Facts and Myths about Wounds

Thomas M. Bozzuto, DO, FACEP, UHM, FFACHM, FUHM. FFAPWCAcMedical Director,

Phoebe Wound Care and Hyperbaric Center, Albany, GA

Past President, American College of Hyperbaric Medicine

Disclosure

• The speaker has no relevant financial interests to disclose

The Burden of Chronic Wounds• Affect 6.5 million people

• Medicare spending in 2014 was $35.3 billion• Infections = $16.7 billion

• Chronic ulcers = $9.4 billion

• Surgical wounds = $6.5 billion

Top 3

Armstrong DG, Wrobel J, Robbins JM: Are diabetic-related wounds and Amputations worse than cancer? Int Wound Journal, 2009; 4(4): 286-7

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25%

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5-Year Mortality

Distribution of Wound Types

Distribution of Wound Types

Perspective on the Global Epidemic of Diabetes:

2003 – 2025

Metabolic Syndrome Diabetes Type 2

Lets talk about facts first

• Diabetic foot ulcers

• A foot ulcer is the initial event in more than 85% of major amputations that are performed on people with diabetes.

• In the United States, every year about 73,000 amputations of the lower limb not related to trauma are performed on people with diabetes.

Diabetic foot ulcers

• Of non-traumatic amputations in the United States, 60% are performed on people with diabetes

• Throughout the world, it’s estimated that every 30 seconds one leg is amputated due to diabetes

Diabetic foot ulcers

• 10% of people with diabetes have a foot ulcer.

• The lifetime risk of developing a foot ulcer for someone with diabetes is 25%.

• Every year, about 1-4% of people with diabetes develop a new foot ulcer.

• Between 10-15% of diabetic foot ulcers do not heal

• Of diabetic foot ulcers that do not heal, 25% will require amputation.

Diabetic foot ulcers

• In one study, research showed that following an amputation, up to 50% of people with diabetes will die within 2 years.

• In the United States, the cost to care for diabetic foot ulcers is about $11 billion per year.

• Approximately 20% of hospital admissions in people with diabetes are due to foot ulcers.

• Waiting to be seen by a doctor for a diabetic foot ulcer for longer than 6 weeks can increase the likelihood that the ulcer will result in an amputation.

• The risk for amputation may be decreased by up to 75% if a team specializing in the care of diabetic foot ulcers is involved.

• Up to 50% of diabetic foot ulcer cases can be prevented with appropriate education focused on teaching people with diabetes how to care for their feet.

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“Usual Care”

Regranex

DermagraftApligraf

TCC

Efficacy of Various Treatments in Healing Diabetic

Ulcers

Diabetic foot ulcers

• An ulcer present for more than 30 days is more likely to become infected.

• Osteomyelitis, is seen in 15% of people with diabetic foot ulcers.

• About 20% of patients with symptoms from PAD have diabetes

Smoking

• Smokers are 16 times more likely than non-smokers to have PAD

• Smokers are more likely to have amputations

• Smokers are more likely to have proximal amputations

• Higher pack-years = more likely to have proximal amputation

• Neither the amputation level nor the amputation itself was enough motivation for the patients to participate in smoking cessation.

Anderson JJ, et al. A comparison of diabetic smokers and non-smokers who undergo lower extremity amputation: a retrospective review of 112 patients. Diabet Foot Ankle. 2012; 3: 10.3402/dfa.v3i0.19178

Neuropathic Testing

If the patient feels less than 7/10 points they have loss of protective sensation

True or False

• Neurontin (gabapentin) is the first line treatment for diabetic neuropathy

True or False

• Neurontin (gabapentin) is the first line treatment for diabetic neuropathy

• FALSE

• Gabapentin is NOT FDA approved for the treatment of diabetic neuropathy

• Which ones are?• pregabalin (Lyrica)

• duloxetine (Cymbalta)

Venous and Arterial Leg Ulcers

• Venous Leg Ulcers

• Open lesion between knee and ankle that occurs in the presence of venous disease

• Venous disease is the MOST COMMON cause of leg ulcers (60-80%)

• Arterial Leg Ulcers

• Can occur anywhere in lower extremity

• Account for 5-10% of leg ulcers

Arterial Ulcers

• Risk factors• Diabetes mellitus

• Foot deformity and callus formation resulting in focal areas of high pressure

• Poor footwear that inadequately protects against high pressure and shear

• Obesity

• Absence of protective sensation due to peripheral neuropathy

• Limited joint mobility

Venous Leg Ulcers -Scope of the Problem

• Comprises 70% of LE ulcers in the U.S.

• 500,000-1,000,000 people

• Over 40% report first ulcer by age 50

• 13% report first ulcer by age 30

• Recurrence rate – 72% at one year

• US annual healthcare expenditure $1.9-2.5 billion

• Each case > $40,000

• 2 million annual workdays lost

Venous Leg Ulcers -Scope of the Problem

• Most redness in VLUs are from stasis dermatitis, NOT cellulitis

• Antibiotics should not be given unless an ulcer is evident and infection is suspected.

• If an antibiotic IS prescribed, it should cover MRSA• TMP-SMX

• doxycycline

• Fluoroquinolones

• clindamycin

• AVOID• PCNs

• Cephalosporins

Scope of the Problem

• Median duration 9 months

• 20% have not healed in one year

• 66% had episodes of ulceration lasting 5 years

• 2-3% of total US healthcare budget

Treatment

• Underlying pathophysiology is failure of muscle pump

• If this is corrected, 93% of all VU’s will heal at a mean of 5.3 months (requires at least 80% compliance with wear)

• Physical modalities

• Exercise

• Compression

Treatment

• Key Points

• Compression is the mainstay of therapy

• Always precede compression with arterial evaluation of leg

• 40-50 mmHg is required

• Sustained compression is required

True or False

• THE DEEPER THE WOUND, THE GREATER THE PAIN

True or False

• OCEAN WATER WILL HELP CLEANSE AND HEAL THE WOUND

True or False

• LET A SCAB DEVELOP OVER A WOUND, BECAUSE SCABS ARE GOOD!

True or False

• ANTIBIOTICS SHOULD ALWAYS BE GIVEN FOR WOUNDS

• There is no evidence to support the routine use of antibiotics in the treatment of chronic wounds.

• 61% of chronic wound patients had received at least one antibiotic within a 6 month period

• Swab cultures are not effective in diagnosing wound infection

True or False

• Hydrogen peroxide is a fast way to cleanse a wound

• Alcohol is a sure way to disinfect a wound

• Betadine and peroxide help wound healing by reducing the bacteria in the wound bed.

• Dakin’s solution is a good disinfectant

BetadinePeroxideDakin’s

Hypochlorous acid

Toxicity Index for Common Wound Cleansers

Cleanser Primary Use Toxicity Index

Shur Clens Wound 10

BiolexSaf ClensCara Klens

WoundWoundWound

100

Ultra KlenzClinical CareUni WashIvory Soap

WoundWound

SkinSkin

1,000

Constant ClensDermal Wound CleanserPuri-clensHibiclensBetadine Surgical Scrub

WoundWoundWound

SkinSkin

10,000

Techni-Care ScrubBard Skin CleanserHollister Skin Cleanser

SkinSkinSkin

100,000

True or False

• Itching means the wound is healing.

• You should let a wound open to get some “air”. Studies have consistently proven

that a moist wound environment

rather than a dry one is best for wound healing.

True or False

• Frequent dressing changes with gauze dressings will reduce wound infections.

• Gauze dressings are an effective and cost-efficient way to promote wound healing. Wet to dry is the best.

Wet-to-DryFrom standard to sub-standard

• A gauze dressing does little to impede fluid evaporation and allows for a loss of skin temperature, resulting in impaired healing

• Wet-to-dry is NOT selective and often removes healthy tissues

• Infection rates are higher

• Frequency required for change is not financially feasible

• Removing a dried dressing disperses a significant number of bacteria

• When the dressing dries out, the gauze becomes hypertonic –drawing fluid, blood and protein that may cause a barrier at the skin surface

Wet-to-DryFrom standard to sub-standard

• Gauze dressings present no physical barrier to entry of exogenous bacteria (bacteria can penetrate up to 64 layers of gauze

• Gauze is cheap, but the real cost of care needs to consider

• Labor cost of health care professional

• Indirect cost of ancillary supplies and services

• Cost of duration of care

Saline and Gauze Advanced Dressings

Dressing change frequency Daily Three times per week

Price of dressing $0.75 $10.00

Price of gloves $0.10 $0.10

Price of irrigation syringe $0.86 $0.86

Price of saline $1.12 $0.56

Price of tape $0.08 --

Cost per dressing change $2.91 $11.52

Materials cost per week $20.37 $34.56

Cost of one nursing visit $100.00 100.00

Cost of one week of visits $700.00 $300.00

Weekly labor costs $700.00 $300.00

Weekly labor cost + materials $720.37 $334.56

Amount of progress after 4 weeks

Percent wound reduction 50% 100%

Cost for 4 weeks of care $2,881.48 $1,338.24

Supply cost per 1% reduction (with patient doing self-care)

$1.63 $1.38

Wet-to Dry

• Saline and gauze are essentially a “one size fits all”

• There are many advanced dressings that are specific to certain types of wounds

• Knowledge of advanced wound dressings is not common in health care providers

• Advanced dressings may be incorrectly perceived as more expensive when only considering dressing cost

True or False

• The use of a doughnut cushion can help relieve pressure and heal pressure ulcers faster

• Most medical supply stores unfortunately still sell doughnut-type cushions for the treatment of pressure sores. However, they have not been found to help and can often lead to worsening of the pressure sore. Experts repeatedly advise against the use of doughnuts for the prevention and/or treatment of pressure wounds.

True or False

• Patients with venous insufficiency should keep their legs elevated as much as possible

Action of the Musculovenous Pump in Lowering Venous Pressure in the Leg

Relationship between Opioid Treatment and Rate of Healing in Chronic Wounds

• After controlling for co-morbidities and pain score, opioid exposure was associated with delayed wound healing

• Opioid exposure may impact keratinocyte biology and wound healing

• Opioid exposure in the post-op period was associated with wound dehiscence

• Opioid exposure may impact ultimate wound healing and increase time to healing

Why?• There are functionally active μ-opiate receptors on human

keratinocytes.

• Activation of these receptors by the μ-opiate agonist β-endorphin results upregulation of TGF-β and cytokeratin 16

• Shown that CK 16 response can be blocked by incubation together with the μ-opiate receptor antagonist naltrexone

Biligardi PL, Sumanovski LT, Büchner S, et al. Different Expression of μ-Opiate Receptor in Chronic and Acute Wounds and the Effect of β-Endorphin on Transforming Growth Factor β Type II Receptor and Cytokeratin 16 Expression. J Invest Derm. 120:1, Jan 2003. https://www.sciencedirect.com/science/article/pii/S0022202X15301287

Non-healing stratified by opiate exposure

Non healing stratified by opiate dose

Shanmugam VK, Couch KS, McNish S, Amdur RL. Relationship between Opioid Treatment and Rate of Healing in Chronic Wounds. Accepted Article doi:10.111/wrr.12496.

Advances in Skin & Wound Care – March 2017

Questions?