SCIENCE, PRACTICE AND EDUCATION to shock and poor perfusion. Diffusive constraints due to oedema and oxygen consumption by bacte- rial biofilm can also contribute to hypoxic wounds. 2 Ischemic wounds are notoriously difficult to treat and often become chronic and non-healing. 3 This leads to a vicious cycle, as neutrophil accumulation in chronic wounds due to ongoing tissue damage and debris further depletes oxygen in the wound bed, hence impeding wound healing. 2 Providing supplemental oxygen to wounds has been shown to deliver nutrients and immunoglobulin, mo- bilise bone marrow-derived endothelial progenitor cells and modulate redox-sensitive gene expression to accelerate wound healing and reduce rates of infec- tion; this has traditionally been provided in the form of systemic hyperbaric oxygen therapy (HBOT). HBOT is defined as 100% oxygen delivered sys- temically at 2 to 3 times the atmospheric pressure to raise the partial pressure of oxygen systemically from 10 to 15 times the normal value, thus creating an oxygen diffusion gradient into hypoxic tissue to maintain transcutaneous oxygen levels (tcPO2) of 30 mmHg or greater, the optimal level for devel- oping normal granulation. 4 HBOT is also known to stimulate fibroblast proliferation and differentia- tion, promote collagen formation and cross-linking, encourage neovascularisation, reduce oedema and enhance leucocytes’ microbial-killing abilities. 5 Recently, topical oxygen therapy (TOT) has emerged as a more promising alternative for delivering oxygen topically to wounds, as HBOT is limited by cost, availability and the risk of systemic oxygen toxicity. TOT is only effective when the oxygen delivered can diffuse through the tissue into oxygen-deficient cells. There are four main categories of TOT: (1) topi- cal pressurised oxygen therapy (TPOT), (2) topical continuous oxygen therapy (TCOT), (3) wound dressings that release oxygen and (4) topical oxygen emulsion. A sustained increase in the level of vascular endothelial growth factor (VEGF) has been shown in recent studies to be useful with TOT for promoting chronic wound closure in arterial and venous wounds and in pressure injuries. 6 AIM This case study illustrates the successful treatment of an ischemic ulceration in a neonate using TOT combined with the modern M.O.I.S.T. wound care concept. Wound care in the neonatal population is rudimentary and lacks evidence-based recommen- dations, so care protocols are largely adapted from adult guidelines. ‘M.O.I.S.T.’ are the factors to consider when manag- ing difficult-to-heal wounds. The acronym stands for Moisture balance, Oxygen balance, Infection control, Support and Tissue management. 7 These factors form the basis for promoting moist wound healing. Wound care in pre- and full-term neonates may differ from adults, due to their immature skin structure, which makes them more susceptible to infection, the toxicity of topical medications or dressings, blis- ter formation, changes in ambient temperature and trans-epidermal water and electrolyte loss. Percuta- neous absorption of common wound care products containing alcohol, chlorhexidine, povidone-iodine and silver sulfadiazine can be harmful to the paedi- Table 1: The M.O.I.S.T. wound care concept (adapted from Dissemond et al, 2017) 7 Moisture Balance Oxygen Balance Infection Control Support Dry wounds: Haemoglobin Antiseptics Modify the: - Wound gels spray Medicinal honey - Inflammatory mediators Moist wounds: Hyperbaric Dialkylcarbamoyl- - Alginates oxygen chloride-coated - Hyaluronic - Hydrofibre wound dressings acid - Foams Normobaric oxygen Silver-coated - Matrix metall- Superabsorbent wound dressings oproteinases - pH -Growth factors Tissue Management Wound cleansing: - Normal saline - Ringer’s solution - Preserved solutions Debridement: - Autolytic - Biosurgical - Surgical - Enzymatic JOURNAL OF WOUND MANAGEMENT 39 OFFICIAL JOURNAL OF THE EUROPEAN WOUND MANAGEMENT ASSOCIATION
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