Lesson 7: Refractory Wounds Flashcards
Managment Guidelines for Refractory Wounds
- Causative factors addressed?
- Do we need to biopsy?
- Systemic factors addressed?
- Reassess wound bed
- Reassess wound edges
- Adherence to care plan?
Protease Inhibitors
Ie. Promogran, Prisma
Dressings that reduce levels of MMPs in wound bed to protect growth factors
Goal to reduce interference with repair
- Attracts/binds MMPs into the dressing
- Reduces MMP with impregnated dressing
Guidelines
- For clean wound bed that can’t granulate
- Exhibits signs of persistent inflammation
- Clean and apply
- Should see response in 2 weeks
Acellular Matrix Dressing
Matrix that consists of collagen, glycoproteins, and growth factors
- provides scaffolding for cell migrations + attachment
- Synthetic or porcine
Guidelines
- For clean wounds ready to granulate
- Maintain moist wound surface
- Avoid cytotoxic agents
Can be used in abdominal wall reconstruction
- Limited tensile strength
- Monitor for adherence and revascularization
Cell/Tissue Substitute Products (Bioengineered Skin)
Matric dressing with embedded living cells
- Collagen provides support for cell migration
- Growth factors produced provide additional stimulus to repair
For venous ulcers >1 month in duration, surface only
Dermal skin substitutes
- Fibroblasts are seeded on bioabsorbable mesh
- For full thickness diabetic foot ulcers with no tendon, bone, or joint exposed
Bilayer Skin Equivalents
- Fibroblasts and keratinocytes on a collagen matrix
- Generates new collagen and epidermis
Growth Factor Therapy
- To promote chemotaxis, cell proliferation, and tissue formation
- Either a gel or solution derived from patient’s own blood
- For refractory diabetic foot ulcers or neurological wounds
- Adjunct therapy only
Hyperbaric Oxygen Therapy
- 100% oxygen in pressurized chamber
- Encourages vasoconstriction and hyperoxygenation increased delivery to wound bed by 10x
- Enhanced bacterial killing and antibiotic efficiency
Indications
- reversible ischemia
- severe infection
- Osteoradionecrosis
Contraindications
- Untreated pneumothorax
- Pregnancy
- Petroleum-based wound care products
Guidelines
- Usually 5-7 days per week
- Need pretreatment workup
Electrical Stimulation
Electrical current applicated to wound bed locally
Goals
- Enhanced cell migration
- Stimulates fibroblasts
- Enhances perfusion/oxygenation status
- Inhibit bacteria
For refractory pressure injuries
Negative Pressure Wound Therapy
- Negative pressure to wound bed to stimulate healing
- Manages exudate and reduces edema
Indications
- Wound is clean but not granulating
- Deep wounds with large volumes of exudate
- Surgical flaps and grafts
- Large surgical wounds at risk of dehiscence
Contraindications
- Heavily necrotic wounds
- Infected wounds
- Malignant wounds
- Exposed organs or vessels
Foam-based or gauze based
Ultrasonic Mist
Use of sound waves to delivery energy via saline mist
Mechanism
- Breakdown small clots to improve perfusion
- Increase enzymatic and fibrolytic energy
- Reduce bacterial counts
- Increased fibroblast migration
Split Thickness Skin Graft
Removal of epidermis and portions of dermis to place over viable, nonhealing wound
Indications
- Surface wounds failing to epithelization
- Large granulating wounds where full epithelialization is unlikely
- Burns
Need to maintain close contact between graft and wound bed postop
- Usually via NPWT or compression wrap (like Coban)
Myocutaneous flap
Full thickness tissue flaps created by lifting tissue on 3 sides with 4th side intact
Flap is rotated or advanced to cover wound bed
Indications
- Full thickness wound with high risk of recurrence
- Injury or surgical excision creating major tissue defect
