Treatment and Healing Chronic Wounds

Dr. Luinio S. Tongson, FPCS, CWS, MSPH

Wound Care Conference Singapore

Chronic Wounds
Wound that does not heal in an orderly set of stages and in a predictable amount of time the way most wounds do Do not heal within three months(1) Often remain in the inflammatory stage for too long.(2)

1.Mustoe T (March 1718, 2005). "Dermal ulcer healing: Advances in understanding". Paris, France: EUROCONFERENCES. 2.Snyder RJ (2005). "Treatment of nonhealing ulcers with allografts".Clin.Dermatol. 23 (4): 38895.

Classification
Majority (1,2) Venous ulcers Diabetic ulcer Pressure ulcers Others Radiation poisoning Ischemia (2)

1. Moreo K. "Understanding and overcoming the challenges of effective case management for patients with chronic wounds". Case Manager 16 (2): 623, 67. 2. Mustoe T. "Understanding chronic wounds: a unifying hypothesis on their pathogenesis and implications for therapy". Am. J. Surg. 187 (5A): 65S70S.

Primary Intention

Secondary Intention

Tertiary Intention

Barriers to healing

Delayed healing
Exudate Chronic contents Excess Necrosis Microorganisms Number Pathogenecity

Non-healing
Cellular dysfunction Wrong phenotype Defective receptors ??? Biochemical imbalance Incorrect cytokine expression Excessive protease production

Eschar black/dry
Slough yellow/wet

Host resistance

Incomplete cascades?

Think WHOLE not HOLE

Metabolic Factors
Diabetes mellitus Renal failure

Systemic Factors
Chemotherapy Gene damage Steroids

Local Factors

Chronic Wound
Nutritional Factors
Proteins Minerals Vitamins

Pressure Infection Necrotic tissue Dessication Chronic exudate

Local Factors that Impede Wound Healing

Inadequate blood supply Increased skin tension Poor surgical apposition Wound dehiscence Poor venous drainage Presence of foreign body &/or reactions Infection Excess local mobility .
Grey, J., Enoch, S., Harding, K. ABC of wound healing Wound assessment BMJ. 2006 February 4; 332(7536): 285288.

Systemic Factors that Impede Wound Healing

Advancing age Obesity Smoking Malnutrition Systemic malignancy Chemotherapy Radiotherapy Immunosupresive drugs Inherited neutrophil and macrophage disorder .
Grey, J., Enoch, S., Harding, K. ABC of wound healing Wound assessment BMJ. 2006 February 4; 332(7536): 285288.

Laboratory Investigation

. Grey, J., Enoch, S., Harding, K. ABC of wound healing Wound assessment BMJ. 2006 February 4; 332(7536): 285288.

Treatment Plan
Review of the patient's medical record focusing on the chronic disease baseline norms for the patient.

Broderick ,N,, Understanding chronic wound healing . The Nurse Practitioner: The American Journal of Primary Health Care. Oct 2009 Vol 34 Num 10 , pp 16 - 22

Treatment Plan
Review the patient's current medications to evaluate if any of the medications will inhibit wound healing

Broderick ,N,, Understanding chronic wound healing . The Nurse Practitioner: The American Journal of Primary Health Care. Oct 2009 Vol 34 Num 10 , pp 16 - 22

Medication that Impair Wound Healing

Corticosteroids Antiplatelet Nonsteroidal anti-inflammatory drugs Cytotoxic medications Nicotine Anticoagulants Immunosuppressives Anti-RA medications Vasoconstrictors
Broderick ,N,, Understanding chronic wound healing . The Nurse Practitioner: The American Journal of Primary Health Care. Oct 2009 Vol 34 Num 10 , pp 16 - 22

Medication that Enhance Wound Healing

Pentoxifylline Prostaglandins Growth factors Sex hormones Retinoids Phenytoin Vitamins A and C Zinc
Broderick ,N,, Understanding chronic wound healing . The Nurse Practitioner: The American Journal of Primary Health Care. Oct 2009 Vol 34 Num 10 , pp 16 - 22

Treatment Plan
Basic nutritional assessment would include body mass index. Any indications of malnutrition
Assessment to include lab tests, a food diary, or at a minimum, assessment of intake for the past 24 hours.

Protein severe illness or large wounds is 1 to 1.5 g/kg.

. Evans E. Nutritional assessment in chronic wound care . J Wound Ostomy Continence Nurs. 2005; 32 (5): 317-320.

Treatment Plan
Nutritional issues become more of a challenge for the elderly due to decreased appetite. Encourage patients to increase their consumption of proteins and to consume an appropriate amount of calories. Patients with CRF add more challenge to ensure nutritional intake meets the required calorie count.

Broderick ,N,, Understanding chronic wound healing . The Nurse Practitioner: The American Journal of Primary Health Care. Oct 2009 Vol 34 Num 10 , pp 16 - 22

Treatment Plan
Assessment tool Monofilament
Patients with diabetes are at risk for neuropathic changes as early as 7 years into the disease which puts them at risk for foot ulcers and early amputation.
Falanga V, Brem H, Ennis WJ, Wolcott R, Gould L, Ayello EA.,. et al. Maintenance debridement in the treatment of difficult-to-heal chronic wounds. OWM Supplement. 2008; 1-15

Treatment Plan
Vascular assessment: Venous insufficiency VS Peripheral Arterial Disease

Broderick ,N,, Understanding chronic wound healing . The Nurse Practitioner: The American Journal of Primary Health Care. Oct 2009 Vol 34 Num 10 , pp 16 - 22

Slide CVC VS PAD

Treatment Plan: TIME

Moist wound healing is the gold standard for wound care.1 Dry wounds increase the chance of infection, increases pain, and allows for poor scar formation.1,2 Proper dressing choices.

1. JonesV, Harding K. Moist wound healing optimizing the wound environment. In: Chronic Wound Care: A Clinical Source Book for Healthcare Professionals. 4th ed. Mavern, PA: HMP Communications; 2007: 199-204. [Context Link] 2. Bolton L. Operational definition of moist wound healing. J Wound Ostomy Continence Nurs. 2007;34 (1):23-29

Treatment Plan: TIME

Wound assessment
Cause of the wound Drainage Wound base appearance Periwound skin Pain related to the wound and dressing changes

Broderick ,N,, Understanding chronic wound healing . The Nurse Practitioner: The American Journal of Primary Health Care. Oct 2009 Vol 34 Num 10 , pp 16 - 22

Treatment Plan
Evaluation of the patient's level of pain.
Does the patient only have pain with dressing changes or is it chronically present in the wound site area.

Research: new dressing that contains ibuprofen* for those patients who are unable, to take oral pain medications. Decreasing dressing changes can reduce pain.
. Gray M. Context for WOC practice. J Wound Ostomy Continence Nurs. 2009: 36(1):11-13.

Treatment Plan
Wound bed preparation is central to the healing process. Removal of tissue that is colonized with biofilm is an essential component of continuous wound management. Debridement is an avenue used to "jumpstart" the wound healing process in a stalled wound.
Falanga V, Brem H, Ennis WJ, Wolcott R, Gould L, Ayello EA.,. et al. Maintenance debridement in the treatment of difficult-to-heal chronic wounds. OWM Supplement. 2008; 1-15.

Pathologic Process of Chronic Wound

Prolonged inflammatory phase Cellular senescence Deficiency of growth factor receptor sites No initial bleeding event to trigger cascade Higher level of proteases

Broderick ,N,, Understanding chronic wound healing . The Nurse Practitioner: The American Journal of Primary Health Care. Oct 2009 Vol 34 Num 10 , pp 16 - 22

National Clinical Guidelines for Foot Care National Electronic Library for Health
Modern Dressing Alginate, foam, hydrogel, hydrocolloid dressing 9 Randomized trials 2 Controlled trials Newer dressing or gels VS gauze dressing Moist dressing suggest improved performance over gauze Small trial does not provide an adequate evidence base Choice of different dressing depend on the type or stage of wound, personal experience, availability of dressing, patient preference and the site of wound

Advance Wound Care Modalities

Growth factor therapy
Growth factors under study Vascular endothelial growth factor (VEGF) Fibroblast growth factor(FGF) Keratinocyte growth factor (KGF)

Advance Wound Care Modalities

Extracellular matrices (Non living) Dermal regeneration template (Integra) Allogenic dermal matrix (AlloDerm) Matrix of human dermal fibroblast (TransCyte) Porcine small intestine submucosa (Oasis)

Negative Pressure Therapy

Removes edema and chronic exudate Reduces bacterial colonization Enhances formation of new blood vessels Increases cellular proliferation Improves wound oxygenation

Niezgoda JA, Schibly B. Negative-pressure wound therapy (VAC). In: The Wound Management Manual, pp 65-71, edited by B Lee, McGraw-Hill, New York, 2005.

Hyperbaric Oxygen Therapy

Medicare and Medicaid coverage for HBO: Wagner grade 3 or higher that failed standard wound care therapy. A large multicenter randomized clinical trial is needed to properly test the efficacy of this expensive modality

Wunderlich RP, Peters EJ, Lavery LA. Systemic hyperbaric oxygen therapy: lower-extremity wound healing and the diabetic foot. Diabetes Care 23:1551-1555, 2000.

Bio-engineered Tissue
Randomised 12-week trial of 208 patients
Bilayered construct comprising living fibroblasts and keratinocytes from neonatal foreskin Complete wound closure in 56% of patients VS 38% in controls. Active group had incidence of osteomyelitis and amputation 1

12-week randomised study with living foreskin fibroblasts in a vicryl mesh

Complete wound closure of neuropathic foot ulcers: 30% active group VS 18% control group. 2
Veves A, Falanga V, Armstrong DG, Sabolinski ML. Graftskin, a human skin equivalent, is effective in the
management of noninfected neuropathic diabetic foot ulcers: a prospective randomized multicenter clinical trial. Diabetes Care 2001; 24: 29095. 63 Marston WA, Hanft J, Norwood P, Pollak R. The efficacy and safety of Dermagraft in improving the healing of chronic diabetic foot ulcers: results of a prospective randomized trial. Diabetes Care 2003; 26: 170105.

Modified Wagner Classification of Diabetic Foot

Grade O
Grade I Grade IIA Grade IIB Grade IIIA Grade IIIB

Skin intact, may have bony deformities or pre-ulcerative lesions

Localized superficial ulcer Deep ulcer to tendon, bone, ligament, joint Same as above, plus infection/cellulitis Deep abscess with or without cellulitis Osteomyelitis with or without cellulitis

Grade IV Grade V

Gangrene of toes or forefoot Gangrene of whole foot

Wagner FW Jr. The diabetic foot. Orthopedics 1987;10:163-72.

Wagner Grade 0
Action Foot Care Education

Wagner Grade 1
Action Freedom from weight bearing Local wound care Antibiotics for cellulitis

Common Methods to Off-Load the Foot

Non Weight Bearing

Bed rest Wheel chair Crutch assisted gait

Mechanical Off loading

Total contact cast Felted foam Half shoes Therapeutic shoes Custom splints Removable cast walkers

Wagner Grade 2
Action Bed rest Glycemic control Wound cultures Antibiotics Foot x-ray +/- Doppler studies Debridement if indicated

Wagner Grade 3
Action Bed rest Glycemic control Hospitalization Wound culture Parenteral antibiotic Debridement +/- Bypass surgery Amputation if indicated

Wagner Grade 4
Action
Bed rest Glycemic control Admit to hospital Wound culture Parenteral antibiotic Debridement +/- Bypass surgery Amputation if indicated

Indication for Amputation

Primary Amputation
Unreconstructable arterial occlusive disease Necrosis of significant areas of weight bearing portion of the foot Fixed, unremediable flexion contracture of the leg Very limited life expectancy because of comorbid conditions
Treatment of CLI, Journal of Vascular Surgery, S 267-268; Jan 2000

Indication for Amputation

Secondary amputation
Unreconstructable vascular disease Persistent infection despite aggressive vascular reconstruction

Treatment of CLI, Journal of Vascular Surgery, S 267-268; Jan 2000

Amputation
If unavoidable, aim for the most distal amputation that will heal and return the patient to optimal function.

ADA Consensus Development Conference, 1999

Wagner Grade 5
Action Same as Grade 4 Major Amputation

Indication for Major Amputation in Diabetic Foot

Absolute

Life threatening sepsis

Massive foot necrosis

Wagner 5 lesion

Indications for Amputation

Relative Strong behavioral overtones Major non-compliance Significant neuropathy Economics

What is a pressure ulcer?

Defined as: an area of localised damage to the skin and underlying tissue caused by pressure, shear, friction and/or a combination of these
European Pressure Ulcer Advisory Panel EPUAP (2003)

bed sores, pressure damage, pressure injuries and decubitus ulcers

How does that ulcer form?

Pressure

Necrosis

Decubitus ulcer

Impaired blood flow

Local tissue injury

Decreased oxygen delivery

At Risk of Pressure Ulcer

Anyone with limited mobility Generally poor health or weakness Paralysis Injury or illness that requires bed rest or wheelchair use Recovery after surgery Sedation Coma

Pressure Prevention
The doctor of the future will give no medicine, but will interest her or his patients in the care of the human frame, in a proper diet, and in the cause and PREVENTION of disease.
Thomas Edison

Pressure Ulcer Prevention

Early Risk Assessment Care Plan upon admission

Risk

Quality Improvement/ Monitor Program

Admission interventions for each selected risk factor Admit & daily skin exams documented for at-risk population

Daily skin check

Risk Factors of Pressure Ulcers

Pressure Shearing Friction Level of mobility Sensory impairment Continence Level of consciousness Acute, chronic and terminal illness

Comorbidity Posture Cognition, psychological status Previous pressure damage Extremes of age Nutrition and hydration status Moisture to the skin

Role of A Nurse
Pressure Ulcer

Preventive Interventions

Cost Effective Quality and Safety Care

Improve and Best Practice

Better Care Outcome

Feedback

Pressure Ulcer Treatment

Admit assessment Treatment Risk Assessment plan

Quality Improvement/ Monitor Program

upon admission Admission treatment order based on current standards or product guidelines Weekly assessments

Weekly re-assess

Key priorities for implementation

Patients with a grade 12 pressure ulcer should: as a minimum provision be placed on a high specification foam mattress/cushion, and be closely observed for skin changes

Key priorities for implementation

Patients with grade 34 pressure ulcers should: as a minimum provision be placed on a high specification foam mattress with an alternating pressure overlay, or a sophisticated continuous low pressure system the optimum wound healing environment should be created by using modern dressings

Management of Ulcers
Risk factors addressed debridement Continence care wound cleansing Nutritional dressings improvement adjuvant therapies Mobility Pressure reduction Consider operative repair Wound Care

Referral to surgeon
Depending on: Failure of previous conservative management interventions Level of risk Previous positive effect of surgical techniques Patient preference Ulcer assessment General skin assessment

6 Treatment Principles
Pressure relieve Debridement Infection Wet dressing Risk factors Surgery

Seiler W.O.; Stahelin H.B.: Decubitus ulcers: treatment through

therapeutic principles. Geriatrics 1985 40: 30-44 (1985).

Surgical Treatment
Three principles: Excisional debridement of the ulcer Partial of complete ostectomy to reduce the bony prominence Closure of the wound Musculocutaneous flaps: excellent blood supply, provision of bulky padding, against infection Fasciocutaneous flaps: adequate blood supply, durable coverage, minimal functional deformity

If wounds do not heal

Indentifying factors

that impair wound healing

It's a motivating concept!
Ref: Zederfeldt B.: Factor influencing wound healing; in Sundel B.W., Symposium on wound
healing (Mlndal Sweden, Lindgren,A.Sner A.B. 1980)

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Venous REFLUX

Venous ulcers
Inspect Clean/debride Measure

Venous ulcers

Venous ulcers

Venous ulcers

C0
Life Style Changes

C1

C2

C3

C4

C5

C6

Sclerotherapy
Compression

Topical
Surgery

Medications