Wound Bed Preparation: The Science Behind the Removal of Barriers to Healing [PART 1]
Abstract: Wound healing involves a well-orchestrated, complex process leading to repair of injured tissues. However, chronic wounds do not follow the normal pattern of repair. This is due to underlying physiological problems associated with their development, which unless corrected would continue to cause wound deterioration. The key to effective wound care lies in a combination of three approaches: treatment of underlying medical problems, assessment and treatment of local wound bed, and effective management of any patient-centered concerns. An essential component of this recommended approach is restoration of healthy granulation tissue in the wound bed. Wound bed preparation brings a number of existing procedures, including debridement, treatment of infection, and management of exudate levels, together into a systematic approach to help restore the chronic wound bed environment. The aim of wound bed preparation is to remove the barriers to healing and initiate the repair process. This review explores the scientific rationale behind this concept and examines how wound bed preparation offers healthcare professionals an improved paradigm for the treatment of chronic wounds. By implementing wound bed preparation, the formation of healthy granulation tissue will be optimized and the efficiency of biotechnological therapies improved, which would ultimately reduce the time to wound closure.
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Chronic Wounds: Factors Influencing Healing Within 3 Months and Nonhealing After 5?6 Months of Care
Chronic wounds affect approximately 2.5 million to 4.5 million people in the US and are particularly a problem for the elderly. Nonhealing or slow healing wounds represent a major health burden and drain on resources, contributing to substantial disability, morbidity, and costs. This study was conducted to identify factors that influence the healing of chronic wounds within 3 months of starting treatment, compared to factors influencing nonhealing wounds after 5 or 6 months of treatment. A retrospective review of medical records of subjects with chronic pressure, diabetic, or venous ulcers using a structured data collection form and protocol was conducted at 4 sites located in disperse geographic areas. The sample consisted of 400 subjects with at least 3 months of data. Demographic, case mix, wound characteristics, and treatment characteristics were analyzed. Consistent with the literature, wounds that were larger, deeper, infected, draining larger amounts of exudate, and/or covered with slough or eschar were significantly less likely to heal within 3 months and more likely not to heal after 5?6 months of treatment. Medicaid insurance coverage and being non-white were also associated with poorer healing. A lower percentage of antimicrobial dressings was associated with faster healing, while a lower percentage of moisture-management dressings was associated with nonhealing after 5?6 months. The analysis also showed that inappropriate management of wound exudate and necrotic tissue was associated with poorer healing outcomes. While the influence of insurance coverage and race on healing needs further exploration, healing rates could improve in certain centers through better adherence to evidence-based wound management recommendations.
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Debridement: Rationale and Therapeutic Options
Abstract: Debridement is commonly defined as the process of removing necrotic, devitalized tissue and foreign material from a wound. The presence of necrotic tissue within a wound may impair wound repair processes by stimulating inflammation and delaying granulation and epithelialization. However, the above definition of debridement may not tell the whole story. Debridement may additionally remove senescent cells from the wound bed and nonmigratory cells from the ulcer edge and also remove excessive or abnormal bacteria; all of which may allow for improved availability of growth factors. This supplement will review the rationale for debridement, existing clinical data supporting debridement, and the various debridement options available. The supplement was supported through an unrestricted education grant from Healthpoint Ltd., Ft. Worth, Texas.
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A Prospective, Randomized, Comparative Study of Collagenase and Papain-Urea for Pressure Ulcer Debridement
Abstract: Objective: To evaluate and compare the ability of two commercial chemical debridement ointments to effectively remove devitalized tissue and promote granulation in pressure ulcers requiring debridement. One of the test agents was an enzymatic formulation (collagenase) and the other a formulation of papain and urea. Design: This study was a prospective, randomized, parallel group, tri-center, open-label, clinical trial with a two-week screening period to stabilize the wound and an evaluation period of four weeks in duration. Setting: The patients who participated in the trial were nursing home residents in northern New Jersey. Participants: Twenty-eight patients were randomly assigned to ulcer treatment with either collagenase debriding ointment (n = 12) or papain-urea debriding ointment (n = 14). Two patients dropped out early due to unrelated treatment issues. Measurements: Wounds were treated once daily until complete debridement or four weeks. The major outcome of nonviable (necrotic) tissue reduction (determined by planimetry) was assessed weekly by intention to treat. The amount of nonviable tissue, degree of wound granulation, and overall wound response were evaluated weekly using a visual scale. Wound area measurements were performed by morphometric analysis of perimeter tracings. Results: The papain-urea debriding ointment was significantly more effective (p < 0.0167) than the collagenase ointment in reducing the amount of necrotic tissue at each of the three prospectively determined weekly evaluations. Development of granulation tissue in wounds treated with papain-urea was significantly enhanced as compared to wounds treated with collagenase. Epithelialization generally correlated with the development of a granulating wound bed as determined by visual assessment. However, the general increase in the amount of epithelial tissue associated with the papain-urea-treated wounds did not predict a significantly different rate of reduction in the actual wound area. Conclusion: This study evaluated th
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Debridement: Rationale and Therapeutic Options
Abstract: Debridement is commonly defined as the process of removing necrotic, devitalized tissue and foreign material from a wound. The presence of necrotic tissue within a wound may impair wound repair processes by stimulating inflammation and delaying granulation and epithelialization. However, the above definition of debridement may not tell the whole story. Debridement may additionally remove senescent cells from the wound bed and nonmigratory cells from the ulcer edge and also remove excessive or abnormal bacteria; all of which may allow for improved availability of growth factors. This supplement will review the rationale for debridement, existing clinical data supporting debridement, and the various debridement options available. The supplement was supported through an unrestricted education grant from Healthpoint Ltd., Ft. Worth, Texas.
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Clinical and Economic Impact of Hydrosurgical Debridement on Chronic Wounds
Abstract: The high-powered parallel waterjet is a new surgical debridement tool that precisely removes tissue using a high-energy water beam. In this retrospective study, 20 patients with chronic wounds who were operatively debrided with the high-powered parallel waterjet were compared with 14 chronic wound patients debrided with conventional instruments. The hydrosurgery patients required a mean of 1.14 surgeries to obtain a prepared wound bed compared to 2.0 surgeries for conventional patients. This improvement in patient outcomes resulted in approximate savings of $2,800 for the hospital, per patient, when using the waterjet. The introduction of this new surgical technology has changed the paradigm for surgical debridement of chronic wounds.
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Is Noncontact Normothermic Wound Therapy Cost Effective for the Treatment of Stages 3 and 4 Pressure Ulcers?
Abstract: Purpose: Chronic pressure ulcers are significant health problems for patients in long-term care facilities. The value of restoring quality of life following a pressure ulcer injury has attracted new treatments. The goal of this study was to examine the incremental cost effectiveness of noncontact normothermic wound therapy (NNWT) relative to the current standard of care for treatment of stages 3 and 4 pressure ulcers. Methods: A Markov cost-effectiveness computer simulation model with hypothetical patients was created. The base case involved a 72-year-old man living in a nursing home with a stage 3 ischial pressure ulcer. Standard care was assumed to include moisture-retentive dressings, a pressure-reducing surface, repositioning, and debridement. A secondary economic analysis of stage 4 pressure ulcers was completed. The main outcome measures were quality-adjusted life years (QALYs) and costs. Results: Randomized clinical trials have found that NNWT (n = 72 patients), in combination with the use of pressure-reducing surfaces and repositioning, decreases the surface area of stages 3 and 4 pressure ulcers by 2.5 fold (SD 59%) over standard care (n = 59 patients). A prospective, randomized trial found the eight-week healing rates for stage 3 ulcers are 71 percent with NNWT and 54 percent for standard care. At these healing rates, our modeling for stage 3 pressure ulcers found that for a 40-month time frame NNWT saves $6,630.00 (SE $98.00) and increases QALYs by 0.10 (SE 0.0005) life years as compared to standard care. For stage 4 pressure ulcers, NNWT saves $15,216.00 (SE $186.00) and increases QALYs by 0.14 (SE 0.001). Conclusions: NNWT in patients with stages 3 and 4 pressure ulcers is an economically attractive intervention. Additional well-controlled clinical trials are necessary to further define the role of NNWT in the care of chronic wounds. Disclosure: This study was funded in part by Augustine Medical Inc., Eden Prairie, Minnesota. The funding organization did not participate in the design, cond
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Wet-to-Dry Gauze Dressings: Fact and Fiction
Abstract: Background. The aims of this research were to identify what actually constitutes a wet-to-dry dressing, explain why it is used, and describe how specialist nurses interpret this technique. Method. A descriptive exploratory questionnaire was sent to a convenience sample of general surgeons in New Hampshire and Vermont. Nine wound, ostomy, and continence nurses were interviewed as key informants. Results. The research showed that wet-to-dry dressings and gauze are commonly prescribed for situations where there is little evidence to support their use, such as with open surgical wounds healing by secondary intention. It demonstrated that there is inconsistency among surgeons and specialist nurses on how the technique should be performed, particularly relating to whether the gauze should be dry or moist when removed. Although 75 percent of respondents had access to more sophisticated dressings, reasons for not using these dressings included conflict with traditional approaches to wound care, lack of education, and cost issues. Conclusion. These data suggests that a more professional multidisciplinary approach to wound care, which is firmly evidence based, needs to be developed.
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Efficacy of Polyurethane Foam Dressing in Debrided Diabetic Lower Limb Wounds
Abstract: Aim: The aim of this study was to assess whether polyurethane foam dressings are superior to conventional dressings for promoting early wound healing in debrided wounds of patients with diabetes. Methods: Patients with diabetes who underwent debridement for infections of the lower limb were included in this prospective study. Patients were randomly assigned to a study group and a control group. The study was conducted between January 1, 2005, and July 31, 2005. Foam with a size of 10 mm x 10 cm x 30 cm and Shore hardness of 10 was used for the study group. No topical antibiotics or desloughing ointments were used. Controls were dressed with conventional techniques using antibiotic and hydrocolloid ointments. Dressings were changed daily, and bedside debridement was performed when required. In both groups, the affected limb was strictly offloaded. All patients with wounds that had a surface area > 20 cm2 underwent split skin grafting (SSG). Duration of wound healing was calculated as the number of days from the date of first debridement to date of SSG. In those who did not require SSG, wound healing was calculated as the number of days from the date of the first debridement to the date the wound was detected as completely epithelized. Results: A total of 48 patients were studied, 24 in each group. The mean duration for wound healing was 22.5 ± 15.4 days in the foam group and 52.0 ± 22.7 days in the control group (P < 0.0001). Conclusion: There was a significant reduction in the time taken for wounds to heal when sterile, non-medicated polyurethane foam dressings were used compared to conventional dressings.
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Case Report: Implications for a Patient Diagnosed with Fournier?s Gangrene
Abstract: Purpose: Fournier?s gangrene (FG) is a soft-tissue infection of the perineum. The purpose of this case report was to illustrate the role of a physical therapist in treating the wounds of a patient diagnosed with FG, as such research is not currently found in the literature. Intervention: The patient received antibiotic therapy, fluid resuscitation, nutritional support, surgical debridements, physical therapy for wound care and functional mobility training, split-thickness skin grafting, and patient education. Outcomes: The patient recovered fully, despite comorbidities, complications, and patient noncompliance, which all delayed full closure. Conclusion: Patients diagnosed with FG may recover and return to their pre-morbid level of function if they receive care that is carefully coordinated and aggressively delivered by the members of their interdisciplinary teams.
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