Page 5 - 59peadiatric-surgery-speciality8-14_opt

44 Wound Healing
Negative Pressure Wound Therapy
2.50 Newer devices and technology have been developed and are thought to
provide potential advantages for treatment and management of large,
complex, and chronic wounds. In particular, negative pressure wound
2.00
mUnits Elastase Activity per mg Total Protein 1.50 tion, and reducing wound size through equal distribution of mechanical
therapy (NPWT) is thought to be beneficial by removing fluid, increas-
ing perfusion, applying mechanical stretch triggering cellular prolifera-
forces.
32,33
Data on NPWT from randomised controlled trials is scarce;
however, case reports and retrospective studies have demonstrated
enhanced healing in acute traumatic wounds, chronic wounds, infected
1.00
wounds, wounds secondary to diabetes, sternal wounds, and lower limb
34
wounds. NPWT does appear to prepare a wound bed for surgery and
decrease time to healing. Several studies have shown that NPWT can
0.50
provide safe and cost-effective wound care in children and provide such
patient advantages as less frequent dressing changes, outpatient man-
0 agement, resumption of daily activities, and a high degree of patient
Plasma Acute Chronic tolerance with decreased pain. 35-37 It can be particularly useful in large
wounds and in chronic or nonhealing wounds.
Source: Yager DR, Chen SM, Ward BS, Olutoye OO, Diegelmann RF, Cohen IK. Ability of
chronic wound fluid to degrade peptide growth factors is associated with increased levels of Nutrition in Wound Healing
elastase activity and diminished levels of proteinase inhibitors. Wound Repair and Regeneration Nutrition is fundamental to cellular function and tissue survival, repair,
1997; 5:23. and integrity. All phases of wound healing require nutrients for cell
Figure 8.7: Levels of elastase activity are significantly higher in chronic wound function and survival. Inadequate nutrition is associated with decreased
fluid compared with acute wound fluid. Elastase activity was determined by a wound tensile strength and longer healing times. Optimisation of
colorimetric assay using methoxysuccinyl-ala-ala-proval-p-nitoanilide substrate.
nutrition of all paediatric surgical patients is essential for surgical care
and will directly impact tissue healing from visceral anastomosis to
Prevention is the best treatment for hospital-acquired ulcers. cutaneous tissue.
Assess patients daily for pressure ulcer risk, and evaluate at-risk Healing requires adequate protein, fat, carbohydrates, vitamins,
areas frequently. This includes visualisation of the back and sacrum, and minerals: Proteins supply amino acids required for collagen
areas under blood pressure cuffs, tracheostomy sites, oral and nasal synthesis. Carbohydrates and fats provide an important energy source
tubes, oxygen delivery devices, arm boards, and cast edges. Apply to support wound repair. Vitamin C is an essential cofactor for
protective padding to at-risk sites, turn and reposition patients every 2 hydroxylation during collagen synthesis. Vitamin A is required for
hours; specialty beds that redistribute weight may be used. If an ulcer normal epithelialisation and proteoglycan synthesis. Zinc is important
does develop, clean the site regularly, debride necrotic tissue, manage for cell proliferation and granulation tissue formation.
bacterial colonisation and infection, and maximise nutritional status. Initial and continued nutritional assessment of paediatric surgical
Maintaining a physiologic local wound environment helps to create patients is important to provide the proper support and ensure adequate
conditions conducive to rapid repair and restoration of function. Topical wound healing for both acute and chronic wounds. Assessment may
wound management allows manipulation to positively influence the include body mass index and laboratory data such as serum albumin
local environment. This includes cleansing, preventing and managing and prealbumin.
infection, debridement, protecting periwound skin, and use of dressings Paediatric versus Adult Wounds
to mimic skin and create a more physiologic local environment. Take Although wound healing in neonates and children follows the same
measures to create adequate moisture level, control temperature, orderly progression of events as that for adults, tissue defects gener-
establish physiologic pH, ensure good local blood flow, and control ally tend to close faster. In children, fibroblasts are present in greater
38
bacterial burden. numbers, collagen and elastin are more rapidly produced, and granula-
For local wound care, a variety of dressing choices exist. Common tion tissue forms faster than it does in adults. Distinct intricacies of
39
components include hydrogel (glycerin), foam (polymers), hydrocolloid the neonatal and paediatric populations, such as epidermal and dermal
(carboxymethylcellulose), collagen, alginate, cellulose, cotton, rayon, immaturity, a high body surface-to-weight ratio, sensitivity to pain, and
and transparent dressings (polyurethane). Saline-moistened gauze placed an immature immune system, create additional levels of complexity. 39
in the wound bed and covered by a semiocclusive dry dressing is a simple There is a paucity of research in paediatric wound care to guide
and effective wound care option. Ultimately, the choice of dressing is practice, and few wound care products have been studied in children.
based on numerous factors, including clinical indications, patient and Due to the lack of guidelines and evidence-based practice, it is
caregiver needs, product availability, health care setting, and cost. important to be mindful that the normally rapid wound-healing response
Surgery remains an important aspect of wound care. This is of children can be delayed by a number of factors, including impaired
particularly true for chronic and complex wounds. Surgical debridement perfusion, infection, prolonged pressure, oedema, poor nutrition, and
helps to create a wound bed with more physiologic conditions. Skin the wound macro- and micro-environment.
grafts and tissue flaps can be used to replace missing tissue, fill defects,
and cover underlying structures. Surgical decision making for wound Conclusion
care should include a complete patient assessment incorporating Treatment starts with thorough patient and wound assessment. Monitor
comorbid conditions and nutritional status. Further, decision making wounds frequently and evaluate treatment daily. Select and adjust
should involve a wound assessment that includes causative factors, wound care regimens based on patient condition, wound status, and
tissue condition, and chronicity. Finally, selection of the wound closure resources. When necessary, timely surgical intervention is essential to
method should be made preoperatively to decrease blood loss, ensure ensure optimal healing. In many cases, such as wounds from burns,
optimal and adequate donor sites, and minimise ischaemic times. trauma, and hospital-acquired pressure ulceration, policies and guide-
lines leading to prevention are the best first steps.