Multidisciplinary approach for the enhancement of healing in selected problem wounds

Multidisciplinary approach for the

enhancement of healing in selected

problem wounds

K. Hoxha1, P. Baroni1, E. Bondioli2, D. Melandri2,

P. Longobardi1, I. Tomasini3

1-Centro iperbarico Ravenna; 2-Burn Centre and Regional Skin Bank, Bufalini

Hospital, AUSL Cesena; 3 -Blood Transfusion Service, S.M. delle Croci Hospital AUSL

Ravenna

Contact: Klarida Hoxha, Centro iperbarico, via Augusto Torre 3, 48124 Ravenna.

Tel. 0039-0544-500152,

email: [email protected]

Objectives

To verify if a multidisciplinary approach allows the

enhancement of healing in selected problem wounds

better than the benchmarking

Etiology % reduction in wound area at 4 week as

predictor of healing

Venous Leg ulcer > 28.79% at 4 weeks will heal at 24 weeks

Diabetic Foot Ulcer > 50% at 4 weeks will heal at 12 weeks

Surgical Wound 50% at 2 weeks will heal at 3 weeks

Pressure Ulcer > 50% after 2 weeks

At Hyperbaric Center of Ravenna, in 2013, 398

patients with cutaneous wound were treated

for a total of 32,161 Wound Care procedures.

Inclusion criteria:

− ulcer present for > 6 weeks;

− size from 5 cm2 to the whole leg circumference;

− Falanga score ≥ B2.

The etiology was:

– traumatic (38%),

– venous stasis (22%),

– mixed vascular insufficiency (14%), rheumatic (14%),

– pressure (7%),

– arterial insufficiency (6%).

Methods

What treatment involves

• Mechanical ultrasound

debridement

• Homologous Platelet Rich

Plasma (PRP) was prepared and activated, at clinical use, in

1:1 ratio with gluconate calcium and

thrombin on a support of modulating matrix

proteases. The final product, so gelled, was

topically applied once a week for 4 weeks.

HBOT

(20 sessions in a multiplace

chamber at 254 kPa with a

FiO2 in mask > 0.9, for 90

minutes, 5 days per week)

What treatment involves

FREMS Frequency Rhythmic Electrical

Modulation System,

20 sessions, 1 per day, 5 days per week

What treatment involves

Allograft once every two weeks for

three times.

The evaluation was carried out

every week (measurement

of ulcer area with Visitrak®,

transcutaneous oximetry,

photography and clinical

examination).

Why this choice: PRP Selected problem wounds have

poor expression of Trx-1, HIF-1

>> stem cells CD133

(endothelium) and CD34 (blood

vessels).

PRP activated, release over 300

GFs.

PDGF and TGF-β stimulates

proliferation of fibroblasts and

production of extracellular matrix.

PRP / platelet gel enhance wound

healing and survival rate of skin

grafts.

Hom DB & al. Laryngoscope. 2003 Sep;113(9):1566-71

HBOT improves the systemic factors

that impair healing. Criteria for the

appropriate indication to HBOT depend

on the patient rather than cutaneous

ulcer.

induces platelet activation and protein

release.

Shaw FL & al., Clin Biochem. 2009 Apr;42(6):467-76

Why this choice: HBOT

increases stem cells in the circulation;

their ability to get to the wound and cause

the vasculogenesis

HBOT improves the healing (in animals)

induced by the administration of GFs in

the wound bed Thom SR & al., Wound Repair Regen. 2011 Mar-Apr;19(2):149-61.

Why this choice: HBOT

Why this choice: FREMS

• Positive, significant effect on

pain reduction (VAS)

• significant acceleration of the

wound-healing process

compared with conventional

treatments (PUSH tool total

index).

Electrical stimulation as adjuvant treatment for chronic leg ulcers of

different aetiology: an RCT.

Magnoni C, Rossi E, Fiorentini C, Baggio A, Ferrari B, Alberto G.

J Wound Care. 2013 Oct;22(10):525-6, 528-33.

Results

Skin

wound

Healed

(%)

Improved

(%)

Stationary

(%)

Drop out

(%)

Traumatic 6,2 22,4 10,4 -

Venous 80,5 12,2 4,9 2,4

Rheumatic 72 24 - 4

Mixed

(Vascular)

69,2 30,8 - -

Pressure 57,1 28,6 14,3 -

Ischemic 33,3 - 66,7 -

•Most of the wounds healed or improved (reduced by 72%,

Falanga score A2) after eight weeks from the inclusion.

•Arterial insufficiency (ischemic) ulcers had less benefit.

•There were no side effects.

Conclusion

Our experience suggests clinical

efficacy of multidisciplinary approach

for the enhancement of healing in

selected problem wounds.

Pasquale Longobardi Master Med. Subacquea Iperbarica,

Scuola Superiore S. Anna (Pisa)

www.iperbaricoravennablog.it [email protected]