Best Practices in Community Wound Care

1. Best Practices in Community Wound Care YANGAMA JOKWIRO BScNS MSc Physiology

2. Challenges in community wound care • Availability of expertise • Cultural practices • Reimbursement of products used and labour involved • Cost effectiveness • Red tape in acquiring wound care products • Difficulty in coordinating care with Specialists

3. Mobility status Urinary continence Bowel continence Feeding assistance needed Pressure ulcer history Recent weight loss Height & weight Skin exam Admission assessment for community risk factors

4. Recapping on prior knowledge • Skin is the largest organ which provides protection, sensation, communication, thermoregulation, metabolic synthesis and COSMESIS • Three layers epidermis, dermis and hypodermis

5. The skin

6. Physiology of wound healing • Haemostasis Vasoconstriction Platelet response Biochemical response intrinsic clotting pathway extrinsic clotting pathway clot retraction and fibrinolysis

7. Physiology of wound healing • Tissue Repair Highly orchestrated process Soluble mediators, blood and parenchymal cells, and extracellular matrix Three Phases Inflammation phase (0-3 days) Reconstruction/proliferation phase (2-24 days) Maturation/remodeling phase (24days-1 year) (wound never gain 80% of their original strength)_

10. Modes of Healing • Primary intention • Delayed Primary intention • Secondary intention • Skin graft • Flap

11. Importance of moisture balance in wound care • Insufficient moisture in exposed wound tissues causes desiccation and cell death, and prevents epithelial migration and matrix deposition • Excessive moisture due to exudate inhibits cell proliferation and breaks down matrix components • Moisture balance in the wound bed is maintained by appropriate choice of dressings

12. Wet to wet or wet to dry dressing • Although normal saline is isotonic, as it evaporates from the dressing, it becomes hypertonic and tissue fluid is drawn into the dressing • Blood and proteins eventually accumulate on dressing surface and dressing dries out completely • Has to be applied at least three times a day

13. Chronic wounds • Diabetic ulcer • Decubitus ulcer • Venous stasis ulcer • Neuropathic foot • Pressure ulcers • Malignant wounds

14. Why is the chronic wound chronic? • Growth factors may be deficient (PDGF TGF) • Increased bacteria • Decreased oxygen • Cells are senescent and unable to respond to growth factors • Cell are slow to proliferate and migrate (<5mm per week closure rate)

15. Why is the chronic wound Chronic ? • Fungating cancer People often find that they have several symptoms at the same time. The most common symptoms of a fungating wound include: discharge an unpleasant smell pain bleeding itching.

16. Why is the Chronic wound chronic • Diabetes mellitus Most common problem in patients with chronic wounds (prevention better than cure) decreased inflammatory response fibroblast impairment leads to decreased collagen deposition Impaired granulocytic function and chemotaxis increase the risk of wound infection

17. Why is the chronic wound chronic? • Immunosuppressive medication Potent effect on the inflammatory stage of healing glucocorticoid interfere with wound macrophages, fibrogenesis and wound contraction Stabilize lysosomal membranes, altering the balance of inflammatory mediators • can be reversed by topical administration of vitamin A

18. Why is the Chronic wound Chronic • Malnutrition lower serum albumin below 2gm/dl decrease fibroblast proliferation, angiogenesis, cellular mitosis and remodelling. phagocytic activity and lymphocyte function are decreased after only 4 weeks of malnutrition Vitamins A,C, and B6 are necessary for collagen synthesis and cross-linking Deficiencies in B1 and B2 copper and zinc are associated with poor collagen synthesis and epithelialization

19. PEM HIV with wasting Diabetes Burns and sepsis Cystic fibrosis Cancer Chronic fatigue syndrome Alzheimer’s Parkinson’s Hepatitis Ulcerative colitis Crohn’s disease COPD Idiopathic pulmonary fibrosis Myocardial ischemia Renal disease MS Conditions associated with low GSH (GLUTATHIONE) and ability to fight free radical (ROS)

20. Do we need to monitor nutritional status? • Track percent meals consumed • Monitor changes in weight • Monitor protein intake (< 90% RDA) • Consider laboratory tests

21. Do we need to nutritional Interventions • Supplements • Feeding assistance programs • Feeding assistance devices • Vitamins & minerals • Dietitian

22. Keys to selecting dressings • Must use clinical judgment • Keep wound bed continuously moist • Keeps surrounding skin dry • Control exudate without desiccating (drying out) wound bed • Caregiver time

23. Appearance of Wound • Wound with clean granular base • Wound with crater • Wound with necrotic/non-viable tissue • Wound with exudate • Wound with sinus, tunnel, undermining • Wound with infection

24. Wound with clean granular base • Objectives: Protect & keep moist • Treatments: • Hydrocolloid • Hydrogel • Secondary dressing • Vacuum assisted closure (VAC) device • Wet to damp saline (Temporarily)

25. Wound with crater • Objective: Fill the space with uniform contact • Treatments: • Hydrogel • Alginate • Foam • Hydrocolloid • Vacuum assisted closure (VAC) device • Wet to damp saline (Temporarily)

26. Wound with necrotic/non-viable tissue • Objective: Debride and cleanse • Treatments: • Enzymatic dressing • Hydrogel dressings • Calcium alginates • Pulse irrigation • Vacuum assisted closure (VAC) device • Hypertonic salts • Wet to damp saline (Temporarily)

27. Wound with exudate • Objectives: Absorb and contain • Treatments: • Alginate • Foam • Vacuum assisted closure (VAC) device • Wet to damp saline (Temporarily)

28. Wound with sinus, tunnel, undermining • Objectives: Prevent pre-mature closure, absorb exudate • Treatments: Loose packing • Impregnate gauze with hydrogel • Calcium alginate if high drainage • Vacuum assisted closure (VAC) device • Wet to damp saline (Temporarily)

29. Wound with infection • Objectives: Decrease local bacterial count • Treatments: • Pulse irrigation • Long-acting time-release antibiotic • Short-acting antibiotic or antimicrobial • Vacuum assisted closure (VAC) device • Wet to damp saline (Temporarily)

30. Autolytic debridement • Autologous enzymes debride tissue • Moisture retentive dressings • Leukocytes collect in wound • Upon cell death – lysosomal enzymes released – degrading proteins and mucopolysaccharides • ??? Allowing bacteria to collect ???

31. “In the old days we only had to know saline and gauze” • Hydrocolloid • Hydrogel • Calcium alginate • Foam • Collagenase • Antimicrobials • Growth factors • Matrix enhancing agents

32. HYDROCOLLOID • Indications: Venous ulcers, pressure ulcers, diabetic ulcers, 1st and 2nd degree burns • Absorbency and film dressing • Highly absorbent gel (polyurethane) • Oxygen and water vapor permeable • Adhesion and elasticity • Bacterial barrier • Allows for autolytic debridement • Can stay in place for 72 hours

33. Hydrocolloids • Smith & Nephew • Replicare, Cutinova hydro • Coloplast • Comfeel • 3M • Tegasorb • ConvaTec/CVL • DuoDERM • J&J • NU-DERM

34. HYDROGEL • Indications: Mildly exuding wounds, clean wounds, partial thickness wounds • Absorbs 5 times own weight • Hydrophilic polysaccharide particles • Cooling soothing effect • Facilitates autolytic debridement • Delivered in many forms • Amorphous gel, Sheets, Strands • Can stay in place for 24 hours

35. Hydrogels • Smith & Nephew (Impregnated gauze) • Sheets (Flexigel), Amorphous (SoloSite) • Carrington • CarraGauze, Carrasyn Gel • ConvaTec/CVL • DuoDERM Gel • Healthpoint • Curasol, Curasol Gel • J & J • Nu-GEL • Kendall • Curafil, Curafil Gel • 3M • Tegagel

36. CALCIUM ALGINATE • Indications: Wounds with large amount of drainage • Absorbs up to 30 times weight • Seaweed, highly mannuronic acid fibers • Forms a hydrophilic gel • Comes in many forms • Sheets, tubes, loose fibers packs • Maintains a moist wound environment • Can stay in place 24 to 72 hours

37. Calcium Alginates • Smith & Nephew • AlgiSite • Carrington • CarraSorb • ConvaTec/CVL • KALTOSTAT • Dow Hickam • SORBSAN • J & J • FIBRACOL • Kendall • CURASORB • 3M • Tegagen

38. FOAM • Indications: Highly exudative wound requiring a non-stick surface (e.g. venous stasis) • Highly absorbent (20 times weight) • Non-adherent wound contact layer, hydrocellular foam, waterproof outer layer • Can be formed • Cavity, heel, sacral, trach etc. • Allows for autolytic debridement and gaseous exchange • Can be left in place for 72 to 96 hours

39. Foams • Smith & Nephew • Allevyn, Allevyn adhesive • Beiersdorf • Cutinova foam • Carrington • Carrasmart • ConvaTec/CVL • Hydrasorb • J & J • Nu-Derm, Tielle • Kedndall • Curaform

40. Enzymatic Debridement • Indications: A wound requiring debridement of fibrinous exudate, other necrotic material or slough • Removes: • Senescent fibroblasts - can’t produce cytokines or collagen • Necrotic tissue harboring bacteria

41. Enzymatic Debridement • Healthpoint • ACCUZYME • Papain (Papaya) – digestant of nonviable protein • Active over pH 3 to 12 • Require stimulators: urea • Solvent action on activators of papain, denatures non-viable protein • May burn when applied • APPLY DIRECTLY TO THE WOUND • Irrigate out – BID or QD • May need to crosshatch eschar

42. Enzymatic Debridement • Healthpoint • PANAFIL • Indication: Granulating wounds with slough and infection • Papain-urea proteolytic activity removes non-viable protein • Chlorophyllin Copper complex-reduces fibrin formation • Allows macrophages to arrive and signal fibroblasts • Fibroblasts initiate collagen deposition • Copper enhances structural integrity of deposited collagen • Application: QD or BID, although 48 – 72 hour changes OK, can be applied under pressure dressings

43. Combination Agents • Healthpoint • XENADERM • Balsam Peru – increases blood flow to wound site • Castor oil – creates moist wound environment • Trypsin – maintains clean wound bed • Aluminum magnesium hydroxide stearate – repels fluids • BID for stage I and II wounds

44. Antimicrobials • Indications: Infected wounds, wounds with bacterial counts greater than 105 • Bacterial count greater than this decrease wound healing rates • Bacterial proteases degrade growth factors • Therapeutic concentration at the site of the wound

45. Antimicrobials • Water-based topical antibiotics • Penetrate granulation tissue • Inhibit fibroblast growth

46. Antimicrobials • Silvedene • Sulfamylon • Acticoat • Iodoflex • Polysporin/Bacitracin • Dakin’s

47. Sulfamylon • 5 % Sulfamylon cream • (Mafenide Acetate, Bertek Pharm) • Bacteriostatic vs. Gram neg, Gram pos. (including pseudomonas), and some anaerobes • Metabolyte cleared through kidneys • Inhibits carbonic anhydrase • DOES NOT INHIBIT FIBROBLASTS

48. Acticoat • Nanocrystalline silver coating • Silver coated on polyethylene mesh • Rayon polyester core • Bacteriostatic • Can stay in place for one week • Non-stick • Indications: Venous ulcers, diabetic ulcers

49. Iodoflex/Iodosorb • Iodine gel or impregnated pad • Wound exudate absorbed by cadexomer polymer – gel • As polymer expands 9% elemental iodine released • 72 hours: color change from brown to gray • Lowers pH • Toxic to fibroblasts?

50. Mechanical Debridement • Pulse Irrigation • Vacuum-Assisted Closure • Sharp debridement Removes: • Devitalized tissues • Bacteria and proteolytic enzymes • Senescent cells