Wound Bed Preparation

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By Steven A. Kahn, MD

When treating severe burns, surgeons generally consider eschar removal to be the major factor and the top challenge in both initiating and planning for the optimal course of treatment for each patient. Before grafting, all devitalized tissue must be removed, leaving a wound bed of only healthy tissue. Some burn wounds are clearly full-thickness on initial examination, and some are clearly superficial, with relatively straightforward decision making. However, some wounds have an indeterminate depth and are more challenging. Deep partial-thickness, indeterminate-, and heterogenous-depth wounds require more complex decision making and/or a protracted interval to allow the wound to declare. Eschar removal is sometimes necessary to allow surgeons to assess the wound bed and confirm the depth and severity of certain burns. This, in turn, provides the insights a surgeon needs to determine the best course of treatment, including whether a patient must be treated with an autograft to cover a wound area.

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Wound bed preparation has been performed for decades in managing wounds of various etiologies. The wound healing process consists of a complex interlinked and independent cascade, which not all wounds follow in a consistent, organized manner. The TIMERS acronym, consisting of four general steps, has assisted clinicians globally to provide a systematic approach to wound bed preparation that includes Tissue debridement, Infection or Inflammation, Moisture balance, Edge effect, Regeneration and repair, and Social factors.1 Clinicians should have practical knowledge of the principles of advanced wound care management, as well as the challenges faced in treating complex wounds.

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Wound bed maintenance is the process taken by the bedside clinician or nurse to create or preserve the wound environment at optimal conditions and thus encourage the chronic wound to move to a state of closure or healing. Critical thinking skills require a trained eye focused on the characteristics of the wound to move a chronic wound in to a healing phase and ultimately wound closure. The goal of every assessment and encounter includes promoting positive wound characteristics while suppressing negative wound characteristics. This can often feel like a balancing act with not much wiggle room, yet knowing the basic principles of wound healing can help the wound get closer to the finish line.

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Preparing the wound bed to encourage and promote healing is a well-established concept. Wound healing is a complex process that progresses through several phases, including coagulation and hemostasis, inflammation, cell proliferation and repair, and epithelialization and remodeling of scar tissue. In many instances, a non-healing wound can become stalled in one of the phases and fail to progress through the healing process. It is estimated that between 4% and 5% of the adult population will have a non-healing wound at some point.

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Patient education should be a priority to empower patients to care for themselves and improve patient outcomes. Involving patients in their own care can help them to understand about their wound and be more adherent to the overall treatment plan. Remember to involve the caregiver or family if applicable. Ask your patient questions about who will be changing the dressing so the appropriate parties can be involved.

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Anoxia: A condition marked by the absence of oxygen reaching the tissues. It differs from hypoxia, in which there is a decrease in the oxygen levels to tissue.

Biocide tolerance: Demonstrating a tolerance to substances that destroy living things, such as bacteria. The initial stage in the life of biofilm can become biocide tolerant within 12 hours.

Calcium alginate: A water-insoluble, gelatinous substance that is highly absorbent. Dressings with calcium alginate can help to maintain a moist healing environment.

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Sharp debridement is by far the fastest way to remove non-viable tissue from a wound bed. This modality must be performed by a licensed skilled practitioner using sharp instruments or tools to remove unhealthy tissue. It is reimbursed by most payers when documentation and medical necessity support its use. There are times when sharp debridement is contraindicated, however. This blog reviews the contraindications and alternatives to sharp debridement.

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Approximately 2 million people in the United States are living with limb loss, and this figure is expected to double by 2050. Lower-limb amputation accounts for the vast majority of all amputations, and diabetes—specifically, diabetic foot ulcers (DFUs)—is the leading cause of nontraumatic lower-limb amputations in the US. Although already high, the rate of amputation is increasing.

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Complex and hard-to-heal chronic wounds impact millions of people globally. In the United States, care for these types of wounds exceeds $25 billion annually. Wound healing naturally progresses through the overlapping phases of hemostasis, inflammation, proliferation, and remodeling. With chronic and complex wounds, the natural biological healing process stalls in the inflammatory phase, thereby preventing both the proliferative phase and further advancement toward wound closure.

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Tissue viability is crucial in managing all types of wounds, including surgical wounds, traumatic wounds, pressure injuries, lower-extremity ulcers, and skin tears. Accurate assessment and wound diagnosis are important in treating symptoms and understanding the underlying pathophysiology of the wound.

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