Wound Coalition 2019

THE BUZZ REPORT

MALIGNANT WOUNDS

WHY WOUNDS DON’T HEAL ?

• Infection

• Blood flow

• Edema

• Repetitive trauma

• Nutrition

• EPS-extracellular

Polymeric substance

THE BUZZ REPORT1 FDA approves removal of boxed warning from REGRANEX ( becaplermin) gel 0.01% multiple studies demonstrate product saftey

a-first and only FDA approved recombinant platelet-derived growth factor(PDGF) therapy for Tx LE diabetic neuropathic ulcers

THE BUZZ REPORT

Built w miniature temperature sensors seamlessly embedded into fabric . Machine washable.

SIREN SOCKS

THE BUZZ REPORT

“Revolutionary New diagnostic imaging device confirms the antimicrobial effectiveness of Anasept-Antimicrobial Skin and Wound Products”

USED FLORESCENT IMAGING ( Moleculight )

Non cytotoxic , long lasting , clear hydrogel w .057% sodium hypochlorite

B BUZZR REPORT

THE BUZZ REPORT

• New Skilled Nursing Facility ( SNF ) and Home Health Payment Models

• Payment systems correlate payment to the patients conditions and care needs rather than volume of services (COST Based ) provided or resources rendered PDPM ( Patient Driven Payment Model )

• 5 components : PT , OT , SL , nursing , and non-therapy ancillary (NTA) services

THE BUZZ REPORT

• Several wound care items included in NTA services will add points to reimbursement calculation and possibly increase overall daily reimbursement : wound infection , DFU , stage 4 pressure injury severe skin burn or condition , open lesion on foot or foot infection .

• DOCUMENTATION !!

THE BUZZ REPORT• Definition and Characteristics of Chronic Tissue Injury :

1 purple-maroon discoloration of fleshy part buttocks not necessarily over a boney prominence

2 Thinned epidermal tissue , sometimes includes superficial abraded skin or small open lesions

3 present long time4 do not innately improve or deteriorate into partial or full

thickness injury5 typically bilateral6 does not improve or deteriorate over time7 occurs in patients w stable chronic health condotions who

are not at end of life8 no history trauma 9 referred to as “recliner butt” by some10 does not meet the definition of any known skin injury

category

THE BUZZ REPORTMepilex Border Flex-5 layer bordered foam wd dressing

flexible & comfortable 360 degree flexibilitysilicon contact layer ATRAUMATIChigh moisture vapor transmission rate for longer wear

timetransparent film top layer protects against

bacteria/viruses , dressing is shower proofdistributes fluid over wide surface area to maximize

fluid transport to the retention layer and backing filmabsorbs , channel-and traps exudate containing

bacteria away from the wound bed and prevents re-entry to wound bed

exudate progress monitor to track and record fluid , potentially avoiding excess dressing changes : dot pattern on backing film

MEPILEX Border Flex

• Indications : diabetic ft ulcers , venous ulcers , skin tears , and traumatic wds may be used under compression , leave up to 7 dys

THE BUZZ REPORT

• Indications : management of wide range of exuding chronic and acute wounds , DF, venous leg ulcers pressure ulcers , skin tears , and traumatic wounds , may be used under compression

THE BUZZ REPORT• Aquacel Advantage AG : Enhanced hydrofiber

dressings w silver and strengthening fiber are soft , sterile dressing made from 2 layers of 1.2% ionic silver impregnated sodium carboxymethylcellulosefiber w added ethylenediaminetetraacetic acid disodium salt (EDTA) and benzethonium chloride

THE BUZZ REPORT

AQUACEL ADVANTAGE AG :

Kills broad spectrum bacteria w/I dressing including resistant bacteria

May leave up to 7 days

Indications-2nd degree burns , DFU , venous & arterial ulcers , pressure ulcers , dehiscence , traumatic wd , donor sites , oncology wd w exudate i.e. fungoides ,fungating carcinomas , infected wds

MF: most common form of T-cell lymphoma

HYDROFIBER DRESSING

• Defined as a soft sterile non-woven pad or ribbon dressing composed of sodium carboxymethylcellulose, which is incorporated in the form of a fleece held together by a needle-bonding process ( gelling fiber )

• Versatile and can be incorporated into a variety of dressing may have silver ions to reduce bioburden within the dressing

• Aquacel Extra , Maxsorb , ConvaTec

THE BUZZ REPORT

• Simpurity Transparent Film / Silicon Dressing• Indication skin tears surgical wounds , superficial

abrasions , 1st degree burns , stage 1 or 2 pressure injuries , tatoo application and removal , cover eye socket during surgery , protect feeding tubes , IV and catheter sites

• Provides waterproof barrier to external contaminates

• Silicon adhesive is breathable , flexible and gentle on skin

• Sterile and latex free gentle to remove

THE BUZZ REPORT

• BIAKOS Antimicrobial Skin and Wound Cleanser

includes polyhexamethylene biguanide (PHMB) 0,1%

Description : Pure, colorless, isotonic , liquid spray cleanser

Assist mechanical removal of debris and inhibits growth of organism

Indication : Stage 1and 2 pressure ulcers , diabetic foot ulcers , post surgical wounds , 1st and 2nd degree burns , grafted and donor site

Contraindication : presence hyaline cartilage

THE BUZZ REPORT

HYCOL Hydrolyzed Collagen:type 1 bovine hydrolyzed collagen contains no

additives . Available in powder or gel encourage deposition and organization of newly

formed collagen fibers and granulation tissuereduces MMP levels act as sacrificial substrate binding

to MMPs allows fibroblast to proliferate lay down new collagen and secrete glycosaminoglycansResulting in a functional ECM

Indications : partial and full thickness wds , pressure ulcers 1-4 , venous stasis ulcers , arterial ulcers , diabetic ulcers , surgical & traumatic wds , 1st and 2nd degree burns

THE BUZZ REPORT

Gentell Honey Hydrogel:

Indication wound w little or no exudate diabetic skin ulcers , venous stasis ulcers , 1st 2nd burns post surgical incisions , and abrasions

Leptospermum Honey 100%( Manuka honey a moisturizing agent known for antimicrobial properties

Autolytic debridement

Hydrates wd

Contraindications : infected wds or heavy drainage

Cover 2nd dressing change daily or as indicated

Effective antimicrobial agent , anti-inflammatory , antioxidant

THE BUZZ REPORT• PICO 7 SINGLE Use Negative Pressure Wound Therapy System

(sNPWT)• Pocket size , 2 AA alkaline batteries• Silicon contact,• Dressing change indicator• 25% quieter than previous• New belt clip• Indication: traumatic , dehiscence ,

partial thickness burns ,diabetic ,pressure ulcers , flaps , grafts closedsurgical incisions

Contraindicated: malignant , osteo , unexplored fistula ,necrotic tissue w eschar , exposed arteries , veins , nerves , organs anastomotic sites

THE BUZZ REPORTReplicine- Bioactive Keratin Dressing

Keratin regulates key cellular activities (keratinocytes and fibroblast) affecting their migration and proliferation

stablize the cell against mechanical stress in epithelium

hydrates the skin and provides waterproof barrier

THE BUZZ REPORT

• Keragel : thick hydrogel w replicine used burns superficial to partial thickness w dry to medium exudate ( venous, arterial , diabetic , pressure , grafts

• Keragel T : low viscosity hydrogel w replicine

• Keramatrix : absorbable matrix delivers replicine as disolves in wound

• REPLICINE is functional Keratin

THE BUZZ REPORTProcellera : broad spectrum antimicrobial wound dressing featuring Advanced Microcurrent Technology

Embedded in dressing are microcell batteries made of elemental silver and zinc applied in a dot-matrix pattern to a polyester substrate . In the presence of a conductive medium such as wound exudate, water-based hydrogels or saline , microcurrents are generated at the dressing surface , due to its inherent design

the dressing generates electricity that mimics the body’ s physiologic electric fields and may reduce the risk of infection while supporting the bodys natural healing process

Is a primary contact layer Bioelectric Dressing should be used under a secondary dressing

THE BUZZ REPORT

• Procellera : is a primary contact layer Bioelectric Dressing and should be used under 2nd dressing

THE BUZZ REPORT

• Zorflex : 100% activated carbon wound contact dressing works by adsorbing bacteria and other pathogens onto dressing surface

• Conductivity stores body’s natural transepithelialpotential aids healing

• Odor management• Can use extended periods time• Indications: partial –full thickness wds ( cavity &

trauma wds , surgical sites , fungating carcinomas , pressure , venous , diabetic , ulcers ,graft sites

THE BUZZ REPORT

Iodofoam Black Gold : sterile ,single use absorptive foam dressing consisting of polyvinyl alcohol (PVA) foam complexed w iodine to create a controlled release iodophor comprising 8 % iodine

Features: absorbs fluids , removing exudate , debris & loose slough while providing a protective ,soft covering

Releases : iodine to kill bacteria changes color from black to white when iodine depleted

Indications : cleans wet ulcers and wounds , including diabetic , pressure , arterial , venous , burns and infected traumatic or surgical wds

BUZZ REPORT

• Excellagen : 1) Highly –purified fibrillar bovine Type1 collagen

–based topical gel (2.6%)2)Action- a acts as dermal scaffold , promoting

chemotaxis ,cellular adhesion ,,migration and proliferation to stimulate granulation tissue

b-localizes and stabilizes growth factorsc-substrate for excess proteases found

in chronic wds3) apply presence of blood

BUZZ REPORT

4) indication : partial & full thickness wds , pressure ulcers , venous ulcers diabetic ulcers , vascular ulcars , tunneled/undermined wds surgical wds , ( donor sites/grafts , post-Mohs surgery , post laser surgery , podiatric , wound dehiscence) trauma wds ( abrasions , lacerations , 2nd degree burns & skin tears ) and draining wds

5)contraindications : sensitivity bovine coolagen

6) Biodegradable and biocompatible no need daily wd changes

MALIGNANT WOUNDS

PROBLEMS

• SYMPTOMS

• PAIN

• EXUDATE

• MALODOR

• PERIWOUND EXCORIATION

• INFECTION

• BLEEDING

MALIGNANT WOUNDS

A-assess wd characteristics1) Tissue 2) Exudate3) Infection : signs localized infections -- NERDS

( nonhealing , increase exudate , red and bleeding , debris –slough/eschar bone exposed, malodor( smell )

signs for deeper systemic infection STONES ( size increasing , temp increase , exposed bone (os) , new areas breakdown , erythema and edema of periwound skin , exudate levels increase , smell

4)PERIWOUND / maceration

Symptoms of a malignant wound

• 1. Physical symptoms of malignant wounds are a by product of tumor progression,

infection, and/or poor wound care practices. Common symptoms include pain, excessive exudate, malodor, and bleeding.

• 2. Psychosocial symptoms, such as depression, embarrassment, despair, and social isolation, also occur, especially if physical symptoms are poorly managed.

WOUND PAIN

• Chronic by nature : tumor pressure on adjacent organs or nerves , edema , exposed nerve endings , drying exposed dermis , inflammation , infection , maceration and poor wd care practices

• Types pain :1- nociceptive ( aching, throbbing ,sharp)2- neuropathic ( damage to peripheral or central nervous system ) described as tingling , stinging , burning or shooting .3-mixed

WOUND PAIN

Also determine if the pain is persistent despite the absence of painful stimuli or if it is associated with an acute event, such as dressing changes or repositioning. Krasner (1995) developed the first model of chronic wound pain, which differentiated pain associated w underlying etiology ( persistent , cyclic , noncyclic )

Always give IR opiods 1hr before dressing change

PHARMACOLOGIC MANAGEMENT OF MALIGNANT PAIN

SYSTEMIC analgesic :Nociceptive pain use WHO pain ladder both somatic &

visceral , short and long acting opiods.Inflammatory pain use corticosteroids like decadron or prednisone

Neuropathic pain use TCAs , SNRIs , antiepileptic drugs ( gabapentin , pregabalin )

Mixed consider methadone – ½ life 8-59hrsTopical analgesics:

Injectable MS , Amorphous hydrogel ( 5-10mg apply 1-3 x daily

Morphine spray 0.2% sol ( 20mg morphine injection 2ml + 8ml NS )

local ADE topical morphine , itching , burning , pain

TOPICAL ANESTHETICS

• Lidocaine 2% sol. Called viscous lidocaine

• Regenecare Wound Gel commercially available product w 2% lidocaine apply TID or PRN not indicated w infective wounds or over large areas

• Ketamine , amitriptyline , ASA , baclofen , gabapentin , & clonidine 0.1% can be compounded not standardized & research mostly anecdotal

NONPHARMACOLOGICAL INTERVENTIONS

• Reduce perception of pain

1-ACUPUNCTURE

2-Art , music , aromatherapy , or pet therapy

3-Distraction , guided imagery , relaxation

4-Heat or cold

5-HUMOR

6-Hypnosis

7-positioning , therapeutic touch

EXUDATE

• Exudate 2nd to inflammation , vasodilation , increase blood vessel permeability

• May be due to Infection• Minimal exudate: consider thin foam or hydrogel or

hydrocolloid-could increase odor, honey, polymem• Moderate exudate: calcium alginate , gelling fiber , foam .

May layer them to extend wear time,saline wet to wet , polymeric membrane

• Heavy/Copious : super absorbant dressing , incontinent products . Pouching system ie-enluxtra , keramax , optilock

• Protect periskin w liquid barrier film or cream ( zinc oxide-based ) or cavelon or gention violet

• Santyl : not preferred due to daily dressing change . Caution w infection , cation w some cleansors and topicals because deactivation

PolyMem Dressing

Multifunctional polymeric membrane dressings comprise a hydrophilic polyurethane matrix that contains a mild non-toxic wound cleanser (F-68 surfactant) soothing moisturizer ( glycerin ) , a superabsorbent starch co-polymer and a semi-permeable backing film .

MALODOR

Recommend environmental strategies

Air fresheners , essential oils , dryer sheets , candles , coffee grounds , kitty litter or baking soda placed in room

Commercial odor-neutralizing products

Eliminate poor hygiene dirty linens

Increase ventilation

Pouching

Oder-absorbing hydrocolloids w cyclodextrin option for noninfected wds

LOCALIZED WOUND CARE

• Address bacterial burden

• Moisture-balanced dressing , protect nerve endings , decrease wound adherence

• Apply contact layer ( adaptic , xeroform , sorbac , silverlon )

• Gentle irrigation avoid swabbing w gauze

• Irrigation should be body temperature

• Non-adherent dressing

OBSERVE INEFFECTIVE WOUND CARE PRACTICES

Cleansing the wound

1) clean wd bed NS , tap water , or commercial cleanser

2) Devitalized tissue : irrigate w 4-15 PSI

3) Infection : irrigate w 4-15PSI

4) Soiled dressing change more often or use more absorbent dressing : Drawtex , OptiLock , KerraMax

MANAGE bacterial burden

• Localized infection: debridement and topical antimicrobial dressing

• Deeper/Systemic infection: topical vssystemic antibiotics

• Level exudate: Minimal-silver hydrogel , polymeric membrane

dressings w silver, honey , PHMB , betadineModerate/heavy : saline impregnated gauze ,

absorptive silver dressings ( gelling fiber , alginate , polymeric ) honey alginates , gention violet methylene blue or iodine-based dressing

Pathologic Biofilm Quickly Establishes

Colonization by free-floating (planktonic) pathogens

2. Absorption of pathogens into wound bed, permanent attachment

3. Biofilm growth, division Maturation of ‘microcolony’, secretion of 3-dimensional protective layer, the Extracellular Polymeric Substance (EPS)

5. Proliferation of microcolonies

Continuous dispersion, formation of new microcolonies

1

4

6

A new understanding of these microbial communities is driving a revolution that may transform the science of microbiology - Scientific Figure on ResearchGate. Available from: https://www.researchgate.net/Formation-of-a-biofilm-is-analogous-to-the-development-of-a-multicellular-organism-with_fig2_253263880 [accessed 13 Aug, 2018]

Manage bacterial burden

• ANTIBIOTICS: 1) discuss w patient if systemic AB approriate2) topical AB in chronic wound care should be avoided3) topical or systemic metronidazole common

practise. Metrogel 1% paste 5% powder , crushed tablets or powder, applied wd bed(2-500mg tablets ) or via a coated dressing

4) oral therapy : metronidazole250 mg PO daily x 7 dysexpect decrease odor n 2-3 days

5) Irrigation : use 1% solution ( 2-500mg tablets in 100ml in NS or

BLEEDING

• Malignant wd : causes (fragile vasculature , coagulopathy , tumor erosion , infection , or trauma dressing adherence

• Prevention: cleansing w gentle irrigation rather than swabbing w gauze , non adherent contact layer prevent wd bed trauma , avoid meds that cause bleeding

• Bleeding ensues :slow ooze- apply pressure 10-15 min using a calcium

alginate or cauterizing small areas w silver nitrate , carafate , prism

persistent bleeding , moisten gauze w topical 0.5% phenylephrine , oxymetazoline or tranexamic acid (100mg/ml ) apply under pressure. Ice packs. Minimzedressing changes

Bleeding• Heavy bleeding :

Gelatin sponges , fibrant sealants(Evicel , Artiss , Evarrest , Tachosil , Tisseel) or topical epinephrine ( 1:10,000 1:200,000 1:500,000 ) soaked gauze . Can cause ischemic necrosis, Surgicel , topical thrombin

Combat gauze ( QuikClot available in some pharmacies OTC ) can be placed under pressure If persistent & pt doesn’t wish emergent care provide dark towels and sheets minimize appearance blood & medicate for pain and anxiety

WHAT IS IT ???

MARJOLIN ULCER

• Malignant tumors arising in chronic wounds .

• Strictly defined , they include carcinomas that transforms from the chronic open wounds of pressure sores or burns scars . They behave aggressively propensity for local recurrence & lymph node metastasis

THANK YOU