When Wounds Stall: Key Considerations To Jump-Start Healing
Although some nutritionists and nurses like to recommend zinc and vitamin C supplements, Dr. Suzuki notes insufficient clinical evidence.4
“I would rather not make my patients take extra pills although I would not make them stop if they want to take multivitamins,” maintains Dr. Suzuki.
Dr. Suzuki does advocate that patients eat as much protein as they can consume comfortably. He will tell patients to drink a few bottles of protein shakes a day. In his clinical experience, Dr. Suzuki has found that it is easier for patients to consume protein in liquid rather than solid form (i.e. chicken breasts). He suggests eating 1 g of protein per 1 kg of the patient’s ideal body weight as a general guideline.
If wound healing is impaired and nutritional deficit is thought to play a role, Dr. Rogers directs non-diabetic patients to drink one can of Ensure with meals and tells patients with diabetes to drink Glucerna. Dr. Rogers and colleagues are also in the midst of an ongoing randomized controlled trial investigating the supplement Juven (Abbott Laboratories) for wound healing.
Alternatively, Dr. Suzuki conducts a through interview of the patients and their families so he can obtain a general idea of how “well nourished” patients are in terms of protein intake. He cautions that obesity does not signify that patients have adequate albumin in their systems. If obese people become acutely ill, he notes they can still be large and malnourished at the same time.
“There is a difference between ‘well fed’ and ‘well nourished,’” says Dr. Suzuki. “Many studies have proved that ‘malnourished’ patients have more post-op complications and longer hospital stays versus ‘well nourished’ patients.”
Q: What do you try when the wound seems to be stuck and not progressing to healing?
A: First, Dr. Rogers will reevaluate the patient’s vascular status and offloading as well as check for infection. He will then consider growth factors, bioengineered tissue and/or curative surgeries. He notes a thorough, wide debridement can be necessary to jump-start the healing process.
Dr. Suzuki concurs with the importance of performing thorough sharp debridement as the first step to facilitating good wound healing. He also cites the Qoustic (Arobella Medical) low-frequency ultrasound debridement device, which he says can stimulate chronic and “stunned” wounds to get “unstuck.”
Dr. Pupp considers adjunctive measures if wounds do not respond in four weeks. He uses bioengineered skin substitutes including Apligraf (Organogenesis) and Dermagraft as well as autologous platelet growth factors.
“Although these modalities are expensive, their use can prevent extended costly wound care and help save limbs and lives,” maintains Dr. Pupp.
Dr. Suzuki finds it helpful to switch the wound dressings. In his experience, the most expensive dressing does not necessarily work the best since each wound has a different etiology and characteristics. For example, he notes if the wound is too wet or too dry, the wound healing will not progress.
“Changing the dressing materials, from say foam to alginate, or even from one brand to another, can possibly make a huge difference,” points out Dr. Suzuki.
In addition, Dr. Suzuki cites the importance of controlling edema. As he learned in residency training, an edematous limb is like a “flooded house.” Basically nothing works as it should and the body will not repair itself until the edema resolves, notes Dr. Suzuki. In addition to employing different kinds of compression bandages, hoses and leg pumps, he cites the importance of providing patient education and instructions to control leg edema.
Dr. Pupp is a Fellow of the American College of Foot and Ankle Surgeons. He is the Director of the Foot and Ankle Clinic at Oakland Regional Hospital in Southfield, Mich. He is also a member of the Residency Training Committee at Providence Hospital in Southfield, Mich.
Dr. Rogers is the Director of the Amputation Prevention Center at Broadlawns Medical Center in Des Moines, Iowa. He directs research at the center and has been an investigator on over 20 clinical trials.