Wound Care: From then to now

Objectives

Discuss changes in theories of treatment in wound care and implications to current wound care practice.

Review good wound care practice and implications as related to regulatory changes.

Review types of wound debridement. Discuss list indications and

contraindications for wound dressings.

Evolution of wound care dressings…

1948: “Experiments with occlusive dressings of a new plastic” by JP Bull

Discussed properties of a nylon derivative film

Water vapor permeability made it suitable for wound dressings

Also noted that the presence of a variety of organisms was reduced or disappeared

Evolution of wound care dressings…

1963 (Hinman): “Effects of air exposure and occlusion of experimental human skin wounds”Used a sterile polyethylene film in artificially

made wounds on health adult male volunteersWounds were either occluded or allowed to heal

open to airResults: Wounds healing under moist conditions

healed 50% faster than wounds open to air

Winters, CD Nature 1962

Where we’re going…

Traditional dressings:• Gauze, lint and fiber products• Hydrocolloids

Modern Moist Wound Dressings:• Foams• Films• Alginates/Hydrofibers• Collagen• Hydrogels• Topical Antimicrobials• Silicone

Look how far we’ve come!!!

Wet to Dry Gauze: Why not?

Disadvantages of wet to dry:

AHRQ Pressure Ulcer Guidelines Wet-to-dry implies gauze is applied moist and removed

when dry.

Problems? W/D gauze dressings as a form of mechanical debridement

are “non-selective” and, …are rarely applied correctly …may cause pain on removal …may be more costly in terms of labor and supplies …may cause maceration of skin surrounding the wound …may release airborne organisms (cross contamination)

What else???

Moistening gauze that is adhered

Primary objective is lost

Gauze fibers can be left in wound

Moist wound healing is an industry standard: known to improve healing rate

Winter’s research (1960’s)

• Moist wounds healed 2x as fast as wounds allowed to dry

What else???

Inconsistency with application Moisture levels vary with clinicians Wet to moist may dry out and become wet to dry

Drying gauze has a cooling effect on tissue Gauze: 77-81 degrees in wound bed Films/foams: 91-95 degrees in wound bed

vasoconstriction, hypoxia, impairment of phagocytic efficiency

Ovington, L Hanging Wet to Dry Out to Dry. Home HelathCare Nurse. 2001; 19(8), 477-483

There’s more?

Gauze dressings present no bacterial barrier

Lawrence (1994): 64 layers of dry gauze allowed bacterial penetration

Hutchison (1989,1993): Moistened gauze presents less barrier

Hutchison (1990): Review of 3047 wounds showed the following infection rate:

• 2.6% for those dressed with moisture-retentive dressings

• 7.1% for those dressed with gauze

Ovington, L Hanging Wet to Dry Out to Dry. Home HelathCare Nurse. 2001; 19(8), 477-483

Cost of Wound Care

Cost of dry gauze and ancillary supplies$.47 per dressing change

Cost of hydrocolloid and ancillary supplies

$6.15 per dressing change

Daily Cost (dressing cost + clinician cost)

Dry gauze $12.26

Hydrocolloid $3.55

Colwell et al, Decubitus 1993

How should we select dressings?

Hydrating

Absorbing

Fillers

Active

Secondary

Primary

Autolytic

Enzymatic

Non-adhesive

Wound Management Priorities

Reduce or eliminate causative factors Provide systemic support for healing Apply appropriate topical therapy

Debride - remove necrotic tissue Identify and eliminate infection Fill dead space - lightly Absorb excess exudate Maintain moist wound surface Open closed wound edges Protect from trauma and pain Insulate

Selecting Dressings

○ Keeps the wound bed moist ○Prevents both maceration & desiccation

○Offers good Moisture Vapor Transmission Rate

○ Minimizes peri-wound maceration

○ Protects the peri-wound skin

○ Eliminates dead space

○ Assures packing will stay in place

○ Minimizes pain

○ Assures stable environment

○ Provides thermal insulation

○ Always consider caregiver time

Ideal Primary Dressings

Need to be compatible with the wound:

May be hydrating or absorptive

Promote/maintain moist, healing environment

Provide for “breathability” (MVTR)

Provide insulation

Impermeable to microrganisms

minimize contamination from outside

Atraumatic to the wound/periwound area

Cost effective

Ideal Secondary Dressings

Need to be compatible with the wound: Absorb exudate Provide moisture to wound Promote autolysis (debridement) May be used in infected wounds Be atraumatic to wound/periwound

Minimize adherence Minimize movement Minimize stripping

Cost effective

Foams

Benefits:Bordered and un-borderedProvide a moist environmentHigh absorbencyConformable, may be cut to sizeThermal insulationNo residue MVTRNo adherence to wound bed

Foams

Indications:

Superficial and full thickness wounds

Skin grafts, donor sites, burns, skin tears

Under compression for LE ulcers

Contraindications:

Dry wounds

Examples: Mepilex (Border), Allevyn (Plus Adhesive), Polymem, Biatain

Films

Benefits:

Provide a moist environment

Enable autolytic debridement

Provide protection from extraneous forces (microbes, friction, shear, chemicals)

High MVTR

Conformable

Films

Indications:Minor injuries (abrasions)Post-op dressing over suturesIV sites

Contraindications:High exudate woundsFragile skin

Examples: Tegaderm, Opsite

Alginates/Hydrofibers

Benefits:

Provide a moist environment

High absorptive capacity

Conformable/cuttable (rope or sheet form)

Provide hemostasis

No adherence to moist wound bed

Alginates/Hydrofibers

Indications:Highly exuding woundsInfected wounds (change daily)

Contraindications:Dry wounds or wound with eschar

Aquacel, Melgisorb, Seasorb, Kaltostat

Hydrogels

Benefits:

Promote a moist environment

Donate moisture to dry wounds

Aid in autolytic debridement (rehydrate/soften necrotic tissue)

Hydrogels

Indications:Dry woundsWounds with slough woundsWounds with escharOver tissues and tendons to prevent drying

Contraindications:High exudate wounds

Examples: Solosite, Woun’ Dress, SkinTegrity

Silicone

Chemically inert, adverse effects rare Designed to be removed without

trauma or pain Protect friable or newly healed tissue

from injury Less trauma to periwound Examples: Mepilex, Allevyn Gentle

Enzymatic Debriders

January 1, 2008 DESI drug changes Medicare Part D: Reimbursement

Limited for products which contain papain/urea/chlorophyllin complex sodium

What does that mean?? Increased cost to the patient

Enzymatic DebridersAlternatives

Uses chemicals to break-down and digest necrotic tissue

Must know mechanism of action to be effective

Examples: Hypertonic saline, Enzymes, Honey

Antimicrobials

Bacteriocidal: Silver Honey Cadexomer iodine

Bacteriostatic: Methylene Blue and Gentian Violet Xeroform

Antimicrobial action through (+) silver ion

Effective when in contact with wound fluid

Consider:

Kill rate AND sustained release rate

Testing Methods: Simulated wound fluid, saline

Delivery methods: foams, gels, alginates, hydrofibers, creams

(SSD - approved for burns, only)

Silver

How does silver work?

Bacteria elimination: 3 ways

• Cell wall rupture

• Prevents respiration or nutrient processing

• Disturbs replication

Conclusion:• Silver resistance unlikely silver secondary to 3 mechanisms• No cases of bacterial resistance to silver in vivo.

Antiseptics

(+) Destroy or inhibit growth of microorganisms Efficacy on intact skin widely known and

accepted (+) Resistance significantly less than

antibiotics (-) In vitro cytotoxicity to cells of healing

AHRQ: Caution against use NPUAP/EPUAP: Limited use to control

bacterial bioburden

Antiseptics

Hydrogen peroxide Acetic acid

Effective against Pseudomonas aeruginosa Diguanides (Chlorhexidine) Sodium hypochlorite (Dakin’s)

Not recommended unless suitable are unavailable

Povidone Iodine

Collagen

Usually Type I bovine or avian or type III

porcine collagen

Benefits:

May accelerate wound healing

Slight absorption

May be used with topical agents

Examples: Biostep, Fibracol, Puracol

Collagen

Indications: Partial & full thickness wounds Minimal to moderate drainage

Contraindications: Eschar covered Full thickness burns Sensitivity to contents

Who makes it? Organogenesis, Inc

What is it? Dermal layer: human fibroblasts

from neonatal foreskin in a bovine Type I collagen matrix

Epidermal layer: human keratinocytes

What does it do? Accelerates wound repair by

secreting important cells and proteins (GF and cytokines)

Indications: Venous Leg Ulcers and DM Foot Ulcers

Who makes it? Advanced BioHealing, Inc

What is it? Human fibroblast (neonatal foreskin) derived dermal

substitute Contains fibroblasts, ECM and bioabsorbable scaffold

How does it work? Assists in the restoration of the dermal bed Fibroblasts proliferate to fill the interstices of the scaffold

and secrete human dermal collagen, matrix proteins, GF, and cytokines to create a 3-dimensional human dermal substitue

Indications: Full thickness DM > 6 wks duration without tendon, muscle, joint capsule or bone exposure

Graft Jacket Who makes it?

Wright Medical Technology, Inc What is it?

Donated human skin Removed the dermal and epidermal

cells but preserved bioactive components (proteins, blood vessel channels) and structure

What does it do? A 3-dimensional scaffold to support the

body’s own natural repair process of cellular repopulation and vascularization

Supports regeneration of host tissue Indications: DM

Who makes it? Healthpoint, Ltd

What is it? Extracellular matrix composed of

porcine small intestinal submucosa (SIS)

How does it work? Provides a matrix for tissue repair Placed onto wound, cells/nutrients from

adjacent tissues invade the matrix, capillary growth ensues

New tissue formation by the body itself Indications: Partial and full thickness

wounds, PrU, Venous ulcers, chronic vascular ulcers, DM, traumatic wounds, draining wounds, surgical wounds

In Conclusion

Determine wound cause and address Establish plan of care that includes

dressings that will address principles of moist wound healing

Assure pain is addressedThrough pharmacologic and non-

pharmacologic methods