection from extraneous forces (microbes, friction, shear, chemicals)
High MVTR
Conformable
Films
Indications:Minor injuries (abrasions)Post-op dressing over suturesIV sites
Contraindications:High exudate woundsFragile skin
Examples: Tegaderm, Opsite
Alginates/Hydrofibers
Benefits:
Provide a moist environment
High absorptive capacity
Conformable/cuttable (rope or sheet form)
Provide hemostasis
No adherence to moist wound bed
Alginates/Hydrofibers
Indications:Highly exuding woundsInfected wounds (change daily)
Contraindications:Dry wounds or wound with eschar
Aquacel, Melgisorb, Seasorb, Kaltostat
Hydrogels
Benefits:
Promote a moist environment
Donate moisture to dry wounds
Aid in autolytic debridement (rehydrate/soften necrotic tissue)
Hydrogels
Indications:Dry woundsWounds with slough woundsWounds with escharOver tissues and tendons to prevent drying
Contraindications:High exudate wounds
Examples: Solosite, Woun’ Dress, SkinTegrity
Silicone
Chemically inert, adverse effects rare Designed to be removed without
trauma or pain Protect friable or newly healed tissue
from injury Less trauma to periwound Examples: Mepilex, Allevyn Gentle
Enzymatic Debriders
January 1, 2008 DESI drug changes Medicare Part D: Reimbursement
Limited for products which contain papain/urea/chlorophyllin complex sodium
What does that mean?? Increased cost to the patient
Enzymatic DebridersAlternatives
Uses chemicals to break-down and digest necrotic tissue
Must know mechanism of action to be effective
Examples: Hypertonic saline, Enzymes, Honey
Antimicrobials
Bacteriocidal: Silver Honey Cadexomer iodine
Bacteriostatic: Methylene Blue and Gentian Violet Xeroform
Antimicrobial action through (+) silver ion
Effective when in contact with wound fluid
Consider:
Kill rate AND sustained release rate
Testing Methods: Simulated wound fluid, saline
Delivery methods: foams, gels, alginates, hydrofibers, creams
(SSD - approved for burns, only)
Silver
How does silver work?
Bacteria elimination: 3 ways
• Cell wall rupture
• Prevents respiration or nutrient processing
• Disturbs replication
Conclusion:• Silver resistance unlikely silver secondary to 3 mechanisms• No cases of bacterial resistance to silver in vivo.
Antiseptics
(+) Destroy or inhibit growth of microorganisms Efficacy on intact skin widely known and
accepted (+) Resistance significantly less than
antibiotics (-) In vitro cytotoxicity to cells of healing
AHRQ: Caution against use NPUAP/EPUAP: Limited use to control
bacterial bioburden
Antiseptics
Hydrogen peroxide Acetic acid
Effective against Pseudomonas aeruginosa Diguanides (Chlorhexidine) Sodium hypochlorite (Dakin’s)
Not recommended unless suitable are unavailable
Povidone Iodine
Collagen
Usually Type I bovine or avian or type III
porcine collagen
Benefits:
May accelerate wound healing
Slight absorption
May be used with topical agents
Examples: Biostep, Fibracol, Puracol
Collagen
Indications: Partial & full thickness wounds Minimal to moderate drainage
Contraindications: Eschar covered Full thickness burns Sensitivity to contents
Who makes it? Organogenesis, Inc
What is it? Dermal layer: human fibroblasts
from neonatal foreskin in a bovine Type I collagen matrix
Epidermal layer: human keratinocytes
What does it do? Accelerates wound repair by
secreting important cells and proteins (GF and cytokines)
Indications: Venous Leg Ulcers and DM Foot Ulcers
Who makes it? Advanced BioHealing, Inc
What is it? Human fibroblast (neonatal foreskin) derived dermal
substitute Contains fibroblasts, ECM and bioabsorbable scaffold
How does it work? Assists in the restoration of the dermal bed Fibroblasts proliferate to fill the interstices of the scaffold
and secrete human dermal collagen, matrix proteins, GF, and cytokines to create a 3-dimensional human dermal substitue
Indications: Full thickness DM > 6 wks duration without tendon, muscle, joint capsule or bone exposure
Graft Jacket Who makes it?
Wright Medical Technology, Inc What is it?
Donated human skin Removed the dermal and epidermal
cells but preserved bioactive components (proteins, blood vessel channels) and structure
What does it do? A 3-dimensional scaffold to support the
body’s own natural repair process of cellular repopulation and vascularization
Supports regeneration of host tissue Indications: DM
Who makes it? Healthpoint, Ltd
What is it? Extracellular matrix composed of
porcine small intestinal submucosa (SIS)
How does it work? Provides a matrix for tissue repair Placed onto wound, cells/nutrients from
adjacent tissues invade the matrix, capillary growth ensues
New tissue formation by the body itself Indications: Partial and full thickness
wounds, PrU, Venous ulcers, chronic vascular ulcers, DM, traumatic wounds, draining wounds, surgical wounds
In Conclusion
Determine wound cause and address Establish plan of care that includes
dressings that will address principles of moist wound healing
Assure pain is addressedThrough pharmacologic and non-
pharmacologic methods