AAPMR Boston Massachusetts October 4 2015 Logic of
AAPM&R Boston, Massachusetts October 4, 2015 Logic of Products Christine Johnson, MD Associate Professor Physical Medicine and Rehabilitation Department UT Southwestern Medical Center Dallas, Texas 1
Disclaimer • C. Johnson, MD – – nothing pertinent to disclose • J. de Leon, MD - – nothing pertinent to disclose 2
Learning Objectives 1. Understand the basic phases of healing and how to set proper goals for wound care. 2. Understand the basic mechanisms of action for dressing categories and modalities. 3. Be able to logically create an appropriate wound care strategy for basic wounds of all types 3
Products
Dressing Categories Cleansers Wound Hydration Exudate Management Calcium Alginate Normal Saline Antimicrobials Vitamin Ointments Odor Absorbing Dressings Enzymatic Silver Gauze Super absorbent Stimulants Moisture Retention Collagens Hydrofiber Antiseptics Debridement Agents Adjunctive Dressings / Modalities Contact layers Antibiotics Hydrogels Foam Odor Management Hydrocolloid Hyaluronic acid Compression Growth factors NPWT Amniotic tissue Methylene Blue/Gentian Violet Metronidazole Autolytic Skin substitute Transparent film Ultrasound Radiofrequency 5
WOUND MOISTURE LEVEL AS CONTINUUM NECROTIC CLEAN • Autolytic • Promote Granulation • Mechanical • Promote Epithelialization • Enzymatic • Prevent Infection • Excisional • Keep dry with Betadine Swab DRY • Hydrate WET MOIST • Maintain Moisture • Absorb/Manage Moisture • More Occlusive • Less Occlusive • Change Less Frequently • Change More Frequently • More Absorbent Filler • Decrease Wound Stimulants 6
Goal of Treatment • • • 7 NECROTIC WOUND Debridement of Necrotic Tissue Mechanical Enzymatic Autolytic Excisional Keep dry with Betadine Swab CLEAN WOUND Promote Granulation Promote Epithelialization Prevent Infection Protect Structures
Cleansers q AHCPR guidelines report that pressures between 4 and 15 pounds per square inch (psi) are the most suitable for wound cleansing q Clean, noninfected wounds can be gently cleansed with NS or other noncytotoxic solution to minimize disruption of healthy tissue § Spray bottle – 1. 2 psi § Bulb Syringe – 2. 0 psi § Water Pik at lowest setting – 6. 0 psi § 35 ml syringe with 19 gauge needle – 8. 0 psi § Water Pik at middle setting – 42 psi § Water Pik at highest setting - >50 psi q Use pressures of less than 30 psi to selectively debride necrotic tissue while minimizing harm to healthy tissue q Irrigation with antiseptic or antibiotic solutions can be cytotoxic to exposed wound healing cells q Examples – Blairex, NS, Shur Clens, Carra. Klenz, Restore, Allclenz 8
Antiseptic Solutions Actions Acetic Acid • Effective against • Toxic to fibroblasts in standard Pseudomonas aeruginosa in dilutions superficial wounds • Changes color of exudate, which may provide false assurance for elimination of infection • Use only 24 -48 hours Hydrogen Peroxide • Provides mechanical cleansing and some debridement by effervescent action Colloidal Silver 9 Special Considerations • Can cause ulceration of newly formed tissue • Toxic to fibroblast in 1999, the U. S. Food and Drug Administration (FDA) ruled that these colloidal silver products were not considered safe or effective
Antiseptic Solutions Actions Special Considerations Povidone-iodine preparations (Betadine) • Broad spectrum effectiveness when used on intact skin or small, clean wounds • Toxic to fibroblasts in normal dilutions • Not always effective in infected wounds • Long-term use in wounds may cause iodine toxicity Sodium hypochlorite solution (Dakins) • Effective against Staphylococcus and Streptococcus species • Dissolves necrotic tissue • Controls odor • Toxic to fibroblasts in normal dilutions • Protect intact surrounding skin to prevent breakdown • Use only 24 -48 hours Hypochlorous acid solution ( Vashe, Microcyn) • highly active against all bacterial, viral, and fungal human pathogens • a small amount can kill sporeforming and non-spore bacteria in a short time • Less cytotoxic to fibroblast cells 10
DRESSING CATEGORIES 11
HYDROGELS • Hydrophilic non-adhering polymers, usually contain a high percent of water • May contain additives that enhance performance or absorbency • Maintains a moist wound bed • Autolytic debridement • Sheet or gel • Example: Flexigel, Vigilon, XCell, Purilon, Duoderm Gel, Carrasyn, Curasol, Hypergel 12
ALGINATES • Soft, non woven fibers, derived from brown seaweed • Absorbent • Interacts with wound exudate to form a soft gel • Hemostatic properties • Autolytic debridement • Sheet or rope • Examples: Seasorb, Kaltostat, Algisite, Sorbsan, Curasorb 13
HYDROFIBERS • Nonwoven sheet of sodium carboxymethylcellulose, hydrophilic • Absorbent • Forms a highly absorbent gel at the wound interface so that the wound interface remains moist • Hemostatic properties • Autolytic debridement • Sheet or rope • Example: Aquacel 14
FOAMS • Polyurethane pad, sheet or pillow dressing • Absorbent • Manages drainage through evaporation or absorption depending on product • Different backings, thicknesses • Examples: Mepilex Transfer/Lite, Biatain, Lyofoam A, Allevyn, Allevyn A, Allevyn Cavity Plus, Polymem, Hydrofera 15
Absorptive Cover/Composites • Dressings which combine 2 or more physically distinct products and are manufactured as a single dressing • Features may include a bacterial barrier, an absorptive layer (not alginate, foam, hydrocolloid, or hydrogel), semi/non-adherent property for covering the wound, adhesive border • May facilitate autolytic debridement • Examples: Combiderm, Primapore, Covaderm, Alldress, Telfa Island 16
17 Semi-occlusive/Semiimpermeable Gauze Calcium Alginates Hydrofiber Films Hydrogels Non. Occlusive/Permeable Open to Air Impregnated Gauze Foams Hydrocolloids Occlusive/Impermeable Moisture Vapor Permeability
HYDROCOLLOIDS • Hydrophilic colloidal particles “molded” into adhesive wafers (gelatin, pectin, carboxymethylcellulose). • Occlusive or semiocclusive • Autolytic debridement • Self adhesive • Examples: Comfeel Plus/Clear/Triangle, Duoderm CGF/Extrathin/Signal, Replicare, Restore 18
FILMS • Adhesive • Semipermeable, vary in thickness and size • Waterproof, impermeable to bacteria and contaminants • Permit moisture vapor to cross barrier • Autolytic debridement • Examples: Tegaderm, Opsite, Bioclusive 19
CONTACT LAYER • Thin, non-adherent sheets placed directly on an open wound bed to protect the wound tissue from direct contact with other agents or dressings applied to the wound • Examples: Mepitel, Dermanet, Adaptic, N-terface, Dermagran Gauze, Restore 20
What is the main reason to use a HYDOGEL? 1. To absorb wound drainage 2. To add moisture to a wound 3. To stimulate a wound 21
A dressing best utilized to absorb a moderate amount of drainage is 1. A Gauze 2. A Hydrogel 3. An Alginate 4. A Hydrofiber 5. Both 3 & 4 22
Which secondary dressing is more occlusive? 1. Film 2. Hydrocolloid 3. Gauze 4. Alginate 5. Non-Adhesive Foam 6. Hydrofiber 23
Antimicrobial Treatment • Topical Antibiotics – Selectively cytotoxic (acting on bacteria without harming the wound bed tissue) – Narrow spectrum of activity – May promote microbial resistance • Topical Antiseptics – Broad spectrum – Not selectively cytotoxic (kill bacteria but also healthy tissue) – Short duration of action and poor delivery system (bind to alternate sources of protein in the wound and become unavailable) – Silver
Silver • Topical anticeptic • Mechanism of action – AG ionizes to Ag+ – The cation attaches to proteins resulting in structural and functional changes in the cell. • Binds to protein in cell wall, causing rupture and death of the bacterial cell • Binds to bacterial enzymes and prevent their function, resulting in death of the bacterial cell • Bind to bacterial DNA and interfere with cell division and the replication process • No bacterial resistance (so far) – Due to the existence of multiple binding sites for silver • New time released dressings • Examples: Biatain AG, Aquacel AG, Acticoat, Silverlon, Arglaes, Maxorb AG, Silvasorb, Silver. Cel, etc
SILVER Acticoat Silvasorb Gel Algicell AG Puracol AG Interdry ag Maxorb AG Mepilex AG Kerracontact AG Elta Silver. Gel 26
Methylene Blue and Gentian Violet • Bacteriostatic • broad spectrum of activity against microorganisms commonly found in wounds, including methicillin-resistant Staphylococcus aureus (MRSA) and vancomycinresistant enterococcus (VRE) Methylene Blue, Gentian Violet, Silver 27
Odor Absorbing • Some contain activated charcoal • Some contain cyclodextrins • Provide absorption • Manage odor • Examples: Exuderm Odor. Shield, Carboflex 28
Metronidazole • Flagyl • Medication used in wound care to: §Assist with managing the odor from the wound §Assist with decreasing the drainage from the wound §Apply in crushed form and sprinkle on to the wound bed Paul, J and Pieper, Barbara. Topical Metronidazole for the Treatment of Wound Odor: A Review of the Literature, Ostomy Wound Management, March 2008; Vol 54, Issue 3. 29
Debridement Agents • Debridement Agents – Proteolytic • Derived from papaya (Removed from Market by FDA) • [Accuzyme, Panafil] • Site of action – cysteine residues on proteins. Inactive against collagen • Pain and inflammation have been associated with use – Collagenase • Found in collagen • [Santyl] • Site of action – collagen fibers anchoring necrotic tissue to wound bed • Slight transient erythema in surrounding tissue 30
Debridement Agents • Medihoney, Therahoney • • • Manuka Honey derived from the Leptospermum species of plant in New Zealand Mechanisms of Action 1. High Osmolarity • Provides an optimally moist environment conducive to wound healing • Assists with Autolytic Debridement by promoting an outflow of wound fluid helping to soften and liquefy necrotic tissue 2. Low p. H • Has a low p. H of 3. 5 -4. 5 • Helps to lower p. H levels within the wound • Chronic wounds tend to have high p. H
Collagens
Role of Collagen in Tissue Repair • Helps to stop bleeding (hemostatic properties) • Has a low-inflammatory and low-antigenic response, which does not cause an adverse reaction (even when collagen from different species is used) • Enhances the deposition of new collagen and reduces wound contraction • Collagen fragments (peptides – formed on degradation of the dressing) can attract cells into the wound area (chemotaxis) and induce cell growth (cell proliferation) • Collagen peptides break down to amino acids, which can be reused by the cells to help build new proteins • Reduces MMP activity, an effect that helps control the proteolytic environment in the chronic wound
Product Collagen Source Type Form Bio. Pad Equine 1 Native Matrix 100% Silverlon Biostep Porcine 1 Denatured Matrix 55% Smith and Nephew Cellerate Bovine 1 Hydrolyzed Gel 65% Powder 96% Wound Care Innovations Endoform Ovine 1 and 3 Native Structure Pad 90% Native 10% Matrix Hollister Fibracol Plus Bovine / Alginate 1 Native Pad / Rope 95% Systagenix Promogran Bovine / ORC 1 Denatured Matrix 55% Systagenix Prisma Bovine/ORC Silver 1 Denatured Matrix 55% Systagenix Puracol Bovine 1 Native Matrix 100% Medline
Acell • Matri. Stem Products are a complex protein scaffold obtained from the tissue of pigs, which has a structure nearly identical to that of human tissue • Pig bladder
Pri. Matrix® • Derived from fetal bovine dermis • Acellular dermal matrix provides an environment to support cellular repopulation and revascularization processes critical in wound healing. • Rich in Type III collagen, a collagen found in fetal dermis that is active in developing and healing tissues.
Oasis Derived from porcine small intestinal submucosa (SIS)
Hyaluronic Acid • • • Connective tissue is made up of cells and extracellular matrix. The cells include fibroblasts which synthesize collagen, fat cells, macrophages, mast cells, plasma cells and leukocytes. The extracellular matrix consists of collagen fibers, elastic fibers and proteoglycans. Proteoglycans are composed of a core protein linked to a variable number of negatively charged polysaccharide chains ( glycosaminoglycan). These large anions bind water and cations and subsequently form the ground substance of connective tissue.
Hyaluronic Acid • • Proteoglycans tend to form aggregates by linking to a single Hyaluronic Acid chain. The size and make up of these proteoglycans determines the ability to sequester water and subsequently the viscoelastic, osmotic, and permeability properties of the connective tissue. Tissue hydration facilitates cell proliferation and migration. Hyaluronic acid in its native form is readily degraded in the wound bed. Esterification and manufacturing into a fleece material (Hyalo. Matrix ™) allows a controlled rate of delivery to the wound bed.
Growth Factors • Growth Factors – Platelet Derived Growth Factor (PDGF) – Macrophages also secrete PDGF. – PDGF helps mediate the adhesion of neutrophils and macrophages to endothelial cells (chemotactic). – Fibroblasts stimulated by PDGF proliferate and secrete collagen and extracelllular matrix components – Once activated by PDGF, the fibroblast also secretes PDGF to assist the macrophage in inducing other fibroblasts, endothelial cells, and smooth muscle cells to replicate – Stimulated macrophages also secrete vascular endothelial growth factor (VEGF) which stimulates angiogenesis. – Exogenously applied growth factors can be degraded by matrix metalloproteinases (MMP) or absorbed or inactivated by gauze or dressings. – Regranex (becaplermin 0. 01% gel) is a nonsterile topical gel containing a bio-engineered recombinant human platelet derived growth factor. – Regranex is an active enzyme that must be stored in an appropriate temperature range – cool but not frozen. Heating inactivates the enzyme so being left without refrigeration may render it ineffective. Approved only for DM foot ulcers
Bio-engineered Tissue / Skin Substitute • Apligraf – Cultured bilayer dermal-epidermal skin substitute – Comes in a circular disk of Bovine I (tendon) base collagen in latice form which supports fibroblasts and dermal epithelial cells. Over this is a layer of allogenic keratinocytes forming a stratified epidermis. – Graft is viable for 2 -3 days after shipment – Once opened, the application should occur within 2 hours Approved only for DM • Dermagraft – Cryopreserved bio-engineered tissue of human neonatal fibroblast cells seeded on a biodegradable mesh of type I bovine collagen. – Does not contain macrophages, lymphocytes, blood vessels, or hair follicles
Amniotic Tissue • • Human amniotic membrane is comprised of the innermost layer of the placenta and lines the amniotic cavity. The membrane is composed of multiple layers including a single layer of epithelial cells, a basement membrane and an avascular connective tissue matrix. Amniotic membrane is a unique material and its composition contains collagen types I, III, IV, V, and VII. Amniotic membrane is composed of structural extracellular matrix (ECM), that also contains specialized proteins fibronectin, laminins, proteoglycans and glycosaminoglycans. In addition, amniotic membrane contains essential, active, healing growth factors such as epidermal growth factor (EGF), transforming growth factor beta (TGF-b), fibroblast growth factor (FGF), and platelet derived growth factor (PDGF). 8 Amniotic tissues have shown little to no HLA-A, B, C antigens and β 2 microglobulin. 3 Examples: Amnioband, Epifix, Grafix, Biofix, Amnio. Excel
Platelet Rich Plasma • (Autologel) • The Autolo. Gel System formulation is designed to provide: 1. Platelet releasate gel containing growth factors, cytokines, and chemokines for cell growth and formation of new tissue 2. Plasma derived fibrin and fibronectin scaffolding for cell migration 3. Proprietary formulation for increased synthesis and assembly of collagen 4. Plasma and platelet derived inhibitors of metalloproteinase activity (TIMPs) that combat destructive protease activity 5. Human serum albumin to block neutrophil spreading and release of damaging free radicals 6. Proprietary additions to scavenge damaging free radicals 7. Plasma gel for a moist wound environment
Electroconductive Dressings • (Silverlon, Procellera) • Procellera™ is applied as a single layer dressing, consisting of a woven absorbent polyester containing elemental silver and zinc, and provides an effective barrier to microbial penetration for partial and full-thickness wounds. • The characteristic which makes Procellera ™ a unique wound dressing is that a small amount of current is produced and it occurs because it is inherent to the design. When activated, the presence of adjacent positive and negative charged cells spontaneously produce a sustained predetermined current of specific depth similar to the current that occurs at areas of skin injury in normal hosts. This physiologic current of injury is necessary for the initiation of wound healing and the transport of cells to the healing wound site. • Additionally, microbial killing in a bioelectric field is enhanced by the fact that electrically charged microbes are attracted to the positive pole. Gram negative and positive microbes carry a negative charge. All microbes, therefore, are attracted to the positive pole containing silver. Silver then binds the sulfhydril groups of the microbes and denatures the proteins that destroy the respiratory function of the microbe as well as other essential proteins within the microbe. Silver also kills viruses and fungi in a similar method by binding with sulfhydril groups and denaturing other proteins. Moisten if needed with sterile saline or water Dots side down Pack with gauze or foam to maintain contact in wound base and secure with appropriate cover dressing
Compression Wraps • Multilayer compression bandage system. Graduated compression from toes to knee (provides higher pressure at the ankle, with decreasing pressure exhibited at the calf. ) • Decreases edema, reduces pain, helps fluid move out of the leg and be recirculated by the body, aids in healing venous leg ulcers • Do not use on patients with an ankle brachial pressure index (ABPI) of less than 0. 8, or on diabetic patients with advanced small vessel disease. • Profore/Profore Lite, Unna Flex, Unna Boot, Sure Press, Circaid, Jobst stocking 45
Which of the following is not true? 1. No pathogen has been resistant to ionized silver due to its multiple binding sites. 2. Release of ionized silver is decreased when used in combination with saline products. 3. Silver can be used to cure an existing infection. 4. Silver products have different concentrations of silver. 46
Which of the following products is not a wound stimulant? 1. Hyaluronic acid 2. Alginate 3. Collagenase 4. Collagen 5. Amniotic tissue 47
If a wound stays too dry with an telfa island dressing, then 1. Add a hydrogel 2. Switch the cover dressing to a hydrocolloid 3. Switch the cover dressing to adhesive foam 4. Switch the cover dressing to a semipermeable film 5. Change less frequently 6. All of the above 48
Modalities 49 • Ultrasound • Negative Pressure Wound Therapy • Radiofrequency • Hyperbaric Oxygen
MIST Therapy® System Therapeutic Ultrasound Ultrasound Applications High Intensity Ultrasound Low Intensity Ultrasound MHz Thermal Diagnostic Imaging High Frequency Sports Medicine Fetal Monitoring Physical Therapy Typically 1 -3 MHz k. Hz Debridement Wound Healing Low Frequency Söring, Misonix (22. 5 KHz), Arobella (35 KHz) MIST Therapy 40 KHz A form of mechanical energy, not electrical energy Mechanical vibration at increasing frequencies is known as sound energy Normal human sound range is 15 Hz- 20, 000 Hz so beyond that limit is ULTRASOUND
Noncontact Ultrasound
Non-Contact Ultrasound Therapy (MIST) Post Treatment • • • Promotes wound healing Non-contact reduces the potential for bacterial cross contamination Efficient and effective wound cleansing Selective debridement of nonviable tissue Removal of exudates Removal of bacteria and reduction of bioburden Assists flap and graft take Assists tissue granulation Helps promote perfusion Non-contact patient friendly wound treatment Methicillin Resistant Staph aureus -MRSA control Post-treatment 52
Contact Ultrasound • • Low-frequency ultrasound has been shown to have cellularlevel physical effects, known as cavitation and microstreaming, that can promote healing. Cavitation is the formation and oscillation of microscopic bubbles, which expand collapse as they resonate with the ultrasound frequency. It assists in fragmentation/debridement of non-viable, necrotic tissues, and it is also bacteriocidal Acoustic microstreaming is the physical force of sound pressure waves that can displace small molecules and move fluids along and/or through cell membranes. Cells are stimulated to release NO (nitric oxide) resulting in resolution of vasospasm and vasodilatation of blood vessels and an increase in blood flow to the treated site. The system's unique, dome-shaped Qoustic Qurette™ vibrates at 35 k. Hz, converting electrical energy to ultrasound waves and focusing them intensively on the wound. Sterile saline solution transfers the ultrasonic energy to the wound, where tiny vibrating gas bubbles and cellular-level fluid movement separate dead and harmful cells from healthy tissue.
Negative Pressure Wound Therapy (NPWT) • • KCI Freedom VAC KCI ATS VAC KCI Info. VAC KCI Acti. VAC KCI Provena Incisonal VAC KCI VAC Ulta with Verflow Smith & Nephew PICO Incisional Dressing SNa. P
V. A. C. ® Therapy Prepares the wound bed for closure • Maintains a moist wound environment • Removes exudate and infectious material • Promotes perfusion • Reduces edema • Promotes granulation tissue formation
Provant Fibroblast Stimulator • Provant Wound Closure System is based on Cell Proliferation Induction (CPI) technology. CPI uses a radiofrequency to stimulate dormant cells. • Stimulation causes cells to release growth factors and divide rapidly.
Hyperbaric Oxygen Therapy • There is no significant topical absorption of oxygen • Must be applied systemically • Patient breathes 100% oxygen while inside a treatment chamber at an atmosphere pressure higher than sea level.
HBO • Inhalation of pure 100% O 2 under increased atmospheric pressure • Benefits: – increase in the overall pressure to reduce the volume of inert gas bubbles • Decompression illness – Increase partial pressure of oxygen in tissues • Local wound healing – Increased oxygen transport capacity • Carbon monoxide poisoning
HBO • Increased oxygen transport capacity of the blood • Under normal atm pressure, O 2 transport limited by the oxygen binding capacity of hemoglobin • At normal atmospheric pressure, 97% of delivered oxygen is hemoglobin bound – 3% dissolved in plasma • Under hyperbaric conditions, arterial oxygen tensions – can exceed 2000 mm Hg – 10 -20 fold increase
WOUND MOISTURE LEVEL AS CONTINUUM NECROTIC CLEAN • Autolytic • Promote Granulation • Mechanical • Promote Epithelialization • Enzymatic • Prevent Infection • Excisional • Keep dry with Betadine Swab DRY • Hydrate • More Occlusive • Change Less Frequently WET MOIST • Maintain Moisture • Absorb/Manage Moisture • Less Occlusive • Change More Frequently • More Absorbent Filler • Decrease Wound Stimulants 60
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