Modifying perfusion, nutrition, and stress to promote wound healing in patients with acute wounds

Assessing Soft Tissue Perfusion Using Laser-Assisted Angiography in Tibial Plateau and Pilon Fractures: A Pilot Study

OBJECTIVES

To determine whether skin perfusion surrounding tibial plateau and pilon fractures is associated with the Tscherne classification for severity of soft tissue injury. The secondary aim was to determine if soft tissue perfusion improves from the time of injury to the time of definitive fracture fixation in fractures treated using a staged protocol.

DESIGN

Prospective cohort study.

SETTING

Academic trauma center.

PATIENTS

Eight pilon fracture patients and 19 tibial plateau fracture patients who underwent open reduction internal fixation.

MAIN OUTCOME MEASURES

Skin perfusion (fluorescence units) as measured by LA-ICGA.

RESULTS

Six patients were classified as Tscherne grade 0, 9 as grade 1, 10 as grade 2, and 2 as grade 3. Perfusion decreased by 14 fluorescence units (95% confidence interval, -21 to -6; P < 0.01) with each increase in Tscherne grade. Sixteen patients underwent staged fixation with an external fixator (mean time to definitive fixation 14.1 days). The mean perfusion increased significantly at the time of definitive fixation by a mean of 13.9 fluorescence units (95% confidence interval 4.8-22.9; P = 0.01).

CONCLUSIONS

LA-ICGA perfusion measures are associated with severity of soft tissue injury surrounding orthopaedic trauma fractures and appear to improve over time when fractures are stabilized in an external fixator. Further research is warranted to investigate whether objective perfusion measures are predictive of postoperative wound healing complications and whether this tool can be used to effectively guide timing of safe surgical fixation.

LEVEL OF EVIDENCE

Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Optimizing the patient for surgical treatment of the wound

Plastic surgeons are consulted often to close wounds that fail or are difficult to heal. Optimizing the patient's medical condition before surgical closure of a wound can mean the difference between a successful outcome and an undesirable one. It is imperative that plastic surgeons have an extensive knowledge of the modifiable risk factors affecting the wound-healing process and their subsequent complications. This knowledge allows the surgeon to tailor the treatment options and intervene when appropriate to optimize outcomes for successful surgical closure of a wound. Whether the impairments to wound healing and closure are local or systemic, they must be addressed appropriately.

Psychophysiological Response to Severe Sport Injury Among Competitive Male Athletes: A Preliminary Investigation

Features of posttraumatic distress have been associated with treatment noncompliance and delayed surgical recovery among general medical and trauma populations. Although cognitive-affective and behavioral features of posttraumatic distress have been demonstrated among adult and adolescent athletes with injuries, physiological responses associated with posttraumatic distress have not yet been examined in this population. The objective of this study was to examine psychophysiological stress reactivity to orthopedic trauma among male athletes who sustained a severe sport injury. Athletes with injuries (n= 7) and non-injured athlete controls (n= 5) completed self-report measures of psychological distress and were then shown injury video footage while heart rate and skin conductance measures were recorded. After exposure to orthopedic trauma-related video footage, athletes with injuries demonstrated significantly greater skin conductance reactivity and subjective distress compared to controls. As demonstrated among other medical and trauma populations, athletes with injuries exhibit exaggerated stress reactivity profiles when primed with orthopedic trauma stimuli.

Considerations in prevention of surgical site infections following cardiac surgery: when your patient is diabetic

The incidence of surgical site infections among patients with diabetes continues to occur at a greater rate when compared with their nondiabetic counterparts. Preexisting vascular changes, delayed wound healing, and impaired immune factors contribute. Adult patients with diabetes likely possess comorbid coronary artery disease, thus increasing the need for cardiac surgery. The resultant potential for infection can be combated with supplementary interventions above those universally taken. Modifiable risk factors of hyperglycemia and obesity are targeted preoperatively. Glycemic control, adequate tissue perfusion, and adjunct use of nasal mupirocin are addressed intraoperatively. Lastly, focus is placed on nutrition, exercise, and continued glucose control postoperatively and beyond discharge.

Acute wounds

The most important factors in the management of acute wounds are the history and physical examination. The goals of wound care are fivefold: avoid further tissue damage, achieve wound closure as rapidly as possible, restore function to the injured tissue, facilitate the patient's expedient return to normal daily activities, and restore the patient's quality of life. The treating physician must have a good understanding of the wound healing mechanism. One must rule out all associated occult injuries that may be life threatening. Proper wound assessment and management with minimal discomfort to the patient are crucial. The primary goal is to facilitate the healing process to achieve a cosmetically pleasing and functional result.

Effect of nutritional supplements on wound healing in home-nursed elderly: a randomized trial

OBJECTIVE

The objective was to determine whether provision of oral nutritional supplements, delivered by community nurses, could improve nutritional status and wound healing in home-nursed elderly.

METHODS

This was a double-blind, randomized trial in 50 elderly patients referred for wound management. Patients received 237 mL/d of 4 or 8 kJ/mL of an oral nutritional supplement for 4 wk. Nutritional status was measured with the Subjective Global Assessment and the Mini-Mental State Examination questionnaire to determine cognitive function and wound characteristics to assess healing. Differences between variables were examined with the Mann-Whitney or Student's t test for comparing two groups, one-way analysis of variance when there was more than two groups, and chi-square analysis for comparing two categorical variables. Associations between variables were examined with Pearson's correlation and regression analysis.

RESULTS

At baseline, 34% subjects were moderately malnourished and 8% were severely malnourished. In both groups, there was significantly greater improvement in Mini-Mental State Examination scores at week 4 (95% confidence interval -2.0 to -0.001, P = 0.04) and a greater decrease in the wound effusion score (95% confidence interval -2.0 to 0.0, P = 0.045). Median length of stay did not differ between groups (P > 0.05).

CONCLUSIONS

Malnutrition is common in elderly patients who are nursed at home for wound management. Provision of energy- and protein-dense oral supplements by community nurses is effective in improving some indices of wound healing and cognitive function in this group. Although further study is needed to determine the effect on length of stay, the nutritional needs of this vulnerable group should not be overlooked.

The pragmatics of feeding the pediatric patient with acute respiratory distress syndrome

Acute respiratory distress syndrome (ARDS) represents the ultimate pulmonary response to a wide range of injuries, from septicemia to trauma. Optimal nutrition is vital to enhancing oxygen delivery, supporting adequate cardiac contractility and respiratory musculature, eliminating fluid and electrolyte imbalances, and supporting the proinflammatory response. Research is providing a better understanding of nutrients that specifically address the complex physiologic changes in ARDS. This article highlights the pathophysiology of ARDS as it relates to nutrition, relevant nutritional assessment, and important enteral and parenteral considerations for the pediatric patient who has ARDS.

Perceived stress and cortisol levels predict speed of wound healing in healthy male adults

The main purpose of the present study was to investigate the association between perceived stress and impaired cutaneous wound healing in humans using a novel wound assessment technique, and taking into account putative mediating factors such as cortisol levels, health behaviours, and personality factors. The study made use of a prospective, within-subjects design in which 24 male non-smokers participated. Every subject received a standard 4mm-punch biopsy, and the healing progress was monitored via high-resolution ultrasound scanning. Participants completed questionnaires on perceived stress, health behaviours, and personality factors, and sampled saliva for cortisol assessment after awakening at 2 weeks prior, directly after, and 2 weeks after the biopsy. The overall results showed a significant negative correlation between speed of wound healing, and both Perceived Stress scale (PSS) scores (r=-.59; p<.01), and General Health Questionnaire (GHQ) scores (r=-.59; p<.01) at the time of the biopsy. The area under the morning cortisol response curve was negatively correlated with speed of wound healing (r=-.55; p<.05), indicating a clear elevation in the morning cortisol slope of those whose wounds were slowest to heal. A median split of the complete sample yielded that the 'slow healing' group showed higher stress levels (PSS t=3.93, p<.01, GHQ t=2.50, p<.05), lower trait optimism (t=3.25, p<.05), and higher cortisol levels to awakening (F=5.60, p<.05) compared with the 'fast healing' group. None of the health behaviours investigated (i.e. alcohol consumption, exercise, healthy eating, and sleep) were correlated with healing speed at any time point. Our data hint at a considerable influence of stress on wound healing, and suggests that elevated cortisol levels, rather than altered health behaviours, play a role in this effect.