Wound healing and wound care 3210303 ศัลยศาสตร์ทวั ไป (General surgery) ผศ.ทพ.กิติ ศิรวิ ฒั น์
Content Type of wound Wound healing Wound care Clinical application
Type of wound Closed wounds Contusion wounds Hematoma
Open wounds Abrasion wounds Incision wounds Lacerated wounds Puncture wounds Gun shot wounds
Wound healing Primary wound healing Primary suture , Skin grafting, Flap operation Not necessary to have wound contraction and epithelial migration Delayed primary wound healing (Tertiary wound healing)
Secondary wound healing Partial thickness wounds Superficial eg. First degree burn , abrasion Healing occurs mainly by epithelialization Minimal collagen production and scar formation
Wound Healing Phases of Wound Healing
Pathopysiology wound healing
Phase of healing Inflammatory phase 1-7 days
Fibroblastic (Proliferative) phase 4-21 days
Maturation (Remodeling) phase 3 m.- 2 y.
Model of Wound Healing (1) Hemostasis: within minutes post-injury, platelets aggregate at the injury site to form a fibrin clot. (2) Inflammatory: bacteria and debris are phagocytosed and removed, and factors are released that cause the migration and division of cells involved in the proliferative phase. (3) Proliferative: angiogenesis, collagen deposition, granulation tissue formation, epithelialization, and wound contraction (4) Remodeling: collagen is remodeled and realigned along tension lines and cells that are no longer needed are removed by apoptosis.
Inflammatory phase Stop bleeding Wound prepare for healing
Inflammatory phase Clot formation Vasoconstriction Platelet aggregation stable clot
Vasodilatationďƒ&#x;bradykinin,serotonin Increased vascular permeability
Growth factor elaboration Neutrophil Macrophage (2-3 days) Lymphocyte Fibroblast,Endothelium cell (start second phase of wound healing)
Growth Factors in wound healing Epithelial Growth Factor (EGF) Fibroblast Growth Factor (FGF) Platelet-Derived Growth Factor (PDGF) Transforming Growth Factor-Beta (TGF-b) Transforming Growth Factor-Alpha(TGF-a) Interleukin-1(IL1) Tumor Necrosis Factor-Alpha (TNF-a)
Proliferation phase the building of new tissue to filled the wound space Cell Fibroblast Fibroplasia, Extracellular Matrix (ECM)-Collagen Endothelial cell Angiogenesis
Gross Granulation tissue formation Wound contraction Epithelialization
Proliferation phase
Fibroplasia
Fibrin-platelet provision matrix, macrophage, extracellular matrix growth factors proliferation of fibroblast (max. conden. In 3-5 days)
Fibroblast synthesize and secret collagen secret growth factors : induce the growth of blood vessel through a process call angiogenesis
Proliferation phase Granulation : Consist of Small blood vessels Endothelial cell proliferation and migration Fibroblast in provisional matrix Collagen Fibronectin Hyaluronic acid
Growth factor from platelet, macrophage, fibroblast : vascular endothelial growth factor,VEGF
Proliferation phase Wound contraction From Myofibroblast?
Epithelialization Glycoprotein : fibronectin , tenascin induce keratinocyte migration Keratinocyte (at basal cell layer) migrate from the edge of the wound Keratinocyte proliferation Keratinocyte + fibroblast laminin+collagen type IV to form new basement membrane
Wound contraction
Epithelialization Secondary wound healing in donor site of skin graft
Clinical application Reactive lesion Pyogenic granuloma Irritating fibroma
Maturation phase (Remodeling Phase)
Maturation phase (Remodeling Phase) About three weeks and can continue about six months or longer Final scar tissue being form by simultaneous synthesis and lyses of collagen Scar tissue may achieve 70 to 80 percent tensile strength by the end of three months
Hypertrophic scar : Excessive healing
Keloid
Wound Healing : Phases of Wound Healing Inflammatory phase Stop bleeding Wound prepare for healing Proliferative phase Granulation tissue formation Wound contraction Epithelialization
Maturation phase Wound strength Scar maturation
Abnormal wound healing Reactive lesion : Pyogenic granuloma, Irritating fibroma Keloid Hypertrophic scar Unhealed wound : Chronic wound
Model of wound healing
Hemostasis
Post op bleeding, Dry Socket
Platelet PDGF
Inflammation
PMN, Macrophage, Lymphocyte
Wound Infection VEGE
Granulation Tissue
Proliferation
Fibroblast, Endothelial cell
Epithelization and wound contraction
Pyogenic Granuloma
Callus, Woven bone formation matrix metalloproteinase
Collagen rearrangement, lamella bone
Remodeling
Collagen Rearragement
Hypertrophic Scar, Keloid
Critical Wound Healing Period Tissue Skin
5-7 days
Mucosa
5-7 days
Subcutaneous
7-14 days
Peritoneum
7-14 days
Fascia
14-28 days 0
5
7
14
Tissue Healing Time/Days
21
28
Inflammatory phase Cell or tissue injury Vasoconstriction Hemostasis Vasodilatation Cell inflammatory migration Cytokine release Increase vascular permeability
Wound Care : Promote normal wound healing
Microorganism
Wound
Patient
Objective of wound care Preserve viable tissue Restore tissue continuity and function Avoid infection Minimize scar formation By maintain good environment for healing and protection of secondary infection
Wound Care : Goal Bacteria balance, Infection control
Microorganism
Wound
Balanced moist environment
Patient
Patient readiness
Wound Care : Wound Balanced moist environment
Wound Cleaning the wound : Open wound Wound Debridement Wound closure-Reconstruction Ladder Wound Dressing
Cleaning The wound Local anesthesia? Clean with antiseptic solution Surrounding wound : alcohol, povidone iodine, hibitane Wound : povidone iodine, NSS
Irrigation: High pressure, large volume Copious irrigation : 2-300 cc. NSS Pressure irrigation by syringe 20-50 cc. with 18-20 gauge needle
Wound Debridement
Wound Debridement Removal of foreign matter, bacteria and devitalized tissue Creates sharp wound edges which are easier to repair Results in more cosmetically acceptable scar
Nonhealable wounds should have only nonviable tissue removed; active debridement to bleeding tissue is contraindicated, as it only worsens the ulcer
Anesthesia Topical Local Nerve blocks IV sedation
Local anesthesia Through the open edge of the wound At the junction of dermis and superficial fascia Laceration length equals cc’s of anesthetic Use small needle and slow infiltration to minimize pain
Local anesthesia
Irrigation Purpose is to remove foreign material and debris without damaging tissue High pressure, large volume 16 or 18 gauge angiocath attached to 30 cc syringe NSS or sterile water
Exploration After wound in anesthetized With fingertip or hemostat Liberal use of X-rays
Debridement
Evaluate for any underlying injury Nerve Artery Salivary gland and duct Sinus
Wound Closure-Reconstruction Ladder Secondary closure Primary wound closure Delayed primary closure Skin graft Local flap Distant flap
Primary wound closure
Secondary closure
Skin graft Split thickness skin grafts (STSG) Full thickness skin grafts (FTSG)
Local flap
Local flap
Distant flap
Wound Dressing Dry dressing : Gauze Wet dressing : Gauze + Saline Wet to dry dressing Wet to wet dressing
Occlusive dressing Moist wound healing
Moist wound healing and Occlusive dressing Moisture facilitate Epidermal migration Angiogenesis Connective tissue synthesis Autolysis debridement
Limit the pain greater than non-occlusive dressing
Practical Application:Dressing Characteristics of an ideal moist wound dressing (Seaman 2002) Maintains a moist wound environment Absorbs excess exudate Eliminates dead space Does not harm the wound Provides thermal insulation Provides a bacterial barrier
การหายของแผลโดยทําให้ ช่ ุมชืน Moist Wound Healing
Absorbency Hydro cellular/Foam Ca-Alginate Hydrocolloid Hydro-Gel Film*
Low
Moderate
Exudates
High
Wound Care : Wound Balanced moist environment
Wound Cleaning the wound Wound Debridement Wound Dressing Wound closure-Reconstruction Ladder
Treat cause in Chronic wound: Compromised host : DM Vascular compromised area : Radiation
Cleansing
Antiseptic
Debridement
Wound closure
Reconstructive Ladder
Bacterial Balance
Wound Dressing
A Balanced moist wound : exudate control Occlusive Dressing
Wound Care Bacteria balance, Infection control Antibiotic prophylaxis and treatment Tetanus Vaccine and passive immunization
Microorganism
Rabies Vaccine and passive immunization
Contaminant Concern CDC Surgical Wound Classification 1. Clean 2. Clean-contaminated 3. Contaminated 4. Dirty Tetanus& Rabies concern :Tetanus prone wound
Spectrum of Bacterial Burden
Contaminated
Healing
Colonised
Slow healing
Increased bacterial burden
Delayed healing
Infected
Non-healing
Type of Operation/Procedure wound Clean Clean-contaminated Contaminated Dirty
CDC Surgical Wound Classification Clean: (1-5% risk of infection) uninfected operative wounds in which no inflammation is encountered and the respiratory, alimentary, genital, or uninfected urinary tracts are not entered. In addition, clean wounds are primarily closed, and if necessary, drained with closed drainage. Operative incisional wounds that follow nonpenetrating (blunt) trauma should be included in this category if they meet the criteria.
Clean-contaminated: (3-11% risk) operative wounds in which
the respiratory, alimentary, genital, or urinary tract is entered under controlled conditions and without unusual contamination. Specifically, operations involving the biliary tract, appendix, vagina, and oropharynx are included in this category, provided no evidence of infection or major break in technique is encountered.
CDC Surgical Wound Classification
Contaminated: (10-17% risk) open, fresh, accidental wounds, operations with major breaks in sterile technique or gross spillage from the gastrointestinal tract, and incisions in which acute, nonpurulent inflammation is encountered.
Dirty or infected: (>27% risk) old traumatic wounds with retained devitalized tissue and those that involve existing clinical infection or perforated viscera. This definition suggests that the organisms causing postoperative infection were present in the operative field before the operation.
Antibiotic prophylaxis in surgery
Bacteria balance, Infection control Bacteria balance : Infection control Topical antimicrobial agent Antibiotic
Maintain good environment for healing Moist environment Exudate management
Bacitracin, polymyxin B, neomycin Bacitracin Inhibit cell wall synthesis Effective against Gram-positive cocci
Neomycin Inhibit protein synthesis Effective against Gram-negative bact.
Polymyxin B Disrupt bacterial cell membrane Effective against Gram-negative bact.
FLAMAZINE™ Silver Sulfadiazine 1% w/w Silver Sulphadiazine In hydrophilic cream base (oil in water emulsion) Micronized crystalline powder Sterile
Antibacterial Efficacy
gram positive gram negative (yeasts & fungi) Chlorhexidine Povidone Iodine Sodium Fusidate
Nanocrystalline Silver Ag 47108 Advanced, unique technology Extremely small particles of silver Size: One-billionth(10-9 m) Coating of 1 micron thick Greater surface area available for anti-bacterial effect Activated by water to be Ag+ and free radical
Viewed under SEM
Nanocrystalline silver on HDPM
3 day Format
7 day Format
Tetanus prone wound
Wound information Time since injury
6 hours
Depth of injury
1 cm
Mechanism of injury
Dead tissue present Foreign material (grass, dirt, etc.) contamination
Is tetanus prone
Is not tetanus prone < 6 hours < 1 cm
Crush, burn, gun shot, frostbite, penetration through clothing
Sharp cut
yes
no
yes
no
Tetanus immunization Tetanus Prone Wound History of Tetanus prevention
Prophylaxis against tetanus Tetanus antitoxin (TAT) : Passive immune passive immunization 250 unit IM in adult 2.3 unit/lb for children
Tetanus toxoid (TT) : Active immune Active immunization (ไม่เคยได้รบั Vaccine,ได้เกิน 10 ปี ) Subcutaneous 0.5 ml (0,1,6)
Booter dose 0.5 ml. for already immunized pt.
Rabies concern Cleansing : alcohol, povidone iodine Copious irrigation : NSS human rabies immunoglobulin (20 IU/kg) : Passive immune Rabies vaccine 1.0 ml : 3,7,14,28 POD : Active immune Avoid suture
Nature of Injury Animal bite
Human bite
Crush injury-example leg rolled over by a car tire, hand caught in a press
Notes Cat bites penetrate deeper than other animals and especially on the hand often enter deep joints-associated with a high infection rate. Be aggressive in cleaning the wound and treating with antibiotics. Especially to hand, high risk for infection, be aggressive in cleaning the wound and treating with antibiotics. Use antibiotics that will treat anerobic bacteria present in the human mouth. There is often more underlying damage than you may initially think. Donâ&#x20AC;&#x2122;t be fooled if the skin looks uninjured-the muscle may be severely damaged.
Dirty wounds-covered with grass, dirt, Will need thorough debridement and etc. removal of foreign materialSlide 65
Wound Care Bacteria balance, Infection control Antibiotic prophylaxis and treatment Tetanus Vaccine and passive immunization
Microorganism
Rabies Vaccine and passive immunization
Contaminant Concern CDC Surgical Wound Classification 1. Clean 2. Clean-contaminated 3. Contaminated 4. Dirty Tetanus& Rabies concern :Tetanus prone wound
Wound Care Patient readiness Nutrition Risk Management Growth factor
Patient
Medical illness
Stem cell Cell Growth factor
Malnutrition Risk habits
Inflammatory enzyme Circulation
Nutrition and Risk Management High protein diet Control blood sugar Avoid smoking and alcohol drinking Avoid pressure that compromise blood circulation
Smoking history Compromise blood perfusion : Nicotine Tissue hypoxia : Carbonmonoxide
Fetal wound repair biology Regeneration â&#x2030; Reparation First - and second - trimester fetal lamb skin incisional wounds appear histologically indistinguishable from normal skin within 2 weeks. Early gestational fetal skin repair may be a process more closely resembling regeneration and growth than healing by scar formation.
Clinical application Scar care cream : PDGF PRP , PRF (platelet rich plasma, platelet rich fibrin) in bone graft, ridge presevation
Fetal Wound Repair: regeneration VS reparation
Wound Care Patient readiness Nutrition Risk Management Growth factor
Patient
Medical illness
Stem cell Cell Growth factor
Malnutrition Risk habits
Inflammatory enzyme Circulation
Wound Care : Goal Bacteria balance, Infection control
Microorganism
Wound
Balanced moist environment
Patient
Patient readiness
Wound Care : Bacteria balance, Infection control Antibiotic prophylaxis and treatment Tetanus Vaccine and passive immunization
Microorganism
Rabies Vaccine and passive immunization
Cleaning the wound : Open wound Nutrition Wound Debridement Risk Management Wound closure-Reconstruction Ladder
Wound Wound Dressing
Balanced moist environment
Patient
Growth factor Stem cell
Patient readiness
Timing of injury: when did the injury occur? Golden period 6 hr. Maxillofacial : 24 hr.
Acute wound Chronic wound
Nature of injury Time of injury
Wound
Patient
Delayed healing, Chronic wound
Type of wounds
Medical illness and personal habits
Antibiotic Prophylaxis
Tetanus prone wound?
Hx. Tetanus immunization
Tetanus prophylaxis
Wound care: Cleaning,Debridement,Wound Closure,Dressing,Medication
Question What happens, if weâ&#x20AC;&#x2122;ll not curette granulation tissue after tooth extraction? Whatâ&#x20AC;&#x2122;ll you will see at tooth extraction wound? 3 days post-op 7 days post-op 2 week post-op
Antibiotic in oral surgery? Impaction Incision and drain Torectomy
Whatâ&#x20AC;&#x2122;s wrong in one month postextraction wound?
Home work and examination Bisphosphonate related osteonecrosis VS wound healing Alveolar osteitis VS wound healing
VAC device application
Practical Application: Monitor wound exudate Monitor the quantity and quality of wound exudate to prevent periwound maceration. Maceration is the softening and damage to periwound tissues with increased exposure to moisture and inflammatory exudate.
Practical Application: Monitor wound exudate The quantity of exudate: examining the dressing on removal None The wound is nonexudative and has no discharge
Small Cover <33% of the dressing’s surface area
Moderate Cover 33%-67% of the dressing’s surface area
Large Cover >67% of the dressing’s surface area
Practical Application: Monitor wound exudate The quality of the exudate Serous exudate Clear and is indicative of serum or transudate
Sanguinous exudate Bright red to dark brown,indicates blood loss from the area and a potentially friable wound bed.
Purulent exudate Indicates the presence of inflammatory cells and is usually the result of infection, necrosis, or sterile inflammation
These may exist singularly or concrurrently (ie, serosanguinous exudate)
Wound beds need to be assessed for presence of Granulation tissue (red) Fibrin slough (yellow) Eschar (black) Bone Tendon Other underlying structure
Eschar formation
Practice
Wound Care : Bacteria balance, Infection control Antibiotic prophylaxis and treatment Tetanus Vaccine and passive immunization
Microorganism
Rabies Vaccine and passive immunization
Cleaning the wound : Open wound Nutrition Wound Debridement Risk Management Wound closure-Reconstruction Ladder
Wound Wound Dressing
Balanced moist environment
Patient
Growth factor Stem cell
Patient readiness