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Wound Care:
From then to now
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.
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
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
Where we’re going…

Traditional dressings:
• Gauze, lint and fiber
  products
• Hydrocolloids




                          Look how far we’ve come!!!
Wet to Dry Gauze: Why not?
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)
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
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
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
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
How should we select
     dressings?
                   Autolytic

      Fillers                  Primary


Hydrating                        Non-adhesive


                                Active
 Absorbing

                               Secondary
       Enzymatic
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
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
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
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
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
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
Films
   Benefits:
     Provide   a moist environment
     Enable    autolytic debridement
     Provide protection from extraneous
      forces (microbes, friction, shear,
      chemicals)
     High   MVTR
     Conformable
Films
   Indications:
     Minor  injuries (abrasions)
     Post-op dressing over sutures
     IV sites
   Contraindications:
     High exudate wounds
     Fragile skin
   Examples: Tegaderm, Opsite
Alginates/Hydrofibers

   Benefits:
     Provide   a moist environment
     High   absorptive capacity
     Conformable/cuttable   (rope or sheet
      form)
     Provide   hemostasis
     No   adherence to moist wound bed
Alginates/Hydrofibers

   Indications:
     Highly exuding wounds
     Infected wounds (change daily)

   Contraindications:
     Dry   wounds or wound with eschar
   Aquacel, Melgisorb, Seasorb, Kaltostat
Hydrogels

   Benefits:
     Promote    a moist environment
     Donate    moisture to dry wounds
     Aid in autolytic debridement
      (rehydrate/soften necrotic tissue)
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
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
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
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
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
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)
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.
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
Antiseptics
   Hydrogen peroxide
   Acetic acid
     Effective   against Pseudomonas aeruginosa
   Diguanides (Chlorhexidine)
   Sodium hypochlorite (Dakin’s)
     Notrecommended unless suitable are
      unavailable
   Povidone Iodine
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
Collagen

   Indications:
       Partial & full thickness wounds
       Minimal to moderate drainage
   Contraindications:
       Eschar covered
       Full thickness burns
       Sensitivity to contents
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.
Bioengineered Products

Processed Tissue
 Primatrix®       Acellular collagen dermis (fetal
                           bovine origin)



   Oasis®         Acellular bovine graft
                   (Bovine Small Intestinal
                   Submucosa)
   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
   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
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
Wound Care: From then to now
   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
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

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Wound Care: From then to now

  • 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
  • 5. Where we’re going… Traditional dressings: • Gauze, lint and fiber products • Hydrocolloids Look how far we’ve come!!!
  • 6. Wet to Dry Gauze: Why not?
  • 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
  • 22. Alginates/Hydrofibers  Indications:  Highly exuding wounds  Infected wounds (change daily)  Contraindications:  Dry wounds or wound with eschar  Aquacel, Melgisorb, Seasorb, Kaltostat
  • 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
  • 32. Antiseptics  Hydrogen peroxide  Acetic acid  Effective against Pseudomonas aeruginosa  Diguanides (Chlorhexidine)  Sodium hypochlorite (Dakin’s)  Notrecommended unless suitable are unavailable  Povidone Iodine
  • 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.
  • 36. Bioengineered Products Processed Tissue  Primatrix® Acellular collagen dermis (fetal bovine origin)  Oasis® Acellular bovine graft (Bovine Small Intestinal Submucosa)
  • 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

  1. Further confirmed by winters in the 80’s
  2. 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%
  3. 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%
  4. 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)
  5. 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.
  6. Probably more of an issue in home environment where infection control is not rigorously practiced
  7. Colwell et al
  8. 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)
  9. 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
  10. 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?
  11. NPUAP/EPUAP guidelines
  12. 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.
  13. 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!!
  14. 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
  15. p.88 NPUAP/EPUAP guidelines
  16. Supposed to stimulate healing Come in all form and need secodary- gels, pads, sheets, powder
  17. Typically non adhesive primary formulation of collagen selected is based on wound size, vol of exudate Dry minmal- gel with appropriate dressing applied