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Exudate Management

in Wound and Burn Cases


dr. Donna Savitry, SpBP-RE

RS Bhayangkara tk I RS Sukanto Kramat Jati


RS Premierr Bintaro Tangerang Selatan
Unistem Clinic - Rawamangun
Wound: Definition

A wound is the result of disruption of normal


anatomic structure and function 1

1. Boateng JS, Matthews KH, Stevens HN, Eccleston GM. Wound healing dressings and drug delivery systems: a review.
Journal of pharmaceutical sciences. 2008 Aug 1;97(8):2892-923.
Wound: Acute and Chronic
Acute wounds are usually
tissue injuries that heal
completely, with minimal
scarring, within the
expected time frame,
usually 812 weeks. 1
Wounds that demonstrate
delayed healing 12 weeks
after the initial insult are
termed chronic wounds,
often as a result of
prolonged pathological
inflammation. 2
1. Boateng JS, Matthews KH, Stevens HN, Eccleston GM. Wound healing dressings and drug delivery systems: a review.
Journal of pharmaceutical sciences. 2008 Aug 1;97(8):2892-923.
2. Harper D, Young A, McNaught CE. The physiology of wound healing. Surgery (Oxford). 2014 Sep 30;32(9):445-50.
Wound: Acute and Chronic

Chronic or non-
healing ulcers are
characterized by
defective remodeling
of the ECM, a failure
to re-epithelialize,
and prolonged
inflammation. 2

1. Schultz G, Sibbald G, Falanga V, et al. Wound bed preparation: a systematic approach to wound management.
Wound Repair Regen 2003; 11: 128
Types of Wound
Acute:
Traumatic
Surgical
Burn

Chronic:
Diabetic foot
Venous leg ulcer
Pressure ulcer

1. Dowsett C, Newton H. Wound bed preparation: TIME in practice. Wounds UK. 2005; 1(3): 58-70
2. Jones V, Grey JE, Harding KG. Wound dressings. British medical journal. 2006 Apr 1;7544:777.
3. Muzzarelli RA, Morganti P, Morganti G, Palombo P, Palombo M, Biagini G, Belmonte MM, Giantomassi F, Orlandi F, Muzzarelli C. Chitin nanofibrils/chitosan glycolate composites as
wound medicaments. Carbohydrate Polymers. 2007 Oct 1;70(3):274-84.
4. Holland AJ, Martin HC, Cass DT. Laser Doppler imaging prediction of burn wound outcome in children. Burns. 2002 Feb 28;28(1):11-7.
Wound Healing Phases
Coagulation & Inflammation
Proliferation
Epithelization & Remodelling

Chronic wound
stuck in the
inflammatory
and
proliferative
stages of
healing which
delays closure.

1. Yao K, Bae L, Yew WP. Post-operative wound management. Australian Family Physician. 2013; 42(12):4
2. Dowsett C, Newton H. Wound bed preparation: TIME in practice. Wounds UK. 2005.;1(3): 58-70
Dry vs Moist Wound Healing
Moist wound environment has been accepted by wound experts to
support wound healing and reduce the risk of infection
Dry Wound Healing Moist Wound Healing

Dry wound healing scab/crust Wound heals faster and better in moist environment
Scab protects the wound from contamination Moist wound environment prevents the formation of
However, scab also delays wound healing because it scab
becomes a physical barriers for cell proliferation Less scar, therefore a better cosmetic result
1. Winter, G. D. Formation of the scab and the rate of epithelialization of superficial wounds in the skin of the young domestic pig, Nature. 1962; 193:293294
2. Dyson M, Young S, Pendle CL, Webster DF, Lang SM. Comparison of the effects of moist and dry conditions on dermal repair. Journal of investigative
dermatology. 1988 Nov 30;91(5):434-9.
Moist Wound Healing
First introduced in 1962.1

A moist wound environment has


been shown to accelerate wound
healing by up to 50% compared
with exposure to air.1,2,3

A moist environment
physiologically favors migration
and matrix formation and
accelerates healing of wounds by
promoting autolytic
debridement.1,2

Moist wound healing also reduces


wound pain and tenderness,
reduces fibrosis, decreases wound
infection rates, and produces a
better cosmetic outcome.2 1. Winter, G. D. Formation of the scab and the rate of epithelialization of superficial
wounds in the skin of the young domestic pig, Nature. 1962; 193:293294
2. Schultz GS, Sibbald RG, Falanga V, Ayello EA, Dowsett C, Harding K, Romanelli
M, Stacey MC, Teot L, Vanscheidt W. Wound bed preparation: a systematic
approach to wound management. Wound repair and regeneration. 2003 Mar
1;11(s1):S1-28.
3. Field CK, Kerstein MD. Overview of wound healing in a moist environment. The
American journal of surgery. 1994 Jan 31;167(1):S2-6.
Types of Wound Closure1
Primary

Secondary

1. Yao K, Bae L, Yew WP. Post-operative wound management. Australian Family Physician. 2013; 42(12):4
Factors That Can Delay The Wound Healing1

Infection Repeated trauma or


Vascular Insufficiency continued pressure
Malnutrition Effects of medication
Dehydration (eg: steroids, cytotoxics,
NSAID)
Immunodefiency
Smoking
Lack of oxygen delivery
to the tissues Old age
Inappropriate wound
management
Stress

1. Flynn J. Understanding chronic wound management: part I. The Pharm Journal. 2009; 282: 777-780
Wound Assessment
The process of diagnosis
identifies a disease or medical
condition from the patients
signs and symptoms, and from
any tests performed. In the
effective treatment of patients
with wounds, the diagnostic
process will:
Determine the cause of the
wound
Identify any comorbidities/
complications that may
contribute to the wound or delay
healing
Assess the status of the wound
Help to develop the
management plan.
1. World Union of Wound Healing Societies (WUWHS). Principles of best practice: Diagnostics and wounds. A consensus document. London: MEP Ltd, 2008.
Current State of Wound

Necrotic
Granulating

Infected

Epithelizing
Sloughy

1. Grey JE, Enoch S, Harding KG. Wound assessment. British Medical Journal. 2006 Feb 2;7536:285.
Wound Assessment:
A Message from The Exudate

1. World Union of Wound Healing Societies (WUWHS). Principles of best practice: Wound exudate and the role of
dressings. A consensus document. London: MEP Ltd, 2007.
Wound Assessment:
A Message from The Exudate

1. World Union of Wound Healing Societies (WUWHS). Principles of best practice: Wound exudate and the role of
dressings. A consensus document. London: MEP Ltd, 2007.
Wound Bed Preparation:
Focus Systematically on Critical Components
to Accelerate Endogenous Healing

Wound bed preparation is the management of a wound in order


to accelerate endogenous healing or to facilitate the
effectiveness of other therapeutic measures. 1

Wound bed preparation as a concept allows the clinician to


focus systematically on all of the critical components of a non-
healing wound to: 2
Identify the cause of the problem,
Implement a care program
to achieve a stable wound that has healthy granulation tissue and a
well vascularised wound bed.

1. Schultz G, Sibbald G, Falanga V, et al. Wound bed preparation: a systematic approach to wound management. Wound Repair Regen 2003; 11: 128
2. Dowsett C, Newton H. Wound bed preparation: TIME in practice. Wounds UK. 2005.;1(3): 58-70
Wound Bed Preparation:
Treat The Whole Patient,
Not Just The Hole in The Patient

IMPORTANT!
Remember to assess the
whole patient; the
wound bed preparation
care cycle promotes
the treatment of the
whole patient and not
just the hole in the
patient.

1. Dowsett C, Newton H. Wound bed preparation: TIME in practice. Wounds UK. 2005; 1(3): 58-70
TIME1: A Practical Framework
for Wound Bed Preparation

o Tissue Tissue
debridement
management
o Control of Infection Epithelial Wound bed Infection
preparation Inflammation
and inflammation Edge
o Moisture balance
Moisture
o Advancement of balance
the epithelial Edge
of the wound.

1. Leaper DJ. Extending the TIME concept: what have we learned in the past 10 years? Int Wound J. 2012 Dec;9
Suppl 2:1-19.
TIME - Tissue

1. Dowsett C, Newton H. Wound bed preparation: TIME in practice. Wounds UK. 2005.;1(3): 58-70
2. Care RW. A study of biofilm-based wound management in subjects with critical limb ischaemia. Journal of wound care. 2008 Apr;17(4):145.
3. Wannous H, Lucas Y, Treuillet S. Enhanced assessment of the wound-healing process by accurate multiview tissue classification. IEEE transactions on Medical
Imaging. 2011 Feb;30(2):315-26.
Tissue : Debridement
Debridement is the process of removing devitalised
tissue and/or foreign material from a wound and it
may occur naturally.
Types of debridement1:
Autolytic
Enzymatic
Mechanical
Surgical-Sharp
Biological (Maggot)

1. Dowsett C, Newton H. Wound bed preparation: TIME in practice. Wounds UK. 2005.;1(3): 58-70
TIME - Infection-Inflammation

Emphasis is often placed on the bacterial burden, but in fact


host resistance is often the critical factor in determining whether
infection will occur. 1

Host resistance is lowered by poor tissue perfusion, poor nutrition,


local oedema and other behavioural factors such as smoking
and drinking excess alcohol.

1. Dowsett C, Newton H. Wound bed preparation: TIME in practice. Wounds UK. 2005; 1(3): 58-70
TIME - Moisture

Scab of a dry Macerated wound


1. wound
Dowsett C, Newton H. Wound bed preparation: TIME in practice. Wounds UK. 2005; 1(3): 58-70
2. Brem H, Balledux J, Bloom T, Kerstein MD, Hollier L. Healing of diabetic foot ulcers and pressure ulcers with human skin equivalent: a new paradigm in wound
healing. Archives of surgery. 2000 Jun 1;135(6):627-34.
3. Woo KY, Ayello EA, Sibbald RG. The skin and periwound skin disorders and management. Wound Healing Southern Africa. 2009 Sep 28;2(2):43-8.
Moisture : Exudate - Myths & Facts

is derived from fluid that has leaked out of blood


vessels and closely resembles blood plasma
1. World Union of Wound Healing Societies (WUWHS). Principles of best practice: Wound exudate and the role of dressings. A consensus document. London:
MEP Ltd, 2007.
Moisture : Exudate - Myths & Facts
Composition: contains a variety of substances including water,
electrolytes, nutrients, inflammatory mediators, white cells,
protein-digesting enzymes (eg matrix metalloproteinases
MMPs), growth factors and waste products.
In the healing wound , exudate appears to promote healing in
a number of ways, including stimulating cell proliferation.
In wounds not healing as expected (chronic wounds), exudate
appears to have opposite effects. This exudate contains
elevated levels of inflammatory mediators and activated
MMPs.

1. World Union of Wound Healing Societies (WUWHS). Principles of best practice: Wound exudate and the role of dressings. A consensus document. London:
MEP Ltd, 2007.
Moisture : Exudate - Myths & Facts

Wound exudate is often misconceived as bad.


In fact, exudate is known to assist healing by: 1
Preventing the wound bed from drying out
Aiding the migration of tissue-repairing cells
Providing essential nutrients for cell metabolism
Enabling the diffusion of immune and growth factors
Assisting separation of dead or damaged tissue (autolysis).

1. World Union of Wound Healing Societies (WUWHS). Principles of best practice: Wound exudate and the role of dressings. A consensus document. London:
MEP Ltd, 2007.
The Characteristics of Ideal
Wound Dressing1

Ideal Wound Dressing:

Maintains a moist wound environment


Absorbs excess exudate
Eliminates dead space
Does not harm the wound
Provides thermal insulation
Provides bacterial barrier

1. Seaman S. Dressing selection in chronic wound management. J Am Podiatr Med Assoc. 2002;92(1):24-25
MVTR (Moisture Vapor Transmision Rate) as The
Parameter to Define a Moisture Retentive Dressing
The degree to maintain moist wound
environment (moisture retentiveness) of a
wound dressing is measured by MVTR.

The water vapour permeability is officially


referred to as MVTR in the British
Pharmacopoeia and measures the
amount of water vapour lost through a
dressing to the atmosphere from the
wound bed over defined time periods. 1

A dressing is moisture retentive when its


MVTR < 840 g/m2/24 hour. 2

1. Boateng JS, Matthews KH, Stevens HN, Eccleston GM. Wound healing dressings and drug delivery systems: a review. Journal of pharmaceutical sciences.
2008 Aug 1;97(8):2892-923.
2. Seaman S. Dressing selection in chronic wound management. J Am Podiatr Med Assoc. 2002;92(1):24-25
Types of
Modern
Dressing

Abdelrahman T, Newton H. Wound dressings:


principles and practice. Surgery (oxford). 2011 Oct
31;29(10):491-5.
NICE Guideline Development
Group interpretation:
There is no robust evidence to support
the use of one dressing over another.
However, in the majority of clinical
situations a semi-permeable film
membrane with or without an absorbent
island is preferable.
The GDG consensus was that the use of
gauze as a primary dressing should be
avoided because of its association with
pain and disruption of healing tissues at
the time of dressing change.

National Institute for Health and Clinical Excellence (2008) Quick reference guide: surgical site infection. London: NICE.
http://www.nice.org.uk/guidance/cg74
TIME - Edge

The wound bed must be full of well vascularised granulation tissue in order
for the proliferating epidermal cells to migrate. This also ensures that there
is adequate oxygen and nutrients to support epidermal regeneration. 1

It is important to remember that wounds rely on both macro- and


microcirculation particularly in the lower limb.

Always consider the elements of T,I, and M first to ensure that the use of
advanced therapies are appropriate and if used are applied to a well
prepared wound bed to ensure optimal effect.

1. Dowsett C, Newton H. Wound bed preparation: TIME in practice. Wounds UK. 2005.;1(3): 58-70
Management of Exudate
Effective Exudate Management
Strategies
Dressing material and indicated usage
Criteria for dressing
selection
Summary
The management of wounds has progressed from merely
assessing the status of the wound to understanding the underlying
molecular and cellular abnormalities that prevent the wound from
healing.

The concept of wound bed preparation has evolved


to provide a systematic approach
to removing the barriers
to natural healing
Tp enhance the effects of advanced therapies.

Wound bed preparation and the TIME framework are to be


successful when used alongside the wound bed preparation care
cycle.