wound care presentation

Wound Care ProductsDEPARTMENT OF PODIATRIC SURGERYDEPARTMENT OF PODIATRIC SURGERY

Wound Management

QUALITY OF LIFE

Science & Technology

Clinical Practice

Revolutions

• 1960’s Moist wound healing

• 1990’s Advanced technological products

• 1999’s Wound Bed Preparation

»Tissue engineered products

Wound Healing Cascade

• Coagulation: 0-2 hours

• Inflammation: 0-3 days

• Cell migration and proliferation: 3-21 days

• Angiogenesis

• Remodeling: 21 days -1.5 years

Systemic Assessment

Age

Body Build

Stress

Nutrition

Medications

Tissue Oxygenation

Immunity

Concomitant Disease

What’s Available?

• Traditional Treatment Modalities

– Hydrogels: Normlgel, Hypergel, Clearsite, etc

– Hydrocolloids: Duoderm, Comfeel, Restore, Tegasorb, Replicare

– Transparent films: Opsite, Tegaderm, bioclusive, epiview

– Wet to dry dressing

– Foam dressings: Allevyn, Biatain, Hydrasorb, etc.

– Calcium alginates: Sorbsan, AlgiSite, Curasorb, Kaltostat

– Enzymatic: Santyl, Panafil, Accuzyme, Gladase,

– Biological: Maggot therapy

– Antibacterial: Acticoat, Iodosorb, Prisma

Hydrogels

Normlgel, Hypergel, Clearsite, Curasol gel, Solosite, Intrasite, Hydrogel, Nu-Gel, Skintegrity, Clearsite, etc

Hydrogels• Hydrophillic / glycerin based gels

• High water content, viscosity varies by manufacturer

• Limited absorptive capacity

• Autolytic debridement of necrotic / slough tissues

• Partial or full thickness wounds

• Hydrogels help maintain a moist wound healing environment for granulation, epithelialization, and facilitation of autolytic debridement.

Hydrogel Sheet Dressing Flexderm, Vigilon, Flexigel, Curasol Gel, Restore, CarraGauze, etc

• Higher rate of absorption

• Cooling, soothing effect on superficial wounds

Hydrogel Sheet

Xeroform

Hydrocolloids Duoderm, Comfeel, Restore, Tegasorb, Replicare, Nu-

Derm, Dermatell, Curaderm, Hydrocol

Hydrocolloids• Components of gelatin, pectin or cellulose

• More occlusive compare to other dressings

• Waterproof

• Partial thickness wounds with low - moderate exudate

• Contraindicated for clinical infected wounds

• Conformable

• Adhesive, may damage fragile periwound skin

Hydrocolloid Application

Promogran

• Advanced wound care device comprised of a sterile freeze dried composite of 45% oxidized regenerated cellulose (ORC) and 55% collagen.

– Maintains moist microenvironment at the wound surface– Enhances granulation tissue formation, epithelization and

rapid wound healing.

• PRISMA: Anti-Bacterial property

Transparent FilmsOpsite, Tegaderm, Bioclusive, Epiview

Transparent Films• Polyurethane or co-polyester composition

• Waterproof and gas permeable

• Superficial wounds with no / minimal exudate

• Promote autolysis of necrotic / slough tissue

• Permit evaluation of wound progress

• Can tear healthy skin if improperly removed

• Occlusion may reduce pain

Transparent Film Autolytic Debridement

Transparent Films

Alginates

Sorbsan, AlgiSite, Curasorb, Kaltostat, Gentell, Restore, SeaSorb, Maxorb, Curasorb, AlgiDerm

Alginates• Non-woven fibers derived

from brown seaweed

• Useful for filling moderate exudate wounds

• Interact with fluid to form a gel-like

• Safe to use with clinical infected wounds

• Will not debride hard eschar

Alginate Application

Aquacel Hydrofiber Dressing

• Centuries of proven antimicrobial activity

• Cytotoxicity concerns associated with carriers not silver - ex. Silver nitrate, Silver sulfadiazine15

• Traditional delivery required repeated applications due to binding with chlorine and proteins

• Contemporary silver dressings allow for continued release up to 7 days

• Broad spectrum - inactivates almost all know bacteria including MRSA and VRE15

• No documented cases of bacterial resistance15

• Ex: Silver Cel, Acticaot15Demling and DeSanti (2001)

Nanocrystalline Silver

Common Silver Compounds

Sulfadiazine Silver Cream

• Commonly used in variety of wounds

• Effective against broad range of resistant organisms

• Painless upon application• Difficult to remove• May form pseudoeschar

Silver Nitrate Solution 0.5%

• Used in 1943 in treatment of burns• Wide spectrum of activity• No known bacterial resistance• Staining of skin• Frequent dressing changes• Not effective with eschar

What’s Available?

Enzymatic Panafil, Accuzyme, Gladase, Kovia ointment, Ziox ointment, Ethezyme

Skin Substitutes/Tissue Engineered

• Tissue engineered xenografts– Oasis, MediSkin, EZ Derm

• Tissue engineered allografts– Apligraf, Dermagraft, GammaGraft, Alloderm

• Tissue engineered acellular dermal replacements:– GraftJacket, GammaGraft, Integra, Primatrix

• Oasis: Freeze dried porcine xenograft, stored at room temperature, long shelf life.

• EZ Derm: Porcine xenografts, long shelf live, stored at room temperature

• Mediskin: frozen epidermal/dermal porcine modified xenograft; must be kept frozen at less than 32 degrees Fahrenheit, thawed at room temperature 1-2 hours prior to application.

Oasis

• Small Intestine Submucosa– Derived from porcine small intestine– Complex matrix of collagen, growth factors

and other proteins

• Apligraf: Bi-layered laminate of epidermis and dermis and grown from neonatal foreskin; shelf life up to 10 days when stored in its own shipping container.

• Dermagraft: human fibroblast derived dermal skin substitutes

• GraftJacket: Contains dermal elements and no epidermis, allow rapid revascularization and cell re-popularization, can use on tendons, capsule, exposed bone

Apligraf

• Bilayered living skin substitute– Epidermal layer of human keratinocytes– Dermal layer of human fibroblasts– Bovine type I collagen lattice

• Mechanism of Action– Provide a collagen scaffolding– Provide cellular structures– Release growth factors from cell

Indications for the Use ofDermagraft®

DERMAGRAFT is indicated for use in the treatment in full-thickness diabetic foot ulcers greater than six weeks duration which extend through the dermis, but without tendon, muscle, joint capsule, or bone exposure. DERMAGRAFT should be used in conjunction with standard wound care regimens and in patients that have adequate blood supply to the involved foot.

Week 0 Week 9 Week 5

Case Study 2

• Alloderm: Freeze dried de-cellularized human product. Defined as human allogeneic skin; acellular tissue; allograft.

• GammaGraft: Irradiated human skin allograft from human cadaveric donors. Stored in a foil pouch at room temperature for up to 2 years.

• Integra: Bilayer Matrix (Integra Bilayer Matrix Wound Dressing—Intergra BMWD and Single layer Wound Dressing)

• Primatrix: acellular dermal matrix from fetal bovine skin, stored at room temperature up to 2 years.

What’s Available?

• Fibrin Glue: Combination of fibrinogen, calcium and thrombin

• Fibrin Gel: Combination of calcium and thrombin and autologous plasma.

• Platelet Gel: Autologous blood is collected and centrifuged to isolate platelet rich plasma and then combined with thrombin.

Regranex: Becaplermin

• PDGF-BB: Recombinant Human Platelet-Derived Growth Factor 1997

• Stimulates mesenchymal cells

Mist U/S Transport Technology (MUST)

• Increases mast cell degranulation– Vascular permeability– Realease of mitogenic growth factors– Migration of macrophages and fibroblasts– Capillary density– Calcium up take in fibroblasts– Collagen synthesis– Tensile strength and elasticity of collagen

• 40 KHz• Effective in reducing bacterial load, stimulate

debridement, induce granulation buds.

Superoxidized Water

• Superoxidized Water (Dermacyn; Oculus Innovative Sciences, Petaluma, Calif)

– Flush wounds under 8 pounds per square inch of pressure (twice weekly) AND/OR

– Sock wounds with superoxidized water for 30 minutes AND/OR

– Use as wet dressing to the wound daily

Negative Pressure Wound Therapy: Vacuum Assisted

Closure (VAC)

• 48 hour dressing changes

• Aggressive reduction in interstitial fluids

• Can be used for any size of wound

• Can be used on infected wound (12 hour change)

• Can treat more than one wound at a time.

VAC: KCI-Kinetic Concepts, Inc, The Versatile 1 (Blue Sky

Medical)• Contraindications:

– Fistulas to organs or body cavities ???– Necrotic tissue with eschar present: Need

debridement – Untreated Osteomyelitis– Malignancy in the wound– Application of dressing over exposed arteries

or veins.