Management of Chronic Difficult Wounds in the Long...
Transcript of Management of Chronic Difficult Wounds in the Long...
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
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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