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Wound Bed Preparation

Over the years, the rationale for wound débridement has held the following unwavering goals: rid the wound of necrotic tissue, reduce the wound bacterial burden, and correct abnormal wound repair—all with the intention of facilitating the cascade of wound healing. With the introduction of "advanced" wound therapies, such as bioengineered skin and platelet-derived growth factors in the 1990s, it quickly became apparent that these therapies would not be effective unless a conducive environment for wound healing was established.1 Since 2000, the concept of wound bed preparation has given a more focused approach to wound management and, consequently, to the value of débridement in the successful care of patients with chronic wounds. Falanga and Sibbald were among the first to coin the term wound bed preparation.1,2 They have since defined the individual concepts within the model in numerous journal publications. At the crux of the model is the importance of débridement, bacterial control, and adequate moisture balance within the wound bed. These three points, at a minimum, are necessary to establish an environment conducive to healing.

The TIME framework was also inspired by Falanga's work and developed by the International Wound Bed Preparation Advisory Board. It was further refined by the European Wound Management Association (EWMA) as a means of capturing the essential components of wound examination and ensuring targeted interventions. TIME is an acronym for tissue management, infection or inflammation, moisture balance/imbalance, and epithelial or edge advancement.3 Tissue management involves appropriate application of the various débridement strategies with an overall clinical outcome of a viable wound base. Infection necessitates appropriate assessment of the cellular processes hindering healing, such as the presence of excessive inflammatory cytokines and proteases and ultimately reduction of the bacterial burden and chronic inflammation. Moisture assessment requires the ongoing examination of the wound bed and the procurement of moisture-balancing dressings that prevent both dry environments and excessive fluid environments. And finally, the edge of the wound must be routinely examined to determine if any abnormalities exist or if advanced therapies are warranted to aid in wound contraction.

The overall concept of wound bed preparation continues to develop and take on a more holistic approach, emphasizing "the global management of the wound to accelerate endogenous healing or to facilitate the effectiveness of other therapeutic measures."4 Use of the term has also led to the understanding that chronic wounds heal differently than do acute wounds and require a unique approach.1 Experts now agree that the concept has come to involve several comprehensive elements necessary for wound bed preparation, not just examination of the wound bed itself. (Table 11.1) The foremost objective is to determine the "healability,"2 or capacity to heal, of the patient. By taking a thorough assessment of the patient, not just his or her wound, factors such as comorbidities, blood supply, and nutrition are seen as instrumental considerations in a ...

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