Chronic wound

from Wikipedia, the free encyclopedia

In the case of a chronic wound , wound healing slows down to stagnation. For those affected, a chronic wound means , in addition to the physical discomfort from pain , exudation and bulky bandages , a reduction in their quality of life due to the cost of materials and supplies, dependence on others, difficulties in choosing clothes and partial loss of self-determined everyday life. The chronic wound is a symptom of underlying diseases that need to be treated, or is due to factors that have to be eliminated in order to enable healing. Depending on the type and severity of the underlying disease, compression therapy or vascular surgery to improve the blood flow or pressure-relieving measures to relieve the wound can be carried out.

definition

The term “chronic wound” is defined inconsistently. The working group of the expert standard for the care of people with chronic wounds , which was developed in 2009 and updated for the first time in 2015, speaks of a chronic wound if, with optimal therapy, no healing tendency can be recognized after four to twelve weeks. The Association of Initiative Chronic Wounds (ICW), on the other hand, regards a healing process that lasts eight weeks or longer as a characteristic of a chronic wound. In addition, according to the definition of the ICW, certain wounds that develop as a result of diseases are to be regarded as chronic wounds from the moment they arise. This applies to venous leg ulcers in chronic venous insufficiency (CVI) , wounds in connection with diabetic foot syndrome and pressure ulcers, which develop as so-called pressure ulcers, especially in less mobile patients.

distribution

There is no reliable data on the prevalence of chronic wounds, but information that is internationally inconsistent. However, it is assumed that 1 to 2% of the adult population of all western industrial nations has a chronic wound. The risk of developing a chronic wound increases with age and is 4 to 5% after the age of 80. Different figures are available for the number of people in Germany who are affected by chronic wounds. Estimates range from at least 800,000 or 900,000 patients in total up to 4 million who are affected by the three most common clinical pictures alone - pressure ulcers, venous leg ulcers and diabetic foot ulcers. The majority of patients with chronic wounds in German-speaking countries are cared for as part of outpatient care . Compared to the costs of the materials used, the actual wound care service is only reimbursed to a small extent. The resulting low cost-effectiveness of such a complex and decisive nursing measure, which also requires experience, know-how and specialist knowledge, means that outpatient providers tend to care for patients with chronic wounds less often. Homecare companies and similar concepts that cross -finance care services through the sale of wound care products often settle in this care gap. It is assumed that the number of people affected by chronic wounds will increase in the future. In addition to the increase in life expectancy, the increasing number of cases of obesity and diabetes are also seen as promoting factors.

Emergence

If the interaction of degrading (= catabolic ) and building (= anabolic ) reactions in the healing process shifts in favor of the destructive processes, a chronic wound develops. The healing of the wound accordingly mostly stagnates in the first phase of wound healing, the inflammation phase , less often in the second, the granulation phase .

Basics

The body's own enzymes play a key role in the normal healing process . Proteases are proteolytic enzymes that break down and break down proteins . This enables them to destroy foreign bodies in the wound and break down permanently damaged, irreversible tissue. Proteases create the basis for the regeneration of the destroyed tissue structures and ultimately enable wound closure. Immediately after the formation of a wound, the proportion of proteases therefore increases rapidly, but decreases again after five to seven days with normal healing. In chronic wounds, the activity of the proteases, especially the matrix metallo-proteases (MMP), can be demonstrated for a significantly longer period. This leads to the destruction of proteins that are necessary for the wound to heal and in the course of this to an impairment of the wound closure. Chronic wounds also contain a disproportionate number of leukocytes and, in particular, granulocytes , as well as macrophages , which maintain the inflammatory process and can damage newly formed tissue. In the course of various triggering or promoting factors, various pathophysiological developments can occur that can disrupt or prevent healing.

Factors

The cause of the development of a chronic wound can be a postoperative wound healing disorder after a medical intervention. More frequently chronic wounds, however, develop in the context of pressure ulcers , the leg ulcer , the diabetic foot syndrome , from tumor wounds or wounds at Shin (pretibial called. Lesions along with advancing age - - as a result of damage to the so-called "aged skin") that caused by falls or bumps. A chronic wound always goes back to an underlying disease and is promoted by favorable factors. It is therefore not to be understood as an independent clinical picture, but as a symptom . The efficient therapy of the underlying disease and the elimination of the factors that cause and promote the wound are therefore the prerequisites for successful healing in the care of people with chronic wounds.

Triggering factors

The factors that can trigger the development of a chronic wound include inflammation , infection , hypoxia, and ischemia . In addition, there are some wound-specific factors that are the result of a poor wound condition and can in turn interfere with healing, such as the amount of exudate , existing necrosis or a biofilm in which germs protect each other and keep them on the wound.

  • Wound infections arise from the accumulation and interaction of various germs and pathogens that are always - but not always in large numbers - found on chronic wounds. Microbiologically , the number of germs present is given in colony-forming units (CFU) . A germ count of more than 1x10 to the power of 6 CFU per gram of tissue can permanently disrupt wound healing. A correspondingly large number of pathogens can trigger an inflammatory reaction, as a result of which increased amounts of exudate occur, which damage the wound edge and surrounding area. In addition, the production of MMP begins, which in turn endangers fresh tissue. In some publications, the bacteria are also assigned a toxic effect. In addition to gram-positive staphylococci and streptococci , gram-negative bacteria , such as the moist germ Pseudomonas aeruginosa or Enterobacter cloacae, play a special role in the development of a chronic wound .
  • Adequate microcirculation , i.e. adequate blood flow to the tissue, is a basic requirement for trouble-free healing of the wound. If the body's circulation is interrupted in the affected areas, ischemia can develop. The cause is usually a lengthening or interruption of the blood circulation due to damage to the diffusion path or occlusion , improper compression therapy or other external pressure, for example from medical devices, as well as combinations thereof.

Favoring factors

In addition, there are factors that favor the development of a chronic wound, such as obesity or diabetes . The location of the wound is also a factor. The area where the damage occurs can favor the development of a chronic wound in two ways: If the injury is, for example, in a body region that is often exposed to pressure, friction or moisture, this can promote the development of a chronic wound and at the same time make wound care more difficult . Individual, patient-specific factors such as B. his living conditions or the willingness to accept the necessary measures of the therapy, to participate in it, or to actively help shape its processes. The latter is summarized under the term of adherence and is accordingly taken into account in the course of the treatment.

Care for people with chronic wounds

At the international level, the professionals who care for people with chronic wounds are organized in the World Union of Wound Healing Societies (WUWHS). The European Wound Management Association (EWMA), which was founded in Great Britain in 1991, established itself in the field of chronic wounds. The so-called "Conference " of this specialist society takes place annually in another European country and took place in 2016 at the same time as the German Wound Congress , the largest specialist conference on this topic in the German-speaking area. This joint event by EWMA and three German-speaking specialist societies in Bremen was the world's largest wound congress with over 6,000 visitors. As co-organizer of the Bremer wound Congress is at the national level, the initiative Chronic wound e. V. (ICW), alongside the German Society for Wound Healing and Wound Treatment (DGfW) , the most important German specialist society in the field of chronic wounds. In the WundD-A-CH , the umbrella organization of the German-speaking wound specialist societies, the ICW cooperates with the Austrian Wound Association (AWA) and the Swiss Society for Wound Treatment (SAfW) At the local level there are also numerous smaller societies and initiatives that are dedicated to caring for people with chronic wounds on a club basis, through the organization of specialist conferences and specialist further qualifications or through the establishment of networks. These include the Wundzentrum Hamburg eV , the Diabetic Foot Network (formerly Foot Network ) in Cologne and the Wundmanagement Tirol association .

Structural aspects

All of the specially dedicated in German-speaking in the subject area of chronic wounds, associations and initiatives have in common that in them various professional groups interprofessional and within the professions different disciplines disciplines come together. The interprofessional and interdisciplinary cooperation of all providers involved in the care of people with chronic wounds is crucial for the successful treatment of this clinical picture. In the course of the treatment time, often months - sometimes years - caused by the slowness of the slow healing process, those affected go through many different care stations and come together with differently oriented therapists, nurses and other supporting professions such as podiatrists or orthopedic shoemakers . The exchange of information between all those involved in care during the transition, for example as part of discharge management , should take place without any loss of information in order to avoid breaks in care and therapy. Therefore, their effective and hierarchy-free cooperation, for example in the context of the networking of local providers and facilities, is the basis of successful therapy for people with chronic wounds. For several reasons, such locally acting networked structures are relevant to health policy . For example, you are able to negotiate the cooperation of different providers within the framework of integrated care , which goes beyond the structures of the health care system , in separate contracts or contracts with the health insurance companies that extend beyond the standard services . For this dialogue, it makes sense for providers who are entrusted with the treatment and care of people with chronic wounds to organize themselves in appropriate initiatives, associations and networks. Another fundamental aspect for this is the emphasis on further qualification of the respective practitioner in the field of chronic wounds, for which such institutions often also create structural prerequisites. The Chronic Wounds Initiative (ICW) e. V., the German Society for Wound Healing and Wound Treatment (DGfW) e. V., the Austrian Society for Vascular Care (ÖGVP), the Swiss Association for Wound Care (SafW) or the European Wound Management Association (EWMA).

Individual aspects

Since the development of a chronic wound can have different causes and is also influenced by many factors, the affected patient group is relatively heterogeneous. Thus, the focus and the approach of the suppliers differs depending on the case. The care of people with chronic wounds is therefore not standardized, but always individual, while maintaining the quality of life and at the same time promoting adherence, self-care potential and the positive self-perception of those affected. Carers tend to focus on the wound and give less priority to the burdensome aspects of the protracted illness that change the patient's life. This can have negative effects on the person's body image . The body image of people with chronic wounds is subject to a variety of negative and even destructive influences due to the disease. This ranges from feelings of shame in the face of increasing body odors to ignorant behavior towards one's own body components, for example in the case of body island shrinkage in patients with diabetic foot syndrome.

Wound treatment

People with chronic wounds often have a long medical history. Often the chronic wound itself is only an expression of a protracted underlying disease. The psychological situation of the person affected, the type and extent of the underlying disease and other factors can be the cause or support for the stagnant healing and must be included in a therapeutic concept. Therefore, adequate diagnostics precede the actual wound care.

Diagnosis

The ABCDE rule summarizes five aspects - anamnesis, bacteria, clinical analysis, blood flow and extras - and is a memory aid for the components of the proper diagnosis of chronic wounds. In the anamnesis , the origin of the wound, underlying and accompanying diseases and the general condition of the patient are recorded. In a second step, the number and type of bacteria present are determined using a smear . A clinical ( clinical ) study reveals the location, and the condition of the wound and the wound environment. The blood flow situation is clarified by examining the venous and arterial vascular systems . Finally, additional diagnostic procedures supplement the basic diagnostics as "extras", for example a biopsy .

Wound dressings

With a few exceptional cases, chronic wounds are treated according to the principle of warm, moist wound care. Here come dressings and other wound care products are used on the one hand a moist and warm wound climate ensure other hand abpolstern the wound to shock and friction and protect against external influences.

Care options for wound healing disorders

Dressings used on chronic wounds include hydrocolloid dressings , foam dressings , alginates, hydrofiber, and film dressings. In addition, bandages that contain special active ingredients or other additives are used, for example silver or activated carbon to combat bacteria and odors. There are also bandages with polihexanide for disinfection or with ibuprofen for pain relief . In addition, there are care options that are designed to respond to certain factors that cause wounds or inhibit healing. These include products which, by applying hemoglobin to the wound surface , are intended to counteract the oxygen deficiency that often accompanies ischemia , or which are designed to regulate the number of matrix metalloproteases in the wound area. Other corresponding products contain chitosan or hyaluronic acid to support the body's own wound healing mechanisms or - for example, cellulose obtained from bacteria - which is supposed to promote epithelialization.

One consequence of the chronic nature of the wound is that wound treatment does not always initiate or improve the healing process. However, it should always be possible to improve the quality of life of the person affected, for example by reducing wound exudate, relieving pain or odors and increasing mobility.

Causal therapy

The simultaneous elimination of the triggering and favorable factors and the treatment of the underlying clinical picture form the basis for the healing of a chronic wound. Depending on the underlying disease, various measures can be taken as part of what is known as causal therapy .

Elimination of factors

  • The occurrence of germs within chronic wounds often results in the formation of a so-called biofilm . This term describes a survival strategy for pathogens that come together in a cooperative community. A biofilm is created when germs surround themselves with a layer of mucus made up of polysaccharides and dead germs. On the one hand, this layer makes it easier for the biofilm to adhere to surfaces; on the other hand, it promotes communication between the pathogens - so-called quorum sensing - and finally protects the germs effectively against antibiotics . Between 60 and 90% of chronic wounds and 6% of acute wounds have a biofilm. It is usually eliminated by absorbing it with compresses or specially designed wound pads during the cleaning of the wound bed as part of the debridement .
  • A lack of oxygen in the wound, i.e. hypoxia caused by a restricted or interrupted supply of oxygen , can be counteracted by several measures. Vascular surgery and interventional measures improved venous and lymphatic drainage, for example through variceal surgery . Another possibility is to promote oxygen binding in the blood through hyperbaric oxygenation . However, the pressure chambers used are not available everywhere. Products that can be used locally are less expensive and more readily available. In the Anglo-American language area, appropriate oxygen-containing wound dressings are common. Another possibility is the application of oxygen bound in hemoglobin by means of a liquid or spray.
  • Fibrin covering the wound bed can hamper Anheilung. Fibrin is a protein that plays an essential role in blood clotting and is activated in injuries to act as a "glue". However, as a result of the continued inflammatory reaction, excessive production of fibrin occurs in chronic wounds, which eventually becomes visible as a pale coating on the wound bed and has to be removed by debridement . To remove thinner fibrin coatings, dry or moistened compresses and specially developed cleaning cloths or pads are used in the course of so-called " mechanical debridement ", with which the fibrin can be rubbed from the wound bed. This method can cause pain in the patient and also destroy newly formed tissue. The dissolving of the deposits through moisture in " autolytic debridement " is gentler but more tedious . Special hydrogels , alginates and complex wound dressings are used here, which continuously release fluids such as Ringer's solution . Autolytic debridement is a cleaning method that supports and accelerates the body's own cleaning processes that take place inside the wound, and also results in the removal of thicker fibrin coatings.
  • An effusion is a condition of the healing of a wound. Exudate has the task of flushing foreign bodies and destroyed tissue from the wound and at the same time allowing epithelial cells to migrate. A sufficient amount of exudate in the wound is therefore desirable, on which the modern principle of moist wound care is based. However, an excess of exudate, which can develop particularly in the context of the continued inflammatory reaction typical of chronic wounds, interferes with the healing of the wound. In this case, substances that promote wound healing and epithelial cells are flushed out of the wound, while the sensitive edge of the wound and even the intact skin around the wound can be damaged by the constant action of moisture through maceration . In order to reduce the amount of exudate in the wound, particularly absorbent wound dressings are used that contain superabsorbents , for example .

Treatment of the underlying disease

  • In the course of the diabetic foot syndrome , wounds that are difficult to heal often develop as a result of incorrect and excessive loading of certain areas on the soles of the feet. So-called diabetic foot ulcers are not really chronic wounds that stagnate as a result of an imbalance in the mechanisms that build up and break down. In the case of such foot ulcers as a result of the diabetic foot syndrome, a healing process does begin, but the damage always occurs again as a result of stress when it occurs. A prerequisite for the healing of a diabetic foot ulcer is therefore the relief of the affected foot areas, for example with an adapted shoe supply by an orthopedic shoemaker .
  • A chronic wound that is caused by pronounced edema as a result of a vascular disease on the lower leg is known as a leg ulcer . Venous leg ulcers are the most common of these . In about half of all patients with leg ulcers, the wound has existed for more than a year. A prerequisite for healing is consistent compression therapy that improves micro- and macrocirculation within the legs and reduces edema . The leg ulcer has a high rate of recurrence . Therefore, those affected continue to wear their compression garments, usually compression stockings , even after the wound has healed.
  • The pressure ulcer does not arise exclusively, as the common expression "bedsore" implies, when lying down, but also when sitting. A typical localization of this damage is therefore also the buttocks. It is a pressure sore that develops in patients who sit or lie motionless in one position for long periods of time. As a result of an emptiness, which occurs due to permanent pressure from the outside, especially on the sacrum , ischium and both heels , the tissue between the skin and bones dies - in a poor physical condition after just a few hours . The prerequisite for the healing of a pressure ulcer is therefore the mobilization of the person concerned and the pressure relief on the damaged body region.

Tumor wounds

Tumor wounds, also known as malignancy- associated or malignant wounds, form when the skin is damaged by cancer . This can be related to a skin tumor , but it can also be triggered by a skin metastasis from another tumor or by an ulcer that breaks through the skin from deeper tissue layers. About 10% of tumor patients have a malignant wound. It can appear on any part of the body, but the most common area is the chest area. When caring for people with such - often heavily exuding - tumor wounds, the focus is not on measures to enable and promote wound healing, but on palliative measures that focus on the painful situation and other aspects of the person's quality of life.

literature

  • Kerstin Protz: Modern wound care. Practical knowledge, standards and documentation . Elsevier Verlag, Munich 2016, ISBN 978-3-437-27885-3
  • Joachim Dissemond: Visual diagnosis of chronic wounds. About the clinical inspection for diagnosis . 3. Edition. Viavital Verlag, Cologne 2016, ISBN 978-3-934371-55-2
  • ICW eV (Hrsg.): Standards of the ICW eV for the diagnosis and therapy of chronic wounds . In: WundManagement. Volume 11, 2/2017, ISSN  1864-1121
  • Susanne Danzer: Chronic wounds. Assessment and treatment . 4th edition. Kohlhammer Verlag, Stuttgart 2014, ISBN 978-3-17-026708-4
  • Eva-Maria Panfil, Gerhard Schröder (Ed.): Care of people with chronic wounds . 3. Edition. Verlag Hans Huber, Bern 2015, ISBN 978-3-456-85194-5

Web links

Notes and individual references

  1. ^ A b German Network for Quality Development in Nursing (Ed.): Expert standard care of people with chronic wounds. 1st update, publication series of the DNQP, Osnabrück 2015, ISBN 978-3-00-023708-9 .
  2. ↑ Joachim Dissemond : Eye diagnosis of chronic wounds. About the clinical inspection for diagnosis , 3rd edition, Viavital Verlag, Cologne 2016, p. 11
  3. ↑ Kristina Heyer , Katharina Herberger , Kerstin Protz , Gerd Glaeske , Matthias Augustin : "Epidemiology of chronic wounds in Germany: Analysis of statutory health insurance data ", Wound Repair and Regeneration 2016; 24 (2) pages 434-442.
  4. ↑ Final report of the PMV research group, 2016 (.pdf) Evaluation of the AOK routine data of the insured in Hesse on behalf of BVMed , BVMed website, accessed on March 21, 2016
  5. ↑ M. Beeres: Chronic Wounds , in WundManagement. Volume 12, 1/2018 ISSN  1864-1121 , pp. 5–6
  6. ↑ a b c A. Buß, S. Stupeit, N. Lahmann: Main problem at the interfaces of the care of patients with chronic wounds. in the journal of wound healing. Volume 18, 1/2013 ISSN  1439-6718 , pp. 9-14
  7. ↑ Werner Sellmer: "Caring for chronic wounds economically ". MEDIZIN & PRACTICE Extra, 2018; Page 7–11
  8. ↑ a b Ch. Busch, I. Aschermann, Ch.D. Mnich: Treatment of Chronic Ulcers. A critical short analysis in Phlebology , Volume 46, 1/2017 ISSN  0939-978X , pp. 13-17
  9. ↑ S. Danzer: Factors of wound healing in nursing journal 6/2016, Kohlhammer Verlag, Stuttgart, ISSN 0945-1129, page 330 to page 333
  10. ↑ a b J. Dissemond: Ulcus cruris - Genesis, Diagnostics and Therapy , 2nd edition, Uni-Med Verlag, Bremen 2007, ISBN 978-3-89599-298-8
  11. ↑ S. Danzer, B. Assenheimer: 100 questions on wound treatment, 4th edition, Schlütersche Verlagbuchhandlung, Hannover 2011, ISBN 978-3-89993-775-6 , p. 11
  12. ↑ K. Protz: Blickdiagnose. On the trail of the cause , in Der Hausarzt , Volume 53, 17/2016 ISSN  1434-8950 , pp. 72-74
  13. ↑ R. Brambilla, J. Hurlow, S. Landis, R. Wolcott: Innovations in hard-to-heal Wounds , Clinical Report, Wounds International on behalf of the World Union of Wound Healing Societies (WUWHS position paper), 2016
  14. ↑ PEter Kurz: Suitable antiseptic wound irrigation solutions for infected wounds , in Medicine & Practice, Verlag für Medical Publications, pp. 64–69
  15. ^ "Chronic Wound", in Peter Altmeyer, Enzyklopädie der Dermatologie , accessed online on May 7, 2018
  16. ↑ Hans Lippert (ed.): Wundatlas Compendium of Complex Wound Treatment, Georg Thieme Verlag, Stuttgart 2006, ISBN 3-13-140832-4 , page 193 to page 195
  17. ↑ Web presence of the World Union of Wound Healing Societies accessed on March 5, 2018
  18. ↑ Website of the European Wound Management Association accessed on March 5, 2018
  19. ↑ Review of the German Wound Congress 2016 on the website of the German Wound Congress accessed on March 5, 2018
  20. ↑ Website of the Chronische Wunde eV initiative accessed on March 5, 2018
  21. ↑ Wund DA-CH on the website of the umbrella association for wound management accessed on March 5, 2018
  22. ↑ Web presence of the Association of Wundmanagement Tirol accessed on March 5, 2018
  23. ↑ Web presence of the Network Diabetic Foot, Cologne, accessed on March 5, 2018
  24. ↑ a b c Matthias Augustin , Eike Sebastian Debus (eds.): Modern wound care in the field of tension between quality requirements, responsibilities and the need to save. Volume 2, Beta Verlag, Bonn 2011, ISBN 978-3-927603-89-9 , pp. 53-57
  25. ↑ Matthias Augustin, Eike Sebastian Debus (ed.): Modern wound care in the field of tension between quality requirements, responsibilities and the need to save. Volume 2 , Beta Verlag, Bonn 2011, ISBN 978-3-927603-89-9 , pp. 61-71
  26. ↑ A. Uschok: Body image and social support for patients with venous leg ulcers , Verlag Hans Huber, Bern 2008, ISBN 978-3-456-84560-9 , p. 68
  27. ↑ K. Hodeck, A. Bahrmann: Pflegewissen Diabetes . Springer Verlag, Berlin Heidelberg 2014, ISBN 978-3-642-38408-0 , p. 79
  28. ↑ J. Dissemond: Rare causes of chronic wounds in wound management, 12th year, mhp Verlag, Wiesbaden, 1/2018 ISSN  1864-1121, pages 29 to 31
  29. ↑ Wound Center Hamburg eV: Wound knowledge, easy - practical , 2nd revised edition, Hamburg 2017, pp 6-7
  30. ↑ A. Elend, C. Hoppe, M. Augustin : Biofilm and Debridement in Diabetic Foot Syndrome , WundManagement 12 (1), Wiesbaden 2018, pp. 17-20
  31. ↑ T. Proschek: New therapeutic approaches for challenging wound situations in nursing journal, 8/2017, ISSN 0945-1129, pages 34–37
  32. ↑ D. Hochlehnert, G. Engels, S. Morbach: The diabetic foot syndrome - About the entity for therapy , Springer Verlag, Berlin 2016, ISBN 978-3-662-43943-2 , pp. 3–5
  33. ^ Initiative Chronic Wound eV (Ed.): Bed sores - does not have to be a problem. Expert information for patients and relatives , 3rd edition, Quedlinburg 2013, pp. 4–6