WOUND BIOBURDEN laa AND DEBRIDEMENT © ss terse Scanned with CamScannerBIOBURDEN: * | The human body is in constant contact with multiple microorganisms originating from both endogenous and exogenous sources. These microorganisms are usually present without any evidence of infection because a balance exists between host resistance and microbial growth. Infection occurs when this equilibrium upset, either because of lowered host defenses or increased microorganisms quantity or virulence. The skin provides a physical and chemical barrier to microorganisms. Many microorganisms are survive on the skin and are known as colonizers. or normal flora. Scanned with CamScannerNormal Flora © Defi: Normal flora is the mixture of microorganisms (bacteria and fungi) that are regularly found at any anatomical site of human body. on Scanned with CamScannerENTRY OF MICROORGANISMS IN BODY + Break in skin (including wounds) allow microorganisms access to deeper tissue and structures. + Where they can more readily adhere and multiply. Scanned with CamScannerINFLAMMATION - ion is a vital part of the immune system's response to injury and infection. It is the body's way of signaling the immune system to heal and repair damaged tissue, as well as defend itself against foreign invaders, such as viruses and bacteria. Inflammation is characterized as being either acute or chronic. * Acute inflammation is the initial response to tissue invasion or | injury , this type of inflammation can result from microorganisms or any type of tissue injury. * Chronic inflammation occurs if the invasion or injury of tissue isn’t resolved and persist over a long period of time. * Chronic inflammation is also characterized by the proliferation of fibroblasts and scar tissue. Scanned with CamScannerINFECTION: * When host resistance fails to control the growth of microorganisms, localized wound infection results. * Localization infection may lead to severe infections such as extensive cellulitis, osteomyelitis, and sepsis. * A wound that has exposed bone or that can be probed to the bone with a sterile instrument should be evaluated for osteomyelitis. Scanned with CamScannerDEFINITION OF INFECTION . foe infection is a serious problem that can lead to delay in discharge as well as adverse patient complication such as sepsis, amputation and even death. * Wound infection has been defined as the invasion and multiplication of microorganisms in wound tissue resulting in pathophysiological | _ effects or tissue injury. Scanned with CamScanner| Wound contamination: presence of transient bacteria on wound surface with no multiplication. * Wound colonization: permanent bacteria “colonize” on surface. * Wound infection prolongs the inflammatory phase and disrupts the proliferative phase of wound healing. Scanned with CamScannerMETHOD TO IDENTIFYING THE WOUND INFECTION + In practice, wound infection is defined and diagnosed based on clinical sign and symptoms of infection or on the findings from wound cultures. * The advantage and disadvantage of using these methods can be evaluated in light of the key elements contained in the definition of wound infection. Scanned with CamScannerDelayed healing of the ulcer/wound Discoloration of the granulation tissue Serous - a clear drainage. Sanguineous - a bloody drainage. Serosanguineous - a clear, blood-tinged drainage. Purulent - a thick yellow, brown, green or grey drainage. Scanned with CamScannerWOUND CULTURES AND SPECIMENS * Like clinical signs and symptoms, the identification of wound infection based on culture findings may be inconclusive, numerous methods are available for clinical and research purposes. * The methods presented here are limited to those most commonly used in practice Scanned with CamScannerPp 5 1. The first step is the acquisition of a specimen from the wound. 2. The second step includes the laboratory procedures used to grow, identify, and quantify the microorganisms. Scanned with CamScannerMMON TYPES OF SPECIMEN * Wound Tissue * Needle-aspirated Wound Fluid * Swabs Scanned with CamScannerLevine Technique for Wound Culture Supplies; swab specimen container, normal saline, package of 4x 4 gauze, clean gloves, PPE (personal protection equipment) * Wash hands, apply gloves and PPE * Clean wound with normal saline + Lightly pat wound dry + Identify 1 cm of clean wound tissue Using sterile technique * Moisten sterile swab with normal saline * Apply firm pressure while rotating the swab in clean area of wound bed. Goal is to express fluid from wound bed * Place swab applicator into specimen container SSE Scanned with CamScanner* Moistening the swab is believed to provide more precise data than a dry swab. _ © The Levine technique consists of rotating a swab over an area with sufficient pressure to express fluid from within the wound tissue. | © This technique is believed to be more reflective of “tissue™ bioburden than swabs of exudate or swabs taken with a Z-stroke * Theoretically, the Levine technique is the best technique for wound swabbing provided the wound is cleaned first and the area sampled is over viable tissue, not necrotic tissue or eschar Scanned with CamScannerANALYZING CULTURES AND SPECIMENS: + Laboratory procedures for the microbiological analysis of wound specimens include isolation and identification of the microorganisms alone or in combination with quantification of the microorganisms isolated. * When done alone, isolation and identification is referred to as qualitative culture: * when done in conjunction with quantification, it’s referred to as quantitative culture. Scanned with CamScannerMANAGING WOUND BURDEN | ting wound bio burden requires a multifaceted approach consisting of one or more of the following, * Correction of the host factors that contributed to the infection . Removal of devitalized tissue and foreign debris * Initiation of antimicrobial therapy. * In managing wound bio burden, attention should be given to supporting or restoring host defenses to microorganism invasion, such as adequate blood supply and tissue oxygen, nutrition, management of blood sugar, and control of edema. Scanned with CamScannerWOUND CLEANING | Wound cleaning is a process that removes these less adherent inflammatory contaminants from the wound surface and renders the wound less conducive to microbial growth. + Effective wound cleaning requires selection of methods that minimize chemical and mechanical trauma to wound tissue while removing surface debris and contaminants. Scanned with CamScannerCLEANING AGENTS . | chines orci ep were factors depends on a balance between their antibacterial properties and their cytotoxicity to wound healing cells, such as white blood cells (WBCs) and fibroblasts. + For the majority of wounds, isotonic saline is adequate to clean the wound surface. Scanned with CamScannerCLEANING DEVICES Pesta hp cleaning device used to deliver the solution to the wound surface. It’s essential that the method used provide sufficient force to remove surface contaminants and debris while minimizing trauma to the wound. Avariety of scrubbing cloths, sponges, and brushes are available for wound cleaning. Research indicates that the optimum pressure for wound cleaning is between 5 and 15 psi. Scanned with CamScannerANTIMICROBIAL THERAPY | When removal of necrotic tissue doesn’t reduce bacterial burden to a level compatible with healing, additional interventions to reduce the number of organisms on the wound surface are indicated. + These antimicrobial therapies consist of elemental topical antimicrobials and antibiotics, both topical and systemic. The effectiveness of systemic antibiotics is dependent on an adequate blood supply to the wound. Scanned with CamScannerTopical antibiotics traditionally used to control bioburden in chronic wounds * Mafenide acetate (Sulfamylon) * Metronidazole (Flagyl, Metizol, * Metro Gel) + Mupirocin (Bactroban) * Nitrofurazone (Furacin) * Polysporin + Silver sulfadiazine (Silvadene) Scanned with CamScanner— D DEBRIDEMENT Debridement is the Removal of necrotic (dead) tissue, exudate and metabolic waste from a wound in order to improve and facilitate the healing process. It’s also done to remove foreign material from tissue. Wound debridement can: > help healthy tissue grow > minimize scarring > reduce complications of infections Scanned with CamScannerWHY DEBRIDE? * To remove the physical barrier to epidermal resurfacing. contraction. or granulation * To reduce bacteria burden by removing necrotic tissue * To convert a chronic wound to an acute wound by stimulating the healing cascade ® To facilitate earlier coverage of the wound with active dressings or biological. * Necrotic tissue prolongs the inflammatory phase and delays wound healing = Necrotic tissue is a medium for bacterial * Debridement facilitates visualization of the wound wall and base. With necrotic tissue present. it is not possible to asses viable tissue. Scanned with CamScannerWHAT IS NECROTIC TISSUE? + Necrotic tissue is dead or devitalized tissue. + This tissue cannot be salvaged and must be removed to allow wound healing to take place. WHY NECROTIC TISSUES ACCUMULATE? * Poor blood supply (usually) + Increased interstitial fluid pressure * A common scenario in wounds such as pressure ulcer. Scanned with CamScannerSUMMARY OF NECROTIC TISSUE CHARACTERISTICS Scanned with CamScannerTYPES OF NECROTIC TISSUES PREDOMINANT TYPES OF NECROTIC TISSUE INCLUDE: + SLOUGH + FIBRIN + ESCHAR + GANGRENE + HYPERKERATOSIS Scanned with CamScannerTYPES OF NECROTIC TISSUES Scanned with CamScannerINDICATION DEBRIDE 1. Necrotic tissue Eschar slough 2. Foreign material 3. Debris 4. Blisters 5. Callus Scanned with CamScannerMonitor stable necrotic heels for odor and signs of edema. erythema. fluid wave, or drainage. which may signal the need for debridement. Scanned with CamScannerMETHODS OF DEBRIDMENT Mechanical debridement ’ of mechanical debridement inclnde wet to-dry dress hydrotherapy gets a a Sera pulsed ia mae + Mechanical debridement may be more painful than other debridement methods. and the healthcare provider should consider premedicating the patient for pain. + Mechanical methods may be harmful to healthy granulation tissue on the surface of the wound ‘and —_ to bleeding. trauma. and disruption of the collagen matrix along with the necrotic tissue. Scanned with CamScannerWawona DRESSINGS + Despite the drawbacks, such as pain and the necessary cress sppecaianep tm tace tars per day, the use of wet-to-dry dressings to debride a wound unfortunately remains common treatment in all healthcare settings. + This method involves placing a moist saline gauze dressing on the wound surface and removing it when it’s dry + The removal of the dried gauze dressing facilitates removal of devitalized tissue and debris from the wound bed. However, newly formed granulation tissue and new cell growth are also removed. + To prevent pain and to help remove the dry gauze. clinicians often wet the dressing before removal Scanned with CamScannerIROTHERAPY Hydrotherapy (or whirlpool) debridement may be indicated for patients with large wounds that need aggressive cleaning or softening of necrotic tissue. It is contraindicated in granulating wounds because it can macerate and injure the wound bed. Hydrotherapy should be discontinued after necrotic tissue has been removed from the wound bed. Hydrotherapy is performed by putting the patient's wound in a whirlpool bath and letting the swirling waters soften and loosen dead tissue. This procedure is usually performed in the physical therapy department. with an average treatment duration of 10 to 20 minutes up to twice per day This type of debridement may cause periwound maceration. traumatize the wound bed. and put the patient at risk for waterborne infections such as Pseudomonas aeruginos. Scanned with CamScannerPULSED LAVAGE Pulsed lavage debridement is often indicated for patients with large amounts of necrotic tissue and for those in whom other debridement methods are not an option . + Itis accomplished by using specialized equipment that combines a pulsating irrigation fhaad with eects With poised lavage. can clean and debride a wound at variable irrigation pressures (measured in per square inch [psi]. tissue growth. This treatment takes 15 to 30 minutes and should be done twice daily if more than half of the wound contains necrotic tissue. Scanned with CamScannerHARP/SURGICAL EBRIDEMENT * Sharp surgical debridement includes the use of a scalpel. forceps. scissors. hydro surgery devices. or lasers to remove dead tissue. Sharp debridement is considered by many clinicians to be the gold standard of debridement. + Itcan cause pain. so a topical anesthetic, such as lidocaine cream or gels. may be required. Patients may also need follow-up appointments for serial debridement. Scanned with CamScannerScanned with CamScannerENZYMATIC DEBRIDEMENT Enzymatic debridement is considered safe, effective, and easy to perform. Enzymes are effective wound surface cleaning agents that accelerate eschar degradation and debridement. The removal of debris helps a chronic wound move from the inflammatory stage to the proliferative stage. resulting in enhanced wound healing. Enzymatic agents are an ideal option for patients who are not candidates for Surgery, for Patients receiving care ina long-term facility or at home where other debridement methods may not be available. and for patients receiving maintenance debridement Enzymatic debridement is accomplished by applying topical enzymatic agents to devitalized tissue Enzymatic Debridement Scanned with CamScanner|avtotytic DEBRIDEMENT + Ina moist wound, phagocytic cells and proteolytic enzymatic enzymes can soften and liquefy the necrotic tissue that is then digested by macrophages. + Autolytic debridement can be facilitated with appropriate dressings in the superficial een hat can bie aecoons ever ons Kites dope peso . ee open cress. 2 as a semi-occlusive or occlusive dressings: types include films. hydrocolloids. hydrogels. and calcium alginate dressings. Scanned with CamScannerMaggot THERAPY (BIOLOGICAL OR LARVAL THERAPY) > Maggot therapy was ee eee ce ee ee favor due in part to the “disgust factor” and the use of newer modalities such antimicrobial agents in wound treatments. + In this type of debridement, several applications of sterilized medicinal Lucilia sericata (greenbottle fly) maggots are placed in the wound bed every 2 to 3 days. Scanned with CamScannerCHOOSING A DEBRIDEMENT METHOD HOW MUCH TBE DO YOU HAVE To DEBRIDE? + WHAT ARE THE WOUND CHARACTERISTICS? + HOW SELECTIVE A METHOD IS NEEDED? + WHAT METHODS ARE PERMITTED? + WHAT'S THE CARE SETTING? + HOW MUCH DEBRIDEMENT IS ENOUGH > Scanned with CamScannerCONTRAINDICATION DO NOT DEBRIDE - GRANULAR TISSUE . VIABLE TISSUE - STABLE HEEL ULCER - GANGRENE - ELECTRICAL BURNS . DEEPER TISSUE - MUSCLE. TENDON, LIGAMENT. BONE . NERVES. BLOOD VESSELS 8. AVOID IN PATIENTS WITH IMPAIRED CLOTTING MECHANISMS NDE WI Scanned with CamScannerCOMPLICATION OF DEBRIDEMENT Like all medical procedures, debridement poses a risk for complications. These include. * Irritation * Bleeding * Damage to healthy tissue + Allergic reaction + Infection * Bacterial infection Scanned with CamScanner