Kara Couch

Clinical approach to wounds: Débridement and wound bed preparation including the use of dressings and wound-healing adjuvants

Summary: This is a clinical review of current techniques in wound bed preparation found to be effective in assisting the wound-healing process. The process begins with the identification of a correct diagnosis of the wound’s etiology and continues with optimizing the patient’s medical condition, including blood flow to the wound site. Débridement as the basis of most wound-healing strategies is then emphasized. Various débridement techniques, including surgery, topical agents, and biosurgery, are thoroughly discussed and illustrated. Wound dressings, including the use of negative pressure wound therapy, are then reviewed. To properly determine the timing of advance therapeutic intervention, the wound-healing progress needs to be monitored carefully with weekly measurements. A reduction in wound area of 10 to 15 percent per week represents normal healing and does not mandate a change in the current wound-healing strategy. However, if this level of wound area reduction is not met consistently on a weekly basis, then alternative healing interventions should be considered. There is a growing body of evidence that can provide guidance on the appropriate use of such adjuvants in the problem wound. Several adjuvants are discussed, including growth factor, bioengineered tissues, and hyperbaric medicine.

Negative-Pressure Wound Therapy in the Military: Lessons Learned

Summary: The utilization of negative pressure for medicinal purposes dates back to 600 bc. The U.S. military has been engaged in continuous overseas combat operations since 2001. Negative-pressure wound therapy has been in use in the treatment of casualties from these operations since 2004. It represents a new standard of practice in combat wound care; it promotes granulation tissue formation and creates mechanical forces supporting wound contraction, facilitating definitive wound closure. This article describes (1) the use of negative-pressure wound therapy in combat casualty care, (2) inherent challenges of its use in theater of operations and across the echelons of care, (3) modifications of this wound therapy to meet military-specific needs, and (4) future directions with this novel wound care modality.

Postoperative wound dehiscence: Predictors and associations

The Agency for Healthcare Research and Quality patient safety indicators (PSI) were developed as a metric of hospital complication rates. PSI‐14 measures postoperative wound dehiscence and specifically how often a surgical wound in the abdominal or pelvic area fails to heal after abdominopelvic surgery. Wound dehiscence is estimated to occur in 0.5–3.4% of abdominopelvic surgeries, and carries a mortality of up to 40%. Postoperative wound dehiscence has been adopted as a surrogate safety outcome measure as it impacts morbidity, length of stay, healthcare costs and readmission rates. Postoperative wound dehiscence cases from the Nationwide Inpatient Sample demonstrate 9.6% excess mortality, 9.4 days of excess hospitalization and

Relationship between opioid treatment and rate of healing in chronic wounds

40,323 in excess hospital charges relative to matched controls. The purpose of the current study was to investigate the associations between PSI‐14 and measurable medical and surgical comorbidities using the Explorys technology platform to query electronic health record data from a large hospital system serving a diverse patient population in the Washington, DC and Baltimore, MD metropolitan areas. The study population included 25,636 eligible patients who had undergone abdominopelvic surgery between January 1, 2008 and December 31, 2012. Of these cases, 786 (2.97%) had postoperative wound dehiscence. Patient‐associated comorbidities were strongly associated with PSI‐14, suggesting that this indicator may not solely be an indicator of hospital safety. There was a strong association between PSI‐14 and opioid use after surgery and this finding merits further investigation.

Modalities to Treat Venous Ulcers: Compression, Surgery, and Bioengineered Tissue.

Opioids are routinely used analgesics in patients with chronic wounds; however the impact of opioid exposure on wound healing is poorly understood. The purpose of this study was to investigate the association between opioid exposure and wound outcome in the Wound Etiology and Healing study. This longitudinal observational study was conducted on 450 subjects enrolled in the Wound Etiology and Healing biorepository. Data were collected prospectively including baseline characteristics, pain score, longitudinal opioid exposure, and total wound surface area (tWSA). Data were analyzed using static multivariate models, fixed‐effects mixed models, and time to event analysis. Using fixed‐effects models, opioid dose was significantly associated with tWSA after accounting for the effects of pain score and baseline co‐variates (p < 0.0001). For each 1‐unit increase in ln(opioid dose + 1) the ln(tWSA + 1) increased by 0.16 units (95% confidence interval 0.13–0.19, p < 0.0001). Visits where opioids were present had ln(tWSA + 1) 0.48 units larger (95% confidence interval 0.38–0.58, p < 0.0001) than visits with no opioid exposure. Using time‐to‐event analysis, patients who never received opioids healed faster than those who received opioids (log‐rank chi‐square 11.00, p = 0.0009). Using Cox regression analysis, patients with mean opioid dose ≥10 mg were significantly less likely to heal than those with no opioid (HR 0.67 [0.49–0.91], p = 0.011) after adjusting for wound size. Patients with opioid dose >0 to <10 mg had a similar hazard of not healing as those with no opioid exposure (HR 0.88 [0.65–1.19], p = 0.40). In conclusion, opioid analgesics are commonly prescribed to patients with chronic wounds; however, the data presented suggest that opioid exposure is associated with reduced likelihood of healing in patients with chronic wounds. Whether this is a causal relationship will require further study.

The Role of Peripheral Nerve Surgery in the Management of Painful Chronic Wounds: Indications and Outcomes

Background: Venous leg ulcers (VLUs) represent the most common ulcers of the lower extremity. VLUs are notorious for delayed and prolonged healing with high rates of recurrence. Most patients with VLUs also have significant comorbidities that interfere with primary wound healing. Thus, caring for patients with VLUs requires an interdisciplinary approach that addresses the abnormal venous anatomy and the downstream effects that lead to inflammation, ulceration, and a hostile wound microenvironment. Methods: The current literature regarding venous ulcer treatment with an emphasis on compression, surgical options, and use of bioengineered tissue was reviewed. A combination of society guidelines, Cochrane reviews, and over 80 primary articles with high-level evidence were utilized to develop this summary and algorithm for an integrated approach to treating patients with venous ulcers. Details regarding compression modalities and venous diagnostic imaging are presented to help the clinician understand the rationale for using these technologies. Results: The comprehensive approach to the patient with chronic venous insufficiency (CVI) includes advances in compression, diagnostics, minimally invasive surgical treatment of venous disease, wound bed preparation, and bioengineered skin and soft tissue substitutes. An algorithm that incorporates early treatment of the ulcer and the venous disease leading to healing with prevention of recurrence is presented. Conclusions: Utilizing guidelines that incorporate evidence-based modalities will lead to the highest quality outcomes with the most appropriate resource utilization. A proactive approach to treating venous disease will alleviate suffering and prevent the long-term sequelae of CVI.

A 66 year old woman with hemoptysis

Background: Patients with chronic wounds caused by healing problems often present with chronic pain at the site. Proper wound care with or without appropriate reconstruction usually addresses both the wound and its associated pain. However, wounds occasionally remain painful despite successful reconstruction, particularly when they are complicated by an underlying condition. These patients frequently develop a disabling chronic pain condition despite the application of current treatment modalities. The authors used a novel approach to manage this difficult clinical situation, by addressing the sensory nerve supply to the affected wound region. Methods: Five women and two men with intractable chronic pain despite wound reconstruction underwent surgery and were followed for a mean period of 27 months (range, 8 to 40 months). The involved sensory nerve was identified preoperatively by physical examination, confirmed by nerve block, and then surgically excised and implanted into adjacent muscle. Each patients pain reduction, ambulation status, and quality-of-life improvement were evaluated. Results: The involved nerves included the ilioinguinal, lateral femoral cutaneous, sural, saphenous, superficial peroneal, and deep peroneal nerves, and the genital branch of the genitofemoral nerve. All seven patients reported significant pain reduction (p < 0.0001), improved ambulation (p < 0.0001), and improved quality of life (p < 0.0001), as evaluated at last follow-up (mean, 27 months). Conclusions: This study suggests that an additional treatment modality in the management of chronic wounds can be considered for patients with disabling pain. As an adjunct to other interventions, this novel application of peripheral nerve surgery can critically improve symptoms in selected patients with intractable chronic wound pain.

The International Consolidated Venous Ulcer Guideline Update 2015: Process Improvement, Evidence Analysis, and Future Goals.

Chief symptoms A 66-year-old Hispanic Caucasian woman with a 14-year history of diffuse scleroderma and a history of bilateral breast cancer presented for evaluation of a vasculitic rash and hemoptysis with positive proteinase 3 (PR3) serology, raising concern for possible granulomatosis with polyangiitis (Wegener’s) (GPA) or antineutrophil cytoplasmic antibody (ANCA)–associated vasculitis (AAV).