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 -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 • 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. Studies of different types of moist wound dressings showed no differences in pressure ulcer healing outcomes Strength of evidence: A - more than one random controlled trial Ovington L. Ostomy / Wound Management 1999; 45 (Suppl. 1A): 945-1065

Types of Dressings Foams Calcium Alginates

Calcium Alginates Absorbency +++ Wear time 12 to 48 hours Hydrogels Comments * Hemostasis Hydrocolloids * Can be used in infected wounds Transparent Films * Rope - wicks vertically Gauze * Wafer - wicks laterally Non-adherent

Rosene D. Pirrello, Pharmacist Specialist, Palliative Care Team University of California - UC Irvine Health PCQN 2014 Integrating Palliative and Curative Wound Care

Hydrocolloids

Absorbency + Wear Time 2 to 7 days Comments * Not vascular insufficiency / infection * Must have seal * Good autolytic debridement Components: * Hydrophilic - gelatin, pectin * Hydrophobic - cellulose * Adhesive - can cause allergy

Hydrogels

Absorbency ++ Wear Time 12 to 72 hours Comments * Lattice - saline propylene glycol hydrocolloid * Good autolytic debridement * Amorphous & sheet forms

Transparent Films

Absorbency 0 Wear Time 1 to 7 days Comments * Adhesive forms may damage surrounding skin * Cannot have leakage channels * Best re-epithelialization / protection

Rosene D. Pirrello, Pharmacist Specialist, Palliative Care Team University of California - UC Irvine Health PCQN 2014 Integrating Palliative and Curative Wound Care

Dressing Summary Foams

Calcium Alginates

Hydrogels

Hydrocolloids

Transparent Films

Gauze

Non-adherent

Prepare the Wound Carefully… Gauze Residual exudate can add to pressure and Cotton mesh pain Kerlix • Wick exudate away from wound surface 4x4’s • “ Clean ” the wound bed Synthetic Keep open wound warm / moist Kling • Wrap to keep warm Conform • Don’t let wound dry out Hypertonic / Absorbing Dry nerve endings Exposure to air PAIN

…Prepare the Wound Carefully Non-adherent Protect skin margins and surrounding tissues with Non-impregnated barrier films & creams • Polymer solutions form a uniform film when applied to the skin Adaptic • Protect intact and damaged skin from irritation and drainage Telfa • Allow moisture-vapor permeability • Prolonged peri-wound inflammation results Soft silicones in a edematous, hemorrhagic granulation tissue Impregnated Vaseline gauze Xeroform

Rosene D. Pirrello, Pharmacist Specialist, Palliative Care Team University of California - UC Irvine Health PCQN 2014 Integrating Palliative and Curative Wound Care

…Topical Opioids Dress the Wound Carefully Morphine Pharmacology Use dressings that Dressings that attach to • Water soluble • Protect the wound from the wound bed pain • Does not cross intact dermis pressure – pack lightly • Pulling the tissue inside the significantly • Insulate the wound wound is very painful • Easily absorbed through • Remove drainage from the • Traumatic inflammatory wound bed peri-wound surface response reoccurs Formulation • Adhere to healthy tissue, • 1 – 10 mg morphine / ml hydrogel ( 0.1 – 1%) not to the wound • Apply to open wound every dressing change • Frequently produces effective analgesia until next dressing change

Choose Least Traumatic Dressings Neuropathic Wound Pain Occurs frequently in wounds due to ischemia, nerve damage Adrenergic / Na+ channel blocker serotonergic agonist Carbamazepine, lidocaine, Amitriptyline, nortriptyline, valproic acid, mexiletine imipramine, desipramine NMDA antagonist SNRI Methadone, ketamine Duloxetine, venlafaxine Ca channel blocker GABA agonist Dykes, J Wound Care, 2001 Gabapentin, pregabalin Baclofen

Topical Opioids… Dressings for Packing Pathophysiology • The inflammatory • Fill dead space • Not saline-soaked process recruits and sensitizes • Moisture balance gauze peripheral opioid • Vaseline covered receptors • Non-toxic to cells • Bacterial balance gauze • Pain control • Alginates • Minimize pressure

NEJM 1995; 332 ( 25 ): 1685-90

Rosene D. Pirrello, Pharmacist Specialist, Palliative Care Team University of California - UC Irvine Health PCQN 2014 Integrating Palliative and Curative Wound Care

Minimize Trauma During Dressing Removal Before a dressing change • Inquire if the patient has a preferred method to remove tape / dressing ? • Inform the patient to ask for a “timeout” during the procedure

Soak Dressings Off Remove Dressing & Power of Saline or gentle wound cleanser Warm; consider topical lidocaine Wraps Gently Compassionate Touch

Bacterial Burden • Anaerobes • Tissue depth Odor . . . Topical Systemic • Alginate dressings

John Metronidazole Gel Compounding

• 62 year old man • US commercial product is 1 % gel • 18-month Hx malignant melanoma • Use 1 gm metronidazole powder per • Now metastatic 100 ml ( 100 mg / 10 ml ) of hydrogel or • Tumour didn’t respond to , radiation therapy KY gel, or Declined to participate in clinical trials • Crush 2 x 500 mg tablets per 100 ml • Pain well controlled • May add morphine sulfate 0.1 – 0.5% ( 1 – 5 mg / ml )

Rosene D. Pirrello, Pharmacist Specialist, Palliative Care Team University of California - UC Irvine Health PCQN 2014 Integrating Palliative and Curative Wound Care

Topical Antiseptics Aromatherapy - Malodor

• Clean air spray • Hydrogen peroxide Lemon, eucalyptus, thymus & tea tree oil • Sodium hypochlorite, e.g., Hygeol, Dakin's Neutralizes odors, purifies room • Povidone iodine, e.g., Betadine Uplifts mood • Aniline dyes, e.g., Neutral Red, Crystal Violet • Nasal comfort gel • Aluminum salts, e.g., Burow’s Solution Aloe vera, chamomile, rose & sandalwood Used by patient or caregiver on upper lip These agents will delay healing and • Lavender room spray decrease bacterial burden

Odor Control

• Decrease • Alternate smells bacterial burden Aromatherapy • Ventilation Vanilla • Absorbers Vinegar ( cider ) Exudate . . . Kitty litter Beware perfumes Charcoal Coffee grounds Burning flame, e.g., candle

Aromatherapy - Comfort Exudate / Dressing Layers • Lavender 1. Alginates Relaxes, calms Absorbent + Improves comfort Bacteriostatic Provides clean feeling Hemostatic • Melissa 2 % in Eucerin Cream 2. Foams Absorbent +++ Relaxes, calms 3. Cotton – pads, gauze Effective for agitation Hold, cover up • Beware sticking, pain

Rosene D. Pirrello, Pharmacist Specialist, Palliative Care Team University of California - UC Irvine Health PCQN 2014 Integrating Palliative and Curative Wound Care

Tearing of Friable Tissues • Minimize tearing Inert mesh Mepitel Bleeding . . . Alginates Non-adherent dressings Tulle Petrolatum coated

Mary • 65 year old woman • 3-year Hx inflammatory breast cancer • Tumor unresponsive to several chemotherapy and radiotherapy protocols • Extensive open, areas of skin ulceration across her chest due to recurrent tumor • Painful – at rest, with dressing changes • Friable, oozing, occasional bleeding

Risk of Bleeding

• Alginates • Silver nitrate • Moh’s Paste (Zinc Chloride) • Topical thromboplastin 1,000 5,000 10,000 units / ampule • Tranexamic acid 500 mg / 10 ml ampule • Reassess NSAIDs, aspirin, anticoagulants

Rosene D. Pirrello, Pharmacist Specialist, Palliative Care Team University of California - UC Irvine Health PCQN 2014 Integrating Palliative and Curative Wound Care

Acute Bleed • Minimize dressing changes – alginates • Goals of care, advance directives Family discussion • Pressure bandage • Dark towels • Sedatives – midazolam, lorazepam

www.chronicwoundcarebook.com

Non-pharmacological Interventions • Warmth & cold • Relaxation ( warm towels ) • Imagery • Massage, pressure, • Cognitive distraction, vibration reframing • Exercise • Education, both oral & • Repositioning written • Immobilization • Psychotherapy • Counter-stimulation • Support groups, pastoral counseling www.o-wm.com www.woundsresearch.com

Summary Specific General Reviews: The best clinical practices for • Alvarez OM, Kalinski C, et al: Incorporating Wound Healing Strategies to Improve Palliation (Symptom Management) In Patients with Chronic chronic wound care Wounds, (2007) Journal of Palliative Medicine 10 (5): 1161-1189.

Prevent • Ferris FD, Bodtke SK: “Management of Pressure Ulcers and Fungating Wounds”, Chapter 26, in Principles and Practice of Palliative Care and Supportive Oncology, Berger, AM, Shuster, JL, and Von Roenn, Treat the cause Local wound care JH.(eds.) 4th ed., Lippincott, Williams & Wilkins, Philadelphia, Pennsylvania, 2013.

Quality of life

Rosene D. Pirrello, Pharmacist Specialist, Palliative Care Team University of California - UC Irvine Health PCQN 2014