Robert Klein, DPM, CWS, on Advanced Wound Care Dressings

In this podcast, Robert Klein, DPM, CWS, speaks about advanced wound care dressings, including how cellular and tissue-based products work, the challenges of using them, and how they impact healing times for wounds. 

Robert Klein, DPM, CWS, is a wound care specialist with Prisma Health and a clinical assistant professor of surgery at The University of South Carolina School of Medicine in Greenville, South Carolina.

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TRANSCRIPTION:

Jessica Bard: Hello everyone and welcome to another installment of "Podcast360," your go‑to resource for medical news and clinical updates. I'm your moderator, Jessica Bard, with Consultant360 Specialty Network.

There are dozens of cellular tissue products that help wounds heal more efficiently. Dr Robert Klein is here to speak with us today about contraindications and challenges in using advanced wound care dressings. Dr Klein is a wound care specialist with Prisma Health and a clinical assistant professor of surgery at the University of South Carolina School of Medicine in Greenville, South Carolina.

Thanks so much for joining us today, Dr Klein. We really appreciate your time. To get started here, I'm going to steal your joke that you made earlier. I hear that time heals all wounds. Is that true in wound healing?

Dr Robert Klein: I can't say that's true 100 percent of the time within wound healing. There is a principle that we apply within wound healing, or wound care, called the TIME principle. It's an acronym. The T component for time stands for tissue. Whenever we think about wound healing, we have to take all of that bad tissue off.

Any devitalized tissue, necrotic tissue, cellular debris. That's the first component of TIME. The second component of TIME in that acronym is the I and that's infection and inflammation. When we think about wound healing, we have to address any underlying infection with the appropriate antibiotics.

We also have to address the chronic inflammatory state or inflammation within the wound. We can do that through some advanced wound care dressings. The other component to the acronym of that TIME principle is M. The M stands for moisture imbalance. A lot of these wounds are exudative wounds that put out fluid. We need to manage the exudate.

That's where negative pressure wound therapy comes in. We can put a wound vac on the wound. We can manage the exudate through wound vac. We can use some types of advanced wound care dressings that are absorptive that can also take care of that moisture imbalance.

Then lastly on that acronym of TIME, the E, that's the edge or that non‑advancing or non‑adhering wound edge. When we think about the TIME principle, we want to take all of that undermining tissue and tunneling out appropriately debride the wound and get that edge effect where you can get keratinocytes to migrate across that wound edge. You can have that advancing wound edge.

Does time heal all wounds? Absolutely not. When you have the TIME principle as part of your thought process in taking care of wounds, I think the TIME principle itself can heal a lot of wounds.

Jessica: That's really memorable. That's good. [laughs] How do cellular and tissue‑based products work? How do they impact healing times for wounds?

Dr Klein: Cellular tissue products are a huge advancement within wound healing. I've had to think about things that really changed the way that I treat wounds. I would say negative pressure wound therapy and cellular tissue products are two things that really have been amazing within wound healing.

Within cellular tissue products, we have a lot of different products that are available. We have organ donor skin, or human skin, that we can use. We can use porcine collagen. We can use bovine collagen. We can use amnion products. We can use chorion products. We can use fish skin. There are so many different products out there with cellular tissue to help close wounds.

Basically, the concept behind them all is that they can provide cellular products. Some of the products have growth factors, especially our organ donor skin or human skin. They have growth factors that they can contribute. They have collagen that they contribute. They have cellular mediators that contribute.

They help stimulate that extracellular matrix that helps build up the wound. The cellular tissue products work on a very complex level that I'm not sure I can answer in such a short question. They help in so many different ways. They really, basically, give the wound what it needs to help the wound to heal.

Jessica: You just listed some of the products that are available. We know that there are a lot. What factors do you consider when making that choice in product?

Dr Klein: For me, I've used a lot of different products over the years. It's funny, reps come to see us all the time in our offices and they have the latest and greatest product that they just come out with. There's just a ton of cellular tissue products on the market.

When I think about using cellular tissue products is one, has the wound not decreased by 50 percent in over a four‑week period of time? At least for diabetic foot. There was a study that was published by Peter Sheehan that demonstrated that if the wound does not decrease by 50 percent in a four‑week time, now this is diabetic foot ulcers again.

If it doesn't decrease 50 percent in a four‑week time the likelihood of that wound going on to closure after four weeks is about nine percent.

When I look at cellular tissue products, I'm actually looking at the wound. Has the wound progressed where it needs a cellular tissue product to take it on to wound healing? For me, that applies for diabetic foot ulcerations.

For my partners at my wound care center, it also applies, to some degree for the venous leg ulcerations. The stats might be a little bit different on when they pull the trigger. It's the same concept.

The other thing that I look at when I think about cellular tissue products, again, is that wound bed preparation. As a wound care provider, we have all these great products that are out there. If the wound hasn't been properly prepared, once again, that TIME principle.

Taking the bad tissue off. Treating underlying infection and inflammation. Taking care of that moisture imbalance and getting that advancing wound edge. If you don't take that into consideration, you can put the most advanced and the most expensive cellular tissue product on the wound. You'll probably likely wound up with a failure.

For me, wound bed preparation is the most important part. The cellular tissue product, once the wound bed has been prepared properly, really takes it on to closure.

I think it's a fair statement. Some people may be critical of this but it's a fair statement that irrespective of what you put on it at that particular point, any of the cellular tissue products pretty much clinician choice will probably take that wound on to closure.

Jessica: What are the contraindications for cellular and tissue‑based products?

Dr Klein: Infection, active bleeding, allergies to any of the products in the cellular tissue product, and malignancy.

Say you have a wound that had a malignancy. It's a wound that I would not put a cellular tissue product on because God forbid, there was still cancer cells or malignant cells still within that wound. You've got growth factors which could stimulate those cells as well. Malignancy is another thing that I factor into when thinking about contraindications for cellular tissue products.

Jessica: What clinical data is available demonstrating the effectiveness of advanced wound care dressings?

Dr Klein: When you talk about advanced wound care dressings that opens up...I wouldn't say Pandora's box, but it opens up a large box of products because our cellular tissue products are just one component of advanced wound care dressings. We have collagen with silver products. We have a whole variety of products that we can use to close wounds.

When I think about advanced wound care products that also, to me at least, in my tool kit of what I use, I think about those collagen with silver products and other type of products. There are a tremendous number of studies that have been published. Retrospective studies, prospective studies, RCTs.

There are a significant number of studies and data out there on advanced wound care dressings. I think that's just something that as a provider you need to familiarize yourself with.

Jessica: How about challenges? What are the challenges of using advanced wound care dressings?

Dr Klein: One of the biggest obstacles, unfortunately, is insurance companies because you have so many different cellular tissue products out there, just talking about CTPs, that not all the CTPs are covered by each of the insurance companies.

There may be a product that I might particularly like to use. It might be a dermal matrix. It might be an amnion product. The insurance company may have a formulary that they have established that they may allow one or two different types of cellular tissue products to be applied to that particular wound.

For me the biggest challenge that I have is one, is getting coverage from the insurance companies to use these products. That's probably my biggest challenge that I have.

Jessica: Is there anything else that you would like to add today on this topic? Anything that we missed that you think is important?

Dr Klein: We covered it really well. I want to summarize really. I think it's clinician's choice. I give a lecture on cellular tissue products. I've got a slide that comes up. It's got Homer Simpson on it and he is at his little nuclear reactor that he is running if you ever watched "The Simpsons." Not that I'm saying you should watch The Simpsons.

I may have watched an episode or two every now and then. It really is clinician's choice. What works best in your hands is really what you should use.

To me, it falls on wound bed preparation. If you prepare the wound very well, I think, for the most part, irrespective of what you put on from a cellular tissue product perspective, you're probably going to get a good result.

Jessica: Thank you so much for your time today, Dr Klein. We really appreciate it. It was a pleasure speaking with you.

Dr Klein: Thank you. It's my pleasure.   

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