Comprehensive Strategies in Wound Care: Insights From Madhavi Ponnapalli, MD

Wound care and debridement techniques

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Wound care is a multifaceted discipline requiring careful consideration of various factors, from debridement to compression therapy. Madhavi Ponnapalli, MD, an expert in infectious diseases and wound care, highlights the importance of tailored approaches to address diverse wound types and patient needs. By leveraging evidence-based techniques, such as negative pressure wound therapy and strategic nutritional support, Ponnapalli emphasizes a holistic approach to achieving better healing outcomes. In this interview, she shares her expertise on the key elements of wound management and the factors influencing successful treatment plans.

ICT: Can you explain the importance of debridement in wound care, especially with infection, and how the choice of instruments can impact the effectiveness of debridement for different wound types?

Madhavi Ponnapalli, MD: Debridement is used to remove dead or nonviable tissue from the wound bed and periwound area. This tissue impedes wound coverage by healthy cells, creates inflammation, and acts as a nidus for infection. Removing it allows the wound to return to the acute phase of healing.

Common instruments for debridement are a curette, scalpel, or scissors. A curette is an effective way to remove slough from the wound bed. If tougher tissue occurs in some necrotic wounds, a scalpel or scissors may be best for cutting away the dead tissue. For a callus, scissors can be used to cut it away since they can cover an open wound and prevent proper healing.

Serial debridements have been shown to improve wound healing rates, so it is not ‘one and done.’

ICT: What are the most used modalities for offloading foot wounds, and how do you determine the best approach for each patient?

MP: Offloading to remove the pressure on a foot wound is a significant factor in healing. The modality is determined by the location of the wound, the patient’s ability to balance, and the patient's compliance.

Offloading shoes consist of front and back offloaders, which elevate the front or back of the foot, depending on where the wound is. This eliminates pressure on the wound, allowing it to heal.

A total contact cast is used for plantar wounds. It is placed on the patient and floats the area of the wound. The cast cannot be removed except with a cast saw, which is useful for nonadherent patients with offloading shoes.

A CAM (controlled ankle motion) walker boot can also immobilize the foot and aid in healing. Patients who are bed-bound can use pressure-relieving ankle foot orthosis to keep their feet off the bed so ulcers in the ankle and heel area can heal.

ICT: How do you evaluate which type of wound dressing is most appropriate for different wound types, and what are the key factors to consider when making this decision?

MP: Multiple factors determine wound dressings, including drainage, necrotic tissue, slough, and granulation. The most important factor is the amount of drainage, as moisture balance is crucial to wound healing. For wounds with heavy drainage, absorptive dressings, such as alginates or foam dressings, are useful for wicking fluid away from the wound.

For dry wounds, moisture is essential, so we use products that add moisture, like petroleum-impregnated dressings or hydrocolloids. For necrotic tissue, sodium hypochlorite (Dakins) dressings help remove dead tissue. We use collagenase to break down the slough. For granulation, collagen dressings can speed up healing. This is by no means an exhaustive list and wound dressings need to be modified during healing according to the needs of the wound. They are used in conjunction with debridement.

Wet-to-dry dressings are not recommended since they are nonselective in their debridement and can remove healing and undesirable tissue.

ICT: When selecting compression wraps or stockings for a patient, what factors influence your choice, and how do these options contribute to better wound healing outcomes?

MP: Compression is for patients with venous stasis who develop ulcers due to venous hypertension in the legs. It can also be used in patients with lymphedema. The type of wraps we use depends on the patient’s vascular status, amount of edema, and patient tolerability.

Assessing arterial flow is the first step; vascular surgery consultation is necessary if a patient has severe arterial disease. If they do not, then compression depends on patient tolerability.

Most compression systems consist of 2- to 4-layer wraps that exert even pressure around the lower legs while the patient is mobile. The pressure can vary between 20-30 mm Hg to 30-40 mm Hg. These stay on for several days until the patient returns to the wound care center to have them changed. If a patient cannot tolerate or does not want wraps, then Velcro wrap or zipper wrap can be used. The patient can put these on themselves, and there are instructions on how to adjust them to achieve the proper pressure for effective compression. Compression stockings can also be used for milder cases.

Ace wraps are not useful for compression because they are too elastically strained and do not provide uniform pressure around the leg.

Studies have shown that compression wraps speed up ulcer healing and prevent recurrent cellulitis.

ICT: Could you discuss the benefits of negative pressure wound therapy and the specific nutritional needs, including caloric and protein intake, for patients with large decubitus wounds?

MP: Sacral pressure injuries can range from deep tissue injury (stage 1) to ulcers that reach the bone (stage 4). The first step is reducing the pressure, which can be done with different mattresses, depending on the severity of the wound.

Once a deep wound is debrided, negative pressure wound therapy is applied. Negative pressure wound therapy (NPWT) cannot be used if a large amount of necrosis is present in the wound bed. Once the wound is debrided and is clean, it can be placed. It allows the excess drainage to be sucked away from the wound bed for moisture balance; it draws the wound edges together, removes bacteria, and promotes perfusion as well.

For patients with large ulcers, healing requires increased nutritional intake so the body can become anabolic. Protein intake should be around 1.5 gm/kg, and calories should be 30 kcal/kg of body weight. Increased intake of vitamins C and D can also be helpful. Oral nutritional supplements (like Ensure) are needed to achieve this increased level if a patient can eat. If a patient is on tube feeds, the goal should not be maintenance but excess calories and protein for healing.