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 17–18, 2005). "Dermal ulcer healing: Advances in understanding". Paris, France: EUROCONFERENCES.2.Snyder RJ (2005). "Treatment of nonhealing ulcers with allografts".Clin.Dermatol. 23 (4): 388–95.

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): 62–3, 67.

2. Mustoe T. "Understanding chronic wounds: a unifying hypothesis on their

pathogenesis and implications for therapy". Am. J. Surg. 187 (5A): 65S–70S.

Primary Intention

Secondary Intention

Tertiary Intention

Barriers to healing

Exudate Necrosis

Micro-

organisms

Cellular

dysfunctionBiochemical

imbalance

Chronic

contents

Excess

Eschar –

black/dry

Slough –

yellow/wet

Number

Pathoge-

necity

Host

resistance

Wrong

phenotype

Defective

receptors

???

Incorrect

cytokine

expression

Excessive

protease

production

Incomplete

cascades?

Delayed healing Non-healing

“Think WHOLE not HOLE”

Systemic

Factors• Chemotherapy

• Gene damage

• Steroids

Chronic

Wound

Metabolic Factors• Diabetes mellitus

• Renal failure

Nutritional Factors• Proteins

• Minerals

• Vitamins

Local Factors• 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): 285–288.

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): 285–288.

Laboratory Investigation

.

Grey, J., Enoch, S., Harding, K. ABC of wound healing

Wound assessment BMJ. 2006 February 4; 332(7536): 285–288.

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

• VasoconstrictorsBroderick ,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 "jump-

start" 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 therapyGrowth 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 multicenterrandomized 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: 290–95. 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: 1701–05.

Modified Wagner Classification

of Diabetic Foot

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

Grade I Localized superficial ulcer

Grade IIA Deep ulcer to tendon, bone, ligament, joint

Grade IIB Same as above, plus infection/cellulitis

Grade IIIA Deep abscess with or without cellulitis

Grade IIIB Osteomyelitis with or without cellulitis

Grade IV Gangrene of toes or forefoot

Grade V 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 co-

morbid 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 theseEuropean Pressure Ulcer Advisory Panel EPUAP (2003)

• “bed sores”, “pressure damage”, “pressure

injuries” and “decubitus ulcers”

How does that ulcer form?

Decubitus ulcer

Pressure

Impaired blood flow

Decreased oxygen delivery

Local tissue injury

Necrosis

“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

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 Prevention

Risk Assessment upon admission

Admission interventions for each selected risk factor

Admit & daily skin exams documented for at-risk population

Quality

Improvement/

Monitor Program

RiskEarly

Care Plan

Daily skin

check

Pressure Ulcer Prevention

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

Cost Effective

Quality and Safety Care

Better Care

Outcome

Improve and Best

Practice

Preventive Interventions

Feedback

Risk Assessment upon admission

Admission treatment order based on current standards or product guidelines

Weekly assessments

Quality

Improvement/

Monitor Program

Admit

assessment

Treatment

plan

Weekly

re-assess

Pressure Ulcer Treatment

Key priorities for implementation

• Patients with a grade 1−2 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 3−4 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

• Wound Care

– debridement

– wound cleansing

– dressings

– adjuvant therapies

• Pressure reduction

• Risk factors addressed

– Continence care

– Nutritional improvement

– Mobility

• Consider operative repair

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

66

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 (Mölndal Sweden, Lindgren,A.Söner A.B. 1980)

Venous

REFLUX

Venous ulcers

• Inspect

• Clean/debride

• Measure

Venous ulcers

Venous ulcers

Venous ulcers

C0 C1 C2 C3 C4 C5 C6

Life Style Changes

Sclerotherapy

Compression

Topical

Surgery

Medications