BioMonde LIVE is delighted to share this Expert Guest Webinar, presented by Vascular Specialist, Dr Leanne Atkin.
By watching this webinar replay, you will learn:
Importance of prompt debridement.
Assess and diagnose devitalised tissue with accuracy.
Optimal patient management via early intervention.
Wound hygiene and debridement for anti-biofilm strategy.
Pros and cons of debridement options.
Advantages of larval debridement.
Pathways and guidelines to aid wound bed preparation.
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[Applause] Hello everybody good evening and welcome to bomond live thank you very much for joining us my name is Rebecca and I am the um UK marketing and customer service manager here at bamont and I’m delighted to be joined by Dr Leanne Atkin who is our expert guest speaker for this evening
So the webinar tonight is all about debridment and just why debridment is so important so the session this evening is going to last for about an hour um we think lean’s going to speak around about 45 minutes for you but timings may vary ever so slightly so do just sit tight
And enjoy the evening and we will set aside some dedicated time for you just at the end of the session for any questions that you may have for Leanne now for those of you who are new to biom mod live um if you haven’t joined on
Before I am just going to get you acquainted with a couple of buttons which I think you’re going to find useful as we go through the session this evening so the first is the chat button um and that’s going to be your space to network this evening and just to
Interact amongst yourselves so just for some peace of mind guys we can’t see or hear you your cameras and your microphones will be switched off for the duration of the webinar so you can communicate through that chat function of Zoom okay and the second button to be
Aware of is just the Q&A button and that links back to that question and answer session I just mentioned so if you do have any questions for Leanne this evening um if you think of anything as we’re going through the session tonight do just press that button and type those
Questions in what we’ll do then at the end we’ll accumulate all of those questions and we’ll hopefully get around to answering as many as we we can for you and you can see we’ve got some biomon social um links there on the slide as well so do please check those
Out and if you are enjoying uh the webinar this evening it would be great if you wouldn’t mind just popping a little post up about it so to introduce your speaker this evening uh I’m delighted to be joined by Dr Leanne Atkin Leanne is a vascular nurse
Consultant and at the mid Yorkshire NHS trust and she is also a lecturer at at the University of Huddersfield as well and I’m sure some of you will be familiar with Leanne already because she has done a couple of bomond live webinars for us before the first on Peripheral arterial disease and the
Second on Venus ulceration both absolutely brilliant sessions so I do recommend after this evening if you just go and have a little look at those they are available on our YouTube channel so let’s have a look at what you’re going to be learning with Leanne this evening so Leanne is primarily here
To talk to you about the importance of prompter brident but around that you’re also going to be learning to assess and diagnose the vitalized tissue with accuracy you’ll be looking at optimal patient management via early intervention Leanne will be discussing wound hygiene and debridment for an antibiofilm strategy and she’ll be
Exploring pros and cons of various options for debridment that are available to you and within that we are going to be looking at some advantages particularly of love to bridan as well and lastly Lan is going to cover some Pathways and guidelines for you just to Aid that wound bed
Preparation so that’s it for me for now I am going to stop screen sharing lean and that will just hopefully allow you to share your screen and whenever you’re comfortable then just feel free to begin your presentation but lean thank you so much for joining us this evening it’s so
Appreciated and I can’t wait to see this session thank you thank you so hopefully you should all be able to see my slides now and you should be able to hear me okay um thank you for that lovely introduction um as Rebecca said my name’s Leanne I’m a vascular nurse
Consultant at Mid Yorks NHS trust I have a title by the name of doctor but that’s Doctor by PhD I’m a very proud nurse I am a joint clinical academic but I’m still down and dirty in clinic uh on a Tuesday Wednesday and a Friday and Wednesday is double legoa Clinic it’s
Like double maths if you remember but actually it’s my favorite day of the week and so I’m hopefully going to bring to you some of the academic side in terms of the science and the research but also some of the Practical applications of the reasons why and how
You as clinicians out there can really start to improve your practice with debrian I really like this title that Bond asked me to deliver because actually we really need to rethink what we believe debridment is and why we think this is so important a lot what we’re going to talk
About today is actually um the movement of the science um in terms of what we used to do to what we should be doing now and a lot of what I’m going to talk about is based on this publication um that I can’t believe now is five years
Old and but we’ve published this timers document uh back in 20089 talking about how we can improve healing for those patients with hard to heal wounds and this document really talks about the fundamental aspects of care it sets the scene of what you need to do to try to optimize wound healing
In any patient that you’re seeing no matter what the underlying pathophysiology is it talks about that early intervention so let’s treat a wound from day one as a potential hard to heal wound it’s about thinking about the accurate assessment and diagnosis what is the underlying pathophysiology
Why has the wound occurred how do we actually combat that disease or manage the reasons why it talks about the optimal patient management strategy so really bringing in that patient activation the well-being of the patient themselves to try to get them involved in their own clinical decision making he
Also talks about the appropriateness of skilled health professionals and actually how we need to escalate patients up and down are skilled professionals and I believe that escalation is the marker of Best Care not a marker of failure of care and it really talks about when do we need to
Actually refer to Specialists and who that should be and at what time scale unfortunately it seems many patients only get to see by specialist wound clinics such as plastic surgery teams or vascular clinics when wound healing has failed to occur and I mean failed in terms of that wounds been present for
Months and months and I think that really we need to start to revisit that and actually if a wound hasn’t healed within 12 weeks of therapy then I think that patient should be referred earlier but a key part of all of this in terms of this fundamental aspect of
Wound care is good wound management and when I talk about good wound management it’s really thinking about that effective wound bed preparation and the timer document stands for tissue infection moisture wound edges repair and the social aspects of that patient but today we’re really going to focus on actually that
Tissue aspect in terms of what do you do if you’ve got a wound with devitalized tissue wounds that you need to debride and that’s what we’re going to focus on today I just want to remind you what debridment is we use the word a lot but
Actually it’s a French word um it it means remove the constraints and and actually what you do most is you debride a horse so you take the bridal out of the horse so you are debriding that horse of that actual constraint and that’s where it comes from in the French
Language but it’s this amazingly attractive gentleman Henry ladran who first actually used the word debridment within the medical term and for us it starts to think about removing that vitalized tissue this humor document is now quite a few years old but actually I love this definition of debridment because I
Really think it starts to Encompass all that we’re trying to do as clinicians so debridment is defined as the act of removing Adent dead or contaminated tissue from a wound and must be clearly separated from the act of cleansing which is defined as removing dirt or loose metabolic waste material or
Foreign material so it’s about the removal of this adherent dead or contaminated tissue and that’s what we’re going to focus on today so why do we need to debride and well the first reason is it helps to remove the physical barrier that’s attached to that surface of the wound
That’s going to actually impact that epithelization it may well increase contraction of the wound are actually is a is a um an hindrance to that granulation regrowth but actually what you will find with devitalized tissue is that it is an absolute Feast of a place for bacteria
So it’s a huge bacterial burden that’s on that wound so there is an increased risk of actual infection but the science has moved on more because actually what we know we need to do by removing that devitalized tissue is actually convert that chronic wound into an acute wound we used to
Believe that be careful with wounds don’t cleanse them too much don’t rub them too much don’t cause bleeding all of that is bad well actually we know from the science and we’ll go through why that is that that we’ve moved on if you like and actually re stimulating
That wound healing Cascade so that causing that requirement of hemostasis that acute inflammatory response can start to stimulate and Cascade that new wound healing and all of this is what we’re trying to do is actually arrange coverage of that wound earlier so to facilitate wound healing it’s like this
Picture that you can see here and I do love this picture because many patients still say should I leave my wound to dry out and you can see what happens to a wound if you leave an open wound to dry out it doesn’t form a scab like like
Like you do in children when they graze their knee you actually have this devitalized tissue being becoming dehydrated and sat there on top of that wound that then hinders that or the the movement of those cells to be able to facilitate wound healing it also acts as
A huge um growth of bacteria so we know from that moist wound healing that we should be trying to remove that device size tissue get that wound bed as clean as possible allowing that granulation Bud to come up and allowing those epithelial cells to start to skate over the top of the
Wound but while in the UK debridment is really poorly done especially within the UK and we all know that wound bed preparation is key and it’s recognized by most nurses and podiatrists that we need to debride that wound but when we talk about debriding most clinicians believe it’s about applying
Addressing but actually I’d say that we could be doing so much more rather than just applying addressing and I do think that if you look at the evidence base in terms of what’s happening within diabetic foot ulceration where they regularly Blade debride the callus and the wound bed
Itself we’re not using that knowledge and that emergence of science within other fields such as the management of Venus leg ulceration many people will not physically debde a Venus leg ulcer but actually should we be moving that act forward based on the science that we’ve got so debridements two things
Callis debridment we’re not going to talk about that tonight but I just wanted to put these slides up to say that callus debridment is a vital skill when it comes to wound bed preparation it’s a vital skill to actually stop the formation of ulcers and increased
Pressure it’s a vital skill to be able to determine what’s underneath that is there a non-healing wound or not or in that other patient that you can see with a a neuropathic ulcer underneath their first metatarsal head your callus can actually form like a noose around the
Neck we need to remove that callus to be able to allow that the pressure to be relieved and that wound to heal but we’re not talking about callous debridment tonight we’re talking about debridment of that devitalized tissue so devitalized tissue comes in Array of different forms it comes in sluy tissue
Which is tends to be yellow over time the yellow sluy tissue can dehydrate and you can get esca or necrotic tissue and sometimes like on that picture on the far left you can get devitalized tissue as a way of trauma or hematoma formation in the base of that wound and each of
These wounds we need to facilitate wound healing by removal of the devitalized tissue so what is SLU you’ll see every day in clinical practice you’ll know that it comes in very different forms this is classic Slough that you can see within this slide um it tends to be um
Pale yellow adhered to the wound bed itself and and that SLU is formed as part of that natural inflammatory process it’s normal for a wound to have a degree of slon it it will always hinder wound healing but it is normal part of that wound healing Cascade if
You look at that sluy tissue underneath a microscope you’ll find that it contains a host of different things including fibrin white blood cells bacteria Deb dead dead cells um and different types of protein material within that I say SLU typically looks like that but I’m going
To show you a whole range of slides tonight of the varying nature of what SLU can look like because SLU can look from all the way from mozzarella cheese it’s quite loose and removable and to snotty stringy SLU to SLU that these extremely ader and look slightly more
Darker in color sometimes even grayer in color rather than yellow with SLU though that that’s part of the normal inflammatory process the other type of devitalized tissue is necrosis um also can be called gangrene or escar or necrotic tissue and this is dead cells this is caused by a lack of
Oxygenation a lack of blood supply to that specific area and no form of necrosis can ever be um Reser reversed we really need to think about removing that area because it’s like we being a plug of devitalized tissue that’s stopping that wound healing from occurring initially necrotic tissue can
Look um quite thin and superficial it can feel quite um soft at times but as it dries out it can become very hard and very leathery so much so you could tap it with a fingernail and it feels like you’re tapping at wood really it can become so
Dry I think narcotic tissue is worth than sluy tissue because of the number of bacteria that will be involved in this you’ll often find when you have necrotic tissue you’ve also got a significant malodor that malodor is because of the anerobic bacteria that’s happening within that wound and we can’t
Stop to think about how bad it must be to live with a wound never mind living with a wound with a significant odor we ask these patients to ensure they’ve got a good nutrition they’re inake in a balanced diet how would your appetite be if you could just smell necrotic tissue on
Yourself the problem is with this as well as as it starts to actually debride through natural autolysis through your body you can find that the exudate levels start to increase the odor starts to increase we have this huge barrier in terms of cellular growth and really worryingly with narcotic tissue you
Don’t know how deep that wound is really going it that Titanic tip of the iceberg if you like you don’t know whether that’s just half a centimeter that you’d be able to Blade your bride off or you don’t know actually if that’s going all the way down to the to the
Bone the one thing I just want to remind us of though is when we’re talking about um nonhealing wounds um so a non-healing wound versus an acute wound cellularly look identical they’ve got the same type of makeup they’ve got the same type of cells that’s trying to activate
This the only difference is the wound that’s healing between a wound that’s become chronic or nonhealing is two things it’s an increased amount of mmps caused by that chronic inflammatory cycle that that wound is stuck in along with the increased amount of biofilm that’s on the wound and we now know from
The science that around 80% of non-healing wounds have actually got a biofilm and it’s probably the biofilm that’s causing that wound to stall to heal the wound colonization Continuum has changed over the last decade and we now really have a clear distinction between actually contamination and colonization is normal and actually will
Not impact on wound healing we can get localized infection so the host is not getting a response but you’ve got a high amount of back bacterial burden on that wound bed such as pseud amonous infections and they might need treating with topical antimicrobials but once we get spreading infections or systemic infections we
Need to be thinking about our antibiotic therapy but actually just look at that Continuum across the top in terms of biofilm you can get biofilm ranging throughout all of these wounds and it’s the biofilm that’s actually going to impact that wound healing and this is why many times you will take a wound
Swab and you’ll find that you are growing some organisms but that’s just colonization of that biofilm it doesn’t mean that patient requires antibiotics they only require antibiotics if there signs of spreading or systemic infection a biofilm is a really interesting thing and a biofilm is a group of different bacteria that start
To actually provide a colony together when they start to provide this Colony together they excrete the this substance called EPs and I like to think of eps like trial if you like so they start to form in this treal and that treal does two things it attaches them to the
Actual wound bed but it provides a protection over the top of the bacteria and this gives those those bacteria a great environment to reproduce to recolonize and actually to continue to impact on wound healing and when a biofilm becomes mature which can happen after only 24 hours then it really starts to impact
Because it increases or stops that wound becoming moving forward so it gets stuck in that chronic inflammatory cycle you get increased amounts of mmps you get increased amounts of exudates and this all causes cells Essence so the cells basically go to sleep I like to think of these biofilms
If you like in this protective Dome have you ever used um silver dressing on a patient with simonis and found no effect and that’s because the actual ponus bacteria is sat within this protective bubble of this biofilm so no matter what you do or what you put on top of it you
Can’t actually penetrate down to that bacteria so the silver looks ineffective because the back the the the pseudomonas continues to be profound it’s only actually if we start to debride those wounds so exposing that bacteria removing that bofilm then we can start to think about peeling off that bacteria
That’s causing that wound to become chronic you can’t see a biofilm with a naked eye but you certainly can see the clinical signs of a chronic biofilm infection and all of these are that that that that really superficial stuffy tissue that you want to sort of pull off
In strips that’s a mature biofilm that chronic pomonis that you can see from that bright green exudate within those pictures that’s a chronic bofilm and no matter what type of antimicrobial you’re using that biofilm and that pseudomonas is protected so you’re not actually being able to eliminate
That we often say that if you have got Slough that you’re able to debride and then it reforms really quickly think about whether that’s a biofilm if you’ve got that granulation tissue that’s extremely fragile so you touch it it can bleed in an area just from Simple Touch it’s probably because of a
Biofil if you’ve got that wound that’s just showing those chronic low levels of inflammation with small amounts of Emma around that wound bed but no true host response it is again it’s probably about that bio film and we need to think about actually how do we move these wounds forward so
If we have this wound with this devitalized tissue on it we know that non-healing wounds are an ideal environment for the biofilm to come we know that if biofilms comb it causes that chronic inflammatory response that chronic inflammatory response leads to sluy tissue and delayed wound healing
And that if you’ve got delayed wound healing you’re more like to get a biofilm the biofilm is more likely to causeing inflammatory response and you can see why we get stuck in this cycle of having these patients with a wound like this that you just don’t seem to be
Making any progress with in terms of moving that wound towards wound healing we’re going to put a lot of links within the the diagram within the sessions tonight at the end of it so you’ll be able to look at all of these documents I’m referring to um but I
Think the greatest thing that’s happened happened recently is this wound hygiene and it talks about strategies of what we can have to actually prevent the formation of biofilm and it’s thinking about when we debride how we debride how quickly we debride and actually how do we think about an antibiofilm strategy
Going forward to try to break out that cycle of that chronic inflammation so hopefully I’ve presented with you the real clear reason why we need to debe these wounds but actually when it comes to debridment what options have you got and there are many options that you’ve got available to
You but you’ve got to remember I like to think about a wound with any devitalized tissue as being in that negative stance so we’re on minus days or minus weeks and you can only actually start wound healing if you can get that wound from clean sorry from from sluy tissue
Devitalized tissue to clean that’s sort of point zero and then wound healing can occur so when we think about debridment the one thing I want you to think about is speed because we’ve got lots of options available to us but how do you go about choosing
Those so we need to be thinking first off about speed if that wound is not going to heal until we C debde that wound how quickly can we get that wound bed to clean we also want to choose something that’s very selective in other words that will protect those healthy
Granulation buds that may be underneath that superficial sluy tissue we don’t want to damage those so how can we protect those at the same time as de debriding that devitalized tissue in an Ideal World you want something that you can use both on that sluy tissue and on that necrotic tissue
Because quite often you get wounds with different types of SLU are SLU and necrosis together but we also want something that’s easy to use Easy to access overall cost effective and acceptable to our patients I like this little table that’s it’s quite old now but it’s from the Canada wound Association and it
Really just starts you to think about where are your advantages in terms of the debridement options that you’ve got so I just want to go through those options that’s available to you in your clinical practice just to get you thinking about which you should be choosing in
Future so the first one is atic deriv and this will be your goto I can imagine this is what happens in 99% of your patients at this moment in time and when I talk about atic debridment it’s simply the application of addressing a silica debridment happens naturally through
Autosis so if you had a tiny little bit of sluy tissue and you are well in yourself your body will get rid of that without any form of wound dressing what happens is that the body pulls through to the surface of the skin extra enzymatic fluid through that dermis
Subcutaneous tissue onto that epidermis and that slowly pulling through of this enzymatic fluid starts to debride that fluffy tissue all of the wound dressings that you currently use just enhance that process and they’ll enhance that process by two methods either number one they’ll add extra moisture to increase that
Process or they’ll provide a green house of protection so keeping that moisture that comes through on the wound bed mo for longer periods to facilitate that aysis a bment is good because it’s easy to do anybody body can do it who can redress a wound but I have a huge
Problem with atic debridment because it is so slow you think about these two wounds that you’re seeing here if you chose to debride this when any of the dressing that’s available to you some form of hydrofiber or some form of Honey dressings or some form of of gel
Dressings how long would that take in terms of getting that wound to debde you not talking days are you you are talking weeks before you get that wound to debride and if you believe that that wound is in a negative State you are just spending weeks and weeks to get it
To point zero to allow it to heal I also think some of the wom dressings when we start to debride especially when we start to debride necrotic tissue we can stimulate that bacterial response and therefore we increase the risk of infections for our patients the second one which is the one that I
Tend to turn to First is surgical or sharp debridment and and for this we tend to use curettes it’s relatively quick it’s cheap so long as it’s done out of a theater environment you can be selective if you’ve got good hands however there is a degree of Competency require there
Is a need for some formal education and some sign off of additional competen is and I get that for a lot clinicians actually picking up a blade there is a big Fear Factor and I get that Fear Factor because actually if I look at that wound I may well have the
Confidence to start to take a blade to debride that however I know that Anatomy below that tissue I know where the arteries the nerves the veins run I know where the tendons are likely to be and actually that’s really important in terms of that surgical debridment or
Sharp debridment and that’s why for many um wound care practitioners sharp and surgical debridment is really not within their current scope I think we have to acknowledge though that the debridment pads that’s out there can really help so the debridment pads often Monon filament pads that you can actually start to rub
Onto that wound will lift some of the devitalized tissue and also lift some of that biofill they are relatively easy to use they’re cost effective the be used in any type of environment that’s out there the difficulty is with them I don’t think they are ideally suitable
For all types of non devitalized tissue so you can see that superficial sluy tissue on the amputation site they may well pick up some of that stringy snotty stuff at the top end of that wound they certainly won’t be able to do much for that very aded sluy tissue right at the
Base of that wound and they’ll make very little impact in terms of that devitalized tissue that necrotic tissue SL sluy dehydrated tissue they’re not going to make any impact for that whatsoever so I think they have the place but to me it’s only for very superficial amounts of devitalized tissue that’s relatively not
Well aded I do think curette debridment is the thing that’s going to be in a lot of the future um and this is relatively easy and cheap to do I think giving a nurse a scalpel they are always get Twitchy giving them a ring curet sometimes can make it feel more safe and
It costs pennies they’re about 54 P each and you can debride a wound like this that pre picture that post picture you can see how you’ve got rid of the devis lized tissue you will have disrupted the biofilm and you’ve kicked that wound from that non-healing state into that
Acute healing State and and I must say it’s the most satisfying thing that I do in terms terms of removing that tissue with a curette I find them difficult to do any harm with but also I do understand that there can cause bleeding and I think
It’s very different for me to be able to control bleeding in a clinical setting than controlling bleeding in a home setting what I just want to point out really that the science is is there to really talk about the debridment and actually maybe using our debridment skills more and more where we possibly
Can and simple Shar de bridan can stimulate healing in chronic wounds and this paper showed that it’s s well tolerated and can easily be performed in an outpatient setting and simply by debriding a wound on a regular basis with a cure you can find that you will stimulate wound healing three times
Quicker than what you can by non debridement and it’s simply that activation of those cells you are moving that wound from that and that sleepy state if you like to actually kickstarting that wound healing but again it has to be recognized that curette de bridan is only suitable on certain wounds all of
These wounds that you can see here even if you are a Master with a curet you’re never going to actually get to a clean wound bed and I say that because each of these wounds are very undul ated they’ve got pockets of depths in certain areas which is really difficult to get to
They’ve got mixed type of sluy tissue some of that is that soft and SL slotty tissue some of it is much harder well aded tissue and some of that has got signs of pseudomonas colonization in terms of that amputation picture at the bottom and I think when we’re talking
About these wounds this is where LV therapist starts to actually play a significant role LV therapy is really good it’s got huge amounts of evidence to say how effective it is but actually it’s the most selective method of debridment that we’ve got there are some cons you know the
Biggest con is the time delay that if you want ly today you have to order it today but you won’t get it until tomorrow people say that Lobby is expensive I do not think it’s expensive when you look at that overall picture because one bag of L therapy May cost more but I
Will simply say to you if that gets you to week zero surely it becomes cost effective because if you don’t use lav therapy you might be using things like Hydro fibers and honey dressings for weeks slash months before getting to that clean wound point and all of that
Is a significant amount of cost not just product cost but your time I think the acceptability of lar has also increased greatly we used to previously use loose margets that you can see within that picture and there was always a fear factor of the patience of escapes I think now that the maggots
Have come within the tea bag so therefore you cannot lose a maggot anywhere the patients find them much more acceptable because they’re no longer feared about losing those maggots I must say I think that they’re amazing little things so the the lavy therapy that bomond used comes from the
The green bottle fly and we’ve used this W widely within medicine since 1920 um it slightly got less of use when we antibiotics were introduced because they sort of was seen as the Savior but it was reu reintroduced back into wom care in the 1980s and within 1995 within
The UK became readily available to us and it has huge advantages they’re extremely rapid at debriding that devitalized tissue they’re selective they’re very easy to use it requires very little skill in terms of application we know more and more that the actual secretions from the Lara is
The thing that is Magic It’s Magic fluid because it helps to debride the wound we know that it helps to reduce the bacterial burden including MRSA we know that it starts to reduce that chronic inflam infammatory response within the wound and all of that starts to promote wound
Healing you put them on in the tiny little things by the time they come off the size of a fish in magget there’s many mys so you one of the mys that I commonly hear is you can’t use lva therapy in patients wear the pseudomonas because the pseudomonas will peill the
Lva you can see in this gentleman here there is sud amonous contamination and the lav therapy loved it and you’re able to take a wound that we’ve done some blade debridment of but you were still faced with a very devitalized looking wound bed one application of lvy therapy
You can go to a womb bed where you can see you’ve removed a lot of that deviced tissue but you’ve also done something else youve started to stimulate the growth of that new granulation tissue that you can see we’ve used it on patients where they’ve had significant trauma to their
Feet and I would be I would never be brave enough to take a scalpel to that because I know the structures that’s underneath that but actually one application of lva you’re already getting rid of a lot of the diviz tissue the second application of laa you’re all
The way down to that new healthy tissue but you’ve been able to protect those structures you can see the tendons are visible but actually the tendons are still viable if a surgeon would have taken a night of this they may well have disrupted that function of that tendon
And therefore the function and the long-term outcome of that font so what we’re saying um within lav therapy is that it’s not for every time that you have devitalized tissue but there are certain patients where actually live therapy holds some great advantages to you so we encourage you
Really to think about using a debridment pathway this is one that bomond has developed and I really like like this because it starts you to think about the urgency of debridment and that’s the one thing I want you to take away from this session today what is the urgency in
Your specific patients we have to think about the risk to the patient of having that nonhealing wound the risk of of infection the risks of needing further revascularization or operations the actual bioburden itself trying to actually reduce produce those microorganisms and that biofilm that may well be impacting on wound healing it’s
Thinking about what’s the consistency of SLO if it’s thin and and shallow maybe that debent pad may work if it’s thick and well aded you need to be thinking of other therapies we’ve got to remember that the div the diviz tissue is a physical barrier towards healing and a
Breeding ground of that bacteria so the sooner we remove it the better and we also need to think about many patients especially those with pressure um injuries how do you determine the depth until you actually debde how do you know what your treatment should be until you
Understand the size of your problem and if you would like to contact your biomon local rep they will be able to help you with this so they am not saying that lav therapy should be used for every patient with a Divine slice tissue where debridment is needed but they’re simply
Saying we need to be thinking about when is Fast derent required and actually what’s the role of Li therapy within that and they can help you design your own local Pathways and your own local formularies where they can say where we should be using lav therapy first line
Second Line third line or even not at all the actual science and evidence base for lav therapy is massive it’s probably got one of the biggest um evidence base of anything that we do within wound care there’s over 2,000 articles published on this and we there is proven science in
Terms of how effective it is at debridment and preparing that wound bed for healing there’s evidence of that bacterial reduction including that reduction and eradication of MRSA we know more and more about the lvi secretions stimulating granulation growth faster than any other therapy and we know that they are hugely effective
In terms of breaking down that treal in terms of that EPS that’s that’s holding that biofilm in place and I really think that this quote from gamon summarize it all that LV therapy has a seemingly unarguable ability to inhibit to inhibit and degrade bacterial biofilms associated with impaired wound healing
And if you go back to the B beginning of my slides I said to you there’s only really two reasons why a wound doesn’t heal number one he biofilm and that’s going to be present on 80% of the wound and the other is that stuck in that chronic inflammatory Cycle lav Therapy
Has evidence to show that it’s able to move a wound for both of those factors in terms of moving forward when I talk about debridment though I have to always talk about when we shouldn’t be debriding when you shouldn’t be debriding number one is patience patients with um digital ulcers
Caused by critical limb esmia or chronic limb-threatening esea such as these pictures here we also need to be careful in patients with pyoderma because actually debriding those wounds can just make the wound B bigger we also need to be thinking about is there a patient any evidence of underlying vasculitis or
Calciphylaxis because both of these things need to be managed um systemically rather than just debridment alone there are some patients where cautious is needed and and this is not a direct contraindication I’m not saying you shouldn’t debde these patients but we need a little degree of caution we need
A degree of caution if that patient’s got a bleeding disorder or is on any form of anti-coagulation therapy and actually the one thing that I haven’t mentioned so far today is we really need to think about that patient’s pain and their tolerability of that debridment I’m not too sure how I would
Feel if somebody came towards me with a scalpel and a blade and said I’m just going to remove some of your devitalized tissue I’m not too sure I would feel if somebody even came with me with a curette and said that they’re going to scrape away the devitalized tissue I
Think we need to understand that patients pain more and think about their tolerability lav therapy causes no pain and no discomfort to our patients it’s something that we need to consider but prior to any form of debridment full holistic assessment must be undertaken especially in patients with critical
Lemia if you have toes like this we Mother Nature does is doing the job for you we don’t need to be encouraging debridement we shouldn’t be managing these produ this patient with debridment products we should be just trying to keep those toes as dry as possible not allowing bacteria to start to flourish
Because in toes like this mother nature will do the job they will eventually Auto amputate and actually Mother Nature will form a line between that V vital and devitalized tissue so cautious is needed in any patient with pril arterial disease we also in a degreed to caution in terms of
Recognizing when patients have infection all of these patients have got the vitalized tissue but it’s on a background of significant localized infection which will cause systemic infection if not treated well all of these patients are diabetic patients and I’ve got diabetic foot infections so we need to be ensuring that we are treating
That device Li tissue in combination with antibi antibiotic therapy potential surgical debridment and even potential revascularization so if you’ve got any patient where you’ve got a wound on the foot my caution to you is please please think about the involvement of that white MDT the foot itself has got lots of
Bones lots of joints lots of muscles lots of tendons and the blood supply down to those little toes and onto that foot is complex and we need that wider MDT to try to optimize that wound healing in that patient but just to finish really I just want you to think about if
This was your patient if this was your patient and a seemingly easy to heal with wound you can see that that patient’s got some devitalized tissue that’s in a negative stance you’re on minus weeks we need to get that wound to point zero in the that middle picture to allow wound healing to
Occur and the most the most important aspect is time we need to be thinking about how quick can we remove that devitalized tissue to get it to that wound healing where the wound healing bed is perfectly prepared for wound healing to come so rather than just always turning to wound dressings think
About that speed of debridment think about what other products are available to you wound healing and wound delays in wound healing there’s never a simple single Factor there’s often many contributing factors at play but every wound that you’re seeing out there that is not healing will have a
Very similar cell response there will be high levels of proteases elevated inflammatory markers low growth factor activity and reduce cellular peripher good wounded bridan helps to get cure all of those things it really helps us in terms of aiding that wound healing so is it time for a change I’d like you to
Think about where you are in terms of your optimal wound healing do you assess patient in a timely fashion are you able to ensure that you’ve got that accurate diagnosis are you good at WB bed preparation are you able to offer your patients Speedy debridment to get them
To point zero as soon as you can what is your management for a biofilm if 80% of wounds out there have got a biofilm present how are you managing that at each and every addressing change and I’d really like you to start focusing on wound healing I hate the fact that many
Nurses tell me they’re good at wound management I don’t want you to be good at managing wounds I want you to be good at healing wounds in combination with your patients because actually it’s only when we start to focus on the time and focus on the healing and we start to
Actively actively prevent chronic wounds in the future thank you so much for listening um I hope you found that interesting and hopefully we’ve got some questions to answer thank you so much lean that was a really brilliant presentation I loved it and I hope everybody at home did as well so yes
There are a few questions that have come in so let’s have a little look and at this point I am going to invite um everybody my colleague Vicky Phillips on to the call as well um Vicki is the clinical support manager at bamon so she can answer any specific queries
Surrounding larel therapy okay so the first question that’s com in is um your thoughts on using medical grade honey dressings as an alternative solution compared to Silver dressings um I think antimicrobial dressings all have their place um and um and it’s really interesting that my first thought about honey is an
Antimicrobial dressing um I I think they all have the place um I think that they can all be overused me personally the problem I have with honey dressings is that I do find that they can tend to increase the levels of exudate and you might combat that with
Well yeah because they’re starting to impact wound healing and when you start to impact wound healing you might get increased exate level I get that but the thing that really sort of bothers me with honey is patients can find it painful and I don’t understand why and I
Don’t understand why 50% of my patients I can put it on and they get no pain whatsoever and 50% of my patients are pulling it off within a few hours and there are talks that it changes the pH of the wound bed that might actually bathe the nerve endings causing that
Pain I don’t use much honey in my clinical practice because I don’t like the fact that I could give a therapy to a patient that they’re going to find painful towards the end of that day that just bothers me as a clinician that it’s just not something that I do I’m not
Saying it’s not a bad product um but I would say my use of antimicrobial dressings have gone down significantly since I’ve started wound hygiene good wound cleansing good wounded bridan actually you reduce the need for um antimicrobial dressings and my silver spend has gone down by about three
Fifths and so it’s gone down significantly and and we used to have problems all the time in our Legal Clinic of chronic pseudomonas that we could never get on top of and we were just chasing it with various antimicrobials we had they have any of that now because all of my team actively
Cleanse and debride every single dressing chain brilliant thank you for answering that one lean so the next question that’s come through um is regarding debridment options and this person is asking have you had good experience with mechanical debridment using products such as debrisoft or UCS cloth and they’ve
Commented that they think these are a cheaper option for trusts who have a lesser budget or in the community um when this can be done by Community nurses on their rounds yeah yeah um so so um I I hate naming products especially competitive products when I’m
On these type of calls but I will tell you how it goes in my clinic and so um every patient gets a UCS um wipe in my clinic but truthfully I use that more as a cleansing wipe for the leg and the the the surrounding tissue to to to hydrate
That and pick off the surrounding skin and using them on the wound bed itself yeah can be useful um along with mechanical debridment p they can be useful but it’s only useful I think on certain types of sluy tissue and I think it’s that very very wet mozzarella
Cheese type sluff that’s quite loose in the first place and absolutely you know if you’ve got that type of sluff I won’t be turning for a bag of lva therapy I would just be doing mechanical debridment to getting rid of that but those remember those pictures that I
Showed you with all the different types of sluff in different areas and different depths that to me is a sweet spot of the lav therapy because no mechanical debridment pad is going to be able to do that I I know that they do the lollies to get into the hard places
But again it’s only good really on that superficial wet sluy tissue once that sluy tissue starts to dehydrate and it’s so well aded to that WB bed you can’t get it off with a debridment pad you struggle to get it off with a curette oh lovely thanks Leanne for
Being so honest on that one so the next question that’s come through um this could be for both of you to answer actually um and it’s what can be used to hydrate a dry wound in preparation for Lara therapy um and they’re also asking about wounds that might have a mix of
That wet and dry tissue that you mentioned Leanne um and they’ve said could those wounds benefit greatly from lavel therapy so I’ll take that first then I’ll hand it over to Vicki if you’ve got a mixed bag so at least 5050 sluy and and necrotic tissue I I won’t
Bother rehydrated I won’t bother worrying about reh hydrating the necrotic tissue part you can get your lva therapy on and actually the exudate that comes from the lva feeding off the wet aspect of that wound will start to debride the other aspect at the same time so wouldn’t be overly bothered if
You have a whole load of necrotic esar that is not the time for LV therapy they want some to to to feed on and sometimes it can be just too too too hard for them to get through there’s lots of things that you can use um in my clinical
Practice I use a combination of wound gels that you can put on to hydrate it just for 24 hours the one thing is make sure you wash them off well because some of them can be toxic to the lvy therapy themselves the other things that we can
Use is stuff like um the gel dressings that can help to rehydrate a little bit or the ones that contain High volumes of ringer solution where you can actually wash the wound bed through but anything that you’re going to donate wound water H EX you’re going to donate moisture to
The wound bed anything will do you probably only need it for 24 hours so actually if it’s that dry or do your lva therapy today get get some of that rehydrating on right now by the time your lva comes tomorrow your wound bed’s probably going to be suitable for it and
You are you just have to increase your knowledge of what type of devitalized tissue you’re looking at because there’s ranges of this if it’s a big thick plug plug that’s hard as anything and you could sort of have it like a candle you might need three or four days of
Rehydration but most wounds that we’re talking about tonight will be just a really small amount of necrotic tissue that actually if you can go put a blade in the middle of it and you can see the redness coming through the middle of it one day of rehydration you’ll be all right with your
Lava brilliant thank you Vicki do you want to add anything to that or Happ not really I think we uncovered it I think the most the most important thing to just um reiterate is that um there’s a lot of people who think that if you are having to soften the the
The necrosis before you put Lara that you have to have a rest day but that’s not the case just a really good wash with some saline sterile water whatever is enough so um yeah like Leanne said if you think it needs something then just overnight whilst you’re waiting for the
Larae to come is usually the perfect amount of time oh wonderful thank you both the next question that’s com through from Paula she’s asking where can she find training for Shar de bridan please um so there’s multiple options of Shar de bridan um so um um here we are
Name dropping again um so probably the the best course that’s available at the moment is run by accelerate um so they’re a private Enterprise company but do NHS work mostly and if you just look at their website accelerate um you’ll see that they’ve got bment cost they use
Some really good woo models that’s designed at the University of Huddersfield so actually can feel the different Tio Lays and that’s a really good one I know wound care today um often have a debridment session within their conference so that might be worth looking at too um and um there is also
Some kadava training so there is a a company Smith and nephew um that actually you’re allow they enable you to do some kadava training um down in their facility so actually you work on on on on on on limbs of of of of of of dead
Bodies um that can be really useful the problem is with that though they don’t bleed and and and I think that that becomes the difficult thing but it is a good way to see different types of devitalized tissue and there are competency Frameworks though because
There is no requirement for you to do a formalized course you can learn this in house so if you’ve got somebody who you debrides within your team they can teach you how to debridment and there are competency Frameworks around that if you look at wound hygiene competency framework it talks about competencies of
You using mechanical debridment um and sharp debridment and you can do those in house so there’s plenty of options for you lovely thank you lean and exactly the same question has come through for the curettes as well um with competency and training requirements so similar route yeah all of them and accelerate um
And wound care today all cover curet along with so does the wound hygiene um competency framework they all come pet lovely thank you very much so a question for you Vicki can anyone request or initiate lavel therapy that is a good question so um although it is a a
Prescription product so it does need to be because it’s unlicensed it does need to be an independent prescriber who actually writes it up I don’t think that means that you have to wait for the Independent prescriber to suggest it I think it’s really important if you think
Your patient is suitable for Lara to ask the question because the worst than one’s going to say is no that it’s not suitable for this patient and they got to remember the independent prescribers most of them you know they’ve got a big workload they not necessarily going to
Be able to see all the patients who are suitable for Lara so yeah I think it is always worth asking the question even if it’s not you that makes the final decision lovely thank you and a very similar question actually from Tracy um she’s had concerns in the past with the
Process being slow um in requesting ly from a prescriber to the point of application and she’s wondering would she ever be able to prescribe as a non-medical prescriber I think the answer is no to that isn’t it only if she’s an independent prescriber so yeah nurses can do their independent prescribing
Podiatrists um we’ve even had a physio not long ago um prescribe it so as if you’ve got your independent prescribing qualification yes you are covered um but yeah otherwise you’d need to find someone so it’s a really good idea to go away after sessions like this and and
Find out who’s covered in your local area to write it out brilliant thank you and a question now probably for both of you um so Sita has said she’s um a little bit hesitant with using lvi just due to pain levels um she’s had situations in the past with patients
Where she’s actually had to discontinue the use due to pain levels have you got any advice for her please well I found that really interesting because I’ve never had that with my patients I’ve had some patients that’s got a bit bleedy and oozi with them as as side effect but
I’ve never had any patients where pain has been the issue I can imagine the patient that she’s talking about though May well have a degree of oversensitive neuropathy and so what they’re finding is actually that the movement of the lva is stimulating the nerve endings that’s giving the pain and those type of
Patients any pain management is really difficult to be able to get right with them but certainly she’s doing the right thing you know if any form of therapy is increasing a patient’s pain that therapy needs to be sted from my point of view um it’s just not appropriate but it’s
Not something I see or I’ve heard of in my clinical practice in terms of the lva many of them don’t like it many of them tell me that they can feel them moving and it feels like they want twitch the hair all the time but none of my patients have reported increasing pain
Vicki is that something that you see um we do occasionally I think the main thing to remember is that with a therapy like this it is a bit different and I think it’s important just to spend 10 minutes talking to your patient about any queries concerns things like that
They might have because movement like you say lean is a bit weird it’s a bit uncomfortable and if you’re not expecting it it can be quite anxiety inducing so if you can just spend sort of 10 minutes before you reply it explaining to your patient that as they
Get bigger you might feel them but it’s totally normal also talking to them about how the larae feed so explaining to them that they don’t bite cuz they haven’t got teeth so not you’re not going to feel anything munching or crunching and I really think you know
Just spending a little bit of time with patients before can really help them um when they do get some Sensations to to um be able just to cope with it a bit better and you know all understanding that is really important Vicki because you know I’ll always remember the time
That you put the lva into the bags and and I was like well how are they’re going to feed how are they going to work now and and I really did believe that the LA had teeth and the chowed down and you know and it was only through doing
Your education through your company that I realized that these are straws and what they do is spit in zoomatic fluid that kills the bacteria and dissolves the divis siiz tissue and then they suck it back up again and that’s what they ingest but you know once I got that I
Thought that really helped me explain it to my patients that actually they’re not going to chew on you per se because actually they’re in a bag all we’re using basically is their spit to dissolve this down and I often think with the movement thing though I’d love
To do a study I’d love to do a study of actual ly that’s alive and L that’s dead and ask you know 50/50 Can you feel it because it’s the same thing if if you’re next to a mother and that mother says my child’s got headlight you instantly want
To itch your hair and it’s just something in you that look it’s there it’s itching now just talking about headlight and and I often think is there a degree of that within the LV therapy and I’d love to do a study to to to understand definitely brilliant thank you both and
We’ve had a little flurry of questions actually just around the daily care processes for lvi so we’ll do these ones quite quickly everybody um so the first um question that’s come in is can lvi be used in the community yes yeah brilliant uh the second one is just about securing
That bioag down onto a wound bed so um have you got any tips and tricks for what secondary dressings to use and the tape and things like that to secure the bag in place please um so from my point of view um it depends where it is you
Know if you’ve got um a cavity and that cavity let’s say is on a thigh on the top of your thigh you don’t need to scure it with anything but the lvy in the cavity put some moist SCS over the top of it a bandage or retaining
Something you’re you’re on a winner the difficulty comes let’s say if it’s on the sole of the foot and you’re holding that on and you need needing to rehydrate them every day and you don’t want that bag to fall off because if that bag falls off onto the carpet
You’ve lost all of that that that cost you might want to secure it just with some form of tape just a thin layer of tape just over the top of that bag to keep it in that position but all of this depends on the location the surrounding
Skin condition and and and and how much ex is coming from that wound I would just say it go it goes back to just your common sense you’ll know what to do with these it’s not rocket science and you can’t go wrong is what I’d also say brilliant thank you very much for
Answering that and just um just to close then on the um point of the sort of daily uh care processes um we’ve had an interesting question um from uh somebody in Germany they have heard in the past that you need to turn the bio bag around on the wound bed
Twice which I’ve never he before so that was something we used to do when it was biofoam I believe a while ago because the way it was sort of um made up you had lots of little chips in it so you had to make sure that the larae um could
Get to everything but yeah with the buyer bags you don’t have to worry about that if anything you’re going to put them on the back foot because the way they work there they all be sort of face down as it were and if you flip them
Over they then all got to turn back around again to get to their food source so yeah just leave leave them well alone they’ll be fine but that person’s not going mad I’ve heard that before I’ve heard that we’ve had not flip them twice but flip them once and every time you
Rehydrate them you should flip them over yeah and I’ve even asked that question went where’s that come from um and and the answer is no all you need to do is just rewater them that’s the only thing that they require oh brilliant so some nice updated education there thank you
Both um so just moving back now quickly towards uh debridment in General um so the question here is is the bridan enough for treating a wound that shows signs of ponus with that blue or green and green drainage and should it be followed with antibiotics or an antimicrobial dressing as well so
Um in first off no antibiotics needed that’s an easy one unless they’ve got a systemic infection absolutely we don’t treat localized pseudomonas with anti with any form of antibiotics lava therapy are effective at eliminating pseudomonas um however pseudomonas can be persistent so if you are debriding
With um um lav therapy and you still you’ve used one and you’ve gone from 90% sluy tissue down to 10% sluy tissue you may well still have a residual ponus remaining and then you could SWAT to an antimicrobial dressing just to carry on you a little bit more debridment get rid
Of that pseudomonas burden and or if you’ve got a huge amount of ponus Burden what you might decide to do is to treat with some antimicrobial therapy whilst your La is on order and then swap it back over and ponus is a is a persistent
Devil is what it is um so it’s very unusual that you can treat it just once it often requires a course of treatment over a number of weeks to be able to get on on top of that ponus but the one thing that’s really good for pamon B us
Is good wound hygiene What good cleansing and regular debridement to get rid of it lovely thank you and the last couple of questions Now ladies uh before we close the Q&A session so the first one is what is the level of sterility expected for bedside or clinic based conservative debridment and they’ve gone
On to ask with questions clean technique or sterile procedure oh here we go this has been this is I wonder if this persons in the UK um to me it’s a clean technique it and it’s and it’s a part of your entt non-touch and if I was doing some form
Of debridment I would certainly do my entt Approach um however I have to say that and I think if I wasn’t debdon I think entt in patients with leg ulceration is extremely difficult if not impossible to do um so I think that we really need to be forcing back on this
Infection control because actually what we really need to do with these patients is wash their whole leg debride that that that those skin cells REM moisturiz and you know I I still believe in the use of buckets of water um you know not soaking for a long time but actually
Cleansing that skin and that’s around in tissue I think this is an infection control debate to be had um but in my practice it’s a clean technique lovely thank you Leanne and the last question of the evening how good or bad is fluorescence usage in
Wound care well who knows is it and it’s an emerging science and it’s something I’ve certainly got my eye on um because it do you know if I could have a bedside test to be able to show what’s the level of bacteria um where is that bacteria in
The wom but itself I think it’d be really useful um I’ve seen a lot of the studies and I’ve seen a lot of them in terms of showing how some therapies you can really see your action there and then the difficulty is with it is is it
Really showing you what you think you’re showing and actually how easy is it to use in clinical practice because you need a very dark room and most of our clinical rooms have got daylight of some description coming in by a frosted window and that can make it really
Difficult to use I am interested all I’d say to you is though I have bought a device and I hardly ever use it and that sort of worries me that if I have that tool if it was so valuable to me would I be using it more and more I think it’s
Great for an academic and I think it’s great for research and science I’m not too sure how valuable it is in everyday clinical practice but my eyes on that space and I am open to be turned if the science shows me that it’s good um in
The future so I think just watch that space it’s an unanswered question at the minute oh definitely we’ll wait and see thank you so much Leanne for answering those questions and thank you to everybody at home as well really brilliant set of questions this evening so thank
You so if you’ve enjoyed the session this evening everybody um you can find more biom mod live webinars on on our website we have mapped out basically the entire year for you so if you do want to register for any of those please go ahead and do so and we do have some
Other learning options for you as well so we’ve got biom one now which is our online video portal we’ve got bomond Academy which is bite-sized e-learning modules and lastly is biome on Direct which is a onetoone remote consultation with Vicki and we um I have just popped some
Contact details on the slides here for you as well so do feel free to make a note of those if you’ve got any questions at all after today on lval therapy we can certainly do our best to help you and we are on every form of social media you can possibly imagine so
Do please come and say hello there it would be great to connect with you but thank you a huge thank you to Leanne it’s been a wonderful session this evening I’ve thoroughly enjoyed it and thank you to Vicki as well for coming on for those questions at the end and a
Huge thank you to everybody at home I really hope you’ve enjoyed and we’d love to see you again on another bomond live in future good evening [Applause] everybody