The document discusses the evolution of wound care theories and dressings from the 1940s to present. It reviews different types of wound debridement and various wound dressings including foams, films, alginates, hydrogels, and antimicrobials. Newer bioengineered skin substitutes are also examined that utilize growth factors, fibroblasts, and other components to accelerate healing. The key principles of wound care highlighted are maintaining a moist environment, removing dead tissue, managing infection, and selecting dressings appropriate for the wound type and patient needs.
2. Objectives
Discuss changes in theories of treatment in
wound care and implications to current
wound care practice.
Review good wound care practice and
implications as related to regulatory
changes.
Review types of wound debridement.
Discuss list indications and
contraindications for wound dressings.
3. Evolution of wound care
dressings…
1948: “Experiments with occlusive
dressings of a new plastic” by JP Bull
Discussed properties of a nylon derivative
film
Water vapor permeability made it suitable
for wound dressings
Also noted that the presence of a variety
of organisms was reduced or
disappeared
4. Evolution of wound care
dressings…
1963 (Hinman): “Effects of air exposure and
occlusion of experimental human skin wounds”
Useda sterile polyethylene film in artificially
made wounds on health adult male volunteers
Wounds were either occluded or allowed to heal
open to air
Results:Wounds healing under moist conditions
healed 50% faster than wounds open to air
Winters, CD Nature 1962
7. Disadvantages of wet to dry:
AHRQ Pressure Ulcer Guidelines
Wet-to-dry implies gauze is applied moist and removed
when dry.
Problems?
W/D gauze dressings as a form of mechanical debridement
are “non-selective” and,
…are rarely applied correctly
…may cause pain on removal
…may be more costly in terms of labor and supplies
…may cause maceration of skin surrounding the wound
…may release airborne organisms (cross contamination)
8. What else???
Moistening gauze that is adhered
Primary objective is lost
Gauze fibers can be left in wound
Moist wound healing is an industry standard:
known to improve healing rate
Winter’s research (1960’s)
• Moist wounds healed 2x as fast as wounds
allowed to dry
9. What else???
Inconsistency with application
Moisture levels vary with clinicians
Wet to moist may dry out and become wet to dry
Drying gauze has a cooling effect on tissue
Gauze: 77-81 degrees in wound bed
Films/foams: 91-95 degrees in wound bed
vasoconstriction, hypoxia, impairment of
phagocytic efficiency
Ovington, L Hanging Wet to Dry Out to Dry. Home HelathCare Nurse. 2001; 19(8), 477-483
10. There’s more?
Gauze dressings present no bacterial barrier
Lawrence (1994): 64 layers of dry gauze
allowed bacterial penetration
Hutchison (1989,1993): Moistened gauze
presents less barrier
Hutchison (1990): Review of 3047 wounds
showed the following infection rate:
• 2.6% for those dressed with moisture-
retentive dressings
• 7.1% for those dressed with gauze
Ovington, L Hanging Wet to Dry Out to Dry. Home HelathCare Nurse. 2001; 19(8), 477-483
11. Cost of Wound Care
Cost of dry gauze and ancillary supplies
$.47 per dressing change
Cost of hydrocolloid and ancillary
supplies
$6.15 per dressing change
Daily Cost (dressing cost + clinician cost)
Dry gauze $12.26
Hydrocolloid $3.55
12. How should we select
dressings?
Autolytic
Fillers Primary
Hydrating Non-adhesive
Active
Absorbing
Secondary
Enzymatic
13. Wound Management Priorities
Reduce or eliminate causative factors
Provide systemic support for healing
Apply appropriate topical therapy
Debride - remove necrotic tissue
Identify and eliminate infection
Fill dead space - lightly
Absorb excess exudate
Maintain moist wound surface
Open closed wound edges
Protect from trauma and pain
Insulate
14. Selecting Dressings
○ Keeps the wound bed moist
○ Prevents both maceration & desiccation
○ Offers good Moisture Vapor Transmission Rate
○ Minimizes peri-wound maceration
○ Protects the peri-wound skin
○ Eliminates dead space
○ Assures packing will stay in place
○ Minimizes pain
○ Assures stable environment
○ Provides thermal insulation
○ Always consider caregiver time
15. Ideal Primary Dressings
Need to be compatible with the wound:
May be hydrating or absorptive
Promote/maintain moist, healing environment
Provide for “breathability” (MVTR)
Provide insulation
Impermeable to microrganisms
minimize contamination from outside
Atraumatic to the wound/periwound area
Cost effective
16. Ideal Secondary Dressings
Need to be compatible with the wound:
Absorb exudate
Provide moisture to wound
Promote autolysis (debridement)
May be used in infected wounds
Be atraumatic to wound/periwound
Minimize adherence
Minimize movement
Minimize stripping
Cost effective
17. Foams
Benefits:
Bordered and un-bordered
Provide a moist environment
High absorbency
Conformable, may be cut to size
Thermal insulation
No residue
MVTR
No adherence to wound bed
18. Foams
Indications:
Superficial and full thickness wounds
Skin grafts, donor sites, burns, skin tears
Under compression for LE ulcers
Contraindications:
Dry wounds
Examples: Mepilex (Border), Allevyn (Plus
Adhesive), Polymem, Biatain
19. Films
Benefits:
Provide a moist environment
Enable autolytic debridement
Provide protection from extraneous
forces (microbes, friction, shear,
chemicals)
High MVTR
Conformable
20. Films
Indications:
Minor injuries (abrasions)
Post-op dressing over sutures
IV sites
Contraindications:
High exudate wounds
Fragile skin
Examples: Tegaderm, Opsite
21. Alginates/Hydrofibers
Benefits:
Provide a moist environment
High absorptive capacity
Conformable/cuttable (rope or sheet
form)
Provide hemostasis
No adherence to moist wound bed
23. Hydrogels
Benefits:
Promote a moist environment
Donate moisture to dry wounds
Aid in autolytic debridement
(rehydrate/soften necrotic tissue)
24. Hydrogels
Indications:
Drywounds
Wounds with slough wounds
Wounds with eschar
Over tissues and tendons to prevent drying
Contraindications:
High exudate wounds
Examples: Solosite, Woun’ Dress, SkinTegrity
25. Silicone
Chemically inert, adverse effects rare
Designed to be removed without
trauma or pain
Protect friable or newly healed tissue
from injury
Less trauma to periwound
Examples: Mepilex, Allevyn Gentle
26. Enzymatic Debriders
January 1, 2008 DESI drug changes
Medicare Part D: Reimbursement
Limitedfor products which contain
papain/urea/chlorophyllin complex
sodium
What does that mean??
Increased cost to the patient
27. Enzymatic Debriders
Alternatives
Uses chemicals to break-down and
digest necrotic tissue
Must know mechanism of action to be
effective
Examples: Hypertonic saline,
Enzymes, Honey
28. Antimicrobials
Bact er i oci dal :
Si l ver
Honey
Cadexom er i odi ne
Bact er i ost at i c:
M hyl ene Bl ue and Gent i an Vi ol et
et
Xer of or m
29. Silver
Antimicrobial action through (+) silver ion
Effective when in contact with wound fluid
Consider:
Kill rate AND sustained release rate
Testing Methods: Simulated wound fluid, saline
Delivery methods: foams, gels, alginates,
hydrofibers, creams
(SSD - approved for burns, only)
30. How does silver work?
Bacteria elimination: 3 ways
• Cell wall rupture
• Prevents respiration or nutrient processing
• Disturbs replication
Conclusion:
• Silver resistance unlikely silver secondary to 3 mechanisms
• No cases of bacterial resistance to silver in vivo.
31. Antiseptics
(+) Destroy or inhibit growth of
microorganisms
Efficacyon intact skin widely known and
accepted
(+) Resistance significantly less than
antibiotics
(-) In vitro cytotoxicity to cells of healing
AHRQ: Caution against use
NPUAP/EPUAP: Limited use to control
bacterial bioburden
33. Collagen
Usually Type I bovine or avian or type III
porcine collagen
Benefits:
May accelerate wound healing
Slight absorption
May be used with topical agents
Examples: Biostep, Fibracol, Puracol
34. Collagen
Indications:
Partial & full thickness wounds
Minimal to moderate drainage
Contraindications:
Eschar covered
Full thickness burns
Sensitivity to contents
35. Bioengineered Products
Growth Factor Preparations
Regranex® PDGF preparation in a
hydrogel
Single-Layered Tissue
Dermagraft® Human fibroblasts on
matrix mesh
Bilayered Tissue
Apligraf® Human fibroblasts and
keratinocytes in a
bovine collagen matrix.
37. Who makes it?
Organogenesis, Inc
What is it?
Dermal layer: human fibroblasts
from neonatal foreskin in a
bovine Type I collagen matrix
Epidermal layer: human
keratinocytes
What does it do?
Accelerates wound repair by
secreting important cells and
proteins (GF and cytokines)
Indications: Venous Leg Ulcers
and DM Foot Ulcers
38. Who makes it?
Advanced BioHealing, Inc
What is it?
Human fibroblast (neonatal foreskin) derived dermal
substitute
Contains fibroblasts, ECM and bioabsorbable scaffold
How does it work?
Assists in the restoration of the dermal bed
Fibroblasts proliferate to fill the interstices of the
scaffold and secrete human dermal collagen, matrix
proteins, GF, and cytokines to create a 3-dimensional
human dermal substitue
Indications: Full thickness DM > 6 wks duration without
tendon, muscle, joint capsule or bone exposure
39. Graft Jacket
Who makes it?
Wright Medical Technology, Inc
What is it?
Donated human skin
Removed the dermal and epidermal
cells but preserved bioactive
components (proteins, blood vessel
channels) and structure
What does it do?
A 3-dimensional scaffold to support the
body’s own natural repair process of
cellular repopulation and vascularization
Supports regeneration of host tissue
Indications: DM
41. Who makes it?
Healthpoint, Ltd
What is it?
Extracellular matrix composed of
porcine small intestinal submucosa
(SIS)
How does it work?
Provides a matrix for tissue repair
Placed onto wound, cells/nutrients from
adjacent tissues invade the matrix,
capillary growth ensues
New tissue formation by the body itself
Indications: Partial and full thickness
wounds, PrU, Venous ulcers, chronic
vascular ulcers, DM, traumatic wounds,
draining wounds, surgical wounds
42. In Conclusion
Determine wound cause and address
Establish plan of care that includes
dressings that will address principles
of moist wound healing
Assure pain is addressed
Through
pharmacologic and non-
pharmacologic methods
Editor's Notes
Further confirmed by winters in the 80’s
But not displaced by new moist wound dressings, one would think that for so many new choices for wound care that a variety would expect to find a variety of dressing products in use among wound care patients. Despite the benefits of new dressings gauze is still the most widely used in wound care. In late 90 13 home agencies in one geographic area gathered info for 1 week regarding the types of dressing used forr 1029 patients with 1638 classidied wounds-the majority were dry gauze 406, 3 rd most use sale moistened with (145) 2 nd no dressing at all252advanced moisture retentive dressings accounted for less than 25%
So let’s start with most clinicians consider the standard of care for wound care and work from there as look to other treqtment modaliteies.. Which is quaze.. In a study conducted in need updated from 1999But not displaced by new moist wound dressings, one would think that for so many new choices for wound care that a variety would expect to find a variety of dressing products in use among wound care patients. Despite the benefits of new dressings gauze is still the most widely used in wound care. In late 90 13 home agencies in one geographic area gathered info for 1 week regarding the types of dressing used forr 1029 patients with 1638 classidied wounds-the majority were dry gauze 406, 3 rd most use sale moistened with (145) 2 nd no dressing at all252advanced moisture retentive dressings accounted for less than 25%
Non-selective means that both non-viable and viable tissue may be removed There is now a general consensus in the wound community that wet-to-dry dressings are very problematic. As you can see, the AHRQ states that a wet-to-dry dressing implies that it is applied moist and removed when dry. This is very problematic for many reasons, not the lesat of which is that it is non-selective – no control over removal of healthy or necrotic tissue. Above information from reference (Lawrence/Lancet. 1992;339(8796):807) (Sussman/Bates-Jensen)
Drying gauze has a cooling effect on tissue Gauze: 77-81 degrees in wound bed Films/foams: 91-95 degrees in wound bed vasoconstriction and hypoxia, impairment of leukocyte mobility and phagocytic efficiencyIn an open wound with nothing to impede fluid evaporation, the tissue temperature has been measured at 21°C. A gauze dressing placed in the wound does little to impede fluid evaporation and tissue temperature measures 25°C to 27°C—still approximately 10° below normal tissue temperature (Thomas, 1990). All impede wound healing and increase susceptibility to infection Gauze dressings present no physical barrier to the entry of exogenous bacteria. In one dramatic in vitro study it was shown that bacteria were capable of penetrating up to 64 layers of dry gauze (Lawrence, 1994). Moistened gauze presents even less of a barrier to bacterial penetration.
Probably more of an issue in home environment where infection control is not rigorously practiced
Colwell et al
Appropriate topical therapy may only be successful after removal if causative factors (eg., pressure, shear, poor vascularity) and assurance of sufficient systemic support for wound healing. (Emory University - principles)
Regardless of the wound condition, these principles of wound management should always be taken into consideration. It is not possible for one dressing to satisfy all the varying conditions which will occur during the healing process. Choose a dressing that protects the peri-wound skin. What is "MVTR"? MVTR stands for "Moisture Vapor Transmission Rate", a measure of the passage of gaseous H 2 O through a barrier. It's also know as "WVTR", or "Water Vapor Transmission Rate". How is moisture resistance measured? Moisture resistance is measured in a special chamber where it is divided vertically by the substrate/barrier material. A dry atmosphere is in one chamber, and a moist atmosphere is in the other. A 24-hour test is run to see how much moisture passes through the substrate/barrier from the "wet" chamber to the "dry" chamber. Standard test procedures (TAPPI T-464, ASTM E96) can specify any one of five combinations of temperature and humidity in the "wet" chamber. The toughest conditions are 100°F / 95%RH (Relative Humidity). 35
When health care providers are seeking the “ideal dressing”, the following questions should be considered: - Does the dressing protect from secondary infection? - Does it provide a moist wound environment? - Does it provide thermal insulation? - Can it be removed without causing trauma to the skin? - Does the dressing remove/absorb drainage and debris? - Is it free from particulates and toxic products?
NPUAP/EPUAP guidelines
Chemical Debridement (Enzymatic) Process of debridement by the use of enzymes. The enzymes break down and digest necrotic tissue by interacting with proteins. • Recommended for moist necrotic tissue (slough) and hard necrosis. • If used on dry eschar, the eschar should be cross-hatched with a scapel and a moisture retentive dressing used (e.g. Film). • Specific to specific tissue such as elastin, fibrin, or denatured collagen; Therefore, a physicians order is required to specify which type. • May cause a transient redness and maceration to the surrounding skin.
Take home message: The amount of silver in a dressing does not make it more effective. The solubility of the compound (how well it can deliver Ag+) is what makes a product function best!!
1. Cell wall rupture When Ag+ binds to proteins in the cell wall, the wall might break and the contents of the call leak out, resulting in death of the bacterial cell. 2. Preventing “eating and breathing” Ag+ might also bind to bacterial enzymes, resulting in the inability of the bacterial cell to carry out processes necessary for respiration or to take in or process nutrients. 3. Disturbing replication Ag+ might also bind to bacterial cell DNA and interfere with cell division and the replication process
p.88 NPUAP/EPUAP guidelines
Supposed to stimulate healing Come in all form and need secodary- gels, pads, sheets, powder
Typically non adhesive primary formulation of collagen selected is based on wound size, vol of exudate Dry minmal- gel with appropriate dressing applied