Wound Care

April 2, 2007

Most wounds can be prevented. In fact, 99.9 percent are preventable. Why are they not prevented? Because of economic issues, explains Kenneth B. Rehm, DPM, medical director of the Diabetic Foot & Wound Treatment Centers, located in San Diego.

Rehm, who is board certified in the prevention and treatment of diabetic foot wounds, a fellow of the American Wound Care Association, a diplomate of the American Board of Medical Specialties in Podiatry, and chief executive officer of KBR Health Products, Inc., says that most chronic wound patients come from nursing homes and hospitals where the typical Medicare patient resides. In nursing homes and acute care hospital settings, the patients arent exercised enough, he points out. He gives the example of patients who have had strokes or back or hip surgeries and the lower extremities do not grasp enough attention from clinicians. He says the patients arent turned enough, and clinicians do not aid the patient in exercising the lower extremities often enough.

Clinicians dont know what they dont know, he asserts. No. 1, prevention measures arent being taken properly, and No. 2, the wound will get too bad for effective treatment. The most overlooked aspects of wound care are pressure relief, circulation, and nutrition.

The very first thing to address is circulation, he says. The very next is to rid it of infection. However, most importantly, Rehm says circulation is absolutely imperative in not only discerning how to treat the wound, but also in assessing just how successful certain wound care attempts will be.

If there is no blood flow to get down to the wound, antibiotic products can not get down there. And, when you debreed or cut the wound, the area will not heal from the debridement. Do your homework, he insists. You study the circulation. You dont cut a wound with no circulation to it and then leave it to turn gangrene. In addition to verifying circulation, the level of oxygen in the blood also must be assessed. Brian Dowd, director of global marketing for wound care, with the Safety and Patient Care Division of Tyco Healthcare, couldnt agree more with the importance of circulation in wound care. He addresses the use of antibiotics in this patient group.

Were exasperating the problem by prescribing antibiotics, specifically in chronic wounds where quite frankly it will do no good, he points out. One of the problems with a chronic wound is that there is no blood flow anyway, so if youre giving a patient an antibiotic to be delivered through the blood and there is no blood flow through the wound, it sort of makes sense then that you are not delivering the antibiotic, however, you are further increasing the risk of more drug resistant bacteria.

In addition to circulation, the nutrition of the body is imperative to address. You need to address their diet because proteins are very important, Rehm advises. A wound will leak out proteins and you need proteins to build the new skin and collagen of the new wound.

The prevention of swelling (edema) and the prevention of pressure to the wound are important aspects in wound care. With any wound area that you are treating, you want to treat it with some kind of pressure relief, Rehm says. He offers three types of pressure to address:

Pounding (or direct pressure) Rubbing (or shearing pressure) Friction (or rubbing pressure) You want to keep those new cells alive and you do not want to do damage by rubbing them away, he explains. Once you reestablish circulation, gotten rid of the bacterial infection, and once you have debrided it, now you can see the field starting to grow grass. It starts growing this granulation tissue which is red tissue that serves as a lattice framework for the new skin. The wound usually starts healing at the ends.

Once you start growing the grass, you need a fertilizer. This is where a lot of the wound care products come in. A lot of these are based in growth factors. However, he warns that the prevention of reoccurrence is the challenging part.

To address this Dowd and the Tyco team have been involved in extensive testing of the wound environment and how wound dressings play such an intricate role.

The greatest thing currently going on, from my perspective, is a greater understanding for controlling the bacterial environment, Dowd explains. Environments in wound care really are interrelated.

Dowd offers that three environments exist when addressing wound care. The first is that of the patient environment or system. This includes controlling proper nutrition, and ensuring patient compliance in not only the wound care, but any underlying diseases as well. This environment includes the clinician and the patient.

The next is the wound environment. This includes the clinician as well as manufacturers of wound care products. It encircles what is going on in that wound the debridment aspect of it, cleaning the wound, and ensuring that the wound is free of necrotic tissue and is healthy and beginning its road to recovery.

Last is the dressing, a new founded level in the wound environment, Dowd explains. In the past the dressing has been viewed as a separate entity, but clinicians now realize that all of these things are interrelated. This environment rest upon the manufacturers, he adds.

Oftentimes, we are so focused on the patient and the wound that were not really understanding what is going on in that dressing. The actual role of the dressing in wound healing and bacterial growth are very commonly overlooked. The dressing itself may be a harbor for bacteria. I recommend topical treatments first; until that patient gets systemic, Dowd offers.

Tyco now features a polyhexamethylene biguanide (PHMB)-impregnated dressing to address the reduction of bacteria in wound dressings.

From a manufacturer perspective, we are insuring that our products keep pace with changes in bacterial strains and prevalence, adds Carl Liebert, group product manager, infection management, Smith & Nephew Wound Management. We do this through laboratory testing to ensure that we are not only inhibitory but bactericidal against these evolving pathogens. For example, USA 100, 300 and 500 are emerging as our more common CA-MRSA strains.

Liebert adds that bactericidal dressings, such as Smith & Nephews ACTICOAT and IODOSORB, are applied to manage infection. Additionally, the use of bactericidal dressings has been gaining more acceptance, particularly in patient populations with elevated infection risks such as diabetics or people with poor nutritional status, he adds.

Regardless, protecting the patient and upholding the tried and true practices of infection control is always at the forefront of the fight in the proper management of wounds.

You have those gowns outside the room? They have the gloves? Use them. A lot of docs, including myself, go into the room thinking they are big shots. The spread of infections in facilities is of prime importance; we have to stop this, Rehm concludes.