Wound dressingWound dressing

Dr. Rohan ParisDr. Rohan Paris

woundwound Break in the epithelial integrity of Break in the epithelial integrity of

the skin and may be accompanied the skin and may be accompanied by disruption of the structure and by disruption of the structure and function of underlying normal function of underlying normal tissuetissue

May result from precise disruption May result from precise disruption of tissue by surgeon’s knife to of tissue by surgeon’s knife to wide spread tissue damage.wide spread tissue damage.

Continuity of the skin must be Continuity of the skin must be restored expeditiouslyrestored expeditiously

Crucial role in maintaining Crucial role in maintaining homeostasishomeostasis

Healing of acute wound involves Healing of acute wound involves complex, dynamic, well complex, dynamic, well orchestrated series of events orchestrated series of events

Healed woundHealed wound Connective tissue have been repairedConnective tissue have been repaired Completely reepithelialisedCompletely reepithelialised Returned to normal structure & functionReturned to normal structure & function No need of continued drainage & dressingNo need of continued drainage & dressing

Some Wounds fail to heal timely & Some Wounds fail to heal timely & orderly manner resulting in orderly manner resulting in chronic non healing wound chronic non healing wound

Out line of wound healingOut line of wound healing

Primary healing( healing by 1Primary healing( healing by 1 stst intention) intention) Wound is closed within 12-24 hours of it’s creation Wound is closed within 12-24 hours of it’s creation Edges approximated using suture, glue, tapes or mechanical Edges approximated using suture, glue, tapes or mechanical

devicedevice Epithelial regeneration predominant over fibrosis.Epithelial regeneration predominant over fibrosis.

Delayed Primary healingDelayed Primary healing Contaminated or poorly delineated woundsContaminated or poorly delineated wounds Left open for few daysLeft open for few days Closure performed after host defenses have helped to debride Closure performed after host defenses have helped to debride

the wound. the wound.

Secondary healing(2Secondary healing(2ndnd intention) intention) In extensive loss of soft tissueIn extensive loss of soft tissue

Phases of wound healingPhases of wound healing

4 overlapping but well defined phases4 overlapping but well defined phases Haemostasis Haemostasis InflamoteryInflamotery

Early Within 24-48 hours, PMN Predominate Early Within 24-48 hours, PMN Predominate Late 2-3 days, Macrophages predominate Late 2-3 days, Macrophages predominate

both involved cytokines and other chemical mediators, & both involved cytokines and other chemical mediators, & inflammatory cellsinflammatory cells

Proliferation Proliferation 2-21 days, formation of ECM2-21 days, formation of ECM Remodling & Scar MaturationRemodling & Scar Maturation

Wk 1 to several wksWk 1 to several wks

1 2 3 4 5 6 7 . Vascular Scar Epithelial ScarClotting Response Inflammation Formation Healing Contraction Remodeling

Sequence of Molecular and Cellular Events in Skin Wound HealingSequence of Molecular and Cellular Events in Skin Wound Healing

Four Phases of Healing

HemostasisInflammatio

nRepairRemodeling

Factors involved in wound healingFactors involved in wound healing

Cellular factorsCellular factors Plt, RBCPlt, RBC PMNPMN LCLC MQMQ Fibroblast, MyofibroblastFibroblast, Myofibroblast

Chemical FactorsChemical Factors CK, TGF, PDGF, MetaloprotinesCK, TGF, PDGF, Metaloprotines

Local Factors impeding wound Local Factors impeding wound healinghealing

Blood SupplyBlood Supply Increased skin tensionIncreased skin tension Poor venus drainagePoor venus drainage Presence of FB, Slough, Non viable tissue.Presence of FB, Slough, Non viable tissue. InfectionInfection Excess Local mobilityExcess Local mobility Malignant transformationMalignant transformation Underlying osteomyelitisUnderlying osteomyelitis

Reduced Local O2 TensionReduced Local O2 Tension

normal tissue 45 mmhg to 0 near the center normal tissue 45 mmhg to 0 near the center of the woundof the wound

suboptimal environment temperature suboptimal environment temperature

Importance of moisture balance in Importance of moisture balance in wound carewound care

• Insufficient moisture in exposed wound tissues causes Insufficient moisture in exposed wound tissues causes desiccation and cell death, desiccation and cell death, and prevents epithelial migration and prevents epithelial migration and matrix depositionand matrix deposition

• Excessive moisture due to exudate inhibits cell Excessive moisture due to exudate inhibits cell proliferation and breaks down matrix componentsproliferation and breaks down matrix components

• Moisture balance in the wound bed is maintained by Moisture balance in the wound bed is maintained by appropriate choice of dressingsappropriate choice of dressings

Although normal saline is isotonic, as it Although normal saline is isotonic, as it evaporates from the dressing, it becomes evaporates from the dressing, it becomes hypertonic and tissue fluid is drawn into the hypertonic and tissue fluid is drawn into the dressingdressing Blood and proteins eventually accumulate on Blood and proteins eventually accumulate on

dressing surface and dressing dries out completelydressing surface and dressing dries out completely

Has to be applied at least three times a dayHas to be applied at least three times a day

Wound dressingWound dressing

Appreciate why you apply dressingAppreciate why you apply dressing What you expect from themWhat you expect from them How often they should be changedHow often they should be changed

DRESSINGS - material applied to wound with or without medication, to give protection and assist in healing.

Keys to selecting dressingsKeys to selecting dressings

Must use clinical judgmentMust use clinical judgment Keep wound bed continuously moistKeep wound bed continuously moist Keeps surrounding skin dryKeeps surrounding skin dry Control exudate without desiccating Control exudate without desiccating

(drying out) wound bed(drying out) wound bed Caregiver time Caregiver time

Ideal surgical dressingIdeal surgical dressing

They shouldThey should

1/ be absorbent , remove excess exudate1/ be absorbent , remove excess exudate

2/ maintain moist environment2/ maintain moist environment

3/ aid tissues to remove necrotic material3/ aid tissues to remove necrotic material

4/ promote healing4/ promote healing

5/ prevent trauma to underlying healing 5/ prevent trauma to underlying healing grnulation tissuegrnulation tissue

6/ leak-proof, prevent passage of organism 6/ leak-proof, prevent passage of organism to woundto wound

Cont…Cont…

7/ maintain temperature & gaseous exchange7/ maintain temperature & gaseous exchange

8/ allow easy pain free dressing change8/ allow easy pain free dressing change

9/ odourless9/ odourless

10/ cosmetically acceptable & comfortable10/ cosmetically acceptable & comfortable

11/ inexpensive11/ inexpensive

Wound Dressings-Current State Wound Dressings-Current State Of AffairsOf Affairs

1 of the greatest and most confusing challenges 1 of the greatest and most confusing challenges in wound carein wound care

Over 3000 wound dressing productsOver 3000 wound dressing products Over 30 different dressing categoriesOver 30 different dressing categories Inappropriate dressings can lead to a delay in Inappropriate dressings can lead to a delay in

wound healingwound healing Many dressing choice strategies exist and have Many dressing choice strategies exist and have

merit; the clinician must choose which to use.merit; the clinician must choose which to use.

Broussard CL. Dressing decisions. In Krasner DL, Rodeheaver GT, Sibbald RG,eds. Chronic Wound Care: A Clinical Source Book for Healthcare Professionals. 4 th ed. Malvern, PA: HMP Communications, 2007: 249-262.

Which One Is Best?Which One Is Best?

““In the old days we only had to In the old days we only had to know saline and gauze”know saline and gauze”

HydrocolloidHydrocolloid HydrogelHydrogel Calcium alginateCalcium alginate FoamFoam CollagenaseCollagenase AntimicrobialsAntimicrobials Growth factors Growth factors Matrix enhancing agentsMatrix enhancing agents

HYDROCOLLOIDHYDROCOLLOID

Absorbency and film dressingAbsorbency and film dressing Highly absorbent gel (polyurethane)Highly absorbent gel (polyurethane) Oxygen and water vapor permeableOxygen and water vapor permeable

Adhesion and elasticityAdhesion and elasticity Bacterial barrierBacterial barrier Allows for autolytic debridementAllows for autolytic debridement Can stay in place for 72 hoursCan stay in place for 72 hours Indications: Venous ulcers, pressure ulcers, diabetic Indications: Venous ulcers, pressure ulcers, diabetic

ulcers, 1ulcers, 1stst and 2 and 2ndnd degree burns degree burns

HydrocolloidsHydrocolloids Smith & NephewSmith & Nephew

Replicare, Cutinova hydroReplicare, Cutinova hydro ColoplastColoplast

ComfeelComfeel 3M3M

TegasorbTegasorb ConvaTec/CVLConvaTec/CVL

DuoDERMDuoDERM J&JJ&J

NU-DERMNU-DERM

HYDROGELHYDROGEL

Absorbs 5 times own weightAbsorbs 5 times own weight Hydrophilic polysaccharide particlesHydrophilic polysaccharide particles

Cooling soothing effectCooling soothing effect Facilitates autolytic debridementFacilitates autolytic debridement Delivered in many formsDelivered in many forms

Amorphous gel, Sheets, Strands Amorphous gel, Sheets, Strands Can stay in place for 24 hoursCan stay in place for 24 hours Indications: Mildly exuding wounds, clean wounds, Indications: Mildly exuding wounds, clean wounds,

partial thickness woundspartial thickness wounds

HydrogelsHydrogels Smith & Nephew (Impregnated gauze)Smith & Nephew (Impregnated gauze)

Sheets (Flexigel), Sheets (Flexigel), Amorphous (Amorphous (SoloSiteSoloSite)) CarringtonCarrington

CarraGauze, Carrasyn GelCarraGauze, Carrasyn Gel ConvaTec/CVLConvaTec/CVL

DuoDERM GelDuoDERM Gel HealthpointHealthpoint

Curasol,Curasol, Curasol Gel Curasol Gel J & JJ & J

Nu-GELNu-GEL KendallKendall

Curafil, Curafil GelCurafil, Curafil Gel 3M3M

TegagelTegagel

CALCIUM ALGINATECALCIUM ALGINATE

Absorbs up to 30 times weightAbsorbs up to 30 times weight

Comes in many formsComes in many forms Sheets, tubes, loose fibers packsSheets, tubes, loose fibers packs

Maintains a moist wound environmentMaintains a moist wound environment Can stay in place 24 to 72 hoursCan stay in place 24 to 72 hours Indications: Wounds with large amount of drainageIndications: Wounds with large amount of drainage

Calcium AlginatesCalcium Alginates Smith & NephewSmith & Nephew

AlgiSite AlgiSite CarringtonCarrington

CarraSorbCarraSorb ConvaTec/CVLConvaTec/CVL

KALTOSTATKALTOSTAT Dow HickamDow Hickam

SORBSANSORBSAN J & JJ & J

FIBRACOLFIBRACOL KendallKendall

CURASORBCURASORB 3M3M

TegagenTegagen

FOAMFOAM

Highly absorbent (20 times weight)Highly absorbent (20 times weight) Non-adherent wound contact layer, hydrocellular foam, Non-adherent wound contact layer, hydrocellular foam,

waterproof outer layerwaterproof outer layer Allows for autolytic debridement and gaseous exchangeAllows for autolytic debridement and gaseous exchange Can be left in place for 72 to 96 hoursCan be left in place for 72 to 96 hours Indications: Highly exudative wound requiring a non-Indications: Highly exudative wound requiring a non-

stick surface (e.g. venous stasis)stick surface (e.g. venous stasis)

FoamsFoams Smith & NephewSmith & Nephew

AllevynAllevyn,, Allevyn adhesive Allevyn adhesive BeiersdorfBeiersdorf

Cutinova foamCutinova foam CarringtonCarrington

CarrasmartCarrasmart ConvaTec/CVLConvaTec/CVL

HydrasorbHydrasorb J & JJ & J

Nu-Derm, TielleNu-Derm, Tielle KedndallKedndall

CuraformCuraform

Enzymatic DebridementEnzymatic Debridement

Indications: A wound requiring debridement of Indications: A wound requiring debridement of fibrinous exudate, other necrotic material or fibrinous exudate, other necrotic material or sloughslough

Removes:Removes: Senescent fibroblasts - can’t produce cytokines or Senescent fibroblasts - can’t produce cytokines or

collagencollagen Necrotic tissue harboring bacteriaNecrotic tissue harboring bacteria

Enzymatic DebridementEnzymatic Debridement

HealthpointHealthpoint ACCUZYMEACCUZYME

Papain (Papaya) – digestant of nonviable proteinPapain (Papaya) – digestant of nonviable protein Active over pH 3 to 12Active over pH 3 to 12 Require stimulators: ureaRequire stimulators: urea

Solvent action on activators of papain, denatures non-viable proteinSolvent action on activators of papain, denatures non-viable protein May burn when appliedMay burn when applied APPLY DIRECTLY TO THE WOUNDAPPLY DIRECTLY TO THE WOUND Irrigate out – BID or QDIrrigate out – BID or QD May need to crosshatch escharMay need to crosshatch eschar

Combination AgentsCombination Agents

HealthpointHealthpoint XENADERMXENADERM

Balsam Peru – increases blood flow to wound siteBalsam Peru – increases blood flow to wound site Castor oil – creates moist wound environmentCastor oil – creates moist wound environment Trypsin – maintains clean wound bedTrypsin – maintains clean wound bed Aluminum magnesium hydroxide stearate – repels fluids Aluminum magnesium hydroxide stearate – repels fluids BID for stage I and II woundsBID for stage I and II wounds

AntimicrobialsAntimicrobials

Indications: Infected wounds, wounds with Indications: Infected wounds, wounds with bacterial counts greater than 10bacterial counts greater than 1055

Bacterial count greater than this decrease wound Bacterial count greater than this decrease wound healing rateshealing rates

Bacterial proteases degrade growth factorsBacterial proteases degrade growth factors Therapeutic concentration at the site of the Therapeutic concentration at the site of the

woundwound

AntimicrobialsAntimicrobials

Water-based topical antibioticsWater-based topical antibiotics Penetrate granulation tissuePenetrate granulation tissue Inhibit fibroblast growthInhibit fibroblast growth

AntimicrobialsAntimicrobials

SilvedeneSilvedene SulfamylonSulfamylon ActicoatActicoat IodoflexIodoflex Polysporin/BacitracinPolysporin/Bacitracin Dakin’sDakin’s

SulfamylonSulfamylon

5 % Sulfamylon cream5 % Sulfamylon cream (Mafenide Acetate, Bertek Pharm)(Mafenide Acetate, Bertek Pharm)

Bacteriostatic vs. Gram neg, Gram pos. (including Bacteriostatic vs. Gram neg, Gram pos. (including pseudomonas), and some anaerobespseudomonas), and some anaerobes

Metabolyte cleared through kidneysMetabolyte cleared through kidneys Inhibits carbonic anhydraseInhibits carbonic anhydrase DOES NOT INHIBIT FIBROBLASTSDOES NOT INHIBIT FIBROBLASTS

ActicoatActicoat

Nanocrystalline silver coatingNanocrystalline silver coating Silver coated on polyethylene meshSilver coated on polyethylene mesh Rayon polyester coreRayon polyester core BacteriostaticBacteriostatic Can stay in place for one weekCan stay in place for one week Non-stickNon-stick Indications: Venous ulcers, diabetic Indications: Venous ulcers, diabetic

ulcersulcers

Iodoflex/IodosorbIodoflex/Iodosorb

Iodine gel or impregnated padIodine gel or impregnated pad Wound exudate absorbed by cadexomer polymer – Wound exudate absorbed by cadexomer polymer –

gelgel As polymer expands 9% elemental iodine releasedAs polymer expands 9% elemental iodine released 72 hours: color change from brown to gray72 hours: color change from brown to gray Lowers pHLowers pH Toxic to fibroblasts?Toxic to fibroblasts?

Appearance of WoundAppearance of Wound

Wound with clean granular baseWound with clean granular base Wound with craterWound with crater Wound with necrotic/non-viable tissueWound with necrotic/non-viable tissue Wound with exudateWound with exudate Wound with sinus, tunnel, underminingWound with sinus, tunnel, undermining Wound with infectionWound with infection

Wound with clean granular baseWound with clean granular base

Objectives: Protect & keep moistObjectives: Protect & keep moist Treatments:Treatments:

HydrocolloidHydrocolloid HydrogelHydrogel Vacuum assisted closure (VAC) deviceVacuum assisted closure (VAC) device

Wound with craterWound with crater

Objective: Fill the space with uniform contactObjective: Fill the space with uniform contact Treatments:Treatments:

HydrogelHydrogel AlginateAlginate FoamFoam HydrocolloidHydrocolloid Vacuum assisted closure (VAC) deviceVacuum assisted closure (VAC) device

Wound with necrotic/non-viable Wound with necrotic/non-viable tissuetissue

Objective: Debride and cleanseObjective: Debride and cleanse Treatments:Treatments:

Enzymatic dressingEnzymatic dressing Hydrogel dressingsHydrogel dressings Calcium alginatesCalcium alginates Pulse irrigationPulse irrigation Vacuum assisted closure (VAC) deviceVacuum assisted closure (VAC) device Hypertonic saltsHypertonic salts

Wound with exudateWound with exudate

Objectives: Absorb and containObjectives: Absorb and contain Treatments:Treatments:

AlginateAlginate FoamFoam Vacuum assisted closure (VAC) deviceVacuum assisted closure (VAC) device

Wound with sinus, tunnel, Wound with sinus, tunnel, underminingundermining

Objectives: Prevent pre-mature closure, absorb Objectives: Prevent pre-mature closure, absorb exudateexudate

Treatments: Loose packingTreatments: Loose packing Impregnate gauze with hydrogelImpregnate gauze with hydrogel Calcium alginate if high drainageCalcium alginate if high drainage Vacuum assisted closure (VAC) deviceVacuum assisted closure (VAC) device

Wound with infectionWound with infection

Objectives: Decrease local bacterial countObjectives: Decrease local bacterial count Treatments:Treatments:

Pulse irrigationPulse irrigation Long-acting time-release antibioticLong-acting time-release antibiotic Short-acting antibiotic or antimicrobialShort-acting antibiotic or antimicrobial Vacuum assisted closure (VAC) deviceVacuum assisted closure (VAC) device

Slow healing woundsSlow healing wounds

Topical negative pressure Topical negative pressure

This therapy involves the controlled application of This therapy involves the controlled application of sub-atmospheric pressure to the local wound sub-atmospheric pressure to the local wound environment, using a sealed wound dressing environment, using a sealed wound dressing connected to a vacuum pump. connected to a vacuum pump.

The continued vacuum draws out The continued vacuum draws out fluidfluid from the from the wound and increases blood flow to the area.wound and increases blood flow to the area.

The vacuum may be applied continuously or The vacuum may be applied continuously or intermittently, depending on the type of wound intermittently, depending on the type of wound being treated and the clinical objectives.being treated and the clinical objectives.

Typically, the dressing is changed two to three Typically, the dressing is changed two to three times per week.times per week.

Application of a vacuum pump using a foam dressing to a wound

Pump used to create negative pressure

General rules General rules

No tight dressings– compromise blood supplyNo tight dressings– compromise blood supply Tight dressing only to control bleeding Tight dressing only to control bleeding

temporary temporary Pressure should be equally distributedPressure should be equally distributed Newer allow tight banding around limbs or Newer allow tight banding around limbs or

fingersfingers When changing shouldn’t damage tissues of When changing shouldn’t damage tissues of

healing wound. healing wound.

Thank youThank you