Preparing the Wound Bed – Debridement, Bacterial Balance, and ...

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ut systemic antibiotics are needed if deeper tissue symptoms and signs are present (see Recommendations 6 and 9). Hydrogels 53-56 provide a high concentration of water in insoluble polymers. They may be synthetic or semisynthetic with bases of propylene glycol, saline, or hydrocolloids. They are inert to normal biological processes and permeable to metabolites with some absorptive and water-donating properties. They are best in dry, sloughy wounds with low exudate levels. They require changing every 24 to 72 hours and have very little anti-infective properties. They are available in amorphous or sheet forms. Hydrocolloids 57 are occlusive dressings containing carboxymethylcellulose, other polysaccharides, and proteins. They have both dry (elastomers) and wet tack (adhesives), changing physical form by slowly reacting with wound fluid to form a linked matrix gel. Fibrinolytic activity is due to pectin and antibacterial properties, owing partly to a low pH. Occlusion is accomplished by a foam or film sheet backing. Hydrocolloids provide an anaerobic environment that can sometimes promote hypertropic granulation. They are best for autolytic debridement and mild to moderately exudating wounds. 58 They are relatively contraindicated with arterial insufficiency, vasculitis, and infection. They have a long wear time (2 to 7 days), but must be changed if the wound fluid leaks through the edges. The hydrocolloid residue may be mistaken for infection and should be cleansed prior to wound bed assessment. Film dressings are best for the late stages of wound healing. Many are permeable to water vapor and oxygen, but impermeable to water and micro-organisms unless leakage channels develop from the periphery. They vary in their moisture-vapor permeability properties with Opsite ® (Smith & Nephew, Largo, Fla) (MVTR – 862 gm/m 2 /24 hrs) and Tegaderm (3M Pharmaceuticals, London, Ontario, Canada, and Minneapolis, Minn.) (MVTR – 846 gm/m 2 /24 hrs) 59 compared to IV 3000 (MVTR 3000, Smith and Nephew, Largo, Fla) designed to keep areas around cannulas dry, but this dressing would be too dehydrating for most chronic wounds. Film dressings come in adhesive and nonadhesive forms. They function best for superficial, nonexudative wounds. 60 They can be left in place for long periods or until they fall off if the seal is intact. Removal by stretching the edges will minimize superficial tears. Friable or bleeding wounds may benefit from the tack provided by fenestrated silicone surfaces (ie, Mepitel, Mepilex; Molnlycke, Oakville, Ontario, Canada) that can be left intact while secondary dressings are changed. 32 OstomyWound Management Recommendation 12 Evaluate the Expected Rate of Wound Healing to Determine if Treatment is Optimal An orderly sequence of healing should occur if the underlying cause has been treated, optimized local wound care implemented, and patient-centered concerns addressed. It is essential to have systematic wound documentation. Deep ulcers with significant depth (those progressing from Stage IV to Stage II) can be measured with alginate molds that are weighed and the weight related to volume or precise determinations. In most clinical settings, depth can be measured with a wooden stick in the deepest portion of an ulcer or an average of the deepest and most superficial portion used for documentation. Length and width are very accurate for superficial wounds with the widest width being measured at right angles to the longest length. 61 For precise determinations, tracings of superficial ulcers can be analyzed with computer planimetry. All sinuses and areas of undermining also should be documented. All ulcers will heal after the removal of nonviable tissue through maturation of granulation base and filling the defect to re-epithelialization. During the early debridement stage, a wound may actually increase in size before it contracts. Two studies have used a modified Gillman formula to demonstrate that healing rates of venous ulcers at 4 weeks can be used to accurately predict ulcers that will heal by week 12. 62,63 A wound that is not 30% smaller between weeks 0 and 4 is unlikely to heal by week 12. If an ulcer is not progressing in a measurable way, the treatment of the cause, local wound care, and patient-related issues must be reassessed. If all these factors are optimal, biological agents or adjunctive therapies may be indicated. Recommendation 13 Use Biological Agents When Other Factors Have Been Corrected and Healing Does not Progress at the Expected Rate Biological agents are expensive, but they stimulate wound healing. To date, growth factors have been relatively disappointing because they can be likened to a symphony orchestra, using only one player, such as the flute, without the rest of the orchestra. The single player does not allow for an orderly progression of healing. Despite these limitations, however, platelet-derived growth factor in a hydrogel (Regranex ® ; Ortho-McNeil Pharmaceutical, Inc., Raritan, NJ) has been marketed for use in the treatment of diabetic neurotropic foot ulcers. Platelet-derived growth factor is very
important as a catalyst very early on in wound healing to promote cellular migration and collagen synthesis. It is applied daily, and the study showed that with best clinical practices and Regranex ® , healing rate was increased by 15% in a 20-week trial from 35% in the control group to 50% having complete wound closure in diabetic neurotropic foot ulcers. Recent advances in tissue culture techniques (Reinwald and Green) 64 have made it possible to culture cells from human foreskin donors. Donated newborn foreskins are used to extract epidermal precursor cells and fibroblasts to master skin banks. Both cells and the mothers are extensively and repeatedly screened for possible infectious agents. From one piece of donated tissue, these cells are transferred to working cell banks and can produce enough skin substitute to cover four to six football fields. Dermagraft (Advanced Tissue Sciences/Smith & Nephew Inc., La Jolla, Calif. and Largo, Fla.) is a human fibroblast-derived dermis consisting of bio-absorbable polygalactin mesh on which fibroblasts are seeded. The cells proliferate on the mesh in specialized bioreactors to form tissue that is cryopreserved and frozen for long-term storage. Dermagraft‚ in the therapeutic range, increased the 12week healing of DNFU from 32% to 54% over best clinical practices. This difference in healing rate was maintained over the 32-week trial period demonstrating the potential long-term benefits of advanced therapies. Apligraf ® (Organogenesis, Canton, Mass. and Novartis, East Hanover, NJ) consists of dermal fibroblasts and Type I bovine collagen matrix with an epidermis and differentiating stratum corneum. In a controlled trial, 63% of venous ulcers healed, compared with 48% of active control patients by week 24. A subanalysis of ulcers present for more than 1 year demonstrated complete healing of 47% of patients treated with Apligraf ®/ and compression compared to 19% treated with compression therapy alone. Recently hyaluronic acid in a bipolymer has been made available for difficult to treat wounds. Hyaluronic acid is a major carbohydrate component of the extracellular matrix, inducing a prompt angiogenic response, promoting rapid formation of granulation tissue, assisting fibroblast growth and migration, and directing the organization of collagen disposition. 65 This agent has shown promise in case series, but no controlled trials have been published to date. Conclusion The wound care professional has an ever-expanding tool- box for ideal wound care. Debridement, bacterial balance, and moist interactive healing all must be optimized as integral parts of preparing the wound bed. If the underlying cause, patient-related factors, and the wound bed have all been appropriately treated, the new and expanding drawer of biologicals offers increased hope for some of our most difficult chronic wounds. - OWM Acknowledgment Some concepts presented in this paper were first developed through a series of articles by Diane Krasner and R. Gary Sibbald on wound care in Nursing Clinics of North America 27 ; Hyperbaric Medicine Practice, 2nd Edition 66 ; and The Diabetic Foot, 6th Edition. 67 The local wound care paradigm (debridement, bacterial balance, and moisture balance) was presented by R. Gary Sibbald as part of a planning session at The Symposium on Advanced Wound Care and Medical Research Forum on Wound Repair in Dallas, Texas, April 1–4, 2000. Concepts used in the charts have been modified from an educational retreat sponsored by an unrestricted educational grant from Smith & Nephew Canada and a 1998 Peel regional initiative and wound care guide, compiled by Caremark Ltd. References 1. Lazarus GS, Cooper DM, Knighton DR, et al. Definitions and guidelines for assessment of wounds and evaluation of healing. Arch Dermatol. 1994;130(4):489–493. 2. Winter GD. Formation of the scab and the rate of epithelialization of superficial wounds in the skin of the young domestic pig. Nature. 1962;193:293-294. 3. Winter GD. Epidermal regeneration studied in the domestic pig. In: Mailbesch HI, Rovee DT, eds. Epidermal Wound Healing. Chicago, Ill: Year Book Medical Publishers; 1972:71–112. 4. Sykes MT, Godsey JB. Vascular evaluation of the diabetic foot. Clin Podiatr Med Surg. 1998;15(a):49–83. 5. Moffatt C, O’Hare L. Ankle pulses are not sufficient to detect impaired circulation in patients with leg ulcers. Journal of Wound Care. 1995;4(3):134–138. 6. Moffatt CJ, Dorman MC. Recurrence of leg ulcers within a community ulcer service. Journal of Wound Care. 1995;4(2):57–61. 7. Margolis D, Gross E, Wood CR, Lazarus GS. Planimetric rate of healing in venous ulcers of the leg treated with pressure bandage and hydrocolloid dressing. JAAD. 1993;28:418–421. 8. Young MJ, Cavanagh PR, Thomas G, et al. The effect of callus removal on dynamic plantar foot pressures in diabetic patients. Diabet Med. 1992;9(1):55–57. 9. Panel for the Prediction and Prevention of Pressure Ulcers in Adults. Clinical Practice Guideline Number 3: Pressure Ulcers in Adults: Prediction and Prevention. Rockville, Md: US Department of Health and Human Services. Public Health Service. Agency for Health Care Policy and Research; 1992. AHCPR Publication 92-0047. 10. Krasner D. Pressure ulcers: assessment, classification and November 2000 Vol. 46 Issue 11 33
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