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Walking the Wounded

Walking the Wounded. Craig Evans Physiotherapist Rankin Park Limb Centre. AROC RPC Results summarised (Rees, Baines and Dunne 2015). Admission: RPC has increased complexity of patients Increased comorbidities Increased patients with carer and support Decreased admission FIM’s

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Walking the Wounded

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  1. Walking the Wounded Craig Evans Physiotherapist Rankin Park Limb Centre

  2. AROC RPC Results summarised (Rees, Baines and Dunne 2015) Admission: • RPC has increased complexity of patients • Increased comorbidities • Increased patients with carer and support • Decreased admission FIM’s Inpatient: • Increased LOS ( Due to external service issues ) • Decreased complications ( RPC good nursing care ) Discharge: • Lower FIM scores • Increased FIM change • Increased services at home but increased discharge to home

  3. Episodes of care at RPC

  4. FIM change over 10 + years

  5. Average Age change over the years

  6. More FIM data…

  7. Overall admissions

  8. From AROC we know…

  9. What presents…

  10. What Is needed for wound healing? • Happy healthy cells! • Remove oedema and slough • Moist vs dry • Circulation – O2 and nutrition • Approximate wound edges • Prevent adherent scarring

  11. Wound Healing http://classconnection.s3.amazonaws.com/964/flashcards/520964/png/healing1321212453488.png

  12. A building analogy… http://cawc.net/images/uploads/Principles-of-Wound-Healing.pdf

  13. Different dressings and materials

  14. Negative Pressure Wound Therapy POSITIVES • Collection of exudate away from wound • low frequency dressings • “Anatomically clean” – reduce exposure to infection. • Low odour • Promotes granulation • Approximates wound • Increased perfusion.

  15. Negative Pressure Wound Therapy NEGATIVES • Wound maceration • Retention of dressings • Wound infection • “suction rash” • Interfere with mobility • Noisy – sleep probs • Prosthesis issues? • Cost?

  16. Negative Pressure Wound Therapy • Cochrane review (Dumville et al 2015) – NPWT on second intention wounds(SIW). • 2 studies • Lack of evidence or adverse effects • New study – shock, anguish, frustration, powerlessness (McCaughan, 2015) • RCTs aren’t everything…

  17. Wound Research… 1000s! No 2 wounds are the same – comparison issues Need to use different dressings at different times. Consensus is difficult

  18. Other considerations… Circulation / Perfusion / Oxygen

  19. Other considerations… Depression linked with lower prosthetic use rates post discharge (?) Exercise may help mood Pain Home environment / accessibility Can a prosthesis be fitted?

  20. Early Prosthetic fitting… IPOPs – since ?1980s / earlier? More recently found to have similar complications, less revision surgery required (Ali et al 2013) Active suction sockets (Traballesi et al 2012)

  21. Early Prosthetic fitting… Use of NPWT concurrently with prosthesis (Fuller et al 2011)

  22. Silicone Liners(Larsson and Johannesson,1997)

  23. Nothing to lose… BK1

  24. Walking helps… • Active exercise – increases CO and BP • Wound compressed in socket +/- ? Silicone • “Squeezes” out the “bad stuff” • Cyclical Pumping – blood flow, reduces oedema • Good for the psyche • Better function

  25. Case Study: BK2 49 yo male Amputation: (R) TTA 17/6/16 B/G: T2DM; Obesity; PVD – (L) TTA 2014; H/T; Depression; eMRSA Post op complications: Hb 78, multiple debridements + VAC, depression. Rehab adm 4/8/16

  26. Case BK2: 9/8/16

  27. Case BK2: 29/8/16

  28. Case BK2: 16/9/16 no prosthesis.

  29. Strict prosthetic protocol

  30. Case BK2: 20/9/16 (Prosthesis)

  31. Case BK2: 26/9/16 Discharge!!!

  32. Strict prosthetic protocol

  33. Case BK2: 28/9/16 – 1st OP visit

  34. Case BK2: 5/10/17

  35. Case BK2: 5/10/16

  36. Case BK2: 2/11/16

  37. Amputee mortality / survival rates Kulkarni Pande and Morris (2006) “Survival rates in dysvascular lower limb amputees.” International Journal of Surgery (2006) 4: 217-221 English Cohort (n=201)

  38. Amputee mortality / survival rates

  39. Prosthetic fitting for delayed wounds • Doesn’t always go right. • Meticulous • Monitoring wound and fit • Strict protocol • Who are the best candidates?

  40. References AJ Hayes et al (2011). “Risk equations to predict life expectancy of people with Type 2 diabetes mellitus following major complications: a study from Western Australia.” Diabet. Med. 28, 428–435 (2011) Kulkarni Pande and Morris (2006) “Survival rates in dysvascular lower limb amputees.” International Journal of Surgery (2006) 4: 217-221 Larsson and Johannesson (1997)? Dumville JC, Owens GL, Crosbie EJ, Peinemann F, Liu Z. Negative pressure wound therapy for treating surgical wounds healing by secondary intention. CochraneDatabaseof SystematicReviews 2015, Issue 6. Art. No.: CD011278. DOI: 10.1002/14651858.CD011278.pub2. MM Ali et al (2013). “ A contemporary comparative analysis of immediate postoperative prosthesis placement following below-knee amputation.” Annals of Vascular Surgery 27(8): 1146-53, 2013 Nov. Traballesi et al (2012). “Residual limb wounds or ulcers heal in transtibial amputees using active suction socket system. A randomised controlled study.” European journal of physical & rehabilitation medicine 48(4): 613-23 2012 Dec. M Fuller et al (2011). “A novel approach to wound management and prosthetic use with concurrent vacuum-assisted closure therapy.” Prosthetics and Orthotics International 35(2): 246-9, 2011 Jun

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