Update on Wound Bed Preparation: a Review of the Principles of Treating the Root Cause of Wounds, Pain and Wound Healing, and Local Wound Care

Home , Chronic wound, Wound assessment, Wound bed preparation

CONFERENCE HIGHLIGHTS Update on Wound Bed Preparation: A review of the principles of treating the root cause of wounds, pain and wound healing, and local wound care

PRESENTERS : ttendees at this session were introduced TABLE 1 to the following concepts of wound bed R. G ARY SIBBALD preparation: Treatments for the causes BS C MD FRCPC A of various wounds (M ED ) FRCPC • treating the cause and addressing (D ERM ) patient-centred concerns, including pain; Wound type Treatment of the cause • understanding healable, non-healable and maintenance KEVIN WOO Venous Bandages for healing. wounds in the context of wound bed preparation; RN MS C ACNP ulcer Stockings for maintenance. • optimization of local wound care (i.e. debridement, GNC(C) Pressure Relieve, reduce and infection–inflammation and moisture balance); and LAURIE GOODMAN ulcer redistribute pressure. • understanding superficial critical colonization and RN BA IIWCC Promote activity and decrease deep infection. immobility. Manage incontinence Treat the cause and moisture. Dr. Sibbald began by showing the wound bed prepar- Reduce shear and friction. ation paradigm in patients with chronic wounds Enhance and optimize nutrition. (Figure 1). With respect to treating the cause, the following recommendation apply: determine the Diabetic Ensure that the vascular supply blood supply available to promote healing; identify foot ulcer is adequate. and treat the cause (if possible) to determine heal- Control infection. ability; and review the cofactors and comorbidities to Redistribute plantar pressure. create an individualized plan of care. Table 1 outlines

R. Gary Sibbald is a FIGURE 1 professor at the Wound bed preparation paradigm Dalla Lana School of Public Health at the Persons with Chronic Wounds University of Toronto and president of the World Union of Wound Treat Cause Healing Societies in Patient-Centred (e.g. vascular supply, Local Wound Care Toronto, Ontario. edema, pressure, shear) Concerns: Pain Kevin Woo is an assistant professor Infection in the School of Debridement of Moisture (superficial/deep) Nursing at Queen’s Devitalized Tissue Balance Downloading Inflammation University in Kingston, Ontario. Laurie Goodman is a nurse clinician at the Edge-Non-healing Wound Skin & Wound Care Biological Agents, Growth Factors, Skin Substitutes, Credit Valley Hospital in Adjunctive Therapies Mississauga, Ontario.

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1.800.263.7400 Hollisterwoundcare and the wave logo are trademarks of Hollister Incorporated. RESTORE, TRIACT and the TRIACT graphic are trademarks of Hollister www.hollisterwoundcarsterwoundcarre.come.com Wound Care LLC. ©2011 Hollister Wound Care LLC. treatments for the causes of various wounds. wounds (where cytotoxicity is less important than A maintenance wound is defined as a healable antimicrobial action) include chlorhexidine, povidone wound with healthcare system problems for delivery iodine, crystal violet/methylene blue and acetic acid. of services, or a non-healable chronic wound that is not deteriorating. In non-healable wounds, moisture Pain and wound healing balance and active debridement are contraindicated; Kevin Woo noted that chronic wounds are indeed however, the use of topical antiseptics has been shown quite painful. The following data have been compiled to decrease local bacterial counts. regarding chronic wounds and patient pain. Antiseptic agents that can be used for non-healable • Leg ulcers: 65–83% of patients with arterial ulcers reported pain. 1

TABLE 2 • Pressure ulcers: 84% of patients reported pain at Strategies and objectives for pain management rest; 88% reported pain with dressing changes. 2 Strategy Objectives • Diabetic foot ulcers: 75% of patients reported painful symptoms. 3 Education Web-based learning Face-to-face education: There are 2 main triggers of wound pain: wound- • Explain mechanism of pain related triggers (e.g. underlying pathology, infection, • Dispel misconceptions about pain inflammation) and procedure-related triggers (e.g. • Address concerns about addiction debridement, dressing removal, cleansing, repos- • Emphasize the availability of multiple strategies itioning). Pharmacological Topical: • Ibuprofen (dressing) Arterial ulcer pain can be classified in the following • Morphine 3 ways: • Lidocaine • Nociceptive: inflammatory response, local infection, Systemic: gangrene, claudication, vasospasm. • Nociceptive pain: ASA, NSAIDs, acetaminophen • Neuropathic: nerve damage, local ischemia, diabetes, for mild to moderate pain trauma. • Opioids for moderate to intense pain • Iatrogenic: dressing changes, debridement, retention • Neuropathic pain: SNRIs, anticonvulsants bandages. Local wound care Atraumatic interface (silicone) Sequester: remove inflammatory mediators Venous ulcer pain can be classified in the following Protect periwound skin 3 ways: Treat infections • Nociceptive: edema, eczema, lipodermatosclerosis, Anxiety reduction Relaxation phlebitis, atrophie blanche, local infection. Imagery • Neuropathic: nerve damage, local ischemia. Distraction • Iatrogenic: dressing changes, compression bandages. Education Music therapy Diabetic foot ulcer pain can be classified in the follow - Support groups ing 3 ways: Cognitive therapy Cognitive behavioural therapy • Inflammatory response, local infection, local trauma Problem-solving skills (Charcot). Positive thinking • Neuropathic: nerve damage, local ischemia, cramps, Therapeutic alliance Communication techniques autonomic dysfunction. (e.g. reflective listening) • Iatrogenic: cast/shoe/footwear, dressing changes, Goal-setting debridement. Align expectations Demonstrate sympathy Pressure ulcer pain can be classified in the following Empowerment Allow the individual to call “time out” 3 ways: Respect an individual’s choices • Inflammatory response, local infection, local trauma Maximize autonomy: active participation (shear, friction), chemical irritation (incontinence), Functional focused therapy deep tissue injury.

ASA, acetylsalicylic acid; NSAID, non-steroidal anti-inflammatory drug; • Neuropathic: nerve damage, local ischemia. SNRI, serotonin–norepinephrine reuptake inhibitor • Iatrogenic: patient positioning, dressing changes, debridement.

20 Wound Care Canada / Volume 10, Number 1 Soins des plaies Canada / Volume 10, numéro 1 FIGURE 2 Microbial progression in wounds

Contamination (host control)

Colonization (established bacterial Host resistance population, host control bacterial balance) Bacteria (load x virulence)

Critical Colonization (established bacterial population, wound Topical antimicrobials not progressing, bacterial imbalance, no signs of infection)

Infection (bacterial control) Systemic antibiotics

With respect to pain and trauma, it has been demon - face area reduction with surgical debridement vs. no strated that patients find dressing cleaning most surgical debridement (34%, p=0.019). 5 painful, followed by dressing removal and dressing The importance of moist, interactive wound healing reapplication. A number of approaches can be taken cannot be stressed enough, said Goodman. Dressing for evaluating, managing and preventing pain (Table 2). choices include foams, Hydrofiber, calcium alginate, Psychological stress regarding pain is an under- acrylic dressings, hydrocolloids, films and hydrogels. addressed issue in wound care, Woo said. “It’s impor - tant to understand how stress can suppress the Antimicrobial dressings immune system, and how it may affect wound Sibbald noted that the microbial progression of healing.” Clearly, he added, this is a subject that wounds progresses along the following course (Figure requires further study. 2): contamination, colonization, critical colonization and infection. Local wound care

Laurie Goodman said that wounds should be cleansed TABLE 3 and their characteristics assessed, and they should Debridement options for healable wounds also be monitored. The provision of local wound care Wound type Debridement options follows the mnemonic DIM+E: Surgical Sharp • Debride healable wounds (conservative for non- Conservative healable, maintenance wounds). Hydro-Jet • Treat critical colonization: Infection, persistent inflam - mation. Autolytic Hydrogels Hydrocolloids • Achieve Moisture balance. Alginates • Consider advanced therapies ( Edge) for healable but stalled chronic wounds. Biological Maggots Debridement options for healable wounds are listed Larvae in Table 3. A review published in 2009 found that Mechanical Wet to dry sharp debridement is the most clinically and cost-effec - Whirlpool tive way of physically removing and suppressing Ultrasound biofilms. 4 A retrospective review by Cardinal and col - Water stream leagues of 366 venous leg ulcers and 310 diabetic foot Chemical/ Collagenase ulcers over the course of 12 weeks found that venous enzymatic leg ulcers had a significantly higher median wound sur -

Wound Care Canada / Volume 10, Number 1 Soins des plaies Canada / Volume 10, numéro 1 21 Sharp debridement is the most clinically and cost-effective 2. Treat the cause of the wound. way of physically removing and suppressing biofilms. 3. Provide local wound healing (i.e. dressings). She further noted that with the use of evidence- informed practice, interprofessional teams and health - There are 4 categories of antimicrobial dressings: care system support, the costs of providing optimal honey, slow-release iodine, silver and polyhexamethyl - therapy within the community could be much lowered. ene biguanide (PHMB). Moreover, healing rates would improve and the num - ber of nursing visits, infection rates and incidence of Honey amputation would decrease. 9 A Cochrane review regarding the use of honey indicat - ed that, with respect to venous leg ulcers, honey as an Conclusions adjuvant to compression does not significantly The following key points were addressed during this increase leg ulcer healing at 12 weeks. With respect to interesting and informative session. With respect to superficial and partial thickness burns, honey may wounds and wound bed preparation, clinicians should: improve healing times in mild to moderate superficial • Treat the primary cause of the wound and address and partial thickness burns, compared with conven - patient-centred concerns, including pain. tional dressings. 6 • Understand the differences between healable, non- healable and maintenance wounds as part of wound Slow-release iodine bed preparation. Ten trials have been conducted regarding the use of • Optimize local wound care (i.e. know when to cadexomer iodine for the treatment of venous leg debride, differentiate between infection and inflam - ulcers. In one study, ulcer healing at 6 weeks was mation, and ensure moisture balance). better with cadexomer than with standard care (not • Once a diagnosis is made, understand the difference involving compression). A second study involving between superficial critical colonization and deep compression plus cadexomer vs. standard care showed infection, and treat with appropriate antimicrobials. similar results. Indeed, daily and weekly healing rates in these trials favoured cadexomer iodine. 7 References 1. Briggs M, Nelson EA. Topical agents or dressings for pain in venous leg ulcers. Cochrane Database Syst Rev . 2003;(1):CD001177. Silver 2. Szor JK, Bourguignon C. Description of pressure ulcer pain at rest Silver remains an effective agent in the treatment of and at dressing change. J Wound Ostomy Continence Nurs. non-healing wounds. In a meta-analysis of the effec - 1999;26(3):115-120. 3. Goodridge D, Trepman E, Sloan J, et al. Quality of life of adults with tiveness of silver-releasing dressings in the manage - unhealed and healed diabetic foot ulcers. Foot Ankle Int . 2006 ment of non-healing chronic wounds, compared with Apr;27:274-280. alternatives, silver dressings significantly 8: 4. Wolcott RD, Kennedy JP, Dowd SE. Regular debridement is the main tool for maintaining a healthy wound bed in most chronic wounds. • improved wound healing; J Wound Care . 2009;18:54-56. • reduced odour; 5. Cardinal M, Eisenbud DE, Armstrong DG, et al. Serial surgical • decreased pain-related symptoms; and debridement: a retrospective study on clinical outcomes in chronic lower extremity wounds. Wound Repair Regen . 2009;17:306-311. • decreased wound exudate. 6. Jull AB, Rodgers A, Walker N. Honey as a treatment for topical In addition, silver dressings demonstrated a pro - wounds. Cochrane Database Syst Rev . 2008;(4):CD005083. longed dressing wear time, compared with alternative 7. O’Meara S, Al-Kurdi D, Ologun Y, et al. Antibiotics and antiseptics for venous leg ulcers. Cochrane Database Syst Rev . 2010(1): wound management approaches. CD003557. 8. Lo SF, Chang CJ, Hu WY, et al. The effectiveness of silver-releasing PHMB dressings in the management of non-healing chronic wounds: a meta-analysis. J Clin Nurs . 2009;18:716-728. PHMB foam vs. foam alone has been shown to 9. Shannon, RJ. A Cost-utility evaluation of best practice implementa - improve wound healing and provide enhanced pain tion of leg and foot ulcer care in the Ontario community. Wound control. Care Can . 2007;5(Suppl. 1):S53.

Integration of evidence-based wound care Goodman said the 3 tenets of evidence-based wound care are as follows: 1. Provide adequate wound assessment and client assessment.

22 Wound Care Canada / Volume 10, Number 1 Soins des plaies Canada / Volume 10, numéro 1 CAWC Institute of Wound Prevention and Management

The CAWC Institute Events Include: 2012 L SERIES SCHEDULE Level 1: Knowledge Learning Basic wound management knowledge to support LEVELS 1, 2 & 3 a best practice approach to patient care, including: wound healing principles; wound bed preparation; Thunder Bay, ON pressure ulcers, venous leg ulcers and diabetic foot ulcers. March 29 – April 1 Level 2: Skills Learning Valhalla Inn Interactive learning and practice of wound care skills, including: local wound care; debridement, infection Montréal, QC control and dressing selection; lower leg assessment and compression therapy; foot care and foot wear; May 3 – 6 pressure, friction and shear management. (Delivered in French) Level 3: Attitude Learning Steps and methods for practicing within a team Toronto, ON to develop and sustain prevention strategies, with June 21 – 24 a focus on pressure ulcer and diabetic foot ulcer awareness and prevention. Kelowna, BC October 11 – 14 Toronto, ON November 29 – December 2

For more information, please contact: Diana Seminara, Event Coordinator, Canadian Association of Wound Care · 416-485-2292 x225 · [email protected] Register now at www.cawc.net