Surgical dressings

1. Surgical dressings Dr. Sujith Thampy S4 Unit

2. History • Until the early 1980s, only a few wound care products were available apart from traditional dressings (eg: gauze-based products), paste (eg: zinc paste) & bandages

3. In mid 1990s,it expanded into well-recognized groups of products, such as vapor-permeable adhesive films, hydrogels, hydrocolloids, alginates & synthetic foams In second half of 1990s, combination products & engineered skin substitutes were developed. Currently, the global tendency demonstrates in decreasing no of product categories & making the market more transparent Lot of research-on the basis of physiology The first modern wound dressings introduced during mid 1980s combined 2 main characteristics moisture keeping &absorbing or moisture keeping & antibacterial

4. An ideal wound dressing should….. • Protect from external forces & contamination • Protection against drying & loss of body water& electrolytes • Discourage infection • Provide thermal insulation • Reduce odour • Be easy to apply • Be cost and resource effective

5. Phase-adapted functions Early phase-cleaning Every wound contains variable amount of dirt debris & bacteria along with exudate, which hinder wound healing both mechanically & biologically, & increase risk of infection. Dressings should support & speed up cleaning of excessive exudates

6. Granulation phase Adequate regulation of wound moisture is important requirement for formation of granulation tissue It should absorb excessive secretions ,prevent drying of wound & delivers moisture when it is needed. It`s atraumatic character (not adhering to the wound) ensure that the rest of wound is maintained

7. Epithelialisation Mature granulation tissue & a moist sliding surface for migration epithelial cells If excessive secretions epithelial cells will swim away, if too dry a scab will hinder epithelialisation Cell stripping during dressing change can be prevented by using atraumatic materials

8. Requirements of wound dressings • Absorbency- capacity of dressing to remove secretion due to capillary effect & hold it in its material • Wound friendliness- shouldn`t adhere to wound even after prolonged term use & allow a less painful removal- can be achieved by impregnating dressing with ointments, gels& other hydrophobic materials

9. Gas permeability Continuous gas exchange helps in the regulation of concentration of O2 & pH and thereby helps in the cellular processes

10. Safety of use

11. Methods of wound dressings Dry dressings Limited indications - as a part of first aid - for wounds that heal with primary intension - for burns Moist dressings Natural skin

12. Dry gauze - Made up of dry cotton; soft, highly absorbent, pliable, highly permeable to air & strong • For initial treatment of acute, dirty, highly secreting wounds & sutured wounds healing by primary intention • As they stick to wound; ointments or moistening should be done in the granulation and epithelialisation phase

13. Non woven swabs • Simliar to gauze, rapidly absorbent pliable • But not so strong & will adhere to wound also • Can be used for fixation of tracheostomies , tubes, drains & cannulas

14. Combinedabsorbentdressings • Combination of absorbent materials in layers-demonstrate good absorbency • Secretions are well distributed & drawn away from the wound & held in the depth of the absorbent core

15. Soft foam dressings Double layer poly urethane foam Open pore underside is in contact with wound & absorb all the exudates Ensure rapid & intense cleaning of dirty wound In granulation phase it acts as matrix for formation of new tissue & stimulates the formation of granulation mechanically Denser top layer act as a barrier to secondary infection & prevent fluid loss

16. Moist dressings Moist wound treatment -standard treatment for all wounds under going 20 healing Especially in c/c wounds Scientific basis by research of Winter in1962 “In the old days we only had to know saline and gauze” • Foam • Ointment dressings • Antimicrobials • Enzymatic Debridement • Hydrocolloid • Hydrogel • Calcium alginate

17. Hydrocolloid • Highly absorbent gel (polyurethane) • Oxygen and water vapour permeable • Allows for autolytic debridement • Indications: Venous ulcers, pressure ulcers, diabetic ulcers, 1st and 2nd degree burns • Can stay in place for 72 hours

18. Hydrogel • Absorbs 5 times own weight • Hydrophilic polysaccharide particles • Facilitates autolytic debridement • Delivered in many forms • Amorphous gel, Sheets, Strands • Indications: Mildly exuding wounds, clean wounds , partial thickness wounds • Can stay in place for 24 hours

19. Calcium alginate Mannuronic acid fibers- Seaweed Forms a hydrophilic gel Comes as- Sheets, tubes, loose fibers packs Absorbs up to 30 times weight Maintains a moist wound environment. Indications: Wounds with large amount of drainage Can stay in place 24 to 72 hrs

20. Foam • Hydrocellular foam, waterproof outer layer • Highly absorbent (20 times weight) • Non-adherent to wound • Allows for autolytic debridement and gaseous exchange • Indications: Highly exudative wound requiring a non-stick surface (e.g. venous stasis) • Can be left in place for 72 to 96 hours

21. Ointment dressings Open weave cotton textile or non woven material is impregnated with ointment Do not absorb or do not adhere to wound Absorbent dressing is needed above the ointment dressing to absorb secretions

22. Enzymatic Debridement • Removes: • Senescent fibroblasts • Necrotic tissue harboring bacteria • Indications: A wound with lot of fibrinous exudate, other necrotic material or slough • Papain (Papaya) – digestant of nonviable protein • Denatures nonviable protein • Apply directly to wound

23. Antimicrobials • Indications: Infected wounds, wounds with bacterial counts greater than 105 • Bacterial count greater than this decrease wound healing rates • Bacterial proteases degrade growth factors • Therapeutic concentration at the site of the wound Acticoat- Nanocrystalline silver coating on polyethylene mesh

24. Natural skin • Autologous grafts • large surface wounds, burns. • transplantation of the patient's own skin from an adjacent undamaged area • definitive coverage of burned skin with good quality of healed skin. • Acellular Dermal Replacement • For deep wounds-loss of dermis • Tissue-derived or manufactured products which provide temporary wound closure • Incorporate and promote generation of a neodermis which support epidermal tissue. • Require autograft later

25. Natural skin • Allogenic skin graft • Cadaveric skin • Preservation can be done by freeze-drying, glutaraldehyde fixation, or glycerolization. • To provide sufficient cadaver skin instantly accessible for the patient with a burns- skin banks in European countries

26. Natural skin • Xenogenic grafts • application of non-human tissue to wounds. • unlimited availability under well-controlled conditions still makes animal skin a favorable wound covering. • Porcine skin- most common- high similarity to human skin • Sterility is an essential concern- Ionizing radiation- most suitable method • Coupled with freeze-drying- decrease the antigenic properties & increase its potential to inhibit bacterial growth.

27. Innovations in Wound Management • Biosurgery (Larval Therapy) • Laser therapy • MySkin • Growth inducing factors • Hyaluronic acid dressing • Tenderwet • VAC therapy • Multi-Layer • Compression System

28. Biosurgery (Larval Therapy) • Lucilia sericata (greenbottles) Phaenicia sericata (green blow fly) • Debride wounds by dissolving the dead & infected tissue • Disinfect wound by killing bacteria • Stimulate wound healing. • Removes slough and malodor • Special dressing technique • Sterile breed of larvae • Allergic reaction • Ethical issues • Research

29. Laser therapy • Biostimulation or photobiostimulation • application of low-power monochromatic and coherent light • Increase the speed, quality and tensile strength of tissue repair, resolve inflammation and provide pain relief • Responses of cells occur due to changes in photoacceptor molecules such as porphyrin. • Needs expert handling • Costly & Time-consuming

30. MySkin • Cultured autologous epidermal substitute • Contains living cells expanded from the tissue of individual patients. (only their own cells) • Comprises a layer of keratinocytes (epidermal cells) on a polymer-like coating which facilitates the transfer of cells into the wound where they can initiate healing. • Use silicone substrate layer to support cell delivery, wound coverage and allow exudate management. • Treatment of burns, ulcers and other nonhealing wounds.

31. Method Thin biopsy of skin is taken from the thigh area -in sterile saline solution-treated with a digestive enzyme overnight-next day keratinocytes are isolated from the dermal/epidermal junction, multiplied in cell culture and stored in liquid nitrogen Three days before dressings, keratinocytes are thawed and cultured on a silicone disc, transfer keratinocytes from the dressing to the wound bed and promote re-epithelialization…(four days) -after standard dressing

32. Growth promoting factors • Proteins that direct biological processes • Chronic wound deficient • Platelet-Derived Growth Factors (pdGF) • Activates endothelial cells and fibroblasts • Stimulates vascular proliferation, migration, new blood vessel formation • Recruits smooth muscle cells and pericytes to stabilize newly formed vessels

33. Growth promoting factors • Oxidized Regenerated Cellulose (ORC)/Collagen • Modulates protease activity • Growth factor remains active • Growth factors delivered back to wound over time • Modifies hostile proteolytic environment of chronic wound

34. Hyaluronic acid dressing • Vapor-permeable films • Industrially manufactured and purified hyaluronic acid. • Indicated for use on diabetic foot ulcers and venous leg ulcers • Hyalograft 3D and Laserskin (HYAFF-11) • Composed of a benzyl ester derivative of hyaluronic acid • May be used as membranes for direct wound dressing or as scaffolds for the cultivation of fibroblasts and keratinocytes for transplantation. Hyalofill

35. Xelma • Extracellular matrix protein- amelogenin, a thickening agent propylene glycol alginate (PGA) and water. • Temporarily replaces the damaged extracellular matrix protein for cell attachment. • Favours wound healing by restoring vital cell functions • Treatment of hard-to-heal ulcers, primarily venous leg ulcers, use withstandard compression therapy of non-infected wounds.

36. Tenderwet • Extremely effective dressing for chronic, infected and non infected during cleaning & start of granulation phase • Allows continous irrigation of wound

37. Mode of Action

38. Multi-Layer Compression System • For management of venous leg ulcers and related conditions • Used on patient`s ankle • Provides sustained graduated compression from the ankle to below the knee • 3 layers

39. Multi-Layer Compression System THIRD LAYER- Cohesive compression bandage delivers additional pressure. SECOND LAYER-Compression bandage gives visual cue to aid proper application. Bandage is printed with a rectangular pattern that turns to a square when correct level of stretch is achieved. FIRST LAYER-Padding is made of cotton.

40. VAC therapy • Application of topical negative sub-atmospheric pressure across the surface of the wound • Evacuates excess exudate • Kills anaerobic bacteria • Controls odour • Mechanically pulls edges of wounds together

41. Indications • Chronic non-healing wounds: • Pressure ulcers • Venous/arterial ulcers • Diabetic ulcers • Sub-acute non-healing wounds • Dehisced surgical wounds • Acute and traumatic wounds • Meshed flaps and grafts • Graft and flap donor sites • Others like burns; snake and spider bites

42. Closing thoughts What we do is just conventional old method of dressing we have to improve & the world is also finding a lot more……

43. THANK U & BYE……… TO MEET AGAIN