Chronic Wound

Akmalia Rizke Nur F G992003011

Presentasi Kasus.
By:
Chris Nandita M G992003030

Afifah Syifaul Ummah (G992102064)

Supervisor: Dr. dr. Amru Sungkar, Sp.B, Sp.BP-RE(KKF)

KEPANITERAAN KLINIK SMF ILMU BEDAH PLASTIK REKONSTRUKSI DAN

ESTETIK
FK UNS/RSUD DR MOEWARDI SURAKARTA
2022
Introduction
• The body has a protective barrier against environmental changes, namely the skin.Healthy
skin integrity plays an important role in maintaining the physiological homeostasis of the
human body
• Chronic wounds mostly affect people over the age of 60. The incidence is 0.78% of the
population and the prevalence ranges from 0.18 to 0.32%. As the population ages, the
number of chronic wounds is expected to rise. Ulcers that heal within 12 weeks are usually
classified as acute, and longer-lasting ones as chronic. Diabetic foot ulcers can lead to
complications that result in 85% of amputation for total cases
Definition
• A chronic wound is one that fails to progress through a normal, orderly, and timely sequence of
repair, or in which the repair process fails to restore anatomic and functional integrity after three
months
Etiology
• Molecular and cellular deficiencies in chronic wounds (red
circles) and factors required to overcome them (green rectangles).
Nonhealing ulcers and wounds represent a failure to achieve
complete reepithelialization in the appropriate temporal
sequence of tissue repair. Such wounds are characterized by
excessive inflammation (including elevated levels of proteases,
ROS, and inflammatory cytokines), by senescent cell populations
with impaired proliferative and secretory capacities, and by
defective MSCs. Excessive inflammation leads to degradation of
newly synthesized growth factors and ECM. There is a need to
restore the proper balance of cytokines, growth factors, and
proteases, to recruit functional cells (epithelial cells, fibroblasts,
and endothelial cells) to the wound area, and to deliver healthy
functional MSCs directly to the wound to compensate for the
patient's own dysfunctional stem cells. ECM, extracellular matrix;
MSCs, mesenchymal stem cells; ROS, reactive oxygen species.
Etiology
• Repeated physical trauma plays a role in chronic wound formation by continually initiating the inflammatory cascade.

• Periwound skin damage caused by excessive amounts of exudate and other bodily fluids can perpetuate the non-healing status of
chronic wounds. Maceration, excoriation, dry (fragile) skin, hyperkeratosis, callus and eczema are frequent problems that
interfere with the integrity of periwound skin. They can create a gateway for infection as well as cause wound edge deterioration
preventing wound closure.
Classification
1. Arterial and venous ulcer
Arterial ulcers are typically located on the
distal extremities and may be deep, with
tendon or bone exposed
2. Diabetic ulcer
the most common cause of lower extremity
amputation
3. Pressure Ulcer
A pressure ulcer is a localized injury to the
skin or underlying tissue—usually over a bony
prominence such as the sacrum, coccyx, hip,
or heel—that results from pressure in
combination with shear force
Pathophysiology
• Ischemia
Ischemia is an important factor in the formation and persistence of wounds, especially when it occurs repetitively (as it usually does) or
when combined with a patient's old age. Ischemia causes tissue to become inflamed and cells to release factors that attract neutrophils
such as interleukins, chemokines, leukotrienes, and complement factors.

• Bacterial colonization
Since more oxygen in the wound environment allows white blood cells to produce ROS to kill bacteria, patients with inadequate tissue
oxygenation, for example those who developed hypothermia during surgery, are at higher risk for infection.The host's immune response to
the presence of bacteria prolongs inflammation, delays healing, and damages tissue. Infection can lead not only to chronic wounds but
also to gangrene, loss of the infected limb, and death of the patient. More recently, an interplay between bacterial colonization and
increases in reactive oxygen species leading to formation and production of biofilms has been shown to the generate chronic wounds.

• Growth factors and proteolytic enzymes

Chronic wounds also differ in makeup from acute wounds in that their levels of proteolytic enzymes such as elastase, and matrix
metalloproteinases (MMPs) are higher, while their concentrations of growth factors such as Platelet-derived growth factor and Keratinocyte
Growth Factor are lower. Since growth factors (GFs) are imperative in timely wound healing, inadequate GF levels may be an important
factor in chronic wound formation. In chronic wounds, the formation and release of growth factors may be prevented, the factors may be
sequestered and unable to perform their metabolic roles, or degraded in excess by cellular or bacterial proteases.
Assesment
• Assessment is consist of patient assessment, wound assessment, and advanced assessment

• Patient assessment: patient history to determine medical comorbidities, contributing factors possibly leading to the chronic
wound, prior trauma, prior history of wounds, current medications, and allergies. the presence of diabetes mellitus with
neuropathy will be important to note for those patients presenting with a DFU as will a history of deep venous thrombosis for
those presenting with a suspected VLU.

• Laboratory studies at the time of presentation, including hematology, serum chemistries, and nutritional parameters

• An assessment of the patients' living situation and their likely reliability in following prescribed treatments is important in the
actual determination of which therapies should be employed to manage the wound(s)

• Assesment of wounds : The wound location, size, and depth; presence of drainage; and tissue type should be documented. Based
on the location and appearance, most chronic wounds can be categorized by etiology, which allows for adequate workup and
treatment recommendations.
Assesment
Management
• TIMERS principle
tissue debridement

infection control

moisture balance

edges of the wound

regeneration and repair of tissue, and

Social factors
Debridement
• Debridement is the removal of dead cells and is an essential part of wound care. It is the first-line treatment for
chronic wounds. In addition to removing dead cells and tissue, debridement of biofilm—multicellular communities
held together by a self-produced extracellular matrix that can halt the healing process—is a key factor in wound
healing. The National Institutes of Health reports that 80% of wound infections are due to biofilm. Biofilm is
invisible to the naked eye, and detection with different techniques is currently being investigated. Without
destruction of biofilm, wound healing can stall during the inflammatory phase.
Infection control
• When assessing a chronic wound for infection, physicians should be aware that chronic infected wounds have
different signs and symptoms than acute infected wounds. Typical signs of infection such as erythema, edema,
pain, and fever are not always present. Two mnemonics are used to identify chronic wounds with infectious
processes:

• NERDS (for wounds with biofilm or critical colonization): nonhealing, exudative, red and bleeds easily, debris, and
smell. Sensitivity is 73% and specificity is 80.5% when three criteria are present.

• STONEES (for infection): size increasing, temperature increased, os (probes to or exposed bone), new areas of
breakdown, exudative, erythema/edema, and smell. Sensitivity is 90% and specificity is 69.4% when three criteria
are present.
Moisture balance
• Moisture balance is an essential part of wound care. Chronic wounds should never be exposed to air to “dry out,” as
is often recommended. Moist wounds heal more quickly and have less risk of infection. If a wound appears dry,
moisture needs to be added; this is accomplished by choosing an appropriate dressing. Conversely, if a wound is
draining, the drainage needs to be controlled and kept off of the periwound. The proper dressing should hold the
moisture on the wound bed to prevent desiccation.
Regenerasi dan perbaikan
jaringan
These actions affect and enhance wound closure pathways by reducing the effects of
proinflammatory cytokines Some examples of therapies include stem cells, growth
factors and oxygen
Social Factors
Patients and their caregivers may not understand their disease process. It’s important to
assess their level of health literacy, then provide education with the appropriate
methods that facilitate the learning process.
Wound Dressing
Management of Biofilm
In addition to cleansing and debridement, management of bioburden and decreasing the risk of
biofilm formation are important in preventing the wound from becoming chronic or for resuming a
positive healing process. Treatment of infection is usually addressed with topical or systemic antibiotic
or antimicrobial therapy. Wound bioburden is typically polymicrobial, thus making identification of the
causative organism difficult at best. In turn, this increases the difficulty in choosing an antibiotic and
the mode of delivery. Adding to this difficulty is the issue that many chronic wounds are poorly
perfused, and if systemic blood flow is impaired, then so is systemic antibiotic delivery at a therapeutic
level.5 Topical broad-spectrum antiseptic agents and antimicrobial dressings are preferred because of
their broad-spectrum activity and effectiveness. For those patients being treated with systemic
antibiotics, it is recommended that topical antiseptics and dressings also be used.
Conclusion

A chronic wound is a wound that fails to progress through the normal, regular, and timely sequence of
repair, or in which the repair process fails to restore anatomic and functional integrity after three months and
which persists longer is termed chronic. The causes include defects in stem cells, lack of microvasculature
and hypoxia, cell failure, cell aging, lack of growth factors and ECM secretion, degradation of growth
factors and ECM, proteases, infection, inflammatory cytokines, and high ROS.

From these causes, wounds can be divided into venous and arterial ulcers, diabetic ulcers, and pressure
ulcers. The assessment consists of an assessment of the patient, of the wound, and with follow-up
examinations. After assessment, the wound can be treated using the TIMER principle. Knowing and
managing chronic wounds properly will definitely be very beneficial for reducing morbidity and quality of
life for patients
Thankyou.