ManagementofChronicDifficultWoundsintheLongTermCare

Se:ngJaniceLocke,MS,GNP,BC

NursePracBBonerEricksonHealthMedicalGroup–

RenaissanceGardensatFoxRun,Novi

ObjecBves

•  AtthecompleBonofthissession,parBcipantswillbeableto:– Describenormalwoundhealingstages–  IdenBfywhatconsBtutesachronicwound– DescribewhichpaBentsareatriskfordevelopingchronicwounds

–  IdenBfygoalsfortreaBngchronicwounds– DescribetreatmentopBonsformanagingchronicwounds

–  IdenBfymethodsforevaluaBngwoundhealing

DisclosureandDisclaimer

•  IhavenofinancialrelaBonshipswithanywoundproductcompaniestodisclose.

•  Some“off‐label”usesofproductsaswellassomeanecdotalevidencewillbepresented.

•  AYemptswillbemadetousegenerictermsforwoundcareproductshoweverbrandnameswillbediscussedandopinionsregardingspecificproductsaremyown.

Normalwoundhealingprocess

•  WoundhealingoccursasacellularresponsetoBssueinjuryandinvolvesacBvaBonofseveralcelltypes.

•  Acutewoundsusuallyhealinanorderlyandefficientmanner.

•  RestoraBonofskinintegrityfollowinganacutesurgicalwoundin“normal”individualsisusuallycompletewithin2‐4weeks.

Normalwoundhealing

•  Hemostasis–immediateresponsetoinjury– Smallvesselscontracttoprovidesomehemostasis

– Plateletsaggregatetotriggerclo:ngcascadeandreleaseessenBalgrowthfactorsandcytokines

– ResulBngfibrinmatrixstabilizesthewoundandprovidesaprovisionalscaffoldforthewoundhealingprocess

Normalwoundhealing

•  Inflamma,on–  Keycomponentsofthisphaseareincreasedvascularpermeabilityandcellularrecruitment.

–  Cellsarerecruitedthatwill•  Createstructuralproteins•  MediatevasodilaBonandcellmigraBon•  CausevesselpermeabilityresulBnginaccumulaBonofplasmaandcellularelements(edema)

•  Digestbacteria,foreigndebrisandnecroBcBssue.–  Thisisusuallythephasewherechronicwoundsbecomearrested

Normalwoundhealing

•  EpithelializaBon– ProliferaBonandmigraBonofepithelialcellsunBlindividualcellsaresurroundedbycellsofasimilartype.

– ChallengedbywoundsthatarenotclosedbyprimaryintenBon.

– Presenceofbiofilmandsenescentcellsonwoundedgeorbasealsochallengesthisstage.

Normalwoundhealing

•  Fibroplasia– Makethegroundsubstanceofthewoundbase

– ProducecontracBleproteinsthatworktopulltheedgesofthewoundtogether.

•  MaturaBon– Disorganizedcollagenisdegradedandreformedtoenhancethetensilestrengthofthewound.

Chronicwounds

•  Achronicwoundisonethatdoesnothealwithina“reasonable”Bme–usually3months.

•  A“stalledwound”doesnotdecreaseinsizeby30%in3weeksorby50%in4‐5weeks.

•  Astalledwoundisn’tnecessarilygoingtobeachronicwound–mayjustneeda“kickstart”toresumehealingprocess.

Chronicwounds

•  Oeenstalledintheinflammatoryphase– ThepresenceofnecroBcBssue,foreignmaterial,andbacteriaresultintheabnormalproducBonofmetallloproteaseswhichalterthebalanceofinflammaBonandimpairthefuncBonofthecytokinesinvolvedininiBaBonandprogressionofwoundhealing(growthfactors).

Factorsassociatedwithnon‐healingwounds

•  Intrinsic–  ImpairedcirculaBon

– Diseaseprocesses(inflammatory,metabolic,malignancy)

– MalnutriBon– Age– Obesity–  InfecBon

Factorsassociatedwithnon‐healingwounds

•  Extrinsic– Mechanicalforces(pressure,shear,fricBon)

– Pharmacology– Foreignbodies

•  Psychosocial– PaBent/familypreferences,beliefs,goals,expectaBons

– Caregiver/paBentrelaBonship

Factorsassociatedwithnon‐healingwounds

•  Access/implementaBon– Availabilityofcare– Financialresources– Abilitytounderstandandperformcare

Individualwoundfactorsassociatedwithdelayedhealing

•  Lackofacute“trigger”forhealing•  Extendedinflammatoryphase•  Presenceofmatrixmetalloproteases(MMPs)•  LowlevelsofBssueinhibitorsofproteases(TIMPs)

•  Deficiencyofgrowthfactorreceptorsitesand/orgrowthfactordestrucBonbyMMPs

•  Inefficient/senecentcells•  Biofilm

Whoisatriskfornon‐healingwounds

•  PaBentswith:– Vascularimpairment

–  Impairedimmunestatus– MetastaBccancer– Advancedage– Diabetes– Neuropathy/SCI– MalnutriBon

IdenBfygoalsoftreatment

•  ConsistentwithpaBent/familyvaluesandlifestyle

•  Cure/healing•  PalliaBon/comfort

TreatmentopBons‐Systemic

•  Illnessmanagement– Bloodsugarcontrol– ManagementofoxygenaBon

•  CirculaBonmanagement–  ImprovecirculaBontoarea

•  Offloading

•  RevascularizaBon•  Edemamanagement

TreatmentopBons

•  Reduce/eliminatecausaBvefactors– ManagementoffecalandurinaryinconBnence

•  Useoffecalbags/condomcathetersorindwellingcathetersforshortperiodsofBme.

– PressureredistribuBon/reducBon– ControlfricBon/shear

Treatment‐NutriBon

•  Complexissue–lotsofconflicBngdataandlackofstrong(levelAandBevidence)tosupportspecificrecommendaBonsforsupplementaBon

•  Albumin,TotalProtein,TotalLymphocyteCount,Pre‐albumin,Transferrinlevels.

Treatment‐NutriBon

•  Proteinrequirements– Healthyadult=0.8gmprotein/Kg/24hours– 1.5‐2.1gm/KgormorecouldberequireddependingonindividualmetabolicandclinicalcondiBon

•  Micronutrients– Zinc,Copper,Iron,VitaminA,VitaminC,VitaminE,Arginine,Glutamine

•  ConsultRD

InfecBon

•  Cultures––  Swabculturesmostfrequentlyused–theyreflectthesurfacecolonizaBonratherthaninfecBon.AHQRGuidelinerecommendsagainstusingswabculturestodefinemicrobiologyofapressureulcer.

–  ForinfecBoncontrolpracBces,aswabculturemaybeusefulinidenBfyingpaBentscolonizedwithMRSAorotherresistantbacteria.

–  BloodcultureordeepBssuebiopsycultureismoreclinicallysignificant.

–  CulturingdeepBssuespecimensfromasurgicallycleanedanddebridedulceristhegoldstandardforwoundculture.

ColonizaBonvsInfecBon

•  Bothcandelay/impairhealing•  SuperficialinfecBonislocalizedwithoutsystemicsigns,non‐healingulcer– Localwoundcare

•  DebridementofnecroBcBssue

•  Moistwounddressing•  NutriBonalsupportandpressurereducBon

– TrialoftopicalanBbioBctoreducelocalbacterialcounts

TopicalanBmicrobialagents

•  Silversulfadiazine1%cream•  CombinaBonanBbioBcointments•  Silver‐containingdressings•  Avoidcytotoxicagents– Hydrogenperoxide– Povidone‐iodine

•  AHQRrecommends2weektrialoftopicalabxforcleanwoundsthatfailtohealaeer2‐4weeksofopBmalcare.

DeepinfecBon

•  CelluliBs–paBentswithneuropathymaynothavepain.Leukocytosisandfevermayormaynotbepresent.

•  OsteomyeliBs–hasbeenreportedin17‐34%ofpaBents

•  Bacteremia

•  Basetreatmentonbacterialcultureswheneverpossible

LocalCareofthewound

•  TIME•  T=Bssue(nonviable/deficient).– Debridement–episodicorconBnuous

•  I=InfecBonorInflammaBon–  Topicaland/orsystemicanBbioBcs

•  M=moistureimbalance– Applymoisturebalancingdressings

•  E=edge–  EvaluateandcorrectimpedimentstoepithelialmigraBon

Cleansing

•  pHbalancedcleansers•  Normalsaline

•  Soapandwater•  Psi

Debridement

•  EnzymaBc•  Sharp/surgical•  Mechanical

•  Biologic

Debridement

Post‐debridement

Debridement

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Moisturecontrol

•  MaintainingappropriateamountofmoistureinwoundbediscriBcal.–  toomoist=maceraBon/denuding,increasedbreakdown•  Hydrofibers•  Calciumalginates

•  Foams•  CombinaBonproducts

Moisturecontrol

•  Toodry=dessicaBon.DrywoundslackwoundfluidsthatprovidetheBssuegrowthfactorstofacilitatereepithelializaBon– Salinemoistenedgauze

– Transparentfilms– Hydrocolloids– Hydrogels

Moisturecontrol

Edges

•  Examineedgesofthewound•  Epibole=theupperedgesoftheepidermisrolltoenvelopthebasementmembraneorloweredgesoftheepidermissothatepithelialmigraBondoesnotoccuratwoundedges.

•  TheedgescurlunderandepithelialmigraBonstops.

Epibole

Topicaltreatments

•  Dressings–  Films–  Foams

–  Hydrocolloids–  Hydrogels–  Hydrofibers–  Composites

•  Othertopicals–  CollagenMatrix–  Growthfactor–  Xenaderm–  Barriercreams

–  Silverproducts–  Honey

TopicalTreatments

•  Filmdressings–– willnotmanageexcessmoisture.Avoidusingifthereisanydrainagefromthewound.

– Douseifthewoundistoodry.– CancombinewithSantylointmenttohelpsoeeneschar

– Also,canapplyoverescharthathasbeencrosshatched.

UseoffilmdressingforautolyBcdebridement

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FoamsandHydrofibers

•  UsewithwoundsthataremoreheavilyexudaBngtohelpwithmanagementofwoundfluid.

HydrogelsandHydrocolloids

•  UsefulinpromoBngautolyBcdebridementandaddingmoisturetoawound

TheimageaboveisacopyrightedproductofAAWC(www.aawconline.org)andhasbeenreproducedwithpermission.

PainControlinchronicwounds

•  Twotypesofpainassociatedwithopenwounds:– NocicepBvepainfromtheBssuedamagecreaBngthewound

– Neuropathicpainfromdamagedperipheralnervesatthesiteofthewound

Painassessment

•  The“usual”painassessmentwillhelpdeterminethemostappropriatetreatment– LocaBon– Timing– Severity– AggravaBng/alleviaBngfactors– Quality

Topicaltreatmentofpain

•  Dressingchoice–avoiddressingsthatadheretothewoundbedandinessencedomechanicaldebridementwitheverydressingchangeacausepain.– Protectskinsurroundingthewound– Premedicatewithsystemicpainmedpriortodressingchanges

TopicalTreatmentsforpain

•  TopicalmedicaBonpriortodebridement– EMLA(EuteBcMixtureofLocalAnestheBcs,2.5%lidocaineand2.5%prilocaine,AstraZeneca,Wilmington,Del)

– 2%Lidocainegel

Topicaltreatmentsforpain

•  Topicalopioids:– Morphineinawater‐basedgel

– Methadoneinaninertwoundpowder– TheusualconcentraBoninthestudiesis1%concentraBonoftheopioid.

– UseofpowderorgeldependsonthecondiBonofthewound.

•  Foam/IbuprofencombinaBondressings.

OthertreatmentmodaliBes

•  NPWT•  HyperbaricOxygentreatments

•  Compression

•  EsBmulaBon

•  Ultrasound•  ContactcasBng/offloading

•  Maggottherapy

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Complementary,alternaBveandintegraBvetherapy

•  Accupuncture•  Yoga/meditaBon•  Biofeedback•  Guidedimagery

•  Massage•  TherapeuBctouch

•  Herbs/dietarysupplements

•  Aromatherapy

•  Exercise•  EmoBonalhealth/stressmanagement

•  Spiritualhealth

Managingthehardtohealwound

•  Assessment– Misseddiagnosis?

– CofactorscontribuBngtothelackofhealing• Woundfactors

–  Edges–  Base–  Biofilm

–  Localtreatment–appropriatechoice,beingdoneappropriately?

Managinghardtohealwounds

•  PaBentfactors– CooperaBng/parBcipaBngincare?(“compliant”)

–  Illnessprogression– Mentalhealth/social/spiritual

•  Establishgoalsforcare– Healing– Maintenance/palliaBon– Symptomcontrol

Treatmentofhardtohealwounds

•  AddresseBologyandcofactorsaffecBnghealingbasedongoalsoftreatment– Debride/cauterizeedgesofwoundifepibolepresent

– TreathypergranulaBon/exuberantgranulaBon– Treat/managebiofilminwoundbed– Treat/managelocalandsystemicinfecBon

– Treat/managesystemicillnessasable.

HypergranulaBon

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ManaginglocalinfecBon/biofilm

•  Topicalagents– Silversulfadiazine– TopicalanBbioBcs– Topicalsilver–hydrofiber,gels– Flagyl500mgtabcrushed,mixedinSantylointmentandapplieddailytotwicedailyfor7days*

*Note:thisisan“offlabeluse”ofFlagyl.WorkswellinwoundswithfoulodorindicaBnghighlocalbacterialcountinwoundbed

Diphenylhydantoinsodium(phenytoin)

•  Capacitytoaccelerateulcerhealingwasreportedover40yearsagoandhasbeenusedinmanydifferentkindsofwounds.

•  PossiblemechanismsofacBon:– DecreaseinserumcorBcosteriod

– AcceleraBonofassemblyandpresenceofcollagenandfibrinintheulcerarea

– SBmulaBonofalkalinephosphatasesecreBon

OthertreatmentopBonsunderstudy

•  OralPentoxifyllinealongwithcompressiontotreaBngvenousulcers

•  Effectsofstressresponse(epinepherine)andtheimpactonwoundhealing=AnewuseforBetablockertherapy?

Assessforhealing

•  PressureUlcerScaleforHealing(PUSH)•  PressureSoreStatusTool(PSST)•  SessingScale•  WoundHealingScale.

PressureUlcerScaleforHealing(PUSH)

•  LengthxWidth(incm2)=scoreof0‐10(0cm2‐>24cm2)

•  Exudateamount=scoreof0‐3(none,light,moderate,heavy)

•  Tissuetype=scoreof0‐4(closed,epithelialBssue,granulaBonBssue,slough,necroBcBssue)

•  Totalthe3sub‐scores.IfthetotalscoregoesdownoverBme,thewoundishealing.

WoundsBllnothealing?

•  Reassessgoalsofcare•  Changethelocaltreatment

•  Refertowoundcareclinic,vascularsurgeon,infecBousdiseasespecialist