Although the atmosphere was understandably more subdued than in previous years due to the tragic events of September 11, the 16th Annual Clinical Symposium on Advances in Skin & Wound Care delivered on the promise of a top-notch educational program, from the opening lecture by special guest speaker Ted Kennedy, Jr, to the final session on legal issues in skin and wound care.
The exhibit hall was bustling with activity all 3 days that exhibits were open, as attendees took full advantage of the opportunity to talk with industry representatives and learn about the latest advances in products and services for their patients. During exhibit hall hours, the 80-plus posters accepted by the multidisciplinary planning panel could also be viewed, with poster presenters available to answer questions during select times. FIGURE 1
For those who could not attend the conference this year, here are some of the highlights.
* Special guest speaker Ted Kennedy, Jr, spoke eloquently of his respect for health care professionals. He said that when asked who his heroes are, he does not hesitate to respond, "nurses." This stems from the years he spent in treatment for bone cancer in his right leg. Following surgery to remove the leg below the knee, he endured 2 years of chemotherapy. In that time, he came to appreciate the care and comfort that nurses provide.
Kennedy also acknowledged the fear attendees may have felt in getting on a plane to fly to Orlando for the conference. He said that he, too, had been apprehensive. But he had learned to deal with fear as a child-not only the fear that went with having cancer and losing his leg at age 13, but also the fear that "someone would do to my father [Senator Ted Kennedy of Massachusetts] what they had done to my uncles [President John F. Kennedy and Senator Robert Kennedy]."
* In her lecture on palliative wound care, Barbara Bates-Jensen, PhD, RN, CWOCN, reviewed the general principles of palliative care, then related them to managing patients with wounds. She reminded attendees that the goal of palliative wound care is to minimize symptoms, including (1) preventing deterioration of the wound, (2) reducing discomfort and pain, (3) preventing infection, (4) managing exudate, (5) managing odor, and (6) providing for optimal functional capacity. She shared strategies for accomplishing these goals, including:
- using pain medication before full body positioning
- selecting support surfaces for comfort and function as much as for effectiveness
- reducing the frequency of dressing changes as much as possible
- avoiding wet-to-dry gauze dressings because they can be painful
- debriding necrotic tissue appropriately to prevent infection and odor
- carefully cleansing wounds to remove exudate and metabolic waste, using warmed solutions if necessary to reduce pain
- matching moisture-retentive dressings to the amount of exudate produced by the wound
- using topical metronidazole to control odor.
* Joseph McCulloch, PhD, PT, CWS, and Luther Kloth, MS, PT, CWS, FAPTA, examined 4 adjunctive modalities used to manage patients with wounds. McCulloch said that intermittent pneumatic compression (IPC) can be used to promote healing of chronic wounds. Research suggests that IPC increases blood flow velocity and fibrinolysis; research on oxygen tension is contradictory. Treatment is usually given 1 to 2 hours daily, although benefits have been seen with 1 hour of therapy 3 times a week. FIGURE 2
McCulloch also discussed the use of negative pressure wound therapy (NPWT, also known as VAC). He said that NPWT is indicated for pressure ulcers, open wounds, meshed grafts, flaps, and chronic wounds. Research has shown that the intermittent vacuum of the device has resulted in increased local blood flow, an increase in the rate of granulation tissue formation, and a decrease in bacterial colonization. (For more on NPWT, see Guidelines for Using Negative Pressure Wound Therapy in this issue.)
Kloth reviewed the evidence suggesting that noncontact normothermic wound therapy can be used to accelerate tissue healing. He said that this therapeutic modality works by increasing perfusion via the microvasculature, increasing subcutaneous oxygen tension, decreasing the affinity of oxygen for hemoglobin, increasing bacterial killing by neutrophils, and decreasing tissue vulnerability to infection. In vitro studies have shown that warming decreases the inhibitory effect of chronic wound fluid on fibroblast activity and increases the proliferation of endothelial cells. Noncontact normothermic wound therapy is indicated for Stage III and IV pressure ulcers and venous leg ulcers and neuropathic foot ulcers that have not responded to standard care.
These indications apply to electrical stimulation as well, Kloth said. Although the use of electrical stimulation for wounds has been brought under scrutiny by the Centers for Medicare and Medicaid Services (formerly the Health Care Financing Administration [HCFA]), Kloth said there is clinical evidence to support its use. Research has shown that electrical stimulation reduces wound-related pain and accelerates tissue healing by increasing (1) migration of cells to the wound (galvanotaxis), (2) perfusion and capillary density, (3) transcutaneous oxygen tension, (4) cellular protein and DNA synthesis, (5) calcium uptake and expression of insulin receptors on the fibroblast cell surface, and (6) expression of fibroblast receptors for TGF-[beta]. FIGURE 3
* McCulloch and Kloth also teamed with Pamela Scarborough-Roessler, MS, PT, CDE, CWS, for a 2-part basic debridement skills workshop. In part 1, they discussed types of debridement, and in part 2, they gave attendees the opportunity to practice sharp debridement skills by debriding the tough outer skin of a pig's foot. The goal was to help attendees appreciate kinesthetically the actual removal of eschar.
In the first exercise, attendees were told to use a scalpel to cut a cross-hatched, checkerboard pattern into the tissue, then to remove individual sections with sharp instruments. The speakers emphasized that this technique is useful when trying to remove a small amount of eschar per debridement session; a moist dressing is then applied to facilitate autolytic debridement.
The second exercise involved removing tissue down to the fascial plane, using scissors, scalpel, and forceps as necessary. This technique simulated a more aggressive dissection of necrotic tissue, the speakers said.
Finally, attendees were told to turn their specimen onto the reverse side. This side was stained to represent necrotic tendon and muscle. The goal of the final exercise was to simulate removing as much necrotic tissue as possible without compromising function of the structure.
* Mikel Gray, PhD, CUNP, CCCN, FAAN, looked at urinary incontinence and skin breakdown. He said that the literature has shown a clear association between urinary incontinence and pressure ulcer development; however, a cause and effect relationship has not been established. Urinary incontinence probably does not cause Stage III or IV pressure ulcers, which originate within deeper tissue, he said, but may be a cause of Stage I and II pressure ulcers.
In addition, there is little systematic evidence for a relationship between urinary incontinence and reduced pressure ulcer healing. However, Gray said, ample clinical and anecdotal evidence supports urinary incontinence as increasing healing time and interfering with topical therapy.
* In discussing the diagnosis of and treatment options for osteomyelitis in the diabetic foot, Larry Lavery, DPM, MPH, reminded attendees of the common omissions or errors that can lead to a misdiagnosis: FIGURES 4 and 5
- not examining the wound
- treating an ulcer that is not infected
- failing to recognize an infection
- failing to recognize a deep infection
- using the wrong antimicrobial agents
- failing to identify peripheral vascular disease.
He reviewed the cardinal signs of infection-swelling, redness, warmth, pain, fever, and loss of function-but cautioned that a patient with diabetes may not exhibit these signs due to impaired immune response, leukocyte dysfunction, and neuropathy. In evaluating this patient, the clinician should also carefully attempt to probe to bone. This has been strongly associated with osteomyelitis.
Bone biopsy is the gold standard for differentiating between the pathogens of a soft tissue infection and those of osteomyelitis. In soft tissue infection, multiple organisms-both aerobic and anaerobic-are typically cultured. By contrast, only 1 or 2 types of Gram-positive organisms are generally cultured in osteomyelitis, almost universally aerobes. There is a tradeoff to bone biopsy, however: Although it can identify the specific pathogens infecting the wound and can confirm or rule out osteomyelitis, it also causes a wound that can lead to complications.
Lavery said that managing patients with osteomyelitis revolves around 3 activities: (1) surgically debriding devitalized soft tissue and bone; (2) initiating empiric antibiotics, then switching to more specific antibiotics when the culture and sensitivity results are available; and (3) carefully monitoring the patient for recurrence.
For information about attending next year's Clinical Symposium, scheduled for September 21 to 24, 2002, at the Hyatt Regency Dallas at Reunion, Dallas, TX, visit the official Web site of Advances in Skin & Wound Care and the Clinical Symposium on Advances in Skin & Wound Care, http://www.woundcarenet.com. To order tapes or a CD/ROM of this year's Clinical Symposium sessions, call 1-800-679-3646 or send an E-mail message to [email protected].