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MALE SPEAKER: Our next speaker is Dr. Matt Garoufalis who is a dear friend of mine. Matt has been on our platform many times and present. He comes with fabulous credentials. He does a tremendous amount of diabetic wound care. He is involved with the VA in wound care management. He is past president of the College of Illinois State Podiatric Medical Association and the American Podiatric Medical Association. And today, Dr. Garoufalis is going to be talking about wound beds, assessment, preparation and dressings of choice.

So please welcome Dr. Garoufalis and this talk is actually sponsored by 3M.

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MATT GAROUFALIS: Good morning, everyone. Thank you for being here this morning and that was a great presentation we just heard and I’ll make some references to that as we go along here.

Wound beds, we sometimes don’t pay enough attention to wound bed management. So I’m going to cover some ground rules on wound care that we can all use going forward to increase and manage our outcomes a little bit better. So, first of all, everything revolves around money. So we’ll talk about money right off the bat. There’s a huge cost for wounds. This is just some information about venous leg ulcers, pressure ulcers and diabetic foot ulcers and the amount of money that they cost the US health economy every year, $24 billion for venous leg ulcers, $1.3 billion for pressure ulcers and I’m sure that is low, and $10 billion or more for diabetic foot ulcers. These numbers are ranged all over the place, but this is just a good starting point.

So let’s go with venous leg ulcers first. [00:02:00] There’s many more venous leg ulcers that need to be treated than there are diabetic foot ulcers and yet, they go missed time and time again. And on this slide, we talk about 2.5 million patients or 1% of the US population suffering with venous leg ulcers. Just that by itself is enough to keep us well employed for a very long time. Venous leg ulcers account for 75% of all the ulcers out there. As I said, they’re more common than any other type of ulcers. For many countries, these account for a significant percentage of those countries’ healthcare budget all by themselves.

These patients that present to us with venous leg ulcers have some other comorbidities that you might recognize. They’re anemic. They have asthma. The slide talks about several comorbidities that are there. I included one on surgery because surprisingly… and hip surgery there, but there’s all kinds of surgeries because after a surgical procedure, patients tend to become not as ambulatory. They’re recuperating from their surgery which is the perfect time for venous stasis to occur resulting in a venous leg ulcer because they’re not as mobile. They’re not using that calf pump and as a result, they develop venous stasis and venous ulceration, so something to be aware of that we don’t think is a comorbidity but it happens with increasing regularity.

So interesting thing about VULs, they’re the most common type of ulcer, but they’re also the most misdiagnosed type of ulcer. And why is that? Because, typically, we do not… we are not the primary person seeing this patient for the first time. They see their PCPs. They see their family practice docs and they’re not well versed in diagnosing venous leg ulcers. [00:04:03] They think it’s just a small wound. Maybe it’s just a blemish. Maybe it’s just an abrasion and they don’t know that it’s really venous stasis and a venous leg ulcer.

As a result, these patients self-treat, go for months and even years with just a little bandage on their leg and they think that that’s fine. Lately though with more and more education and more and more guidelines being published, we’re finding that we can find more of these patients and treat them effectively. We also know that a multidisciplinary outcome or treatment plan for these patients is the best way to treat them.

Compression is still the mainstay for venous leg ulcers. Multilayer is better than single-layer. Debridement is a necessity and I’ll talk about debridement in a moment, but we must debride all wounds. Moist wound care, absorbent dressing, low grade activity, not a lot, but they have to move at least 10 or 15 minutes an hour. They have to make that calf pump work. If that calf pump works, it moves the blood around and decreases the incidence of venous stasis and improves the healing rate of venous leg ulcers.

So, as I said, compression is the mainstay. These patients, once they develop venous stasis or venous leg ulcer will need some form of compression the rest of their lives, okay? That’s a little take home point. Once they develop venous stasis or venous leg ulcer, they will need some form of compression or therapy the rest of their lives and why? A hole in your leg not only disrupts the tissue, it disrupts the lymphatic system. Once the lymphatic system is disrupted, it cannot be repaired. So once they develop that hole in their leg, they’ll have the sequela of that hole in their leg the rest of their life. Even though it may heal… you may get it to heal, they’re still going to have issues. [00:06:03]

So they’ll need compression at the very least. They may need multi-component systems, pumps at home. They may need an intermittent pneumatic compression and this is becoming more and more common. The patients that I treat in my clinic, every single patient with venous stasis or venous leg ulcer has an at home intermittent compression pump. That’s how strongly I feel that this is a life long issue.

So let’s go over the diabetic foot and there’s a lot of information out there about the diabetic foot and what its effects are, what its causes are. This is a poster from the International Diabetes Foundation talking about every 30 seconds there’s a lower limb amputation because of diabetes. It talks about diabetic neuropathy. This is from APMA talking about the related cost in dollars from just diabetes at $245 billion. This also is part of the article that was published a few years ago about the effect that one visit to a podiatrist has on the treatment of the patient with a diabetic foot ulcer and that it can save several billion dollars a year with just one visit to a podiatrist.

So this poster was created. This is from David Armstrong talking about the cost of diabetic limb complications outpacing the cost of breast cancer, colorectal cancer, lung cancer, prostate cancer, and leukemia. So it’s a very costly process.

And of course, we’ve all seen this chart. I think every talk on diabetic foot ulcers may have this chart in there talking about the five-year mortality rate due to the consequences of diabetes. And we see that neuropathic ulcers, amputations, ischemic ulcers and PAD outpace some very common cancers. [00:08:00] Of course, we don’t get the commercials on TV for diabetic foot ulcers the way these other cancers are treated, but that’s just the way it goes. We need to do a better job of lowering these mortality rates and we’re getting better at it all the time.

This is from the CDC and many times, we think that diabetic foot ulcers is just a… something that affects the lower socioeconomic bracket, not so much. This information tells us that around the world, no matter what social economic bracket you are in, there’s an increasing threat of diabetes and its complications and it continues to grow. Again, as I said earlier, what does it mean for us? Continued employment, no problem, we have lots of patients to treat.

This is also from the CDC looking at in our population in the US diabetes and pre-diabetes, approaching 50% of our population. So that’s staggering and that number will only increase with time. We have a lot of work in front of us. So let me talk a couple of theories here, a couple of ways to approach diabetic patients. This was done by a former student of mine and published in wound repair regeneration about diabetic metabolic memory and it may help to explain why our diabetic patients have such a difficult time healing not only their diabetic foot ulcer but why they have so many comorbidities affiliated or associated with their diabetes.

What the theory states is that during periods of hypermethylation or hyperglycosylation, in other words, when their blood sugar is very high, during the normal course of mitosis that occurs at a very cellular level… and sorry to talk about mitosis first thing in the morning because that may bring nightmares to some people, but cells divide via mitosis every second. [00:10:03] Our DNA is replicated every second. But during periods of hypermethylation when the blood sugar is very high, these cell divisions occur with mutations and these mutations are irreversible and reproducible.

So during periods when a patient has a high blood sugar and we can see this by their hemoglobin A1C whether it’s 12, 15, or higher, cell division occurs with mutations. These mutations continue to happen. And as a result, this patient because of this theory of metabolic memory loses the ability of cellular communication. Many of the proteins that we need to keep going with our bodily functions are no longer produced in a correct manner in a diabetic’s system. So these mutations which are replicated over and over can be thought of as a cause for some of the comorbidities and some of the difficulties we have in working with our diabetic patients.

The other issue that we have is cognitive impairment. We know that for our diabetic patients and now, it is well documented that as soon as a patient presents with their first diabetic foot ulcer, there is already cognitive impairment in place and that’s a hard thing to say and it’s a hard thing to recognize, but as we tell our patients how to take care of their diabetic foot ulcer what footwear is appropriate and they nod their head yes. And they come back a week later and they haven’t done a thing as to what you recommended the week before, it’s not that you’re a bad educator. It’s not that you didn’t explain it correctly.

It could be that they’re unable to process what you said because of their cognitive impairment. [00:12:02] It’s important especially in our diabetic patients to get family members in on this conversation, explain to them what needs to be done so that they can help get this patient to follow your instructions. The catch is what happens if the entire family is diabetic. That can present a bit of a problem, right? So this is just another thing, another nugget to keep in mind maybe this is why I can’t get through.

So let’s talk about the time concept on wound bed preparation now that we have a little background on these wounds and how difficult they are to treat. The time concept has been around for about 15 years, believe it or not and it talks about tissue, inflammation, moisture balance and epithelial edge advancement.

Let’s talk about tissue first and tissue is all about debridement. Debridement must occur and on the initial presentation, once you’ve established that there’s adequate blood flow to the area, that has to be one of the first things that you document and make sure of, there’s adequate blood flow. If there isn’t, you can debride some of the necrotic tissue but unless you get blood flow there and you go further, you’re out of luck. You’re not going to be able to go any further.

So once we know there’s adequate blood flow, we need to debride and debride aggressively. If that means a trip to the OR, it means a trip to the OR. We must be aggressive in our debridement. There’s various forms of debridement and while not every patient is a surgical candidate, there are other ways that we can debride that wound, but we must be aggressive.

What are some of the benefits of debridement? Well, we know that it removes the necrotic soft tissue and I underline this very busy slide just to get the high points out there. We remove the tissue with the highest bacteria counts and also, once you get a little bleeding as a result of your debridement, you’re activating the platelets and the growth factors inside those platelets to help heal that wound. [00:14:07] And it allows you, once you remove the devitalized tissue, to understand and see the quality of the tissue beneath that into the wound bed.

As a result, typically after your initial debridement, your wound is going to be larger than it was on presentation. You must explain this to the patient as to why this is. But it must happen. If it’s not larger, most of the time you haven’t done an adequate debridement.

There’s cleansing materials that you can use to help take care of the bioburden. There’s all sorts of antiseptics and chemicals. I put povidone-iodine down there cautiously because you should use that in a dilute fashion. The only time that you’re going to use povidone-iodine directly on a wound for a long period of time is if that is already gangrene present and you’re keeping it from going to wet gangrene. Otherwise, full strength Betadine has no place on a wound week after week.

You can use negative pressure therapy to also help clean up the wound. It can remove the exudates. It can reduce edema. It can also help promote granulation tissue and stimulate the itch effect.

Inflammation is necessary in wound healing, but it must be controlled. Excessive inflammation is going to just increase the MMPs, not allow for that wound to progress and not allow for new capillary bed formation.

Sometimes this inflammation or topical infection can be treated with IV antibiotics if there’s adequate blood flow because you have to make sure that the medication can reach the site. [00:16:00] But more often, we’re using more and more topical antibiotics which work great. These can be in the form of antibiotic beads, topical antimicrobial solutions, PHMB, things like that that can treat the wound and the microbes in the wound directly.

So we need to know, as I mentioned earlier, about venous leg ulcers that any time that there’s a hole in the foot, leg or anywhere else in the system, the lymphatic system is also damaged. So you have to be ready for that and you have to prepare the patient that they’re not going to be the same once this is healed. And compression therapy or some other form of therapy may become a way of life.

So this is the wound infection spectrum, and we know that all wounds are contaminated that there could be localized infection. We also know not, not, do not, right, emphasize that again, swab cultures are not indicated at any time. The deep tissue culture is what’s indicated after you’re debridement. Swab cultures will always come back contaminated and you’ll be treating something that maybe subclinical and expose the patient to further risk because now they’re taking a high powered antibiotic when that organism is really not the contaminating organism.

So wound moisture balance is important. We have heard the old adage, if it’s wet, dry it and if it’s dry, wet it. That’s good to a certain extent as long as we do it with moderation. Sometimes we do need negative pressure to control it. Sometimes we need a moistening dressing to help control a wound that is dry. Typically, a wound that is dry is also a wound that doesn’t have adequate circulation. So we have to look at that.

Epithelial edge advancement. This is a key to wound closure. [00:18:00] And this is something that we can actually measure. And this is where the four-week model, that’s been around for about 14 years now, comes into play. And we employ the four-week model on the patients that we treat because we found it to be very effective.

What the four-week model states is once you have adequate blood flow, once you have the bugs under control, then you start using good standard wound care which is typically a calcium alginate, a foam or a collagen. It is not wet to dry. Wet to dry is never the standard of care. Wet to dry will cause you to get sued if you use it for any more than a day or two.

So I hope we’re not using wet to dry. Please get rid of it. Don’t use it as the main stay. It doesn’t work because no one’s going to keep a wound wet to dry. And you don’t want to rip dry gauze off a wound because you’re ripping good tissue when you do that.

So good standard of care products, calcium alginate, collagen, some of the foams, they do a great job. We’re looking to use that for four weeks and we’re looking to measure the wound to see in a diabetic foot ulcer if it’s closed by 50% in four weeks or VUL by 40% at four weeks.

If we do that, if we reach that percentage by using those products, continue down that road. If however we have not reached that percentage at four weeks, we have to change course. And typically when we change course, as we reevaluate the patient, reassess their circulatory status, reassess the infection status. We might need to go to an advanced wound care product at that point to get that wound to close.

This is the chart produced by Sheen back in 2003 when he came up with this theory. If we get to 50%, we have about a 60% of closing that wound at 12 weeks. [00:20:03] However, if we’re not at 50% at four weeks, we have less than 10% of closing that wound with the wound care that we’re using.

So if we’re using a collagen on that wound and we’re at week four and we’re at 30%. And we keep applying collagen in that wound and at week 12, we’re at 40% or 50%. And at week 16%, we’re at 60%. And then if the wound goes south, we’re in trouble. We didn’t follow this guideline and the catch with that, there’s lots of literature out there that states this is an appropriate and preferred guideline to follow for wound care.

So if it goes south and you’ve been treating it with foam or collagen for weeks and for months, guess what, this is the guideline. This is the standard of care. You’re in a little trouble. You’ll be visiting Amy. So with our patients, we all understand there’s lots of quality of life issues that frankly many of us are not prepared to deal with. We didn’t get a lot of psychological training in school as I recall. Not too much. But yet, we have to deal with this with our patients and understand what’s going on. We have to deal with the pain, the exudates, the odor, the physical issues of what’s going on. How about sleep disturbance? Something we knew nothing about. But these patients can’t sleep with their wounds.

Functional disabilities, functional dependence. What challenges do they have every day that we need to be aware of that we also need to treat as the treating physician? And then we have to be aware of the social issues because this affects what the patient does, when the patient comes to see us and how they react to what we do.

So these quality of life issues, above and beyond treatment of the physical wound, we need to be aware of. [00:22:02] So here’s our goal. Our goal is to select the appropriate dressing and restoring and maintaining normal wound physiology. And there aren’t only thousands of dressings to choose from. But depending on what’s going on with that wound, if it’s painful, if it’s dry, depending on the drainage, we need to pick the appropriate dressing at the appropriate time and be aware of the handful of dressings we choose in our armamentarium as to what’s going to work and when they’re going to work.

So I would encourage everybody to get an armamentarium or several dressings that work for these different categories. A drying agent, something that will keep the wound a certain moisture, an antibacterial dressing, something that is absorbed to if there’s some moisture. And then an advanced dressing that you would use, once you’ve gone through that four-week model, then we need to talk about the advanced dressings, which are the skin substitute dressings and gauze.

So how about dressings that improve the quality of life? How about putting a waterproof dressing on a patient that is relatively compliant, right? This patient taking a shower with a heel ulceration, needs to be relatively compliant and understand what’s going on. But yet, what have you done to improve their quality of life by allowing a patient to take a shower? Wow, that’s dramatic.

So these are some of the things that we can think about and now we have dressings that will actually allow this to happen. The days of putting the dressing on, wrapping it in gauze and sending them out the door, they’re fading away. We now have some high-tech dressings that are multilayered, multidimensional that can do a lot of different things over the span that they’re being used for that week or the every other day dressing change. [00:24:00] We now have these dressings. This is an example of a foam dressing that 3M makes that is multidimensional and yet, it’s very, very thin.

So take a look at these dressings, understand how they work. They’re built in different ways. Tear them apart. Take a look at them. Go to some of these workshops that are going on so you can get hands on, and take a look at these dressings and see what they’re made of. And then you’ll be able to better judge which is the appropriate dressing at the appropriate time and improve the quality of life and the healing outcome of those patients.

So I put this quote in there, not that anybody remembers the movie, but the quote is good. The only way to discover the limits of possible is to go beyond them to the impossible. And what we have been able to do in the last 10 years in wound care is to go to the impossible. Wounds that we were not able to treat just a short time ago, now with technology and science, we can treat. And we can treat them aggressively and have great outcomes.

So I encourage everybody to spend some time out in the exhibit hall, of course, 3M sponsored this talk so they’re right outside the door, the first table. But there’s lots of things to look at and lots of things to learn about. Learn how they can affect your patient in terms of wound care and increase your outcomes and success rates.

So thank you for being here this morning. I’ll be around today and tomorrow if you have any questions, always glad to help. Thanks so much.

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