Wound bed preparation

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Wound bed preparation (WBP) is a systematic approach to wound management by identifying and removing barriers to healing. The concept was originally developed in plastic surgery. [1] [2] During the year 2000, the concept was applied to systematizing the treatment of chronic wounds. The 2000 proposals [3] [4] [5] recommended that wound management address the identifiable impediments to healing in order to achieve more successful outcomes. Three publications appeared that year that focused on the concept of managing the healing processes of a wound exudate, bioburden and devitalized tissue. Initially, emphasis was placed on debridement, moisture balance and bacterial balance as the three guiding principles of good wound care, while at the same time recognizing that the provision of care includes a vast array of patient, clinical and environmental variables. [3]

Contents

Since 2000

Since the year 2000, the wound bed preparation concept has continued to improve. For example, the TIME acronym (Tissue management, Inflammation and infection control, Moisture balance, Epithelial (edge) advancement) has supported the transition of basic science to the bedside in order to exploit appropriate wound healing interventions [6] and has not deviated from the important tenets of debridement, moisture balance, and bacterial balance.

The TIME framework is not a continuum and as such is applicable to a wide range of wounds. The WBP model can be effectively applied only when a high level of precision is utilized in the assessment of the patient and their wound. The corollary of this is that intervention demands an equally high level of precision and this should be preceded by a comprehensive wound assessment.

Wound assessment is a vital first step in the precision management process.

The purpose of wound assessment is:

To identify:

To determine:

To gather data:

Unfortunately, universal agreement as regards the precise mechanisms of how this should be accomplished is yet to be agreed.

Debridement, moisture and bacterial balance

Debridement is an essential element of effective wound care. [7] Although this view is deeply rooted in practice it is nonetheless based on empirical observation. Bradley et al. have stated that it is “unclear whether wound debridement is a beneficial process that expedites healing”. [8] Despite this confusing situation, current recommendation favours regular debridement. [9] It is thought that even in an immune compromised patient debridement can assist in establishing a favourable balance of the wound bioburden. [9]

Moisture balance

Establishing a moisture balance beneficial to the wound bed is another prerequisite of care. The natural response to injury is inflammation typified by the local expression of histamine and bradykinin [10] and leading to vasodilation of the vessels that are in relative close proximity to the site of injury. As serum based fluid moves out of the vessels into the interstitial spaces the resultant soft tissue oedema manifests on the wound surface as exudate. [11] In the chronic wound this exudate contains a surfeit of proteolytic enzymes and other components not seen in acute wounds and these compounds have a corrosive effect on the wound bed and surrounding peri-wound skin. [10] The application of dressings, topical negative pressure, compression garments and leg elevation/exercise have been identified as methods for management of wound exudate. [10]

Bacterial balance

All wounds are considered to harbor microorganisms. Management of the bacterial balance is of vital importance if delays in healing are to be avoided. The biological removal of micro-organisms, including potential pathogens, and tissue debris from the wound of an immune-competent patient is a wound cleansing activity that takes place almost immediately after wounding and which helps to reduce the threat of infection. However, a range of risk factors exist that increase the likelihood of infection intervening, and these include; age, depleted nutrition, down-regulation of the immune system, systemic disease, and poor tissue perfusion of oxygen. Thus, in the above circumstances or when a wound has become infected, wound cleansing activities beyond the natural biological processes are required so that the wound bioburden is maintained at a level where the host can remain in control.

Wound cleansing and excision

Wound cleansing is a fundamental component of wound care. It consists of the removal of foreign matter, dead (devitalized) tissue and other physical impedimenta to healing, such as ragged edges. [12] Despite the move in the 21st century toward evidence-based practice, the only general consensus that exists here is that cleansing and excision reduce infection rates. [13] The recommendation has been made that cleansing is required when: [14]

Wound cleansing is often undertaken as a ritual exercise rather than as an evidence-based activity. However, it has a role to play in all four domains of the WBP model. Wounds that are 'clean' and progressing do not require extraneous cleansing. [15]

Criteria for a cleansing agent

Wound cleansing forms an integral part of wound management and generally suggests the application of a fluid to aid the removal of surface contaminants, bacteria, and debris from the wound surface and surrounding skin. [16] Water as a cleansing agent, especially in chronic wounds has been proposed [14] and is widely used [17] especially in the management of infected wounds. [18] Despite the plethora of work focussing on the value of water/saline in wound cleansing there is no current consensus as to whether water has an active role to play in the promotion of healing.

With this unclear position in mind, alternative cleansing agents such as antiseptics that possess the potential to improve clinical outcomes should be considered.

The use of antiseptics on open wounds is justified in terms of prevention/treatment of infection and improved healing outcomes.

Criteria by which a wound cleansing agent could be deemed suitable for use on wounds include:

There is a scant evidential provision in respect of guidance as to the optimal wound cleanser. In general, recommendations for practice are based on consensus opinion often derived from clinical experience and in vitro and/or in vivo studies.

Biofilm infection

Attaching to a surface is a natural association for bacteria in the wild. Biofilm phenotype bacteria are microbial communities that are attached to a surface and are embedded in an extracellular polymeric substance (EPS) consisting of proteins, glycoproteins, nucleic acids (RNA, DNA) and polysaccharides (slime). [19] This mantle affords protection from antimicrobial and cellular attack. In contrast, planktonic phenotype bacteria are free-floating in nature and do not possess the defence structures afforded by the creation of the EPS slime. Within the biofilm, a rich biological diversity may be found. The attached (sessile) bacteria release proteases which help to perpetuate a chronic inflammatory state. [20] Therefore, the potential exists for these exogenous proteases to work in tandem with endogenously produced proteases and degrade growth factors and tissue proteins that are necessary for the healing process.

Biofilm management

We are developing greater insight into the association between delayed healing and the presence of biofilm. [21] [22] The relationship between delayed healing and the need for debridement is also being acknowledged. [23] It has been suggested that the presence of wound slough provides an indication of biofilm presence, [24] therefore, indicating the need to reduce the wound bioburden.

Methods of effectively managing wound biofilms have been reported and include the use of topical agents, systemic antibiotics and regular episodes of debridement. [23] [25]

Despite these advances it has been recognised that indiscriminate and widespread use of antibiotics both inside and outside of medicine is playing a substantial role in the emergence of bacterial resistance. [26]

On a more positive note, antiseptics have been reported to possess a clear cut role in the control of wound bioburden where there are indications or risk of infection. [27]

Polyhexamethylene biguanide (polyhexanide, PHMB)

Polyhexamethylene biguanide hydrochloride is a fast-acting, broad-spectrum synthetic compound that binds to the cell envelope of both Gram-positive and Gram-negative bacteria, disrupting the bacterial cell membrane and enabling seepage of ions. [28] [29] PHMB has a long history of use as a contact lens cleanser, mouthwash and more recently in wound care.

It is regarded as being quite safe to use as it has been incorporated as a preservative in cosmetics. [30] A retrospective analysis of wound cleanser clinical efficacy and cost-effectiveness focussed on Polyhexamethylene biguanide solution, Ringer’s solution or saline in 112 venous leg ulcer patients. [31] The study group received the Polyhexamethylene biguanide solution (n=59) and the control group received either Ringer’s solution or saline (n=53). In both arms, ulcer healing patterns were evaluated. Within the first 3 months of treatment, a shorter time to healing was recorded in the study group when compared with the control group - 60% v. 28% with corresponding mean time to healing being 3.31 months (study group) compared to 4.42 months (control group) p= <0.0001. More patients in the Polyhexamethylene biguanide group healed in the 6-month period when compared with the controls - 97% v. 89%. The authors concluded that optimization of the local wound environment was significantly influenced through cleansing with polyhexanide solution.

In an in vitro model developed to compare the efficiency of wound-rinsing solutions, Kaehn et al. compared four sterile wound-cleansing solutions (saline, Ringer’s solution, Prontosan® and Octenisept®) using a wound coating model consisting of slides containing dried blood plasma or fibrin. [32] The concentration of dissolved proteins was measured and the findings indicate that a surfactant containing solution (polyhexamethylene biguanide with betaine) (Prontosan®) was more effective than saline in removing the protein (adhered dried plasma or fibrin). The proteins in the antiseptic solution (Octenisept®) were denatured and became insoluble. The authors suggest this implies that the antiseptic solution is unsuitable as a 'general' wound cleanser and that its use should be restricted to infected wounds.

In a double-blind, randomised, stratified, controlled, parallel-group study [33] the influence of two antiseptics (octenidine, polyhexanide) versus a placebo of Ringer’s solution on wound healing in a porcine model was conducted. Assessment of healing was recorded using planimetry and histopathology. At nine days post wounding the octenidine treated wounds demonstrated retarded contraction at significantly greater extent than placebo and polyhexanide. At days 18 and 28 the polyhexanide treated wounds supported contraction significantly more than placebo and octenidine. The polyhexanide treated wounds led to complete wound closure after 22.9 days, in comparison to the placebo octenidine treated wounds respectively, 24.1 days (p < 0.05) and 28.3 days (no statistical difference to placebo).

Prontosan

Prontosan (B Braun) Wound Irrigation Solution and Prontosan Wound Gel are proprietary preparations of PHMB with betaine, an alkaloid surfactant. Surfactants lower the surface tension of the fluid medium making it easier to infiltrate wound coatings, debris and bacteria. [31] Both the wound irrigation solution and the wound gel are colorless cleansing agents that are indicated for use in acute and chronic wounds. They also have the potential to be used in conjunction with a range of dressing materials which include occlusive dressings.

In vitro studies on clinical isolates of E. coli and S. epidermidis have demonstrated the anti-biofilm efficacy of PHMB. The activity of five biocides at various concentrations was recorded following exposure to the isolates. The biocides found to be most active towards planktonic (free floating) cells were PHMB and peracetic acid. A corresponding level of activity towards biofilm phenotype bacteria was also found with the two agents. [34] [35]

Prontosan's activity on MRSA biofilms has been investigated using an in vivo porcine wound model. [36] Prontosan activity was compared with Ringer’s solution, saline, and untreated control. A comparative reduction in MRSA at 48 and 72 hours in the Prontosan-treated group was found to be statistically significant compared to the other groups (p-value <0.05). The study results indicated that extended irrigation with Prontosan may provide additional reduction in wound bioburden as the largest reduction of MRSA was found from 48 to 72 hours.

A clinical evaluation of Prontosan wound cleanser was undertaken with ten community care patients where saline had been used for at least one month previously on wounds that had a mean duration of 2.6 years. [37] The findings include; an overall reduction in wound size, a reduction in malodour, reduction or elimination of wound pain. These results correlate well with the patients’ reports of improvement in quality of life and a reduction in the number of nursing visits. In addition, the wound cleansing effects of Prontosan with achieving a visible wound bed was reported by the author and linked to the removal of wound biofilm. Although this association is speculative it does appear to correspond with the other reported improvements found in these wounds.

Conclusions

Wound bed preparation is an accepted strategy that facilitates wound management interventions. Management of wound exudate, bioburden and debridement are all associated with effective wound cleansing and are thus integral components of effectual wound bed preparation. Choice of cleansing solution should consider not only the piecemeal wound requirements but also the patient and be reinforced by a sound knowledge/experience base. This knowledge should include insight into bacterial phenotype 'behavior' and the most appropriate methods of management. Current findings indicate that PHMB in conjunction with a surfactant (betaine) is superior to Ringer's solution and saline when used as wound cleansers and also appears to demonstrate efficacy when used in wounds where biofilms are suspected or present.

Related Research Articles

An antiseptic is an antimicrobial substance or compound that is applied to living tissue to reduce the possibility of sepsis, infection or putrefaction. Antiseptics are generally distinguished from antibiotics by the latter's ability to safely destroy bacteria within the body, and from disinfectants, which destroy microorganisms found on non-living objects.

<span class="mw-page-title-main">Gangrene</span> Type of tissue death by a lack of blood supply

Gangrene is a type of tissue death caused by a lack of blood supply. Symptoms may include a change in skin color to red or black, numbness, swelling, pain, skin breakdown, and coolness. The feet and hands are most commonly affected. If the gangrene is caused by an infectious agent, it may present with a fever or sepsis.

<span class="mw-page-title-main">Wound</span> Acute injury from laceration, puncture, blunt force, or compression

A wound is a rapid onset of injury that involves lacerated or punctured skin, or a contusion from blunt force trauma or compression. In pathology, a wound is an acute injury that damages the epidermis of the skin. To heal a wound, the body undertakes a series of actions collectively known as the wound healing process.

<span class="mw-page-title-main">Pressure ulcer</span> Skin ulcer (bed sore)

Pressure ulcers, also known as pressure sores, bed sores or pressure injuries, are localised damage to the skin and/or underlying tissue that usually occur over a bony prominence as a result of usually long-term pressure, or pressure in combination with shear or friction. The most common sites are the skin overlying the sacrum, coccyx, heels, and hips, though other sites can be affected, such as the elbows, knees, ankles, back of shoulders, or the back of the cranium.

<span class="mw-page-title-main">Dressing (medical)</span> Sterile pad or compress applied to wounds

A dressing or compress is a sterile pad applied to a wound to promote healing and protect the wound from further harm. A dressing is designed to be in direct contact with the wound, as distinguished from a bandage, which is most often used to hold a dressing in place. Many modern dressings are self-adhesive.

<span class="mw-page-title-main">Maggot therapy</span> Wound care by maggot therapy

Maggot therapy is a type of biotherapy involving the introduction of live, disinfected maggots into non-healing skin and soft-tissue wounds of a human or other animal for the purpose of cleaning out the necrotic (dead) tissue within a wound (debridement), and disinfection.

A chronic wound is a wound that does not heal in an orderly set of stages and in a predictable amount of time the way most wounds do; wounds that do not heal within three months are often considered chronic. Chronic wounds seem to be detained in one or more of the phases of wound healing. For example, chronic wounds often remain in the inflammatory stage for too long. To overcome that stage and jump-start the healing process, a number of factors need to be addressed such as bacterial burden, necrotic tissue, and moisture balance of the whole wound. In acute wounds, there is a precise balance between production and degradation of molecules such as collagen; in chronic wounds this balance is lost and degradation plays too large a role.

The history of wound care spans from prehistory to modern medicine. Wounds naturally heal by themselves, but hunter-gatherers would have noticed several factors and certain herbal remedies would speed up or assist the process, especially if it was grievous. In ancient history, this was followed by the realisation of the necessity of hygiene and the halting of bleeding, where wound dressing techniques and surgery developed. Eventually the germ theory of disease also assisted in improving wound care.

<span class="mw-page-title-main">Negative-pressure wound therapy</span> Therapeutic technique

Negative-pressure wound therapy (NPWT), also known as a vacuum assisted closure (VAC), is a therapeutic technique using a suction pump, tubing, and a dressing to remove excess exudate and promote healing in acute or chronic wounds and second- and third-degree burns. The therapy involves the controlled application of sub-atmospheric pressure to the local wound environment using a sealed wound dressing connected to a vacuum pump. The use of this technique in wound management started in the 1990s and this technique is often recommended for treatment of a range of wounds including dehisced surgical wounds, closed surgical wounds, open abdominal wounds, open fractures, pressure injuries or pressure ulcers, diabetic foot ulcers, venous insufficiency ulcers, some types of skin grafts, burns, sternal wounds. It may also be considered after a clean surgery in a person who is obese.

<span class="mw-page-title-main">Open fracture</span> Medical condition

An open fracture, also called a compound fracture, is a type of bone fracture that has an open wound in the skin near the fractured bone. The skin wound is usually caused by the bone breaking through the surface of the skin. Open fractures are emergencies and are often caused by high energy trauma such as road traffic accidents and are associated with a high degree of damage to the bone and nearby soft tissue. An open fracture can be life threatening or limb-threatening due to the risk of a deep infection and/or bleeding. Other complications including a risk of malunion of the bone or nonunion of the bone. The severity of open fractures can vary. For diagnosing and classifying open fractures, Gustilo-Anderson open fracture classification is the most commonly used method. It can also be used to guide treatment, and to predict clinical outcomes. Advanced trauma life support is the first line of action in dealing with open fractures and to rule out other life-threatening condition in cases of trauma. The person is also administered antibiotics for at least 24 hours to reduce the risk of an infection. Cephalosporins are generally the first line of antibiotics. Therapeutic irrigation, wound debridement, early wound closure and bone fixation are the main management of open fractures. All these actions aimed to reduce the risk of infections. The bone that is most commonly injured is the tibia and working-age young men are the group of people who are at highest risk of an open fracture. Older people with osteoporosis and soft-tissue problems are also at risk.

<span class="mw-page-title-main">Scaling and root planing</span> Dental procedure

Scaling and root planing, also known as conventional periodontal therapy, non-surgical periodontal therapy or deep cleaning, is a procedure involving removal of dental plaque and calculus and then smoothing, or planing, of the (exposed) surfaces of the roots, removing cementum or dentine that is impregnated with calculus, toxins, or microorganisms, the agents that cause inflammation. It is a part of non-surgical periodontal therapy. This helps to establish a periodontium that is in remission of periodontal disease. Periodontal scalers and periodontal curettes are some of the tools involved.

<span class="mw-page-title-main">Polyhexanide</span> Chemical compound

Polyhexanide is a polymer used as a disinfectant and antiseptic. In dermatological use, it is spelled polihexanide (INN) and sold under the names Lavasept, Serasept, Prontosan, and Omnicide. PHMB has been shown to be effective against Pseudomonas aeruginosa, Staphylococcus aureus, Escherichia coli, Candida albicans, Aspergillus brasiliensis, enterococci, and Klebsiella pneumoniae.

<span class="mw-page-title-main">Tropical ulcer</span> Type of chronic ulcerative skin lesion

Tropical ulcer, more commonly known as jungle rot, is a chronic ulcerative skin lesion thought to be caused by polymicrobial infection with a variety of microorganisms, including mycobacteria. It is common in tropical climates.

<span class="mw-page-title-main">Arterial insufficiency ulcer</span> Medical condition

Arterial insufficiency ulcers are mostly located on the lateral surface of the ankle or the distal digits. They are commonly caused by peripheral artery disease (PAD).

Proteases are in use, or have been proposed or tried, for a number of purposes related to medicine or surgery. Some preparations involving protease have undergone successful clinical trials and have regulatory authorization; and some further ones have shown apparently useful effects in experimental medical studies. Proteases have also been used by proponents of alternative therapies, or identified in materials of traditional or folk medicine. A serine protease of human origin, activated protein C, was produced in recombinant form and marketed as Drotrecogin alfa and licensed for intensive-care treatment of severe sepsis. It was voluntarily withdrawn by the manufacturer in 2011 after being shown to be ineffective.

An alginate dressing is a natural wound dressing derived from carbohydrate sources released by clinical bacterial species, in the same manner as biofilm formation. These types of dressings are best used on wounds that have a large amount of exudate. They may be used on full-thickness burns, surgical wounds, split-thickness graft donor sites, Mohs surgery defects, refractory decubiti, and chronic ulcers. They can also be applied onto dry wounds after normal saline is first applied to the site of application.

Chronic wound pain is a condition described as unremitting, disabling, and recalcitrant pain experienced by individuals with various types of chronic wounds. Chronic wounds such as venous leg ulcers, arterial ulcers, diabetic foot ulcers, pressure ulcers, and malignant wounds can have an enormous impact on an individual’s quality of life with pain being one of the most distressing symptoms.

The periwound is tissue surrounding a wound. Periwound area is traditionally limited to 4 cm outside the wound's edge but can extend beyond this limit if outward damage to the skin is present. Periwound assessment is an important step of wound assessment before wound treatment is prescribed.

Wound assessment is a component of wound management. As far as may be practical, the assessment is to be accomplished before prescribing any treatment plan. The objective is to collect information about the patient and about the wound, that may be relevant to planning and implementing the treatment.

Micropore particle technology consists of fine, highly porous particles that remove fluid by a combination of capillary action and evaporation. Currently, they are mainly used in wound healing, where they absorb wound exudate into their micropore structure. Here capillary flow transports the exudate away from the wound surface towards the upper surface of the MPPT layer, where a highly expanded surface area facilitates effective evaporation. The MPPT essentially acts as small micro-pumps, which, due to their small size, are able to access all crevices in the wound surface.

References

  1. ↑ Montandon, Denys (1977), Symposium on Wound Healing, Volume 4, Issue 3 of Clinics in plastic surgery: an international quarterly, Philadelphia, Pennsylvania: W. B. Saunders Company
  2. ↑ Robinson, J. B.; Friedman, R. M. (1996), "Wound Healing and Closure", Selected Readings in Plastic Surgery, 8 (1)
  3. 1 2 Sibbald RG, Williamson D, Orsted HL, Campbell K, Keast D, Krasner D, et al. (2006). "Preparing the wound bed—debridement, bacterial balance, and moisture balance". Ostomy Wound Manage. 46 (11): 14–22, 24–8, 30–5, quiz 36–7. PMID   11889735.
  4. ↑ Falanga V (2000). "Classification for Wound Bed Preparation and Stimulation of Chronic Wounds (Editorial)". Wound Repair and Regeneration. 8 (5): 347–52. doi:10.1111/j.1524-475x.2000.00347.x. S2CID   30657267.
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  10. 1 2 3 White, RJ; Cutting, KF (2006). "Modern exudate management: a review of wound treatments". World Wide Wounds. Archived from the original on 30 January 2010. Retrieved 12 December 2009.
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  15. ↑ Williams, C; Young, T (1998). Myth and Reality in Wound Care. Dinton, Wilts: Quay Books.
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  17. ↑ Hall S (2007). "A review of the effect of tap water versus normal saline on infection rates in acute traumatic wounds". Journal of Wound Care. 16 (1): 38–41. doi:10.12968/jowc.2007.16.1.26990. PMID   17334147.
  18. ↑ Fernandez, R; Griffiths, R (15 February 2012). "Water for wound cleansing". The Cochrane Database of Systematic Reviews (2): CD003861. doi:10.1002/14651858.CD003861.pub3. PMID   22336796.
  19. ↑ Cooper R, Okhiria O (2006). "Biofilms, wound infection and the issue of control". Wounds-UK. 2 (3): 48–57.
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  21. ↑ Schierle CF, De la Garza M, Mustoe TA, Galiano RD (2009). "Staphylococcal biofilms impair wound healing by delaying reepithelialization in a murine cutaneous wound model". Wound Repair and Regeneration. 17 (3): 54–59. doi:10.1111/j.1524-475X.2009.00489.x. PMID   19660043. S2CID   1332547.
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  24. ↑ Cutting KF, Wolcott R, Dowd SE, Percival SL. Biofilms and significance to wound healing. In: S. L. Percival KFC, editor. The microbiology of wounds. Boca Raton, FL, USA: CRC Press, Taylor and Francis Group 2010.
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  32. ↑ Kaehn K (2009). "An in-vitro model for comparing the efficiency of wound-rinsing solutions". Journal of Wound Care. 18 (6): 229–36. doi:10.12968/jowc.2009.18.6.42800. PMID   19661846.
  33. ↑ Kramer A, Roth B, Müller G, Rudolph P, Klöcker N (2004). "Influence of the Antiseptic Agents Polyhexanide and Octenidine on FL Cells and on Healing of Experimental Superficial Aseptic Wounds in Piglets". Skin Pharmacol Physiol. 17 (3): 141–46. doi:10.1159/000077241. PMID   15087593. S2CID   22661415.
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  36. ↑ Davis SC, Rivas Y, Gil J, Valdes J, Perez R, Kirsner R. Unpublished study - Determination of the effects of Prontosan irrigation solution on meticillin resistant Staphylococcus aureus biofilms in a partial thickness porcine wound model. Miller School of Medicine, Dept of Dermatology and Cutaneous Surgery Wound Healing Research Laboratory 2007( ):University of Miami.
  37. ↑ Horrocks A (2006). "Prontosan wound irrigation and gel: management of chronic wounds". British Journal of Nursing. 15 (22): 1222–28. doi:10.12968/bjon.2006.15.22.22559. PMID   17346020.
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