Primum non nocere: A therapeutic imperative for modern wound care

In a seminal symposium on wound management held in the mid-1980s, Gordon R. Tobin, II, MD, FACS, a professor of plastic and reconstructive surgery, University of Louisville, KY, described the goal of all wound management as successful closure of the wound to increase function and to decrease hospital stay and disability.^1,2 Many wounds have clinical deterrents that inhibit that goal, such as excessive exudate, debris, de-vascularized tissue, bacterial bioburden, and deleterious cytokines. Control of these deterrents helps to move the healing trajectory from impaired toward ideal.³

To accomplish the goal of satisfactory wound healing or wound closure, a plethora of medicants, dressings, and devices have been introduced into and placed onto both acute and chronic wounds. Not all of these materials have been innocuous to wound tissue; many have been cytotoxic to fibroblasts, keratinocytes, or other cells in the wound healing process.

A new paradigm

Primum non nocere, which means “above all, do no harm,” is typically attributed to Thomas Sydenham, MD, a physician sometimes known as the English Hippocrates who practiced during the mid-1800s.⁴ The admonition of “above all, do no harm” should be a therapeutic imperative for wound care. Based on the principles of not doing harm to the wound, a new paradigm was reported for effective wound healing by simplifying the approach to wound care.²

This new paradigm revolves around meticulous wound bed preparation to allow the wound to proceed to endogenous healing or to set the stage for successful wound closure with autologous tissue.⁵ The principles of treatment of this paradigm are to remove deterrents to normal healing without adding any agents that might interrupt the normal cellular or humoral processes of the wound healing milieu. Wounds that do not spontaneously close are then closed expeditiously with autologous epidermis and dermis.² (See Figure 1.)

Figure 1. A paradigm that fulfills the adage “Primum non nocere”

Several new products that remove deterrents to wound healing without adding agents that inhibit healing have been introduced. Antimicrobials that mimic the leukocyte’s oxidative burst to eradicate pathogens, and dressings and devices that can draw debris, bacteria, and harmful cytokines from the wound are replacing agents that are placed into the wound and have harmful side effects. Closure with autologous skin is supplanting skin substitutes. Despite these advances, many aspects of wound healing and wound care have failed to address the directive of primum non nocere.

During a recently held symposium titled Scientific Advances in Wound Care: An Update, which was hosted by the department of surgery at the Uniformed Services University of the Health Sciences and the Walter Reed National Military Medical Center, Bethesda, MD, participants discussed the need for tools to be developed in the areas of inflammation, infection, biomarkers, wound strength, and scarring that could improve outcomes without the addition of injurious agents.⁶ In each area, novel approaches could be developed that would do no harm to the wound and allow the healing trajectory to shift from its present compromised position toward a more ideal trajectory as represented by fetal wound healing.³ It was the opinion of those present, including the panelists, that such approaches should become a therapeutic imperative.

Products used in wound care can be synergistic and designed to aid various acute and chronic wounds to heal without outside interference and without doing any undue harm to healing tissues. The paradigm of “do no harm,” particularly when it comes to wound care, allows surgeons to follow their inherent drive to do what is best for their patients.

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References

1. Tobin GR. Closure of contaminated wounds: Biologic and technical considerations. Surg Clin N Amer. 1984;64(4):639.
2. Winkler M, Steadman ME. Removing deterrents without adding potentially harmful agents: A new paradigm for effective wound healing. Today’s Wound Clinic. April 2014. Available at: www.todayswoundclinic.com/files/TWC_April2014_Winkler.pdf. Accessed July 25, 2016.
3. Robson MC, Steed DL, Franz MG. Wound healing: Biologic features and approaches to maximize healing trajectories. Curr Prob Surg. 200l;38(2):61-140.
4. Smith CM. Origin and uses of primum non nocere—above all, do no harm! J Clin Pharmacol. 2005;45(4):371-377.
5. Schultz GS, Sibbald RG, Falanga V, et al. Wound bed preparation: A systematic approach to wound management. Wound Rep Regen. 2003;11(Suppl 1):S1-S28.
6. Scientific Advances in Wound Care: An Update. Symposium held at USU Walter Reed Surgery, USUHS, Bethesda, MD. June 25, 2015.