Enzymatic Debridement Collagenase (Santyl) Digests necrotic collagen – Specific and selective for...

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


• 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


• Contraindications– Dry gangrene– Poor circulatory support• Not enough lysozomes to make the debridement work

but it won’t cause any harm.

– Infection


• Advantages– Non-invasive– Selective– Does not disrupt

healthy tissue– Easy: leave on 48-

72 hours, rinse wound with saline and apply another.

– Painless


• 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???)


• 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


• 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


• 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


• 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


• How it works:– http://www.youtube.com/watch?v=88XHwSty9jw

http://www.youtube.com/watch?v=88XHwSty9jw


• Indications– Any type of wound– Size minimum• 2.5cm in one direction

– Enough room to place a sponge


• Considerations– Cost– Carry around – Change 2-3x/week– Can Pt self fix?– Can be combines with some other products• Silver is most common

– Infection


• 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)


• How to apply– http://www.youtube.com/watch?v=ucHAM_ZElzs

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


• 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


• 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


• 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


• Alternatives– TCC-EZ• Making TCC easier?

– http://www.youtube.com/watch?v=YSJ_rojfmAA

http://www.youtube.com/watch?v=YSJ_rojfmAA


• 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


• 4 main causes of pressure ulcers– Pressure– Shear – Friction– Moisture


• Pressure– Intensity– Duration– Tissue tolerance: health of overall skin in relation

to the pressure it can tolerate• Have to do pressure relief!


• 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


• Positioning– 30 degree side turn– HOB <30 degrees– NO DONUTS!

• Mattress replacement– Group 1 (static)– Group 2 (dynamic)– Group 3 (fluidized)


• 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


• 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


• 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!


• 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


• 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

Enzymatic Debridement Collagenase (Santyl) Digests necrotic collagen – Specific and selective for...

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