Maand: July 2015

Categorieën
Level 2

Basic steps in wound care: debridement

MIL64071//1

Debridement is considered a cornerstone in wound care. Common sense dictates only a clean wound heals. Observing animals lick their wounds adds to this.
It remains the question if and how debridement translates to the clinical practice.

IF: Wilcox checked this in 2013. In  a study of 154 644 patients with 312 744 wounds of all causes debridement were checked as a parameter.  He found the following. The more frequent the debridements, the better the healing outcome. Although limited by retrospective data, this study’s strength was the analysis of the largest wound data set to date.

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The bias is in the quality of the data where you do not know if debridement was the only parameter which differs between the groups, however this is offset by “n”, the sheer number of subjects. They explain further in the article.

The best way to debride is to surgical debridement were all dead material is removed using scalpels, forceps, scissors etcetera. If sharp debridement is not possible alternative methods may be used.

It is important to also keep biofilms in mind, they may be not visible. In a non-healing wound it should be removed, in a healing wound it may be wise to leave it in situ. Common sense dictates removing is more damaging than leaving it in situ.

Frequency of Debridements and Time to Heal: A Retrospective Cohort Study of 312 744 Wounds.  James R. Wilcox, RN ; Marissa J. Carter, PhD, MA; Scott Covington, MD
http://archderm.jamanetwork.com/article.aspx?articleid=1720508

HOW: debridement works seems simple but leads to other questions. It works because you remove debris and other causes of infection in the wound.You also help the body removing unwanted material.  But if you rephrase the answer to it works because you remove barriers to healing you may have to take a second look. Not only debris itself but also tissue directly adjacent to the wound may be a barrier to healing. This leads to the question: which living tissue is a barrier to healing. ..the road to debridement 2.0

Debridement 2.0
Sometimes it may make sense to debride the wound to the point where you remove some living tissue as well. For instance in burns. Presumably in the near future we discover other instances where removing living tissue. Al in all the affected area is usually larger than the wound itself. This is often overlooked in research. Subjects: burn wounds, but also scar tissue and, but we do not know that, metabolically impaired tissue. This is one of the almost uncharted areas in wound care.

nihms235813f4In some cases a closer observation will reveal which “visible” healthy tissue is compromised. This allows to identify and remove more damaged tissue. In the future, this may speed up healing.

Using Gene Transcription Patterns (Bar Coding Scans) to Guide Wound Debridement and Healing
Marjana Tomic-Canic, PhD, RN, Director, Elizabeth A. Ayello, PhD, RN, ACNS-BC, ETN, FAPWCA, FAAN, President, Olivera Stojadinovic, MD, Instructor, Michael S. Golinko, MD, MA, General Surgery Resident, and Harold Brem, MD, Chief   http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2948232/
and
Surgical wound debridement sequentially characterized in a porcine burn model with multispectral imaging.
King DR, Li W, Squiers JJ, Mohan R, Sellke E, Mo W, Zhang X, Fan W, DiMaio JM, Thatcher JE. http://www.ncbi.nlm.nih.gov/pubmed/26073358

 

 

 

Take away:

  1. Proper debriding makes sense.
  2. Proper means clean but also by using the right knowledge and skills.
  3. And thinking on something as simple a removing stuff from a wound may bring progress.
  4. Agree to disagree…discussion improves wound care

Here is a lecture on debridement.

Categorieën
General

Woundcare spending

How much do we spend on wound care in relative and absolute terms is a hard question to answer. Luckily we have some information thanks to the Welsh NHS system which provides some data.

The article in the total cost of managing patients with chronic wounds in Wales amounted to £328·8 million – an average cost of £1727 per patient and 5·5% of total expenditure on the health service in Wales.  With a prevalence of 6%. Not too far away from the Welsh expenses on Cancer. The figures for 2012-13 show the total spend has increased from £356.8m in 2011-12 to £360.9m in 2012-13.

So there you have it!

Wound care is expensive, it equals the cancer expenses (90%). Wound care costs were generally believed to be somewhere between 1,5-4% on any healthcare budget. This article adds the number 5.5%. If wounds were a disease it would be easily in the top five of any health care list. I am no specialist but I would bet these numbers are not that different for any EU country.  However, apparently it is not a disease because it rarely shows up on those lists.

First question to answer is: is this real? The answer is: we do not know. We have combined figures from very different sources, there may be logical errors in combining them. And wound care costs are varying from 1 to 5,5%… also not exactly strong data.  And then the question inevitably is: what costs are inside the data we compare?

But even if the data are questionable there are a few issues we should think about.: The sheer number of people literally suffering from wounds; not a few but a significant part of your population up to 6%. And even at low estimates the numbers demand attention.

So how are wounds looked at?
Insurers may see it as a cost disease (Baumol).
Most doctors see it as a complication instead of an indication.

Reality is, it is not a disease but an expensive complication where we, even though many suffer from it, know very little of. I would strongly advice to make it an indication, have a fresh look at the issue and start over. Research not progressing to the point where we have a strong underpinning is paradoxically a chance. I am happy to explain the intellectual challenges and opportunities this field has. Proper research will not magically shrink expenses or turn it into a disease, it will only justify why we spend so much on it. And hopefully bring the much needed attention.

 

Sources: Estimating the costs associated with the management of patients with chronic wounds using linked routine data – Phillips – 2015 – International Wound Journal – Wiley Online Library

http://www.icid.salisbury.nhs.uk/ClinicalManagement/TissueViability/Pages/WoundCareGuidelines.aspx

http://gov.wales/newsroom/healthandsocialcare/2014/140611cancer/?lang=en

Categorieën
General Level 4

Epic failure: Hyperbaric oxygen therapy for treating chronic wounds

The Cochrane published the review Hyperbaric oxygen therapy for treating chronic wounds (original article)

Here are the results:

  • For diabetes-related foot ulcers, we found that HBOT seemed to improve the chance of healing in the short term (up to six weeks), but not with longer term follow-up. HBOT may reduce the number of major amputations in people with diabetes who have chronic foot ulcers.
  • For chronic wounds caused by a disease to the veins of the leg, we found that HBOT may reduce the size of wounds.
  • For chronic wounds caused by lack of blood supply through the arteries or chronic pressure ulcers, we found no evidence to confirm or refute any effects of HBOT.

These results are to be expected. Not because HBOT is not working, but because researchers lack critical information, simply because it is not available. The Cochrane results are inevitable and reproducible non-conclusive but Cochrane is not to blame. Let’s explain two of the many logical errors causing the failure of wound care research.

It starts with the inclusion criteria. If your inclusion criterion is “a non-healing wound”, you are lost from the start. (the real list is below) There are many reasons wounds do not heal. They can, for example, be patient related, wound related, mechanical or metabolic. (Levels 1,2,3 and 4 which are usually independent of each other)

The first notion regarding chronic wound is that wat caused it, is not necessarily preventing it from closing. Yet we place them all on a pile, sorted by cause of the wound (logical error 1) and then investigate if intervention x is functional. So you are testing in the blind, which is very different from double-blind. That is a gross neglect of reality.

Therefore, if you are lucky,  you will discover how many non-healing wounds accidentally fit your solution (logical error 2). This is very different from finding how effective your intervention is. In today’s setup, it is therefore almost impossible to discover how effective your intervention is. Because we lack markers and/or knowledge to diagnose and characterize the cause of not healing. Therefore, we have no choice but to pile wounds together. It is a pity we do not recognize this beforehand. If you cannot select the wounds which are lacking the solution you provide, the chances of success are next to 0. (logical error 1+2)

And now the real issue: it would be very interesting to figure out which wounds respond. And why and how they respond. This will enable us to recognise this the next time before we apply an expensive treatment. Or in other words, the non-responders are more interesting than the responders. Sadly research is acting in exact the opposite way.

It starts with the inclusion criteria. If your inclusion criterion is “a non-healing wound”, you are lost from the start. (the real list is below) There are many reasons wounds do not heal. They can be patient related, wound related, mechanical or metabolic. (Levels 1,2,3 and 4 which are usually independent of each other)

 

And now the real issue: it would be very interesting to figure out which wounds respond. And why and how they respond. This will enable us to recognise this the next time before we apply an expensive treatment.

If you need help: harmjsmit@gmail.com

 

Inclusion criteria varied in these trials. Doctor 1992 included any person with diabetes with a chronic foot lesion (time not specified); Faglia 1996a included people with diabetes and Wagner grade 2, 3 or 4 lesions (Wagner 1987); Lin 2001 and Kessler 2003 people with “early diabetic feet”, Wagner grades 0, 1 or 2, while Duzgun 2008; Abidia 2003 and Londahl 2010 included people with diabetes whose lesions had been present for more than four weeks, six weeks and three months respectively. In addition, Londahl 2010
required evidence of good standard wound care in a specialist clinic setting for a minimum of two months. Exclusion criteria generally followed from the specific inclusions detailed above, but Abidia 2003 also specifically excluded participants for whom vascular surgical procedures were planned and Kessler 2003 excluded all patients with transcutaneous oxygen tensions of < 30 mmHg. Ma 2013 included patients with diagnosed diabetes, at least one fullthickness wound below the ankle (Wagner grades III or less) for > 3 month, standard care for > 2 month, TcPO2 > 30 mmHg. Khandelwal 2013 included patients with a diabetic foot ulcer of at least 8 weeks duration, patients with only stage III and IV diabetic foot ulcer and the absence of vascular insufficiency.