Deconstructing the Stalled Wound
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It appears that the patient response probably does not require a native rekindling of injury and inflammation.48
Aside from the obvious nutritional support that should be applied to all patients, deficiencies in arginine should be considered, which can impact wound healing related to nitrous oxide levels noted previously.51 Other modalities that may help to change wound dynamics include negative pressure wound therapy (NPWT) and hyperbaric oxygen therapy (HBOT).
As noted above, unrelieved pain has detrimental effects on wound healing. A rational approach to pain control should be adopted to try to prevent the situation of chronic pain. This involves starting treatments at a low dose and increasing slowly. It also involves differentiating local nociceptive pain from centrally controlled neuropathic pain. Tissue injury often results in nociceptive pain, in which persistent pain is felt by peripheral nerves in the skin in response to the release of mediators from the damaged tissue.18,29–31 Treatment of nociceptive pain involves a graded system of analgesics ranging from non-steroidal anti-inflammatory drugs (NSAIDS), acetaminophen weak opioids (eg, codeine) to strong opioids (eg, morphine).
Neuropathic pain is usually associated with a chronic pain state. It may occur following direct injuries to nerve fibers or where tissue injury results in dysfunctional nerves, sending incorrect signals to pain centers. This results in exaggerated, ongoing pain that necessitates treatment with centrally acting agents.29–31,52 Thus, the range of treatments may involve the sequential prescription of drugs—tricyclic antidepressants (amitriptyline, nortriptyline desipramine); anticonvulsants (gabapentin/pregabalin) ending with third tier options of Serotonin- norepinephrine reuptake inhibitor (SNRIs) antidepressants: duloxetine, venlafaxine and anticonvulsants: (carbamazepine, sodium valproate).29–31,52
Lastly, it is likely that a range of new diagnostic tools will assist with decision making in stalled wounds. Measurements of MMPs, biofilm identification, and nitrous oxide levels (in wound fluid) would all be of enormous value in aiding therapeutic choices in stalled wounds.
The difficulty in dealing with the stalled wound is that the biologic processes occurring at a molecular level are often compounded by physical factors relating to the management of the physical environment, (ie, a moist healing environment, control of wound exudate, and control of bacterial contamination). Significantly improving healing in stalled wounds may require going beyond the physical environment to address the biological mechanisms, although the physical factors cannot be ignored and take first place in the sequence of management.
Thus initial factors that need to be addressed as the primary response include host disease control, nutrition, banning smoking, examining concomitant drug therapy that may be influencing wound healing, adequate debridement, controlling edema, exercise program, off-loading, dressing selection, or change of dressing type.
In stalled wounds, an imbalance exists in the production of MMPs and their natural inhibitors (TIMPs). This has been shown to slow down the healing process.6–8,19 Prolonged MMP expression destroys growth factors, impairing the wound’s ability to heal.