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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


International Wound Journal 2012;9(Suppl. 12):1-19


TIME IS NOW DIME : Wound Bed Preparation DIME Model


4 PHASES OF WOUND HEALING


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


Color-enhanced scanning electron micrograph of a biofilm. Source: CDC Image Bank.

https://microbewiki.kenyon.edu/index.php/File:SEM_biofilm_CDC_Image_Bank1.jpg


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


FEW

MINUTES

2-4 HOURS

6-12 HOURS

24 HOURS


Wolcott, R. D., Kennedy, J. P., & Dowd, S. E. (2009). Journal of Wound Care, 18(2), 54–56.


WOUND BED PREPARATION

Debridement

Removal of non viable

or necrotic tissues

Biofilm management

Control of bacteria

burden

BED


LOW FREQUENCY CONTACT ULTRASOUND ASSISTED WOUND DEBRIDEMENT (LFCUD)


HANDPIECE

DOUBLE BALL- POCKETS

HOOF – SUPERFICIAL WOUNDS

SPATULA – INTERMEDIATE SPACES


HOW DOES IT WORK?

• PHYSICAL EFFECTS

Cavitation

Thermal effect

Mechanical abrasion


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


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


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)


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 √


Italian Journal of Wound Care 2017


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


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


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


INDICATION

ALL WOUNDS

1. Malignant or hemorrhagic wounds

2. Exposed spinal cord

3. Radiation induced wound


Immediate Outcome

Before After


After 2 applications

Hoof

Before After


After 2 applications

33

Before After

Hoof


30 sessions@ 2.2 ATA

- 6 weeks -


Aug 5, 2015

Oct 26, 2015 - 2 months

later

Diabetic Foot Ulcer


2 months later…. Sept

25, 2017

Diabetic Foot Ulcer


Pressure Injury

Before

After

Debridement done on Aug

23, 2017

Debridement done on July

17, 2017


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


ALL ASPECTS AT THE SAME TIME WITH THE SAME INTENSITY


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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