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ITS T.I.M.E TO PREPARE FOR CLOSURE - ITS ALL ABOUT THE BED-
DR DIVYA PANICKER
ASKINA HYPERBARIC HEALTHCARE CENTER
B. Braun Melsungen AG 2
The Concept of Wound Bed Preparation and TIME
▪ Wound bed preparation (WBP)
is an important component of
the TIME global wound care framework
▪ The WBP concept includes tissue
management (debridement) and
biofilm prevention and removal
strategies
▪ Proper moisture balance and
wound cleansing are associated
aspects of WBP
WBP is a well established concept
TIME framework is a practical tool to assist practitioners when assessing &
managing patients
Wound bed preparation
TIME
Address patient
issues
Wound
diagnosis
Co-morbidity
factors
▪ Psychological
issues
▪ Social
circumstances
▪ Environmental
factors
e.g.
▪ Organ failure
▪ Diabetes
▪ Vascular
disease
▪ Pyoderma
gangrenosum
▪ Malignancy
▪ Tissue: non viable
▪ Infection or inflammation
▪ Moisture balance
▪ Edges/epithelialisation
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International Wound Journal 2012;9(Suppl. 12):1-19
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TIME IS NOW DIME : Wound Bed Preparation DIME Model
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4 PHASES OF WOUND HEALING
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Only A Clean Wound Can Heal!
PATHWAY TO WOUND CLOSURE
The wound bed is the foundation of the wound
Failing to prepare is preparing to fail
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Color-enhanced scanning electron micrograph of a biofilm. Source: CDC Image Bank.
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BIOFILM
1) James GA et al. Biofilms in chronic wounds. Wound Repair Regen 2008; 16(1): 37-44
2) Biofilm made easy. Vol. 1 Issue 3, May 2010 (http://www.woundsinternational.com/pdf/content_8851.pdf)
60 - 90% of chronic wounds & 6% of acute wounds have a
biofilm present which is a major barrier to wound healing:1,2
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FEW
MINUTES
2-4 HOURS
6-12 HOURS
24 HOURS
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Wolcott, R. D., Kennedy, J. P., & Dowd, S. E. (2009). Journal of Wound Care, 18(2), 54–56.
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WOUND BED PREPARATION
Debridement
Removal of non viable
or necrotic tissues
Biofilm management
Control of bacteria
burden
BED
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LOW FREQUENCY CONTACT ULTRASOUND ASSISTED WOUND DEBRIDEMENT (LFCUD)
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HANDPIECE
DOUBLE BALL- POCKETS
HOOF – SUPERFICIAL WOUNDS
SPATULA – INTERMEDIATE SPACES
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HOW DOES IT WORK?
• PHYSICAL EFFECTS
Cavitation
Thermal effect
Mechanical abrasion
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HOW DOES IT WORK?
UAW Product Presentation
• Low frequency ultrasound (25kHz)
• Ultrasonic vibrations Cavitation Bubbles Debridement
Microstreaming
Stimulates release of growth factors,
fibroblast migration & epithelization
Healthy tissue not affected due
to its higher elastin content
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1 Small gas bubbles appear
2 Liquid evaporates / gas bubbles grow
3 Shift
4 Unilateral inversion
5 Liquid perforates bubble / generates shock wave
low pressure low pressure turn high pressure high pressure
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Clinical Effects
1. Debridement & selective debridement
• Cavitation & microstreaming create a shearing force which is greater
than strength of necrotic tissue, liquefies & breaks off the non viable
tissue
• Healthy tissue is more elastic
2. Wound healing stimulatory effects/maintain wound in healing mode
• Stimulate the release of growth factors, fibroblast migration &
proliferation and encourage epithelialization on periwound
(Sussman & Dyson, 2007)3. Bactericidal
• Bacteria and biofilm is dislodged by cavitation & microstreaming effect
• Shockwaves disrupt the cell membrane, encourage nitrous oxide
production (Altland et al, 2004)
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Key Benefits Hospital Patient
1. Time and cost saving:• Applicable by nursing staff √ √
• Local anesthetics sufficient √ √
• No extensive operative settings √
• Access to difficult to reach areas √
• Completely autoclavable √
• As effective as sharp debridement √
2. Less pain and traumatic √
3. Faster & better outcome (20-30 second per cm²) √ √
4. Can be repeated √
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Italian Journal of Wound Care 2017
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IMPORTANT !
Cavitation only emerge in liquids.
A wet or moistly operation field is important.
Without liquid strong THERMAL effects are generated!
Liquid is needed to:
•transmit the energy
•cool down the working area
•transport the fragmented tissue and cells
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BIOFILM-BASED APPROACH (BBWC)
WOUND BED PREPARATION
Schulz G et al: Consensus guidelines for the identification and treatment of biofilms in chronic non healing wounds. Wound Rep
Reg(2017) 25 744-757
• Sequential Debridement
• Combined with an Antimicrobial
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Betaine a gentle effective surfactant
to penetrate, clean and
remove wound debris and
biofilm
Polyhexanide (PHMB)
a powerful antimicrobial
agent that can reduce
bioburden
UAW has a good effect in disrupting biofilms and
promotes the antibacterial effect of PHMB.
Alhede M. Crone S. Garde C. et al. Wound Care 2015 24(2) 64 66-9 72
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INDICATION
ALL WOUNDS
1. Malignant or hemorrhagic wounds
2. Exposed spinal cord
3. Radiation induced wound
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Immediate Outcome
Before After
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Immediate Outcome
Before After
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After 2 applications
Hoof
Before After
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After 2 applications
33
Before After
Hoof
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30 sessions@ 2.2 ATA
- 6 weeks -
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Aug 5, 2015
Oct 26, 2015 - 2 months
later
Diabetic Foot Ulcer
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2 months later…. Sept
25, 2017
Diabetic Foot Ulcer
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Pressure Injury
Before
After
Debridement done on Aug
23, 2017
Debridement done on July
17, 2017
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PATHWAY TO WOUND CLOSURE
a thing added to something else as a supplementary rather than an essential part.
NEED TO HAVE RATHER THEN NICE TO HAVE
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ALL ASPECTS AT THE SAME TIME WITH THE SAME INTENSITY
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References
1. Thomson CH. Biofilm: do they affect wound healing? Int Wound J 2011;8:63-7
2. Attinger C, Wolcott R. Clinically addressing biofilm in chronic wounds. Adv Wound Care 2012;1:127-
132
3. Butcher G, Pinnuck L. Wound bed preparation: Ultrasonic-assisted debridement. BJN 2013 (Tissue
Viability Supplement), Vol 22, No 6
4. Herberger K et al: Efficacy, tolerability and patient benefit of ultrasound-assisted wound treatment
versus surgical debridement: a randomized clinical study. 2011
5. Suchkova V. et al: Ultrasound enhancement of fibrinolysis at frequencies of 27 to 100 kHz.; Ultrasound
Med Biol. 2002 Mar;28(3):377-82.
6. Leaper DJ, Schultz G, Carville K, Fletcher J, Swanson T, Drake R. Extending the TIME concept: what
have we learned in the past 10 years? Int Wound J 2014; 9 (Suppl. 2):1-19
7. A. Marcoccia et al: Ultrasonic-assisted Wound Debridement for Scleroderm Digital Ulcers. Italian
Journal of Wound Care 2017; 1(2):73-78
THANK YOU
FOR YOUR TIME
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