SURGICAL, ENZYMATIC, Monara Dini DPM Inflammatory phase: Injury - PowerPoint PPT Presentation

4/16/2016 NORMAL WOUND HEALING • Components: SURGICAL, ENZYMATIC, Monara Dini DPM – Inflammatory phase: Injury 7 days & HYDROSURGICAL Assistant Clinical – Proliferative phase: 3 days 3 weeks Professor, DEBRIDEMENT UCSF/SFGH – Remodeling phase: 3 weeks 1-2 years MECHANISM OF ACTION WOUND HEALING REQUIREMENTS T issue non E dge of wound I nfection or M oisture non-advancing or viable or inflammation imbalance undermined deficient • Signal (inflammation) High bacterial Desiccation Non-migrating Defective matrix counts or or excess keratinocytes • Building Blocks (protein) and cell debris Non-responsive prolonged fluid • Energy (oxygen) inflammation wound cells – Perfusion Biological agents Debridement Antimicrobials Dressings • Proper environment Adjunct Therapies compression Debridement – Debridement, moist wound, dry surrounding skin, exudate management, protection Stimulate Restore cell Restore wound Low bacterial keratinocyte migration, base and ECM counts and migration maceration proteins controlled If wound is not healing one or more of these requirements is not met avoided inflammation 1

4/16/2016 SURGICAL DEBRIDEMENT: MECHANISM SURGICAL DEBRIDEMENT OF ACTION � Fast � Selective � Excision of nonviable tissue revitalizes the wound bed with cytokines and growth factors � +/- anesthetic � Mild-moderate bleeding � Randomized, prospective, double-blind trial Surgical No � N= 118 at 10 centers Debridement Debridement � Retrospective analysis of 2 � ALL patients had aggressive sharp debridement VLU 11.7% (SAR) 8.7% SAR controlled, prospective, � Centers with more frequent debridement = Higher rate of randomized trials 50% (12 wk 28% (12 wk healing � 366 VLUs, 310 DFUs closure rate) closure rate) � Serial debridement: DFU 15.5% (SAR) 12.5% (SAR) � higher rate of healing � shorter time to healing 30% (12 wk 13% (12 wk closure rate) closure rate) 2

4/16/2016 ENZYMATIC DEBRIDEMENT: MECHANISM ENZYMATIC DEBRIDEMENT OF ACTION � Naturally occurring proteolytic enzymes stimulate break down of necrotic tissue: � Slow � Not selective Collagenase: � Material digested by enzyme may provide a medium for bacterial growth � Painless Specifically digests � Minimal blood loss ONLY triple helical collagen � No anesthetic required � Prospective & retrospective studies that compared collagenase or papain-urea (1960-2008) • Collagenase more effective � Does enzymatic debridement remove necrotic debris and than placebo promote wound healing in ulcers • Collagenase and Papain-urea (i.e. pressure ulcers, leg ulcers, rate of healing is equivocal or burn wounds)? 3

4/16/2016 HYDROSURGICAL DEBRIDEMENT � Versajet: � FDA-approved medical device � Ability to focus a high-powered (15,000 psi) stream of water into a high-energy cutting device � +/- anesthetic � Mild-moderate bleeding 4

4/16/2016 CONCLUSION � Wound debridement is a vital adjunct in the care of patients with chronic foot ulcers 5