adjunctive wound therapies

negative pressure wound therapy (NPWT)

mechanical wound care tx that promotes wound healing through the application of subatmospheric pressure or suction to the wound bed

delivered via computerized unit attached to a gauze or foam dressing placed in the wound and secured with an airtight film

causes mechanical stress to tissue stimulating mitosis, formation of new bvs, and wound closure

supports wound healing by removes excess wound fluids, stimulating granulation tissue, reducing bacterial burden, and maintaining a moist wound environment

two types based on dressing used : gauze (PHBM impregnated) or foam

indications": acute and traumatic wounds, subacute (dehisced incisions), stage 3 or 4 PIs, chronic open wounds, meshed grafts, flaps

incisional NPWT

placed over an incision at risk for dehiscence to promote closure

instillation with dwell NPWT

intended for instillation of select fluids into the compromised wound for the purpose of cleansing and decreasing bioburden

contraindications for NPWT

non enteric and unexplored fistulas

necrotic tissue with eschar

untreated osteo, or local/systemic clinical infection

malignancy in the wound

exposed vasculature, nerves anastomotic stie or organs

no exudate

risk factors of NPWT

pt at high risk for bleeding/hemorrhage

pt on anticoags or plt aggregation inhibitors

pt with friable vessels, infected bvs, vascular anastomosis, infected wounds osteo, exposed organ, vessels, nerves, tendons, ligaments

sharp edges in wound

SCI

enteric fistulas

pt requiring MRI, hyperbaric chamber, defibrillation

pt size and weight

use near vagus nerve (causes bradycardia)

circumferential dressing application

mode of therapy: intermitent vs variable vs continuous negative pressure

guidelines for safe NPWT use

do not place interface dressings directly on intact skin

monitor frequently for signs of life threatening complication- bleeding and act immediately if present

stop NPWT if active bleding develops suddnely or in large amount of if frank blood in tubing or canister

ensure adequate vascular supply to lower limb before tx heel or foot PI

debride PI prior to use

ensure entire dressing is removed from wound bed with each dressing change

optimal pressures range 75-125 mmHg

document amount and characteristics of wound exudate in the canister

if pain is expected or reported use a nonadherent dressing on wound bed underneath the foam dressing, lower level of pressure or change type or pressure (cont vs intermittent)

electrical stimulation

transfer of energy to a wound through an electrical current that occurs when one electrode pad is placed over a wet medium in the wound and another on intact skin away from the wound

for the electric circuit to be complete- 2 electrodes must be used

used to imitate the bodys natural “current of injury” in dry (eliminated voltage gradient) or chronic wounds (chronic wounds become negative charge, similar to surrounding tissue)

key components of inflammation (neutrophils, macrophages, plts) all have charges that will be attracted to the charges emitted from the electrical stim therapy re-initiating inflammatory process of healing

effects= inc o2 and nutrient transport to the tissues, reduces edema, reduces pain, increases fibroblastosis and collagen development, improves scar tissue elasticity

e stim indications

PIs- pulse e stim for recalcitrant stage 2 PIs and stage 3 or 4

venous ulcers

traumatic wounds

surgical wounds

ischemic ulcers

donor sites

wound flaps

burn wounds

contraindications for e stim

osteo

presence of cardiac pacemaker

presence of malignancy

placement of electrodes: tangenital to the heart, along regions of phrenic nerve, over carotid sinus, over laryngeal musculature, over topical substance containing metal ions (povidone iodine and mercurochrome) unless thoroughly cleaned

medicare reimbursement for e stim

available when performed by PT or OT and

• after apropriate standard wound care has been tried for at least 30 days and there are no measureable signs of healing

• wound must be evaluated by treating physician no less than q30 days

• continued tx not covered if measurable signs of healing have not been demonstrated within any 30 day period of tx

• must be d/cd when wound demonstrates a 100% epithelialized wound bed

e stim procedure

electrodes can be placed so wound is in the middle or one electrode can be placed directly over the wound and the other a distance away

electrodes are placed over a wet medium

when placed in the wound a moist dressing can be used and then the electrode placed on top of wet dressing

recommended tx time= 60 minutes 5-7 days/week is a drawback

different polarities have different effects on the wound

negative polarity:

• aid epidermal proliferation and migration, inc blood flow, aids fibroblast proliferation, enhanced collagen synthesis, lyses necrotic tissue, dec edema, stimulates granulation

positive polarity:

• attracts macrophages, enhances epithelial growth, acts as bactericidal, aids granulation formation

ultrasound

low frequency sound waves transmitted to the wound usually through a gel medium

the reaction of the bodys tissues to the wound waves differ. muscle tendons and bone absorb these waves more readily than fat but harder surfaces will also reflect the US energy

these differing reaction impact the assoc temp increase of the tissue

as temp increases, so dose the tissues metabolic rate, resulting in inc delivery of o2 to the cells and removal of wastes

tissue can be heated to 40-45 C without causing damage

an increase of 5C can be generated wit a 2 MHz US at 1.5 watts per cm2 for 5 min

assists in wound healing by increasing the presence of macrophages, fibroblasts, endothelial cells and collagen- thought to be from the thermal effects and non thermal effects (cellular micromassage)

• inc collagen elasticity

• dec muscle and joint stiffness

• diminished pain

• dec muscle spasms

• inc o2 transport

• decreases hyperemia

• accelerates wound recovery

• dec edema

indications for US

chronic wounds

recalcitrant wounds

PIs- stage 3 or 4 and DTI

venous ulcers

trauma wounds

contraindications for US

acute infection

osteo

active profuse bleeding

severe arterial insufficiency

acute DVT

necrotic covered wounds

not recommended: near prostheses or electronic implanted devices, over lower back or uterus in pregnant women, over areas of malignancy, on face or head

UltraMIST therapy

delivery of low frequency low intensity US waves to wound through a generated mist of saline using a non contact US device

promotes wound healing by stimulating cells, increasing blood flow and dec bioburden through gentle cleansing

approved by FDA and Medicare

indications

• cleaning of wound with yellow slough, fibrin, or tissue exudates or bacteria

• can be used on acute, traumatic, chronic and dehisced wounds

tx delivered 3x/week for 3-20 min with larger wound receiving longer tx duration

hyperbaric oxygen therapy (HBOT)

pt breathes pure 100% O2 in a chamber that generates an atmospheric pressure greater than sea level for 60-90 minutes

chambers are multiplace (more than one pt) or mono place (single pt)

amount and pressure of dissolved o2 improves supply of oxygen to the bodys tissues resulting in improved tissue oxygenation in hypoxic wound

indications for HBOT

problem/compromised wounds

arterial insufficiency

gas gangrene

osteo

compromised flaps and grafts

burns

DFUs wagner grade 3 or greater

pulsed lavage

hydrotherapy delivered by handheld device that provides pressurized pulsed solution to wound bed for purpose of irrigating and debriding as and evidence based alternative to whirlpool

irrigates wound bed with precisely calibrated pressure, facilitates debridement, removes debris, reduces bateria and infection risk, promotes granulation/epithelium

pros

• optional concurrent suction

• ability to control PSI, 4-15

• undermining and tunnel access

• can be used as an adjunt to other forms of debridement

cons

• tubing and wound tips designed for one time use only and can be expensive

precautions

• pt should be in single room or isolated tx room

• cover bed with waterproof pad or sheet

• therapist wears waterproof gown, goggles, gloves

• pt and therapist both wear masks to prevent inhalation of possible aerosolized organisms

whirlpool is contraindicated for wound care bc

biofilm and psuedomonas are harbored

damage to granulation tissue, interruption of epithelial migration, maceration

venous congestion

bioengineered alternative tissues (BATs)

artificial off the shelf alternative to skin grafts

avoid the pain/potential complications of harvesting and grafting

types

• dermo inductive= actively participate in recruitment and activation of wound bed tissue

• dermo conductive= serve as scaffold matrix only

dermo inductive BATs

Apligraf

• bilayered, composed of bovine collagen and living keratinocytes and fibroblasts from neonatal foreskin

• indicated in conjunction with compression for VLUs of >1 mo age unresponsive to conventional therapy

• must be applied by licensed provider

Dermagraft

• created from seeding of human dermal fibroblasts onto a mesh scaffold

• mode of action basically re-epithelialization

• indicated for greatment of full thickness DFUs

• multiple applications may be needed

dermo conductive BATs

integra

• cross linked bovine tendon collagen and glycosaminoglycan

• biodegradeable matrix provides scaffold for cellular invasion and capillary growth

• multiple indications

Oasis

• porcine small intestine submucosa containing natural collagen and growth factors

• provides scaffold for new tissue growth

• absorbed into wound bed

• muliple indications

GraftJacket

• made from donated human skin with the epidermis and dermal cells removed

• 3 dimensional

• mulitple indications