PRODUCTS FOR THE “WOUNDED” Advance Wound Care Modalities

1. PRODUCTS FOR THE “WOUNDED”Advance Wound Care Modalities SHAWNEEN SCHMITT, RN MSN MS CWOCN CFCN WOCN ADVISOR FOR THE WISCONSIN PRESSURE UCLER COALITION October 21, 2010

2. Objectives • Describe the phases of wound healing • Define “DIME” • State a reason when advance wound care treatments should to be considered • List at least three types of advance modalities to aid in wound healing • Describe three products that can used to enhance wound healing for a pressure ulcer • Identify two resources for wound care product information

3. Wound Healing Phases • Hemostasis: An injury to the skin/tissue takes place releasing platelets to the open area to create a fibrin clot to protect the immune system and thermal regulation • Inflammatory Phase: The clotting factors stimulate the release of histamines causing vasodilatation and thinning of the cell wall releasing Neutrophils to start phagocytosis of bacteria and foreign debris. Keratinocytes found in the epidermis release cytokines and growth factors as well as the enzyme collagenase. This phase last 3-5 days • Proliferative Phase: This is found when wounds become full thickness and the soft tissue defect begins to replaced with new blood vessels and granulating tissue composed of hyaluronic acid and collagen produced by fibroblast cells. When this new tissue reaches the epithelial level then wound contraction can begin at the wound edge • Remodeling Phase: This occurs when epithelialization occurs, the wound in closed and the tissue tensile strength develops

4. Wound Bed Preparation • Normal wound healing follows an orderly process of the three phases • When a wound is stalled between the inflammatory and proliferative phase, the wound may not heal. It becomes chronic requiring wound bed preparation to remove senescent (old/dead) cells that impair new cell migration and growth • D= debridement • I = inflammation or infection assessment • M= moisture balance • E= Edge effect – this is referred to the wound edge and failing to show signs of epithelialization that is the epithelial cells fail to migrate across from one wound edge to the other side. This is a chronic non-healing wound • If the wound has not reduced in size by 30% in 3-4 weeks then advance wound care should be considered

5. Medicare Viewpoint • Medicare refers to the medical care needed to treat chronic wounds as "wound therapy." • A chronic wound is a sore, blister, or skin injury that has not healed after 30 days of treatment by a doctor. • Chronic wounds are serious and need medical attention. They can take months or years to heal; and some never do heal. They can be very painful and cause a lot of discomfort for the person who has one. • http://www.medicare.com/services-and-procedures/wound-care-and-wound-therapy.html

6. Advanced Products to be Reviewed • Antimicrobial dressings (Silver, Iodine, Honey) • Antifungal products (Nystatin) • Specialty dressings (Hyluronic Acid, Interdry, Silicone) • Collagen (Prisma, Promogram, Fibracol) • Chemical Debrider (Santyl) • Engineered Tissue (Apligraf, Dermgraft) • Extracellular Matrix (Oasis, Integra) • Growth Factors (Regranex) • Complimentary Therapy • Negative Pressure Wound Therapy (NPWT)

7. Antimicrobial Dressings • These are topical products that incorporate agents such as silver, cadexemer iodine or medical honey • When agents come in contact with wound exudate they release their antimicrobial properties to reduce the bacterial load. • These dressings can come in a variety of delivery forms, shapes and sizes • Gels, Hydrocolloids, Foams, Alginates, Powders, Fabric/cloth • Intended to be used in draining and non-healing wounds • Can be used in all types of wounds • Advantage: Reduce or prevent infection • Disadvantage: Staining of the skin, agent resistance

8. Antimicrobial Dressings (cont) • Silver comes in various delivery systems and quantities that can create an immediate release or sustain release of the ionic Nanocrystal silver. • It is an effective barrier to bacterial penetration in wound tissue • Requires wounds to have moderate to large drainage to be effective • Patients can develop an allergic reaction to silver and some forms of silver can be cytoxic • Not to be used on patient’s receiving an MRI or have EKG or EEG electrodes on • Do not use any oil-based products on skin near silver dressing • Requires often a secondary dressing • Some silver dressings can manage odor when combined with charcoal, several can causing staining of surrounding skin

9. Antimicrobial Dressings (cont) • Cadexemer iodineis a type of sustained release iodine that does not affect the fibroblast formation in tissue and collagen growth. It helps to absorb slough, tissue debris and exudates. It lasts up to 72 hours. • It comes in the form of a gel/paste or a mesh pad • It is affective in wet wounds with moderate to large exudates • It should not be used in people with sensitivity to iodine • It is contraindicated in patients with thyroiditis, Graves disease, nontoxic goiter and pregnant or nursing mothers. • The product may need to be changed before 3 days if it turns from an orange-rust color to a yellow-brown color • Requires a secondary dressing

10. Antimicrobial Dressings(cont) • Medical Honey is Active Leptospermum Honey from New Zealand, possess unique qualities that make it ideal for the management of chronic and acute wounds and burns. • It is effective against a broad spectrum of bacteria, including antibiotic-resistant strains such as MRSA and VRE • Can be used for autolytic debridement of slough • It has been used successfully along with other advanced wound care modalities, including being used before, during, and after negative pressure applications • It is appropriate for all types of wounds and comes in a gel, hydrocolloid or as an alginate • Can be left in place from 1 -3 days depending on the amount of exudates and does require a secondary dressing.

11. Antifungal Products • These products are designed to inhibit the growth of organisms (fungi/yeast) that can cause superficial skin infections • The pH of the skin is in an acidic range varying to different parts of the body. This is important to maintain because it regulates the permeability and integrity of the skin cells. Once the defense is altered fungi and bacteria can enter and penetrate the skin usually in moist dark areas such as skin folds • These products come in the form of powders (for folds) or creams/ointments (for open areas) • Two primary ingredients are either Miconozole 2% or Fluconazole (Nystatin) • Should be discontinued when yeasty (red satellite rash) subsides

12. Chemical Debrider • Collagenase is a type of chemical enzymatic debriding agent derived from the fermentation of the bacterium – Clostridium histolyticum which aids in the digestion of necrotic collagen tissue • Collagen comprises 75% of the body’s skin tissue. Thus this enzyme can contribute to the formation of granulating tissue. • Product is contraindicated with patient’s having a sensitivity • A secondary dressing is required • The half-life of this product is 26 hours requiring daily dressing changes • Requires a prescription • Products no longer available are ointments with papain-urea

13. Specialty Dressings • These are dressings have unique properties that can manage bacteria , aid in autolytic debridement, pain management and/or protects newly formed granulating tissue. Can be used in all types of wounds • hyaluronic acid (an avian protein) comes in the form of a cellulose or liquid that forms a gel with the wound exudates • Interdry is a product that is a polyurethane coated silk-like fabric impregnated with silver used between skin folds to reduce skin to skin friction and can be a barrier for MRSA, MSRE, VRE, Pseudomonas • Silicone dressings are thin and flexible gel-like that aid in pain management as well as aid in reducing hypertrophic and keloid scar formation

14. Collagen Dressings • Collagen is the most abundant protein in the body which is produced by fibroblasts which is found in the connective tissues such as skin, bone and ligaments • In wound healing, collagen stimulates granulating and epithelialization • It can also create an environment for wound debridement by binding with enzymes (proteases) while protecting growth factors needed for granulation • Can be used on all types of wounds including skin grafts and donor sites. Cannot be used over eschar • This type of dressing is a bovine collagen produced in sheets, pads or gels that is absorbed into the new tissue as well as helps maintain a moist wound environment • Requires a secondary dressing

15. Extracellular Matrix • Matrix dressings are made from the small intestine lining of a pig that consists of collagen and growth factors that support cell growth • It provides a natural extracellular matrix (grid or scaffold) that has a three dimensional structure to aid in tissue remodeling/building • This is a very thin dressing that isn’t removed but reapplied over it on a weekly basis till wound is epithealized • Not to be used on people sensitive to pork • Require dressing to be rehydrated with sterile saline after application and covered with a secondary dressing

16. Growth Factors • There is only one FDA-approved platelet-derived growth factor comprised of cytokines that activates cells to form new granulating tissue and blood vessels • It has been approved only for use on diabetic ulcers and requires adequate blood flow that is not ischemic • Chronic wounds have been found deficient in growth factors • Doing serial sharp debridement enhances the growth factor effectiveness • Contains a preservative that may cause sensitivity reaction • Requires a prescription and is expensive ($700.00 /tube) • Is applied daily in a carefully measured dose and can only be left in place for 12 hours. Needs a secondary dressing of moist saline gauze

17. Engineered Tissue • This type of tissue is a biologic substitute or synthetic skin that can emulate normal skin functions (such as allowing vapor transmission, resists shear and friction and act a bacterial barrier) to aid in accelerating wound healing • This tissue contain one or both epidermal and dermal cells that have the cytokines, growth factors, structural support to help restore wound healing but does not contain hair follicles, blood vessels or nerve endings • Can only be applied by a physician or a trained person under the direction of a doctor and requires a prescription. • Requires a secondary dressing changed weekly until the wound is healed

18. Complimentary Therapy • These therapeutic modalities are designed to enhance wound healing along with conventional/primary wound care • Electrotherapy (E-Stim) is the application of an electrical current to transfer energy through the wound/skin attracting cells for new blood vessel growth (angiogenesis) there by accelerating wound healing. It is contraindicated for people with cancer, osteomyelitis, implanted electrical devices • Ultrasound delivers sound waves in the form of mechanical vibration on the cellular level thereby encouraging growth factor and collagen production, increase nitric oxide and angiogenesis • Ultraviolet Light is used to increase epithelial cell growth, destroy bacteria and stimulate granulating tissue. This is still investigational due to the increase potential for skin cancer.

19. Complimentary Therapy (cont) • Hyperbaric Oxygen Therapy (HBOT) is the administration of 100% oxygen to patients within an airtight tube or chamber at pressure greater than 1 atmosphere • Note: adequate oxygenation of the tissue in primary in wound healing and is needed for collagen transport, fibroblast formation and angiogenesis. A lack of oxygen is called hypoxia • HBOT is usually done once or twice daily approximately 45- 120 minutes in length for up to 4-6 weeks. • This treatment is primarily for diabetic wounds with impaired circulation for limb salvage. Studies indicate that it has no impact of pressure ulcer healing • Oxygen at high doses can be toxic and effect brain, lungs and ears • Often requires travel to HBOT site and in expensive

20. Negative Pressure Wound Therapy (NPWT) • NPWT is a controlled application of continuous or intermittent subatmospheric negative pressure applied to a wound bed by means of a specialized reticulated foam or gauze dressing, tubing attached to a pump and an occlusive adhesive cover dressing so it is air-tight • The purpose of this therapy is to create a balanced moist wound environment by removing excess exudates, bacteria and debris and create tissue growth by means of angiogenesis formation thereby improving blood and oxygen perfusion to the new tissue • NPWT is in place continuously and is changed usually 3 x per week up to an average of 4 months duration. Evidence of wound healing must be shown for this treatment to continue • Pumps are rented and dressings can be expensive if not covered by insurance • Pain management is very important in the beginning of treatment • It is contraindicated for wounds with exposed blood vessels, organs or nerves, malignancy in the wound, untreated osteomyelitis, nonenteric fistulas and wounds with eschar or non-debrided slough

21. Resources • Bryant, R. & Nix, D. (2007). Acute and Chronic Wounds. Current Management Concepts (3rd Ed). Mosby. St. Louis • Hess, C. T. (2008). Skin & Wound Care (6th Ed.) Wolters Kluwer, Philadelphia, PA. • http://advancingthepractice.aawconline.org/index.php?option%0B=com_content&task=section&id=9&Itemid=31 • http://mhcwoundcare.com/downloads/Woundcare_Module6_Glossary.pdf • http://www.nursing.uiowa.edu/sites/chronicwound/ • Krasner, D., Rodeheaver, G. & Sibbald, R. G. (2007) Chronic Wound Care: A Clinical Source Book for Healthcare Professional (4th Ed). HMP Communications, Malvern, PA • Kuehn, B. (2007). Chronic Wound Care Guidelines Issued. JAMA. 279 (9). • Warriner, R. (2005). Infection and the Chronic Wound: A Focus on Silver. Advances in Skin & Wound Care. 18(1), 2-12. • Woo, K., Ayello, E., & Sibbald, R. G. (2007). The Edge Effect: Current Therapeutic Options to Advance the Wound Edge. Advances in Skin & Wound Care. 20(2), 99-117.

22. Thank You for Your Attention Q&A? sschmitt@communitymemorial.com