WOUND MANAGEMENTDr Yap Gaik Chin

Wound Care TeamSurgical Department

Wound Management

Management of non healing wound is a complex process and requires a multidisciplinary approach

Starts from the first assessment upon inspection of patient by making a general assessment and further local assessment of the wound

Outline

Assessment ( General & local )

TIME – wound bed preparation

Wound cleansing

Types of debridement

Types of dressing

General assessment

Age Psychosocial health Complicating conditions

vascular problem, diabetic, smoking, immunosuppressive

Nutritional status Pain/Comfort Hygiene

Local /Wound Assessment

Wound etiology Pressure, trauma, shearing, friction

Size Wound edges Wound Bed

necrotic, granulation tissue, odour, exudate Surrounding skin ( colour, moisture)

Wound AppearanceThe Colour Model

In early 1980s, Lars Hellgrens, a Sweeden dermatologist was the first to claim that wounds could be categorised according to the colour of the wound surface

Red-Granulation Yellow-Slough Pink-Epithelialization Black-Necrotic

What is TIME?

Mnemonic for Principles of Wound Bed Preparation

What is wound bed preparation?

Management of wound to accelerate endogenous healing or facilitate the effectiveness of other therapeutic measures

TIME

T : Tissue Viability I : Inflammation, Infection M : Moisture Imbalance E : Epidermal Margin/ Edge of

Wound

Tissue Viability

Viable ( Granulation, Epithelialising) Non viable ( Necrotic, Sloughly, Eschar)

How does non viable tissue impede healing?

Prolongs inflammation Impedes epitheliazation Medium for bacteria growth

Goals of treating chronic wounds

Clear away dead or necrotic tissue Debridement

Always ensure adequate tissue oxygenation for angiogenesis and granulation process

Inflammation , Infection

The bacterial continuum What is infection? End spectrum of bacterial continuum ,

more infected than critically colonized wound

Assessing of wound infection1. Contamination2. Colonized 3. Critically colonized4. Infection ( Local, Systemic)

Clinical presentation

Classic Presentation of infection of local wound

1. Advancing erythema2. Fever3. Warmth4. Oedema/ Swelling5. Pain6. Purulence

Clinical Presentation

Secondary clinical presentation of local wound

1. Delayed healing2. Change in colour of wound bed3. Absent/abnormal granulation tissue4. ↑ or abnormal odour 5. ↑ drainage/exudate6. ↑ pain @ wound site

Moisture Balance

Too much moisture –impede wound healing

Cause Dessication / Maceration of skin Need to match exudate volume with

product absorbency for optimal moisture balance

Epidermal Margin/ Edge of wound

Non advancing wound edge

Also known as non healing wound

Undermining of edge is either critically colonised or infected

What if Epidermis Fails to advance?

Reconsider the principles of wound bed preparation and the acronym TIME,

1. Has necrotic tissue been debrided?2. Is there a well vascularised wound bed?3. Has infection been adequately

controlled?4. What is the status of inflammation or

infection in this patient?5. How well is moisture balance optimized?6. What dressings have been applied

before?

Wound Cleansing

Removing foreign debris & necrotic tissue

The process of removing inflammatory contaminants from the wound surface since necrotic tissue, excess exudate and foreign objects impede healing & ↑ the risk of infection

Routine cleansing ( Fluid irrigation, mild scrub)

Debridement

Reducing bioburden

Antibiotic should be used to reduce bacterial level within the wound

Selection of antibiotic is based upon proven efficiency against microorganisms obtained from culture.

Routine Wound Cleansing

Saline Octanisept Superoxide solution Water for irrigation PHMB with Betaine

Antiseptic Skin Cleansers

Antiseptics should not be used to clean wounds

Topical antiseptics:1. Betadine2. Povidone-Iodine3. Dakin’s Solution ( Eusol)4. Acetic Acid-> effective against

Pseudomonas A organisms5. Hydrogen Peroxide

What is scrubbing?

A method of high pressure irrigation which is a gentle mechanical action to loosen debris and necrotic tissue

Reasons for debridement

Wound healing is impaired due to prolong inflammation

Necrotic tissue –culture medium for bacteria

Amtibiotics do not reach the wound milieu

Dressings especially antimicrobial or silver do not reach wound bed

For staging of undetermined stage pressure ulcer

Methods of Debridement

Surgical Mechanical Autolytic Enzymatic Biological

Maggot Debridement Therapy( MDT)

Autolytic Debridement

Wound bed utilizes phagocytes and proteolytic enzymes to remove non viable tissueining a moist environment

This process can be promoted and enhanced by maintaining a moist environment

Surgical Debridement

Recommended for removal of thick, adherent eschar and devitalized tissue in large wounds

Not recommended in severely compromised patients

Analgesia / anaesthesia may be required

Enzymatic Debridement

The use of topically applied enzymatic agents to stimulate the breakdown of non viable tissue

Faster debridement process compared to autolytic

Eg: Honey, Prolase dressing

Mechanical Debridement

Used for decades where dressings are allowed to proceed from moist to dry

Manually removing the dressing causes a form of non selective debridement

Works best on wounds with moderate amounts of necrotic debris

Biological Debridement

Small maggots are introduced to a wound to consume necrotic tissue

Able to debride a wound within 1-2/7

The maggots derive nutrients through a process called ` extracorporeal digestion’

What is the purpose of dressings?

Protect wound from trauma or microbial contamination

Absorb drainage and debride wound Control & prevent haemorrhage

( pressure dressing) Reduce pain Maintain temperature and moisture of

wound Provide psychological comfort

Categories of dressings

Traditional Conventional

Leaves, herbs, Honey, Gauze

Advanced/ environmental dressingsI. more expensive II. Can be left in situ for several daysIII. Films, Alginates, Silver, Hydrogels,

Foams, Hydrocolloids, Charcoals

The Ideal Dressing

Safe and easy to use Remove excess exudate Provide thermal insulation Trauma protection Provide barrier to pathogens Allow gaseous exchange Water proof Non adherent Maintain moist wound healing

environment

Reference

The Compendium of Wound Care Dressings in Malaysia, Volume 2 , Harikrishna K.R Nair

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