Wound Care Therapies

Wound Care Therapies
Michael Criswell DNP, CCNS, CSC, CCRN, CWOCN
IUHA In-patient Wound Care
Department
Michael Criswell, DNP, CCNS, CSC, CWOCN
IUHA Wound Care Office Hours:
M-F 8:00 – 4:30 pm
Office #: AG 459
CISCO #: (765) 838-5279
Cell #: (765) 491-3980
Closed: Nights, Weekends, Holidays
The department has 3- Wound Therapy Associate
(WTA) RN’s assisting with wound care coverage
7/4/2014
Wound Care Consults
• New or POA wounds ( Acute or Chronic)
• Stage Pressure Ulcer I – IV, unstageable and
SDTI’s
• Therapeutic bed Recommendation
• LEVD with Venous Leg Ulcers
• LEAD with Arterial Leg or Foot ulcers
• LEND with Diabetic Neuropathic leg or foot Ulcers
• Incontinence Associated Dermatitis (IAD) or
Moisture Associated Skin Dermatitis (MASD)
7/4/2014
Wound Therapy Provided
Conventional Wound Dressings
Topical Advanced Wound Dressings: (Medi-Honey,
Prisma)
NPWT- Wound Vac (Open Cell Foam and Gauze);
Fistula High Output Dressing
MIST - Non-Contact Low-frequency Ultrasound
Pulse Lavage for Wound Irrigation
Multilayer Layer Compression Wraps for LEVD(CoBand II, Profore)
7/4/2014
"There is something beautiful about all
scars of whatever nature. A scar means
the hurt is over, the wound is closed and
healed, done with." - Harry Crews
7/4/2014
5
WOUND
A wound is a bodily injury caused by
physical means, with disruption of the
normal continuity of structures. This can
be identified as an acute or a chronic
wound.
Wound Identification
ACUTE: “disruption in the integrity of the skin and underlying
tissues that progress in a timely and uncomplicated manner.”
Usually caused by trauma or surgery and heals in
approximately 2 weeks to 6 months
CHRONIC: “one that deviates from suspected sequence of
repair in terms of time, appearance and response to
aggressive and appropriate treatment.”
Takes 6 months or more because of underlying conditions,
such as pressure, diabetes, poor circulation, poor nutritional
state, immunosuppression, or infection.
Types of Wounds
Pressure Ulcers
Lower Extremity Wounds;
Arterial Insufficiency Ulcers
Diabetic Neuropathic Ulcers
Venous Insufficiency Ulcers
Surgical Wounds
Traumatic Wounds
Burns
Tumors
Phases of Wound Healing
Inflammatory phase:
Immediate to 4-6 days
Hemostasis: vasoconstriction, platelet aggregation,
fibrin formation and Thromboplastin makes clot
Inflammation: vasodilation. Neutrophil infiltration,
monocyte infiltration and differentiation to
macrophage and lymphocyte infiltration =
Phagocytosis
Characterized by Edema, Erythema, Heat, and Pain.
Phases of Wound Healing
Proliferative Phase:
4 days to 3 weeks
Granulation: Fibroblasts lay bed of collagen,
fills defect and produces new capillaries
Contraction: Wound edges pull together to
reduce defect
Epithelialization: Crosses moist surface, Cell
migrate from wound margins, travel about 3 cm
from point of origin in all directions
Phases of Wound Healing
Remodeling Phase:
3 weeks to 2 years
New collagen forms which increases tensile
strength to wounds
Scar tissue is only 80 percent as strong as
original tissue
Tissue always at risk for breakdown due to
reduced tensile strength
Phases of Wound Healing
Factors Affecting Wound Healing
Although many factors influence wound healing
the most important are:
Nutritional deficiencies
– (albumin <2.6 gm/dL), vitamin deficiencies (unusual)
Aging
Wound infections
Hypoxia
Edema
Steroids
Diabetes
Radiation
Review of Wound Healing
Three Types of Wound Healing
Primary
Primary Delayed
Secondary
Primary Intention
The wound surfaces opposed
Heals without complications
Minimal new tissue
Best results
Delayed Primary (AKA Tertiary):
Left open initially
Wound margins approximated 4-6 days later
Secondary Intention
Surfaces not approximated
Wound defect filled by granulation
Covered with epithelium
Less functional with larger scar
More sensitive to thermal and mechanical injury
Secondary Wound Healing
Worrying Statistics
Chronic wounds account for 1-2 % of the
population and 2-4% of health care
expenditures
Diabetic foot ulcers
246 million people are living with Diabetes
46% of diabetics are between 40 –59 years old
Globally a leg is amputated due to diabetes every
30 seconds
60% of amputations are due to infection
45% of amputees die within 5 years
1 in 14 adults in the world will have diabetes by
2025
Diabetic Foot Ulcers
Caused by neuropathy, ischemia & infection
Autonomic nerve failure, Neuropathy, decreased sweating,
dry easily damaged skin, diminished or absent sensation
warm foot, foot deformities
Increased susceptibility to infection- Diabetes has a
detrimental effect on neutrophil function
Located- primarily on plantar aspect of foot, over
metatarsal heads and under heel
Venous leg ulcers
1 - 1.3% of the world’s population have a
venous leg ulcer, or approximately 7 million
individuals worldwide at any given time have
LEVD with 3 million of those people
progressing to ulceration (Bergen et al., 2007).
Prevalence is increasing due to sedentary
lifestyle and obesity
Venous ulcer can take years to heal with
recurrence rates as high as 76%
LEVD: Venous Insufficiency
Ulcers
Causes- faulty communicating & superficial vein valves,
damaged deep vein valves, deep vein occlusion, and skeletal
muscle pump failure.
Located on - medial lower leg and ankle (gaiter area) and on
malleolar area
Appearance includes:
Edema
Shallow irregular ulcers with exudate
Hemosiderin staining
Erythematous, scaly, pruritic, weepy wounds
Venous eczema. cellulitis
Ankle flaring (cluster of reticular/spider veins)
LEAD
Ischemic ulcers much less common than
Venous or Diabetic ulcers.
LEAD prevalence rates range 18- 29 % among
those 60 yrs. and older with similar rates
reported for those over 50 yrs. who are at high
risk due to Diabetes and smoking.
An estimated 5- 10 million people in the U.S
have LEAD
Arterial Insufficiency Ulcers
Predisposing factors include: PVD, smoking, diabetes
mellitus, dyslipidemia, hypertension, and advanced age
Location includes: Between toes or tips of toes, over
phalangeal heads around lateral malleolus, areas of trauma
or rubbing from footwear
Appearance: Thin shiny skin, hair loss on ankle and foot
pallor on elevation and dependent rubor, absent or
diminished pulses decreased ABI, “punched out” wound
appearance
Pressure Ulcers Defined:
Pressure ulcers are localized injury to the skin and/or
underlying tissue usually over a bony prominence (e.g., the
sacrum, trochanter, ischium, or heel), as a result of pressure,
or pressure in combination with shear and/or friction.
In 2009, the National Pressure Ulcer Advisory Panel (NPUAP/EPUAP)
defined a pressure ulcer as:
“A localized injury to the skin and/or underlying tissue usually over a
bony prominence, as a result of pressure, or pressure in combination
with shear. Friction generates shear and when friction is high, the
shear is also high, so the inclusion of shear presumes the presence of
friction”
(L. Edsberg, personal communication February, 2010; WOCN, 2010, p. 1).
7/4/2014
Contributing Factors
1
Friction
Immobility
Shear
Pressure
Ulcers
Pressure
Incontinence
Malnutrition
Why is Pressure Ulcer Prevention
Important?
2.5 million patients per year.
Cost: Pressure ulcers cost $9.1-$11.6 billion per year in the US.
Cost of individual patient care ranges from $20,900 to 151,700 per
pressure ulcer. Medicare estimated in 2007 that each pressure
ulcer added $43,180 in costs to a hospital stay.
Lawsuits: More than 17,000 lawsuits are related to pressure
ulcers annually. It is the second most common claim after
wrongful death and greater than falls or emotional distress.
Pain: Pressure ulcers may be associated with severe pain.
Death: About 60,000 patients die as a direct result of a pressure
ulcer each year.
Internet Citation: Preventing Pressure Ulcers in Hospitals: A Toolkit for Improving Quality. April 2011. Agency for Healthcare Research and Quality,
Rockville, MD. http://www.ahrq.gov/professionals/systems/long-term-care/resources/pressure-ulcers/pressureulcertoolkit/putool1.html
7/4/2014
Under…..Pressure!
Common Sites for Pressure Ulceration
Sacrum = 28.3 %; Heels = 23.6 %;
Ischium = 3.2 %; Trochanter = 2.8 %
7/4/2014
Pressure Ulcer Staging and
Treatment
7/4/2014
Medical Device Related Pressure Ulcers
Considered a
pressure ulcer
Mucous
membrane
ulcers
are not staged
Oxygen delivery
devices a
significant risk
factor
Literature on MDR-PrU’s
2079 patients in critical care, step down on general care
units
83 patients had 113 PrU
34.5% were from medical devices
Depth of injury
35% stage I
24% unstageable
3% stage III
Patients with medical device PrU were 2.4 times more
likely to develop a PrU
Black et al. Use of Wound Dressings to Enhance Prevention of Pressure Ulcers By Medical Devices. Int. Wound J. 2013.
Suspected Deep Tissue Injury
(sDTI)
Epidemiology (Vangilder N = 10,728)
sDTI’s are likely to be facility acquired
9.5% of all PU’s identified are sDTI’s
13.4% of FA ulcers are sDTI’s
sDTI’s are more common in high acuity settings
ICU (14% of all ulcers & 20% of FA ulcers)
LTAC (10% of all ulcers & 18% of FA ulcers)
Offloading to relieve pressure
Building evidence for noncontact Ultrasound (MIST)
Xenaderm unknown
No evidence today to support:
Early debridement or HBO
Cost of Treatment
Long Term Care Facilities/Hospitals
What it means per incident:
Pressure Ulcer
$3,259 to $52,93
Venous Stasis Ulcer
$9,695 per patient
Neuropathic Ulcer
$16,000 to $28,000
per incident
Pressure Ulcer
$3,259 to $52,93
Source: WoundVision.com
Wound Treatment Strategy
If there is infection, treat it.
If it’s wet, absorb it.
If it’s dry, hydrate it.
If there is a hole, fill it.
If there is necrotic tissue, remove it.
If there is healthy tissue, protect it.
Wound Type
Wet
Dry
Infected
Shallow
Foam, Hydrofiber
Hydrogel, Hydrocolloid
Transparent Film
Silver Antimicrobial
Deep
Alginate, Hydrofiber
Hydrogel
Silver antimicrobial
Conventional Wound Care
Therapies
Hydrogels – Normagel Clearsite, Silvermed, Curafil
Hydrocolloids – Thick and thin types, Duoderm, Restore, Comfeel,
Tegasorb,
Transparent films- Opsite, Tegaderm
Foam dressings – Mepilex, Allevyn, Optifoam, Hydrasorb,
Alginates/Hydrofibers – Aquacel AG, Kaltostat, Maxsorb AG, Algisite
Enzymatic – Santyl, Panafil, Accuzyme, Gladase
Biological- Maggot therapy
Antibacterial – Isosorb, Acticoat
Collagens: Prisma AG, Puracol Plus
Cleansers: Restore Hollister Wound Cleanser
Moisture Barriers/Antifungals: Critic-Aid Zinc, Clear, Critic aid with 2%
Miconazole, Nystatin
Compression Wraps: Multi-Layer Profore and CoBand II
Wet to Dry Dressings
Indicated for Mechanical Debridement ONLY
•
•
•
•
•
•
•
Causes Injury to New Granulation Tissue Growth
Is Painful
Predisposes Wound to Infection
Drying Out Reduces Temperature of Local Tissue
Becomes a Foreign Body
Not an Effective Barrier to Bacteria
Delays Healing Time
Hydrogels – Sheet and Gel
Hydrofiber Sheet and Rope
Silver Dressings: The Clinical
Bottom Line
The Effectiveness of silver-releasing dressings in the
management of chronic wounds: A meta-analysis
8 studies selected form 1957 references incorporated 1399
participants
Silver dressings significantly improved wound healing (CI (95):
p< 0.001)
Reduced odor (CI (95), p < 0.001) QOL
Reduced pain symptoms (CI (95), p < 0.001) QOL
Decreased exudate (CI (95), p = 0.028
When compared to alternative wound management
approaches
Alginates: Sheet and Rope
Alginate Dressings: the Clinical
Bottom Line
Systematic Review was performed to assess
alginate dressings in surgery and wound
management. Alginate was compared to several
different dressing types. (Level1)
Gauze –Alginate absorbed 3 X’s citrated blood in lab
Paraffin Gauze- split thickness grafts and donor sites
– healing was better patient comfort was higher less
bulky dressing absorbed more blood
Hydrocolloid – similar outcomes 90 % healing rates
for both dressings
Joanna Briggs Institute 2013 EBP Summary
Collagens Oxidative Regenerative
Cellulose (ORC)
Antimicrobial
MediHoney
• MEDIHONEY Calcium Alginate Dressing (2” x 2”, 4”
x 5”, ¾”x 12”)
• MEDIHONEY Honeycolloid
• (2” x 2”, 4” x 5”)
• Plain and adhesive versions
• (adhesive has thin film backing
• and ¾inch adhesive border)
• MEDIHONEY Tube
• (1.5 oz, 3.5 oz)
MEDIHONEY: MECHANISMS OF ACTION
Osmotic Activity
Promotes both autolytic and mechanical
debridement
Aids in cleansing, debridement and edema
reduction
Constant outflow of fluid helps to
mechanically lift necrotic tissue
Lymphatic fluid delivers plasminogen to the
wound site helping to break down necrotic
tissue through fibrinolysis
Antimicrobials and Antiseptics for
Venous Leg Ulcers
Cochrane Database: 45 RCT’s reporting 53 comparisons
with a total of 4486 participants.
Cadexomer Iodine – more participants were healed with
Cad Iodine compared to standard care. Complete healing 412 weeks (95% CI)
Honey Based preparations – No between group difference
in time to healing or complete healing was detected for
honey based products when compared to usual care.
The Cochrane review - Honey products for acute and
chronic wounds and of the 25 studies evaluated, 21
favored Honey arm over the control arm ( 11 of the honey
are had stat sig results)
Foams
The Border Trial: (Santamaria)
Use of foam dressings for friction, moisture, and pressure
relief
RCT (N = 440) comparing foam dressings to standard of
care
Study showed stat sig, reductions in pressure ulcers in ICU,
OR, ED
Control = 20 (13.5%), Intervention = 5 (3.1%) p = 0.001
Barrier Creams/Paste
Multi-Layer Compression Wraps
Compression Wraps: The Clinical
Bottom Line
Systematic Review and Meta-analysis
48 RCT’s with a total of 4321 participants,
evidence suggests compression improves
healing of venous leg ulcers compared with no
compression
With differences between compression
systems: 4 LSB versus 2 Layer SS heals 1.3
times faster.
Support Surfaces
Multiple Pressure Points (greater than 2 turning surfaces)
Standard Mattress
Waffle (EHOB) mattress overlay
Gel Mattress Overlay
Waffle Seat Cushion
Multiple Pressure Points (fewer than 2 turning surfaces)
Static Air Mattress (Waffle Mattress overlay)
Alternating Pressure Pad and Pump (Dolphin UHC)
Low Air Loss Mattress
Alternating Pressure Pad and Pump with Low Air Loss ( Envision Hill-Rom)
Air Fluidization Bed ( Rite Hite Clinitron Hill-Rom)
Intermediate Level Pressure
Redistribution Devices
Mattress
Overlay
Purchase Replacement Mattress
Alternating
Pressure Pad
High-Level Therapeutic Surfaces
Air Support Bed
with Low Shear
Surface
Air Fluidized
Bed
Hybrid Air Support/
Air Fluidized Bed
The M.A.P™ System solution
Monitor Alert and Protect (MAP) Guide caregivers through accurate
and timely repositioning
Notifications when repositioning becomes necessary based on
predefined sensitivity and pressure metrics
Monitors accumulated pressure over time created by a patient on a
bed surface
Automatic charting and data analysis capabilities to support
managerial requirements
MIST® Therapy
A vibration or a mechanical pressure wave with a frequency
greater than the upper limit of human hearing
This pressure wave moving through a medium (air, water or mist)
causes the molecules of the medium to vibrate
Penetrates deep into the wound bed and accelerates the body’s
normal healing process by:
Cavitation and acoustic microstreaming along cell surface of
firbroblasts
Reducing Biofilm, Bacteria and Inflammation
MIST® Therapy Promotes Wound Healing
“The MIST Therapy
System produces a lowfrequency, ultrasoundgenerated mist used to
promote wound healing
through wound cleansing
and maintenance
debridement by the
removal of yellow slough,
fibrin, tissue exudates,
and bacteria.”
MIST Therapy: The Clinical
Bottom Line
In the meta-analysis using only MIST Therapy ultrasound clinical data,
eight (8) peer-reviewed studies with consistent designs for treatment
and control wound groups were pooled to review the effects of MIST
Therapy on acute and chronic wounds.
Results indicated “MIST Therapy demonstrated consistency of
reduction in wound area, volume, pain and healing times across a wide
range of wounds.”
Mayo Clinic – Prospective parallel group randomized controlled trial –
35 pts received MIST and standard of care and 35 pts who received
standard of care alone. 12 weeks or until fully healed MIST 3 times a
week
MIST had stat sig greater than 50 % reduction in wound healing at 12
weeks than those treated with standard of care alone. ( 63% vs 29% p
< 0.001)
NPWT
DEFINITION: Negative pressure wound therapy
(NPWT) provides an occlusive controlled subatmospheric pressure (negative pressure) suction
dressing that promotes moist wound healing.
Controlled sub-atmospheric pressure improves
tissue perfusion, stimulates granulation tissue,
reduces edema and excessive wound fluid, reduces
overall wound size, helps increase the rate of
granulation tissue formation and epithelial migration.
NPWT: The Clinical Bottom Line
In the Systematic Review on advanced wound therapies for nonhealing diabetic, venous and arterial ulcers conducted by the
department of veterans affairs QUERI Program 2013
1-RCT’s met criteria -NPWT improved wound healing for arterial ulcers
with partial foot amputation when compared to standard of care ( 56%
versus 39 % p = 0.004) decreased mean time to healing (56 days
versus 77 days, p = 0.005) more infections in the NPWT group ( 17 %
versus 6 %, p = 0.004)
3- RCT’s met criteria - NPWT reduced second amputations for DFU’s
compared to advanced moist wound healing (4.1 % versus 10.2 %, p =
0.04) NPWT reported a significant positive effect on mental and
physical health compared to standard care.
Hyperbaric Oxygen Therapy HBOT
Hyperbaric medicine, also known as hyperbaric oxygen therapy
(HBOT), is the medical use of oxygen at a level higher than atmospheric
oxygen.
By placing someone in a 3 psi pressure hyperbaric environment, the
increase in atmospheric pressure at sea level goes from 760 mm Hg to
915 mm Hg or up to 7 %. This higher concentration in oxygen aids
significantly in wound healing.
NOTE: 100% oxygen must be used (not air or partially enriched air)
for full benefit, and the pressure must be at least 1.4 ATA.
The number of hourly treatments required is
usually 40 to 80 for optimal benefit
Advanced Wound Care Therapies
Conventional wound care management is based
on wound characteristics:
Wound depth, color, and exudate levels
Advanced wound care therapies is based on
delayed healing characteristics:
Increased Proteases, decreased growth factors,
and decreased cell numbers
Advanced Wound Care Therapies
Skin substitutes
– (i.e.: Dermagraft®, Apligraf®, Integra®) Human fibroblasts and
Keratoinocytes in a bovine collagen matrix/bovine collagen
chrondroitin -6-sulfate
Growth Factor/Cytokine Preparations
– (i.e.: Regranex®); Procurren Solutions
Wound Matrix- Derma Equivalent Skin Substitutes
– Oasis®, Prisma®; Alloderm: Decellarized cadaver dermis; GraftJacket
• NPWT (Negative Pressure Wound Therapy)
(i.e.: V.A.C., Prospera®, MoblVac®)
Cell Proliferation Induction (CPI®)
– Provant® Wound Therapy System
HBO (Hyperbaric Oxygen)
The Problem with Current Advanced
Wound Therapies
Unreliable product outcome – doesn’t always result in healing
Results in a perceived lack of efficacy
Due to higher cost, product gets niched into a ‘last chance’
therapy
Current Understanding
New Advanced Technology more expensive
Needs more clinical evidence with well conducted without bias
RCT’s to drive product adoption & appropriate usage
Only endpoint considered is total healing
Required Outcome for New Therapies
Need to prove clinical effectiveness