medical comorbidities and their impacto on wound healing
TRANSCRIPT
MEDICAL COMORBIDITIES AND THEIR IMPACT ON WOUND
HEALING
Lee C. Ruotsi, MD, CWS, UHM
“CARE FOR THE WOUND IS ONLY PART OF THE STORY. SUCCESS
DEPENDS ON HOW YOU MANAGE THE REST OF THE PATIENT’S
PROBLEMS”
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NORMAL WOUND HEALING
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HEMOSTASIS
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PROLIFERATIVE
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INFLAMMATORY
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REMODELING
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ABNORMAL WOUND HEALING
Failure to progress through normal orderly stages of wound healing.
Chronicity typically defined by failure to progress normally over a 30 day period.
Most common “hangup” appears to be in the inflammatory phase.
Visually; inadequate granulation, persistent or excessive exudate, deficient wound contraction and/or absence of neo-epithelialization.
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“A chronic wound is an acute wound with an impediment”
T.K Hunt, M.D.
“The impediment may be the treating physician”
Harriett Hopf, M.D.
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SYSTEMIC FACTORS Diabetes
Rheumatoid Disease Scleroderma
Lupus SMOKING
Vasculitis Renal Failure
Chemotherapy Radiation
Unusual
A GOOD H & P
Past Medical History Past Surgical History Past Wounding History; location, timing,
treatment Medications Family History Review of Systems Thorough Exam
GENERAL APPEARANCE
Cushingoid (puffy) appearance Rheumatoid joints Cachexia Scleroderma face Abnormal affect and behavior Focal neurologic deficit Tobacco
DIABETES MELLITUS 20.8 mil (7% of pop.) 6.2 mil undiagnosed! 800,000 new cases per year (120,000 DFU’s) Lifetime risk of ulceration 15% Complex multifactorial effect of DM on micro and
macro-vascular complications Reduced flexibility and resistance of tissues to
tensile compression and shear forces Strong evidence through DCCS and UKPDS that
tight control delays onset of both primary and secondary complications
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NEUROPATHY
MOTOR
Anterior tibial weakness Pedal muscle atrophy
Fat pad atrophy Digital instability and
deformities Increased peak pressures
due to deformities Ulcerations over
deformities
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NEUROPATHY
SENSORY
Diabetic sensory polyneuropathy
Peri-nerve edema Increased wounding risk
due to loss of protective sensation (L.O.P.S.)
Unable to feel pressure or pain over prominences or
with trauma
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NEUROPATHY
AUTONOMIC
Faulty sweat gland activity
Dry, fissured skin leads to infection and ulceration
Uncontrolled vasodilatation due to
decreased arteriolar tone
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RHEUMATOID DISEASE Systemic autoimmune disorder of unknown etiol. Leg ulcerations in 8 – 9% of patients Ulcer is smooth, irregularly shaped and painful Felty’s Syndrome; Combination of RA,
splenomegaly, granulocytopenia and leg ulcers Systemic Treatment: High dose steroids,
cyclophosphamide, Dapsone, disease modifying agents
Wound treatment: Standard wound care, bioengineered skin
RHEUMATOID LEG ULCERS
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SYSTEMIC LUPUS (SLE) Systemic autoimmune disease of unknown etiology Incidence of leg ulcers 2 – 8% Ulcers typically over pre-tibial areas and extremely
painful Characterized by well defined wound margins, purulent
bed and varying amount of granulation Surrounding skin may be normal or erythematous with
evidence of atrophie blanche Treatment is challenging; topical retinoic acid,
intralesional steroids
LUPUS RELATED LEG ULCERS
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SCLERODERMA
Autoimmune disorder of unknown etiology
Ulcers usually over digits and bony prom.
Epithelialization usually difficult
C.R.E.S.T. Syndrome Occlusive dressings
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RAYNAUDS
Intermittent, severe ischemia of fingers/toes
May be precipitated by cold or localized trauma
Sympathetic mediation Soft tissue atrophy and
non-healing ulcerations Vasodilators, platelet
agents, Pentoxyfilene, PD-5’s, nitrates
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VASCULITIS
Inflammation of blood vessel of ? Etiology
Male = Female Prevalent in elderly Flat, red nodules
macules or purpura Lesions frequently
ulcerate and are difficult to heal
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FACTOR V LEYDEN
Protein C resistance Increased risk of
thrombosis, venous > arterial
Progressive thrombotic occlusion leads to poor blood supply and wounding
Difficult to heal
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RENAL FAILURE
Foot ulceration 5x higher in stage 4 & 5 CKD
2x higher prevalence of amputation, PAD, neuropathy
Dialysis is independent risk factor for ulceration
Multifactorial proposed etiologies
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PROTEIN ENERGY MALNUTRITION Rapid and insidious onset Populations at risk – elderly and poor Albumin, fibrinogen and globulin all important Indices: albumin, transferrin, TLC, pre-albumin Hyperglycemia delays wound healing Variety of supplements available B & C vits: immunity, inflammation and collagen D,E,A,K vits: clotting, healing and anti-oxidants Fe, Zn, Cu: small amounts but critical
ABC’S OF NUTRITION ASSESSMENT
A) Anthropometrics: Ht, wt, skinfolds
B) Biochemical: alb, pre-alb, transferrin, TLC,
minerals, BUN/Cr, hgb, hct
C) Clinical signs: skin – pale, dry, scaly, swollen
hair – thin, dull, changed texture
eyes – sunken, scleral yellowing
mouth – cheilosis, tongue color,
missing teeth, gums
D) Dietary: calorie counts, % consumption
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MEDICATIONS
Systemic Steroids Topical Steroids NSAIDS Amlodipine/Nifedipine Methotrexate Warfarin Heparin
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CHEMOTHERAPY
49 pts with stage II – III breast cancer received 3 drug chemo with vinorelbine, cisplatin and 5-FU for up to 6 cycles and up to 30 minutes pre-op. No wound infections or delays in healing noted
Colleoni, et al, 2003
100 pts treated with multi-agent platinum based chemo following surgery for ovarian ca had no increase (11%) in wound complications compared to those receiving no chemo
Kolb, et al, 199231
CHEMOTHERAPY Bevacizumab (Avastin) - Monoclonal antibody
against VEGF inhibits angiogenesis in tumor and healthy tissue alike
Cetuximab (Erbitux) - Monoclonal antibody against EGFR. Led to slightly prolonged hospital stays and drain removals
Harari, et al, 2003
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RADIATION THERAPY
Impairs vascularity and depletes cell lines
Impacts all phases of wound healing
Progressive over time Good response to
HBOT Radiation Proctitis
Clark, Cone et al, 2008
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Hypoxic
HypocellularHypovascular
RADIATION RELATED WOUNDS
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PYODERMA GANGRENOSUM
Non-infectious neutrophilic dermatosis
Painful ulcers of varying depth and size
Violaceous borders Most commonly
associated with underlying disease
Pathergy !
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FACTITIOUS DISORDER
Accompanies various psychiatric disorders
Lesions in various stages of healing
Usually sharp borders Tend to be in
accessible areas, usually sparing mid-back
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ETOH INDUCED LIMO DISEASE
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SMOKING
Impairs wound healing via local hypoxia, endothelial and vasomotor dysfunction, atherosclerosis, platelet activation and inhibition of collagen synthesis
Increased risk of post-op infection and wound rupture compared to non-smokers
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SUMMARY Careful H&P History of prior wounding Lifestyle and mobility questions Nutritional assessment Wound characteristics Prior treatment; successes and failures
Pay attention:
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