ALACIA BIGHAM, MD ASSISTANT PROFESSOR OF INTERNAL … Care_Bigham.pdf · CONTROL INFECTION /...
Transcript of ALACIA BIGHAM, MD ASSISTANT PROFESSOR OF INTERNAL … Care_Bigham.pdf · CONTROL INFECTION /...
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ALACIA BIGHAM, MD ASSISTANT PROFESSOR OF INTERNAL MEDICINE ASSISTANT PROFESSOR OF INTERNAL MEDICINE
UNIVERSITY OF KENTUCKY
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COMMERCIAL FACULTYCOMMERCIAL FACULTY DISCLOSURE
NONE
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OBJECTIVES LIST THE BASIC PRINCIPLES OF WOUND HEALING REVIEW THE TYPES OF WOUNDS TYPICALLY ENCOUNTERED IN PRIMARY CAREENCOUNTERED IN PRIMARY CARE
LEARN TO INITIATE A BASIC TREATMENT PLAN BASED ON WOUND TYPEBASED ON WOUND TYPE
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OBJECTIVESR W W S AG G G D S OR REVIEW THE NEW STAGING GUIDELINES FOR PRESSURE ULCERS
LEARNWHEN AND WHERE TO REFER PATIENTS LEARNWHEN AND WHERE TO REFER PATIENTS FOR ADDITIONAL THERAPY
REVIEW ADVANCED WOUND THERAPIESREVIEW ADVANCED WOUND THERAPIES
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EPIDERMISTHIN , AVASCULAR, PROTECTIVE OUTER LAYER
BASAL LAYER CONSISTS OF DIVIDING CELLS OF DIVIDING CELLS THAT REPLACE THE DESQUAMATED CELLS
REGENERATES EVERY 4 6 ‐REGENERATES EVERY 4‐6 WEEKS
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DERMIS PROVIDES STRENGTH, SUPPORT BLOOD AND OXYGEN TO THE SKIN
CONTAINS BLOOD VESSELS, HAIR FOLLICLES, FOLLICLES, LYMPHATIC'S, SEBACEOUS GLANDS AND SWEAT GLANDS;AND SWEAT GLANDS;
CONTAINS FIBROBLASTS, COLLAGEN, ELASTIC FIBERFIBER
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ETIOLOGY OF CHRONIC WOUNDS WHEN THERE IS AN INTERRUPTION OF THE EPIDERMIS AND/OR DERMIS THERE IS POTENTIAL FOR CHRONICITY THIS IS PARTICULARLY TRUE IF FOR CHRONICITY. THIS IS PARTICULARLY TRUE IF THERE IS CIRCULATORY COMPROMISE, NEUROLOGIC COMPROMISE, OR UNCONTROLLED ,MOISTURE, PRESSURE, OR SWELLING.
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BASICS OF WOUND CARE ASSURE ADEQUATE BLOOD SUPPLY ASSURE ADEQUATE NUTRITION KEEP WOUND BED CLEAN AND MOIST (EXCEPT ARTERIAL OR HEEL ULCERS)CONTROL SWELLING CONTROL SWELLING
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BASICS OF WOUND CARE
CONTROL INFECTION / BIO‐BURDEN GET RID OF DEAD TISSUE (EXCEPT DRY HEEL WOUNDS)AVOID HYPERGLYCEMIA AVOID HYPERGLYCEMIA
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BASICS OF WOUND CARE AVOID FRICTION/SHEAR AVOID EXCESSIVE MOISTURE/PROTECT PERIWOUNDPERIWOUND
RULE OUT OSTEOMYELITIS CHOOSE DRESSING BASED ON WOUND CHOOSE DRESSING BASED ON WOUND TYPE/CHARACTERISTICS
CONTROL PAIN CONTROL PAIN
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ADEQUATE BLOOD SUPPLY CHECK PULSE, COLOR, TEMPERATURE DISTAL TO WOUND ON EXTREMITIES;
IF PULSES ARE NOT PRESENT TO PALPATION OR ARE ONLY PRESENT TO DOPPLER OBTAIN ABI AND ARE ONLY PRESENT TO DOPPLER OBTAIN ABI AND AVOID COMPRESSION THAT IS NOT REMOVED AT LEAST DAILY.
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ADEQUATE BLOOD SUPPLY IF ABI IS LESS THAN 0.6 THE WOUND WILL NOT HEAL WITHOUT INTERVENTION
IF ABI IS 0.6 TO 1.0 WOUND WILL HEAL SLOWLY—CAN TAKE MONTHSCAN TAKE MONTHS.
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WOUND HEALING IS DELAYED OR PREVENTED IN THE PRESENCE OF CONTAMINATED OR DEVITALIZED TISSUEDEVITALIZED TISSUE
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CONTROL INFECTION/BIOBURDEN RULE OUT INFECTION WITH TISSUE CULTURE (NOT SWAB)CONTROL BACTERIAL BURDEN WITH TOPICAL CONTROL BACTERIAL BURDEN WITH TOPICAL
TARGET ORAL ANTIBIOTIC TO TISSUE CULTURE
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CONTROL INFECTION/BIOBURDEN EMPIRIC ORAL THERAPY (AWAITING CULTURE RESULTS) IF WOUND LOOKS INFECTED
THINK MRSA THINK MRSA
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TOPICAL CARE SILVER DRESSINGS ( MOST COMMON) THE ANTISEPTICS
ACETIC ACID 0.25% DAIKENS BETADINE PAINTBETADINE PAINT SULFAMYOLON SOLUTION
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TOPICAL CARETOPICAL CARE
SILVER DRESSINGANTIMICROBIAL BARRIER; ANTIMICROBIAL BARRIER;
BROAD SPECTRUM FOR TOPICAL INFECTIONS (INCLUDING MRSA, AND VRE AND YEAST)
RELEASES SILVER IONS INTO THE WOUND
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TOPICAL CAREMAY RELEASE AT A STEADY STATE FOR EXTENDED PERIODS ( SOME UP TO 7 DAYS)
CONTRAINDICATED IN SILVER ALLERGYCO C S G MANY FORMS ( ALGINATES, FOAMS, POWDER, HYDROGELS, FILMS, HYDROFIBERS, CREAMS
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DEBRIDEMENT
1. AUTOLYTIC2. ENZYMATIC3. MECHANICAL4. SHARP5. LARVAL
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DEBRIDEMENT DEBRIDEMENT IS THE ENZYMATIC OR SHARP DISSECTION PROCESS TO REMOVE TIGHTLY ADHERED NECROTIC MATERIALADHERED NECROTIC MATERIAL
GOAL: MAXIMIZE WOUND CLEANLINESS WHILE GOAL: MAXIMIZE WOUND CLEANLINESS WHILE MINIMIZING TISSUE TRAUMA
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DEBRIDEMENTENZYMATIC DEBRIDEMENT DESTROY NECROTIC TISSUE AND EXUDATES; DISSOLVE DENATURED COLLAGEN CAN BE USED WITH OTHER FORMS OF DEBRIDEMENTDEBRIDEMENT
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DEBRIDEMENTENZYMATIC DEBRIDEMENT1. COLLAGENASE 2. PAPAIN PRODUCTS‐NOT FDA APPROVED
BUT HAVE BEEN COMMONLY USED (EXP: ACUZYME ETHERZYME PANAFIL )(EXP: ACUZYME, ETHERZYME, PANAFIL )
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DEBRIDEMENT TOOLS USED IN SHARP DEBRIDEMENT:
SCALPEL, FORCEPS, SCISSORS, TISSUE NIPPERS, CURETTESCURETTES
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DEBRIDEMENTMECHANICAL DEBRIDEMENT:
PULSE LAVAGEWHIRLPOOLWET TO DRY DRESSING
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DEBRIDEMENTMECHANICAL: PULSE LAVAGE QUICK REMOVAL OF NECROTIC TISSUE REMOVES FOREIGN DEBRIS DECREASES BIOBURDEN SITE SPECIFIC LESS RISK OF MACERATION CAN BE USED WITH ALL TYPES OF WOUNDS
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DEBRIDEMENT MECHANICAL: WHIRLPOOL
DONE BY PHYSICAL THERAPY DEPARTMENTS USE IN WOUNDS WITH >50 PERCENT NECROTIC TISSUE AND ONLY UNTIL WOUND IS CLEAN
DAMAGES HEALTHY TISSUE AND CAUSES TISSUE DAMAGES HEALTHY TISSUE AND CAUSES TISSUE MACERATION
REMOVES FOREIGN CONTAMINANTS, ODOR, LOOSELY ADHERED SLOUGH OR EXUDATES
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DEBRIDEMENT
MECHANICAL: WET TO DRY DRESSINGS NON‐SELECTIVE FULL THICKNESS WOUNDS ONLYS O O S % C O C SHOULD ONLY BE USED IF >70% NECROTIC
SHOULD NOT BE USED IN INFECTED WOUNDS OR WITH EXPOSED TENDONWOUNDS OR WITH EXPOSED TENDON
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DEBRIDEMENT PROBLEMS WITH WET TO DRY PROBLEMS WITH WET‐TO‐DRY
TRAUMATIZES HEALTHY TISSUE BLEEDING IS COMMON BLEEDING IS COMMON PAINFUL, PAINFUL, PAINFUL!!!!! DOES NOTHING TO PROMOTE HEALING
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DEBRIDEMENTMEDICINAL MAGGOTS
‐‐USED OUT WEST, EXPENSIVE AND NOT FDA APPROVED IN HUMANSAPPROVED IN HUMANS
‐‐THE LARVA ARE STERILE AND MUST BE USED WITHIN 24 HOURS AND LEAVE IN PLACE USED WITHIN 24 HOURS AND LEAVE IN PLACE FOR 48 HOURS;
‐‐THEY REMOVE NECROTIC TISSUE;THEY REMOVE NECROTIC TISSUE;
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ASSURE ADEQUATE NUTRITION? STABLE AND ADEQUATE WEIGHT? NORMAL ALBUMIN, PRE‐ALBUMIN? ZINC LEVEL—PARTICULARLY IN THE ELDERLY;? NORMAL HGB
PROTEIN SUPPLEMENTS ARE OFTEN RECOMMENDED UP TO TWICE DAILY RECOMMENDED UP TO TWICE DAILY
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KEEP IT CLEAN WOUNDS ARE CLEANED WITH NORMAL SALINE UNIVERSAL PRECAUTIONS PRODUCTS ARE STERILE BUT CLEAN GLOVES
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OPTIMIZING THE MOIST WOUNDOPTIMIZING THE MOIST WOUND HEALING ENVIRONMENT
WOUNDS THAT ARE TOO DRY PRODUCE FIBRIN
WOUNDS THAT ARE TOO MOIST HYPER GRANULATEGRANULATE
PERIWOUNDS THAT ARE TOO MOIST BECOME MACERATEDMACERATED
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OPTIMIZE THE MOIST WOUNDOPTIMIZE THE MOIST WOUND HEALING ENVIRONMENT IF THE WOUND IS DRY: ADD MOISTURE
(HYDROGELS, SALINE MOIST GAUZE OVER PRODUCT)PRODUCT)
IF THE WOUND IS TOO MOIST : ABSORB THE DRAINAGEDRAINAGE (ALGINATES, HYDROFIBERS, FOAMS, ABSORPTIVE DRESSINGS)
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OPTIMIZE THE MOIST WOUNDOPTIMIZE THE MOIST WOUND HEALING ENVIRONMENT PROTECT THE WOUND MARGIN/PERIWOUND
USE SKIN PREP TO HELP CONTROL MECHANICAL AND CHEMICAL INJURYAND CHEMICAL INJURY
USE MOISTURE BARRIERS WHEN NEEDED USE MOISTURE BARRIERS WHEN NEEDED ZINC OXIDE, DIMETHICONE, PETROLATUM DRESSING BARRIERS WHEN NEEDED
FILMS, HYDROCOLLOIDS, NEGATIVE PRESSURE WOUND THERAPY—WOUND VAC
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PREVENT SWELLING TISSUE SWELLING CAUSES STRESS/STRAIN ON THE WOUNDS AND DECREASES THE CONCENTRATION OF HEALING FACTORS CONCENTRATION OF HEALING FACTORS
COMPRESSION AND ELEVATION ARE THE KEY DIURETICS ARE NOT A PART OF WOUND DIURETICS ARE NOT A PART OF WOUND THERAPY
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TYPES OF COMPRESSION SUREPRESS 30‐40 mmHg ;
OFF AT NIGHT, STRONGER THAN AN ACEACE
PROFORE: 30‐40 mmHg; ON 4‐7 DAYS AND CANNOT GET WET
UNNA BOOT ON FOR 7 DAYS ( BASE OF TOES TO JUST BELOW KNEE)JUST BELOW KNEE)
CIRCAID MANY PIECESMANY PIECES
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TYPES OF COMPRESSION ACE WRAPS ARE ACE WRAPS ARE INAPPROPRIATE FOR COMPRESSION OF CHRONIC WOUNDS
COMPRESSION STOCKINGS WHEN WOUND IS HEALED
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AVOID FRICTION AND SHEAR AVOID FRICTION AND SHEAR WITH APPROPRIATE MATTRESSES/CUSHIONS AND BED SIZESIZE BARIATRIC PATIENTS NEED TO BE PUT ON BARIATRIC BEDS
LOW AIR LOSS MATTRESS FOR THOSE AT RISK;
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RELIEVE PRESSURE OFF LOAD FEET HEELS OFF LOAD FEET, HEELS TOES, ETC WITH BOOTS, HEEL LIFTS, ELEVATION ETC AS NEEDED;
KEEP PRESSURE OFF AFFECTED BONY AFFECTED BONY PROMINENCES AS MUCH AS POSSIBLE
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THINGS TO CONSIDER
DIABETES CONTROL
TOBACCO USEOSTEOMYELITIS
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PAIN CONTROL
TOPICAL ANALGESICS PRIOR TO DEBRIDEMENT LIDOCAINE DEBRIDEMENT: LIDOCAINE GEL, 4% LIQUID, HURRICANE SPRAY, EMLA, , ,
.
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PAIN CONTROLPAIN CONTROLANALGESIA IS IMPROVED WITH ANALGESIA IS IMPROVED WITH CONTROL OF EDEMA, INFECTION, TRAUMA AND MACERATION, REMOVAL OF NECROTIC TISSUE
ORAL ANALGESICS ARE OFTEN NECESSARYNECESSARY
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TYPES OF CHRONIC WOUNDS 1. MOISTURE RELATED WOUNDS 2. PRESSURE ULCERS 3. ARTERIAL ULCER 4. VENOUS ULCERS 5. MIXED ARTERIAL/VENOUS DISEASE 6. NEUROPATHIC ULCERS 7. SURGICAL WOUND COMPLICATIONS
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MOISTURE RELATED ULCERS 1. INTERTRIGO: BETWEEN 2 SKIN FOLDS
‐‐CONTROL MOISTURE
2. INCONTINENCE ASSOCIATED DERMATITIS CLEAN WITH ACIDIC CLEANING AGENTSCLEAN WITH ACIDIC CLEANING AGENTS USE PROTECTANTS
DIMETHICONE ( BREATHABLE, DOSE NOT CLOG PADS/BRIEFS)PADS/BRIEFS)
PETROLATUM ZINC OXIDE
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PRESSURE ULCERS
ISCHEMIA COMPRESSED
TISSUE BONE/DEVICEISCHEMIA
ANDCELL DEATH
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PRESSURE ULCERS STAGING IS FOR PRESSURE ULCERS, NOT OTHER TYPES OF ULCERS/WOUNDS
STAGE IS BASED ON MAXIMUM DEPTH
NEW STAGES PER THE NATIONAL PRESSURE ULCER ADVISORY COUNSEL IN 2007ULCER ADVISORY COUNSEL IN 2007
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STAGING OF PRESSURE ULCERS STAGE I STAGE II STAGE III STAGE IV DTI UNSTAGEABLE
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STAGE IDEFINITION INTACT DEFINITION: INTACT SKIN WITH AN NON‐BLANCHABLE AREA OF REDNESS USUALLY OVER A BONY PROMINENCE BONY PROMINENCE AS A RESULT OF PRESSURE OR PRESSURE IN PRESSURE IN COMBINATION WITH SHEAR AND/OR FRICTION
COPYRIGHT: NPUAP 2007
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STAGE IIPARTIAL THICKNESS PARTIAL THICKNESS LOSS OF DERMIS PRESENTING AS A SHALLOW OPEN ULCER WITH A RED WOUND BED, OU ,WITHOUT SLOUGH. MAY ALSO PRESENT AS AN INTACT OR OPEN AN INTACT OR OPEN RUPTURED SERUM FILLED BLISTER
COPYRIGHT: NPUAP 2007
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STAGE IIIFULL THICKNESS FULL THICKNESS TISSUE LOSS. SUBCUTANEOUS FAT MAY BE VISIBLE BUT BONE, TENDON MUSCLE TENDON, MUSCLE ARE NOT EXPOSED.
MAY HAVE SLOUTH MAY HAVE SLOUTH, UNDERMINING OR TUNNELING
COPYRIGHT NPUAP 2007
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STAGE IVEXTENDS INTO EXTENDS INTO MUSCLE AND/OR SUPPORTING STRUCTURES (FASCIA, TENDON, JOINT CAPSULE). JO C U )BONE OR TENDON IS EXPOSED OR DIRECTLY PALPABLE DIRECTLY PALPABLE MAKING OSTEOMYELITIS LIKELY TO OCCUR
COPYRIGHT NPUAP 2007
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DEEP TISSUE INJURYPURPLE OR MAROON,LOCALIZED AREA OF DISCOLORED, INTACT DISCOLORED, INTACT SKIN OR BLOOD FILLED BLISTER DUE TO DAMAGE OF TO DAMAGE OF UNDERLYING SOFT TISSUE FROM PRESSURE AND OR SHEAR
COPYRIGHT NPUAP 2007
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DEEP TISSUE INJURY PRECEDED BY TISSUE THAT IS PAINFUL, FIRM, MUSHY, BOGGY, WARMER OR COLDER THAN WARMER OR COLDER THAN ADJACENT TISSUE
MAY START AS A THIN BLISTER OVER A DARK WOUND BED THAT PROGRESSES RAPIDLY TO THAT PROGRESSES RAPIDLY TO ESCHAR
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DEEP TISSUE INJURY
OCCURS 48 HOURS AFTER PRECIPITATING EVENT PRECIPITATING EVENT (USUALLY A PERIOD OF CONFINEMENT))
WITHIN 48 HOURS OF PURPLE SKIN, BLISTER DEVELOPS ( STAGE II PRESSURE ULCER
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UNSTAGEABLEFULL THICKNESS FULL THICKNESS TISSUE LOSS IN WHICH ACTUAL DEPTH OF THE ULCER IS COMPLETELY COMPLETELY OBSCURED BY SLOUGH AND/OR ESCHARESCHAR.
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Pressure Ulcers
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Pressure Ulcers Elderly bed‐ridden nursing home patient
Assess prealbumin Assess prealbumin Norm 15‐25 Below 15‐malnourished Below 10‐doubtful will ever
heal‐also check c reactive protein
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Pressure Ulcers Eschar Do not remove or moisten unless coming moisten unless coming off around the edges
If you want it off‐sharp If you want it off sharp debridement is quickest
Can also use santyl ointment
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Arterial Disease No palpable PT or DP‐needs vascular consult Wounds usually distal on the extremity Very painful ABI Arteriogram
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Chronic WoundsCharacteristic Arterial Venous NeuropathicLocation Distal Gaiter or ankle Plantar
Pain Distal On contact Absent
Appearance ofWound bed
Necrotic Beefy red Pink
PhysicalAssessment
Pulses absentNails thickSki hi /thi
Edema+Foot sparedV dil ti
Foot deformities+Absent Achilles tendon reflexSkin shiny/thin
Hair absentVenous dilation tendon reflex
Stocking hypoesthesiaD dDecreased vibratory sense
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Arterial Disease Wounds usually necrotic Gangrene
dry do not apply dressing
Wet Wet medical emergency
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Arterial DiseaseMC 84yo wf with gradually enlarging l thulcer x 4 months‐
instructed to apply NeosporinNeosporin
ABI 0.54 Arteriogram with Arteriogram with Stent placement
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Arterial Disease Originally used santyl for debridement
Pain medsWhen derided used i d b iiodosorb ointment
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Arterial Disease Healed in 10 months of treatment
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Venous Insufficiency 44yo female with edema in LE, worked on horse farm‐foaling on horse farm foaling season
Gradually enlarging y g gulcer
Serial debridement Tissue Cx
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Venous Insufficiency Applied iodosorb ointment and unnabootunnaboot
Healed and re‐opened Applied xcell and Applied xcell and profore
When healed‐compression socks
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Venous Insufficiency 65yo female smoker with COPD
Serial debridements Serial debridements COLLAGENASE Surepress compressionSurepress compression Couldn’t tolerate unnaboots and profore
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Venous Insufficiency
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Venous InsufficiencyWhen clean, applied hydrogel and surepress
Pt also stopped smoking during this timetime
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Venous dermatitis Needs scales removed‐if really thick may use hi l l t lwhirlpool to clean Do not use whirlpool if ulcerationulceration
MOISTURIZER
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Neuropathic ulcers Diabetes Neuropathy unknown etiology Treat like a pressure ulcer Usually on feetOffl di h Offloading shoes CRAFTED OR PREFAB BOOTS/SHOES) Contact casting Contact casting
Moist wound healing‐control drainage Diabetes must be controlledDiabetes must be controlled
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Neuropathic ulcers Iodosorb ointment PromogranH d l fil Hydrogel‐curafil
Santyl Regranex Regranex Alginates
Sorbsan Aquacel ag
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Neuropathic Ulcers 46 yo para with ulcer for 3 mo
Used iodosorb Used iodosorb, debridement
Tests revealed DM IITests revealed DM II Dermagraft, promogran, offloading
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Neuropathic Ulcers 52yo wf para ulcer from splint for foot ddrop
Tissue cx‐s aureusA li d Applied promogran, d/c splint, promogran
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Neuropathic Ulcers Healed in 6 weeks Continue Circaid for swelling
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Charcot foot Fallen arch Usually diabeticMust relieve pressure Sometimes surgical intervention
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Mixed etiology Arterial/Venous Right abi‐0.3, left 0.7F / B Fem/pop Bypass
Aplied dermagraft® Iodosorb profore weekly Iodosorb,profore weekly Pletal 100 mg bid,plavix 75 mg daily
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Mixed etiology‐healed
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OsteomyelitisCommon cause of nonhealing in chronic woundsBone scans have potential false positivesMRICorrelate with sed rate, xray, bone cultureT di i ll d i h 6 8 k f IV Traditionally treated with 6‐8 weeks of IV VancomycinNew treatment option is Zyvox 600 mg pr for 6 8 New treatment option is Zyvox 600 mg pr for 6‐8 weeks
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Wound CharacteristicsPeriwound erythema If absent or blanches on digital pressure, is not i di ti f i f tiindicative of infection
Redness that does no blanch may be indicative of infection
Warm to touch? May only indicate inflammation
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Wound CharacteristicsDrainage, purulenceColor, odor, amount
Periwound edemaExtent in mm or cm around wound
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Wound CharacteristicsNecrotic woundWound bed has dark areas of dead tissue, usually with i d l t d i d dincreased purulent drainage and odor
Exposed tendon, boneGangreneGangrene
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Wound Characteristics• Measure longest part of wound for length not dependent on body positionM id h d f l h• Measure width at 90 deg from length
• Measure depth perpendicular to skinM l i • Measure tunnels, sinus tracts
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Dressing Categorieso Alginateso Foam dressingso Gauze dressingso Hydrocolloidso Hydrogelso Transparent films
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Calcium Alginate Absorb drainage Good for heavily exudative wounds Can be left on for one or more days Needs secondary dressing Made of seaweed
Sorbsan at the VA
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Foam Dressings Absorb drainage Can be left on for one or more days For moderate to heavily exudating wounds
Polymemil Mepilex
Biotaine
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Gauze Inexpensive Use wet to moist Do not use wet to dry Must be applied multiple times a day Can be used to pack wounds
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Hydrocolloids Provide autolytic debridement Can be used for protection Does not absorb drainage
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Hydrogel Used to moisten wounds Can be used with gauze in place of wet to moist d idressing
Inexpensive
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Transparent Films Can be left in place for several days Allows visualization of wound Can be used with calcium alginate for skin tears or blistersD b b Does not absorb
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Regranex®Recombinant human platelet‐derived growth factorI di t d f l t it di b ti d Indicated for lower extremity diabetic and venous stasis ulcersHgba1c controlledHgba1c controlledNon smokerEdema controlledEdema controlledNo infectionAlternate every 12 hours with moist dressingy g
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Iodosorb OintmentIodine CadaxemerOnly safe form of iodine for woundsU ith ti i th id ditiUse with caution in thyroid conditionsCan be changed every 1‐3 daysColor indicator when needs to be changedColor indicator when needs to be changedWill kill pseudomonas and MRSA
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Oasis ®
Porcine submucosal intestinal dressing FDA approved Must be re applied every 7‐9 days Needs secondary dressing
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Promogran® Collagen based matrix that provides new skin cells to grow on
Protects growth factors Protects growth factors Needs secondary dressing Indicated for diabetic, venous stasis, pressure ulcers, d cated o d abet c, ve ous stas s, p essu e u ce s,full and partial thickness ulcers
Covered under Medicare B The same product with silver is called “Prisma”
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COLLAGEN GELS, ALGINATES, SHEETS AND POWDERS ARE AVAILABLEDERIVED FROM BOVINE PORCINE AND AVIAN DERIVED FROM BOVINE , PORCINE , AND AVIAN SOURCE
IF MOIST CAN PROMOTE SOME AUTOLYTIC IF MOIST CAN PROMOTE SOME AUTOLYTIC DEBRIDEMENT
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COLLAGEN MAY ENHANCE THE DEPOSITION OF ORGANIZED COLLAGEN FIBERSMAY ENHANCE TISSUE STRENGTH MAY ENHANCE TISSUE STRENGTH
ATTRACTS GRANULOCYTES AND FIBROBLASTBIORESORBABLE BIORESORBABLE
HEMOSTATIC
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Vacuum Assisted Closure DeviceVacuum Assisted Closure Device (VAC) Must be left in place continuously with dressings changed every other day
Indicated for heavily draining wounds Indicated for heavily draining wounds. Can be painful if on intermittent Good closure rates.Good c osu e ates. Can be used on any wound that measurements total 3.0 cm (example 1x1x1cm)
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Skin substitutes Dermagraft® Apligraf®
Both indicated for venous or diabetic wounds Applied after thorough debridementU ith i Use with compression
Do not wash off
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Apligraf®
Week 2Before apligrafp g
Week 52
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Apligraf® DELIVERY OF CELLS (YOUNG FIBROBLASTS AND KERATINOCYTES )PRODUCTION OF NEW MATRIX MATERIAL PRODUCTION OF NEW MATRIX MATERIAL (FIBRONECTIN, VITRONECTIN, PROTEOGLYCANS) CYTOKINES AND GROWTH FACTORCYTOKINES AND GROWTH FACTOR
RECRUITMENT OF OTHER CELLS ( STEM CELLS) INDICATION: FOR VENOUS ULCER, DIABETIC INDICATION: FOR VENOUS ULCER, DIABETIC FOOT ULCERS/NEUROPATHIC ULCERS
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CONCLUSION WE TRY TO PROVIDE THE PROPER ENVIRONMENT FOR THE BODY TO HEAL ITSELFIDENTIFY THE ETIOLOGY OF THE WOUND IDENTIFY THE ETIOLOGY OF THE WOUND
KEEP IN MIND THE BASICS OF WOUND HEALINGDEVELOP E THE PLAN OF CARE BASED ON THE DEVELOP E THE PLAN OF CARE BASED ON THE WOUND TYPE AND CHARACTERISTICS
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THE END
REFERENCES: WOUND CARE ESSENTIALS CONFERENCE MANUAL 2008 WWW.NPUAP.ORG ETUFUGH,CN Phillips TJ. Venous Ulcers. Clinical Dermatology 2007 Jan‐Feb 25 (1): 121‐130 SiegreenMY, Kline RA. Arterial insufficiency and ulceration: diagnosis and treatment options.
Adv Skin Wound Care 2004 June; 17 pp 242 51 Adv Skin Wound Care 2004 June; 17 pp 242‐51 Broussard, cl. (2007) Dressing Decisions. In Krasner, D., Roedheaver, G, & Sibbald, G (Eds)
Chronic Wound care ( 4th edition HMP communications 249‐262