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Integrating Palliative and Curative Wound Care

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Integrating Palliative and Curative Wound Care Integrating Palliative and Curative Wound Care Prevalence of Wounds Integrating Palliative and NPUAP (2001) Hospice population 14% – 28 % Curative Wound Care LTC and Rehab 2% – 28% SCI Units 10% – 30 % Rosene D. Pirrello, Pharmacist Specialist Palliative Care Team Tippett (2005) – 35% of 400 patients in a single hospice had a skin wound Reifsnyder and Magee (2004) – 26.9% of 980 patients at 4 hospices had pressure ulcers Outline What Types of Wounds? • Prevalence and type • Prevention • Assessment, preparation, dressing • Managing pain, odor, exudate, bleeding Types of Wounds How Many Wounds? • Pressure – 50 % • Malignant – 30 % • Venous / edematous – 10 % • Arterial – 5 % • Surgical – 5% • Diabetic – few • Skin Tears – ? Rosene D. Pirrello, Pharmacist Specialist, Palliative Care Team University of California - UC Irvine Health PCQN 2014 Integrating Palliative and Curative Wound Care Co-morbid Disease • Dementia • Stroke • Peripheral Vascular Disease Prevention . • Diabetes • Cancer Pathophysiology… Risk Assessment What is the root cause of all wounds ? Braden Pressure Ulcer Risk Assessment • Pressure • Tissue necrosis in 1 2 3 4 • Malignant Dermis Sensory perception Moisture • Venous / edematous Fat Muscle Activity • Arterial Mobility Associated structures • Diabetic Nutrition Nerves Friction / shear Tendons Vessels Bergstrom N, Braden BJ – Nurs Res 1987 Pressure Relief: …Pathophysiology Surfaces / Positioning • Wounds & surrounding tissues susceptible to Beds Infections Group 1 – Pressure relief mattress Inflammation Group 2 – Low air loss Group 3 – Air fluidized Rosene D. Pirrello, Pharmacist Specialist, Palliative Care Team University of California - UC Irvine Health PCQN 2014 Integrating Palliative and Curative Wound Care Group 1 Well-fitting, smooth sheets Reduce Pressure, Shear, Friction and Group 2 Moisture • High pressure – short • Positioning q 2 hours period only • Weight shift q 15-30 min • Head board < 30° X 5 seconds • Footboard or elevate • Side position at 30°angle knees • Pillow under calves • Protect elbows/heels when on back • Powder of bedpans • Assure adequate device inflation • Incontinence plan, standards Group 3 Rosene D. Pirrello, Pharmacist Specialist, Palliative Care Team University of California - UC Irvine Health PCQN 2014 Integrating Palliative and Curative Wound Care Assess • Person Symptoms Assessment . “Woundedness” • Wound Type, cause Bacterial burden • Context Underlying illness(es), prognosis Nutritional status Margaret . • 68 year old woman • Metastatic lung Ca • Spinal cord compression, paraplegia • Cared for at home • Nutrition good • Loving family Woundedness Assess the Wound • Patient • Dysfunction • Size: L – W – D • Exudate Serous • Family • Dependence • Tunneling Serosanguineous • Caregivers • Anxiety • Undermining Purulent • Depression • Color • Odor • Fear Red = viable tissue Putrid • Abandonment Yellow = slough Fruity • Spiritual Black = eschar • Bubbling Rosene D. Pirrello, Pharmacist Specialist, Palliative Care Team University of California - UC Irvine Health PCQN 2014 Integrating Palliative and Curative Wound Care How to Measure and Chart . Pressure Ulcer Staging • Stage III – full thickness skin loss damage or necrosis of subcutaneous tissue not through underlying fascia • Stage IV – full thickness skin loss extensive damage or necrosis of muscles, bone or supporting structures Undermining Sinus tracts . Margaret • Stage III, sacral ulcer 5 cm X 8.5 cm, undermining, Feet Head additional 10 cm tunneling Color: Red, yellow, bluish-green Fruity smell • Stage II, dermal breakdown • Goal: Healing Pressure Ulcer Staging . Management Strategies • Stage I – persistent changes in a Healable Non-healable defined area of intact skin related to pressure Red, blue or purple hues • Stage II – partial thickness skin loss Epidermis and / or dermis Rosene D. Pirrello, Pharmacist Specialist, Palliative Care Team University of California - UC Irvine Health PCQN 2014 Integrating Palliative and Curative Wound Care Goal of Wound Care . Margaret “The goal is to decrease the burden of the • Stage X, R heel ulcer wound, while simultaneously hoping that eschar the interventions will promote healing.” 4 x 6 cm • Stage III, sacral ulcer “Hoping for the best, planning for the worst” 5 x 8 cm; • Goal: Healing Liao S and Arnold R - JPM 2007 . Goals of Care • Protection Skin Integrity • Prevention Pressure Edema • Presence Body image Psychic distress – patient, caregivers Goals of Care . Debridement • Treat – wound, underlying disease The single most important parameter Stabilize, progression, promote healing for reducing the level of bacterial Moist interactive wound dressing contamination in the chronic wound is Bacterial Burden Treatment the removal of devitalized tissue Symptoms Exudate Pain Odor Bleeding Rodeheaver GT. in Chronic Wound Care, 3rd. Edition, 2001 Rosene D. Pirrello, Pharmacist Specialist, Palliative Care Team University of California - UC Irvine Health PCQN 2014 Integrating Palliative and Curative Wound Care Wound Pain Debridement Nociceptive pain –due to chemical, • Surgery fastest, eg, scalpel, curette, scissors mechanical & thermal stimuli Aggressive – Wound edges Non-aggressive – Surrounding tissues • Autolytic (dressings) – Muscle sheaths • Enzymes – Periosteum Collagenase • Mechanical, e.g., hydrotherapy • Maggot therapy Wound Pain Neuropathic pain – due to nerve damage, death Debridement . Hyperalgesia – due to inflammation – Sensitizes & recruits REQUIRES ADVANCE PLANNING FOR PAIN – Nociceptors – Opioid receptors Allodynia TemporalProfile Plan for Pain Wound Pain Experience • Pre-medicate with analgesics / Adapted from Diane Krasner, 2010 anaesthetics • Choose analgesics to match pain temporal 1. Acute Intermittent profile to analgesic first order Cyclic -dressing changes pharmacokinetics -turning, repositioning 2. Acute Intermittent Match duration of Noncyclic procedure to t½ -sharp debridement -drain removal Wait tCmax before 3. Constant starting -inflammation -underlying disease procedure Rosene D. Pirrello, Pharmacist Specialist, Palliative Care Team University of California - UC Irvine Health PCQN 2014 Integrating Palliative and Curative Wound Care Long Procedures Short Procedures > 1 hour < 1 hour Prolonged debridement Cleansing Cleansing Dressing changes Dressing changes Turning Repositioning Long Procedures Short Procedures PO / PR PO / PR 1 hr 1 hr Cmax Cmax 20 20 PO / PR PO / PR 10 4 hr 10 4 hr Plasma Concentration Plasma Concentration 0 Half-life (t1/2) Time 0 Half-life (t1/2) Time Long Procedures Short Procedures Time Half-life Route Time Half-life to Cmax to Cmax Fentanyl lozenges • Morphine PO / PR 60 min 4 hr • Buccal 15 min 2.5 hr • Hydrocodone SC / IM 30 min 4 hr • Remifentanil IV 1-3 min 1 min • Hydromorphone IV 15 min 4 hr • Nitrous oxide inhaled rapid rapid • Oxycodone • Fentanyl • Ketamine SC 30 min 1-3 hr IV 6-10 min • Anesthetics – topical / injectable • Anesthetics – topical / injectable Rosene D. Pirrello, Pharmacist Specialist, Palliative Care Team University of California - UC Irvine Health PCQN 2014 Integrating Palliative and Curative Wound Care EMLA,* Eutectic Mixture of Local Anesthetics Local Anesthetics Lidocaine Amide - less allergy • Lidocaine 2.5% / prilocaine 2.5% cream Topical Quick onset of action • Liquid when cold, solid at room temp. Injectable Onset 10 - 15 min • Apply thick coat, “icing on a cake” tCmax = 30 - 60 min • Leave on 30-60 minutes Dose < 200 mg / 24 hr • Need complete seal eg, plastic wrap, + Epinephrine bleeding transparent film (adhesive) *Approved for use on open wounds in Canada / Europe, but not US FDA Benzocaine (ester) is a topical sensitizer Lidocaine Topical Solution • 2 % ( 2 gm / 100 ml ) or 4 % ( 4 gm / 100ml ) Spray or drip on • 2 % 10 ml = 200 mg or 4 % 5 ml = 200 mg • Acidic • Buffer with sodium bicarbonate 5 mL of 1 mEq / ml NaHCO3 + 45 mL 2 % or 4 % lidocaine Test with pH paper • Warm Rosene D. Pirrello, Pharmacist Specialist, Palliative Care Team University of California - UC Irvine Health PCQN 2014 Integrating Palliative and Curative Wound Care Cleansing Technique • Rinse Cleansing . • Cleanse • Irrigate Pressure < 15 psi 18 - 20 angiocatheter + 30 – 60 cc syringe SALINE, SALINE, SALINE Cleansing • Hydrogen peroxide • Sodium hypochlorite eg, Hygeol, Dakin's Dressing . • Povidone iodine eg, Betadine • Aniline dyes eg, Neutral Red, Crystal Violet • Aluminum salts eg, Burow’s Solution These agents will delay healing and decrease bacterial burden Moist Interactive Cleansing Healing Guideline • SALINE – preserved vs. unpreserved 1. Use a dressing that will keep the ulcer bed Stove-top saline continuously moist. Wet-to-dry dressings 10 ml / 2 tsp salt in 1 liter / quart water should only be used for debridement and are not considered continuously moist saline Boil 3 - 20 minutes dressings Strength of evidence: A • Cleansers - more than one random controlled trial Skin – bacteriocidal Ovington L. Ostomy / Wound Management Wound – less toxic 1999; 45 (Suppl. 1A): 94S-106S Rosene D. Pirrello, Pharmacist Specialist, Palliative Care Team University of California - UC Irvine Health PCQN 2014 Integrating Palliative and Curative Wound Care Moist Interactive Healing Foams • Increased cellular function Absorbency ++++ • Facilitate autolytic debridement Wear time 1 to 7 days Comments * Need moisture from the • Lower infection rates wound • Decreased pain * May macerate surrounding skin Moist Interactive Healing Guideline 2. Use clinical judgment to select a type of moist wound dressing suitable for an ulcer.
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