enzymatic debridement collagenase (santyl) digests necrotic collagen – specific and selective for...
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Enzymatic Debridement
• Collagenase (Santyl)• Digests necrotic collagen– Specific and selective for denatured collagen
• Effective when used for long periods of time• Maintenance debridement
Collagenase
• Considerations– Cost– Slow acting– Deactivated when combined with heavy metals• Silver:Loses 50% of it’s efficacy when combined with
silver.
– Can be combined with polysporin powder: good when you’re worried about localized infection.
Autolytic Debridement
• Autolysis:– Natural degradation of devitalized tissue using
endogenous enzymes• Moisture retentive or moisture donating
dressing• Occlusive dressing• Eschar and slough are liquefied by rehydration
and activity of lysosomes
Autolytic Debridement
• Indications:– Wounds with necrotic tissue– **No infection (you’re creating a Petri dish)– Wounds with dry eschar particularly benefit– Cross hatching eschar facilitates
• Considerations– It’s gross– It stinks
Autolytic Debridement
• Contraindications– Dry gangrene– Poor circulatory support• Not enough lysozomes to make the debridement work
but it won’t cause any harm.
– Infection
Autolytic Debridement
• Advantages– Non-invasive– Selective– Does not disrupt
healthy tissue– Easy: leave on 48-
72 hours, rinse wound with saline and apply another.
– Painless
Autolytic Debridement
• Disadvantages– SLOW– Potential to grow bacteria– Can macerate surrounding skin– Watch for sensitivity to adhesive
Biological Debridement
• Maggot Therapy!– Biosurgical debridement, Larval Debridement
Therapy• Role– Debridement (maggots secret collagenase and eat liquefied tissue)
– Disinfection (secretions that maggots give off having antimicrobial properties)
– Promotes wound healing (Maybe???)
Biological Debridement
• Initial research published in 1929• But remain widely unused/unpopular– “Ick” factor– Cost– Slow– Removal and disposal questions– Studies limited• DFU 33% slough – traditional, 0% - maggots• VI cost effective compared to hydrogel
Biological Debridement
• Sterile, medical grade maggots placed in wound
• Covered with dressing– Allows oxygen exchange– Contains maggots– Hydrocolloid most commonly used
dressing• In place 1-4 days, make sure you get them ALL out!
Sharp Debridement
• Most widely used – particularly by PT• Scalpel, forceps, scissors (blunt to cut dressings, or sharp to
remove tissue), curette (least popular tool)
Sharp Debridement
• Research supports:– 2009 retrospective study• DFU, VI• Frequent debriders (>2x/12 wks) vs Infrequent
debriders (<2x/12wks)• 241 wounds• Frequent debriders showed a greater decrease in
surface area of wound• Frequent debriders had better median healing rates
Sharp Debridement
• Research support:– 2009 study of DFU• Growth factors alone vs growth factors with
debridement• Growth factor plus debridement healed faster
Sharp Debridement
• Advantages– Fast– Method of choice for thick, adherent or large
amounts of slough, eschar– Method of choice in presence of infection
• If sepsis, surgeon will perform debridement, not PT!
– Selective– Can be combined with many techniques– Inexpensive, but questionable reimbursement
• Every 20 square cm $25
Sharp Debridement
• Considerations– Pain– Anticoagulants/bleeding disorder– Blood loss• Silver nitrate to stop bleeding
– Enough blood flow?– Potential for infection– Know your anatomy!– Comfort level
Sharp Debridement
• Modified Sterile Technique– Sterile gloves– Sterile equipment– Sterile field
Sharp Debridement
Things to remember• Position patient and self comfortably!
– This can take 60-90 minutes in some cases!• Wash hands!• Explain the procedure (before bringing in equipment)
– ESPECIALLY the first time to reduce anxiety• “only interested in removing dead/harmful tissue, some blood is ok
because it means the circulation to the area is good but it is NOT our goal to make you bleed”
• Stay sterile• Flush with saline• Dispose of material properly
Sharp Debridement
• Tips:– Hold scalpel like a pencil– The blade is sharp!– Cut parallel to the surface• Particularly along edges
– If you aren’t sure – don’t do it– If not in use - have your safety on!
DebridementBefore Debridement
Debridement
AfterDebridement(1 hour later)
Negative Pressure Wound Therapy
• NPWT• Suction applied to
wound via open-celled foam sponge
• Foam secured with vapor permeable drape
• Suction attached to canister to collect excess drainage
Negative Pressure Wound Therapy
• Benefits– Edema reduction
• Increase perfusion distance = blood flow increase
– Increase perfusion • 31% to wound bed, 15% to periwound
– Stimulates granulation tissue formation• Microdeformation
– Removal of exudate• ? Bacterial colonization
– Increased angiogenesis
Negative Pressure Wound Therapy
• Suction 50-150 mmHg– 150 mmHg is common for abdominal wounds– 50-75mmHg for feet– Lower pressure on distal wounds
• Continuous or intermittent– Intermittent over graft sites or distal foot wounds with poor
circulation– Commonly use continuous
• Clean application bedside, sterile application in OR• Lots of sponsored research
– Increased speed of healing negates cost• Cost of vac is $150-200 per day
Negative Pressure Wound Therapy
• How it works:– http://www.youtube.com/watch?v=88XHwSty9jw
Negative Pressure Wound Therapy
• Indications– Any type of wound– Size minimum• 2.5cm in one direction
– Enough room to place a sponge
Negative Pressure Wound Therapy
• Considerations– Cost– Carry around – Change 2-3x/week– Can Pt self fix?– Can be combines with some other products• Silver is most common
– Infection
Negative Pressure Wound Therapy
• Contraindications– Malignancy in wound– Untreated osteomyelitis– Fistulas/tracts – do you know where they end?– Bleeding: stop bleeding before using suction– Know your anatomy!• No blood vessels, nerve endings, anastamosis, most
organs• Can put a vac over exposed bowel (seen a lot with
compartment syndrome of the abdomen)
Negative Pressure Wound Therapy
• How to apply– http://www.youtube.com/watch?v=ucHAM_ZElzs
Hyperbaric Oxygen
• Inhaled 100% oxygen delivered to patient in enclosed environment pressurized to >1.4ATA– Typically 2.4-3.0 ATA
• Easily transported via RBC and hemoglobin• Goal is to increase aerobic cellular metabolism
Hyperbaric Oxygen
• 0.3 volume percent of oxygen is dissolved in plasma at sea level (1 ATA) breathing RA
• 6.9 volume percent of oxygen is dissolved in plasma at 3 ATA breathing 100% O2
• Increased volume percent = increased diffusion radius = more O2 gets to the tissues– When tissues have more oxygen, they heal faster!
Hyperbaric Oxygen
• So what?– Re-establish normal cellular metabolism– Promote angiogenesis– Increase granulation tissue formation– Debate: Salvage marginal tissue?– Decrease tissue edema– Meet increased demand of tissue
Hyperbaric Oxygen
• Indications– Refractory osteomyelitis: (osteomyelitis that has been treated
for 30 days with antibiotics but has not responded.)– Acute traumatic ischemic injury/Crush Injury– Compromised skin grafts and muscle flaps– Necrotizing fasciitis– Gas gangrene
• Life threatening. Get to surgeon to Debride or amputate immediately!!!
– Others:• CO poisoning, smoke inhalation, decompression sickness, arterial gas
emboli, cyanide poisoning
Hyperbaric Oxygen
• Contraindications– Untreated pneumothorax
• Strongly consider– Fever (signs of septic infection)– Claustrophobia – COPD, CHF– High FiO2 (don’t give them MORE oxygen as it may supress their
respiratory drive)
– Chemotherapy
Skin Grafting
• Performed by MD or PA• Should be considered with healthy wound
beds that are failing to heal• Adequate blood supply• Ability to tolerate• Too much wound exudate is a problem– Will flood out the graft and it won’t take
Skin Grafting
• Autograft– From Pt’s own tissue (thigh or buttocks)• Full thickness (rare to take)• Partial thickness (most common)
• Allograft– Created from same species (cadaver graft)
• Done in OR, usually a hospitalization
Skin Grafting
• Xenograft– Created from different species (animal origin)– Oasis Wound Matrix
• Dry product (long shelf life)
• Performed in office• Multiple applications
Skin Grafting
• Bioengineered Tissue– Apligraf, Dermagraft– Living bilayered skin substitute• Epidermal layer formed by human keratinocytes• Dermal layer composed of human fibroblasts in bovine
collagen matrix
– Contains matrix proteins and expresses cytokines– But no melanocytes, macrophages, lymphocytes,
blood vessels, hair follicles or sweat glands• Never looks like normal skin!
Skin Grafting
• Bioengineered Tissue– Full thickness wounds without exposed structures– Non-infected VI with compression– Used in conjuncture with good wound care• Debridement• Non-infected• Good blood supply** KEY
– Without this, the graft won’t take
• Off-loading and compression
Muscle Flap
• Flap surgery– Musculocutaneous when need to fill depth• Skin grafts on the other hand are superficial
– Provides rich vascular tissue– May also require skin grafting– Usually gluteus maximus– If successful, muscle atrophies, but blood supply
remains to feed skin• Success rate is 50%
Muscle Flap
• Surgical debridement• IV antibiotics x6-8 weeks– Ensure no osteomyelitis– NPWT to maintain health of
wound edges• Surgical procedure +
hospitalization• Air fluidized bed x6-8
weeks-non-weight bearing
Muscle Flap
• Muscle atrophies– NOT for cushioning– Pressure relief is necessary**• But how did they get the wound in the first place?• May have to do MORE pressure relief than before!!!
• Who?– Usually SCI patients– Function can be compromised in ambulatory
patients
Total Contact Casting
• Diabetic Foot Ulcer – gold standard• GOAL: Need to offload the foot for healing to occur
• Most patients are neuropathic– Can protect foot from further trauma– Can’t feel if it isn’t a good fit
• Best if can eliminate 2/3 of weight bearing time
Total Contact Casting
• Benefits– Decreases plantar pressures by
increasing weight bearing over entire lower leg
– Redistribute pressure– Prevent trauma– Reduce edema– Immobilize joints and soft tissue• Helpful to prevent shear forces
Total Contact Casting
• Considerations– Gold standard, but only 45% of wound clinics
perform some sort of offloading– If you do it wrong – can seriously harm– No room for absorption• No where for the fluid to go so it can cause maceration
to the whole area!
– Close follow-up needed• By patient-time consuming• By clinician
Total Contact Casting
• How performed– Ulcer covered with gauze– Cotton b/w toes– Stockinette applied– ¼ thick felt along malleoli and ant tibia– Foam padding around toes– Plaster shell molded– Walking heel can be attached– Finished with fiberglass roll around plaster
Total Contact Casting
• Alternatives– TCC-EZ• Making TCC easier?
– http://www.youtube.com/watch?v=YSJ_rojfmAA
Total Contact Casting
• Alternatives– Cam walker• Off the shelf• Better than nothing
– Neuropathic Walker (aka: bivalve boot)
• Custom molded• Optional rocker sole• Easily removed by patient
– Positive and negative attribute
• Poor compliance
Unna’s Boot
• Heavy gauze impregnated with Calamine lotion, zinc oxide paste, glycerin, gelatin
• Apply lotion to skin• Start applying wrap– Start at metatarsal heads– 50% overlap– No stretch– Circular slightly angled wrap (no figure 8 wrap, not
beneficial for edema)– Stop ~1 inch below knee
Unna’s Boot
• Application– Takes ~1 hour to dry– Can cover with kerlix and ace wrap– Not very firm
• Stays on 5-10 days• Removes easily with scissors
Unna’s Boot
• Indications– Most commonly used for Venous Insufficiency
wounds• Benefits– Mandatory compliance– Will moisturize skin– Passive edema control
Unna’s Boot
• Considerations– Heavily draining wounds– Maceration– Neuropathic patients– Balance-can throw off gait pattern– Infection which can start without notice because it’s on for
5-10 days – Compliance – Dry?– Contact dermatitis– Poor fit with fluctuating edema
Becaplermin
• Regranex Gel• Platelet derived growth factor• Indications– Lower extremity diabetic neuropathic ulcers
extending into subcutaneous tissue and beyond– Adequate blood supply– Lots of off label use
Becaplermin
• Should be combined with:– Good wound care– Sharp debridement• Must have contact with receptors
– Infection control• 15 gram tube ($600-$800)• Must be refrigerated– Cannot get heated AT ALL!!!
Becaplermin
• Contraindications– Known hypersensitivity– Necrotic Tissue: growth factors won’t be exposed to appropriate
tissues
– Infection– Neoplasm at the site– Black Box Warning (but NOT pulled from the market)
• >3 tubes = increased incidence of cancer**• No specific type• FDA Black Box Warning
Pressure Ulcer Prevention
• A big part of what we do – unique perspective• Pressure ulcer– Can develop anywhere– Particularly boney prominences
• Ischial tuberosity• Sacrum• Greater trochanter• Vertebrae• Scapula• Head/face• Etc, Etc, Etc
Pressure Ulcer Prevention
• 4 main causes of pressure ulcers– Pressure– Shear – Friction– Moisture
Pressure Ulcer Prevention
• Pressure– Intensity– Duration– Tissue tolerance: health of overall skin in relation
to the pressure it can tolerate• Have to do pressure relief!
Pressure Ulcer Prevention
• Positioning– Turns at minimum every two hours
• Specific to the patient – If poor skin quality or lots of bony prominences, they will need to be turned
more often!
– Offloading• Occiput, heels, elbows
– Wear schedules for splints, braces– Frequent skin checks!!!!– Caution with different skin tones
• The darker the skin tone, the harder it is to pick up little changes in the wound
Pressure Ulcer Prevention
• Positioning– 30 degree side turn– HOB <30 degrees– NO DONUTS!
• Mattress replacement– Group 1 (static)– Group 2 (dynamic)– Group 3 (fluidized)
Pressure Ulcer Prevention
• Positioning– In sitting – weight shift every 15 minutes• People naturally weight shift every 7-8 mins
– Cushions• But be careful…
– Avoid sitting >1 hour if existing ulcer
Pressure Ulcer Prevention
• Shear– Interplay of gravity and friction– Shearing forces stretch blood vessels, decreasing
amount of pressure needed to occlude them– Deep fascia levels over bony prominences– Leads to undermining
Pressure Ulcer Prevention
• Friction– Significant factor in pressure ulcer development– Works with shear to create wounds– Friction alone = blister– Friction + Shear = much bigger problem• Creates huge pressure ulcers.
– Draw sheets – but be careful• Pull the patient up too high, then raise the HOB to
lower them down…this is where the problem occurs!
Pressure Ulcer Prevention
• Moisture– Microclimate of the skin– Greatly alters resiliency of epidermis– Incontinence Associate Dermatitis (IAD) vs
Pressure Ulcer – IAD • Diaper rash• Skin protectant (zinc oxide, barrier cream)• Management of incontinence
Pressure Ulcer Prevention
• Nutrition– Malnutrition is a significant risk factor– Malnutrition is a significant factor in wound healing
(patient must have an adequate amount of protein for proper wound healing)
– Catabolic vs Anabolic– Tests for malnutrition
• Albumin: 20 day look at protein intake– Sensitive to hydration, kidney/liver function
• Pre-Albumin: short half life– Protein intake 48-72 hours, effected by kidney failure NOT hydration
• History