Choice of Treatment and Care of Different Wounds

Choice of Treatment and
Care of Different Wounds –
non-operative
APN Eva Au
QEH
Modern wound product
Moist wound dressing method
 Hydrogel, enzymatic cream
 Advanced dressing product
 Alignate, hydrofibre
 Anti-microbial dressing material
 Before we start to apply any dressing
material, something we should
consider ………

Clinical approach
of wound management
Analyze the factors causing delay
wound healing
 State the objective of management
 Use appropriate method or product to
achieve the objective

Clinical approach
of wound management

Factors affecting wound healing
General factors


Age
Nutritional status
 Oral
intake
 Serum albumin
 Total protein

Immune status
 Autoimmune
disease
 Infection

Circulation insufficiency
 Venous ulcer vs arterial ulcer
General factors




Co-morbidity
 Diabetes
 Gouty
Medication
 Steriod
Psychosocial status of patient
Environmental factor
 Temperature
Local factors

What is the reason for non-healing or
deterioration?
 Moisture balance
 Bacterial loading (heavy colonization)
 Infection
 Over-granulation
 Foreign body
 Non-viable tissue
 Nature of tissue exposed on wound bed
Local factors

What is the reason for non-healing or
deterioration?
 Skin tension
eg. wound over joint area
 Pressure & friction
eg. foot deformity, ischial sore, protrude
coccynx
 Micro-circulation
 Edematous of surrounding tissue
 Crust & scab
Clinical signs of
delay wound healing

General signs
Serum albumin
 Infectious markers

 ESR,
CRP,
 WBC, neutrophil count

Local signs
Color and consistency of exudate
 Local sign and symptom of infection

Clinical approach
of wound management

Objective of management
Wound healing
 Prevention of deterioration / inactivation
 Conservative vs surgical management
 Prepare for the next step of medical or surgical
intervention

Advancement of medical
technology
Biological artificial skin



Dermagraft®
It can be used when
patient does not
want or is not
suitable for autograft
Biological dressing
which extracted from
the foreskin of infant
Biological artificial skin

Apply every week which can reduce
the need of skin graft in the operation
theatre
Advancement of medical technology
Polarized light
Bioptron
Bioptron light

A specific optical unit
emitting light that is
similar to the part of
the electromagnetic
spectrum produced
naturally by the sun
but with no UV
radiation
Characteristics

Polarized light
its waves move
(oscillate) in
parallel planes.
 The light emitted
by the
BIOPTRON
devices reaches
a polarization
degree of 95%

Polarization by reflection
Characteristics

Polychromy




Polychromatic light
It contains not only one wavelength (like laser light) but
a wide range, including visible light and a portion of the
infrared range.
The wavelength of BIOPTRON Light ranges from 480 nm
to 3,400 nm
The BIOPTRON electromagnetic spectrum does not
contain UV radiation
Characteristics

Incoherency
Unlike laser light, BIOPTRON Light is incoherent
 This means that the light waves are not
synchronized.

Coherent or in-phase light
Laser Light
Incoherent or out-of-phase light
Bioptron Light
Characteristics

Low energy level
2.4 J / cm2
 This energy density
has bio-stimulative
effects and allows
the light to
stimulate various
biological
processes in the
body in a positive
way

Mechanism

Bio-stimulation effect
Not clearly known
 It is still under research

Biological effect

Inflammation phase
Number of neutrophil increases which can
assists in bacterio-phagoytosis
 Lymphocyte, monocyte and eosinophil appear
in wound
 Numbers of immunoglobulin and protein
increase
 Numbers of lysosomatic enzymes increase

Biological effect

Proliferation Phase
Number of macrophage increases
 Assists in tissue debridement by
phagocytosis
 Release growth factor to stimulate
fibroblase proliferation and collagen
production

Biological effect

Maturation phase
Increase in collagen production
 Therefore reshape the scar

Functions




Reduce
 Pain, inflammation, swelling, scar formation,
allergic reaction
Accelerate
 Healing and regeneration
Regulate
 Immune function
Penetrate
 2.5 cm under the skin
Application

Before applying the Bioptron light therapy
clean the area and remove any dressing
before treatment

Hold the device at a right angle of 90° and
keep a distance of approx. 10 cm

The light beam should not be moved
during the treatment
Application

Cover large areas by treating them point-bypoint until the whole surface has been
covered

Apply the therapy once or twice a day
Advancement of medical technology
Negative Pressure
Wound Therapy
(NPWT)
NPWT

Negative pressure wound therapy
(NPWT) = Vacuum-assisted Closure
(VAC)
Developed since 1993
 Expose wound bed to negative pressure by
closed system

NPWT

Approach
Debride dead tissue thoroughly
 Apply NWPT 125-175 mmHg
 Change every 2 days
 Apply until wound bed covered or filled with
granulation tissue
 Skin graft / flap coverage / other dressing
materials

NPWT
NPWT

Function
Drainage of wound exudate
 Decrease bacterial loading
 Improve local circulation and angiogenesis
 Stimulate granulation and epithelization
 Decrease the number of surgeries
required
 As an adjunctive therapy to simplify the
complexity of surgery afterwards

Clinical Evidence Summary

Level I evidence (systematic review)

The effectiveness of vacuum assisted closure in wound
healing
Higgins 2003

Topical negative pressure for treating with chronic
wounds
Cochrane review 2003
NPWT
3-6-09
27-5-09
1-6-09
Clinical approach of
wound management
Clinical approach of
wound management

Apply appropriate dressing technique
or product to achieve the objective of
management
Dressing technique

Appropriate dressing technique
Speed up the progress of wound healing
 Decrease the demand of advance dressing
materials
 Cost-effective / cost-saving


Before applying any advance dressing
product, do you should consider the most
appropriate the dressing technique??
Dressing technique

Use of solution
The research findings was controversial
 Meta-analysis from The Joanna Briggs Institute
 There was no difference in infection rates and
healing rates in wounds cleansed with either
tap water, distilled water, boiled water,
normal saline or Povidone Iodine

Dressing technique

Use of solution (cont’d)
Boiled and cool water is effective as a wound
cleansing in the absence of normal saline
 Povidine Iodine is an effective solution for
contaminated wound
 However, some of the above conclusions are
based on single studies and limited sample size
 Further studies are required to confirm the
conclusions

Dressing technique

Use of solution (cont’d)
The use of solutions are different in different
clinical settings
 There is no unify method on the choose of
solution
 As a general rule, use NS to clean and
granulated wound
 Variety of solution can be used for contaminated
wound

Dressing technique

Irrigation
There is no research to suggest that swabbing
and scrubbing are effective technique for
wound cleansing
 Irrigation can remove the by-product of tissue
and cellular debris without the injury of
granulation tissue

Dressing technique

Irrigation (cont’d)
The optimum pressure that should be used for
wound cleansing debatable
 Longmire et al. (1987) compared irrigation of
wound using 12 ml syringe and 22g needle to
a bulb syringe
 Combination of this syringe and needle
delivered 13 psi (pounds per square inch)

Dressing technique

Irrigation (cont’d)
The result indicated that statistically significant
decrease in inflammation (p=0.034) &
infection (p=0.017) with no tissue trauma
 Importantly, the volume of the fluid used is a
critical variable to ensure thorough lavage and
reduction in infection

Dressing technique

Squeezing &
inoculation
 Promote wound
drainage
 Decrease the level
of bacterial
concentration
Cellulitis with pus
formation inside
surrounding soft tissue
Dressing technique

Squeezing & inoculation (cont’d)
 Free drainage
 Dry
gauze packing
 Dry NaCl non-woven gauze packing
 Covering with non-occlusive dressing
material
 Decrease
 Increase
bacterial concentration
the frequency of dressing eg. BD
Dressing technique

Skin tension
Healing can be compromised by wound
tension
 Increase the difficulty of epithelization
 Decrease wound tension
e.g. wound over joint by casting or slab

Conservative sharp
debridement
Ulcer covered by callosity
Dressing materials
Moisture balance

Moist wound healing product

e.g. Hydrogel
Moisture balance

Hydrogel
More than 90% of water content
 Colorless, transparent gel commonly
comprising polymers and preservatives
 Suitable for rehydration and autolytic
debridement
 Beware of bacterial loading especially on
those with poor distal circulation and joint
space exposure

Moisture balance

Paste

Little water content than
hydrogel
 e.g.
Iruxol mono cream
 collagenase
Enzymatic debridement
 Not for eschar
 Remove the slough, leaving
the wound bed ready for
healing

Moisture balance

Exudate absorption

e.g. Foam
Moisture balance

Foam
(cont’d)
 Adsorbent
dressing
 Polyurethane foam wafers which absorb
fluid into their matrix
 Different commercial products have
different speed of absorption power and
density
 Can be adhesive or non-adhesive
 Mild pressure relieving property on local
area
Control bacterial loading

Antimicrobial dressing
Beware that this
dressing does not have
enough penetration to
treat deep wound
infection
 Need to rule out any
deep wound infection or
osteomyelitis before use

 X-ray
Control bacterial loading

Silver dressing
Aquacel Ag (~1 ppm), Biatain silver, Polymen
silver, Acticoat(~100 ppm), Urgotul with SSD
 Silver concentration from 1 to 100 ppm
 Different form of silver including metallic silver,
ionic silver, nano-crystalline silver
 Useful in chronic DM foot ulcer which usually
have colonization

Control bacterial loading

Silver dressing & repeated conservative sharp
debridement
week 4
week 0
week 2
week 10
Combined dressing

Silver impregnated collagen
Control bacterial loading and
promote wound healing
simultaneously
 In vitro tests demonstrate that
PRISMA Matrix allows wound
healing and kill bacteria at the
same time

Promote wound healing

Medical Manuka
honey
honey gel
 honey tulle
 honey gel sheet (with
alginate)

Promote wound healing

Medical Manuka honey

(cont’d)
Properties and function
 pH
3.2 – 4.5
 Kill
micro-organism due to acidic nature
 Super-saturated

sugar solution
Draw water from micro-organisms by osmotic effect
 Water
drawing effect inhibits the growth of most
species of bacteria

Moisturize wound bed
Promote wound healing

Medical Manuka honey

Properties and function
 Hydrogen
oxidase
(cont’d)
(cont’d)
peroxide production by glucose
 Produce
on dilution
 1000 times less than 3% H2O2
 Effective antibacterial agent
Stimulate endothelial growth factor (EGF) by
macrophage in the inflammatory phase
 Phytochemicals

Anti-bacterial property
Promote wound healing

Medical Manuka honey

(cont’d)
Advantage:
 Moist
wound bed through osmosis especially for
relatively dry DM foot ulcer

Dis-advantage:
 Frequency
of dressing needs to be increase to
counteract the dilution effect
 A little bit messy because of oozing when
compared with other modern wound dressing
material
Medical honey dressing
week 0
week 2
week 5
week 10
week 12
Conclusion
Consider factors affecting wound healing
 Estimates the probability of wound healing
based on different factors
 Set objective of management
 Use appropriate dressing technique and
product to achieve the goal

Case scenario 1
Poor distal circulation
ESRF
 DM
 Distal circulation
compromise
 Successful rate of
wound healing at
distal region
decreased

Poor distal circulation

Objective of
management:


Inactivation &
prevention of
deterioration
Method:

Dressing prn with
light gauze
covering
Case scenario 2
Co-morbidity






F/75
H’x of SSS on
pacemaker with long
term warfarin
Bleeding tendency
AF on amiodarone
Pleural effusion
Bed bound with
general edematous
• dry eschar
• fluctuate -ve
• skin temp -ve
Co-morbidity



Objective of management:
 Inactivation &
prevention of
deterioration
Method:
 light gauze covering and
free heel to avoid
pressure
 Daily assessment to
observe for systemic &
localized infection
Beware of silent infection
• dry eschar
• fluctuate -ve
• skin temp -ve
Case scenario 3
Immune status





F/ 27
RA
Repeated foot &
leg ulcer
Latent unhealed
ulcer for several
months
On long-term oral
steroid drugs
Dry & fragile skin
Prone to have skin
maceration problem
Pain +++ve
Immune status

Objective & actions
 Promote wound
healing by moist
wound method &
anti-microbial
dressing
 Apply skin barrier
before any
maceration occurs
 Skin care of intact
skin
Dry & fragile skin
Prone to have skin
maceration problem
Pain +++ve
Immune status

Objective & actions
 Check for
pressure point
and callosity
 Excise the corn
before walking
exercise
 Refer P&O for insole
Dry & fragile skin
Prone to have skin
maceration problem
Pain +++ve
Case scenario 4
Anatomical factor






F/ 89
DM, PVD
Rt foot chronic ulcer
on lateral malleolus
3 x 2.5 cm
Slough with no
granulation
Scanty pus
Anatomical factor
Minimal soft tissue on the lateral
malleolus
 Underlying structure with fascia and
bone
 Reluctant to perform aggressive
debridement

Anatomical factor

Dressing method
Extra care is
needed on sharp
debridement
 Minimal
debridement with
pure collagen
dressing
 Enzymatic
debridement is
another choice

2 months later
Case scenario 5
Anatomical factors
M/ 60
 Bed bound
 Heel sore
 Necrotic
skin patch

Anatomical factors

Objective of
management
Prevent
deterioration
 Activate or
inactivate which
depends on clinical
signs

Case scenario 6
Nature of tissue exposed



Fascia / tendon exposed
Treatment approach
 Is the tendon / fascia
healthy?
 Any slough or
necrotic tissue on the
Extensor digitorium exposed
surface
 Paratenon exist
Preserve or not ??
Function of the tendon
 ADL of patient
Nature of tissue exposed

Objective of
management
 Tendon cannot
preserve
 Keep soft tissue
moist for skin
graft
Case scenario 7
Patient’s decision




DM foot ulcer with
amputated toes
PTSG done without
taken
Patient refused surgery
again
Wound culture result
showed moderate
growth of staph. albus
+ve
Patient’s decision

Objective of
management
 Wound bed
preparation and
wound healing

Dressing method:
Repeated bedside
debridement
 Anti-microbial
dressing

Patient’s decision



Surgical removal of
slough p.r.n.
Change to nonadhesive dressing
when discharge
clear
Healing about 3
months after
Thank you !!