Complex Wound Management

Bioburden: Normally defined as the number of bacteria living on a surface that has not been sterilized. The term is most often used in the context of bioburden testing, also known as microbial limit testing, which is a quality control test performed on medical devices and pharmaceutical products.

Wound management is a tremendous clinical challenge for many health care professionals. The World Health Organization has recognized that wound management is a worldwide public health issue best managed by an interprofessional team. This interdisciplinary approach has been shown to increase healing and decrease wound recurrence. However, it requires shared decision making with many clinicians to create an optimal care plan.

The management of wounds, especially complex and chronic wounds, is a daunting clinical challenge. Achieving progress toward wound closure often depends on the right selection of treatment modalities for the wound and acknowledgment of any other underlying clinical considerations that present barriers to healing. However, before treatment selection, a full and accurate wound assessment must be completed. Without analyzing all variables that impact wound healing, clinicians may be unable to identify the proper treatment course.

Wounds have a significant negative impact on patients, including pain, decreased quality of life, and social isolation. Optimal wound healing can help patients and the health care system cope with the burden of chronic wounds. Wound management may not always be the priority in patients whose cases are complicated by severe comorbidities, palliative care, hospice care, surgery, chemotherapy, radiation, or management of a chronic condition.

Patients with wounds are frequently treated pharmacologically for both their wounds and their acute or chronic conditions. On a daily basis, patients usually take at least five drugs to treat multiple chronic conditions, and this level of drug use is termed polypharmacy. Polypharmacy can also be defined as the intake of more medications than are medically necessary for a particular problem or the continuation of intake after the initial problem has been resolved

By Alex M. Aningalan, MSN, RN, CWON, WCC

Fellow wound care specialists may agree that interdisciplinary clinical teams often seek their expertise when a patient presents with a “chronic-appearing wound with an unknown or indeterminate etiology.” As in any other discipline, a comprehensive wound assessment begins with a thorough exploration of possible underlying etiologies—the main causative factors for wound development. Moreover, chronic, nonhealing wounds may warn clinicians to explore possible unaddressed underlying complex etiologies.

For years I was the only medical doctor doing inpatient wound consults in my hospital. I was continually amazed at the variety of wounds that reflected a wide gamut of human disease. Each wound was unique, and beyond the many pressure injuries and venous stasis lesions there were wounds from cancer, substance abuse, vasculitis, trauma, surgical dehiscence, and hematologic disorders. Most doctors viewed these as an unrewarding burden, requiring extended time unwrapping and rewrapping lesions that were malodorous, painful, and sometimes unhealable. The nurses and medical residents were puzzled at my enthusiasm and dubbed me “The Wound Man.”

Venous leg ulcers can be slow to heal; the longer a wound is present, the less likely it is to heal. To move a venous leg ulcer through the phases of wound healing may require more than just basic wound care.

Chronic venous leg ulcers can be prone to chronic inflammation. Changes in the microcirculation down to the capillary level can elevate levels of cytokines and proteases, thus leaving the wound stuck in the inflammatory cycle. Controlling, reducing, or eliminating inflammation is necessary to move the wound toward closure.

Growth factors and cytokines are secreted by the cells and are essential to the complex wound healing and tissue regeneration process. This process involves the interplay of growth factors with chemokines, cytokines, and other signaling molecules. Although there have been numerous advances that have increased our understanding of wound healing, the exact tissue regeneration mechanisms following an injury have yet to be determined.

Angiogenesis: The complex process in which the growth of normal, stable, and functional vessels is critically dependent on the coordinated interplay in space and time of different cell types and growth factors. This process involves the forming of new blood vessels from preexisting vessels by invading the wound clot to organize in a microvascular network throughout granulation tissue.

Autologous cell therapy: A therapeutic intervention that uses an individual’s cells, which are cultured and expanded outside of the body and reintroduced into the donor as a bioengineered skin substitute to aid in wound closure.

Immunomodulation: Therapeutic interventions aimed at modifying the immune response. Healing in chronic and complex wounds can be enhanced with immunomodulating agents.