Management of Chronic Difficult Wounds in the Long Term Care Setting

Janice Locke, MS, GNP, BCNurse Practitioner

Erickson Health Medical Group – Renaissance Gardens at Fox Run, Novi

Objectives

• At the completion of this session, participants will be able to:– Describe normal wound healing stages– Identify what constitutes a chronic wound– Describe which patients are at risk for developing

chronic wounds– Identify goals for treating chronic wounds– Describe treatment options for managing chronic

wounds– Identify methods for evaluating wound healing

Disclosure and Disclaimer

• I have no financial relationships with any wound product companies to disclose.

• Some “off-label” uses of products as well as some anecdotal evidence will be presented.

• Attempts will be made to use generic terms for wound care products however brand names will be discussed and opinions regarding specific products are my own.

Normal wound healing process

• Wound healing occurs as a cellular response to tissue injury and involves activation of several cell types.

• Acute wounds usually heal in an orderly and efficient manner.

• Restoration of skin integrity following an acute surgical wound in “normal” individuals is usually complete within 2-4 weeks.

Normal wound healing

• Hemostasis – immediate response to injury– Small vessels contract to provide some hemostasis– Platelets aggregate to trigger clotting cascade and

release essential growth factors and cytokines– Resulting fibrin matrix stabilizes the wound and

provides a provisional scaffold for the wound healing process

Normal wound healing

• Inflammation – Key components of this phase are increased vascular

permeability and cellular recruitment. – Cells are recruited that will

• Create structural proteins• Mediate vasodilation and cell migration• Cause vessel permeability resulting in accumulation of

plasma and cellular elements (edema)• Digest bacteria, foreign debris and necrotic tissue.

– This is usually the phase where chronic wounds become arrested

Normal wound healing

• Epithelialization– Proliferation and migration of epithelial cells until

individual cells are surrounded by cells of a similar type.

– Challenged by wounds that are not closed by primary intention.

– Presence of biofilm and senescent cells on wound edge or base also challenges this stage.

Normal wound healing

• Fibroplasia– Make the ground substance of the wound base– Produce contractile proteins that work to pull the

edges of the wound together.• Maturation– Disorganized collagen is degraded and reformed to

enhance the tensile strength of the wound.

Chronic wounds

• A chronic wound is one that does not heal within a “reasonable” time – usually 3 months.

• A “stalled wound” does not decrease in size by 30% in 3 weeks or by 50% in 4-5 weeks.

• A stalled wound isn’t necessarily going to be a chronic wound – may just need a “kick start” to resume healing process.

Chronic wounds

• Often stalled in the inflammatory phase– The presence of necrotic tissue, foreign material,

and bacteria result in the abnormal production of metallloproteases which alter the balance of inflammation and impair the function of the cytokines involved in initiation and progression of wound healing (growth factors).

Factors associated with non-healing wounds

• Intrinsic– Impaired circulation– Disease processes (inflammatory, metabolic,

malignancy)– Malnutrition– Age– Obesity– Infection

Factors associated with non-healing wounds

• Extrinsic– Mechanical forces (pressure, shear, friction)– Pharmacology– Foreign bodies

• Psychosocial– Patient/family preferences, beliefs, goals,

expectations– Caregiver/patient relationship

Factors associated with non-healing wounds

• Access/implementation– Availability of care– Financial resources– Ability to understand and perform care

Individual wound factors associated with delayed healing

• Lack of acute “trigger” for healing• Extended inflammatory phase • Presence of matrix metalloproteases (MMPs)• Low levels of tissue inhibitors of proteases

(TIMPs)• Deficiency of growth factor receptor sites and/or

growth factor destruction by MMPs• Inefficient/senecent cells• Biofilm

Who is at risk for non-healing wounds

• Patients with:– Vascular impairment– Impaired immune status– Metastatic cancer– Advanced age– Diabetes– Neuropathy/SCI– Malnutrition

Identify goals of treatment

• Consistent with patient/family values and lifestyle

• Cure/healing• Palliation/comfort

Treatment options - Systemic

• Illness management– Blood sugar control– Management of oxygenation

• Circulation management– Improve circulation to area • Offloading• Revascularization• Edema management

Treatment options

• Reduce/eliminate causative factors– Management of fecal and urinary incontinence• Use of fecal bags/condom catheters or indwelling

catheters for short periods of time.

– Pressure redistribution/reduction– Control friction/shear

Treatment - Nutrition

• Complex issue – lots of conflicting data and lack of strong (level A and B evidence) to support specific recommendations for supplementation

• Albumin, Total Protein, Total Lymphocyte Count, Pre- albumin, Transferrin levels.

Treatment - Nutrition

• Protein requirements– Healthy adult = 0.8gm protein/Kg/24 hours– 1.5-2.1 gm/Kg or more could be required

depending on individual metabolic and clinical condition

• Micronutrients– Zinc, Copper, Iron, Vitamin A, Vitamin C, Vitamin E,

Arginine, Glutamine• Consult RD

Infection

• Cultures – – Swab cultures most frequently used – they reflect the

surface colonization rather than infection. AHQR Guideline recommends against using swab cultures to define microbiology of a pressure ulcer.

– For infection control practices, a swab culture may be useful in identifying patients colonized with MRSA or other resistant bacteria.

– Blood culture or deep tissue biopsy culture is more clinically significant.

– Culturing deep tissue specimens from a surgically cleaned and debrided ulcer is the gold standard for wound culture.

Colonization vs Infection

• Both can delay/impair healing• Superficial infection is localized without

systemic signs, non-healing ulcer– Local wound care• Debridement of necrotic tissue• Moist wound dressing• Nutritional support and pressure reduction

– Trial of topical antibiotic to reduce local bacterial counts

Topical antimicrobial agents

• Silver sulfadiazine 1% cream• Combination antibiotic ointments• Silver-containing dressings • Avoid cytotoxic agents – Hydrogen peroxide– Povidone-iodine

• AHQR recommends 2 week trial of topical abx for clean wounds that fail to heal after 2-4 weeks of optimal care.

Deep infection

• Cellulitis – patients with neuropathy may not have pain. Leukocytosis and fever may or may not be present.

• Osteomyelitis – has been reported in 17-34% of patients

• Bacteremia• Base treatment on bacterial cultures

whenever possible

Local Care of the wound

• TIME• T = tissue (nonviable/deficient). – Debridement – episodic or continuous

• I = Infection or Inflammation– Topical and/or systemic antibiotics

• M = moisture imbalance– Apply moisture balancing dressings

• E = edge– Evaluate and correct impediments to epithelial migration

Cleansing

• pH balanced cleansers• Normal saline• Soap and water• Psi

Debridement

• Enzymatic• Sharp/surgical• Mechanical• Biologic

Debridement

Post-debridement

Debridement

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Moisture control

• Maintaining appropriate amount of moisture in wound bed is critical.– too moist = maceration/denuding, increased

breakdown• Hydrofibers• Calcium alginates• Foams• Combination products

Moisture control

• Too dry = dessication. Dry wounds lack wound fluids that provide the tissue growth factors to facilitate reepithelialization– Saline moistened gauze– Transparent films– Hydrocolloids– Hydrogels

Moisture control

Edges

• Examine edges of the wound• Epibole = the upper edges of the epidermis

roll to envelop the basement membrane or lower edges of the epidermis so that epithelial migration does not occur at wound edges.

• The edges curl under and epithelial migration stops.

Epibole

Topical treatments

• Dressings– Films– Foams– Hydrocolloids– Hydrogels– Hydrofibers– Composites

• Other topicals– Collagen Matrix– Growth factor– Xenaderm– Barrier creams– Silver products– Honey

Topical Treatments

• Film dressings – – will not manage excess moisture. Avoid using if

there is any drainage from the wound.– Do use if the wound is too dry.– Can combine with Santyl ointment to help soften

eschar– Also, can apply over eschar that has been

crosshatched.

Use of film dressing for autolytic debridement

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Foams and Hydrofibers

• Use with wounds that are more heavily exudating to help with management of wound fluid.

Hydrogels and Hydrocolloids

• Useful in promoting autolytic debridement and adding moisture to a wound

The image above is a copyrighted product of AAWC (www.aawconline.org) and has been reproduced with permission.

Pain Control in chronic wounds

• Two types of pain associated with open wounds:– Nociceptive pain from the tissue damage creating

the wound– Neuropathic pain from damaged peripheral nerves

at the site of the wound

Pain assessment

• The “usual” pain assessment will help determine the most appropriate treatment– Location– Timing– Severity– Aggravating/alleviating factors– Quality

Topical treatment of pain

• Dressing choice – avoid dressings that adhere to the wound bed and in essence do mechanical debridement with every dressing change a cause pain.– Protect skin surrounding the wound– Premedicate with systemic pain med prior to

dressing changes

Topical Treatments for pain

• Topical medication prior to debridement– EMLA (Eutetic Mixture of Local Anesthetics, 2.5%

lidocaine and 2.5% prilocaine, AstraZeneca, Wilmington, Del)

– 2% Lidocaine gel

Topical treatments for pain

• Topical opioids:– Morphine in a water-based gel– Methadone in an inert wound powder– The usual concentration in the studies is 1%

concentration of the opioid.– Use of powder or gel depends on the condition of

the wound.• Foam/Ibuprofen combination dressings.

Other treatment modalities

• NPWT• Hyperbaric Oxygen treatments• Compression• E stimulation• Ultrasound• Contact casting/offloading• Maggot therapy

The above images are copyrighted products of AAWC (www.aawconline.org) and are reproduced with permission.

Complementary, alternative and integrative therapy

• Accupuncture• Yoga/meditation• Biofeedback• Guided imagery• Massage• Therapeutic touch

• Herbs/dietary supplements

• Aroma therapy• Exercise• Emotional health/stress

management• Spiritual health

Managing the hard to heal wound

• Assessment– Missed diagnosis?– Cofactors contributing to the lack of healing• Wound factors

– Edges– Base – Biofilm– Local treatment – appropriate choice, being done

appropriately?

Managing hard to heal wounds

• Patient factors– Cooperating/participating in care? (“compliant”)– Illness progression– Mental health/social/spiritual

• Establish goals for care– Healing– Maintenance/palliation– Symptom control

Treatment of hard to heal wounds

• Address etiology and cofactors affecting healing based on goals of treatment– Debride/cauterize edges of wound if epibole

present– Treat hypergranulation/exuberant granulation– Treat/manage biofilm in wound bed– Treat/manage local and systemic infection– Treat/manage systemic illness as able.

Hypergranulation

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Managing local infection/biofilm

• Topical agents– Silver sulfadiazine– Topical antibiotics– Topical silver – hydrofiber, gels– Flagyl 500mg tab crushed, mixed in Santyl

ointment and applied daily to twice daily for 7 days *

* Note: this is an “off label use” of Flagyl. Works well in wounds with foul odor indicating high local bacterial count in wound bed

Diphenyl hydantoin sodium (phenytoin)

• Capacity to accelerate ulcer healing was reported over 40 years ago and has been used in many different kinds of wounds.

• Possible mechanisms of action:– Decrease in serum corticosteriod– Acceleration of assembly and presence of collagen

and fibrin in the ulcer area – Stimulation of alkaline phosphatase secretion

Other treatment options under study

• Oral Pentoxifylline along with compression to treating venous ulcers

• Effects of stress response (epinepherine) and the impact on wound healing = A new use for Beta blocker therapy?

Assess for healing

• Pressure Ulcer Scale for Healing (PUSH)• Pressure Sore Status Tool (PSST)• Sessing Scale• Wound Healing Scale.

Pressure Ulcer Scale for Healing (PUSH)

• Length x Width (in cm2) = score of 0-10 (0 cm2 - >24 cm2)

• Exudate amount = score of 0-3 (none, light, moderate, heavy)

• Tissue type = score of 0-4 (closed, epithelial tissue, granulation tissue, slough, necrotic tissue)

• Total the 3 sub-scores. If the total score goes down over time, the wound is healing.

Wound still not healing?

• Reassess goals of care• Change the local treatment• Refer to wound care clinic, vascular surgeon,

infectious disease specialist

QUESTIONS?