WORKSHOP: DRESSING SELECTION - rcsi.ie · •Also called ‘biologic debridement’ •Most...

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WORKSHOP: DRESSING SELECTION - BIOLOGICAL DRESSINGS - PAIN ASSESSMENTMr. Steven Smet, University Hospital Ghent, Belgium Ms. Emer Shanley, RGN in Community care, Co. Cork, Ireland

Speaker Name: Steven Smet

I have no financial interests or relationships to disclose with regard to the subject matter of this presentation.

Declaration of

Financial Interests or Relationships

Learning objectives

• At the end of this lecture, students will be able to: – Differentiate between the different debridement options

– describe best practices for dressing selection

– Distinguish between the most common available wound dressing groups

– Make a correct choice in wound dressing, based on the general principles of wound healing and the characteristics of the wound dressing

TIME principles

• T: Tissue– Based on following references:

• Anghel EL et. al. Current concepts in Debridement: Science and strategies. American Society of Plastic Surgeons. 2016; 138(3S): 82S-93S

• EWMA Document: Debridement. An updated overview and clarification of the principle role of debridement. Journal of Wound Care. 2013; 22(1): 1-49

• National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. Emily Haesler (Ed.). Cambridge Media: Osborne Park, Australia; 2014.

TIME principles: Tissue

• Recommendations?– Debride devitalized tissue within the wound bed

or edge of pressure ulcers• Only when there’s adequate perfusion to the wound!

– Debride the wound bed when the presence of biofilm is suspected orconfirmed

• Recommendations?– Select the debridement method(s) most

appropriate to the individual, the wound bed and the clinical setting• A variety of surgical and non-surgical strategies

available but non have proven completely effective in a certain setting…

• Multimodal approach to remove necrotic (infected) tissue, biofilm and/or senescent cells

Anghel E et. al., 2016

• Painfull and traumatic solution

• Insufficient for adequate wound bed preparation

• Outlayer: Gentle mechanicaldebridement (Debrisoft®)

• Also called ‘biologic debridement’

• Most important groups:

– Autolytic debridement

• Hydrogels, hydrocolloids, foam dressings

• Stimulation of endogenous proteolytic enzymes– Digestion of necrotic tissue

– Stimulation of granulation tissue

• Some evidence of hydrogel on dry, non infected cat 3-4 pressure ulcers

• Some evidence of hydrocolloïd dressing on cat 2 pressure ulcers…

• Some evidence of advantage of foam dressings abovehydrocolloids in exudate management of cat 2 PU

TIME principles: T

• Most important groups:– Enzymatic debridement

• Ointments with collagenases and proteases

• No specific literature of usage on pressureulcers

• Exudating wound is necessary

• Protect the wound edges

• Ex. Iruxol®, Hyalo® 4 start

– Osmotic debridement

• Medicinal honey (FDA approved as wound dressing, notas debriding or antimicrobial agent…)

• Alginates / hydrofibers

• Dextranomer / cadexomer Iodine dressings

• Cost-effective alternative for treating drug-resistant chronically infected wounds

• Patients who are poor operative candidates

• Most studies in patients with diabetic footulcers

• Standard of care withnecrotic infected(pressure ulcer) wounds

After bedside sharp debridement

After first sharp debridement -> flap surgery

TIME principles: Moisture

• Recent new consensus document

– World Union of Wound Healing Societies (WUWHS) Consensus Document. Wound exudate: effective assessment and management

TIME principles: Moisture• Definition exudate:

– Exuded matter; especially the material composed of serum, fibrin, and white blood cells that escapes into a superficial lesion or area of inflammation” (Merriam-Webster Dictionary, 2018).

TIME principles: Moisture• exudate production is highest during the inflammatory

phase and decreases as healing progresses (Schultz et al, 2011).

TIME principles: Moisture• Although it is clear too much or insufficient exudate

delays healing, there is no internationally accepted standard method for measuring the rate of exudate production nor is there an accepted ‘normal’ rate

TIME principles: Moisture• Definition

• Local management of wound exudate

• Ideal situation: moist environment– No exudate: Hydrogels

– Moderate exuding: Foam dressings, alginogels, honey, dextranomer / cadexomer, alginates, fibredressings

– Heavy exuding: Superabsorbers, honey, dextranomer / cadexomer, alginates, fibredressings, NPWT

• Ideal situation: moist environment

– Adapted bandages for ‘thick’ exudate (ex. Mepilex® XT)

– Be careful with hydrocolloids…

Wound barrier protection

• Working mechanism– Transparent barrier film at the wound edges and

wound environment– Film stays in place for more or less 72 hours– Repeat every 24-48h

• Points of attention?– Apply on dry skin– Don’t apply to frequent– Apply on all the affected zones

Wound barrier protection

• Werking– Protective barrier with zinc oxide

– Light repair effect, additional antimycotic effect withDaktozin

• Points of attention– No observation possible.

– Agressive removal

TIME principles: Tissue and Moisture

• Negative Pressure Wound Therapy (withinstillation)

– Recommendation: Consider NPWT as an earlyadjuvant for the treatment of deep cat 3 or 4 pressure ulcers

• Not on necrotic wounds and/or dry wounds

• Only applied by professionals

TIME principles: Tissue and Moisture• Negative Pressure Wound Therapy (with

instillation)

• Negative Pressure Wound Therapy (withinstillation)

– Often as wound bed preparation beforereconstructive surgery

• Increased local blood flow and granulation

• Decrease of oedema

• Exudate control / control of bacterial proliferation

• Negative Pressure Wound Therapy withinstillation– Can significantly reduce the wound bioburden– Not clear yet which solution to instill

– With PU reconstructive surgery?• High tension incisions• Repetitive incisions• AND high risk patient

TIME principles: Tissue and Moisture• Negative Pressure

Wound Therapy forsurgical incisionmanagement

World Union of Wound Healing Societies (WUWHS) Consensus Document. Closed surgical incisionmanagement: understanding the role of NPWT. Wounds International, 2016

TIME principles: Tissue and Moisture• Negative Pressure Wound Therapy for surgical incision

management– WHO recommendations for surgical site prevention 2016

Prevena®?

TIME: Epithelialization

Non-migrating or underminedepidermal edge• Absence of

– necrosis, – infection and – excessive exsudate

but yet no progression in wound healing (insufficient granulation and epithelialisation)

• R/ need for– revision of the diagnosis– active stimulation of (granulation and) epithelialisation

=> surgery=> biological wound dressings=> biophysical agents

Epidermal edges

6/12 13/12

easily epithelialising wound

difficultly epithelialising wound

– necrosis,

– infection and

– excessive exsudate

• R/ need for– active stimulation of (granulation and) epithelialisation

=> biological wound dressings

=> biophysical agents

High tech biological dressings• Products which inactivate proteinases (MMP’s)

– Eg. Dermax®, Promogran®

• Products that contain ECM components

– Collagen dressings

• Eg. Hyalo regen®, Promogran®,

– Hyaluronic acid dressings

• Eg. Hyalo skin®

• Isolated growth factors (eg. Recombinant PDGF (Regranex®)

• Amniotic membrane

• Skin cell cultures

• Skin equivalents (tissue engineered skin)

• Eg. Apligraf®, Dermagraft®

Need for more than conventional treatment

• Large wounds: conventional treatment is not feasable

– extensive burn wounds

– epidermolysis bullosa

• Hard to heal chronic wounds:conventional treatment is not effective

– Pressure ulcers

– Diabetic ulcers

– vascular ulcers...

Need for more than conventional treatment

• Wound dressing– insufficient because of depth or extension of the injury

• Need for replacement of diseased or injured tissue– autologous skin graft = gold standard

• not always available in sufficient amount

• sometimes deficient due to underlying disease

– allogeneic skin graft (donor tissue)

• severe and growing shortage of human organs and tissues => not alwaysavailable in sufficient amount

– Cultured keratinocytes and tissue engineered skin

Epithelial grafts or“keratinocyte sheet grafts”

• source:

– Autologous grafts:

• Biopsy or burn patient

– Allografts:

• Seologically tested donors in good health

• Neonatal foreskin or elevtive surgery specimen

• culture technique

– Modified Rheinwald and Green technique

– Alternatives for xenogeneic material:

• Fibrin coated culture dishes

• Medium without bovine serum

– multilayered sheets, mounted on vaseline gauze

Allogeneic cultured keratinocytes

• Cell cultures, prepared in clean room, starting from autologous or allogeneic skin

• direct application on the wound: basal cell layer immediately on the wound bed

• vaselin gauze dressing and dry sterile dressing

• dressing can remain on the wound for 5 to 7 days

• repeated application if necessary

Spray grafts

• spray grafting: carriers:• fibrine

• Hyaluronic acid

• comparison– multilayered confluent sheets (conventional “sheet” grafts)

versus

– subconfluent cell transplantation (“spray” grafts)

Composite multilayered dermo-epidermal skin equivalents

• Dermagraft

• Apligraf

• Hyaff + Laserskin

Dermal substitutes• Example

– Integra® products

• Expensive!

– necrosis,

– infection and

– excessive exsudate

• R/ need for– active stimulation of (granulation and) epithelialisation

=> biological wound dressings

=> biophysical agents

Biophysical agents

• Electrical stimulation

• Electromagnetic agents

• Pulsed radio fraquency energy

• Phototherapy (laser/infrared and ultraviolet)

• Acoustic energy (ultrasound)

• Hydrotherapy (whirlpool and pulsed lavage)

• Oxygen (hyperbaric oxygen/ topical oxygen

Pain and pressure wounds

do not forget to ask the patient if she/he has pain!

Pain and wounds

• Anamnesis ( and clinical examination)

• Diagnosis => type of pain

• Treatment of pain

Assessment of pain

• Necessary to assess pain in each pressure wound• Use a valid and reliable scale (eg. Adapted to

age)• Ask the patient to describe the pain (cave

neuropathic pain)• Ask for changes in pain• Combine with QoL and assess the impact of

pressure wounds on QoL

Anamnesis

• Is the pain constant?• Intermittent vs. constant

• When?• During dressing change? At night? After exercise?

• Severity of the pain?• Pain scale (VAS or comparable scale)

• Influencing factors? • Aggravation? Amelioration?

• Type of pain? Description of pain?• Dull / shooting / burning / nagging

• Impact of the pain? • Awake at night? Decreased appetite?

Nocireceptive pain vs. neuropathicpain

-Physiological response of pain on stimulus

-In zone that has been hurted/ affected

-Well-known pain sensation

-Good response to traditional pain killers

-Abnormal response due to dysfunction or damage of nerve tissue

-According to the nerve

-New type of pain sensation

-Not responding well to traditional pain relief

Prevention of pain

• E.g. The use of a lift or transfer sheet canreduce friction and shear

• E.g. Positioning off the pressure ulcer canreduce pain

Management of pain

• Adequate topical dressings

• Topical analgetics

• Systemic analgetics

• Non-medicinal pain reduction

• Multidisciplinary pain reduction

Management of pain

• Adequate topical dressings

• Topical analgetics

• Systemic analgetics

• Non-medicinal pain reduction

• Multidisciplinary pain reduction

Adequate topical dressings

• Moist, non adherent dressing

• Dressing that can remain on the wound for a long time (less bandage changes)

• Ibuprofen impregnated dressing with topicalanalgetics

Systemictreatmentof pain

Literature

– Reddy M. Pressure ulcers: treatment. BMJ Clin Evid. 2015

– Jugun K et al. Factors associated with treatmentfailure of infected pressure sores. AnnSurg. 2016

– Norman G et al. Antibiotics and antiseptics forpressure ulcers. Cochrane Database Syst Rev. 2016

– Gould L et al. Wound Healing Society 2015 update onguidelines for pressure ulcers. Wound Rep Reg. 2016

Literature

• Anghel EL et. al. Current concepts in Debridement: Science and strategies. American Society of Plastic Surgeons. 2016; 138(3S): 82S-93S

• EWMA Document: Debridement. An updated overview and clarification of the principle role of debridement. Journal of Wound Care. 2013; 22(1): 1-49

• National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. Emily Haesler (Ed.). Cambridge Media: Osborne Park, Australia; 2014

• Westby MJ, Dumville JC, Soares MO, Stubbs N, Norman G. Dressings and topical agents for treating pressure ulcers. Cochrane Database of Systematic Reviews 2017, Issue 6. Art. No.: CD011947. DOI: 10.1002/14651858.CD011947.pub2.– Consequently we are unable to determine which dressings or topical agents are the most likely to heal pressure

ulcers, and it is generally unclear whether the treatments examined are more effective than saline gauze…

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