Good evening everybody, and welcome to tonight's webinar with the Webinar vet. My name's Sophie and I'll be chairing tonight. So before I go on to introduce tonight's speaker, I'd just like to point out that you can ask questions throughout the webinar.

In order to do so, just hover over the top or bottom of your screen, click on the toolbar, you'll see a Q&A box, type your question in and that will come through to me. Then at the end of the webinar, I'll read them out to Lisa so that she can answer any of your questions. So tonight we have the wonderful Lisa Telford.

Lisa qualified as an RVN in 2010 from Edinburgh University. After working in general practise for six years as a head nurse, Lisa moved to the hospital for small animals at Edinburgh Vet School as a surgical nurse, becoming Leeds surgical ward nurse in 2017. Two years later, Lisa became dedicated soft tissue surgery nurse, which enables her to be much more involved in wound management cases within the hospital.

And Lisa completed the delving deeper into wounds course in 2017, as she's always had a passion for wound management and bandaging. OK, Lisa, I'll hand over to you. Good evening everyone.

Thank you very much for my lovely introduction. And we're here this evening on this lovely cold, evening, to learn a little bit more about wound management, specifically would be preparation, lavage and delayed wound healing. So we'll get started, I hope that everyone has is sitting somewhere nice and comfortable with a nice cup of tea, and I just want to thank everyone for joining me this evening, .

On this cold evening, so just to get started. So, with, wound healing, it can, progress through many different stages, and it's very, very important, when we are looking at wound management that we need to always have a bit of a refresher, of what happens within wound management because we cannot move on to the next stage of healing and progress through wound healing stages without each step going, one after the other. So.

So it progresses for the through the the four stages. So with that, you will find in many, many textbooks, and much of the literature that they are described as slightly different, and depending on which author that you look at that and to give you the sort of basics of them, we'll go through them this evening just as a little recap. So first stage of wound healing is inflammation, followed by the debridement phase.

Followed by the proliferative phase and then ending at the maturation or remodelling phase. So that's just a little recap on the M4 stages of wound healing, and we'll go into each of those and what happens at each stage of the wound healing following on from that. Oh, sorry, my, my slides have jumped slightly there, but the learning objectives for this evening, my apologies, was a refresher on the stages of wound healing, as I've just stated, looking at the importance of wound control, wound.

Sorry, infection control during wound management. It's very, very imperative, and it's one thing that I'm particularly fussy about when we are managing wound cases in the hospital. It's very, very, pertinent in the press, and veterinary as well as in the human sector and the development of multi-resistant infections, we really need to have a good understanding as to the importance of managing these cases appropriately and the practise environment.

And then the factors to to consider prior to preparing the wound. There's many things that are very important that we've got to remember to prepare beforehand. So there's nothing worse than getting halfway through clipping a wound or lavaging a wound, and then you've realised that you've forgotten something and that then links back to the infection control, because I'll talk a little bit about that later as to, the annoyance and what can happen and how your infection control can drop a little bit whilst managing these cases.

Consideration for wound lava, so I'm sure that everyone has lavar or wound at some point in their career. I am that strange nurse that absolutely adores, wound management and anything that looks, slightly, gross, if you like. I do really enjoy making those wounds nice and clean.

So as I'm sure that people are aware, there's, more than one solution that we can use for lavage. There's many different factors, that we need to consider whilst we're lavaging wounds as well. So, we will go through them, at the time as we come to them.

And then linking back everything in together, there are 12 factors in delayed wound healing, and it's really important that we, are aware of these and some of these actually link back into, how we actually prepare the wound bed because how we prepare the wound bed can actually, if we don't do it appropriately, it can actually delay wound healing. And I think it's like a really important thing to grasp with the 12 factors and delayed wound healing. Because if your wound's not quite progressing in the in either the speed or the pace that you're expecting it to, or you always seem to be stuck in one particular, phase of wound healing, that can indicate that there's a disturbance in the wound healing.

So then what we should do standardly is then go back and look at these 12 delays or 12 factors and delayed wound healing, sorry. And actually assess each one individually and actually pinpoint what actually might be the problem. So it's a really good tool to have to use in practise to always refer back to to know and identify maybe something that you hadn't quite thought of, and then going forward with your wound management and how we can manage that factor, and how we can get our wound to progress going forward.

OK, so sorry, as I say, my slides have decided to jump around a little bit, so we're going back now to a recap on the phases of wound healing, and I know . You know, this year I've been told that you've had webinar but has had a nurse stream on some wound management already. So I've tried not to recap too much of the same present or the same sort of thing, but it is very important that everyone has a good grasp of each, phase of wound healing because if you have a disturbance and wound healing, you can identify which, phase of the healing that seems to be stuck in, and then we look at the the 12 factors and delayed wound healing.

So, as I described earlier, the first stage in wound healing is inflammation. So there is most wounds are caused by some sort of trauma, and that can be sharp trauma or blunt trauma. But regardless, haemorrhage occurs immediately after the injury which activates the platelets to form a clot.

So After that it happened, the clot is then further strengthened by fibrin. Following that, this local The local vasodilation allows further inflammatory cells and lymph fluid to enter the area, and that gives the classic red warm and swollen appearance into the wound surface. So, When we get that initial haemorrhage, it actually has a little bit of a dual purpose and it helps, well.

Very early understanding of management was that actually helped to get rid of some of the contamination with the actual haemorrhage itself. But of course, as we all know, it's essential that that haemorrhage stops. So that's when the clot is formed.

And so after the clot is formed, so then we're not going to get any more haemorrhage. That is when the And local vasodilation occurs and that allows all of these in essential inflammatory cells to flood to the area and the white blood cells, etc. To to help him with the cytosis of the debris, etc.

That may in the contamination that may be within the wound bed. Then going forward, we get the depridement phase. So following on from the inflammatory phase, there is increase in white blood cells to the area due to the er the local vasodilation as mentioned previous.

OK, and that allows the phagocytosis of bacteria debris, and phagocytosis is the destruction and of the bacteria. And the debris. That can occur in 6 hours post-injury and that's to reduce wound by burden and vitalized tissue.

So by burden is one of those terms that I always like to explain if I'm ever in doing any presenting. So basically by urging, if you hear. We see that term at any point this evening.

Basically what that is, is that fibre is any sort of contamination that's that can be foreign body, it can be bacteria, and it can be anything within the wound that they that actually shouldn't be there that can cause a delay in wound healing. So it's a general term just to make everybody aware of what I might be talking about. So this picture that you can see below, this wound bed itself, and you can see that there is a lot of contamination there.

There's some devitalized tissue. You can see the, the colour change within it as well. So as we move down the the stages of wound healing, we want our wound to progress and look a certain way.

Of course. Sometimes you've got to be to be a little bit careful because it's quite a common thing for infla inflammation to be mistaken for infection or vice versa. OK, because if you think about it, many of the characteristics of inflammation are also the same if there is an infection present in the wounds, so you get the.

Swollen warm appearance to the, to the wound bed and things like that, but then to kind of eliminate out those factors, we've got to think about looking at our patient systemically, and checking a, a, a temperature regularly. And if it's a case of that there's no rise in temperature, etc. Then we can start to eliminate other factors.

Also, there's other . Tools that we can use if you like, and that would give us the information as to which whether it is inflammatory or whether it is infection that is present. So the bright face is very, very important.

Of course, and within wound management we can help with the bridement phase on a little bit, through many different, techniques, and I'll talk I'll briefly go over some of them a little bit later, but there's many different ways that we can bride a wound bed as well. So it's one of those things that we, have many different techniques and there's actually some new products that are coming out now that can be used, for the debridement phase. And so we'll talk about them a little bit later, OK?

So this is a word, would you believe it that I sometimes struggle with, I have to really think about it for the moment that I talk about wound management as well, it's quite disgraceful, so my apologies. So proliferative, that was better, phase of healing, and that tends to begin around 3 to 5 days post-injury. So during that phase, the granulation tissue forms, contraction and epithelialization should also occur.

The formation of the granulation occurs by the migration of fibroblast to the area, and that results in an increase in the wound strength. OK. So this is a beautiful picture of the same wound, moving down the stages of wound healing.

So this picture of this wound shows that lovely pink, healthy granulation tissue. So sometimes it's compared to raw steak, sometimes it's compared to strawberry jam. So it's really important that we know that this picture here actually looks healthier than the previous picture in the debridement phase, OK?

So you can see that all that devitalized tissue from the previous photo has now gone. So that discoloured sort of area in the centre has all been debrided away. OK, so now we're left with this lovely fresh looking, granulation tissue.

So it's one of those things that we've got to be a little bit mindful of that if you did have something that looked like this, and then in a few days' time, it started to become more devitalized, then there's something that's delaying that wound healing and we need to have a look at those M12 factors that we'll talk about later. So. One of these cells that I've mentioned in this phase of wound healing is extremely important, and that's the fibroblast.

So as I've mentioned during this stage of wound healing, contraction occurs and epithelialization and starts to occur as well. So this is, one of my favourite stages of wound healing to kind of talk about, especially with the students at the university as well. So it's really important that we have a good understanding of what happens at this space.

Because if we add products, for instance, that can actually damage our wound bed and our cells that are there, all we're going to get is a delay in the wound healing. So that's when it's important that we understand what's happening at a cellular level, at this point in the wound healing. So.

For the contraction and epithelialization to occur, what happens is we get this cell called fibroblast migrating to the area due to the vasodilation and we're getting the new laying down of a fresh blood vessels, so the angiogenesis within the area and to flood the area with all these cells that are essential for making our wounds progress in the correct direction. So with the, when the fibroblasts will arrive, what they actually do is they lay down almost like a net over or what we call a matrix over the whole surface of the wound, OK? So I like to compare it as a fishing net or something like that, OK?

So that lays down over the whole surface of the wound, . In a matrix, and then what happens is that the fibroblast actually convert to a cell called the myofibroblast. I don't know if everyone remembers from biology a while back that when something has the prefix of myo it means muscle.

So then what happens is with the the so the fibroblast converting into my fibroblast, we get the contraction through the muscle cells and that's what actually pulls our wound together, OK? And that's how we actually get the contraction of the wound. So with this process, it's really imperative for our wound management and actually can help us out massively.

So we do not want to damage these really delicate fibreglass cells because we're not going to get the contraction. Contraction is one of those things that unfortunately, it's not one of those things that just lasts forever. It doesn't, it has a life span if that makes sense.

So. With the action of the myofibroblast within the wound to get that contraction in your wound management cases is that that tends to last around 4 to 6 weeks. OK.

So for instance, if we had a wound that was that started out at 10 by 10 centimetres, and then after the contraction fee, the during the peripative phase of healing and we get the contraction and it's exhausted at 6 weeks, but we're still then. Left with a wound that is maybe 2 by 2 centimetres, OK? I'm just, you know, these numbers are just for an example.

We still have a wound to deal with, but we're not gonna get any further contraction. So then what actually happens is epithelialization, OK? And we can get a bit of epithelialization happening at the same time if your wound bed is in the correct, happy environment if that makes sense.

So in this picture, you can actually see at the bottom there that we have that sort of nice healthy light pink halo all around the edge of that wound. What that actually is is the epithelialization cells or the epithelial cells. And what they do is that when you're in fibroblast mesh or matrix is laid down, your epithelial cells will peep along on the top of your matrix, and then they will meet in the middle, OK?

So. When we're having this process happen, that is when we can see that it's so imperative that we look after these cells and we don't use products that can actually damage them. OK, so.

That is the, the sort of a, a, a more in depth overview of what happens at this stage of wound healing. So it's really, really important that we understand that fully, because we can actually do unfortunately quite a lot of damage at this phase of wound healing, so. Please, if you've got any questions, cause that's quite a lot of information to throw at you all, please just, find a little question I can answer that at the end.

OK. So, Because we're getting an increase in wound strength, it will progress and get stronger all the time. OK, so then moving on from the proliferative phase, we get the maturation or remodelling phase.

And this is when, as I say, some texts can give it slightly different names. That's why both of them in this stage. That's the final stage of wound healing, and that can last from weeks to years.

The collagen in the scar is remodelled and slow progression in the wound strength occurs, OK? So that will peak at 80% in strength compared to the original strength of the wound, or sorry, the skin, prior to the injury actually happening. So, I have a lovely scar on my hand, from years of nursing, and I normally show people that my scar is actually quite pronounced.

And what that basically is, is that, when the fibres of the collagen are laid down, they're very unorganised to begin with. So what I do is I lattice my fingers together, and slot them in inside each other to show everyone that, that is how disorganised it tends to look. And then over time that tends to flatten out that's when I, I am separate my hands to show that it is actually laying down a little bit flatter.

And that's when you get the evening out of the the scar tissue, etc. And one of those things, is that, you know, it will, lay down flatter in time, but one, it will never be 100% of the strength originally, and two, sometimes you're scarring, . Unfortunately can actually be a bit of a problem and that it can actually impede movement sometimes.

So sometimes when we're managing cases if we management we've got to actually be a little bit mindful of. Where our scars will be, and, will that actually impede that animal's movement and ability to go about its daily life, or if it's a working animal, will the animal actually be able to work with the scar that may restrict movement, etc. So sometimes we can get so excited that we've actually managed to close a very large defect or a very large wound or a very complicated wound case, but sometimes actually getting it to that stage can actually come with its own complications.

This is when wound assessment and making a plan going forward is imperative at the same time. OK, so, that is a, a bit of a whistle stop tour of, the four stages of wound healing. So I hope everyone, is still with me.

Quite a lot of information to take in this evening. So going forward, intersection control, and as I said earlier, it's one of those things I am rather pedantic about in the hospital. So here is myself with one of our lovely residents, doing some wound management on a case here.

So. Infection control is imperative and please, you know, many, many people when we get cases referred into the hospital, or if because I work with, I also work with managing angels and representatives for Scotland, and we go out to practises and we give some advice, etc. And Much of the time when we get a case referred to us, we will get sent photos, which is absolutely fantastic, and I will read about photos with management as I go on.

But 9 times out of 10, I can just about guarantee you that people will not even be wearing gloves when they're handling the wound. OK, so. This is when I really hammer into people that infection control really really is important.

And my viewpoint of it is is that it's better to be overcautious than be careless with infection control when we come to wounds and wound management. Sorry. And so, And we're talking about infection control, we need to clear an appropriate room.

OK, so. What that means is that, you know, hands up, you know, nobody's perfect in this world and, you know, looking back at my career, I have also done this thing that I'm about to tell you that to try and prevent it happening in the practise. So cleaning an appropriate room is really, really important that we select a room within the practise that is easily cleaned, OK?

I was that nurse that, you know, ignorance is bliss sometimes you don't really think about it, that I was preparing wounds in the preparation area for surgery. OK, but these are wounds that are stuck in the inflammatory phase that potentially have infection going on, and then what have I said that I'm about to talk about is lavage, OK, and wound bed preparation. So then what we do, actually, when we lavage a wound, whether that be with just a needle and syringe, whether it's these pre-prepared pressurised canisters of saline, we are actually aspirating what is in within that wound into the atmosphere, OK?

So when we are thinking about doing that in the surgical prep area. We are lavaging that into the atmosphere and then it settles on anything that it will come in contact with. So as I was saying, when we lavage we then as that all into the air and it settles anywhere within that area and that it would like to wish to so as you can probably Think that if it's in an inappropriate area for practise, somebody can come along, pick up anything, pick up some ban material, pick up a needle syringe, but that's actually been contaminated with what's ever in your room bed.

So something to really consider. When we are thinking about where we're going to treat these wounds in the practise. So, especially if we have one of those wounds that actually has had a confirmation that there is a multi-resistant bacteria present or a multi-resistant pathogen within your wound bed.

Really, really important that we utilise a certain area, of the practise, which of course is isolation. We need to ensure that isolation is utilised to its full potential, . That we keep those patients within the isolation unit and that we're actually doing everything to do with wound management within that room.

I do understand that every practise has an isolation facility, but it is certainly becoming a lot more common for practises to have these facilities, which is great. If it is possible in your area is, large enough, I would be lavaging and preparing and treating all patients in hospitalisation wise as well as wound management wise, within that area of your practise. If you don't have that facility, never fear, if you have an area that is easily cleanable.

OK, so if you can put everything away in cupboards, That you can clear room so there's nothing but bare walls to wipe down, then that is your, your best bet . Whilst you are You know, treating these wounds, etc. So what we tend to do at the hospital is that any wound that is suspected to have a multi-resistant infection or any infection present, you will strip the room back, we'll have nothing but bare walls, and of course cupboard fronts are fine because as long as everything is sealed within, we will then, after the wound management has taken place, we will do a full ceiling to floor deep clean.

OK, and we'll actually shut that that room down for a time period so that nobody else can use that room until the, you know. Whichever disinfectant that you use within your practise, we tend to use androgen currently at the hospital. But we've got to make sure that the products that we use to clean down these areas are actually appropriate and they are going to be effective against the bacteria or the pathogen that we're actually trying to fight against.

And it is quite common for certain disinfectants, not to be effective against certain pathogens. With something that needs to take into consideration as well. So there is certainly that rise in multi-resistant infections, and there is a push towards trying to treat them topically rather than systemically as well.

So this is when we're thinking about Lavar and what solutions that we'll use, etc. PPE, this is a little refresher about that. PPE is the personal protective equipment, and so that's looking at your gloves, that's looking at gowns, aprons.

What we're actually wearing there is a visor mask, which I love using for wound management cases and lava of these cases. So it's a mask in combination with a visor and I wear glasses anyway, but I certainly don't want that anywhere near my eyes, and especially if it's a multi-resistant. So I use them quite commonly, and it's actually frightening when you take the visor mask off, what actually would be all over your face if you didn't actually have the visor mask on.

So it's something that would be a great investment in in everyone's cupboards for these cases as well. Don't really want to be breathing in equally, we don't want to over over our faces or going anywhere near your eyes. PPE so the aprons and things like that are great, but we actually use these full body suits at the university, not extremely breathable, as you can probably imagine, but they are imperative and they do certainly do the job and to make sure that we're protecting ourselves, one against our patients and passing that on to another patient, and also from the reverse barrier nursing side of things as well.

OK. So, elements of, making sure that we are prepared to do our wound management. Super important, so that links back to the infection control that I've just been talking about.

So making sure that we collect. A good patient history. We need to collect a general history about that patient.

So that goes right back to vaccination and what they're fed, blah blah blah blah, etc. Because we will have to manage those cases within the practise and hospital environment. So we need to get a good overall general history.

But then also just as equally, it's very important to get the specific history about what's happened, how did the wound occur, and what was the delay in time from, the, patient being presented at the practise. Because all those sorts of factors are quite important when we're talking about wound management. So we need to know when it presented, how long was it before the point of injury to when it was presented, and then making sure that if it's a case of that it's gonna be being referred on to a referral centre that all that is documented because it's quite important information as well.

So, getting in good practise that patient history taking is really imperative and having good communication with our clients is also very important as well. Prepare an appropriate room, just like I was saying. We need to clear all that day, have no consumables in there other than the consumables that we will need to use at the time for doing the wound management, making sure that we don't contaminate anything because especially if we're dealing with a multi-resistant infection, we will have to either re-sterilize or use a more expensive method to use these products again or dispose a fund, so we don't want to be wasteful.

Collecting all your materials in advance. So if you are aware that a wound management case is coming in, it's a good idea to have a little wound management box if you've got one, or a little kit, if you like, that you can take to areas of the practise and so you can do your, your wound management. And so it's a pre-prepared little box that you can take with you, or if you're doing your nursing consults, etc.

To, to look at in wound management cases so that everything that you You will be in there, so a little selection of dressings, and PPEs so gloves, aprons, gowns, that sort of thing in there, you might want to take some lavage solution, and, sterile swabs, etc. Etc. So it's it's quite nice to have a little kit available.

To you as well, so collecting all your materials in advance and that links back into the infection control that I was telling you about earlier, and that we don't want to get all gloves go up, etc. With all our infection control and tiptop, and then we realise that we forgot to take our dressing out the cupboard now. As I've explained before, I'm, one of those annoying people that have my BDI on everyone for infection control, and the amount people that will go in when they've been dealing with a wound with dirty gloves, touch the cupboard, and then go around looking for the correct dressing in the cupboard.

So they've technically contaminated that whole cupboard with whatever they've been dealing with. So really, really important that when we are bartering up and we are using PPE, I normally recommend everybody to double glove. So we've got a dirty glove and they've got a cleaner glove underneath, but the gold standard would be to take everything off and start again if that makes sense.

But it is a really good practise to get into, double gloving as well. So collecting all your materials in advance would be, avoid that cross-contamination, with these cases. Ensuring that all infection control is adhered to all time, so looking at value in our cases, and utilising isolation, checking that if we have culture on these wounds, that the disinfectant, and the products that we use within the practise are actually going to be effective against what we're dealing with.

As I say it's, it's, sometimes surprising when we actually look into what certain disinfectants aren't actually effective against. So Being prepared on this occasion helps you be prepared for the next time that you can come to deal with this wound or if one of your colleagues is as well. So that's one of the things that sometimes can be quite tricky in wound management is that we get what's called case continuity.

It will naturally be one of those things within the practise. It's not the same person always deals with the same wound. People go on holiday, you know, some people are on consults, some people are operating, duties.

So not the same person isn't going to always be seeing these wounds. So it's really important that we measure the wound. We take photos at each and every dressing change, and if your computer system has the availability to actually upload these onto the patient's records, then everyone has access to them, OK?

Because my concept of what a wound the size of a 50 pence piece and your perception of what the size of a 50 pence piece looks like can be actually quite different. If we actually have photos of a ruler, and you get these wonderful wound probes that there's . Photos of later on the presentation that I can show you and they're from a company called Advances, and they're great for actually probing the wounds so we can actually pull down into the cavities and wounds and actually measure them and as the wound progresses, we can see that cavity filling because the pocket isn't quite as deep anymore.

So there are great products and they are there. So, we're not going to be adding in any contamination into our room beds as well. So they're a great little tool.

So measuring the wounds, taking photos, and making really good clear in history taking and notes for the next person who's going to be dealing with that wound and that will really help your case continuity, . Wound management cases. So, just like I said earlier, wooden bed preparation is imperative and that we have a good think about how we're going to go about such things.

And the bottom picture there, and this is a little example that actually happened to the hospital recently of this is how the top picture is how this wound presented, and this wound had actually been surized 3 times. Trying to get wound closure and each time unfortunately, it was found that the wound was was breaking down at each point. So the wound presented as you can see there is some contamination there, there is some .

Exate coming from that wound, but there's also a lot of hair there, so there's a lot of sort of self-contamination from your patients so we need to think about how we prepare our wound beds going forward. It's really important that we look at the wound as a whole and we assess that wound and make up a wound management plan. OK, so it's really important that we make a plan and that we have almost like a little wound conference if you like, about how we're going to go forward managing that wound because that actually can dictate how we actually prepare that wound bed going forward.

So, as I've explained, this wound at the top there had been surized 3 times to try and get closure. So with that wound bed, we don't actually have a huge amount of clearance with the amount of here that's been clipped away there. So with here, here is one of those things that it can hold on to extra date, and it likes to have a little party with bacteria and things like that, so we need to make sure that we're clipping wide and far.

So when we do that, before we even touch with a clipper blade, we need to make sure that we fill the wound with a water soluble hydrogel or a water soluble sterile loop. A product that we use at the university, which is quite useful for, everyone to be aware of is that you actually get little sterile loop sachets, so it looks like a little sachet of tomato ketchup, type size, and it's about 5 grammes of sterile, lube. As long as it's water soluble, it must be water soluble, because if we, yes, if you stuck a hold of Vaseline in the wound, it would do the same job, but you will never get rid of it within the wound.

And actually, if you use an oil-based product, it will stay within your wound bed for ages because the body finds it very difficult to break down oil-based products. So really, really important that we use the water soluble sterile hydrogels or the sterile lobes, and because then when we're done with it, and it's had its purpose in the wound bed, then we can lava the child afterwards. OK.

So the purpose of the hydrogel is to set. Within the wound bed and if we're going past with the clippers and a little bit of hair falls back into the wound, which inevitably it will, whilst we're doing, such a job, then it doesn't matter because it's actually held within the the hydrogel or the lube, and then what we do is we'll laage it away. If we did not do that.

The hair will actually stick within the wound, and I'm sure everyone in their career has had that one wound management case where maybe you've not put quite enough in and that little stubby little bit here, you cannot get out and you actually have to surgically divide it away so it can be . Yeah, here's just one of those things that is really, really horrible to get stuck into your wooden beds as well. And the body again finds it very, very difficult to break it down, just like we were talking about in the, again, proliferative phase I to think about it, .

Of the wound healing, with the phagocytosis and things like that, that happens, and the debridement phase, the body finds it very difficult to break down the the hair within the wound beds, so it's really important that we, make sure that we prepare our wound beds effectively. So we need to make sure that they're sharp, clipper blades and that they're clean. You know, it's one of those things that patches are very, very busy and people sometimes forget to clean clipper blades before they go away from them.

So having some sort of SOP or a clipper maintenance protocol to having the practise is a really good way to kind of, cut down on a clipper con contamination. So making sure that they're sharp as well and that they're tested and sent away for sharpening or fresh blades are used, and that we need to make sure that if, especially if they've been used on a case that is a wound management case, they need to be thoroughly cleaned, and ideally sterilised post, post the event. So It's one of those things that the clippers can actually add a lot of contamination, so we need to make sure that they are appropriately cleaned and lubricated so we're not causing more trauma to the petty wound area.

So clipping the the wound in the Perry wound area extensively. So this is when it links back into the assessing the wound and making a plan for how we're going to manage that wound going forward. So this patient, as you can see, very, very hairy in the top picture and this is after I had actually, clipped up his wound, and that's me taking my measurements, afterwards.

So what we actually done was an advanced wound therapy technique called negative wound pressure therapy, with him, so actually the amount that I clipped from this patient, unfortunately I don't have a zoomed out version, but I, clipped probably 20 to 30 centimetres all the way around the wound. And it's really important that we click wide and far. And here we go go back and it's a little bit of owner communication and and education as well as to why we need to click far and wide, and with these cases because we may have to look at doing some sort of reconstructive work, and we need to do some sur For the bridement, so we want to make sure that we've given ourselves enough space, back from the wound if that makes sense that we can actually have a an area to play with.

And because sometimes with these wounds that are stuck maybe be in the inflammatory phase, . We're getting copious amounts of extraate produced, then we don't want the extraate to be running down the side of the animal and is sticking to that here, and then the, the hair flicks back into the wound. So we want to make sure that everything is clear from the wound bed quite extensively.

OK, so that might just be a little bit more of just educating owners that, you know, because we have a wound in this area, we're gonna have to put a lot of hair away, but it's for infection control purposes, etc. Etc. After we've done that and we've clipped everything, we still have that sterile hydrogel doing its job catching all those little bits of hair, and then we lavage the remaining hydrogel from the wound.

So as explained earlier, that's why it's so imperative to have a water soluble, so it is easily lavaged out of the area. OK. And then this is me using these wind probes.

So it's a wind probe from a company called Advances, and they become sterile, so we can improve their pockets, to see how deep and how extensive they are. And then there's the really helpful guide on measurement guide. So I take photos with it besides.

So as I said, people's perception of how big something is can be quite different. So we've actually got the ruler beside it. So what I normally do is I probe first to make sure that I'm doing everything in in clean manner if that makes sense.

And then I lay down the outside of the wound and that's not quite so clean, going forward. After we've lavaged the remaining of the hydrogel out of the wound, we then need to think about moving on to our actual lava. So when lava, Sometimes there's a bit of a debate as to whether Harman's or sailing is more appropriate .

If I'm being brutally honest, I normally use ceiling, that's not a mistake to use apartments by any way, shape or form. There is some evidence to say that the ceiling is a little bit acidic and for a wound bed, but there's not much robust evidence behind that currently, but not to say that that won't be getting published soon enough. .

But if we're using a sterile solution, then that is the main thing really. However, going forward, we want to make sure that in some circumstances actually using tap water is just as effective. So if we have RT that comes in that's gonna pebble.

Mashed. So if people don't know that term, and that's when the little bits of grit from the road gets stuck into the wound and it gets right into the different layers of the wound itself. Really an absolute nightmare, to get rid of, and a lot of surgical debridement sometimes and other methods of debridement are required in these cases.

However, if we were lavaging with litres and litres and litres. We could be there for days, OK, so actually just as effective would be to stick that animal underneath the shower and that's at the correct temperature, to then. Get the volume through and then I'm not saying that that's the only method of lava that we use in that patient.

We then move on to sterile solutions afterwards, OK? And so as long as we always finish with that, that is the main thing. But using a shower head in these cases initially is a good idea to get the volume through, to get the the main thing with with lavage is, the term, the solution to pollution is dilution.

So to get the most, you know, volume through as possible is an imperative. And sometimes that's actually setting ourselves enough time aside to actually do such a thing. OK.

So after we have selected our . Solution if that makes sense and that we've actually done a lavage and we then can take a wound swab or a wound biopsy. And it's wound biopsies are the gold standard, but not a lot of clinicians actually prefer them.

They prefer to do the swab, but the swab always just takes the surface of what's on the wound bed itself. Always imperative that we lavage copiously before we take the wound swab because we don't want to just get whatever's in the extra date. So it must be post lavage, OK, volume is one of those things that is really important when we're talking about with lavage as well.

Because we want to make sure that we're putting enough through. So there is a very rough guideline of, 100 mL per square centimetre of wound, and that has come from the human, evidence. There's still some work being done in the background of these guidelines, but that's what we currently try to follow.

So if you think about a very large wounds, sometimes, we should be lavaging sort of 8 litres through these very large defects, and I can probably, Having a handful of cases that I've actually managed to get that much through before somebody says we're too time limited we need to go. So as man as long as you have allocated enough time to yourself to get the maximum volume of lavash through, and then making sure that you're not obviously being detrimental to your patient, but trying to get the most . Volume through is, is really, really imperative.

As well, so I mean some very narcotic wounds that I've seen, getting prepared and people have put maybe 40 mLs of lavage to do that's going to do absolutely nothing. We need to make sure that we're doing copious amounts of lavage. So when do we use chlorhexidine?

I can. Quite honestly put my hand up and I have been that nurse in the past in using chlorhexidine. Chlorhexidine, biggest thing to take away from this evening is that chlorhexidine is cytotoxic to fibroblasts.

So that's why earlier on in the presentation that I made such a fuss about the fibroblast within the wound bed. We do not want to kill those cells at that vital stage of wound healing the profit of phase. So we need to look after our fibroblasts.

Chlorhexidine is very, very cytotoxic to, these, cells. So I normally personally avoid chlorhexidema like the plague, in these types of wound management cases unless we have a confirmed, multi-drug resistant infection, sometimes I will use it but in very rare cases, I tend to, favour other products, but certainly, Throughout my young career, I was merely flushing through some chlorhexidine, and I just made it light pink. So the dilution was, you know what, so it's really important that if we do use chlorhexins use the correct concentration, the correct concentration is 0.05%, OK, so a really important number for everyone to remember.

So that this lavage solution should be warmed to prevent slowing of the leukocyte activity, so you can actually delay your wound healings for up to 8 hours if you use cold lavage solution. So we actually are very fortunate to have a ceiling warmer at the vet school, but certainly if you warm a bag either in the microwave to body temperature or in a warm, sink of warm water. Before you use it, you're going to be massively benefiting your wound.

If you're lavaging the wound every 24 hours for a wound management case, then it's one of those things that we've got to be very mindful that we're slowing that down by 8 hours every time that we use a bag of seaine that's just out of the store cupboard. So really, really important. Also, it's very important to keep our patients warm and looking after our patient as a whole as well.

So pressure of lavage, the ideal lavage pressure is between 8 to 10 PSI, OK? So that can be achieved by using 1 litre of saline apartments as a bag. Using a giving set, attaching a 3 tap, attaching a 20 mil syringe, and then attaching a 20 gauge needle.

20 gauge needles tend to come in 1 inch length, but that's absolutely fine, because we're not actually going anywhere near the wound, we're just using it as our . Needle for the the virus to come through to set it at a certain pressure. So it's really important, so you can see the top picture there that shows you the setup of how the we have it.

If you have a lure lock syringe, it's a lot easier so your son doesn't keep on falling off all the time. That's a good idea. And it just gives you a lot of, a lot more control over your lavage as well.

So somebody just using, even using . 20 mil syringe with just a 20 gauge needle, you're still, there's still gonna be a little bit of variation and pressure but so just tends to limit everything so it's quite a good idea. So.

Lava, making sure that it's warm, making sure that we use if we do have to use chlorhexine that we use at the correct concentration and we measure that very strenuously, and making sure that we use it at the correct pressure and we're using our body temperature so we're not slowing the leukocytic leukocyte activity. There are other products out in the market. One that I particularly like myself is Prontozan.

Which is a polyhexidine, mixed with bigwinide. So this is a new product on the market that is useful in multi-resistant, drug infections, and this product has been, shown in human medicine to be effective against biofilm formation. So that's the protein coat that goes over the bacteria to .

To protect them against in the action of antibiotics. So I find great success with this type of products. You can get in a lava solution, but it's important that we don't lavage that out.

It can sit within the wound bed. I tend to lavage and then I let it sit in the wound bed for 10 minutes if possible, and then I will go ahead and do the rest of my wound management. And, you also get a very handy wound hydro.

Gel. So if you want that action to be a little bit more, long lasting, if that makes sense, then you can use the wound gel. So it's another product that I really quite like, when we're talking about wound laage just to make you aware of that there's something else in the market.

So what I tend to do is I tend to prefer using Frontozan versus the chorhexidine, but that's just my personal preference. So factors affecting wound healing. So there are 12 of them, as I described before.

So we'll go through each of them individually. So necrotic tissue affects, wound healing because if we have dead necrotic tissue within the wound bed, then that is then classified as by burden. And then the body has to break it down through phagocytosis, and then your macrophages, etc.

Are very, very busy, and they have a hard workload to go through. So that is when it's really important that we use our debridement techniques. So going back in to debridement, we're looking at those sharp or surgical debridement.

There is mechanical debridement, so that would be when you use something like, a wet to dry dressing, a dry to dry dressing. There's also a great new product out in the market called Debrisoft, which I particularly quite like for mechanical debridement. Then we're looking at things like enzymatic debridement.

And so using, things like dermisol, which I certainly am not a fan of unfortunately, because it's not very selective and what we tend to find is that the products used inappropriately and excuse me, inappropriately in wound beds and that it's actually used after . The infla inflammatory phase is passed and it's actually been used in the proative phase, which actually harms the wound bed. So it's really important that we use these products effectively, as I explained before, not putting something in the wound bed that's actually going to detriment our wound healing and the rate of the wound healing as well.

So crotic tissue debrided, by sharp surgical, mechanical, you get enzymatic, you get botolytic, which is very popular for products like Monika honey. So working through the osmotic pressure, and what that does is it donates moisture to the wound. The bacteria lies or die, because they've been flooded with fluid, basically.

So it's so osmotic effect through the honey. Autolytic is very, very gentle, and you can do it with . Patients can go away with a honey, Monika honey dressing on, and, and return to the clinic in at a later date, to get the dressing changed, or in a hospitalised patient as well, so very, very gentle, but not as quick as sharp surgical, obviously, and there's also, biome biomechanically, which would be the use of the delightful, sterile maggot.

There is a company called By Monday down in the, in Wales, I believe, that you can purchase either what they call a teabag or what's been compared to a teabag or loose maggots that we can do, and the enzymatic action of the saliva and the maggots in mouth parts are very effective and the . Basically eat all of the then tissue. So I haven't been fortunate enough, fortunate enough to work with them quite yet, but it's something that I'm quite keen to try.

Most people are a little bit grossed out by that, so apologies for that on an evening. So necrotic tissue, really important that we get and we degrade as much of that as possible by one of the methods that I've just mentioned. So really important that we get rid of all that because then we actually reduce the workload for the macrophages and the leukocytes and etc.

To actually have to deal with in the wound bed. Movement. Now movement is one of those things in And wound management that actually that can be the top factor in delayed wound healing.

So again, linking back up into the assessment of wounds, it's really important that we are fully aware of where the location of that wound is because of movement is going to delay. Wound healing, is that going to affect your scarring? And is it, is that then going to link back into actually we're going to get a functional repair, and that the animals actually going to be able to either work or enjoy its life as it normally does.

So movement's one of those things that unfortunately, it's actually quite difficult. Because it actually involves a lot of owner compliance as well, and everyone knows and normally people sigh when I present that saying, oh my God, yeah, I totally appreciate that that it's really difficult to, manage owners in that way because they're desperate to either let them also lead, let them in a crate, let them jump on the sofa, go up the stairs, and all of our hard work can be undone in a very, very short space of time. So restriction of these patients are really really important and different methods that we can actually use to prevent movement is imperative in these cases.

Infection. I've buttered on about that quite a lot in this evening. So we need to make sure that we're taking your swabs, that we're doing, or a wound biopsies and that we're doing that at the time post vash.

OK, so. Please don't just take a dressing off and then stuck a swab in it because all you're gonna get is whatever's in the date, OK? And that does not actually give you a snapshot of what's happening in the wound bed, at that time and see if your clinicians are open to taking wound biopsies, and that's the gold standard, and then linking back again into our infection control, really, really important that we take all these sort of factors into consideration when we are managing these cases.

Oxygen supply, one of those things that we've got to be mindful of if we've done some sort of reconstruction, there are certain dressings actually that limit the amount of oxygen that is available to the wound. So, products, like hydrocoloids actually create an anaerobic environment. So we've got to be mindful of that when we're talking about if this, patient has a multi-drug resistant infection and then we stick a hydrochoide on it's going to give an anaerobic environment, is that then going to let the anaerobic bacteria go wild?

So it's all these sort of things that we've got to think about as to what we're actually using, in the wound. And also if we've done any reconstructive work as well, is there been a disturbance in the . Let's supply any point down the line when we're looking at the You know, wound slowing down, etc.

And then is that we be actually get enough oxygen from the blood supply as well, so something we've got to, to watch out for. Again, that links into the next point, your blood supply. So again, sometimes when our wounds are actually presented to us, and we get massive amounts of haemorrhage if there's been some arterial in involvement, .

We need to make sure that we are making sure that we can restore that as much as possible during surgery and that we are making sure that in any reconstructive work that we're taking in all the vessels into consideration that we're actually going to still have vitalized tissue at the end of it. Local factors, things like tension, which is a big one again, and really quite tricky and to deal with, especially when we're looking at reconstructive work, and if we've got a big wound effect to deal with, also it can be as well that we're we're thinking about how. We're going to deal with this wound and how we're going to reconstruct it and we're thinking about the tension lines.

We want to close wounds, in a certain way that we're not adding tension to them. So that's when we'll see in clinicians pulling the skin in a certain direction to see which way, gives them a little bit more wiggle room with the tension lines on the body. On the compliance we all despair, .

I have many stories that can make your toes curl as to the lack of owner compliance. I have many case studies that I can bore you all with at a later date, as to how we can sometimes have disasters when it comes to owner compliance. So owner compliance can be increased by owner education, which then links into giving some handouts.

So. I am that crazy dog lady, unfortunately, that if my one of my girls was in for anything and somebody brought the dog into the room, I would not even be listening to a word that they said. So please make sure that when we're discharging any patients that we leave animal out of the room whilst we communicate with our clients and to get the information across, but then that is then backed up with a written handout.

An instruction, leaflet basically as to how to care for their their animal and how to keep them restricted, and linking back to the movement in part. Patient interference again we all despair because that then links back into the owner compliance, keeping those ecos on sorry, Elizabethan I shouldn't say eco Elizabethan collars on buster collars, inflatable collars, . Medical pet shirts are great and there's many, many different forms of them now.

I read about them. They are very, very good, and, things like when the the animal goes out for a wee, making sure that any bandages that, when we're dealing with management that they are kept covered and clean and dry as well. Owner compliance and patient interference, one of those biggies, unfortunately that we all despair.

Introgenic factors, things like bandage complications, very, very common to be presented, . Sometimes in practise that sometimes that can link back again to pure owner compliance so we can do the most beautiful bandage that anybody's ever seen. And then the owner goes home, let's out in the garden, runs about in the wet grass, and the bandages have hanging off by the time it comes in.

So bandage complications can sometimes unfortunately come from ourselves at times that our attention just isn't quite right, and these things happen, but we can . We can make steps to to improving that through there's things like the baning angels that I'm involved with, and there's many people who do in private teaching if anybody needed a refresher, but there's . Items that are there that it's more to do with the the owner compliance as well.

So again, client education give them a dressing care sheet and a bandage care sheet when they go home, and then they can refer back to it and unfortunately that then links back to covering our own backs and for BDS cover, etc. That we have done everything in our power to educate our clients. For nutritional health status, so making sure that we are animals are adequately .

Covered with nutrition and that we're giving them enough calories, that their protein levels are appropriate and that we are feeding them enough because for wound healing and healing to occur, they do need more calories to do such a thing. So making sure that our patients aren't underweight or overweight. Health status, things like diabetes and steroid treatment, Cushing's, all sorts of things, those can also delay wound healing as well.

So, having a a good patient history is imperative and knowing what medications they're on at home can also give us an indication of that. For bodies and contamination, so again that links back to our good wound bed preparation. And that goes back to with our necrotic tissue also and so making sure that we are preparing your wound beds and that we're preventing as much of the foreign body and contamination within that wound bed because all your body's gonna have to do is fight against that first before it can move on to the next stage of wound healing.

Altered local pH so that can be things like products that we've actually used within the wound bed that can affect the, the wound pH and also that can be unfortunately animals urinating on their wounds as well. So you know that bandage that might smell a little bit suspicious and something's happened to it, we need to get that off straight away, so don't wait and wonder, just get it off and reapply the bandage if that's the case. Genetic factors that can be things like cat versus dog, that can be things like greyhound skin versus basset hound skin, and the tension lines within the body, each, you know, breed of animal can be very different, and species of animal can be very different as well.

So sometimes you're, you're gonna be up against it and things like that, for certain cases, so having a good overview of your patient is really important as well. In self transformation, what that basically means is there is there any new plastic Cells present and have we had to do a reconstructive process for to get some wound closure from post removal of a mass of some description. That has a neoplastic, action within the wound bed because then that can actually, we can get regrowth, etc.

Or seeding off that neoplasm, and then we can actually get wound breakdown from that as well. So getting prompt results back from your laboratory if we have done any sort of FNA. To surgery, and if we've had in biopsy results, etc.

Or mass removal results, then that may be an indication to either keep a closer eye on your wound if you've not had any margins, or making a plan going forward and if we have had some issues at all with that. So sorry I maybe overran a tad there because of the Unfortunate in technology fails, so my apologies for that, everyone, thank you for sticking with me, and, I hope that, that was in concise enough that I, that you're not totally, despairing with what I've just told you. So thank you very much, everyone for listening.

I just wondered if anybody had any questions. Brilliant. Thank you very much, Lisa.

Absolutely brilliant webinar. You've crammed so much into that hour, which is really great, and you did so well to just come straight back and get straight back onto it after the technical issues, so well done. Thank you.

Sorry about that. Oh, it's OK. It happens.

If anybody does have any questions, I'll just remind you how to ask those. So just hover over the toolbar. It's either on the top or the bottom of your screen, click the Q&A box and send your questions through so I can read it out to Lisa.

I'll just give a few minutes and we'll see if any come through. OK, so we've had one comment in the box. So really enjoyed this webinar.

Lots of simple points to take forward. Thank you very much. We are often asking clients to clean the animal's bedding while sitting with us, or at least put a clean, dry towel over the bed each day to minimise contamination.

Also, sharp a skin, what the heck? I think we can agree on that. Yeah, I am.

I completely agree, and that's coming back to the genetic factors as well, and it is, it is just so difficult to deal with sometimes, you know, and it can be things like that we're fighting against, so like things like Sharpie and Basset hounds and things like that. We actually can have secondary infections already present. Before, so they have skin issues anyway, and then we're having to fight against that with our wound management and prior to even you know, consider doing any form of surgery with them or if they've been unfortunate enough to have a traumatic event that we're dealing with wound management as well.

So this is when it comes down to. Doing your thorough history and then looking at what lavage and volume, temperature, pressure, all these sort of things and that we do our nice big white clips and I do appreciate skin like that. It isn't easy to clip.

And that there's so much of it, and there's so many folds and things like that, it is a nightmare. And then that just goes back to guys just having a think about how much time that we actually allocate ourselves. And that can be quite tough because there's always pressure and practise to do as much as possible in such a short space of time.

But my, one of my big take home messages for people is that to try and and be pretty proactive in practise and about saying no, we need to make sure that we give ourselves enough time to do this case. So maybe doing one less elective case to be able to do this bigger case on that day, and which relieve the pressure and things like that. And again, skin thickness.

All of these sort of things that when we're going to look to do closure, it's very different to dealing with greyhound skin that we've got no subcutaneous fat layer at all. So it's it's really, really tricky as well. And sorry, I've went on so much about the different types of skin.

There was another comment at the beginning, so sorry, it was sharp skin, what the heck? And what was the first part? Sorry.

And so the first part said we often ask clients to clean the animal's bedding whilst in with us, or at least put a clean dry towel over the bed each day to minimise contamination. Yeah, I mean, I think that's a fantastic idea, . Normally what our protocol is in the hospital is that we keep the wound covered until the animal goes home.

So then we, minimise the risk of cross contamination at any point along the way. Some clinicians have a very different viewpoint, even with clinicians that I work with at the hospital. Some are happy that after the six hour period where the fibrin seal has been created, then in their opinion, they don't need those patients don't, do not need any further dressing, changes or anything like that to happen, whilst they're in the hospital environment.

Others are like absolutely not. It needs to be covered at all times and there there's be a barrier there, etc. .

Just in case there are other products out there now that are used in quite infrequently, so in different types of tissue adhesive, etc. So one that's quite popular is Dermabond. And so that actually creates a seal right over the top of the wound, and that can, that decrease over time and actually lasts up to a month.

So some clinicians are quite keen to use that product. It is quite expensive, unfortunately, as, things are if it's a good product. So that just creates, so you get your Mseal with your fibrin, but then.

On top of that, you have the tissue adhesive and that degrades over time. Sometimes it can last up to 66 months and so sorry, 4 weeks. My apologies, as it breaks down.

So actually, as that product goes on, it is a sort of violet blue colour, and as it degrades, actually the big thing to, to educate our clients with is that as that degrades, it actually turns a dark brown or even black colour. So actually it can look like your tissues dying off when actually not, it's just the tissue adhesive breaking down. So if a product like that is used in practise, that's a really important point to put in your discharge instructions that if something like that is used, then the owners are aware of how it, how it looks.

Changing bedding and things like that, absolutely, each day. Within the hospital environment, what we do is we get a change of the bedding, each day. Yes, it is more washing costs, but then that that can be taken up by the cost of your hospitalisation and things like that.

So keeping your wounds covered or whatever your clinician's opinion is on when the fibrin seal is created. Keeping that covered and or just making sure that the, the wound isn't becoming open again, and then changing your bedding each day is a really good idea. Any sort of method to either improve infection control, within in wound management, I always celebrate.

So I think that's a fantastic. Lovely, thank you very much. And just talking about sharppeys, I know even if you place an IV catheter in a sharpei quite often you can see a clear sebum leaking out.

Yeah, you find that you see their wounds healing differently to the dogs because of that. Yeah, and I mean, it's, it's one of those processes. I mean, if I'm brutally honest, I have not dealt with a huge amount of Sharpies in my career.

I don't know if they're just not very popular in Scotland themselves, but I've actually dealt with more Sharpies when I was in general practise than when I was, since I've been in referral actually, would you believe it? And, you know, the, the Sharpies that I see in general practise were quite common for . For a massive tumour production that I tend to find, tend to find, but actually since I went to a referral, I actually haven't dealt with too many of them, but I absolutely agree is that when you're placing an IV catheter or anything at all, you do get that sort of leakage from the skin as well.

So, the healing rates can be very. Different in these animals as well, and it's certainly something to be mindful of as we're progressing because yes, these wounds may not progress at the same pace as something like a Labrador or something like that that as a a little bit more. Not very diplomatic way to put it a bit more normal anatomy if that makes sense.

It can be definitely very thick skinned breeds, with multiple folds, etc. So I absolutely agree they do not kind of follow the rules, and that's when genetic factors are really important to be aware of, especially when we're making a plan of what we're going to do with these patients. Yeah, they are tricky ones for sure.

So that seems to be the end of our questions. We haven't had any others come through. So on that note, I'd just like to ask our attendees to just fill in the feedback form that will have popped up in your browser.

It's just a couple of quick questions so that we can tailor the webinars to suit your needs. And thank you everybody for logging in and listening, and massive thank you to you, Lisa, for delivering such a brilliant webinar tonight. Thank you very much.

If anybody any questions you're very welcome to email me. And my email is [email protected].

If you think of any questions after the webinar, that you would like to ask me, I'm more than happy to get back to you via email, if you'd like me to, so yes, any, anytime and just find an email. Brilliant. And if you didn't catch that email address, you can always email the webinar vet and they can forward on Lisa's email address to you.

That's very kind. Thank you, Lisa. You're very welcome.