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Advances in Wound Care Dec 2022Diabetic foot ulcerations have devastating complications, including amputations, poor quality of life, and life-threatening infections. Diabetic wounds can be... (Review)
Review
Diabetic foot ulcerations have devastating complications, including amputations, poor quality of life, and life-threatening infections. Diabetic wounds can be protracted, take significant time to heal, and can recur after healing. They are costly consuming health care resources. These consequences have serious public health and clinical implications. Debridement is often used as a standard of care. Debridement consists of both nonmechanical (autolytic, enzymatic) and mechanical methods (sharp/surgical, wet to dry debridement, aqueous high-pressure lavage, ultrasound, and biosurgery/maggot debridement therapy). It is used to remove nonviable tissue, to facilitate wound healing, and help prevent these serious outcomes. What are the various forms and rationale behind debridement? This article comprehensively reviews cutting-edge methods and the science behind debridement and diabetic foot ulcers.
Topics: Debridement; Diabetes Mellitus; Diabetic Foot; Foot Ulcer; Humans; Quality of Life; Wound Healing
PubMed: 34376065
DOI: 10.1089/wound.2021.0016 -
Gastroenterology Jan 2020The purpose of this American Gastroenterological Association (AGA) Institute Clinical Practice Update is to review the available evidence and expert recommendations... (Review)
Review
DESCRIPTION
The purpose of this American Gastroenterological Association (AGA) Institute Clinical Practice Update is to review the available evidence and expert recommendations regarding the clinical care of patients with pancreatic necrosis and to offer concise best practice advice for the optimal management of patients with this highly morbid condition.
METHODS
This expert review was commissioned and approved by the AGA Institute Clinical Practice Updates Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership, and underwent internal peer review by the Clinical Practice Updates Committee and external peer review through standard procedures of Gastroenterology. This review is framed around the 15 best practice advice points agreed upon by the authors, which reflect landmark and recent published articles in this field. This expert review also reflects the experiences of the authors, who are advanced endoscopists or hepatopancreatobiliary surgeons with extensive experience in managing and teaching others to care for patients with pancreatic necrosis. BEST PRACTICE ADVICE 1: Pancreatic necrosis is associated with substantial morbidity and mortality and optimal management requires a multidisciplinary approach, including gastroenterologists, surgeons, interventional radiologists, and specialists in critical care medicine, infectious disease, and nutrition. In situations where clinical expertise may be limited, consideration should be given to transferring patients with significant pancreatic necrosis to an appropriate tertiary-care center. BEST PRACTICE ADVICE 2: Antimicrobial therapy is best indicated for culture-proven infection in pancreatic necrosis or when infection is strongly suspected (ie, gas in the collection, bacteremia, sepsis, or clinical deterioration). Routine use of prophylactic antibiotics to prevent infection of sterile necrosis is not recommended. BEST PRACTICE ADVICE 3: When infected necrosis is suspected, broad-spectrum intravenous antibiotics with ability to penetrate pancreatic necrosis should be favored (eg, carbapenems, quinolones, and metronidazole). Routine use of antifungal agents is not recommended. Computed tomography-guided fine-needle aspiration for Gram stain and cultures is unnecessary in the majority of cases. BEST PRACTICE ADVICE 4: In patients with pancreatic necrosis, enteral feeding should be initiated early to decrease the risk of infected necrosis. A trial of oral nutrition is recommended immediately in patients in whom there is absence of nausea and vomiting and no signs of severe ileus or gastrointestinal luminal obstruction. When oral nutrition is not feasible, enteral nutrition by either nasogastric/duodenal or nasojejunal tube should be initiated as soon as possible. Total parenteral nutrition should be considered only in cases where oral or enteral feeds are not feasible or tolerated. BEST PRACTICE ADVICE 5: Drainage and/or debridement of pancreatic necrosis is indicated in patients with infected necrosis. Drainage and/or debridement may be required in patients with sterile pancreatic necrosis and persistent unwellness marked by abdominal pain, nausea, vomiting, and nutritional failure or with associated complications, including gastrointestinal luminal obstruction; biliary obstruction; recurrent acute pancreatitis; fistulas; or persistent systemic inflammatory response syndrome. BEST PRACTICE ADVICE 6: Pancreatic debridement should be avoided in the early, acute period (first 2 weeks), as it has been associated with increased morbidity and mortality. Debridement should be optimally delayed for 4 weeks and performed earlier only when there is an organized collection and a strong indication. BEST PRACTICE ADVICE 7: Percutaneous drainage and transmural endoscopic drainage are both appropriate first-line, nonsurgical approaches in managing patients with walled-off pancreatic necrosis (WON). Endoscopic therapy through transmural drainage of WON may be preferred, as it avoids the risk of forming a pancreatocutaneous fistula. BEST PRACTICE ADVICE 8: Percutaneous drainage of pancreatic necrosis should be considered in patients with infected or symptomatic necrotic collections in the early, acute period (<2 weeks), and in those with WON who are too ill to undergo endoscopic or surgical intervention. Percutaneous drainage should be strongly considered as an adjunct to endoscopic drainage for WON with deep extension into the paracolic gutters and pelvis or for salvage therapy after endoscopic or surgical debridement with residual necrosis burden. BEST PRACTICE ADVICE 9: Self-expanding metal stents in the form of lumen-apposing metal stents appear to be superior to plastic stents for endoscopic transmural drainage of necrosis. BEST PRACTICE ADVICE 10: The use of direct endoscopic necrosectomy should be reserved for those patients with limited necrosis who do not adequately respond to endoscopic transmural drainage using large-bore, self-expanding metal stents/lumen-apposing metal stents alone or plastic stents combined with irrigation. Direct endoscopic necrosectomy is a therapeutic option in patients with large amounts of infected necrosis, but should be performed at referral centers with the necessary endoscopic expertise and interventional radiology and surgical backup. BEST PRACTICE ADVICE 11: Minimally invasive operative approaches to the debridement of acute necrotizing pancreatitis are preferred to open surgical necrosectomy when possible, given lower morbidity. BEST PRACTICE ADVICE 12: Multiple minimally invasive surgical techniques are feasible and effective, including videoscopic-assisted retroperitoneal debridement, laparoscopic transgastric debridement, and open transgastric debridement. Selection of approach is best determined by pattern of disease, physiology of the patient, experience and expertise of the multidisciplinary team, and available resources. BEST PRACTICE ADVICE 13: Open operative debridement maintains a role in the modern management of acute necrotizing pancreatitis in cases not amenable to less invasive endoscopic and/or surgical procedures. BEST PRACTICE ADVICE 14: For patients with disconnected left pancreatic remnant after acute necrotizing mid-body necrosis, definitive surgical management with distal pancreatectomy should be undertaken in patients with reasonable operative candidacy. Insufficient evidence exists to support the management of the disconnected left pancreatic remnant with long-term transenteric endoscopic stenting. BEST PRACTICE ADVICE 15: A step-up approach consisting of percutaneous drainage or endoscopic transmural drainage using either plastic stents and irrigation or self-expanding metal stents/lumen-apposing metal stents alone, followed by direct endoscopic necrosectomy, and then surgical debridement is reasonable, although approaches may vary based on the available clinical expertise.
Topics: Debridement; Drainage; Endoscopy; Enteral Nutrition; Gastroenterology; Humans; Pancreas; Pancreatitis, Acute Necrotizing; Practice Guidelines as Topic; Randomized Controlled Trials as Topic; Self Expandable Metallic Stents; Societies, Medical; Tomography, X-Ray Computed; Treatment Outcome; United States
PubMed: 31479658
DOI: 10.1053/j.gastro.2019.07.064 -
The Lancet. Infectious Diseases Mar 2023The incidence of necrotising soft-tissue infections has increased during recent decades such that most physicians might see at least one case of these potentially... (Review)
Review
The incidence of necrotising soft-tissue infections has increased during recent decades such that most physicians might see at least one case of these potentially life-threatening infections in their career. Despite advances in care, necrotising soft-tissue infections are still associated with high morbidity and mortality, underlining a need for continued education of the medical community. In particular, failure to suspect necrotising soft-tissue infections, fuelled by poor awareness of the disease, promotes delays to first surgical debridement, amplifying disease severity and adverse outcomes. This Review will focus on practical approaches to management of necrotising soft-tissue infections including prompt recognition, initiation of specific management, exploratory surgery, and aftercare. Increased alertness and awareness for these infections should improve time to diagnosis and early referral to specialised centres, with improvement in the prognosis of necrotising soft-tissue infections.
Topics: Humans; Fasciitis, Necrotizing; Debridement; Soft Tissue Infections; Prognosis; Referral and Consultation
PubMed: 36252579
DOI: 10.1016/S1473-3099(22)00583-7 -
Journal of the American Academy of... Oct 2019Prevention has been a primary goal of pressure ulcer research. Despite such efforts, pressure ulcers remain common in hospitals and in the community. Moreover, pressure...
Prevention has been a primary goal of pressure ulcer research. Despite such efforts, pressure ulcers remain common in hospitals and in the community. Moreover, pressure ulcers often become chronic wounds that are difficult to treat and that tend to recur after healing. Especially given these challenges, dermatologists should have the knowledge and skills to implement pressure ulcer prevention strategies and to effectively treat pressure ulcers in their patients. This continuing medical education article focuses on pressure ulcer prevention and management, with an emphasis on the evidence for commonly accepted practices.
Topics: Debridement; Dermatology; Evidence-Based Medicine; Humans; Negative-Pressure Wound Therapy; Patient Positioning; Pressure Ulcer; Recurrence; Secondary Prevention; Skin Care
PubMed: 30664906
DOI: 10.1016/j.jaad.2018.12.068 -
Advances in Skin & Wound Care Apr 2021To present the 2021 update of the Wound Bed Preparation paradigm.
GENERAL PURPOSE
To present the 2021 update of the Wound Bed Preparation paradigm.
TARGET AUDIENCE
This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care.
LEARNING OBJECTIVES/OUTCOMES
After participating in this educational activity, the participant will: 1. Apply wound assessment strategies. 2. Identify patient concerns about wound care. 3. Select management options for healable, nonhealable, and maintenance wounds.
Topics: Debridement; Education, Continuing; Humans; Wound Healing; Wounds and Injuries
PubMed: 33739948
DOI: 10.1097/01.ASW.0000733724.87630.d6 -
Plastic and Reconstructive Surgery Aug 2021After studying this article, the participant should be able to: 1. Understand the basics of biofilm infection and be able to distinguish between planktonic and biofilm... (Review)
Review
LEARNING OBJECTIVES
After studying this article, the participant should be able to: 1. Understand the basics of biofilm infection and be able to distinguish between planktonic and biofilm modes of growth. 2. Have a working knowledge of conventional and emerging antibiofilm therapies and their modes of action as they pertain to wound care. 3. Understand the challenges associated with testing and marketing antibiofilm strategies and the context within which these strategies may have effective value.
SUMMARY
The Centers for Disease Control and Prevention estimate for human infectious diseases caused by bacteria with a biofilm phenotype is 65 percent and the National Institutes of Health estimate is closer to 80 percent. Biofilms are hostile microbial aggregates because, within their polymeric matrix cocoons, they are protected from antimicrobial therapy and attack from host defenses. Biofilm-infected wounds, even when closed, show functional deficits such as deficient extracellular matrix and impaired barrier function, which are likely to cause wound recidivism. The management of invasive wound infection often includes systemic antimicrobial therapy in combination with débridement of wounds to a healthy tissue bed as determined by the surgeon who has no way of visualizing the biofilm. The exceedingly high incidence of false-negative cultures for bacteria in a biofilm state leads to missed diagnoses of wound infection. The use of topical and parenteral antimicrobial therapy without wound débridement have had limited impact on decreasing biofilm infection, which remains a major problem in wound care. Current claims to manage wound biofilm infection rest on limited early-stage data. In most cases, such data originate from limited experimental systems that lack host immune defense. In making decisions on the choice of commercial products to manage wound biofilm infection, it is important to critically appreciate the mechanism of action and significance of the relevant experimental system. In this work, the authors critically review different categories of antibiofilm products, with emphasis on their strengths and limitations as evident from the published literature.
Topics: Anti-Bacterial Agents; Bacteria; Biofilms; Debridement; Humans; Treatment Outcome; Wound Healing; Wound Infection
PubMed: 34398099
DOI: 10.1097/PRS.0000000000008142 -
Burns : Journal of the International... Jun 2020Bromelain-based Enzymatic Debridement has been introduced as an additional concept to the burn surgeon's armamentarium and is best indicated for mid-to deep dermal burns...
INTRODUCTION
Bromelain-based Enzymatic Debridement has been introduced as an additional concept to the burn surgeon's armamentarium and is best indicated for mid-to deep dermal burns with mixed patterns. Increasing evidence has been published focusing on special regions and settings as well as on limitations of Enzymatic Debridement to improve patient care. To better guide Enzymatic Debridement in view of the increasing experience, there is a need to update the formerly published consensus guidelines with user-orientated recommendations, which were last produced in 2017.
METHODS
A multi-professional expert panel of plastic surgeons and burn care specialists from twelve European centers was convened, to assist in developing current recommendations for best practices with use of Enzymatic Debridement. Consensus statements were based on peer-reviewed publications and clinical relevance, and topics for re-evaluation and refinement were derived from the formerly published European guidelines. For consensus agreement, the methodology employed was an agreement algorithm based on a modification of the Willy and Stellar method. For this study on Enzymatic Debridement, consensus was considered when there was at least 80 % agreement to each statement.
RESULTS
The updated consensus guidelines from 2019 refer to the clinical experience and practice patterns of 1232 summarized patient cases treated by the panelists with ED in Europe (2017: 500 cases), reflecting the impact of the published recommendations. Forty-three statements were formulated, addressing the following topics: indications, pain management and anesthesia, large surface treatment, timing of application for various indications, preparation and application, post-interventional wound management, skin grafting, outcome, scar and revision management, cost-effectiveness, patient´s perspective, logistic aspects and training strategies. The degree of consensus was remarkably high, with consensus in 42 out of 43 statements (97.7%). A classification with regard to timing of application for Enzymatic Debridement was introduced, discriminating immediate/very early (≤12 h), early (12-72 h) or delayed (>72 h) treatment. All further recommendations are addressed in the publication.
CONCLUSIONS
The updated guidelines in this publication represent further refinement of the recommended indication, application and post-interventional management for the use of ED. The published statements contain detailed, user-orientated recommendations aiming to align current and future users and prevent pitfalls, e.g. for the successful implementation of ED in further countries like the USA. The significance of this work is reflected by the magnitude of patient experience behind it, larger than the total number of patients treated in all published ED clinical trials.
Topics: Bandages; Body Surface Area; Bromelains; Burns; Debridement; Europe; Humans; Practice Guidelines as Topic; Skin Transplantation; Time Factors; Wound Healing
PubMed: 32241591
DOI: 10.1016/j.burns.2020.03.002 -
Journal of the American Geriatrics... Aug 2021Older adults are at high risk of developing chronic wounds due to numerous changes that occur with aging. It is reasonable to consider chronic wounds as a geriatric... (Review)
Review
Older adults are at high risk of developing chronic wounds due to numerous changes that occur with aging. It is reasonable to consider chronic wounds as a geriatric syndrome-highly prevalent, multifactorial, and associated with substantial morbidity and mortality. Due to the morbidity and cost associated with chronic wounds, prevention, early diagnosis, and treatment are important. The most common chronic wounds presenting in older adults are pressure and vascular wounds, including those associated with diabetes. Atypical wounds are also common and should raise the suspicion for skin malignancy. Diagnosis is primarily clinical and assessment should include documentation of wound characteristics, such as location, size and depth, presence of slough, drainage, odor, and infection. The mainstay of treatment is based on the TIME principle: Tissue debridement, Infection control, Moisture balance, and optimal wound Edges. The use of protein supplements has been shown to improve wound healing in subsets of older adults. In addition to wound care and optimizing nutrition, disease-specific wound therapy forms an integral part of wound management. Pressure reduction for pressure injury, compression therapy for venous wounds, evaluation of arterial circulation with ABI or arterial Doppler and iCC for diabetic ulcers form the mainstays of therapy. Atypical wounds may present as chronic ulcers and should be biopsied. The goals of treatment should be realistic and for some older adults, palliative wound management may be more appropriate.
Topics: Aged; Chronic Disease; Debridement; Drainage; Humans; Hyperbaric Oxygenation; Pressure Ulcer; Wound Healing
PubMed: 34002364
DOI: 10.1111/jgs.17177 -
Plastic and Reconstructive Surgery Jan 2021Wounds have been one of the most prominent pathologies since the beginning of humanity. For the last 5 decades, a drastic improvement of healing has been observed,...
Wounds have been one of the most prominent pathologies since the beginning of humanity. For the last 5 decades, a drastic improvement of healing has been observed, thanks to new medical devices based on fluid aspiration capacities and the development of negative pressure wound therapy. Negative-pressure wound therapy was initially designed for a double action, fluid aspiration and mechanical stimulation of wound edges by a foam. Successive technical evolutions of negative pressure wound therapy were declined since 1997 when Argenta and Morykwas first presented their solution. The adjunct of instillation in 2009 was considered as the first interactive dressing, allowing topical wound solutions to sequentially reach the wound, in alternance with negative pressure. Other devices based on the same principle were designed to prevent postoperative infections when placed over a suture after surgery. This long evolution could enhance the armamentarium of possible solutions, considerably reducing the wound healing time.
Topics: Anti-Infective Agents, Local; Bandages; Chronic Disease; Crystalloid Solutions; Debridement; Free Tissue Flaps; History, 20th Century; History, 21st Century; Humans; Instillation, Drug; Limb Salvage; Negative-Pressure Wound Therapy; Peripheral Arterial Disease; Skin Transplantation; Surgical Wound Infection; Therapeutic Irrigation; Treatment Outcome; Wound Healing; Wounds and Injuries
PubMed: 33347058
DOI: 10.1097/PRS.0000000000007628 -
Survey of Ophthalmology 2022Periorbital necrotizing fasciitis carries serious risks of loss of vision, eye, and life, and thus represents a true emergency. As such, clinicians must have an... (Review)
Review
Periorbital necrotizing fasciitis carries serious risks of loss of vision, eye, and life, and thus represents a true emergency. As such, clinicians must have an appropriate index of suspicion for necrotizing fasciitis and, upon recognition, need to address the disease rapidly and thoroughly. I review the classic features, systemic implications, and management paradigms of necrotizing fasciitis in the hopes of improving outcomes.
Topics: Debridement; Fasciitis, Necrotizing; Humans
PubMed: 35183613
DOI: 10.1016/j.survophthal.2022.02.006