wound management...cystic fibrosis infections15 urinary tract infections16 biofilm accounts for over...
TRANSCRIPT
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PROPRIETARY & CONFIDENTIAL
© 2018 ConvaTec Inc. TM indicates a trade mark of ConvaTec Inc
Wound
Management
An Update in Best
Practice
Margaret Armitage
Senior Medical Affairs
Specialist
ConvaTec UKI
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Session content: Case study approach
Basic wound assessment and wound tissue type
classification
Overview of local wound factors that delay healing;
exudate, infection & biofilm
A practical approach on dressing selection
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Wound Assessment
Acute….wounds expected to heal within a
predictable time span.
Eg: surgical wound, trauma wound
Chronic….a more long term wound. Slow or fails
to heal.
Eg: leg ulcer, pressure ulcer
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Wound Assessment
Wound Depth
Superficial wounds….only the epidermis involved
Partial thickness wounds…..penetrate the
epidermis and dermis, expose nerve endings, &
can be painful & moist.
Full thickness wound….involves total loss of
epidermis and dermis, extending into
subcutaneous tissues, and sometimes down to
muscle, ligaments and bone.
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Key point:
Wound healing is multifactorial and application of
any wound dressing is of little value unless all the
factors that may delay wound healing have been
assessed and addressed…
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General factors that could delay wound healing…
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Wound Assessment
One of the keys to successful wound management is careful and accurate assessment of the wound…
Knowledge
Your Nose…
Your Ears…
Your Mouth…
Your Eyes…
http://eslprograms.vcc.ca/ESLWEB/Mouth.gif
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Wound Challenge… “Olive”
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Local factors that could delay wound healing...
Excess Exudate
Infection
Biofilm
Oedema
Ischemia
Low oxygen levels
Elevated proteases
Neuropathy
Venous insufficiency
Slough / necrotic tissue
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What is exudate?
Slow escape of liquid containing proteins and white
blood cells from blood vessels as a result of
inflammation. It is a normal part of the body’s
defence mechanism1.
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Effects of exudate production on wound healing
Exudate assists healing2:
Prevents wound bed from drying
out.
Aids migration of tissue-
repairing cells.
Provides essential nutrients for
cell metabolism.
Assists separation of dead or
damaged tissue (autolysis).
Excess exudate may2:
Cause maceration of surrounding tissue.
Delay or prevent wound healing.
Cause subsequent breakdown and further deterioration of the wound bed.
Cause physical and psychosocial morbidity/increased demand on healthcare resources.
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Optimise the wound bed…
Too wet
Remove moisture
Absorption / Retention /
Sequestration
Debridement
Treat infection
Too dry
Add moisture
Moisture balance
Maintain
I.e. Hydrogels
Hydrocolloids
Films
I.e. Hydrofiber®
Alginates
Foams
Super Absorbents
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Poor Exudate Management
Note the maceration to the surrounding skin
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Potential complications of poor exudate management…
Delayed healing and or wound deterioration
Increased risk of systemic or local infection
Increased nursing/podiatry time & dressing costs
Damage to wound surface
Damage to surrounding skin
Failure of odour control
Detrimental effect on quality of life
Bulky dressings
Frequent dressing changes
Pain
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Wound infection
Wound infection occurs when the balance between
the patient’s resistance and the microorganisms
present in the wound is disrupted and organisms
overwhelm the immune defences3.
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The cost of infection
Infected wounds negatively affect patient quality of life:
Pain, malodour, frequent dressing changes, loss of appetite.
Can lead to serious health complications:
Lower limb amputation, sepsis, even death.
Are a burden on Healthcare Organisations4,5
Delay wound healing.
Require specialist intervention.
Associated with hospital admission/delayed discharge.
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How infection affects wound healing?
Prolongs the inflammatory phase
Decreased tissue perfusion (minimal oxygen and nutrition)
Inhibition of granulation/epithelialisation and collagen
synthesis.
Toxins/enzymes that damage the tissue locally
If the patient is systemically unwell (septic),
energy that would normally be used to heal the
wound is diverted to maintaining the patients
physiological status.
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Local barriers to wound healing...
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What is biofilm?
There are many definitions of biofilm.6-12
Simply put it can be described as:
Bacteria
attached to a
surface
embedded in a
protective slime.
Communities of microbes attached to a surface (e.g. catheter, wound),
embedded within a self-produced slime that provides protection against
antimicrobial agents and host defences.
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How do Biofilms form?
Stage 1 – Reversible surface attachment
Bacteria begin to attach to the host surface
Stage 2 – Permanent surface attachment
Bacteria multiple and become firmly attached
Gene patterns change to enhance survival (Quorum sensing)
Stage 3 – Production of EPS
The bacteria secrete a protective matrix – ‘slime’
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Biofilm is common
Biofilm is common, and
has been found in:
Alpine streams
Shower head
Biofilm is very common in
healthcare:13
Dental plaque on teeth14
Cystic Fibrosis infections15
Urinary tract infections16
Biofilm accounts for over
80% of all infections in
healthcare12
Dental plaque
biofilm
(stained)
Biofilm is present in
the majority of
chronic wounds17
and is a major
contributing factor
to delayed wound
healing.6,18,19
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Why is biofilm a problem?
Biofilm exists in at least 78.8% of chronic wounds.17
Biofilm can be difficult to remove completely and reforms
quickly.20
Biofilm keeps the wound in a low-grade inflammatory state
and is a physical barrier to healing.18,19
Delays granulation and re-epithelialisation.
Biofilm tolerates antiseptics,21 antibiotics22 and host
defences.19
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Planktonic bacteria vs. biofilm bacteria
Planktonic: free-living / swimming; isolated; susceptible
Biofilm: surface-attached; communities; protected; tolerant
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Signs a Biofilm may be present
History of antibiotic failure or persistent infection despite
choice of antibiotic treatment
Local or systemic signs of infection that resolve with
antimicrobial therapy, but recur when therapy has ceased
Wet highly exuding wound
Dark unhealthy granulation tissue
Culture-negative result despite a high suspicion of clinical
infection:
Because biofilm bacteria are often non-culturable in microbiology labs
Swabbing and culturing only picks up a fraction of the bioburden
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How can we manage them?
Evidence to date suggests that physical removal, i.e.
vigorous debridement or physical cleansing are the best
methods for reducing biofilm burden23
A biofilm can start reforming within hours. A mature biofilm
is present within 24 hours23
However there is debate as to whether wound biofilm can
be difficult to visualise!23
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Key point…
Management of the three barriers to healing:
Excess Exudate
Infection
Biofilm
....are fundamental to successful wound healing!
Hence, we should consider a dressing regime that manages
all symptoms at the wound bed…
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Dressing selection…?
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Key point:
One of the keys to successful wound management is careful and accurate assessment of the wound bed.
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How do I choose a dressing…???
Ask ‘what do I want the dressing to do…?’
Rehydrate...add moisture?
Absorb exudate? RETAIN exudate.
Deslough?
Reduce bacterial contamination?
Promote granulation?
Promote a moist wound bed?
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Wound Progression…
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Wound Challenge… back to “Olive”
How would you assess this
wound?
What do you consider to be the
key challenges?
How would you manage this
wound?
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Key points:
There are many dressing and treatment choices available to
clinicians
Treatment choice should be based on wound assessment
findings together with a clear understanding of the benefits
and limitations of each option
Consider your local wound care formulary before making
your dressing selection.
The clinician must be clear what desired outcomes are
required
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Thank-you for your attention…
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References:
1. Oxford Medical Dictionary 2010
2. World Union of Wound Healing Societies (WUWHS). Principles of best practice: Wound exudate and the role of
dressings. A consensus document. London: MEP Ltd; 2007. http://www.woundsinternational.com/clinical-
guidelines/wound-exudate-and-the-role-of-dressings-a-consensus-document/page-1. Accessed November 2013.
3. European Wound Management Association(2006). Position Document: Identifying criteria for wound infection. MEP,
London
4. Drew P, Posnett J, Rusling L. The cost of wound care for a local population in England. Int. Wound J. 2007;4:149-155.
5. Harding K, Posnett J, Vowden K. A new methodology for costing wound care. Int Wound J. 2012; doi: 10.1111/iwj.
12006
6. Leaper DJ, Schultz G, Carville K, et al. Extending the TIME concept: what have we learned n the past 10 years. Int.
Wound J. 2012;9(Suppl. 2):1-9.
7. Costerton JW, Stewart SS, Greenberg EP. Bacterial Biofilms: A Common Cause of Persistent Infections. Science.
1999;284:1318-1322
8. Scali C, Kunimoto B. An Update on Chronic Wounds and the Role of Biofilms. Journal of Cutaneous Medicine and
Surgery. 2013;17(6):371-376.
9. Hoiby N, Ciofu O, Johansen HK et al. The clinical impact of bacterial biofilms. Int. J. Oral Sci. 2011;3:55-65.
10. Kimberly A, Mancle BS, Robert S, et al. Wound biofilms: Lessons learned from oral biofilms. Wound Rep. Reg.
2013;21(3):352-62.
11. Burmolle M, Thomsen TT, Fazli M, et al. Biofilms in chronic infections – a matter of opportunity – monospecies biofilms
in multispecies infections. FEMS Immunol. Med. Microbiol. 2010;59:324-336.
12. Sanchez Jr CJ, Mende K, Beckius ML, et al. Biofilm formation by clinical isolates and the implications in chronic
infections. BMC Infectious Diseases. 2013;13:47-12.
http://www.woundsinternational.com/clinical-guidelines/wound-exudate-and-the-role-of-dressings-a-consensus-document/page-1
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References:
13. NIH (2002). Research on microbial biofilms. http://grants.nih.gov/grants/guide/pa-files/PA-03-047.html. Accessed
November 2013.
14. Marsh PD, Bradshaw DJ. Dental plaque as a biofilm. J. Industr. Microbiol. 1995;15:169-175.
15. Costerton JW. Cystic fibrosis pathogenesis and the role of biofilms in persistent infection. Trends Microbiol. 2001; 9:50-
52.
16. Trautner BW, Darouiche RO. Role of biofilm in catheter-associated urinary tract infection. Am. J. Infect. Control.
2004;32(3):177-183.
17. Malone, M,. Bjarnsholt, T., McBain, AJ., et al. The prevalence of biofilms in chronic wounds: a systematic review and
meta-analysis of published data J Wound Care 2017; 26 (1)
18. Metcalf DG, Bowler PG . Biofilm delays wound healing: a review of the evidence. J. Burns Trauma. 2013;1:5-12.
19. Gurjala AN, Geringer MR, Seth AK, et al. Development of a novel, highly quantitative in vivo model for the study of
biofilm-impaired cutaneous wound healing. Wound Rep. Regen. 2011;19:400-10.
20. Hurlow J, Bowler PG. Clinical experience with wound biofilm and management. A case series. Ostomy Wound
Management. 2009;55:38-49.
21. Percival SL, Hill KE, Malic S, et al. Antimicrobial tolerance and the significance of persister cells in recalcitrant chronic
wound biofilms. Wound Rep. Regen. 2011;19:1-9.
22. Stewart PS, Costerton JW. Antibiotic resistance of bacterial in biofilms. The Lancet. 2001;358:135-138
23. Wounds International. Biofilms made easy:Vol1/Issue3/May2010