Chronic Wound Managment HMI

Chronic Wound Management
HIPPOCRATES KAM
VASCULAR & ENDOVASCULAR SURGEON
INTRODUCTION
▪ A wound is a disruption of the normal structure and function of the
skin and skin architecture.
▪ An acute wound has normal wound physiology and healing is

anticipated to progress through the normal stages of wound
healing, whereas a chronic wound is defined as one that is
physiologically impaired
▪ To ensure proper healing, the wound bed needs to be well vascularized,
free of devitalized tissue, clear of infection, and moist.
▪ Wound management should eliminate dead space, control exudate,

prevent bacterial overgrowth, ensure proper fluid balance, be cost-
efficient, and be manageable for the patient and/or nursing staff
(podiatrist).
Because wounds are often contaminated with
bacteria, there is a time limit (the “golden period”)
between the laceration and closure with sutures. It
varies between 6 to 8 hours (hand and feet)
and 24 hours for the vascular face
Chronic Wound
Definition :
Chronic wounds are defined as wounds that fail to proceed through the
normal phases of wound healing in an orderly and timely manner
within a 4-6 week period. Healing is delayed due to patient, wound
and/or environmental factors.
CHRONIC WOUND
ARTERIAL ULCERS  Tromboangiitis obliterans, Raynaud
Arterial ulcers occur because of inadequate perfusion of skin and subcutaneous tissue
at rest. Arterial occlusive disease, common among smokers, diabetics and the elderly,
can lead to claudication, rest pain and gangrene, in addition to localized ulceration.
VENOUS ULCERS  Chronic venous insufficiency

Venous stasis ulcers result from hypoxia in areas of venous congestion in the lower
extremity. Possibly, the thick perivascular fibrin cuffs impede oxygen diffusion into
surrounding tissues. Alternately, macromolecules leaking into perivascular tissue trap
may growth factors needed for the maintenance of skin integrity
PRESSURE ULCER
Pressure ulcers result from ischemia due to prolonged pressure over a bony
prominence. They typically occur in paralyzed or unconscious patients who unable to
either sense or respond to the need for periodic repositioning
▪ DU: Tidak nyeri / nyeri minimal, sensasi berkurang
▪ VU: Nyeri ringan, sensasi masih baik
▪ PU: Nyeri intermittent
▪ AU: Nyeri menetap
1. Pressure Ulcers
Pressure Ulcer Guidelines
1. Positioning and Support Surfaces
2. Nutrition
3. Infection Control (Debridement)
4. Wound Bed Preparation
5. Dressings
 maintains a moist wound healing environment
6. Surgery
7. Use of Adjuvant Agents (limited)
2. Venous Stasis Ulcers
Treatment Guidelines—VU
1 . Arterial disease should be ruled out

2. Lower Extremity Compression
3. Infection Control (Debridement, Infection Assessment, Treatment)
5. Dressings
 moist wound healing environment
6. Surgery
Skin graft, Subfacial endoscopic perforator surgery (SEPS), Less
extensive surgery (venous ablation, endovenous laser ablation or
valvuloplasty), free flap
7. Use of Adjuvant Agents (Bilayered artificial skin)
8. Long-Term Maintenance (compression stockings constantly and
forever)
3. Diabetic Ulcers
Guidelines
1. Diagnosis
2. Offloading
5. Dressings
 moist wound healing environment.
6. Surgery
7. Use of Adjuvant Agents (limited)
4. Arterial Ulcers--AU
▪ Tend to occur on distal areas
▪ Diminished/absent pulses
▪ Punched-out appearance, or gangrene
▪ Requires either salvage revascularization, or amputation—usually the
latter
The guidelines
1. Diagnosis
2. Surgery (Obtain anatomic roadmap prior to revascularization )
If dry gangrene or scar: do NOT debride until arterial in-flow has been re-established
5. Dressings
6. Use of Adjuvant Agents
7. Long-term Maintenance (Risk factor reduction , Antiplatelet therapy , Exercise to
increase arterial blood flow )
Chronic Wound Care Guidelines, Copyright ©2007. The Wound Healing Society 341 N. Maitland Ave: Florida.
Wound Managment
ASSESSMENT OF THE WOUND
Depth, extent (size), location, general

appearance, odor, and notation of
exudates are all essential components of
wound evaluation and need to be
recorded at baseline
A visual inspection of the wound will immediately identify very important clues not only to the
etiology of the lesion but also to its complexity which attributes that will guide further evaluation and
treatment important.
Factors affecting wound healing
● Local
○ Ischemia ● Systemic
○ Age and gender
○ Infection ○ Sex hormones
○ Foreign body ○ Stress
○ Edema, elevated tissue pressure ○ Ischemia
○ Diseases
infection ○ Obesity
○ Medication
○ Alcoholism and
foreign
smoking
IMPAIRED ischemia ○ Immunocompromised
bodies HEALING
conditions
○ Nutrition
edema/ elevated
tissue pressure
1
9
Promotion of Wound Healing
▪ Dressings: keep wound covered & clean

▪ Wound bed moist / Surrounding skin dry
▪ Debridement when necessary
▪ Remove exudate:
Drains, Wound VAC, Irrigation
▪ Pack wounds loosely
▪ Nutritional interventions
Support wound environment
 Moisture balance
 Normal temperature
 Bacterial load control
 PH
What is the Ideal Dressing?
• A moist wound environment

• Allowance for removal without pain or trauma
• Promotion of wound healing
• Capability of absorbing excess exudate
• Provision of mechanical protection
• Nonadherence to the wound
• Allowance of gaseous exchange
• Impermeance to microorganisms Acceptability to the patient
• Ease to use
• Cost effectiveness.
Traditional vs Modern
attached to the wound, painfull, Ease to remove, moist, atraumatic

tissue damage
Moist Wound Healing
Presence of Moist Dry wound

exudate condition
Absorb exudate Maintain moist Add moisture
condition
Antimicrobial Hydrocolloid Hydrogel
Alginate Contact Layer Transparent
Foam Film/Transparent Antimicrobial +Gel
Ointment
Keep wound bed moist but surrounding skin dry

Pack wounds loosely to avoid pressure on new granulation
tissue
TREATMENT ? …
Wound care products
Wound care products
▪ Wound bed preparation

▪ Infection management
▪ Exudate management
Debridement
▪ Surgical
▪ Autolytic
▪ Hydrogel
▪ Helps reduce pain, decrease
wound temperature and
inflammation
▪ Enzymatic
▪ Biological
Hydrogel debridement
▪ Donation of moisture to dry necrotic or sloughy tissue.
▪ Support of autolytic debridement.
▪ Preparation for surgical debridement.
▪ (Limited) absorption of excessive wound fluid.

▪ Used in the initial phase of wound healing
▪ Can be used in later stages if additional moisture is
desirable
Cutimed Sorbact
Swabs made from a DACC-coated acetate.
Primary wound contact dressing for all types of wounds.
Dressing pads made from a DACC-coated acetate swab with an

absorbent core. Used for shallow, low to moderate exuding
wounds.
Ribbon dressings made from DACC-coated cotton.

For use in deep or cavity wounds. Also suitable between digits
or in skin folds where fungal infections may be a problem.
Round swabs suitable for filling deeper wounds.
Cutimed Sorbact gel comprises a Cutimed Sorbact swab coated

with an amorphous hydrogel to support hydrophobic interaction
in wounds with low exudate levels.
Case Study
Hands-on Case Report No. 7, von Hallern B.
Chronic venous insufficiency and venous leg ulcers
Venous leg ulcer at start Clean granulating wound

of treatment by day 11 For sloughy, fibrinous wounds
we recommend using
Cutimed ® Sorbact® gel
dressings!
Exudate management
FOAMS
Exudation
Dynamic MVTR
Optimal situation Saturated dressing
▪ Transmits moisture vapor, O2, and thermal insulation

▪ Rapid and reliable absorption and fluid management
▪ Adaption to different exudate levels and helping to prevent maceration
▪ Combination with compression therapy possible
Cutimed Siltec
Designed to facilitate vertical
absorption
• High Moisture Vapour
Transmission Rate (MVTR)
• Super absorbent particles
Vertical absorption
Reducing maceration
Cutimed Siltec
Perforated silicone layer

• Atraumatic release
• Wound edge protection
TERIMA KASIH

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Chronic Wound Management

▪ An acute wound has normal wound physiology and healing is

▪ Wound management should eliminate dead space, control exudate,

VENOUS ULCERS  Chronic venous insufficiency

1 . Arterial disease should be ruled out

Depth, extent (size), location, general

▪ Dressings: keep wound covered & clean

• A moist wound environment

• Promotion of wound healing

• Capability of absorbing excess exudate

• Provision of mechanical protection

• Nonadherence to the wound

• Allowance of gaseous exchange

• Impermeance to microorganisms Acceptability to the patient

attached to the wound, painfull, Ease to remove, moist, atraumatic

Presence of Moist Dry wound

Keep wound bed moist but surrounding skin dry

▪ Wound bed preparation

▪ (Limited) absorption of excessive wound fluid.

Dressing pads made from a DACC-coated acetate swab with an

Ribbon dressings made from DACC-coated cotton.

Round swabs suitable for filling deeper wounds.

Cutimed Sorbact gel comprises a Cutimed Sorbact swab coated

Venous leg ulcer at start Clean granulating wound

▪ Transmits moisture vapor, O2, and thermal insulation

Perforated silicone layer

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