Topical agents can be selected to optimize local chronic wound care, but they will be completely ineffective without a holistic approach to patient care. Chronic wounds are often complex, recalcitrant to healing, and may persist for months or years due to underlying disease processes or complications. According to findings from control populations in randomized controlled trials (RCTs), a wound that is not 30% smaller by week 4 will usually not heal by week 12.1,2 The exact mechanisms that contribute to poor wound healing remain elusive but likely involve an interplay of systemic and local factors. The wound bed preparation (WBP) model was proposed by Sibbald et al.3,4,5 to systematically manage chronic wounds and optimize achievable patient outcomes. (Fig. 13.1)
Wound bed preparation model.3,4,5
Topical therapy choices are different for healable versus nonhealable wounds. Although complete healing may seem to be the logical goal for most patients, some wounds do not have the ability to heal due to inadequate vasculature, a cause that is not treatable, or coexisting medical conditions/medications that prohibit the healing process. Healable wounds have adequate tissue perfusion and the cause has been corrected or compensated with treatment. In addition, patients with these wounds do not have any other factors that would inhibit healing, including coexisting medical conditions (e.g., advanced cancer), negative protein balance, advanced anemia or prescribed medication (e.g., immunosuppressive drugs) that would prevent normal healing.
A maintenance wound is different from a healable wound or a nonhealable wound. A maintenance wound has the ability to heal but either the patient does not consistently adhere to treatment or the health-care system may restrict access to appropriate resources. To put this in a meaningful context, this type of wound classification system helps clinicians and patients identify a common realistic outcome goal. (Table 13.1)
++ Table Graphic Jump Location Table 13•1Wound Classification According to Healing Ability ||Download (.pdf) Table 13•1 Wound Classification According to Healing Ability
|Wound Prognosis ||Treat the Cause ||Blood Supply ||Coexisting Medical Condition/Drugs |
|Healable ||Yes ||Adequate ||Does not prevent healing |
|Maintenance ||No∗ ||Adequate ||Possibly prevents healing |
|Nonhealable or palliative ||No ||Usually inadequate ||May prevent healing |
Moist interactive healing is contraindicated in nonhealable wounds. Instead, local wound care involves conservative débridement without causing bleeding, bacterial reduction, and moisture reduction. (Fig. 13.2) These wounds are best treated with antiseptics when healing is not immediately achievable (uncontrolled deep infection) or when bacterial burden is more of a concern than tissue toxicity (maintenance or nonhealable wounds).
Nonhealable and maintenance wounds.