Wound Care and Lymphedema Flashcards
Prevalence of wounds in PC
- 60% have 1+ wound at presentation
- Average 1.8 wounds/pt at presentation
- Average 1.5 new wounds before death
Prognostic significance of malignant wounds
1966: 3 months’ avg. survival
1993: 11 months’ avg. survival
Today: no impact on survival
:. Treat wounds!
:. Don’t write off wound patients
Prognostic significance of
pressure ulcers
Correlated w. poor prognosis rather than causative
Nonmalignant patients: death HR 2.42
Malignant patients: death HR 1.48
Worse for women
5 primary goals of wound mx
- Wound healing
- Wound maintenance (i.e. stop growth)
- Wound palliation
- Wound prevention
- Achieving patient GOC
In PC setting, 5 > 4 > 3 > 2 > 1
What is a pressure wound?
Ischemic necrosis d/t to arterial, venous, lymphatic stasis.
The stasis is caused by prolonged pressure over hard surface +/- friction/shearing.
Patient risk factors for pressure wounds
- Advanced age
- Multimorbidity
- Cachexia
- Neuropathy
- Peripheral vascular disease
- Paralysis
What is the primary pressure ulcer risk assessment scale?
Braden Risk Assessment
Describe the Braden Risk Assessment
24-point scale, lower = higher risk
<17 is considered at-risk
6 items, rated 1-4 each
1. Sensory function
2. Moisture
3. Activity (out of bed)
4. Mobility (in bed)
5. Nutrition
6. Friction/shear
What score does the Braden score correlate with in palliative pts?
Palliative Performance Scale
NPUAP Stages 0-I of Pressure Injury
- Healthy skin
- Nonblanchable erythema + intact skin
NPUAP Stage II of Pressure Injury
Exposed dermis or intact blistering
- Visible tissue is healthy/viable
- No visible fat/deeper tissue
- No granulation tissue or slough
NPUAP Stage III of Pressure Injury
Full thickness skin loss to subq tissue
- Fat + granulation tissue present
- Depth depends on anatomical loc’n
- No muscle/fascia/bone visible
- +/- slough that may make it unstageable
NPUAP Stage IV Pressure Injury
Full-thickness skin + tissue loss
- Exposed connective tissue, incl. Bone
- +/- slough that may make it unstageable
NPUAP Stage X Pressure Injury
Wound is too obscured to stage
- Slough and/or eschar
- Debridement will reveal stage III-IV
- Stage I-II don’t make slough
- Don’t debride dry stable eschar
What mnemonic reflects a sample approach to wound healing?
“DIME”
(D)ebridement/(D)ownloading
(I)infection/(I)nflammation management
(M)oisture balance
(E)dge management
Describe debridement approaches
Sharp debridement of dead tissue
- Reduces infx risk
- Promotes healing
- At bedside or in OR
Debriding wound products
- Hydrocolloids, hydrogels, alginates
Describe wound downloading
AKA offloading, pressure redist’n
- Goal is maximum surface area exposed
- Repositioning
- Soft surfaces and/or moving surfaces
- Lifting affected areas (esp. heels)
Describe bacterial flora of
Acute vs. chronic wounds
Acute: gram+ aerobes
Chronic: gram- and anaerobes
4 “stages” of wound infection
- Colonised without infection
- Superficial tissue infection
- Deep tissue infection
- Sepsis
What are some complications
of wound infections?
- fistulae/sinuses
- Abscess formation
- Osteomyelitis
- Compartment syndrome
- Sepsis
What is the first sign/symptom
of wound infection?
Escalating pain–always look for infx
Approaches to superficial vs. deep wound tissue infections
Superficial: topical treatments
e.g. topical antibiotics
e.g. silver- or iodine-infused dressings
Deep: systemic antibiotics
Primary inflammatory mediator
in chronic wounds
Matrix metalloproteinases (MMPs)
* Released by neutrophils/macrophages
* Released by cancer cells
* Released 2* interleukins + TNF-a
How do MMPs impair healing?
Hyperinflammatory state:
* Damage extracellular matrix
* Kill fibroblasts and epithelial cells
* Inactivate growth factors
Name 2 dressings designed
to inactivate MMPs
Promogran©
Prisma© (= Promogran© with Ag+)
How does excess moisture
impair wound healing?
- Excessive tissue maceration
- Reduces tissue tensile strength
- Damage from toxic exudate products
What components of exudate
can impair wound healing?
- Proinflammatory mediators
- MMPs
- bacteria/bacterial toxins
- Necrotic products
What is the pathophysiology of
exudate formation?
- High capillary permeability
- Vascular perm. Factors from cancer
- Increased venous/lymphatic pressure
- Iatrogenic (creams, hydrogels)
Dressing approach to
Highly exudative wounds
- High absorbency dressings (see below)
- Noncontact layer underneath
- Consider plastic on top to protect clothing/fabrics
- Consider abdo pads (not in contact) to save expensive absorbent dressings
- Don’t change contact layer too often
What is an option for
extreme exudate accumulation?
Negative pressure wound therapy
(i.e. suction)
Ostomy bags
What are “edge effects” in the
DIME approach to wounds?
Refers to failure in wound to “edge” inward (i.e. heal).
- Can be managed with NPWT, hyperbaric O2, skin grafts
- Remember that malignant wounds don’t heal
What are 2 mnemonics for signs of
deep and superficial wounds infx?
Superficial: NERDS
Deep: STONES
“NERDS” Mnemonic
⅗ predictive of superficial wound infx
NERDS:
* Nonhealing (or worsening)
* Exudate
* Red wound bed
* Debris
* Smell worsening
“STONES” Mnemonic
4/6 predictive of deep wound infx
STONE(EE)S:
* Size increasing
* Temp increasing (use IR thermometer)
* Osteum exposed
* New breakdown
* Exudate/Erythema/Edema
* Smell worsening
How common are malignant wounds?
15% of advanced cancer patients
* 60% are exophytic/fungating
* 40% are erosive
What 4 cancers are most associated
with malignant wounds?
- Breast
- Lung
- Head/Neck
- Primary skin
What are approaches to treating malignant wounds?
Malignant wounds are unlikely to heal,
And will not heal w/o cancer treatment
- Systemic chemo/hormonal/immunotx
- Local radiation
- 6% miltefosine topically (single small study)
List approaches to wound pain mx
regular/prn opioids, incl. Fentanyls
Topical opioids
EMLA
Nonadherent base dressings
Avoid gauze
List options for
wound odour mx
- Systemic/topical metronidazole
- Charcoal-containing dressing
- Wound cleansing
- Topical antiseptics
- Debridement
- Environmental management
- Aromatherapy
- Ventilation
- Pet litter/charcoal under bed
- Baking soda
What are 2 “natural” options for
debridement and wound odour mx?
Sugar pastes
Honey
Both create hyperosmotic env’t
Honey may have some added effects
What is the risk of bleeding
from malignant wounds?
<10%
List local options
for wound bleeding mx
- Reduce freq. of dressing changes
- Calcium alginate
- ORC collagen
- Silver nitrate cautery
- Thromboplastin
- Zinc chloride paste (Mohs’ paste)
- topical/po TXA
What is the main contraindication for compression tx in VENOUS leg ulcers?
Inadequate arterial supply (per ABI)
List the main categories of wound care products
Absorbents
Hydrating agents
Protease inhibitors
Antimicrobials
Anti-odour
Nonadherent layers
What are 5 considerations in choosing a wound care product
- Wound shape/depth
- Wound moisture
- Patient preference
- Availability
- Cost
What is lymphedema?
Protein-rich insterstitial fluid
(and sequelae)
ALMOST ALWAYS ASYMMETRICAL
Specific causes of Lymphedema
- Cancer treatment (sx, XRT)
- Chronic venous insufficiency
- Tropical illnesses
- Primary lymphedema (congenital)
General cause of lymphedema
Damage to lymph vessels/nodes
Congenital absence/abn of same
Oncology-Associated lymphedema features
- Associated w. Node dissection / XRT
- 1-2 year latency from tx → onset
- Can also mark cancer recurrence
Which 4 cancers are most associated with lymphedema?
- Breast ca (20-30%)
- Gyne Cancer (5-50%)
- Prostate ca (5-30%)
- Melanoma + Sarcoma (5-30%)
List 5 lymphedema sequelae
- High protein → fibrosis
- Abnormal fat distribution
- Skin changes
- Fibrosis can trap nerves/vessels → pain
- Infection ←→ worse lymphedema
List 4 chronic skin changes in lymphedema
- Hyperkeratosis
- Thickened skin folds
- Hyperpigmentation
- Inflammation
List the 3 stages of lymphedema progression
- Spontaneously resolves w. Elevation
- No spontaneous resolution
a. Will progress to fibrosis if untx - Skin changes develop
DDx of unilateral limb swelling consistent with lymphedema (i.e. alternative dx) (3)
- Cancer recurrence
- DVT
- Cellulitis
Skin care in lymphedema (4)
- Fastidious skin hygiene
- Low-pH moisturiser
- Avoid extremes of temperature
a. Heat → hyperemia → swelling
b. Cold → rebound vasodilation - Avoid punctures if at all possible
General patient advice for lymphedema patients.
- Skin care (see slide 55)
- Ongoing exercise
a. Resistance exercise can improve LE
b. Cardio can prevent obesity
c. Obesity worsens LE
What is the basis of lymphedema tx?
Combined Decongestive Therapy (CDT)
Describe combined decongestive therapy (CDT)
Physical therapy for lymphedema
(a) increase current drainage routes
(b) develop collaterals
- Intensive phase to reduce edema
- Maintenance phase to preserve
- Patient responsible for maintenance
Describe CDT in lymphedema Stage I
- Compression garments
- Elevation as able
CDT in Stage II lymphedema
- Initial non-elastic bandaging
- Skin care
- Manual lymphatic drainage
- Followed by chronic compression garment use
Describe Manual Lymphatic Drainage (MLD)
- Goal is to enhance lymphatic vessel contractility/volume
- Proximal → distal massage
- Requires trained professional
- About 45 minutes
- Followed by bandaging
- “Simplified lymphatic drainage” can be done at home
CDT in Stage III lymphedema
- 2-4 week intensive treatment
a. education/psychological support
b. Skin care / cellulitis precautions
c. Multilayer bandaging
d. exercise/weight management - Full-time maintenance per patient
- Aim to repeat in 1 year
What are the principles and advantages of bandaging in lymphedema?
- Inelastic—not ACE/tensor type
- Remain on 24h day; off only for tx
- remain on at night indefinitely
- Replaced by custom compr’n garment
- Benefit 20-60% reduction in edema
List 4 exercise goals/tips in lymphedema
- Weight control
- Abdominal breathing to enhance thoracic duct flow
- Weight training safe/healthy
- Over-vigorous exercise can be counterproductive
Mechanisms of compression tx in lymphedema.
- Reduce pressure gradient
- Mimic flow created by muscle contraction
- Ultimately improve volume/elasticity of lymph vessels
Contraindications to limb compression
- Acute DVT
- Fragile CHF (can shift fluid to chest)
- Arterial insufficiency
- Wounds
- Pain
Drug classes that may worsen lymph/edema (4)
- NSAIDs
- CCBs
- Alpha antagonists
- Diuretics (more complicated)
How can diuretics interact with lymphedema?
- Likely to reduce edema
a. Especially if comorbid venous edema - Increase tissue [protein] and :. fibrosis
a. This is a long-term issue
b. Less of a concern <1 year use
