Whats new in chronic ulcer management

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Whats new in chronic ulcer management ?

• Dhanakom Premprapha

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Wound Definition

• A breach of the epidermis of skin that can lead
  to infection and sepsis

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Classification

• Acute wound
• Chronic wound

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Acute wound

• Mechanical force
• Healing process
• Coagulation phase
• Inflammatory phase
• Proliferative phase
• Remodeling phase

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Chronic wound

• Fail in healing process
• Persist inflammatory phase
• Cellular senescence
• Repetitive trauma

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Chronic wound

• Common cause
• Venous stasis
• Diabetes mellitus
• Pressure necrosis
• Other cause
• Malignancy
• Vasculitis
• Pyoderma gangrenosum

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Type of wound healing

• Primary wound healing
• Secondary wound healing
• Epithelialization

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Wound bed preparation

• Debridement
• Control infection
• Environment for healing
• Moist wound healing
• Dressing

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Debridement

• Why debride?
• Wound assessment
• Infection
• Necrotic tissue delays formation of granulation
  and epithelial tissue
• Initiate healing process

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Debridement

• Surgical debridement
• Mechanical debridement
• Wet to dry dressing
• Forceful saline irrigation

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Debridement

• Enzymatic debridement
• Papain
• Collagenase
• Autolytic debridement
• Occlusive dressing

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Debridement

• Biological debridement
• Maggots therapy
• Quite effective in removing necrotic debris
• Useful when antibiotic resistant

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Topical antibiotic

• Bactericidal gt Bacteriostatic
• Broad spectrum
• Minimal tissue irritation
• Not inhibit healing process
• Minimal systemic effect
• Sustained action

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Topical antibiotic

• Iodine the most toxic agent on fibroblast
• New agent Iodosorb
• Hydrogen peroxide
• Silver compounds
• Silver sulfadiazine
• Silvernitrate
• Noncrystalline silver compounds (Acticoat)

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Topical antibiotic

• Mefenide
• Acetic acid
• Chlorhexidine
• Sodium Hypochlorite (Dakins solution)
• Topical antibiotic

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Wound healing materials

• Traditional product
• Advanced product
• Moist wound healing
• Active product
• Bioactive compounds enhance healing
• Tissue engineering
• Nanotechnology gt Nanocrystalline silver

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Dressing

• Desirable dressing characteristics
• Protect wound from bacterial and FB
• Absorb exudate
• Prevent heat and fluid loss
• Provide compression
• Be nonadherent
• Create a warm, moist occluded environment
• Be esthetically attractive

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Dressing

• Occlusive dressing concept
• Dry wound
• Occlusive
  dressing
• Moist wound

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Dressing

• Occlusive dressing concept
• Maintainaning an occluded environment
• Maintain mildly acidity pH
• Relative low oxygen tension on surface

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Dressing

• Placing an occlusive dressing on an infected
  wound encourages bacterial proliferation and
  exacerbates the infection

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Type of dressing

• Non adherent fabrics
• Absorptive
• Occlusive
• Nonbiologic
• Biologic
• Creams, ointment, solution

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Type of dressing

• Nonadherent fabrics
• Xeroform
• Xeroflo
• Adaptic
• Meditel

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Type of dressing

• Absorptive dressing
• Gauze gt adhere to wound
• Foams gt Absorbent and nonadherent
• gt Expand and conform to wound
• Lyofoam(Convatec), Flexzan(Dow Hickham)
• Curafoam(The kendall company), Biopatch(JJ)

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Type of dressing

• Occlusive dressings Non biologic
• Film Transparent, Nonabsorbtive
• Tegaderm(3M), Bioclusive(JJ),
• Op-site(Smith Nephew)

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Type of dressing

• Occlusive dressings Non biologic
• Hydrocolloids Absorbtive dressing
• Duoderm(Convatec), Cutinova(SmithNephew),
  Nuderm(JJ),

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Type of dressing

• Occlusive dressings Non biologic
• Alginates Calcium salt of seaweed
• Utility in exudative wound
• Algosteril(JJ), Kaltostat(Convatec),

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Type of dressing

• Occlusive dressings Non biologic
• Hydrogels 80 water
• Rehydration to dry wound
• Poor absorptive effect
• Nugel(JJ), Tegagel(3M), Flexigel(SmithNephew)

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Type of dressing

• Occlusive dressings Non biologic

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Type of dressing

• Occlusive dressings Non biologic
• Healing and limit pain gt Nonocclusive
• Not differ in epithelialization and healing

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Type of dressing

• Occlusive dressings Bioactive
• Skin substitutes
• Bilayer analog
• Epidermal analog
• Dermal analog lt dermal factor

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Type of dressing

• Occlusive dressings Bioactive
• Temporary
• Homograft Cadaver skin
• Xenograft Pig skin
• Amnion
• Transcyte(SmithNephew)
• Biobrane(Dow hickham)

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Type of dressing

• Occlusive dressings Bioactive
• Permanent
• Apigraft (Organogenesis Inc, Novartis USA)
• Dermagraft (Advanced tissue sciences Inc, USA)
• Alloderm (Lifecell, USA)
• Integra (Integra life science corporation, USA)

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Negative pressure wound therapy

• Mechanism
• Edema
• Blood perfusion
• Cell proliferation
• Infection
• Dressing change

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Negative pressure wound therapy (V.A.C. system)

• Component
• Open-cell foam
• Suction tube
• Adhesive drape
• Suction and reservoir

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Negative pressure wound therapy (V.A.C. system)
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Negative pressure wound therapy (V.A.C. system)
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Negative pressure wound therapy (V.A.C. system)
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Negative pressure wound therapy (V.A.C. system)
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Negative pressure wound therapy (V.A.C. system)
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Negative pressure wound therapy (V.A.C. system)
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Hyperbaric Oxygen Therapy

• The intermittent systemic administration of 100
  oxygen under pressure greater than atmospheric

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Hyperbaric Oxygen Therapy

• Produce neo-vascularization
• Normalized PMN function
• Direct toxic to anaerobic organism
• Improved activity of ATB
• Improved epithelialization

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Hyperbaric Oxygen Therapy
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Diabetic ulcer

• Neuropathic ulcer
• Ischemic ulcer
• Infective ulcer

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Diabetic ulcer Neuropathic ulcer

• Sensory function
• Pain Touch
• Motor function
• Intrinsic muscles of foot
• Autonomic function
• Sympathetic function

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Diabetic ulcer Neuropathic ulcer

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• ??????????
• ??????????????????????? (Callus)
• ?????????

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Diabetic ulcer Neuropathic ulcer
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Diabetic ulcer Neuropathic ulcer

• ?????
• ???????????????
• ??????????? ???? ? ??? ?
• ??????????????
• Loss of sensation
• Foot deformity (Charcot deformity)
• ??????????????

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Diabetic ulcer Neuropathic ulcer

• Charcot deformity

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Diabetic ulcer Ischemic ulcer

• Intermittent claudication
• Rest pain
• Dry gangrene
• Infection
• Wet gangrene

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Diabetic ulcer Ischemic ulcer

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• ??????????????????????

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Diabetic ulcer Ischemic ulcer

• ?????
• ???????????????
• ?????????????
• ???????????????????????????
• ??????????????
• ??????? ???? ???
• ?????????????????
• ??????????????

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Diabetic ulcer Infective ulcer

• Superficial abscess
• Cellulitis
• Fasciitis
• gt Necrotizing fasciitis
• Deep abscess

Septicemia
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Diabetic ulcer Infective ulcer

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• ?????? ??????
• ?????
• ??? ???
• ??????????????
• ???????????????????????
• ???? ??????????

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Diabetic ulcer Infective ulcer
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Diabetic ulcer

• Diabetic triopathy
• Neuropathy
  Infection
• Limb loss
• Ischemia

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Diabetic ulcer

• ????????????
• X-ray
• Doppler ultrasonography
• ABPI
• Arteriography
• Culture

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Diabetic ulcer
Calcified artery
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Diabetic ulcer Treatment

• Neuropathic ulcer
• Rest
• Debridement
• Dressing
• Off-loading

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Diabetic ulcer Treatment

• Ischemic ulcer Mild
• Intermittent caudication
• Risk modification
• Medication

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Diabetic ulcer Treatment

• Ischemic ulcer Severe
• Rest pain
• ABI lt 5
• Risk modification
• Arterial bypass surgery
• Amputation

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Diabetic ulcer Ischemic ulcer
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Diabetic ulcer Treatment

• Ischemic ulcer Dressing
• Debridement only infective tissue
• Moist wound dressing
• Do not pressure dressing
• Re-evaluate

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Diabetic ulcer Treatment

• Infective ulcer Mild
• OPD case
• I D - Debridement
• Oral ATB
• Control DM
• Dressing

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Diabetic ulcer Treatment

• Infective ulcer Severe
• Fever or sepsis
• Rx IPD
• H/C, Pus C/S
• Parenteral ATB
• Control DM with insulin

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Diabetic ulcer Treatment

• Infective ulcer Severe
• Adequate debridement and drainage
• 2-3 dressing change/day
• Amputation in severe infection

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Diabetic ulcer Infective ulcer

• Ischemia infection

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Diabetic ulcer Infective ulcer

• Ischemia infection

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Diabetic ulcer Prevention

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• ????????????????????????????
• ?????????????????????????????????
• ?????????????????????

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Diabetic ulcer Prevention

• ?????????????????????????????????????
• ??????????????????????????????????
• ?????????????????????????????
• ?????????????????????????????????

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Diabetic ulcer Off-loading

• Redistribute or reduce pressure from wound
• Goal reduce pressure at ulcer while keeping the
  patient ambulatory

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Diabetic ulcer Off-loading

• Total contact cast (TCC)

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Diabetic ulcer Off-loading

• Walking splint/Removable cast walker (RCW)

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Diabetic ulcer Off-loading

• Healing shoes

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Diabetic ulcer Off-loading

• Healing shoes

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Diabetic ulcer Coverage

• Secondary healing
• STSG
• Local flap
• Distant flap
• Free flap

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Venous stasis ulcer

• Chronic venous insufficiency
• Abnormal peripheral venous system that reduces
  venous return

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Venous stasis ulcer
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Venous stasis ulcer
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Venous stasis ulcer

• Classification CVI
• Class 0 No visible and palpable signs of
  disease

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Venous stasis ulcer

• Classification CVI
• Class 1 Telangiectasia or Reticular vein

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Venous stasis ulcer

• Classification CVI
• Class 2 Varicose veins

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Venous stasis ulcer

• Classification CVI
• Class 3 Edema

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Venous stasis ulcer

• Classification CVI
• Class 4 Skin change Hyperpigmentation

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Venous stasis ulcer

• Classification CVI
• Class 5 Healed ulcer
• Class 6 Active ulcer

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Venous stasis ulcer

• Prevention of CVI
• Leg support elastic bandage
• elastic support hose
• ( 30-40 mmHg at ankle )
• Leg elevation
• Skin care

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Venous stasis ulcer

• Treatment
• General treatment
• Local treatment
• Surgery

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Venous stasis ulcer

• Compression therapy
• Importance and effective to improve healing
• Compliance is importance

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Venous stasis ulcer

• Compression therapy
• Tubigrip

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Venous stasis ulcer

• Compression therapy
• Jobst

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Venous stasis ulcer

• Compression therapy
• Contraindication in PAD
• Precaution in CHF
• Multilayer compression wraps
• Profore (Smith Nephew)
• Dynaflex (Dyna-Flex international)

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Venous stasis ulcer

• Profore

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Venous stasis ulcer

• Profore

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Venous stasis ulcer

• Profore

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Venous stasis ulcer

• Profore

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Venous stasis ulcer

• Profore

Tricotex
Allevyn standard
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Venous stasis ulcer

• Profore 1
• Soffban natural
• Natural wool
• Absorb exudate
• Protects bony prominences

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Venous stasis ulcer

• Profore 2
• Soffcrepe
• Adds absorbency and smoothes the orthopaedic wool
  layer

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Venous stasis ulcer

• Profore 3
• Litepress
• Light compression bandage
• Highly conformable

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Venous stasis ulcer

• Profore 4
• Co-plus
• Cohesive flexible bandage
• Applied pressure

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Venous stasis ulcer

• Prevent recurrence

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What direction we go in the caring of out
pateint 2006

• Better patient care is the best reason to adopt
  a multidisciplinary approach to wound care.
  
• 
  Dermatol clin21,(2003)
• Wound care clinic

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Power by vascular unit Department of surgery