Managing the Wound Environment

1
Managing the Wound Environment

• by
• Vince Lepak, MPH, PT
• 27 March, 2000

2
Wound Healing Delays (Sussman, 1998)

• Intrinsic
• Aging
• Chronic diseases
• Circulatory disease
• Malnutrition
• Neuropathy

• Extrinsic
• Medication
• Immune Suppression
• Irradiation
• Psychophysiologic
• Necrotic tissue
• Infection

• Inappropriate wound management
• Trauma
• Wound desiccation
• Inappropriate dressing choice
• Misuse of topical agents
• Inappropriate dressing application

3
Agency for Health Care Policy and Research (AHCPR)

• Public Law 101-239 (Omnibus Budget Reconciliation
  Act of 1989) to enhance the quality,
  appropriateness, and effectiveness of health care
  services and access to these services
• AHCPR carries out its mission by conducting and
  supporting general health services research,
  including medical effectiveness research,
  facilitating development of clinical practice
  guidelines, and disseminating research findings
  and guidelines to health care providers,
  policymakers, and the public.

4
AHCPRs Clinical Practice Guidelines for the
Treatment of Pressure Ulcers

• SOURCE(S)Bergstrom, N., Bennett, M. A.,
  Carlson, C. E., et al. (1994). Treatment of
  pressure ulcers. Clinical practice guideline, No.
  15. Rockville, MD U.S. Department of Health and
  Human Services, Public Health Service, Agency for
  Health Care Policy and Research. AHCPR
  Publication No. 95-0652.
• RELEASE DATE1994 Dec
• ONLINE
• GUIDELINES http//www.ahcpr.gov/clinic/

5
Guideline Development

• The Agency for Health Care Policy and Research
  (AHCPR) convened a 20 member multidisciplinary
  private-sector panel.
• The panel included physicians, nurses, an
  occupational therapist, a biomechanical engineer,
  and a consumer representative.
• They reviewed more 45,000 abstracts, evaluated
  approximately 1,700 papers, and cited 333
  references to support this guideline.

6
Ratings of available evidence supporting
guideline statements

• A Results of two or more randomized controlled
  clinical trials on pressure ulcers in humans
  provide support
• B Results of two or more controlled clinical
  trials on pressure ulcers in humans provide
  support, or when appropriate, results of two or
  more controlled trials in an animal model provide
  indirect support.
• C The rating requires one or more of the
  following (1) results of one controlled trail
  (2) results of at least two case
  series/descriptive studies on pressure ulcers in
  humans or (3) expert opinion.

7
Clinical Algorithms

• Management of Pressure Ulcers Overview
• Nutritional Assessment and Support
• Management of Tissue Loads
• Ulcer Care
• Managing Bacterial Colonization and Infection

8
Clinical Algorithm Ulcer Care (AHCPR, 1994)

• Ulcer Debridement
• Ulcer Cleansing
• Managing Bacterial Colonization and Infection
• Selection of Dressing

9
Step 1 Ulcer Debridement
(Adapted from Rinne, 1999)
10
AHCPR Guideline Debridement Strength of
Evidence C

• Remove devitalized tissue
• supports the growth of pathogens
• Debridement has not been studied in randomized
  trails for treating pressure ulcers
• Debridement choice is based on the patients
  condition and goals.
• advancing cellulitis and sepsis signifies an
  urgent need for sharp debridement

11
AHCPR Guideline Debridement Strength of
Evidence C (continued)

• Heel Ulcers
• dry escar without edema, erythema, fluctuance, or
  drainage do not need debridement. Monitor.
• if complications arise, debridement is mandatory
• Wet-to-dry dressings
• usually dry within 4-6 hours
• moistening prior to removal may partly defeat the
  debriding function
• non-selective

12
Step 2 Cleansing

• Cleanse initially and at each dressing change.
• Use minimal mechanical force
• Do not clean wounds with skin cleansers or
  antiseptic agents
• providone iodine, iodophor, Dakins solution,
  hydrogen peroxide, acetic acid
• Strength of evidence B
• Typically use normal saline with pressures
  between 4 to 15 psi
• Strength of evidence B
• Discontinue whirlpool when ulcer is clean

13
Commercial Cleansers

• Often contain surfactants (surface-active agents)
  to help loosen foreign bodies from the wounds
  surface.
• You can categorized them according to their
  chemical charge (cationic, anionic, non-ionic).
• Remember, these products can delay wound healing

(Rodeheaver, 1997)
14
Toxicity index for wound cleansers (adapted from
Rodeheaver, 1997)
15
Wound Irrigation

• Steady stream of irrigation from a 35 ml syringe
  with a 19 gauge needle 8 psi
• Greater the size of the needle, the greater the
  flow and the greater the pressure
• The larger the size of the syringe, the lower the
  pressure
• Removing devitalized tissue is the most important
  factor in reducing the level of bacterial
  contamination.

(Rodeheaver, 1997)
16
Wound Irrigation Conclusion

• Essential for wound healing
• Always balance the benefit against the cost to
  the wound
• Utilize wound cleansers in a non-traumatic manner
• Irrigate with pressures below 15 psi
• Do not use antiseptic agents in a clean wound
• Clean non-healing wounds with high levels of
  bacteria, consider a two-week trial of topical
  antibiotic
• Bacitracin, Polysporin, Silver Sulfadiazine,
  Metronidazole, Triple antibiotic

(Rodeheaver, 1997)
17
AHCPR Guideline Managing Colonization and
Infection

• Effective wound cleansing and debridement
  minimizes colonization and promotes wound healing
• Strength of Evidence A
• Purulence and foul odor requires more frequent
  cleansing possible debridement
• Strength of Evidence C

18
AHCPR Guideline Managing Colonization and
Infection (continued)

• Do not use cotton swab cultures to diagnose wound
  infection
• Strength of Evidence C
• Center for Disease Control recommends a needle
  aspiration or biopsy of ulcer tissue
• Clean non-healing wounds with high levels of
  bacteria, consider a two-week trial of topical
  antibiotic (should be effective against
  gram-negative, gram-positive, and anaerobic
  organisms)
• Silver Sulfadiazine, Triple antibiotic
• Strength of Evidence A

19
Distinguishing between inflamed and infected
wounds

• Colonization
• Presence of microbes without infection
• Normal skin flora
• Enterococcus
• Staphylococcus
• Bacillus
• Infection
• 104 to 105 organisms per gram of tissue
• systemic signs

(Bates-Jensen, 1998)
20
Table 8-3 Comparison of Wound Characteristic in
Inflamed and Infected Wounds
(Bates-Jensen, 1998)
21
Table 8-1 Wound Exudate Characteristics
(Bates-Jensen, 1998)
22
AHCPR Guideline Pressure Ulcer Dressings

• Use a dressing that promotes moist wound healing
• wet-to-dry dressings should only be used for
  debridement
• Strength of Evidence B
• There is no one single dressing that is
  superior.
• Strength of Evidence B

23
AHCPR Guideline Dressings (continued)

• Use a dressing that protects the periulcer skin
• Strength of Evidence C
• Use a dressing that controls exudate but does not
  desiccate the wound
• Strength of Evidence C
• Consider the caregiver when choosing the dressing
• Strength of Evidence B

24
AHCPR Guideline Dressings (continued)

• Eliminate wound dead space, but avoid
  overpacking
• Strength of Evidence C
• Monitor dressings near the anus
• difficult to keep in place
• consider picture-framing
• Strength of Evidence C

25
Conclusion

• Managing the wound environment according to the
  Agency for Health Care Policy and Research
  Clinical Practice Guideline for the Treatment of
  Pressure Ulcers
• Ulcer Debridement
• Ulcer Cleansing
• Managing Bacterial Colonization and Infection
• Selection of Dressing
• Distinguished between inflamed infected tissue
• Identification and the significance of the five
  types of exudate

26
References

• Bates-Jensen, B. M. (1998). Management of exudate
  and infection. In C. Sussman B. M. Bates-Jensen
  (Eds.), Wound care A collaborative practice
  manual for physical therapists and nurses (pp.
  159-177). Gaithersburg, MD Aspen.
• Krasner, D. (1991, July/August). Resolving the
  dressing dilemma Selecting wound dressings by
  category. Ostomy/Wound Management, 35, 38-43.
• Rinne, C. A. (1999, April). Wound product
  selection use Practical application.
  (Available from Southwest Missouri State
  University, Center for Continuing and
  Professional Education, 901 S. National Avenue,
  Springfield, MO 65804-0089)
• Rodeheaver, G. T. (1997). Wound cleansing, wound
  irrigation, wound disinfection. In D. Krasner
  D. Kane (Eds.), Chronic wound care A clinical
  source book for healthcare professionals (2nd
  ed., pp. 97-108). Wayne, PA Health Management
  Publications.
• Sussman, C. (1998). Wound healing biology and
  chronic wound healing. In C. Sussman B. M.
  Bates-Jensen (Eds.), Wound care A collaborative
  practice manual for physical therapists and
  nurses (pp. 31-48). Gaithersburg, MD Aspen.