War on Wounds - JBC Vascular Summit 2020jbcvascularsummit.com/wp-content/uploads/2018/04/SAT... ·...
Transcript of War on Wounds - JBC Vascular Summit 2020jbcvascularsummit.com/wp-content/uploads/2018/04/SAT... ·...
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No DisclosuresNot an advertisementNo financial ties
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Cost of Wounds
Medicare Spending per
beneficiary 2014
Arterial $9-13K
Chronic $1-5K
DFU $1-11K
Pressure Ulcer $4-21K
Surgical $3-14K
Venous $1-2KAnnual Medicare Spending
ALL Wound Types
$28-$31-$96 BILLION (1)
15% Medicare beneficiaries
8.2 million patients
one type of wound
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The Wound Care Market
Global Advanced Wound Care Market estimation
for 2022: $13-19 Billion
Engineered Skin Substitute Market $600 million 2017, estimated $1.39 billion by 2026 (Finance Industry News-April 2018)
Largest: Chronic wound market
Diabetic foot ulcer
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Wound Basics
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Key Ingredients to fight wounds
For Healing
• Vascularized
• Free of devitalized tissues
• Clear of infection
• Moist… exceptions to come
Dressing
• Eliminate dead space
• Control exudate
• Prevent bacterial overgrowth
• Proper fluid balance
In General
• Cost-efficient
• Manageable for ptsupport
• Location appropriate
• Antibiotics?
• (3)
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Four Stages of Normal Wound Healing
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Wound Healing
Angiogenesis: formation new blood vesselsinitiated by platelets
← ↓
Chronic Wounds arrest in one stage-↓ typically inflammation
(2)
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How to heal the
wound???
1ST - KNOW THE TYPE OF
WOUND YOU ARE DEALING
WITH!
& 2ND HOW BAD IS IT?!
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Grading: University of Texas (5)
Grade
Grade 0 Pre or post ulcerative
Grade 1 Full thickness ulcer not
involving tendon, capsule
or bone
Grade 2 Tendon capsular
involvement without bone
palp
Grade 3 Probes to bone
Stage
A Noninfected
B Infected
C Ischemic
D Infected and ischemic
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Diabetic Wound
Treatment Options
Revascularization
Debridement
Dressing: clean moist and free excess fluids
Extensive open wounds…negative pressure wound therapy
Skin Grafts & Skin Substitutes
Hyperbaric Oxygen Therapy
Pressure reduction with mechanical offloading
Successful: 40-50% wound reduction four weeks
(5)
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Non-invasive Assessments
Revascularization Needed?
ABIs DM: misleading, falsely elevated values
▪ Gen population <0.5 WH unlikely
Toe Pressure normal 60mHg
▪ Non DM >30mmHg WH
▪ DM >45- 55mmHg WH
TBI normal 0.7-0.8
TcPO2 Foot level 60mmHg, ~50mmHg for DM
▪ 20-30mmHg predictive of chronic WH complications
SPP: >30mmHg required for WH
Compression stocking contraindicated ABI <0.5 (10)
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Revascularization
Longitudinal study 564 of DFU and severe limb ischemia (2009)
Angioplasty 75%
▪ 8.2% amputation rate
Bypass 21%
▪ 21.2% amputation rate
No intervention possible 5%
▪ 59.2%amputation rate (7)
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Debridement
Must have adequate blood supply
Devitalized, infected tissue
Chronic Wound: serial debridement
Allows for specialized wound care products
➢ Sharp-appropriate anesthetic
➢ Bedside Grade1 Stage A
➢ Surgical infection or Grade 2-3 Stage A
➢ Irrigation
➢ Autolytic: uses body’s own wound fluid: hydrogel sheet, semipermeable foam, hydrocolloid
➢ Enzymatic: collagenase $ (3)
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Dressings
Infectious Moisture Balance
Silver Alginates
Iodine hydrocolloids
Honey Films
Methylene Blue
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Negative Pressure Wound Vac
Extensive open wounds following debridement
Randomized control trail 342pts (2008)- improved full resolution closure achieved when used(11).
Contraindications
▪ *Exposed organs, blood vessels, vascular grafts= tissue erosion-white sponge
▪ Devitalized tissue
▪ Ongoing infection
▪ ? ischemic wound-REVASCULARIZE
Maintenance of this device (5)
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Growth Factors
Tissue GF promote cellular proliferation and angiogenesis
= improved ulcer healing
UpToDate systematic review of 28 trails and 11 different GT
▪ Quality of trails low, bias high
UpToDate meta-analysis of 12 trials any GF vs placebo or no GF showed significant increase in complete wound healing-mostly platelet derived & recombinant human platelet derived
Platelet derived GF as a gel preparation is approved by FDA for adjunctive therapy for DFU
▪ While effective- high cost, concern increased mortality secondary to malignancy when treated with three or more tubes(5)
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Hyperbaric Oxygen Therapy
Increase tissue oxygen levels, fibroblast proliferation, angiogenesis, augments neutrophil bactericidal activity= wound healing
Pressurized chamber at 2-3 times the normal atmospheric pressure while breathing in 100%pure oxygen↑ O2 dissolved in plasma
Who can do it? monitor TcPO2 at RA then at 100% O2
▪ >100mmHg potential benefit from HBOT (9)
Questionable studies
▪ Longitudinal cohort 6259 patient DMFU with adequate arterial perfusion with HBO did not achieve better wound healing or decrease amputation likelihood (13.)
▪ 70pt trail with ischemic foot ulcer: HBO amputation rate 9%, control 33% (9)
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HBOT Cost
$150-$350 per session: average $10K for total therapy sessions
$100 clinic v $1K and up in hospital setting
Medicare B Coverage: Diabetic wounds of the lower extremities if all of these apply:
▪ Type 1 or Type 2 diabetes and have a lower extremity wound that’s due to diabetes.
▪ Wound classified as Wagner grade III or higher.
▪ Failed an adequate course of standard wound therapy.
▪ Still pay 20% of the Medicare-approved amount (6)
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Osteomyelitis
With or without evidence of local soft tissue infection
Supporting findings
▪ Visible bone or ability to probe to bone
▪ Ulcer >2cm
▪ Ulceration duration longer than one to two weeks
▪ ESR >70mm/h
▪ “Sausage toe”
XrayMRI
Antibiotics? Vs Source Control(12)
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Infection and Antibiotics?
Polymicrobial 5-7organisms (12)
Severe: cellulitis, fever, hemodynamic instability, purulent drainage:
▪ broad spectrum, adjust based on C&S results
Mild- Moderate:
▪ systemic aerobic gram +cocci coverage
Hx of MRSA or high local rates:
▪ empiric ABX targeting MRSA (5)
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Infected or clean?
Dressing Goal?
Adjunct therapy?
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Assessment finding?
Debridement?
Dressing consideration?
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Vascular status?
Wound Products?
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Better or worse?
Infection protection?
A B
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Type of
wound?
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Toe
Considerations
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Don’t lose the war
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Index of References
1.) Nussbaum, S.,Carter, M., Fife, C., DaVanzo,J., Haught, R., Nusgart,M.,Cartwright, D. (2018). An economic evaluation of the impact, cost, and Medicare policy implications of chronic nonhealing wounds. Value in Health, 21(1), 27-32.
2.) Lam, G., Fontaine, R., Ross,F., Kimmel, H., Kimmel, M., Chiu, E. (2017). Hyperbaric oxygen therapy: Exploring the clinical evidence. Advances in Skin and Wound Care. 30(4), 181-190.
3.) Armstrong, D., Meyr, A. (2018). Basic principles of wound management. In:UpToDate.
4.) https://woundeducators.com/wound-debridement-techniques-1-autolytic-debridement/
5.)Armstrong, D., McCulloch, D., Asla, R. (2018). Management of Diabetic Foot Ulcers. In:UpToDate
6.) https://www.medicare.gov/coverage/hyperbaric-oxygen-therapy.html
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Index of References pg 2
7.)Faglia E, Clerici G, Clerissi J, Gabrielli L, Losa S, Mantero M, Caminiti M, Curci V, Quarantiello A, Lupattelli T, Morabito A. (2009). Long-term prognosis of diabetic patients with critical limb ischemia: a population-based cohort study. Diabetes Care. 32(5):822.
8.) www.shieldhealthcare.com/community/wp-content/uploads/2015/07/Stages-of-Healing_image.jpg
9.) Mechem, C., Manaker, S.(2018).Hyperbaric oxygen therapy. IN: UpToDate
10.) Mitchell, R. (2018). Noninvasive diagnosis of arterial disease. In: UpToDate.
11.) Walter, B., Ayala, P., Lantis, J. (2008). Comparison of negative pressure wound therapy using vacuum-assisted closure with advanced moist wound therapy in the treatment of diabetic foot ulcers: a multicenter randomized controlled trial. Diabetes Care.31(4):631
12.) Weintrob, A., Sexton, D. (2018). Clinical manifestations, diagnosis, and management of diabetic infections of the lower extremities. In:UpToDate.
13.) Margolis, D. J., Gupta, J., Hoffstad, O., Papdopoulos, M., Glick, H. A., Thom, S. R., & Mitra, N. (2013). Lack of effectiveness of hyperbaric oxygen therapy for the treatment of diabetic foot ulcer and the prevention of amputation: a cohort study. Diabetes Care, 36(7), 1961-1966. doi:10.2337/dc12-2160