WOUND CARE PATIENT CASE
Lauren Bussian, AJ Cushman, Maria King,
Sarah Nockengost, Bryce Shank
THE PATIENT
• 59 year-old female
• Currently disabled
• History of LE ischemia
• Insured with Medicaid and
Medicare
• Lives with immediate
family within 25 miles of
hospital
• Patient and patient’s
mother both drive
• City/county water at home
DATABASE
Past Medical History:
Surgical History:
•
HTN
•
•
Hepatitis C
•
PVD
•
History of DVT
•
Neuropathy
•
Current 3 pack per day smoker
2013:
•
•
Bilateral ilio-femoral bypass
2 months prior to ER
admission:
•
•
Aorta endarterectomy
R common iliac and L
femoral bypass with Decron
Graft
DATABASE
Medications
Prilosec
Neurontin
Allergies
IVP Dye
Phenobarbital
Keflex
Sulfa
Effexor
Oxybutynin
Spiriva
Nifedical XL
Lisinopril
Trazodone
Norco
Nicoderm
Aspirin
Relevant Side Effects
Headache
GI issues
Dizziness
Loss of balance
Ataxia
Drowsiness
↑ sweating
Muscle pain, leg/muscle
cramps
Confusion
TIMELINE OF CURRENT HOSPITAL VISIT
Day 1
• Admitted to ER
for RLE p! (10/10)
& ischemia
• RLE: ↓motor &
sensory, cool to
touch, ABI <0.5
w/ abnormal
waveforms
• LLE: normal,, ABI=
0.91 w/ normal
waveforms
• Emergent R
axillary-popliteal
bypass
Day 4
• Went into VFib/V-Tach &
coded
• Developed new
area of
drainage
Day 6
• Sx to clean out
subcutaneous
infection in L
groin
• Sartorius muscle
flap in L groin.
• Wound culture
negative
POD 1
• PT ordered
secondary to
copious serous
drainage from
L groin site
PT EVALUATION
Vital Signs:
Afebrile
BP: 110/70 mmHg
Weight: 114 lbs
Lab Values:
WBC: 7.4
Hgb: 7.8
INR: 1.1
Pulses:
•L femoral palpable (yet
femoral artery not visible)
•L dorsalis pedis palpable
Left LE motor and sensory
intact
PT EVALUATION
• L groin wound with 100%
pink muscle in wound bed
• 3.5 cm long x 0.8 cm wide
x 1.6 cm deep
• Copious serous drainage
(>250 ml per shift)
• Periwound intact
• No erythema or
maceration
• No odor
• Bedrest orders
PT EVALUATION
Chief complaint:
Left groin wound presenting with copious drainage
Pain not assessed during evaluation
Patient goals:
To have wound closed
To function without any medical equipment
PHYSICAL THERAPY DIAGNOSIS
Patient is a 59 year old female with signs and symptoms
consistent with an acute surgical wound secondary to
femoral bypass infection or complication that was
corrected with Sartorius muscle flap.
ICF MODEL
Copious Drainage
Low Hgb/Fatigue
Skin Integrity
Left Groin Wound
Ambulation
Patient and mother drive
City/County water
Lives w/family
Lives close to hospital
Participation
w/family and
community
Hx of smoking
Motivated to move
w/o AD
Disabled
UNDERSTANDING THE SURGERY
Sartorius Muscle Flap
1. Proximal end dissected from ASIS
2. Sartorius is rotated along long axis
3. Then sutured medially to inguinal ligament
In an acute lower extremity surgical
wound, does recent cessation from
smoking improve wound healing
rate?
PROGNOSTIC QUESTION
SMOKING CESSATION
REDUCES POSTOPERATIVE
COMPLICATIONS: A
SYSTEMATIC REVIEW AND
META-ANALYSIS
Edward Mills, PhD, MSc et al. The American
Journal of Medicine. 2011.
EDWARD MILLS, PHD, MSC ET AL
“Tobacco remains the leading cause of preventable
death in the world.”
PURPOSE:
To determine the role of smoking cessation and the duration
of cessation required in preventing postoperative
complications.
EDWARD MILLS, PHD, MSC ET AL
SMOKING CESSATION REDUCES POSTOPERATIVE COMPLICATIONS: A SYSTEMATIC REVIEW
AND META-ANALYSIS
EDWARD MILLS, PHD, MSC ET AL. THE AMERICAN JOURNAL OF MEDICINE. 2011.
MATERIALS AND METHODS:
Randomized controlled trials (RCTs) and observational
studies
Data Analysis
• Phi statistic
• Relative Risk (RR)
• Short and long term effects (</> 4 weeks)
• Impact of time (weeks)
EDWARD MILLS, PHD, MSC ET AL
STUDY SELECTION/QUALITY:
Reviewed 847 abstracts
• Included 6 RCTs and 15 observational studies
Exclusion (search was sensitive, not specific)
• Non-human
• Non-English
• Not address the review topic
• Review articles
Risk of bias
• RCTs: modified Cochrane risk-of-bias tool
• Non-RCT: Newcastle-Ottawa Scale
EDWARD MILLS, PHD, MSC ET AL
RCT RESULTS:
6 RCTs
Pooled RR of 0.59
EDWARD MILLS, PHD, MSC ET AL
Author, Year
Intensity of
Program
Lindstrom, 2008
Intensive
Moller, 2002
Myles, 2004
Sorensen, 2003
Sorensen, 2007
Warner, 2005
Intensive
Definition of Perioperative
Complications
-Events causing additional tx
prolonged hospital stay
-Any wound complication
0.49 (0.20-1.16)
-Death/post-op morbidity
-Wound healing complications
0.34 (0.19-0.64)
0.17 (0.05-0.56)
Less Intensive -Post-op wound infections
Intensive
Relative Risk
(95% CI)
0.51 (0.27-0.97)
0.82 (0.06-11.33)
-Adverse events w/in 30d
requiring med/sx tx
0.94 (0.51-1.73)
Less Intensive -Post-op wound infection
0.71 (0.21-2.41)
Less Intensive -Serious post-op events
0.86 (0.24-3.03)
SMOKING
CESSATION
PROGRAM:
More intense
•RR 0.55
Less intense
•RR 0.78
EDWARD MILLS, PHD, MSC ET AL
EACH WEEK OF
CESSATION
•RR -0.191
< 4 WEEKS
• RR 0.92
> 4 WEEKS
•RR 0.45
EDWARD MILLS, PHD, MSC ET AL
OBSERVATIONAL STUDIES:
Complication
Studies
Reporting
RR (95%)
P Value
Other
Total
12
0.76 (0.69-0.84)
<0.0001
significant reduction
Pulmonary
7
0.81 (0.70-0.93)
0.003
no diff b/w early/late quitters*
Wound-healing
5
0.73 (0.61-0.87)
0.0006
significant reduction
Hospital LOS
2
n/a
Other study found identical duration
Mortality
2
1.00 (0.64-1.55)
0.98
no difference
Duration of cessation period
7
0.80 (3-33)
0.02
Removed study- no longer significant
EDWARD MILLS, PHD, MSC ET AL
STRENGTHS:
•
•
•
Extensive searching
Data abstraction in duplicate
RCTs and observational
Regression analysis
 Length of time from
cessation associated with
magnitude
LIMITATIONS:
• Heterogeneous reporting of
outcomes
• Inconsistent definitions of
past smoking status
• Different observational
study designs
• Low power for certain
analyses
EDWARD MILLS, PHD, MSC ET AL
CONCLUSION:
•
•
8-10 million procedures performed on cigarette smokers
If all patients were offered smoking cessation intervention (assuming
25% cessation rate)...
•
•
Roughly 2 million complications avoided!
Large savings for patients and health services.
PATIENT RELEVANCE:
•
Cessation period unknown, however, pt wound healing will still
benefit from quitting with continued cessation during hospital stay
over the next several weeks
Is a Hydrofiber dressing the most
appropriate treatment option to manage
exudate and promote wound healing for
our patient with an acute surgical wound?
INTERVENTION QUESTION
HYDROFIBER DRESSING
DRESSINGS FOR ACUTE
AND CHRONIC WOUNDS:
A SYSTEMATIC REVIEW
Chaby, G et al. JAMA Dermatology. 2007
CHABY, G ET AL
STUDY DESIGN:
Systematic Review of RCTs, meta-analyses and cost-effectiveness
studies
PURPOSE:
Critically review the literature on the efficacy of modern dressings
in healing chronic and acute wounds by secondary intention
CHABY, G ET AL
METHOD:
• Searched MEDLINE, EMBASE, and Cochrane Controlled
Clinical Trials Register from January 1990-June 2006
• 19 reviewers graded articles using Sackett’s criteria checklist
• 99 articles met selection criteria (89 RCT, 3 meta-analyses, 7
systematic reviews, 1 cost-effectiveness study)
• No level A studies found, 14 level B (6 acute), and 79 level C
CHABY, G ET AL
INCLUDED ACUTE WOUNDS:
•
•
•
•
Skin graft donor sites
Partial-thickness burns
Posttraumatic wounds
Post-surgical wounds
EXCLUDED:
• Deep partial and full thickness burns
CHABY, G ET AL
RESULTS of LEVEL B EVIDENCE:
• Hydrofiber dressing (HFD) had a mean time to complete
healing of 7-10 days vs 10-14 days (p=.02) for paraffin gauze
dressing(PFD) in patients with skin graft donor site (SGDS)
wounds
• Pain during dressing change and ease of use had significant
findings in favor of HFD when compared to PFD in acute
SGDS
CHABY, G ET AL
RESULTS of LEVEL B EVIDENCE:
•Hydrofiber dressings increased wound healing rates greater than wet to dry
dressings in deep, acute surgical wounds
•These results approached statistical significance (p=.08)
•Hydrofiber(HFD) dressings received higher scores on ease of application and
removal of first dressing, and re-application on the first post-op day and one week
post-op when compared to alginate dressings on acute surgical wounds
•Patients in HFD group also reported less pain on removal of dressings
CHABY, G ET AL
STUDY LIMITATIONS:
• Level of evidence found (no A, few B for acute wounds)
• Found benefits, but many were not statistically significant
• Ability to generalize to our patient
• Sample size for studies reported was small (23, 50, and 100 respectively)
CHABY, G ET AL
CONCLUSION:
•
These results demonstrate that hydrofiber dressings may be a better choice
compared to paraffin gauze, wet to dry, and alginate dressings
•
Less time to complete healing/ increased healing rate and ease of use
•
Pain during dressing changes can delay healing time and decrease patient
compliance
•
Further research with higher quality evidence needs to be done to validate
these findings
RANDOMISED CLINICAL TRIAL OF
HYDROFIBER DRESSING WITH SILVER
VERSUS POVIDONE-IODINE GAUZE IN
THE MANAGEMENT OF OPEN
SURGICAL AND TRAUMATIC WOUNDS
Jurczak, F. et. al. International Wound Journal. 2007
JURCZAK, F. ET. AL
STUDY DESIGN:
Prospective, randomized clinical trial; Level II evidence
PURPOSE:
To compare the efficacy of Hydrofiber Ag versus povidoneiodine gauze dressings in reducing wound pain, improving
patient comfort and exudate handling, and promoting wound
healing in patients with open surgical or traumatic wounds.
JURCZAK, F. ET. AL
SUBJECT CHARACTERISTICS:
• 67 adult patients with an open surgical wound or an open traumatic wound left to
heal by secondary intent.
• Age range: 17-77 years
• 20 subjects presented with moderate-heavy wound exudate at baseline
• Wounds areas included cervical, back, axilla, gluteal, scrotum, and groin.
• Median wound area: 600 mm^2
• Periwound normal in >65% of subjects within each treatment group
• Wounds open for average of 11 hours
JURCZAK, F. ET. AL
METHOD:
• Subjects randomly assigned to treatment with either Hydrofiber Ag
dressing (n = 35) or povidone-iodine dressing (n = 32).
• Dressings changed as clinically indicated
•
Average of once daily for both treatment groups
• Dressings could be changed at home or in the clinic
• Dressings soaked in saline solution for ~15 min if necessary to facilitate
removal.
• Duration of study = 2 weeks or until complete wound closure
JURCZAK, F. ET. AL
OUTCOME MEASURES:
•
Pain severity during dressing application and removal, as well as while in place
•
Investigator ratings of wound comfort, bleeding, exudate handling and trauma upon
removal.
•
Changes in wound appearance and size
•
Wound infection
•
Need for debridement
•
Ease of use for each treatment
JURCZAK, F. ET. AL
RESULTS:
Pain
Comfort Rating
(% decrease in VAS
score from baseline)
(% rated as ‘excellent’ or
‘good’)
Dressing
Removal
Trauma
Bleeding
Ease of Use
(% reporting “no
bleeding” during
dressing change)
(% reporting “very easy”)
(% reporting “no
trauma” at final
visit)
Hydrofiber
Ag
62 (during removal) 97.1 (during removal)
33 (while in place)
97.1 (while in place)
94.3
88.6
78.9 (during application)
85.0 (during removal)
Povidoneiodine
Gauze
44 (during removal) 83.9 (during removal)
0 (while in place)
64.5 (while in place)
61.3
64.5
38.2 (during application)
52.8 (during removal)
JURCZAK, F. ET. AL
Wound
Closure
Wound
Healing
Mean time
to healing
Wound
Size
Wound Bed
Exudate
Characteristics Management
(% subjects
with closed
wounds prior
to study
termination)
(% subjects with
complete healing or
marked
improvement)
(# of days)
(change from
baseline in
mm^2)
(% epithelialized tissue)
(% reporting
“excellent”)
Hydrofiber
Ag
23
91.2
14.1
-551
42.2
41
Povidoneiodine
Gauze
9
74.2
13.9
-401
31.2
23
JURCZAK, F. ET. AL
STUDY LIMITATIONS:
• Small sample size without a true control group
• Lack of blinding to study treatment
• Baseline differences in pain assessment measured by VAS
• Variation in analgesic use throughout study duration
• Lack of objective outcome measures
• Short duration of study
JURCZAK, F. ET. AL
CONCLUSION:
• Results of this study demonstrate that Hydrofiber dressings with silver is
superior to povidone-iodine gauze for reducing pain and wound trauma
associated with dressing removal, and for improving exudate
management and overall comfort.
• Further research is necessary in order to compare ability of both
dressing options to promote wound healing and prevent infection.
• Several weaknesses of this study limit its ability to determine cause of
effect of intervention.
INTERVENTION QUESTION CONCLUSIONS
Jurczak, et. al.
Int. Wound Journal
• Hydrofiber w/Ag more
effective than gauze at
managing copious drainage
Chaby, et al.
JAMA Dermatology
• Hydrofiber dressing more
effective than paraffin gauze
dressings to facilitate wound
healing
• Hydrofiber dressing may result in
increase healing rate when
compared to wet-to-dry dressings
QUESTIONS & GROUP
TIME
PLAN OF CARE
Frequency: 4x/week
Duration: 5 weeks
Discharge Plan: Send home
w/ orders for OP wound care
Patient Education:
Throughout course of acute
intervention
Three Stages of Intervention:
1. On Bedrest: Post Op 1-7
2. Leg Lowering: Post Op 7-21
➢Non weight-bearing
3. Off Bedrest: Post Op 21-D/C
➢Weight-bearing
PHYSICAL THERAPY GOALS
In 7 days:
1. Wound drainage will decrease from >250 mL per shift to 200 mL per
shift to promote healing of wound.
2. Patient will demonstrate understanding of bedrest orders and
wound precautions to prevent graft damage and infection.
3. Wound area will decrease by 10% in order to allow patient increased
mobility in bed.
4. Patient will demonstrate compliance with bed exercise program to
increase independence with bed mobility.
POTENTIAL LONG TERM GOALS
By Discharge:
1. Patient will demonstrate understanding of wound care principles
and signs of infection to promote healing and prevent infection.
2. Patient will ambulate 300 feet with LRAD to allow independence
with ambulation at home.
3. Wound drainage will decrease from >250 mL to <30 mL to decrease
frequency of dressing changes to reduce risk for infection.
4. Wound area will decrease by 85% in order to promote
independence with ADLs and ambulation.
PATIENT EDUCATION
• Positioning
• Signs of Infection
• Bedrest Orders
• Wound Care
• Factors that slow wound
healing
• Preventing contractures
• Washing
• Water supply
• Dressing
• Application
• Keep it clean!
• Fever, swelling, redness, odor
• Hydrogen peroxide (repeated use)
• Poor nutrition
• SMOKING
• Prevention of DVTs
• Ankle pumps
STAGE ONE: BEDREST
PRIORITY: wound care and prevention of further medical
complications
•
•
•
•
•
•
Bed mobility
Positioning
UE strengthening program
Skin and Wound checks
Monitor Vitals and Lab Values
Wound Dressing
STAGE ONE: BEDREST
• Bed Mobility
• Positioning
• Rolling
• Scooting
• Glute sets
• UE Strengthening
• Sidelying Bilaterally
• Supine
• Prone
• Skin and Wound Checks
• Bed mini dips
• T-Band flexion, abduction, ER, IR, Ws •
• I,T, and Ys while in prone
• Monitor Vitals and Lab Values
• BP, ABI
• INR, WBC, Hgb
• Daily by nursing and patient
Wound Dressing
• Hydrofiber
• Will change as needed
STAGE TWO: LEG LOWERING
PRIORITY: initiating dangling protocol and wound care
Continue to address:
• Bed mobility
• Positioning
• UE strengthening
• Wound dressing
• Monitoring vitals and lab values
• Wound and skin checks
STAGE TWO: LEG LOWERING
• Dangling Protocol
•
•
Increase dependency of L LE
Begin to work on transfers
• Wound Dressing
•
•
Hydrofiber
Progression based on wound
drainage and size
• Skin and Wound Checks
•
Daily by nursing and patient
• Positioning
• Bed Mobility
• UE Strengthening
• Monitor Vitals and Lab
Values
STAGE THREE: OFF BEDREST
PRIORITY: promoting mobility and progressing towards
functional independence prior to discharge
Also Address:
• Gait training
• Therapeutic Exercise
• Transfer training
• Wound and Skin Checks
• Monitor Vitals and Lab Values
STAGE THREE: OFF BEDREST
•
Therapeutic Exercise
•
•
•
•
•
Sit → Stand
Marches
Bridging
Heel/toe raises
Transfer Training
• Bed ← → Chair
• Bed ← → Toilet
•
Monitor Vitals and Lab Values
• BP, ABI
• INR, WBC, Hgb
•
•
Gait Training
• Ambulation with LRAD
Skin and Wound Checks
• Teach independence with wound
care and skin checks
•
Wound Dressing
• Progression based on wound
drainage and size
REFERENCES:
1. Chaby, G. et. al. (2007). Dressings for acute and chronic wounds: a systematic review. Journal
of American Medicine, Archives of Dermatology. 143 (10). 1297-1304.
2. ConvaTec Inc., (2015). AQUACEL® Dressing. Retrieved from:
http://www.convatec.com/wound-skin/aquacel-dressing.
3. Frescos, N. (2011). What causes wound pain? Journal of Foot and Ankle Research, 4(Suppl 1),
P22. http://doi.org/10.1186/1757-1146-4-S1-P22
4. Jurzak, F., Dugre, T., Johnstone, A., Offori, T., Vujovic, Z., Hollander, D., AQUACEL Ag
Surgical/Trauma Wound Study Group. (2007). Randomised clinical trial of Hydrofiber dressing
with silver versus povidone-iodine gauze in the management of open surgical and traumatic
wounds. International Wound Journal. 4(1). 66-76.
5. Mills, E., Eyawo, O., Lockart, I., Kelly, S., Wu, P., Ebbert, J.O. (2011). Smoking Cessation
Reduces Postoperative Complications: A systematic review and meta-analysis. The American
Journal of Medicine 124(2). 144-154.
6. Wei Fu-Chan MD et al. (2009) “Lower Extremity.” Flaps and Reconstructive Surgery (7). 63-70.
QUESTIONS?