Moist Wound Healing
Many occlusive wound management products such as alginates and hydrogels were developed based on the principle that epithelialisation occurrs twice as quickly in wounds covered with a film dressing, as it maintains humidity on the surface and epithelial cells are able to slide across the wounds surface. It’s also been found that a moist environment enhances the natural autolytic process therefore aiding the breakdown of necrotic tissue. The benefits of this technique include assisted epithelial migration, promotion of alterations in PH and oxygen levels, maintainance of an electrical gradient and retainment of wound fluid on the wound surface. These outcomes are undoubtedly beneficial for acute wounds however, doesn’t address some issues that chronic wounds present e.g. deeper cavities, copious amounts of exudate and greater bacterial burden. A Further theory (wound bed preparation) was therefore developed (28).
Wound Bed Preparation
The concept of wound bed preparation has been around for more than two decades. It provides a framework for a structured approach to wound management (38). The process can be defined as: the management of the wound to accelerate endogenous healing or to facilitate the effectiveness of other therapeutic measures (28). The overall goal of wound bed preparation is to create an optimal wound healing environment by producing a well-vascularized, stable wound bed with little to no exudate. It is performed via removing abnormal cells, reducing the bacterial load, decreasing the level of wound exudate and increasing the formation of healthy granulation tissue. The final phase of wound healing occurs when these goals are met. There are four components of wound bed preparation, which address the different pathophysiological abnormalities underlying chronic wounds:
Tissue management
Inflammation and infection control
Moisture balance
Epithelial (edge) advancement (38).
The T.I.M.E. framework comprises the comprehensive strategies that can be applied to the management of different types of wounds to maximize the potential for wound healing. Wound bed preparation in acute, subacute and chronic wounds: There are diverse wound patterns in acute wounds, ranging from post-traumatic abrasions, lacerations and burns to high-energy-explosive wounds. In acute wounds, the normal healing process has not been impaired and healing is ensured if the wound conditions are not compromised. Foreign bodies that may have been embedded should be removed to avoid infection. Crushed or devitalized tissue should be debrided early and aggressively for soft tissue closure or reconstruction. Because bacterial contamination or colonization is more common during the early stage of an acute wound, debridement of any contaminated tissue should take place, to minimize the risk of infection. Subacute wounds describe a spectrum of wounds that are not often addressed. The subacute period is generally defined between 72 hours and 3 months of injury. Higher infection rates have been noted in those wounds reconstructed during the subacute period (38).
Pain Management.
Pain can be an overlooked aspect of wound care, and unresolved pain can have a negative impact on healing. The aetiology and comorbidities associated with chronic wounds can also complicate the assessment of the quantity and quality of the pain perceived by the patient. It is critical to assess pain when establishing a comprehensive care plan. Pain is multi-dimensional; involving both physiological and psychological components. Physical components include the underlying cause of the wound and pain from clinical interventions. Pain is generally categorized into four types (39).
Background pain is related to the underlying cause of the wound, local wound factors and other related pathologies. It’s felt at rest, when there’s no movement or sudden change in the patients’ physical condition. It may be continuous or intermittent.
Treating background pain: Step 1: A non-opioid analgesic with or without an analgesic adjuvant. Adjuvants include tricyclic antidepressants, anticonvulsants, antihistamines, benzodiazepines, steroids, and phenothiazines. Adjuvants are given for their indirect benefits in pain management. Step 2: If pain is not controlled: the initial medication should continue and an opioid (codeine or tramadol) added. Step 3: When a patient still does not respond, previous pain medication should be discontinued and a more potent oral narcotic initiated.
Breakthrough pain generally has a rapid onset, is severe in intensity and brief in duration. It can occur during daily activities. Medicines for breakthrough pain are usually short acting and are sometimes called “rescue medications”. Treating breakthrough pain: increasing the dose of the opioid, adding a stronger short acting pain medication or reducing the time interval between doses. The exact amount of the supplemental dose should be the dose what will relieve the pain without side effects. If possible, the agent used for treatment should be discontinued after the particular episode of breakthrough pain is resolved and the background pain is managed.
Procedural pain results from a routine intervention such as dressing removal, cleansing or dressing application.
Operative pain is associated with any intervention that would normally be performed by a specialist and requires an anaesthetic (local or general) to manage the pain. Psychosocial and Environmental factors play in the causes of wound pain, and must also be considered. Psychosocial factors such as age, environment (e.g. timing of the procedure, temperature of the room, noise level and patient positioning) and previous pain history can all influence a patient's experience of pain and ability to communicate their pain (39).
