Sutures Wound Dressings 932021 1 Wound Care and

Sutures & Wound Dressings 9/3/2021 1

Wound Care and Management l l More than a million Americans suffer from non-healing wounds annually, at a cost of $750 million; Etiology: trauma, inactivity, disease and surgery; 3, 852 wound care products on the market; Some classified as drugs or biologics, while others are classified as devices; 9/3/2021 2

Wound Care Products Goals: l Bind surface epithelium and underlying connective tissues when possible; l Protect wound from infection; l Maintain moist wound environment; l Permit gas exchange; and, l Promote rapid epithelialization. 9/3/2021 3

Principles of Wound Healing l l Hemostasis Inflammation Granulation Tissue remodeling or maturation 9/3/2021 4

Keys to Wound Care l l Identify the causative factors Improve the local environment 9/3/2021 5

Common Underlying Causes of Wounds l l l 9/3/2021 l Trauma-accident or intentional (surgery) Scalds and burns (chemical and physical) Animal bites or insect stings Pressure (spinal injured) Vasculature related, arterial, venous, mixed Immunodeficiency Malignancy Connective tissue disorders Metablolic or endocrine disorders (diabetes) Nutritional deficiencies Psycho social Adverse effects of medications 6

Timetable of Wound Healing l l Hemostasis Inflammation Granulation Tissue remodeling or maturation 9/3/2021 immediate 1 -4 days 4 -21 days-2 years 7

Chronic Wound diagnosis Treat cause Debride Local Wound Care Patient Centered Concerns Cleanse and absorb-Bacterial Management Protect-Moist Interactive Healing Non-healing Wounds 9/3/2021 Biological agents 8

Wound Color Black. Necrotic tissue is non-viable, and it must be removed before healing can take place. Yellow wounds may contain moist necrotic tissue (slough) and/or contain purulent drainage. The primary objective is to remove unhealthy tissue, any contaminants, debris and excess exudate which deter the healing process. Once a clean, moist and viable wound bed is achieved, healing can begin. Red. Is good-the actively healing phase of a wound, cells proliferate, fibroblasts form collagen and eventually small, red, fleshy masses called granulation tissue (angiogenesis) begin to 9/3/2021 9 form.

History of Biomaterials in Medicine l l l Ancient cultures used primitive materials from their natural surroundings to heal their wounds and to cure diseases. The oldest known use of bandages -Sumeria (2100 BC). a medical manuscript written on stone tablets describes detailed procedures of washing wounds, making plaster, and bandaging. 9/3/2021 10

“Early Wound Dressing” Natural adhesive bandages were used 4, 000 years ago by the Egyptians. l In the Edwin Smith papyrus, Egyptians wrote of using woven bandages soaked in a quick setting plasters used as adhesive tapes were discussed in the manuscript. l The oldest bandages that have been found were in the tombs of the Pharaohs. l 9/3/2021 11

Sutures l l Used as the means of repairing damaged tissues, cut vessels, and surgical incisions. Initially a variety of natural materials were used: flax, hair, linen strips, pig bristles, grasses, mandibles of pincher ants, cotton, silk, and the gut of an animal 9/3/2021 12

Sutures l l l The largest group of devices implanted in humans; By definition, a suture is a filament that either approximates or maintains tissues in juxtaposition until the natural healing process has provided a sufficient level of wound strength or compresses blood vessels in order to stop bleeding; Classified into one of two groups, absorbable and nonabsorbable; 9/3/2021 13

Commercially Available Sutures l l l 9/3/2021 l cellulose based (cotton) protein-cellulose (silk) processed collagen (catgut) nylon Polypropylene Aramid Alha-hydroxy acids polyglycologic acid polyglycolide-lactide polymer polytetraflourethylene Stainless steel aluminum alloys 14

Test Specifcation for Sutures l l l l 9/3/2021 l breaking strength elongation-to-break Young's modulus knot security viscoelastic properties tissue reaction cellular response cellular enzyme activity suture metabolism chronic toxicity teratologics mutagenicity carcinogenicity allergenicity Immunigenicity 15

Suture Size 9/3/2021 16

Staples Thin metal used to approximate the edges of the skin (area must be anesthetized); l Staple appliers push the two prongs of the staple down through the epidermis and dermis into the subdermal layer and then bend these prongs inward; l Once these prongs have been bent inwards, the positions of the skin edges are fixed; l The major advantages are speed of closure and less scarring. l Indicated on scalp and abdomen (tendons, nerves 9/3/2021 deep) l 17

Stapling a Craniotomy Skin Incision 9/3/2021 18

Staples 9/3/2021 19

Staple Considerations l If the edges are not lined up flush, misalignment will be maintained during the healing process and may impede the formation a skin layer across the skin surface or result in excessive scar tissue formation. 9/3/2021 20

Removal • removed by your health care provider 3 to 14 days after they are put in. 9/3/2021 21

Materials Used for Hemostais l Surgical cellulose is a material that is comes in thin sheets of interwoven specially treated cellulose that provides a matrix to which platelets and clotting factors can adhere leading to formation on the cellulose of a dense clot which can act as a patch over an area of bleeding. 9/3/2021 22

Tissue Adhesive l l l Indicated for the closure of topical skin incisions including laparoscopic incisions, and trauma-induced lacerations in areas of low skin tension that are simple, thoroughlycleansed, and have easily approximated skin edges. INDERMILTM Tissue Adhesive Receives FDA Approval for Closure of Topical Skin Incisions and Lacerations Indermil may be used in conjunction with, but not in place of, deep dermal stitches. 9/3/2021 23

Device Description l l l Tissue adhesives are sterile, liquid topical composed of n-Butyl or octyl-2 -Cyanoacrylate monomer supplied in a 0. 5 g single patient use, plastic ampule. Each ampule is sealed within a foil packet so the exterior of the ampule is also sterile. Remains liquid until exposed to water or watercontaining substances / tissue, after which it cures (polymerizes) and forms a film that bonds to the underlying surface. 9/3/2021 24

Traditional Wound Care Products Protective and gas permeable l l l Transparent Films Foams Hydrocolloids or Hydrogels l l 9/3/2021 Alginates Specialty Absorptive Dressings 25

Transparent Films l l l 9/3/2021 l Acu-derm Bioclusive Blisterfilm Polyskin II Pro-Clude Op-Site Opraflex Tegaderm Transeal Transite Uniflex Ventex 26

Infection Control Products -Dressings to Secure Catheters l a thin, semi-occlusive, transparent polyurethane film dressing that provides a bacterial/viral barrier and helps secure catheters, reducing mechanical irritation. 9/3/2021 27

Transparent Films l l 9/3/2021 Advantages: l Waterproof and Bacteria-proof l Allows visualization of the wound. l Won’t traumatize wound when removed. Disadvantages l Not rec. for wound with moderate/heavy exudate. l Not rec. for wound with fragile surrounding skin. l Provides no cushioning to wound. 28

Foams Examples l Allevyn l Cutinova Foam l Epilock l Flexzam l Hydrasorb l Lyofoam l Mitraflex l Nu-derm l Polymem 9/3/2021 l Tielle l 29

Foams-polyurethane pads -Indications: Noninfected, draining granular wound l Advantages l Non-adherent l Won’t injure surrounding skin l Can repel contaminants l May be used under compression l Cushions wound surface l Maintains moist wound evironment l Highly conforming l Gas permeable 9/3/2021 30

Hydrocolloids in pad, sheet or filler form for occlusive use. Forms a “gel” as it absorbs water from the wound bed that sits on wound Indications: Small, solitary non-draining ulcers or light-to-moderate exudate wounds l Advantages l Impermeable to bacteria and other contaminants l Promotes autolysis, angiogenesis, and granulation l Self-adhesive and molds well l Limited-to-moderate absorption l Creates moist environment l May be left in place for up to 5 days l May be worn in the shower 9/3/2021 31

Hydrocolloids l l l 9/3/2021 l Aqua. Cel Comfeel Cutinova Hydra Duoderm Hydrapad Intrasite J&J Ulcer Dressing Procol Replicare Restore Triad Ultec 32

Hydrogels -cross-linked hydrophilic matrix impregnated into gauzetype pads which allows transmission of water, vapor and CO 2 but discourages dehydration. Indications: full thickness wounds with moderate drainage l Soothing and conforms to wound l Fills in dead spaces l Highly absorptive l Can be used on infected wounds l Disadvantages l Difficult to keep in place l Encourages gram negative organisms 9/3/2021 33

Hydrogels l l l 9/3/2021 Aqua. Sorb Carrington Gel Carrasyn-V Clear-Site Curasol Gel Flexderm Hydron Intrasite Gel Solosite SAF-Gel Transorb Woun. Dres 34

Adhesive Gel Sheets for Scar Treatment l l l Flexible, adhesive, semiocclusive silicone gel sheet. Reduces raised scars and redness of the scar so it fades and becomes less noticeable. Self-adhesiveness and durability mean that application is simple and the gel sheet can be washed and used several times. 9/3/2021 35

Resorbing Matrices l l Matrix is a primary dressing which transforms into a soft, conformable gel, allowing contact with the entire wound bed; Consists of 45% regenerating cellulose and 55% type I collagen 9/3/2021 36

Resorbing Matrices l l The persisting inflammatory phase in chronic wounds contributes to exudate with high concentrations of matrix metalloproteases (MMPs); Excess MMPs result in degradation of extracellular matrix proteins; Excess MMPs inactivate growth factors; cellulose/collagen combination binds more MMPs than ORC or collagen alone 9/3/2021 37

Apligraf® human skin-like products comprised of living human skin cells 9/3/2021 Organogenesis 38

Living Skin Equivalents l Living bi-layered skin substitutes l l 9/3/2021 Apligraf (formerly Graftskin) l Type I bovine collagen, extracted and purified from bovine tendons, and viable allogenic human fibroblast and keratinocyte cells. Dermagraft l Human neonatal fibroblasts derived from fetal foreskin, extracellular matrix and a bioabsorbable suture like scaffold. 39

Living Skin Equivalents Indications: diabetic foot ulcer care of full-thickness ulcers of neuropathic etiology of at lease three weeks duration and burns Contraindications: -infections -exposed bone, capsule, muscle or tendon 9/3/2021 40