Flicking the Switch: Jump Starting the Challenging Wound

September - October 2022

Flicking the Switch: Jump Starting the Challenging Wound

Editorial Summary

Evaluating the factors which may stall or impair healing is an essential skill to hone for effective clinical practice. This teamed with clinical wound assessment, as well as objective measurement, enables the tracking of progress of wound care patients. Establishing reversible and irreversible factors in a timely fashion enables a pathway to facilitating effective wound healing.

Introduction

Wounds can become chronic and difficult to heal, and profoundly affect the clinical condition and quality of life of patients for months, years or decades. They are considered a vicious cycle within healthcare systems. A number of local and systemic factors contribute to this issue worldwide.

The elderly are an example of a target population for healing deficits. The world population grows and ages with an increased life expectancy but this is proportionally accompanied by the high prevalence of chronic diseases.

The body changes throughout life, a series of personal factors, clinical and socioenvironmental conditions; and, mainly, the knowledge that medical and nursing professionals need to have about the healing process, can influence the increase in the risks for the appearance of wounds, and also directly interfere with healing outcomes.

The awareness of health professionals must be directly related to the initial care with the maintenance of skin integrity, with the prevention of wounds and with the early treatment of the already existing wound, whether surgical or non-surgical. If we do not know how to detect patients at risk or the factors involved with the scarring deficit, we will easily miss the chance of correctly treating an acute wound to prevent this wound from becoming chronic.

Observing the patient and the healing behavior

plays an important role, since healing is influenced by several systemic factors such as advanced age, malnutrition, diabetes, chronic diseases, vascular problems, anemia, vasculitis, and drugs that interfere with immunosuppression.¹The local factors involved with healing are ischemia, edema and infection.

The Healing Process¹

Essentially, the healing process involves three highly complex, interdependent and overlapping stages: the hemostasis and inflammatory phase, the proliferation phase (fibroblasts and collagen synthesis), and the maturation/ remodeling phase.1,2 The healing process depends on the correct interaction between these phases to reach the goal, the healed wound.

So the observation of the measurements (area) of the wound and the documentation of the evolution of the wound are important tools for the evolutionary follow-up. Among the criteria to be observed are the percentage reduction of the area weekly (requiring reliable metric monitoring), the appearance and maintenance of granulation tissue, control of exudates, reduction of deadspaces and perilesional edema, and stimulation of epithelialization. For all this to happen, you need an ideal nutritional condition.

What Is a Wound?

It is important initially to define what a difficult to heal wound is and why this type of wound is a public health problem worldwide.

Dr Adriano A. Mehl Consultant Physician, Adriano Mehl Consulting Curitiba, Brazil

“It is believed that 6% of the world population (approximately 480 million people) have chronic wounds that are difficult to heal and that 16.4% of antibiotic prescriptions are attributed to wound care.”12,13

A wound is defined as a rupture of tissue in the normal anatomical structure with consecutive loss of function. Healing is an organized and interactive cascade of cellular events with an innate immune response to tissue injury. This already gives us an idea of the complexity of the biological reactions that are involved in this process.2

When Does a Wound Become ‘Chronic’ or ‘Hard-to-Heal’?

‘Chronic wounds’ are defined as those that have not followed the normal healing path for 4 weeks. They are trapped in the inflammatory phase of the healing process.1-4 This may have happened due to a neglected or not properly treated local infectious process, as the wounds have the ideal local conditions for the invasion of the bacterial microbiota, mainly. The incidence of infection in chronic wounds is greater than 50%, and the presence of bacterial biofilm has been identified as being between 60% - 90% of cases of biopsies in chronic wounds.1,2,5,6 The chronicity and scarring deficit of wounds are increasingly being correlated with the presence of bacterial biofilms, especially in the elderly, people with diabetes and immobilized patients. These groups are at greater risk of skin invasion by pathogenic microorganisms that violate the skin barrier.5,6

As they are trapped in the inflammatory phase of the healing process, chronic wounds are characterized by a high concentration of inflammatory cytokines; a high level of proteases, a high level of reactive oxygen species; low mitotic activity, non-responsive cells to growth factors, and poor cell migration.1,7

What Are the Concurrent Factors?

A chronic wound that does not heal is typically correlated with a person with comorbidities, such as diabetes, vascular insufficiency, high blood pressure, and chronic kidney disease.4

Then, after the initial tissue damage, several factors can contribute to the delay of the healing process, either due to the severity itself at the injury site, or to the poor health status of the patient.¹

‘Complex wounds’ are those accompanied by aggressive infections, with extensive skin loss, compromised tissue viability (by ischemia or necrosis), and in patients with systemic diseases that impair healing (such as diabetes or vasculitis).8-10

Population aging means a greater number of elderly people with chronic, complex and debilitating wounds, increasing the demand for professionals and tissue viability services.4,10

Redefining Therapeutic Pathways

A ‘difficult to heal wound’ is any wound that has not reduced in area by between 40% - 50% after 4 weeks of treatment, requiring changes in therapeutic strategies. Therefore, a wound that is difficult to heal is one that failed to respond to the evidence-based standard of care.2,11,12 A wound that has not reduced in (surface) area by >40% - 50% within 4 weeks should be considered difficult to heal and referred to a wound specialist or complex wound clinic.

The diagnosis and treatment of difficult to heal wounds cannot neglect the correct treatment of the biofilm.1,2 The prevention of infections and the correct antibiofilm treatment in wounds should be an important focus of attention by health professionals and managers.

Chronic, complex and difficult to heal wounds are considered a public health problem and generate high costs for healthcare services.

It is believed that 6% of the world population (approximately 480 million people) have chronic wounds that are difficult to heal, and that 16.4% of antibiotic prescriptions are

Flicking the Switch: Jump Starting the

attributed to wound care.12,13

They involve specialized care and dressings, prolonged hospitalizations, complex treatments, use of adjuvant therapies, high demand on the time of healthcare professionals, sequence of treatments in dehospitalization, and are associated with high rates of recurrence, judicializations, and chronic morbidity.1,14,15 Chronic wounds have an impact on the quality of life of patients and their families.1 The quality of life for people with wounds that do not heal is similar to that of patients with chronic obstructive pulmonary disease and cardiovascular disease, associated with pain, immobility, infection, amputations and death.1,11,12

There are a number of conditions and risk factors associated with difficult to heal wounds: age, malnutrition, diabetes, anemia, hypoxia, smoking, peripheral vascular disease (arterial and venous), neuropathy, chronic inflammation, systemic medication use, and radiation. But it is worth remembering that external factors such as immobilization, patient adherence to treatment, patient’s economic situation, and demographic and behavioral factors can also significantly affect the difficulty of healing a wound.11

If we consider vascular ulcers of the lower limbs, diabetic foot ulcers, pressure injuries and surgical dehiscence as chronic wounds and all of which are also likely to be complex and difficult to heal, we have to ask: are we really addressing the underlying causes of hard to heal wound modifiable risk factors? Evaluate the person with a wound with a holistic and much broader view of the problem of local wound damage.

There is an aging population, rising health care costs, a sharp rise in the incidence of diabetes, and an increase in obesity.4

Finding a Common Thread

So what do the elderly, diabetics and immobilized people have in common when we approach the topic of wounds that are difficult to heal? These 3 groups also have increased risks for malnutrition, infection and delayed healing.5,6

Nutrition

Initially, I draw attention to the need to assess the nutritional status of patients and ensure adequate energy and protein intake, as recommended by current guidelines,16 not forgetting the importance of correct hydration. Meeting the cellular energy demands that are necessary for healing becomes fundamental, because healing involves a series of reactions, many types of cells, enzymes, growth factors, and other substances.

It is necessary to maintain the ideal pattern to create the healing energy necessary for the healing process, which requires an adequate supply of nutrients and oxygen to cells and tissues, both to fight infection in the wound and for the reconstruction of injured tissue.17

One of the main systemic factors related to scar deficit is malnutrition, when under diagnosed, neglected and not properly treated.18 Unfortunately, less than 50% of patients identified as malnourished receive nutritional intervention19 and the elderly have a 30% greater chance of being malnourished in the hospital environment.

This happens due to the lack of attention of health professionals to malnutrition. It is also due to the lack of programs for the assessment and detection of nutritional status, with appropriate screening, and early and timely nutritional intervention. The lack of attention to these conditions collaborates so that patients with wounds and malnourishment, both in the

“Meeting the cellular energy demands that are necessary for healing becomes fundamental, because healing involves a series of reactions, many types of cells, enzymes, growth factors and other substances.”

“It is necessary to have a holistic view and an interdisciplinary approach to the patient with wounds. This involves not only the local management of the wound and the correct choice

Conclusion

hospital environment, in outpatient clinics and in their homes, have unfavorable outcomes.

It is essential to have professionals with knowledge related to nutrition and the wound healing process, combining clinical control with the correct indication and use of nutritional supplements, dressings and supporting technologies.

Hyperglycaemia

Another obstacle to the wound healing process is the control of sustained hyperglycemia present in diabetes. Hyperglycemia reduces collagen synthesis by fibroblasts, reduces immunity and the inflammatory response.20 Interest in the effects of hyperglycemia is growing and the goal of diabetes mellitus management is to normalize blood glucose levels, since controlling hyperglycemia is associated with a reduction in the development and progression of complications such as scar deficit.

Strict glycemic control is therefore essential, so that healing is not compromised and the potential for wound infection is reduced.

The loss of skeletal muscle mass associated with age and immobility is well known too. Estimates of the severe muscle loss that sarcopenia represents range from 5% - 13% for adults aged between 60 and 70 years, and from 11% - 50% for those aged 80 years and over.21 This contributes a lot to Immobility Syndrome, which is a set of signs and symptoms resulting from the suppression of joint movements and, therefore, the inability to change posture. Immobility may be associated with chronic diseases or debilitating neurological sequelae. Its aggravating factors are malnutrition, dehydration, hypoalbuminemia and anemia.

In order to flick the switch and jump start the challenging wounds it is essential to maintain a holistic view and an interdisciplinary approach to the patient with wounds. This involves not only the local management of the wound and the correct choice of dressing, but also the diagnosis and treatment of systemic factors that interfere with healing, such as nutritional status and hyperglycemia.

Bearing in mind the vital premise that local factors that negatively interfere and induce tissue hypoxia, such as ischemia, inflammation and infection, must be quickly detected, avoided and properly treated.

Patients with wounds need a systematic assistance that includes the clinical evaluation of the patient and the lesion.

Identifying that wounds with 30% - 50% area reduction in the first 2 - 4 weeks have high healing potential, it follows that we need to correctly measure the areas of the wounds and follow them up.

If the patient is not adequately nourished, blood glucose is not controlled, and the dressing is not correct, the healing goals will not be achieved.

Without this vision, we will not be able to break the vicious cycle that perpetuates the coexistence of a person with a wound that is difficult to heal.

References

1. Mehl AA, Schneider Jr B, Schneider FK, Carvalho BHK. Measurement of wound area for early analysis of the scar predictive factor. Rev. Latino-Am. Enfermagem. 2020;28:e3299. 2. Mehl AA, Damião AO, Viana SD, Andretta CP. Hard-to-heal wounds: a randomised trial of an oral proline-containing supplement to aid repair. J Wound Care. 2021 Jan 2;30(1):26-31. doi: 10.12968/jowc.2021.30.1.26.

3. Sen CK, Roy S, Gordillo G. Chapter 14: Wound Healing (Neligan Plastic Surgery, Vol. 1). London: Elsevier, 2017.

4. Sen CK. Human Wound and Its Burden: Updated 2020 Compendium of Estimates. Adv Wound Care (New Rochelle). 2021 May;10(5):281-292. doi: 10.1089/wound.2021.0026.

5. Ganesh K, Sinha M, Mathew-Steiner SS, Das A, Roy S, Sen CK. Chronic Wound Biofilm Model. Adv Wound Care (New Rochelle);4(7):382–388, Jul 1, 2015.

6. Skrlin J. Impact of biofilm on healing and a method for identifying it in the wound. Acta Med Croatica.;70(1):29-32,Mar,2016.

7. Mast BA, Schultz GS. Interactions of cytokines, growth factors, and proteases in acute and chronic wounds. Wound Repair Regen. 1996;4:411-20.

8. Ferreira MC, Tuma P Jr, Carvalho VF, Kamamoto F. Complex wounds. Clinics (Sao Paulo). 2006 Dec;61(6):571-8. doi: 10.1590/s1807-59322006000600014.

9. Coltro PS, Ferreira MC, Batista BP, Nakamoto HA, Milcheski DA, Tuma Júnior P. Role of plasticsurgery on the treatment complex wounds. Rev Col Bras Cir. 2011 Nov-Dec;38(6):381-6. English, Portuguese. doi: 10.1590/s0100-69912011000600003.

10. Nussbaum SR, Carter MJ, Fife CE, et al. An economicevaluation of the impact, cost, and medicare policy implications of chronic nonhealing wounds. Value Health 2018;21:27–32.

11. Atkin L, Bućko Z, Montero EC, Cutting K, Moffatt C, Probst A, Romanelli M, Schultz GS, Tettelbach W. Implementing TIMERS: the race against hard-to-heal wounds. J Wound

of dressing, but also the diagnosis and treatment of systemic factors that interfere with healing, such as nutritional status and hyperglycemia.”

Care Consensus Document. 2019; 28(3 Suppl 3):S1–S49. https://doi.org/10.12968/jowc.2019.28. Sup3a.S1

12. Murphy C, Atkin L, Swanson T, Tachi M, Tan YK, Vega de Ceniga M, Weir D, Wolcott R. International consensus document. Defying hard-to-heal wounds with an early antibiofilmintervention strategy: wound hygiene. J Wound Care 2020; 29(Suppl 3b):S1–28.

13. Oliveira AC, Rocha DM, Bezerra SM, Andrade EM, Santos AM, Nogueira LT. Qualidade de vida de pessoas com feridas crônicas. Acta Paul Enferm. 2019;32(2):194-201.doi. org/10.1590/1982-0194201900027 14. Guest JF, Ayoub N, McIlwraith T, et al. Health economic burden that wounds impose on the national health service in the UK. BMJ Open. 2015;5,12.

15. Drew P, Posnett J, Rusling L. The cost of wound care for a local population in England. Wound Care Audit Team. Int Wound J. 2007 Jun;4(2):149-55.

16. de Oliveira KDL, Haack A, Fortes RC. Terapia nutricional na lesão por pressão: revisão sistemática. Rev. Bras. Geriatr. Gerontol. 2017; 20(4): 567-575. http://dx.doi.org/10.1590/198122562017020.160195

17. Janis JE, Harrison B. Wound Healing: Part I. Basic Science. Plast Reconstr Surg. 2016; 138:9-17S.

18. Citty SW, Cowan LJ, Wingfield Z, Stechmiller J. Optimizing Nutrition Care for Pressure Injuries in Hospitalized Patients. Advances in Wound Care, volume 8, number 7, 2019. DOI: 10.1089/wound.2018.0925)

19. Khalatbari-Soltani S, Marques-Vidal P. Impact of nutritional risk screening in hospitalized patients on management, outcome and costs: A retrospective study. Clin Nutr. 2016 Dec;35(6):1340-1346. doi: 10.1016/j.clnu.2016.02.012.

20. Arya AK, Tripathi K, Das P. Promising roleof ANGPTL4 gene in diabetic wound healing, Int. J. Low Extrem. Wounds. (2014) Mar;13(1):58-63.

21. Malmstrom TK, Miller DK, Herning MM, Morley JE. Low appendicularskeletalmusclemass (ASM) with limited mobility and poor health outcomes in middle-aged African Americans. J Cachexia Sarcopenia Muscle (2013) 4:179–186.