Wound Care for the New Millenium - St. Vincent's …€¢TcPO2 increases in tissue after effective...
Transcript of Wound Care for the New Millenium - St. Vincent's …€¢TcPO2 increases in tissue after effective...
Wound Care for the New Millenium
Geoffrey L. Risley, MD, FACS
Cardiothoracic & Vascular Surgical Associates Medical Director St. Vincent’s Center for Limb Salvage, Advanced
Wound Care & Hyperbaric Therapy Medical Director Jacksonville Vein Center
Medical Director Vascular Access Center of Jacksonville
Disclosures
• Ev3
• C.S.I.
• Endologix
• Atheromed
• Cordis
Goals-Better Understanding
• Wound Healing Process
• Wound Classification/Evaluation
• Treatment Algorithm
• Advances in wound care technology
• How an aggressive integrated multi-disciplinary approach can lead to: • Reduced healing times • Reduced amputation
rates • Improved QOL
Overview Chronic Wounds
• 8 million people in US • 1.1-1.8 million new cases/yr • $25 Billion/year
• 25% DM develop DFU • Responsible for 600K admissions/yr • 12% DFUwill require amputation
• Prevalence VSU 600,000/yr • Loss 2 million wk-dys/yr
• Prevalence acute care pressure ulcer 14% • Occur in 9% of all hospitalized pts w/in 2 wks
Human Skin Wounds: A Major & Snowballing Threat to Public Health and the Economy. Wound Repair & Regeneration, 17:763-771, 2010.
1994
<4.5% Missing data 4.5 - 5.9% 6.0 - 7.4% 7.5 - 8.9% ≥9.0%
Age-adjusted Percentage of U.S. Adults Who Had Diagnosed Diabetes
CDC’s Division of Diabetes Translation. National Diabetes Surveillance System available at http://www.cdc.gov/diabetes/statistics
2000
<4.5% Missing data 4.5 - 5.9% 6.0 - 7.4% 7.5 - 8.9% ≥9.0%
Age-adjusted Percentage of U.S. Adults Who Had Diagnosed Diabetes
CDC’s Division of Diabetes Translation. National Diabetes Surveillance System available at http://www.cdc.gov/diabetes/statistics
2005
<4.5% Missing data 4.5 - 5.9% 6.0 - 7.4% 7.5 - 8.9% ≥9.0%
Age-adjusted Percentage of U.S. Adults Who Had Diagnosed Diabetes
CDC’s Division of Diabetes Translation. National Diabetes Surveillance System available at http://www.cdc.gov/diabetes/statistics
2009
<4.5% Missing data 4.5 - 5.9% 6.0 - 7.4% 7.5 - 8.9% ≥9.0%
Age-adjusted Percentage of U.S. Adults Who Had Diagnosed Diabetes
CDC’s Division of Diabetes Translation. National Diabetes Surveillance System available at http://www.cdc.gov/diabetes/statistics
2000
Obesity Trends* Among U.S. Adults BRFSS, 1990, 2000, 2010
(*BMI ≥30, or about 30 lbs. overweight for 5’4” person)
2010
1990
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
Aging Population
Source: US Census Bureau 2008
The Perfect Storm
Ageing population
Increasing DM Increasing Obesity
Increasing atherosclerosis
CHRONIC WOUNDS
CHRONIC WOUNDS
That’s GROSS DAD!!!!!!!
Wound Healing Process
• Stages • Coagulation • Inflammation • Proliferation • Maturation • Contraction
Chronic Wounds
• Senescent cells
• Hyperinflammatory
• Exudate
• Bacterial load
• Necrotic tissue
Chronic Wound Pathway Ischemia, Trauma, Infection, Necrotic Tissue
Prolonged Inflammatory State Excess PMNs, Macrophages
Excess Cytokines
MMPs/TIMPs Disturbance
Impaired Cell Migration,
Impaired Collagen Production, Growth Factor Destruction
Obstacles to Wound Healing
Extrinsic • Mechanical load • Wound bed
environment • Bacterial burden • Soft tissue/bone
infection • Devitalized tissue
Intrinsic • Systemic disease • Perfusion/oxygenation • Infection process • Nutrition/hydration • Medications
Obstacles to Wound Healing
• Causes of inadequate perfusion • Atherosclerosis • Cardiac failure • Drug abuse • Microvascular disease • Radiation • Peripheral vasoconstriction • Smoking
Obstacles to Wound Healing
• Diseases that interfere with wound healing • Diabetes Mellitus • Arteriosclerosis Obliterans • Collagen Vascular Diseases & Vasculitis • Venous Stasis • Malignancies
Wound Healing Time-line
CHRONIC WOUNDS FAIL TO PROGRESS!!
Where do we start??
When faced with an overwhelming problem
start with a Differential Diagnosis
ARTERIAL ULCERS
Arterial Ulcer Appearance
• Areas trauma/pressure
• Dry, grey, necrotic
• “punched out”
• Minimal exudate
• Limb hair loss
• Absent/diminished pulses
• Pain worse with elevation
PAD
• 10-14% general population
• 20-30% population > 75
• 2.2% men > 50 claudicate
• 7.5% men >75 claudicate
• Symptomatic large vessel atherosclerosis have 10-15X increase in cardiac mortality
PAD Risk Factors
• Lipoproteins • HDL • LDL • Lpa
• Diet
• Smoking
• Hypertension
• Diabetes
• Systemic thrombogenic risk factors
• Obesity/Inactivity
• Genetic Factors
Arterial Supply = Tissue Oxygenation
Assessment • Pulse exam, ?bruit
• Doppler exam/waveform analysis/ratios
• ABI/Segmental Pressue/toe pressure
• PPG, oximetry, TcPO2
• Duplex Scan, Angiography, CTA, MRA
Aortogram CTA
MRA Duplex
PAD
Treatment Options
Risk Factor Modification Medical
Endovascular Surgical BPG
Hybrid Procedure
Bypass • GSV • PTFE • Heparin-coated PTFE • Cryovein • Bovine Artery
Angioplasty • Cryoplasty • Drug-eluting
Stent • Covered • Drug-eluting • Biodegradeable
Atherectomy • Orbital • Silverhawk • Laser
• Remote Endarterectomy
Always Consider PAD
• 10 – 20% 0f all LE ulcers will have PAD
• Only 25% of all Pts. with PAD are treated
• Intervention improves healing • ??? improves QOL and lifespan
VENOUS STASIS ULCERS
Venous Stasis Ulcers
• Caused by chronic venous insufficiency • 7 million suffer with CVI in US
• Responsible for 60-80% al LE Ulcers • 1.5 million new cases VSU/year
• World-wide prevalence of VSU 1-1.3%
What Causes VLUs?
• End result of venous hypertension • Elevation of ambulatory venous pressure
• Chronic Inflammatory up-regulation • Gradual skin scarring • Poor healing potential
Relationship Between Ambulatory Venous
Pressure (AVP) & Venous Stasis Ucleration
AVP (mmHg) Incidence VSU (%)
<45 0
45-49 5
50-59 15
60-69 50
70-79 75
>79 80
J. Vasc. Surg. ‘93; 17:414-9.
Why does CVI cause VSU?
• Prolonged venous hypertension causes “leaky capillaries” • RBC/Macromolecules
leak • Inflammatory
response recruits leukocytes into interstitial space
• ?Reduces o2 diffusion
VSU-what’s in all that fluid?
• Inflammatory mediators released by macrophage/neutrophils • Interleukins • TNF-alpha • Interferon-gamma • Alter MMP/TIMP ratio
• Anti-inflammatory cytokines down-regulated
• Results in unregulated tissue lysis phenotype
VSU are inflammatory ulcers
• Elevated Protease levels
• Elevated pro-inflammatory cytokines
• Healing is associated with reduction in the wound fluid components
What does this have to do with treating VSU?
• Have the correct diagnosis
• Eliminate venous hypertension
• Remove wound fluid from contact with skin & tissue due to the destructive proteins and enzymes in the fluid.
Why diagnose cause?
• Eliminate swelling & wound heals
• Etiology Swelling • CVI • Lymhedema • Morbid obesity • CHF • Renal failure
Diagnosing Venous Disease
Often PE is enough !
Diagnosing Venous Disease
Diagnosing Venous Disease
• Venous Duplex Scan
• Identify Reflux • Saphenous • Deep • Perforator
• Outflow Obstruction?
Treatment Options Eliminate Venous
Hypertension • Compression
• Eliminate Source of Reflux or Obstruction
COMPRESSION ABLATION/STRIPPING
Compression- What does it do?
• Prevents transmission of venous hypertension to skin & surrounding tissue. • Reduces per-wound inflammation
• May narrow veins to allow better function of the valves to prevent reflux.
• TcPO2 increases in tissue after effective compression & edema reduction
Roberts et al, Angiology 2002;53:451.
Inflammatory Mediators in VLU
EFFECT OF COMPRESSION
Optimal Amount Compression
• Overall goal is control of edema
• 40mmHg is optimal
• Accept less if improves compliance and still controls edema
Initial Treatment
• Unna’s Boot (Zinc oxide)/Dome Boot (Calamine lotion)
• Multi-layer compression
• Intermittent Pneumatic Compression
• Compression Hose
In Addition to AVP Correction (Compression)
• Manage Exudate
• Manage Biofilm
• Manage infection
Adjuvant Topical Therapies
• Skin Graft
• Bioengineered dermal substitutes • Apligraf • Dermagraf
• Non-living dermal substitutes • Oasis • Integra
• Growth factors
VLU recurrence after healing
• F/U data in 110 patients after healing
• Recurrent ulceration developed in: • 24% limbs w/in 1 year • 33% limbs w/in 2 years • 49% limbs w/in 5 years
Marston, et al, J. Vasc. Surg. ‘99; 30:491-8.
Prevention of recurrence ROLE OF COMPRESSION
Key Characteristics • Lifelong
• Daily
• Knee high
• 30-40mm Graduated optimal
• Whatever controls edema
Methods • Compression stocking
• Circ-Aide legging
• Short-stretch bandage
• Intermittent pneumatic compression
• No Effect on Ulcer healing rate or % healed
• Has a great effect on ulcer recurrence • 12% vs.28% recurrence @ 12mos comparing
surgery to compression alone
Lancet 2004: 363:1854-59
NEUROPATHIC ULCERS= DIABETIC FOOT ULCER
Diabetic effect on the foot
• Distal symmetrical polyneuropathy • Sensory • Motor
Diabetic foot abnormalities
• Claw/Hammer toe deformity
• Hallux Valgus/Bunion
• Charcot Foot
Correct the Mechanical Abnormality
• Foot reconstruction
• Orthotics
• Total Contact Casting
Promotion of Wound Healing
• Identify etiology(ies)- assessment
• Enact Pathway elements for specific etiologies
• Prepare the Wound Bed • Correct Wound-related Cause of Nonhealing
• Optimize the Patient • Treat Pt.-related Factors Preventing Healing
Normalize the Micro-environment
• Provide moist environment
• Debride necrotic tissue
• Manage exudate
• Control bio-burden
• Normalize systemic factors
Debridement A Mainstay of Modern Wound Care
• Removes dead tissue • Medium for bacterial growth • Senescent cells inhibit cell migration
• Removes Inflammatory mediators
• Removes biofilm • Improve antibacterial effectiveness • Improve tissue bacteriocidal ability
Types of Debridement • Surgical • Sharp debridement using surgical instrument • Fast & Selective • May be costly • Requires specialized training • Must address pain • Not everyone is a candidate
Types of Debridement • Autolytic • Enzymes in wound fluid dissolve debris • Slower than surgical but still selective • Less costly & painful • Maceration can be a problem • Inappropriate if infection present • Good if wound has several stages of healing at
the same time
Types of Debridement • Chemical • Prescription agent dissolves debris • Relatively selective if properly used • Slower than surgical but faster than autolytic • May cause local infection or burning pain • Should score eschar before applying • Helpful in pts. who cannot tolerate surgery
Types of Debridement • Mechanical • Wet to dry dressings, pulsatile lavage or
whirlpool • Nonselective & may injure healthy tissue • May be painful • Labor intensive in some cases • May be appropriate for initial removal of debris
from heavily contaminated wound but not for ongoing treatment
Types of Debridement
• Maggot Therapy • Secrete proteolytic
enzymes • Ingest liquified tissue • Stimulate serous
exudate from wound • Produce antimicrobial
factors
• 30 maggots consume 1 g of necrotic tissue daily
• Selective
Maintenance Debridement
• Ongoing removal of cellular burden and necrotic debris
• Periodic • Serial conservative sharp debridement • Alternating sharp and other types of debridement,
such as enzymes that don’t harm viable tissue
• Continuous • Enzymatic • Autolytic • Mechanical
Reducing Bioburden & Infection
Control • All chronic wounds are contaminated • Unless bioburden is severe, no harm done
• Increased bioburden can lead to local infection • Only symptom may be failure to progress • May have increased exudate, odor, exuberant
granulation tissue, bridging of nonviable epidermis
Biofilm
• Dentistry’s role in chronic wounds
• Dental plaque is a biofilm
• Dental health relies on elimination of biofilm
• Is a protective mechanism of the bacteria
Reducing Bioburden & Infection Control
• Local Infection may have periwound edema, warmth, erythema, purulence, pain • Debride to reduce bioburden • Culture cleansed wound bed
Reducing Bioburden & Infection Control
• May try topical antimicrobials till cx. back • Caution- may be cytotoxic, sensitizers, promote
growth of resistant strains
• May try new antimicrobial dressings • Not cytotoxic but may be allergenic
• Handwashing!!!
Reducing Bioburden & Infection Control
• Positive Cultures or Systemic Infection • Treat based on culture results • Tissue, post debridement swab, needle
aspiration • May need blood tests, radiology, or MRI
Reducing Bioburden & Infection Control
• Use systemic antibiotics • Poor GI absorption may require parenteral
antibiotics. • Poor peripheral circulation may impair
effectiveness • May need excision or amputation
Microbial Identification
• 99% of chronic wounds are polymicrobial, with high abundance.
• Less than 5% of known wound microbes can be readily grown in traditional culture.
• 97% of chronic wounds contain these “easily grown” microbes at less than 1% !
• The limitations and inadequacies of traditional culture routinely lead to empirical therapy, largely ineffective for the microbial reality.
• PathoGenius® is a PCR technique to ID the bacteria in wound
Clinical Pathway for Wound Healing
Advanced Wound Care Practices at St . Vincent’s Center for Advanced Wound Healing
• Comprehensive wound care evaluation utilizing non-invasive diagnostic testing, including our Vascular Lab, Radiology, MRI, Doppler studies, etc.
• Multidisciplinary physician involvement in each and every
case (i.e. Internal Medicine, Vascular Surgeons, Plastic Surgeons, Infectious Disease, and Podiatry)
• Surgical intervention (i.e. debridement, by-pass)
Advanced Techniques (cont)
• Coordination of follow-up wound care and post wound care protocol
• Hyperbaric Oxygen Therapy • Use of advanced wound care products and
techniques: • Apligraf/Dermagraft • Wound Vac • OASIS Matrix
• Off-loading devices and nutritional support
ADJUNCTIVE ROLE OF HYPERBARIC OXYGEN THERAPY
IN WOUND HEALING
HBO Effect - Hyperoxygenation
Breathing pure oxygen at increased atmospheric pressure causes oxygen to be dissolved in plasma, as much as a 10-15 fold increase (2200 mmHg @ 3atm abs) By having plasma in addition to hemoglobin carry oxygen, more oxygen is delivered to compromised tissue.
Oxygen is transported further in poorly vascularized tissue. The oxygen diffusion distance through tissue can be increased 2 to four times that of normal atmospheric pressure.
Tissue oxygen tensions remain elevated for 2 to 4 hours following treatment.
1.
2.
3.
Dr. I. Boerma LIFE WITHOUT BLOOD
• Exsanguinated a pig
• Replaced Blood with plasma only
• Exposed to 100% O2 @ 3ATM x 24hrs
• Resuscitate with blood
• No problems
WE DON’T NEED NO STINKING BLOOD!!!!!
HBO Treatment
High dose oxygen inhalation in which a patient
breathes 100% oxygen under greater than
atmospheric pressure in a full body hyperbaric
chamber
HBO Mechanisms
Immunologic Increases killing by PMNs
Lethal to some anaerobes
Inhibits toxin formation by some anaerobes
Oxygen free radicals
Enhances bactericidal activity of antibiotics
Microcirculatory Increases flexibility of RBCs
Promotes growth of capillaries (neovascularization)
HBO Mechanisms
Other
Decrease tissue edema
Stimulates fibroblast growth
Increases collagen formation & deposition
HBO Covered Indications
1. Air or Gas Embolism
2. Carbon Monoxide Poisoning Carbon Monoxide Poisoning Complicated by Cyanide Poisoning
3. Clostridial Myositis and Myonecrosis (Gas Gangrene)
4. Crush Injury, Compartment Syndrome, and other Acute Traumatic Ischemias
5. Decompression Sickness
6. Enhancement of Healing in Selected Problem Wounds
7. Exceptional Blood Loss (Anemia)
HBO Covered Indications 8. Intracranial Abscess
9. Necrotizing Soft Tissue Infections
10. Osteomyelitis (Refractory)
11. Delayed Radiation Injury (Soft Tissue and Bony Necrosis)
12. Skin Grafts & Flaps (Compromised)
13. Actinomycosis
14. Diabetic wounds of LE (Wagner III or higher) unresponsive to conventional wound care
Source: Hyperbaric Oxygen Therapy Committee of the Undersea and Hyperbaric Medical Society (UHMS).
April 2003
HBO Indications by Specialty
• Plastic Surgeon – compromised flap or preservation of graft
• Vascular, General, OB GYN – necrotizing infection, failed flap/graft
• Orthopedics – chronic osteomyelitis
• Podiatry – diabetic wounds LE, chronic osteo, acute aterial insufficiency, gas gangrene
• Oral Surgeons – osteoradionecrosis [Marx Protocol]
HBO Treatment • Monoplace (1 person) or multiplace
(> 2 person) chamber
• Patient(s) placed entirely within the chamber
• Breathes 100% oxygen
• Chamber pressure is increased to >2 atm abs
• Monitored ability to equalize inner ear pressures - chamber pressure adjusted accordingly
**Breathing 100% oxygen at 1 atm abs (sea level) or exposing isolated parts of body to 100% oxygen does not constitute HBO therapy
Today’s Monoplace Chamber
HBO Treatment
• Approximately 30 treatments – 1-2 hr each
• Treatments 5-6 days / wk over 5-6 wks
• Some require shorter treatment interval
• Some may undergo a longer or a repeat series of
treatments in the setting of recurrent or refractory
problems
HBO Treatment Not a substitute for:
Local wound care
Antibiotic therapy
Vascular intervention
Biomechanical considerations
**Hyperbaric oxygen therapy is a catalyst that hastens the healing process
Multi-specialty Group of Collaborating Physician
Physician Panel
• Geoff Risley, MD • Medical Director • Vascular Surgery
• Carol Bowen-Wells, MD • General Surgery
• Ed Chisholm, MD • General Surgery
• Brad Herbst, DPM • Podiatry
• Ronnie Bateh, DPM • Podiatry
• Gene Ruckh, DPM • Podiatry
• Reginald Sykes, MD • Internal Medicine
• Lenka Zachar, MD • General Surgery
Case Studies
Debridement Compression
Apligraf
Vascular Referral
Re-occurring ulcer for the last 5 years. Diabetes, PVD, DVT, Superficial venous insufficiency, MO
Healed in 6 weeks
History of diabetes, burns to bilateral plantar foot after
walking on the beach in August
HBO Treatment
•55 y.o. male IDDM •Penetrating wound •Polymicrobial •S/P debridement
HBO Treatment
•S/P 15 HBO Tx’s •IV Abx •Wound care •Glucose control
HBO Treatment
•S/P 45 hbo tx •Went on to closure
HBO Treatment
•78 y.o. male IDDM •2 wks S/P resection bone •Con’t drainage
HBO Treatment
•S/P 20 HBO Tx’s
HBO Treatment
•Healed •S/P 30 HBO Tx’s
In Summary, the St. Vincent’s New Wound Care
Program Offers:
• Assessment
• Vascular studies
• Revascularization
• Infection control
• Wound excision
• Remodeling
• Growth factor therapy
• HBO
• Skin grafting & bio-engineered skin products
• Nutritional Support
• Protection devices
• Patient education
• Referrals
• Communication
Questions