Healthcare e-Compendium
A joint initiative of DPSRU & DRSC
Healthcare e-Compendium
A joint initiative of DPSRU & DRSC
Author: Dr. Anant Sinha
MBBS, MS, MCh (Plastic Surgery), Devkamal Hospital and Research Center, Ranchi
download ArticleAbstract
The COVID-19 (severe acute respiratory syndrome SARS CoV-2) pandemic has presented a great challenge and global threat. A wound is a disruption of the normal structure and function of the skin, possibly extending more deeply, and may be regarded as acute and chronic. The management of wounds in the present pandemic is a great challenge for the healthcare professionals. Multiple studies have shown that patients who have wounds also have comorbidities including diabetes, blood pressure, pneumonia, heart disease, respiratory disease, and are at greater risk of COVID‑19. Due to multiple comorbidities, wound patients are at an increased risk for the most extreme complications of COVID-19 and healthcare professionals must focus on reducing their exposure risk by providing them proper care with less movement to the hospitals.
Keywords: COVID-19, SARS COVID-19, Wound, Wound Care, Pandemic, Ulcers.
Introduction
First reported in December 2019 in Wuhan, China, COVID-19 has spread quickly, with confirmed COVID-19 cases in 220 countries worldwide till date [1, 2]. COVID-19, has disrupt normal healthcare setup bringing out extreme changes in the healthcare guidelines, healthcare practice, and hospitalization procedures. This has hampered the established best practices, affecting patients with critical, chronic, and other life‑threatening disease who require continuous treatment and monitoring [3] leaving a large population without treatment and care [3, 4]. Particularly, the patients who require general medical and nursing support for injuries like the wound care management have been affected badly due to changed out-patient hospitalizations. Although, low‑priority wounds can be managed in the home-settings by providing additional support to the patient through visiting nurse services with physician oversight through telehealth. High-priority wounds on the other hand will require additional services available in the clinic or hospital setting. Wound care centers have thus started the procedures of wound management from the home‑setting. This has been done to minimize the chances of COVID-19 exposure among these vulnerable population as they may have cardiac, hypertension, chronic renal failure, chronic lung disease, neurological problems, and diabetes, which may worsen the existing diseased condition [5].
A wound could be an injury to the skin or underlying tissues, organs due to bruises, cut, friction or sheer force, pressure or as a result of disease (leg ulcers or carcinomas) or during a surgery [6]. The injury could rupture the skin preventing its protective function, continuous loss of epithelium which may or may not involve underlying connective tissues (i.e., bone, muscles, or nerves) [7]. A wound can be classified based on its etiology, anatomical location, or its severity (acute or chronic), presenting symptoms, method of closure, or the appearance of the predominant tissue types in the wound bed [8].
Chronic wounds are commonly occurring in 1 to 2 per 100,000 populations in the United States. Furthermore, in patients with diabetes and those over 65 years, lower extremity chronic ulcers predominate [9] with a prevalence ranging from 0.18-2% and up to 5% in patients over 65 years [10]. For managing chronic wounds during COVID-19 pandemic, modern dressing, use of technology such as negative pressure wound therapy, and tele-medicine could be an effective way to manage along with avoiding the exposure risk of COVID-19 [11].
The lower extremity wounds could be classified as follows [12]:
In the present paper, the management of different kinds of wounds described above is presented.
Ischemic Wounds: Cause and Management
Ischemic wounds occur as a result of blocked blood supply to vascular beds in the body. Most often these types of wounds occur on the legs, feet and toes. Particularly they occur on the shins, tops or sides of feet as well as the tips of toes or between the toes (where the skin tends to rub together). The increased consumption and insufficient supply of oxygen in the infected tissue lead to necrosis, resulting in spread of infection and deterioration of patient’s health condition. In case of the infection and necrosis is not salvageable, amputation (trans metatarsal, below-the knee, or above-the-knee) should not be postponed. Blood flow to the extremity, age, general condition of the patient, comorbidities, anticipated length of postoperative hospital stay, and the anticipated need for re-amputations, and postoperative morbidity are the factors that influence the decision to amputate. The level of amputation is determined by a multidisciplinary team consisting of vascular surgeon, infectious diseases physician, orthopedic surgeon, plastic surgeon, endocrinologist or dialectologist, interventional radiologist (if present), podiatrist (if present), and hyperbaric oxygen physician (if present).
In patients with acute limb ischemia and wet gangrene with progressively tissue loss and ascending cellulitis, urgent surgical debridement should be performed to diminish the bacterial load. Broad spectrum antibiotics treatment must be administered immediately and continued postoperatively. In patients with chronic limb ischemia and non-salvageable limbs urgent surgery amputation is recommended. Non-salvage ability can be attributed to advanced lower extremity arterial disease, advanced tissue loss, poor health status of the patients precluding timely intervention or all of the above.
Patients admitted to vascular surgery outpatient ward with chronic peripheral vascular disease may have claudication with non-healing ulcers, while some may have pain in the lower extremity with ulcer or infected toes. The best medical care for this group includes revascularization followed by amputation of the affected toes and wound care [13]. Postponing surgical interventions follow-up on the outpatient basis is recommended. Revascularization and surgical debridement should be postponed, unless the wound are infected [13]. Zinc oxide can be used to prevent moist in the perimeter of the wound.
Prophylactic antibiotic treatment can be initiated in case of suspicion or history of secondary infection. If the non-healing wound (healing slow with a granulated wound bed), skin grafting procedure may be considered. The patients and/or their caregivers should be trained to apply wound care and change the dressings, preferably daily to avoid wound infection. If the caregiver does not live with the patient, he/she should be trained about social distancing, providing wound care under sterile conditions, using a face mask all the time during wound treatment, and ventilating the room during or after each visit by the caregiver. The patient or the caregiver should be informed about how to use telemedicine such as clicking and sharing photographs with the healthcare staff.
Lymphovenous Wounds: Management Procedure
Compression therapy is the mainstay of the treatment for both venous and lymphedema ulcers, as edema, exudation, and exudation-related skin problems are common in these ulcers. Lymphovenous edema causes a dry, itchy skin, which may lead to loss of skin integrity and a rise in bacterial infection even after an unnoticeable physical trauma such as insect bite or itching. Once the infection starts, the wound enlarges rapidly, and the exudation increases. American Venous Forum Guidelines recommend a three component approach for the optimal treatment of Lymphovenous wounds, as described below [14]:
Most of the Lymphovenous bleeding episodes can be stopped with prolonged topical compression on the site of bleeding or suturing the veins under local anesthesia. It is strongly recommended to postpone all the venous surgical procedures during COVID-19 pandemic, with profuse bleeding of the varicosities being the only exceptional case to follow the recommended optimal treatment approach.
For the hospitalization need, it is recommended that priority should be given to the wounds: (i) with signs of systemic infection (ii) heavily exuding wounds with local skin infection requiring dressing change more than once a day; and (iii) Lymphovenous wounds with arterial insufficiency (mixed wounds) that need urgent revascularization, close follow-up, and intravenous administration of broad-spectrum antibiotics. The patients with Lymphovenous ulcers are usually treated at the outpatient clinics where compression treatment is applied either with two or four‑layer bandages which are changed twice a week [14, 15].
In addition to this, wound status and exudation volume, patient’s social circumstances and economic status, or availability of the healthcare facilities determines the hospital visits. However, it is recommended that during the pandemic or war times, the indications should be narrowed and the frequency of dressing should be reduced for the rest of the Lymphovenous ulcer patients.
Shifting from bandages to compression hosiery and wraps
The patients and their caregivers should be encouraged to change their own dressings. Absorbent dressings such as alginates, hydro fibers, and foams, which can stay on the wound for more than three days may be preferred. Silver dressings can be combined to treat local infections or to prevent the wound from getting infected [15]. The frequency of dressing change can be determined according to the amount and nature of the exudation. In case of a suspicion of a local infection and highly exudation, it would be wise to perform daily wound cleansing and dressing. Swap cultures from the exudation or tissue cultures from different sites of the wound should be obtained in each hospital visit. Antibiotics should be given, when a local infection is suspected or systemic signs of infection are present.
Having said this, it is quite unusual for a patient or non-medical personnel to apply two or four‑layer compression bandages in the right manner alone. Compression wraps for highly exuding wounds, infected wounds, and wounds with wound dermatitis that need frequent dressing change and application of creams are thus recommended. The most reasonable and frequently used options are compression hosieries and self-adjustable wraps. However, they have their own pros and cons. For example, ulcer stockings are difficult to wear, particularly in highly edematous legs, ulcers with stasis dermatitis, highly exuding or infected ulcers, irregular shaped extremities, in patients with peripheral arterial disease, or with orthopedic problems; and in elderly population with reduced muscle power who are unable to wear these tight stocking alone and in large ulcers due to pain caused by the stockings [16]. Self-adjustable wraps are available in the market for more than five years and their use has been increasing worldwide in elderly individual.
Shifting to more sparse follow-up intervals by keeping the bandages in situ for more than four days (between 5 to seven days at most)
In patients who are not capable of changing their dressings and applying any form of compression treatment at home for any reason prolonging the follow-up intervals is recommended. For these patients superabsorbent dressings made of polymer and cellulose or multi-layers of standard absorbent dressings such as alginates, hydro fibers and foams should be used to avoid leakages, ruining the integrity of the bandages, and precluding dressing change earlier than planned. Non‑adherent paraffin or silicon embedded interface dressings should be preferred in low exuding or dry wounds to avoid sticking of the gauze or other types of dressings to the wound. Silver‑containing dressings can be chosen in suspicion of local wound infection or bacterial contamination. If the patient or the caregiver desire to apply his/her own multilayer bandage, he/she can be trained in the outpatient clinic on how to apply bandages.
If passive wound dressings are not available, negative pressure wound treatment (or vacuum‑assisted closure) can be used under compression bandages as an option, unless the patient has accompanying peripheral arterial disease. The foam can be left in place up to five to seven days.
Diabetic Foot Ulcer: Management Strategies
Although, diabetic foot ulcer treatment procedures, debridement, and amputations during pandemic circumstances can be neglected owing to increased risk of mortality from COVID-19. However, it should be noted that these are a fragile group at high risk of getting infected, losing a limb, or die if not treated promptly [18].
Prevention of DFU is not possible without active daily involvement of the patient, given the following recommendations: foot care, hygiene, and their glycemic index must be in control use of prescribed shoes and avoidance of dangerous conditions (i.e., hot sand in the summer). Education in DFU care may guarantee that the patient has adequate knowledge of self-foot care and may motivate the patient in daily prevention. For many years, the goal of DFU care was to heal wounds to avoid major amputations [4]. Therefore, a rehabilitation specialist should be responsible for diabetic patients who need to return to walking after a long period of immobility in both primary prevention (when neuropathy is responsible for the initial changes in standing and walking) and secondary prevention.
For managing the diabetic foot ulcers triaging the diabetic foot patients according to the presence of infection and limb ischemia is recommended. The triaging system was suggested to help inform the best setting in which to treat patients. This system applicable based on variety of wound etiologies and complications with only minor modification. The triage categories are presented below [3]:
If the patients present with foot ulcer, severe systemic infection and acute limb-threatening ischemia, these patients are considered to have a high risk for mortality and limb loss; hence, urgent debridement followed by the revascularization procedure is advised. These patients must be hospitalized and treated with short-acting insulin promptly and intravenous broad spectrum antibiotic therapy [19].
If the patients present with foot ulcer with mild/moderate infection and acute/chronic limb ischemia, they should be accepted to have a moderate risk for limb loss and these patients must be hospitalized and the same aforementioned algorithm must be followed and elective revascularization must be performed during the hospitalization period.
The other group of patients with infection are the ones who present with acute/chronic osteomyelitis or acute charcot foot. These patients belong to the low-risk group; however both require timely elective foot surgery and proper offloading with total contact casts.
Patients who develop the following conditions associated with wounds should be treated in a hospital setting:
In addition to using mandated precautions to prevent person-to-person transmission of SARS‑CoV-2, care of these patients may be modified in the following manner [20, 21]:
Local wound care is initiated as the patient is discharged, and step-by-step instructions are provided for follow-up either in person or via telehealth. Clinicians must determine on a case‑by‑case basis whether hospital-based diagnostic studies (e.g. vascular ultrasound, computed tomographic, and magnetic resonance angiography) can be postponed. Diagnostic tests should only be performed if their results will change immediate management.
1a. Usually occurs on foot; Higher risk for amputation;
Neuropathy inhibits the perception of pain and sensation.
1b. Patients bedridden for long time;
Pressure on sites such as the heels, shoulder blades
Figure 1: Ulcers (a) Diabetic Foot Ulcer, (b) Pressure Ulcer
Pressure Ulcers
Pressure ulcers are caused by tissue compression over a bony protuberance or by inadequate perfusion. The wound is formed after a decrease in blood supply to the concerned tissue, or vascular damage to the tissue arteries. Tissues with a compromised blood supply or oxygenation are at risk for ischemia, leading to necrotic tissue formation. Any necrotic tissue should be removed as it promotes bacterial growth and delays wound healing. The patient should also avoid too little or excessive moisture. Protecting periwound skin is helpful and most importantly reducing pressure over the wound area is suggested [22].
Step 1: Wounds should be covered with transparent film and warrant immediate preventative treatment: minimize friction at the wound site, using pressure-reducing products and correcting any existing malnutrition.
Step 2: Wound treatment consists of a moist dressing over the wound dressing. If necrotic tissue is present, consider occlusive dressings such as hydrogels to promote dead tissue enzyme digestion (autolytic debridement) rather than manual debridement.
Stage 3 and 4: Wounds require debridement with a dressing, antibiotics if infected, then referral to the emergency department.
During this pandemic, wound care should not be overlooked and wound care with a regular follow‑up needs to be considered as an essential service, requiring a regular provider-patient interaction only if very urgent to avoid the risk of getting infected [23].
Conclusion:
COVID-19 is now a worldwide pandemic presenting a considerable challenge for healthcare workers. In this context along with other chronic disease and delayed elective surgeries, the treatment of wound has also limited. The present guidance is based on practical experience and clinical treatment guidelines during the pandemic and guideline of relevant clinical experts. Wound should not be overlooked, must be cleaned with disinfectant and prevent from moisture. The diagnosis and treatment strategies described here should ensure that patient receive timely and reasonable treatment with effective COVID-19 prevention and control. It includes reasonable treatment and diagnostics of diabetic foot ulcer, lymph wound and ischemia wounds. In cases of any serious issue prefer to consult physician.
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