Madhuri Reddy, Geriatrician, Founder & Director, Wound Healing Program at Hebrew SeniorLife
Chronic wounds can be notoriously difficult for many clinicians to manage. It is only natural, then, that we are always looking for the newest, most technologically advanced dressings and treatments to help.
Let’s use the example of pressure injuries, a relatively common type of chronic wound. Despite our best efforts, to date, no advanced wound dressings have been shown to be any better than any other dressings. It can be quite difficult to assess whether chronic wounds are infected. We found that the presence of increasing pain may make infection of a chronic wound more likely. It is still unclear what, if any, blood tests or quantitative swab cultures are most diagnostic. Relatively few well-designed RCTs assessing prevention and management of pressure injuries, and management of infection in chronic wounds, have been completed.
"What remains fundamental to chronic wound care continue to be the triad of managing the underlying contributing factors and local wound care"
For the prevention of pressure injuries, all manner of technologically advanced pressure-reducing surfaces is being evaluated, including mechanically rotating beds. Ultimately all these mattresses can just be divided into two types: non-powered—such as mattresses filled with air, water, gel, foam or a combination of these—and powered—use electricity, such as air-fluidized mattresses, low-air-loss beds, and alternating-pressure mattresses. Available evidence shows that mattress overlays on operating tables may decrease the incidence of postoperative pressure injuries. Specialized foam and specialized sheepskin overlays reduce incidence compared with standard hospital mattresses. But despite the enormous cost of powered mattresses as compared with non-powered, the differences between them in terms of clinical outcomes is not clear. It is probably reasonable, as most guidelines suggest, to use the non-powered mattresses for prevention of pressure injuries and management of deep-tissue injuries, stage 1 and stage 2. For anything more than a stage 3 pressure injuries, a powered mattress would be appropriate. Repositioning, hardly a technological advance but remarkably difficult to implement, remains a mainstay of pressure injury prevention and management.
Technological advancements in nutrition for prevention and treatment of pressure injuries also have not borne out. Consulting a dietician and ensuring adequate total calorie and total protein requirements appear most appropriate. The most exciting technological advance in wound care is telehealth. Patients with chronic wounds, in particular, pressure injuries, are likely either older, chronically ill and have difficulty ambulating. Getting out of their place of residence to visit the doctor can be expensive and an ordeal. Wound care often requires frequent visits to a healthcare facility for wound measurements, assessment for potential infection, and debridement. There have been many studies demonstrating the feasibility and validity in the use of telehealth for other aspects of dermatology. Wound care is ideal for telemedicine. Telemedicine can —and is—used in several different ways. Photographs can be taken and sent via a secure electronic transfer to the wound care team. Video consults with the wound care team are another option. Either way, these methods can markedly reduce the number of in-person clinic visits in a population that likely finds these visits onerous.
What remains fundamental to chronic wound care continue to be the triad of managing the underlying contributing factors—such as limited mobility, arterial sufficiency, diabetes, venous stasis —and local wound care—moisture balance, bacterial balance, and debridement in a healable wound. Clinicians should continue to focus on these basics of chronic wound management until better-designed studies can be completed to prove the efficacy of expensive wound dressings and adjunctive therapies. Telemedicine is a welcome technological advance in the field.
Hesham Abboud, MD, PhD, Director of the Multiple Sclerosis and Neuroimmunology Program and staff neurologist at the Parkinson’s and Movement Disorder Center at University Hospitals of Cleveland, Case Western Reserve University School of Medicine