Management of
complex wounds
Ontario Association of General Surgeons
November 1, 2014
S.J.Fratesi MD FRCS© MEd
Associate Professor of Surgery
Northern Ontario School of Medicine
Disclosures
Medical advisor to CCACS (LHIN 13 )
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CARE
Evidence base
1. There is no evidence to indicate which dressings are most
effective
2. There is no level A evidence to support specific dressings
3. There is level B evidence that suggests that Hydrocolloid
dressings are better than saline or paraffin for overall healing
and alginates are ideal for heavily exudative wounds
Dressings
1.
Wound healing is optimal in a moist
environment
1. Occlusive and semi-occlusive
dressings were developed to promote
healing time, absorb blood and
exudate and be painless and easy to
apply and remove
Consensus opinion for management
1. Hydrogels are useful in the debridement stage of
wound healing
2. Foam and low adherence dressings are useful for the
granulation stage
3. Hydrocolloid and light foam dressings are useful for
epithelialization
4. Charcoal is useful for malodorous wounds
5. Alginate’s are useful for exudating or hemorrhagic
wounds
6. Low adherence dressings are useful for fragile skin
*There is no evidence or consensus opinion
to support claims that specific dressings
such as silver containing dressings are most
appropriate for selected indications such as
caring for infected wounds or prevention of
infection
Complex wounds
No specific criteria
Can include both acute and chronic
One or more of the following must be present:
1.
Extensive loss of integument
2.
Infection as a complication
3.
Compromised viability of tissues , necrosis or
circulation
4.
Association with systemic pathology
Most common complex wounds
Wounds in diabetic extremities
Pressure ulcers
Chronic venous ulcers
Arterial ulcers
Chronic wounds o vasculiti or
immunosuppression
Coumadin necrosis
Fournier’ ganrene
Lymphedema /Diabetes (laceration)
Scleroderma (water blister)
Non-healing surgically treated pilonidal complex
Wound Etiology
WHAT CAUSES A WOUND?
NEO/IMMUNE
TRAUMA
MECHANICAL
METABOLIC
VASCULAR
surgery
pressure sore
VENOUS
laceration
ARTERIAL
burn
LYMPHATIC
frostbite
Healing: cellular communication
Tissue damage
Healing/repair
Hemostasis
PDGF IL-1
Inflammation
MMP-9 MMP-2
PDGF FGF VEGF
TIMP-1 TGF-B
Angiogenesis
TNF-A
PDGF MMP_8
TIMP-2
Granulation tissue
KGF
Epithelialization
EGF
Monaco JL, Lawrence TL. Acute wound
Remodeling
healing; an overview. Clinics in Plastic
Surgery 30 (2003): 1-12..
The no healing wound
Growth factors
Cell proliferation
Proteases
Bioburden
u High levels of harmful
proteases (MMP)
u Low levels of growth
factors
u Bioburden
u Minimal cell proliferation
†Falanga V. The Chronic Wound: Impaired Healing and Solutions in the Context of Wound Bed
Preparation. Blood Cells and Diseases, 2004;32:88-94
No healing
Deficient growth factors
Diminished granulation
Delaye epithelialization
Defective ECM formation
Excessive protease formation
HOW MUCH DOES IT COST ?
WHO IS GOING TO PAY?
Interactive wound dressings
Transparent films
Hydrocolloid
Hydrogels
Exudate absorbers
Combination dressings
Specialized foam dressings
Special impregnated dressings
(carbon/silv
)
TIME
T (tissue)
I (infection or inflammation)
M (moisture balance)
E (edge of wound)
New developments in TIME
Biofilms
Evolution of topical antiseptic therapy(silver,
cadoxemer iodine, PHMB)
Advanced use of NPWT
Molecular biologic processes in chronic wounds
Control of wound drainage an periwound
protection in dressing development
Chronic wounds
Failure to heal(40% at
w )
Failure to proceed through an orderly
or timely repair process
Lack of functional or anatomical
stability
Presence of inflammation, ischemia,
pressure or diabetes
The goals of wound assessment
Wound etiology: arterial/venous
/diabetic/pressure sore
Pathophysiology of wound failure
Factors interfering with healing or treatment
The category and classification of the wound
RESTORATION or MAINTENANCE ?
As the skin ages:
Decreased fatty layers(more bony prominence
with less protection)
Decreased cro linking of collagen/elastin(poor
recoil)
Decreased dermal thickening(thin skin)
Decreased rete ridges (flatter basement
membrane leading increased skin tears)
Factors impeding wound healing
Ischemia
Venous insufficiency
Trauma
Deformity
Neuropathy
Bioload
Dressing selection
Systemic (nutrition, diabetes, CRF)
Wound assessment
location
size
Wound characteristics
Wound location
drainage
tunnel
Wound
Wound size
assessment
Tunneling/undermining
Wound bed
Wound edges
edge
bed
Wound drainage
Granulation tissue
Temporary scaffolding of vascularized connective tissue that fills the
wound void
Health tissue has a beefy red appearance
Pale or dusky or friable means poor blood supply or infection
Wound edges
Distinctness
Thickness
Colour
Attachment to wound base
Evidence of epithelialization, scarring
or pigment change
The condition of the wound edge:
Wound healing is initiated and sustained at the
edges
n fibrotic, rolled or macerated
n undermining or tunneling
n static or dynamic
n extension well beyond wound edge
Healing wound
Re-epithelialization
Chronic wound
Often thickened or rolled wound edges (epibole)
Pe wound skin
Examine around the wound then focus on
wound
Look for color, temperature and abnormal
pigmentation
Look for edema or induration
Look for nodules ,fibrosis, induration or
fluctuance
HEMOSIDEROSIS
VENOUS
ULCER
LIPODERMATOSCLEROSIS
Wound bed preparation
Bacterial
Exudate
Debridement
burden
management
+
+
Must optimize the wound healing environment to provide a clean, moist , warm granulating
wound bed that also protects the periwound area and skin
Debridement
u Decrease bacterial burden
u Increase effectiveness of topicals
u Increase effectiveness of leukocytes
u Shorten the inflammatory phase
u Free up energy
u Remove barriers to healing
u Decrease odour
General considerations for
debridement
Contraindications
Red granular wound
Patient
Clinician
Wound
Heel ulcers with dry eschar that are not
characteristics
characteristics
characteristics
red, hot edematous or fluctuant
There is no alternative to surgical
debridement
if that is what is needed
Methods of debridement
Sharp
Surgical
Autolytic
Biological
Mechanical
Enzymatic
Sharp debridement
Reintroduces the healing cascade
Removes: necrotic tissue
bioburden
matrix metallo-proteinases (MMPs)
quiescent/senescent cells
callous to relieve pressure
Debride
YES
NO
u combination of dry
eschar and cellulitis,
u firmly attached, hard dry eschar
exudate or odor
u underlying vascular disease and associated
gangrene(assess & correct)
u antimicrobial therapy
and sharp debridement
u no clear line of demarcation
of the eschar for proper
u dry gangrene may auto-amputate itself
drainage of the wound
u in wet gangrene aggressive debridement may
aggravate further tissue damage and actually
spread the gangrene or make wound more
susceptible to infection and create need for
higher amputation
Wound Biopsy Indications
uQuantitative culture of infected wound
u Chronic / refractory to healing by standard care
u Increasing size despite treatment
u Unusually malodorous or painful
u Granulation tissue extending beyond margins
uIrregular base or margin
u Change in drainage, excess bleeding or exophytic
growth
“When in doubt biopsy” J Shah MD
Infection
Built- in protection from:
Slightly acidic pH
Epithelial cells and lipids
Immune cells
Resident microflora (10 (3)
Bacterial Colon ount
Contamination (N)……….microbes on wound surface……….no clinical effect
Colonization (N)………..replicating microbes on wound surface……no clinical effect
Critical colonization(Abn)…..increasing bioburden reaching critical point…….
plateau or decline in wound status
Infection (Abn)………replicating microbes invade viable tissue(10(6))…..
Decline in wound status ,signs and symptoms of infection
Risk factors for infection
Exposed wound
Chronic wound
Break in skin continuity
Dry or cracked skin or callus
Ischemia
Presence of necrotic debris
Host integrity
Alterations in skin barrier
Infection or inflammation
rubor
Functio
calor
laesa
dolor
tumor
Drainage and decline in status of wound
iagnose infection
Tissue
biopsy
Blood
Swab
tests
cultures
Fluid
aspiration
Topical Wound Overview
RED
YELLOW
BLACK
assessment after proper cleansing
What do wound dressings do?
Maintain the proper moist environment
If wound is to wet ……must absorb moisture
If wound is dry must add moisture to wound
Wound dressing function
Provide thermal insulation
Provide a barrier to microorganisms
Protect exposed nerves to decrease pain
Eliminate dead space to prevent premature contraction
or abscess formation
Assist the body with removal of necrotic tissue and
debris
Provide gas exchange between the wound and
surrounding environment
ategories of dressings
Primary or contact layer
Secondary layer which acts as a occlusive or absorptive or
protective dressing
Spectrum of wound dressings
Gauze
Impregnated
Hydrogel
gauze
Miscellaneous
dressings
Composite
Film
Foam
Hydrocolloid
Alginate
there are 8 major categories of dressings with over 3000 different products
What is V.A.C therapy?
V.A.C. stands for:
acuum ssiste losure.
V.A. . is a noninvasive, active woun closure
system that uses controlled, localized negative
pressure to promote healing in acute and
chronic wounds.
NPWT extended indications
Incisional NPWT i orthopaedic
surgery
Incisional NPWT cardiac surgery
Incisional NPWT vascular surgery
Open abdomen: temporary closure
with modified NPWT...abdominal
compartment syndrome, trauma
surgery , diffuse peritonitis, wound
dehiscence
NPWT exposed wound with
external
fistul enterooatmosher
)
NPWT with fistula
PICO Vac
Clinical Decisio
aking
Two key questions must be answered to determine the most
appropriate local wound care
Is the wound draining or non-draining?
Is the wound granular or necrotic?
Dressing for
Dressing for non
draining wound
draining wound
Protect periwound
Prevent evaporative
from maceration
fluid loss
Absorb
Provide
moisture
moisture
Granular/Necrotic
Dressing for
Dressing for
granular wounds
necrotic wounds
Protect from
Assist with
trauma
debridement
Decision Grid
Granular
Granular
1. Granular and nondraining
X draining
draining
2. Granular and draining
3. Necrotic and nondraining
4. Necrotic and draining
Necrotic
Necrotic
X draining
draining
ranular no draining wounds
1. Should heal as expected
2.
the granulation tissue and periwound must be
protected
3.
moisture may be needed to be added to the
wound to ensure healing
4.
debridement is usually not an issue
5.
treatment modalities usually involve hydrogel or
a transparent film
6.
gauze is often used as the secondary dressing
Granular and draining wounds
1. both the granulation tissue and
periwound must be protected
2.
a more absorptive dressing should be
applied
3.
if heavily draining or associated with
friable granulation tissue suspect
infection
4.
debridement usually not indicated
5.
treatment modalities include alginate’s
semipermeable forms or hydrocolloid
dressings
6.
gauze used as secondary dressing
Necrotic no draining wounds
1.
require debridement and softening
of eschar
2.
moisture may need to be added to
the wound
3.
surrounding tissue must be protected
with a skin sealant
4.
debridement often needed
5.
debridement may be surgical, sharp,
enzymatic or autolytic
6.
dressing options include impregnated
gauze, transparent films, hydrogels or
hydrocolloids
7.
standard gauze used as secondary
dressing
Necrotic draining wounds
1.
necrotic draining wounds require
debridement, absorption and protection
of surrounding tissues
2.
should be observed for the signs and
symptoms of infection
3.
absorb exudate and remove eschar
4.
debridement may be surgical, sharp
enzymatic or autolytic
5.
treatment options include alginate’s,
semipermeable foams or hydrocolloids
6.
gauze is the secondary dressing
Infected wounds
1.
should not be occluded and should be re-bandaged frequently
2.
good dressing choices usually involve a gauze dressing with additional gauze
lairs over alginate’s, semipermeable foams or antimicrobial dressings
VIT A
VIT C
CA/MG
Nutrition
VIT E
PROTEINS
ZINC
NUTRITION
Necessary for epithelialization, collagen
synthesis, immune function , cellular
cohesiveness
Low proteins lead to edema and decreased
resistance to infection
Key factor in wound breakdown and impaired
healing
QUIZZ TIME
2 weeks after initial debridement the wound in A looks like the
wound in B
A
Which of the following statements is most
likely ?
A. Due to endotoxin of gram (-)
organism
B. Due to exotoxin of anaerobic
B
streptococcus
C. Due to cutaneous vasculitis with
thrombosis
D. Due to pathergy
no draining wound with a pink base
may be treated with the following except:
A. a transparent dressing
B. and hydrocolloid dressing
C. a hydrogel
D.
calcium alginate dressing
The ideal surgical dressing is intended
to do all of the following except:
A. act as a bacterial barrier
B. provide thermal insulation
C. reduce pain
D. keep the wound as dry as possible
83 year old woman seen in clinic with associated lesion .States cut foot on
shower base three weeks ago. Sent for management of pyogenic granuloma
Best treatment option:
A. Debride, culture, moisture
retentive dressing
B. Culture ,debride, absorptive
dressing
C. Biopsy to rule out
malignancy
D. Wide excision ,primary
repair
75 year old male seen in clinic with painful lesion lateral malleolus. Wound is
boggy with crepitus, no palpable pulse ,Type 2 diabetes.
Best treatment option:
A. Saline compress , IV
antibiotic after C&S ,then
calcium alginate dressing
B. Acetic acid compress then
hydrogel with po
antibiotics
C. Culture first then debride
with iv/po Rx
D. Debride first ,then
culture, then iv/po RX