Inflammation

After attending the Spring Symposium for Advanced Wound Care and hearing many great lectures, I got to thinking, “What are the pillars of chronic wound care?” We have all heard of the concept “look at the whole patient and not the hole in the patient.” Heck, I have even written about it. But we also need to have a good foundation for how to implement this phrase or where to even start. I did a quick Internet search and came up with some interesting articles that talked about the basics of wound care and management. I found discussions on everything from maintaining a moist wound environment to being financially responsible. All of this information leads me to the concept of developing easy-to-understand pillars or categories to consider when caring for a patient with a chronic wound.

For the wound healing process to be successful, it must pass through four stages: hemostasis, inflammation, proliferation, and remodeling or maturing. Wound healing requires inflammation, but it can be detrimental if it is persistent or encouraged by other factors, such as infection. It is during this phase that wound healing is most likely to stall.

Wound bed preparation is vital to treating biofilm. Resistant to antibiotic treatment, biofilm not only stalls the healing process of chronic wounds but also puts patients at greater risk for amputation. Clinicians should follow the process of successful wound healing described in the TIMERS framework (Tissue, Inflammation/infection, Moisture imbalance, Epithelial edge advancement, Repair/regeneration, and Social factors) to guide wound care. Proper wound bed preparation recognizes that biofilm prevention and treatment in chronic wounds incorporate aggressive wound debridement to suppress biofilm regrowth, disrupt the bacterial burden, and promote a healthy wound bed environment

Wound healing typically progresses through four phases: hemostasis, inflammation, cell proliferation or granulation and repair, and epithelialization and remodeling of scar tissue. Clinicians should achieve wound closure through a standardized framework such as the TIMERS (tissue management, infection or inflammation, moisture balance, edge or epithelialization, regeneration, and social factors) tool, which provides a comprehensive approach to wound management and optimizes the wound bed and conditions to support progression of wounds through the healing process.

Wound bed preparation is the systematic approach clinicians use to identify and remove barriers to the healing process of the wound. The approach aims to create an optimal wound healing environment by focusing on all critical components, including debridement, bacterial balance, and exudate management, as well as taking into account the patient's overall health status and how this may impinge on the wound healing process.

In Part 1 of this series on recalcitrant wounds, we started our discussion on some factors on why wounds may seem to stall or stop healing. It can be very difficult in trying to treat a wound that seems to resist all efforts to get it to heal. In Part 1, we discussed some signs of a recalcitrant wound, exploring alternative etiologies behind a wound and how dressings can impact a wound’s ability to heal. In Part 2, we will discuss other possible factors that can cause a recalcitrant wound, including, infection, prolonged or chronic inflammation, the presence of necrotic tissue, the edge effect, nutrition as well as socio-economic factors. We must also bring up the fact that, due to underlying comorbidities or complications, some wounds may never heal and how to start a conversation about this.

Wound bed preparation is a vital element of wound care. It ensures that the wound has the best environment for closure by addressing the needs of the wound and removing barriers. Wound bed preparation is usually achieved by following a systematic approach such as the TIMERS mnemonic, which consists of tissue, infection/inflammation, moisture management, edge of wound/epibole, repair/regeneration, and social factors. These steps do not necessarily need to occur in order, and some or all of them may need to be repeated as the wound changes and progresses toward closure.

Wound bed preparation is the concept that provides clinicians with a framework for treating hard-to-heal wounds by assessing the patient as a whole and not focusing only on the characteristics of the wound. Moisture management is essential for a wound to heal correctly, so clinicians must regularly assess the wound because excess moisture or exudate can be an indicator of ongoing inflammation or other complicating factors.