Dressing Selection and Wound Healing - Wound … clean uninfected wounds were ... antiseptics such...
Transcript of Dressing Selection and Wound Healing - Wound … clean uninfected wounds were ... antiseptics such...
DRESSING SELECTION AND WOUND HEALING
“It is the false shame of fools to try to conceal wounds that have not healed. “ Horace (BC 65-8) Latin Lyric Poet
HISTORICAL ROLE OF DRESSINGS
OBJECTIVES
After completing this
module, the participant
should be able to:
1. Discuss dressing
selection based on
the 9 principles of
wound healing.
2. Identify various
advanced wound
care dressings.
3. Select appropriate
dressings, based on
the wounds needs.
The use of dressings in wound management can be traced back to the Egyptians. In 1862,
a papyrus dating back to 3000–2500 BC was discovered by American Egyptologist Edwin Smith. When the papyrus was finally translated in 1930 a variety of dressings were
recorded. The dressings included grease, resin, honey, lint, and fresh meat. Wounds were closed by the use of linen strips to which sticky gum had been applied. Antiseptics were
made from green copper pigment and chyrsoedla were used in open wounds.
From 25 BC to 37 AD, Celsus wrote
extensively on medicine. He was the
first to describe rubor, tumor, calor,
and dolor (redness, swelling, heat, and
pain) as cardinal symptoms of
infection. Celsus advocated the
removal of foreign bodies before
closure and expected the wound to
become purulent.
Galen (129–200 AD) was a surgeon
who tended gladiators in Pergamun.
He is famous for his “laudable pus”
theory. Galen advocated that wounds
needed to become infected and form
pus before healing would ensue. As a
result, clean uninfected wounds were
inoculated with a variety of substances
to induce infection. This theory
persisted for more than a thousand
years. 1
Renaissance physician, Dr. Ambrose
Paré followed the theory of his times
and used boiling oils as cautery for
amputation of limbs and wounds.
During a great battle he ran out of
boiling oils used to treat the soldiers.
Dr. Pare began applying egg yolks, oil
of roses, and turpentine. At the
conclusion of the battle, he found the
soldiers to whom the egg yolk mixture
had been applied were making better
progress than those soldiers that had
boiling oil applied to their wounds. Dr.
Pare began to question the theory of
“laudable pus” and changed his
practice.2
During World War I, the use of topical
antiseptics such as Dakin’s solution,
iodine, carbolic acid and mercury was
used to prevent infection in battlefield
wounds. British soldiers were advised
to carry iodine and immediately apply
it to gunshot wounds. Unfortunately,
many developed dermatitis as a result
of indiscriminate use. It was also in
this era a dressing called tulle gras
was developed by Lumiere. This was
gauze that had been impregnated with
paraffin.3
Through World War I, the task of
changing dressings was in the realm of
physicians and medical students. In
the 1930s, the changing of dressings
was given over to experienced nurses
and became recognized as a nursing
task. For the next 40–50 years the
mainstay of wound coverings were
gauze, cotton wool pads, impregnated
gauze, absorbent cotton, and adhesive
pads. The 1960s were the start of a
change in dressings and the
philosophy of their use.
CHANGING PHILOSOPHY
Early pre-clinical and clinical research
in the 1960s started to define the idea
of moist wound healing and the benefit
in optimizing wound healing. The
concept that a wound that is kept
optimally moist will have better
outcomes than one that is allowed to
dry out4,5.
The concept of moist wound care
began to receive serious consideration
in the late 1970s and 1980s. Prior to
this time, drying of the wound was
accomplished by several mechanisms:
the use of povidone iodine as a drying
agent, heat lamps, wet-to-dry
dressings, and leaving the open wound
exposed to air.6 Transparent film
dressings and hydrocolloids were the
first widely used dressings that
addressed moisture retention.
Throughout the 1980s and early 1990s
there was an explosion in the realm of
dressing products. Alginates,
hydrogels, and foams appeared on the
market in a wide variety of products.
The concept of passive dressings
began to change. Dressings were
becoming active in their role to change
the wound milieu in the healing
process. The advent of growth factors
and other biosynthetics such as
collagen began the movement to an
interactive dressing.
Today, research and development is
being focused at the cellular level.
Interactions of the cellular components
within the chronic wound environment
and how interactive dressings can alter
the wound milieu is putting dressing
technology on the cutting edge. What
is next may be limited only by our
understanding of how the body
changes from a normal healing
environment to a chronic wound
environment, our technological ability
to create products and our imagination
on how to get there.
DRESSING CATEGORIES
For more than two decades
practitioners have been taught
categories of dressings in order to
understand how they work and when
to use them (Table 1). The classic
categories are gauze, films, alginates,
foam, hydrogels, hydrocolloid, and
composite dressings. Today, there is
such an expanse of dressing products
that the seven classic categories no
longer are adequate. In order to
embrace the new dressings, an eighth
category was created called interactive
dressings.
Hand in hand with dressing selection is
the question of change frequency. The
time interval for dressing change, will
first and foremost, be based on sound
clinical judgment. If the dressing is
soiled, loose, slipping or curling at the
edges it is obvious that it should be
changed. If there is accumulation of
fluid and debris that saturates the
dressing it will need to be changed. If
infection is present there may be a
need for increased frequency of
dressing change. All dressing products
come from the manufacturer with
recommendations for frequency of
change or how long a particular
dressing is expected to maintain its
action. These recommendations should
be used as guidelines with clinical
judgment ruling supreme.
Dry woven or non-woven sponges and
wraps with varying degrees of
absorbency, based on design. Fabric
composition may include cotton,
polyester or rayon. They are available
as sterile or non-sterile, in bulk, and
with or without adhesive border. The
gauze may be impregnated with other
products such as hydrogel (to
hydrate), sodium chloride (to absorb
and draw).
Figure 1
Thought to be the very first advanced
wound care dressing7, transparent
films are polymer membranes of
varying thickness with adhesive
coatings on one side only to allow
adherence to the skin. These
dressings are impermeable to liquid
and microbes but permeable to
moisture vapor and atmospheric gases
like oxygen. Visualization is easy since
you can see the wound through the
dressing. They are comfortable to
wear because they can stay firmly on
the skin for an extended period of time
making them both an excellent
secondary dressing for long wear time
as well as a good primary dressing for
lacerations, skin tears, and I.V. sites.
Other varieties offer an island
configuration with a soaker pad of
non-adherent gauze, alginate pad or
other component. Films have been
shown to have a lower overall infection
rates associated with their use than
traditional gauze dressings8. It is
important to select the correct
dressing size to allow for
approximately 1-inch of dressing to
contact the intact periwound skin. To
Gauze Dressings (Figure 1)
Transparent Films (Figure 2)
remove, gently pull up just the edge of
the dressing and pull/stretch the
dressing at a parallel angle to the skin,
breaking the seal and allowing. Do not
pull straight up as this can cause
damage to the epidermis.
Figure 2
Calcium-alginate, calcium-sodium-
alginate, and collagen alginate
dressings are natural fiber dressings
derived from processed seaweed.
These dressings are highly absorbent
and conform readily to wounds of
various shapes and sizes. The
chemical reaction between the
dressings and the wound exudate
creates a gel-like substance. The gel in
turn assists in maintaining a moist
wound-healing environment. An
alginate can absorb up to 20 times its
weight. Most alginates come in both
sheet and rope form. Because alginate
dressings are very porous and have no
adhesive properties, secondary
dressings must be used to secure
them9.
Figure 3
By far one of the most versatile
dressings on the market, hydrogels
are primarily water and/or glycerin in
composition. They are three-
dimensional networks of hydrophilic
polymers prepared from materials
such as gelatin, polysaccharides,
cross-linked polyacrylamide polymers,
polyelectrolyte complexes and
polymers or copolymers derived from
methacrylate esters10. Their function
depends on their form, for instance
amorphous (literally meaning “without
form”) hydrogels donate moisture to
the wound and offer gentle application
and removal. This type also provides
a good option for autolytic
debridement and substitution for moist
gauze. Some amorphous hydrogels
additionally have the sophisticated
capability to absorb and/or donate,
depending on the wound’s needs.
Other forms include impregnated
dressings such as gauze and sheet,
strand or semi occlusive varieties. The
latter offers soothing, cooling relief
and gentle healing to wounds such as
skin tears11,12,13. These dressings can
and should be cut to fit the wound.
Figure 4
Figure 5
Alginates (Figure 3)
Hydrogels (Figures 4 and 5)
One of the initial advanced wound care
dressings to come to market14,
hydrocolloids are occlusive and semi
occlusive dressings composed of
carboxymethylcellulose, pectin, or
gelatin and have different absorption
capabilities depending on their
thickness and composition. The
original hydrocolloids were developed
from the adhesive flanges used for the
long term protection of skin
surrounding stomas15. The barrier
produced when the dressing comes in
contact with the tissue, prevents
excretions and exudate from eroding
or denuding the skin surrounding the
wound. As exudate is absorbed by the
dressing, it develops a thick colloidal
gel in the wound bed that increases
the moist healing environment
necessary for granulation,
epithelialization, autolysis.
These wafers come in a variety of
sizes and shapes such as the
“butterfly” design or sacrum shape
that are “hinged” to fit the gluteal fold
of the buttocks. Look for tapered, low
profile edges that decrease the
chances of rolling up and a smooth
satin-like outer coating to decrease
friction and shear.
Although considered a low-tech option
for chronic wound care, in many
settings hydrocolloids remain the most
heavily utilized moist dressing option
for wound management16.
Figure 6
Foams are non-adherent, absorbent
dressings that vary in thickness and
are obtainable in adhesive vs. non-
adhesive varieties. They are
composed of polymers like
polyurethane with small open cells that
trap moisture. They are appropriate
for partial- and full-thickness wounds,
provide for moist wound healing,
thermoregulation and protection. Look
for varieties that offer superior
moisture management, micropores for
low adherence to the wound bed,
decreasing pain and disruption of
healing and a water-proof backing to
prevent strike-through bacterial
penetration. Absorbency and moisture
vapor permeability are varied either by
a physical alteration or by uniting the
foam with an added sheet element.
Figure 7
Composites combine two different
types of dressings with several
functions in one single dressing that
can address different needs. They can
be used as a primary and/or
secondary dressing and feature an
absorptive layer, an adhesive border
and a strike-through barrier. These
dressings are versatile and convenient
offering options for both partial and
full thickness wounds. Their water-
proof nature makes them a popular
choice for areas prone to moisture
assault from incontinence. These
versatile dressings provide a barrier to
bioburden while offering a simple
“Band-Aid” type application and
removal.
Hydrocolloids (Figure 6) Foams (Figure 7)
Composite (Figure 8)
Figure 8
Dressings that interact with the wound
bed components to assist in producing
an improved wound healing milieu.
They can accomplished this via
reducing colonization count, reducing
the level of exudates, improving
wound bed moisture retention,
improving wound collagen matrix,
removal of cellular products or
providing protection for the
epithlializing bed. Interactive dressings
come in various forms.
Safe, broad spectrum antimicrobials or
“biocides” (a general term describing a
chemical agent, usually broad
spectrum, that inactivates
microorganisms)1 and wound dressing
products containing these agents have
been developed to address the needs
of chronic wounds with the intent to
1 McDonnell G, Russell AD. Antiseptic and
disinfectants: Activity, action and resistance. Clinical Microbiology Reviews, January 1999, 12(1):147-179.
minimize colonization and prevent
local infection, thereby enhancing
healing. Both in vitro as well as
clinical observations support the
utilization of various biocide and
antimicrobial products17. Several of
these products are outlined below.
Silver
Silver is more universally effective
than antibiotics, more broadly
powerful than chlorine and blocks the
growth of gram negative and gram
positive bacteria including resistant
MRSA and VRE, fungi, viruses and
yeast. An important feature of ionic
silver is that it kills detrimental
microbes but it is non-cytotoxic to
proliferating granulation tissue, in the
right concentrations2.
The use of silver has been documented
for its broad-spectrum antimicrobial
activity and compatibility with humans
throughout history. The present
recognized antimicrobial properties of
silver have been empirically evident
for more than 3000 years3. A plethora
of literature has reviewed its historical
use, antimicrobial properties and
toxicity. In 1881, a German
obstetrician named Dr. Crede used a
1% silver nitrate solution to eliminate
congenital blindness (Ophthalmia
neonatorum) in newborns caused by
post-partum infection of Neisseria
gonorrhea4 . In 1887, von Behring
used the same compound to treat
2 Ovington LG. The truth about silver. Ostomy
Wound Management 2004;50(9A) suppl, 1S-10S. 3 Russell AD, Hugo WB. Antimicrobial activity
and action of silver. Pro in Med. Chem. 31:351-370, 1994. 4 Crede. Prevention of inflammatory eye
disease in the newborn. Gynaecology Archive, volume 17, Berlin, 1881, 265-66. Available at: http://www.who.int/docstore/bulletin/pdf/2001/issue3/vol79.no.3.262-266.pdf#search='Crede%201%25%20silver%20nitrate' accessed 1-21-06.
Interactive
Antimicrobials (Figure 9)
typhoid and anthrax. In 1964, Moyer5
first used silver for the care of burns.
And in 1968, Fox6 introduced silver
sulfadiazine (SSD), still used today
despite the availability of more
advanced and effective products.
As is true with all antimicrobials, too
high a concentration of silver ions can
prove to be cytotoxic7. Available in
many different forms, ionic silver is
safe and little or no evidence of
associated clinical resistance8. This is
because of silver’s multifaceted mode
of action on pathogenic metabolic
pathways. Silver ions attack the cell
membrane, the membrane transport
system, the RNA and DNA function as
well as the protein function rendering
in nearly impossible for bacterial
mutation to occur. With ease it can
occur when antibiotics are used.
Antibiotic resistant bacteria, for
example MRSA and VRE are easily
eliminated in dressings that have silver
ions present. The longevity of silver
ion presence in the dressings, through
their controlled release mechanisms,
ensures that the wound environment is
hostile to bioburden for relatively long
periods of time.
It is rare to observe allergic reactions
or sensitization associated with silver.
No other unfavorable side effects have
been clinically observed despite the
widespread use of silver containing
dressings, especially in burn wound
applications.
5 Moyer CA, Brentono L, Gravens DL, Margrat
HW, Monafo WW. Treatment of large human burns with 0.5% silver nitrate solution. Arch Surg. 1965;90:812. 6 Fox CL, Rappole BW, Stanford W. Control of
Pseudomonas in burns with silver sulfadiazine. Surg Gynecol Obstet. 1969;(14):168. 7 Poon KM, Burd A. In vitro cytotoxity of silver:
implication for clincal wound care. BURNS 2004;30:140-147. 8 Percival SL, Bowler PG, Russell D. Bacterial
resistance to silver in wound care. Journal of Hospital Infections (2005) 60, 1-7.
Keep in mind that preparations with
silver nitrate are pro-inflammatory and
the petrolatum base in silver
sulfadiazine produces a pseudo-eschar
after it reacts with serous exudate,
which can be particularly difficult to
remove9. Both of these preparations
dump silver ions into to the wound to
compensate for the relatively
unsophisticated delivery systems
typically used for these compounds. New
and improved controlled released
versions of silver dressings address
the shortcomings of the traditional
silver products such as silver nitrate
and silver sulfadiazine18. These novel
products, in addition to delivering
antimicrobial and anti-inflammatory
properties topically, also address other
wound requirements such as fluid
management and close contact with
wounds that are present in difficult to
treat areas19. See table below for
summary:
9 Demling RH, DeSanti L. Effects of silver on
wound management. WOUNDS 2001;13supplA:4.
Figure 9
Summary of the Key Differences between Ionic Silver and Silver Sulfadiazine
Silver Amorphous Hydrogel Silver Sulfadiazine (Silvadene ®)
Silver-salt in a gel base, ionic silver, a
device, not a drug
Silver salt of sulfa drug, requires a
prescription
Effective broad-spectrum antimicrobial Effective broad-spectrum antimicrobial
Effective for 3 days – self-regulating for
controlled release of silver, reaches
wound equilibrium of 1-2 parts per
million in silver ions.
Applied a minimum of B.I.D. Silver ion
release data reported variably. Clinicians
seem to believe that all silver related
activity is exhausted within the first 8-10
hours within the wound, necessitating
removal of the product (pseudoeschar,
see below), and reapplication twice daily
at minimum.
Non-Cytotoxic to delicate wound tissue. Toxic. Usually limited use to 2 weeks
Amorphous gel base is non-irritating,
though “stinging” may be experienced in
isolated cases.
Sulfa/petrolatum combination is a
common skin irritant/allergen. Sulfa
drug use, with its specific mutation
susceptible method of “kill” may result in
resistance buildup in micro-organisms.
Adverse reaction of hematologic
neutropenia in up to 5% of patients
receiving.
Less painful and easy to apply and
remove. Removal is not required as no
pseudo-eschar is formed.
More painful – Difficult to remove. Forms
a pseudo-eschar that may need to be
surgically removed (scraped), causing
pain, wound bed disruption, and may
initiate scarring responses (Glat PM, et
al. Randomized clinical study of
SilvaSorb Gel in Comparison to Silvadene
silver sulfadiazine cream in the
management of partial thickness burns,
Journal of Burn Care & Research, 2009,
20(2):262-267.).
Non-staining to skin and tissue
Stains wound bed and peri-wound skin
(possibly permanently), causing
disfigurement and potentially interfering
with assessment
Less frequent dressing changes; staff
time savings
Time-consuming for staff to apply and
remove; disruptive to patient and wound
environment.
Does not “melt”, i.e. change viscosity
significantly upon application, thus stays
in place easily.
Because product is based on petrolatum,
it tends to liquefy at body temperature,
and tends to “slip off” the wound. Cells
do not proliferate well and tolerate an oil
environment.
Anti-inflammatory action Pro-inflammatory action
Sophisticated microlattice delivery
system that liberates silver into the
tissue and is effective for three days.
Unsophisticated delivery system, lower
level of ionic silver, not stable in
moisture.
©
Cynthia A. Fleck
Researchers have tried to create
transmittable mutations that will
propagate in an environment without
the antimicrobial (silver), just as
antibiotic resistant organisms
propagate in the clinic or an in vitro
situation mimicking the clinic, in the
presence or absence of antibiotics.
Those experiments have shown that
artificially created silver resistance in
the laboratory is poorly transmitted in
successive generations. In addition,
silver in a low concentration is present
in normal environment because silver
ions are present in the environment.
As precious metals go, silver is not a
particularly rare element in nature,
and thus the development of
resistance to silver is rather unlikely.
Finally, the mode of action of silver
ions on the living pathogen is so
multifarious in nature that it is difficult
for pathogens to mutate to respond to
all the mechanisms that exist to
explain the lethality of silver ions.
Antibiotics on the other hand, have a
single mode of lethality, and it is easy
for the pathogens to develop
resistance, a single mutation can
cause such resistance20.
It is true that at least two cases of
isolation of silver resistance has been
noted in clinical isolates (one in Hong
Kong, one in London, UK). However,
these isolates did not present any
clinical challenges to healing, and
more importantly, these isolates,
which seem to have developed
through a random genetic resistance
development, did not respond to
any commercial silver product,
irrespective of the concentration of
silver ion (release rate) that was
associated with the product21,22.
Silver Reservoirs
Fundamentally speaking, as long as
the silver reservoir (whether it be
metallic silver which has to ionize to
make the lethal agent Ag +, or a
compound of silver that instantly
dissolves in a wound fluid) is not
limiting, a natural law called the Le
Chatelier's principle will determine the
concentration of silver ions in the
wound bed. According to this
principle, in a chloride rich wound
environment (all wound environments
have a large amount of chloride ions
present in them), ALL silver dressings
will result in a concentration of 1-2
parts per million (ppm) in the wound
bed, which roughly corresponds to the
concentration of the silver ions when
such dressings are tested in
physiological saline. The fact is that
the 60-70 ppm that is commonly
referred to as the concentration
emanating from a nanocrystalline
silver is seen only when a medium
such as distilled water is used for the
testing. It is possible that such
dressings provide a higher
concentration (more than the
equilibrium 1-2 ppm) of silver ions in
a transient fashion. However, the
only benefit of such a bolus effect is a
high log rate kill in a wound when the
dressing is first applied. The cost to
such bolus effects seems to be the
high cytotoxicity that is seen with
these so called "high-silver" dressings,
and there is some clinical evidence to
show that such dressings may actually
delay wound healing23,24. Both
nanocrystalline silver, as well as ionic
silver showed similar antimicrobial
efficacy in in vitro testing.
There has been a lot of variation in the
test methods used to determine silver
concentration in numerous
publications. There appears to be no
standard technique25. There is clearly
a discrepancy between laws of nature
(silver ion concentration in ANY
environment is determined by
immutable laws of nature) that "it is of
interest to note that the MICs recorded
by us and others are in excess of the
reported maximum solubility of SSD,
namely 1.32 microgram/ml" (which is
1.32 ppm, in the 1-2 ppm "law of
nature" range that other authors have
lately shown to be the only possible
silver ion equilibrium concentration in
the wound bed. Head to head testing,
in a physiological medium (such as
normal saline) seems to provide the
best relative measurement of the
silver release rates of the various
products. It is also true that silver
ions will indeed bind to organic
matter. But the point is that in doing
so, the silver concentration is
transiently reduced from the "law of
nature" concentration of 1-2 ppm,
causing more of the silver reservoir
(be it metallic silver, or an ionic salt of
silver) to ionize, and the "law of
nature" equilibrium concentration of 1-
2 ppm is rapidly restored, irrespective
of the type of silver dressing used26.
That is the Le Chatelier's principle at
work.
Currently there is a plethora of silver
products on the market with a wide
range of silver delivery. Thomas and
McCubbin, examined the silver content
and antimicrobial activity of 10
common silver dressings on the
market. They found significant
differences in the activity of the
products. There was a clear
relationship between the silver content
of the dressing and ability of the
dressing to be bactericidal but other
factors were also identified. Other
factors included: was whether the
silver was a surface coating or
dispersed within the structure of the
dressing; what form of silver (ionic,
metallic or bound, and the dressings
affinity for moisture. Dressings which
had surface silver, silver in ionic form
and those dressings that retained
moisture performed the best. The
challenge to clinicians is to critically
examine the wide selections of silver
products and choose those that will
perform optimally.
Polyhexamethylene biguanide (PHMB)
Polyhexamethylene biguanide is a
polymeric broad-spectrum cationic
antimicrobial agent that is odorless,
clear and colorless10. PHMB is a
membrane-active agent that also
impairs the integrity of the outer
membrane of gram-positive and gram-
negative bacteria, although the
membrane may also act as a
permeability barrier11. Recently this
agent has been added to dressings as
both barriers and active antimicrobials
capable of impairing or preventing the
growth and penetration from a barrier
perspective12 and actively killing
pathogens such as MRSA, vancomycin-
10
Gilbert P. Polyhexamethylene biguanides and infection control. University of Manchester, U.K., available at: http://www.tycohealth-ece.com/files/d0004/ty_at2ej8.pdf#search='Polyhexamethylene%20biguanide%20and%20infection%20control%20by%20Peter%20Gilbert' accessed 1-21-06. 11
McDonnell G, Russell AD. Antiseptic and disinfectants: Activity, action and resistance. Clinical Microbiology Reviews, January 1999, 12(1):147-179. 12
Motta GJ, Corbett LQ, Milne CT. Impact of an antimicrobial gauze upon bacterial colonies in wounds that require packing. Tyco Healthcare, 2003, 1-11.
resistant Enterococci (VRE),
Escherichia coli, Pseudomonas
aeruginosa, Bacteroides fragilis,
Clostridium perfringens and yeasts
such as Candida albicans from a
sustained antimicrobial activity13.
PHMB has been safely used in
ophthalmic solutions14, peri-operative
cleansing solutions15 and other
consumer products such as mouth
wash16.
The cytotoxicity and hemolysis profile
of PHMB containing products is
excellent. PHMB is neither a primary
skin irritant nor a hypersensitizing
agent, which make it particularly well-
suited to chronic wound care. There is
little or no evidence to suggest that
the use of PHMB would lead to the
emergence of resistant strains to the
agent, or it many encourage
development of cross resistance to
antibiotics. The addition of this safe
and effective versatile biocide is a
positive development in wound
management.
Cadexomer Iodine
Iodine is a potent broad-spectrum
antiseptic agent with a controversial
past since it has been shown to impair
the function of cells involved in wound
13
Data on file. Xylos Corporation, Longhorne, PA. 14
Kramer A, Behrens-Baumann W. Prophylactic use of topical anti-infectives in ophthalmology. Ophthalmologica 1997;211:68-76. 15
Kramer A, Behrens-Baumann W. Prophylactic use of topical anti-infectives in ophthalmology. Ophthalmologica 1997;211:68-76. 16
Rosin M, Welk A, Kocher T, et al. The effect of a polyhexamethylene biguanide mouthrinse compared to an essential oil rinse and a chlorhexidine rinse on bacterial counts and 4-day plaque regrowth. J Clin Periodontol 2002;29:392-399.
healing in vitro17. Improved
formulations of iodophors or “iodine
carriers” provide a release of low
levels of iodine over a longer period of
time. These present the clinician with
a viable iodine containing product for
wound bioburden management. They
have been available for several years
in the form of cadexomer iodine.
Cadexomer iodine is a slow-release
antimicrobial capable of absorbing
excess wound exudate while offering a
sustained level of iodine in the wound
bed18. Appraisal of its benefits show
that it is accepted topically and has
demonstrated accelerated healing of
chronic leg ulcers19. Cadexomer iodine
also has established effectiveness in
vivo against Staphylococcus aureus
and methicillin-resistant
Staphylococcus aureus20. Iodine
needs moisture/hydration in order to
be activated, similar to silver ion
containing products The clinical trend
in recent years have been more
favorable to silver and PHMB
containing products compared to
iodine containing products.
Bacteriostatic Foam Dressing
Bacteriostatic, absorptive moist wound
healing PVA foam bound with two
organic pigments (methylene blue and
gentian violet) that inhibits the growth
of bacteria that can lead to infection.
Inhibits the growth of micro-
17
Fleischer W, Reimer K. Povidone iodine in antisepsis: state of the art. Dermatology. 1997:195:3S-9S. 18
Sundberg J, Meller R. A retrospective review of the use of cadexomer iodine in the treatment of chronic wounds. WOUNDS 1997;9:68-86. 19
Danielsen L, Cherry GW, Harding K, Rollman O. Cadexomer iodine in ulcers colonized by Pseudomonas aeruginosa. Journal of Wound Care 1997:6(4):169-172. 20
Mertz PM, Oliveira-Gandia MF, Davis SC. The evaluation of a cadexomer iodine wound dressing on methicillin resistant Staphylococcus aureus (MRSA) in acute wounds. Dermatology Surgery 1999;25:89-93.
organisms. Indicated for the use of
prevention of wound infection in local
management of wounds such as
pressure ulcers, venous stasis ulcers,
arterial ulcers, donor sites, abrasions,
laceration, radiation burns, post-
surgical incisions, and other wounds
caused by trauma.
Keep in mind that bacteriostatic
dressings help prevent an overgrowth
of bacteria and keep bacteria from
growing in the dressing itself.
Bacteriocidal dressings and broad
spectrum antimicrobial dressings
actually have the ability to kill pathogens such as bacteria.
Honey Dressings
Referenced as one of the oldest wound
dressings in ancient medical writings
of Egypt, Greece and parts of India,
new honey-based dressings and
products are now available and
thought to have anti-inflammatory,
antibacterial, debridement and odor
control properties as well as
possessing wound healing capabilities
promoting fibroblast activity,
angiogenesis and epithelialization27.
Honey based wound dressings have
been used in a variety of chronic and
acute wounds as well as burns and
various dermatologic manifestations
such as atopic dermatitis.
Bioengineered cellulose provides moist
wound healing and versatility
significantly reducing pain and
shortening healing time28. Other
biologics and biosynthetics derived
from natural sources provide a healing
scaffold or matrix, assisting the
granulation and epithelialization of
partial- and full-thickness wounds.
These matrix dressings provide a
higher incidence of wound closure in
Biologics and Bio-
synthetics (Figure 10)
Biologics and Biosynthetics (Figure 10)
recalcitrant wounds as compared to standard of care29,30.
Figure 10
Produced by fibroblasts, collagen
represents the most abundant protein
in the human body and the skin31. It
is a natural structural protein found in
all three phases of the wound healing
cascade and stimulates cellular
migration and contributes to new
tissue development and wound
debridment32. Collagen dressings in
the form of sheets, gels, and particles
encourage the deposition and
organization of newly formed tissue,
creating an environment that fosters
healing. These materials are known to
stimulate and recruit specific cells such
as macrophages and fibroblasts to
positively enhance and influence
wound healing. They can be
moisturizing or absorptive, depending
on the delivery system, maintaining
moist wound healing, are easy to
apply and remove and tend to be
conformable.
Collagen dressings are usually
formulated with bovine (derived from
cows) or avian collagen (derived from
birds) or porcine collagen (derived
from pigs). Two proteolytic enzymes,
the matrix metalloproteases (MMPs)
and elastase levels climb in chronic
wounds, causing them to stagnate and
disrupt the cycle of chronicity.
Collagen derived dressing materials,
especially native (non-denatured)
dressings that have gone through
gentler extraction and purification
process have been shown to bring the
detrimental enzymes into check and
allowing fibroblasts to begin laying
down more endogenous collagen to
close wounds33.
Figure 11
This activated absorbent polyacrylate
polymer core dressing absorbs large
protein molecules (necrotic tissue and
bacteria) while irrigating with Ringer’s
solution, a physiologic fluid, creating a
“rinsing effect”. The interactive
dressing supports both moist wound
Collagen (Figure 11)
Polyacrylates (Figure 12)
healing and autolytic debridement,
gently removing dead tissue from the
wound bed while creating an ideal
healing environment. Polyacrylates
debride at a mean rate of 38%34. New
research shows that polyacrylate gel
absorbents debride just as well as
collagenase35. Recent literature has
also shown that the product may be
effective in reducing wound bioburden
by interfering with biofilm as well36.
Figure 12
The use of odor-controlling dressings
is one measure to manage wound
odor37. These products are designed
to act like filters or traps to absorb
odor-causing molecules. Some of
these products incorporate charcoal
that absorbs unpleasant smells from
wounds. Activated charcoal is a widely
used deodorizing agent. It works by
absorbing many odor molecules onto
the large surface area of the activated
charcoal, which prevents the volatile
odor molecules from reaching
receptors in the nose38. Charcoal has
been incorporated into some modern
wound dressing for this purpose.
Decreased odor has been reported
when honey dressings were used to
treat abcesses, diabetic foot ulcers, leg
ulcers, and fungating wounds39.
Honey reduces wound odor via two
mechanisms. First, malodor is
attributed to the presence of anaerobic
bacteria such as Bacteroides spp,
Peptostreptococcus spp, and Prevotella
spp. Honey exerts antibacterial action
in vivo and in vitro against these
anaerobes, reducing their presences in
the wound bed and subsequent the
ability to produce odor. Secondly,
honey provides glucose as an
alternative to the amino acids created
when serum and dead cells are
metabolized by bacteria40. As a result,
lactic acid is produced as compared to
the malodorous ammonia, amines and
sulfur compounds typically formed by
the metabolism of amino acids from
decromposed serum and dead protein tissue without honey41.
Most odors are lipophilic. Novel
dressings that utilize cyclodextrins
(same technology as in Febreze®,
Proctor and Gamble, Cincinnati, Ohio)
use a bucket-shaped conformation of
the hydrated cyclodextrin molecule to
capture lipophilic odor molecules,
which then neutralize the odor (see
figure 13). Cyclodextrins occur
naturally and are proven safe to use in
modern wound care. How do these
newer odor elimination dressings
compare to the older technology of
charcoal based dressings?
Cyclodextrins work optimally in the
presence of wound exudate and need
humidity to work effectively42.
Charcoal activity decreases in the
presence of wound exudate.
Additionally, serum proteins inactivate
charcoal dressings, while
cyclodextrines' odor absorbing function
is enhanced by it43. In addition,
cyclodextrins intrinsically have a
longer active time of odor absorbing
function by nature of their material44.
Prudent wound bed preparation
including debridement, thorough
MANAGING ODOR WITH
DRESSINGS
cleansing, managing bioburden and
exudates is a best practice, “first step”
in eradicating malodor in wounds45.
Figure 13. Molecular structure and
bucket-shaped conformation of the
cyclodextrin (starch) molecule capture
lipophilic odor molecules, which
neutralize the odor.
Dressing removal is considered to be
the time of most pain46. Dried
dressing and adherent products are
most likely to cause pain and trauma
at dressing changes. Products
designed to be non-traumatic should
be used to prevent tissue trauma.
One of the most important things to
consider in selecting a dressing to
diminish pain in the wound is that the
chosen dressing must minimize the
degree of sensory stimulus to the
sensitized wound area47. Any dressing
that sticks to the wound bed, such as
gauze, or dries within the wound bed
and is then pulled away sends more
sensory information to receptors in the
skin than one that is easily rinsed
away or slides off the inflamed
tissue48. Dressings, such as sheet and
amorphous hydrogels, hydrofibers,
alginates, soft silicones49, cellulose
dressings50 provide beneficial wound
healing environments and also offer a
virtually pain-free dressing removal
while curtailing the pain experience
during wearing time.
Select dressings with absorbency that
matches exudate levels51. Choose
dressings that can remain in situ for
longer periods of time52, thus
minimizing the chances of wound
manipulation and a harmful
aggravation of the pain cycle. Contact
layers or dressings that remain in
close proximity to the wound bed
during dressing changes also have
proven beneficial in the pain arena53.
Don’t neglect pain management during
wound cleansing, either. Appropriate
non-cytotoxic wound cleansers used at
body temperature (~100°F) assist in
keeping discomfort lower 54. Avoid
cytotoxic solutions, such as povidone
iodine or hydrogen peroxide, when
cleaning the wound55 as these can
cause discomfort as well as being
lethal to fibroblasts and keratinocytes.
Simple measures, such as the use of
skin preparations (primarily the no-
sting varieties), polymers that adhere
and/or chemically bond to the skin to
strengthen and prepare it for the
adhesive application, provide less
trauma to sensitive peri wound skin56.
Use them whenever you dress a
wound. When removing a dressing,
make every possible effort to avoid
unnecessary manipulation of the
wound and prevent further damage to
the delicate granulation and healing
tissue within the wound bed and peri
wound skin. If the dressing has
become dried out, moisten it with an
isotonic solution before removing57.
Choose dressings that allow less
frequent and therefore less painful
dressing changes. Also, consider
MANAGING PAIN WITH DRESSINGS
contact layers that stay in place when
the dressings are changed, thus
staving off potential wound bed pain.
Another area of concern with regard to
the wound care patient and pain is
how the dressing is attached. A study
by Dykes and colleagues showed that
some adhesive dressing caused skin
stripping upon removal58. One of the
many myths surrounding wound pain
is that, “paper tape is the least painful
way to secure a dressing”. Heightened
nerve sensation in a wide area around
a wound can make any adhesive tape
painful to remove59. A thorough
review of the dressings and tapes that
you and your facility use is imperative.
Are they gentle on thin, aging
epidermis, young immature
integument and skin that has endured
critical illness, adhering with a low
sensitivity adhesive, yet allowing easy
removal and repositioning? Careful
evaluation of your protocols is a
necessary and important first step.
State-of-the-art “tapeless” ways of
securing a dressing have been around
for centuries: Montgomery straps,
Kling gauze, cohesive tape, elastic
netting, “grip” elastic support
bandages and tubular dressings that
offer a bit of support and compression
(7-8 mm Hg) not only provide support
to the dressing but further protect
from the injury and pain of removal
and reapplication of tape60.
Until research proves otherwise,
current guidelines for treatment and
care of pressure ulcers have supported
the use of clean dressings and clean
dressing change technique over sterile
methods61. Bergstrom and her
colleagues have shown that there is
not sufficient evidence that using
sterile technique has any significant
effect on wound healing outcomes.
Expert opinion advocates a no-touch
technique that tries to guarantee that
the procedure utilized to treat wounds
will not increase the ulcer’s bioburden.
In the case of patients with
compromised immune systems (i.e.,
cancer, HIV, AIDS, organ transplant),
sterile dressings and sterile technique
is warranted.
Standardization of products and wound
treatments generates benefits,
primarily when protocols and clinical
pathways are established
collaboratively based on recent
published guidelines, a review of the
literature for available research and/or
best practice62.
For the clinician today, the job of
selecting a dressing can be daunting.
The use of the traditional six
categories of dressings is no longer
adequate as most of the latest
dressings do not fit easily in a
category and actually manage the
tasks of multiple categories. The first
step in selection is understanding the
four basic goals of wound healing.
Wound bed preparation, including
debridement and bioburden control are
mainstays for effective wound healing
(Sibbald RG, Williamson D, Orsted HL,
Campbell K, Keast D, Krasner D,
Sibbald D. Preparing the wound bed –
debridement, bacterial balance and
moisture balance. O/WM.
2000;46(11):14-35. and Falanga V.
Classification for wound bed
preparation and stimulation of chronic
wounds. Wound Rep Regn.
2000;8:347-352.). The savvy clinician
need only remember the acronym
D.I.M.E.S. to prompt prudent and
methodical care. D = Debridement I
= Infection and Inflammation M =
Moisture balance E = Wound’s Edge
and S = Supportive products, services
and education. See diagram below in
figure 14:
CURRENT BEST PRACTICES
DRESSING SELECTION
Figure 14. The D.I.M.E.S. model of wound bed preparation. Goals include, maintaining a moist
healing environment. Moist wound
healing promotes epithlialization,
enhances autolytic debridement,
prevents wound desiccation and
decreases pain. The second objective
is to remove eschar and debris from
the wound bed. This will decrease
bioburden, improve epithlialization and
decrease inflammation. The third goal
is to control exudate. Increased
exudate can cause periwound
maceration and contributes to an
increased bioburden in the wound. The
fourth purpose is to prevent further
wounding. Patients may unknowingly
traumatize their wounds due to
neuropathy or a dressing or product
may be chosen which actually
traumatizes the wound or surrounding
skin.
In this article, two methods of dressing
selection are covered.
The first methodology of dressing
selection has been recently published
by Fleck63,64 and focuses on nine
simple questions.
1. Is the wound healing?
If the answer is “yes”, proceed
with current best practice
treatment. If the answer is
“no”, consider other etiologies
and care modalities, assess
bioburden (bacterial or other
microbial overload in the
wound), look at intrinsic and
extrinsic risk factors such as
nutrition, pressure, shear,
etiology, debris and devitalized
material in the wound bed,
temperature of the wound,
circulation, maceration,
desiccation, chemical stress
and medications as well as
other co-morbidities. Confer
and consult with colleagues if
this is outside your scope of
knowledge and/or practice65.
You should expect to see
progress toward wound healing
within 2-4 weeks of initiation of
treatment66.
2. Is the tissue viable (living)
or necrotic (dead)?
The single most important
parameter in reducing the level
of bacterial contamination in
the chronic wound is removal of
all devitalized material67. If it is
viable, support it and keep it
moist. Vital, healthy living
tissue is usually red or pink. If
it is necrotic, debride it68.
Necrotic tissue can be yellow,
gray, black or some
combination of these colors69.
It has no function, other than
to slow healing, splint the
wound open and provide a
breeding ground for critical
colonization70,71,72,73,74. A dry
cell is a dead cell so moist
wound healing is the goal with
all wounds. Dr. George
Winter’s studies in the early
1960s proved that moist wound
healing provided for better
healing outcomes with less pain
and scarring75. The work of
Hinman and Maibach further
connected these findings in
human models just a year
later76.
3. Is the wound wet or dry?
For most favorable outcomes,
providing an optimal level of
moisture77,78 is recommended.
If the wound is “wet”, apply a
product that manages exudate
while maintaining an optimal
amount of moisture. If the
wound is “dry”, apply a product
that donates or maintains
moisture at optimal levels. One
of the most important criteria
for dressing selection is
exudate amount.
Research and clinical
experience have identified that
in a moist environment,
exudate provides the cells
involved in wound repair with
nutrients, controls infection and
provides the best environment
for healing. Moreover,
revascularization occurs earlier
in moist conditions79. Studies
have demonstrated that cells
communicate and respond to
growth factors and cytokines
contained within wound
exudate80.
4. Is there dead or open space
in the wound?
If so and it is deep, it is
necessary to fill the space,
loosely packing the open area
when dressing the wound81,82.
If there is no dead space,
covering the wound, if it is flat,
is all that’s required83.
Covering the wound provides a
physical barrier to microbes, a
humid, moist and thermally
insulated environment and
protection from the outside
environment.
5. Is the wound or surrounding
area edematous?
Many wounds are accompanied
by edema beyond the
inflammatory phase.
Furthermore, lower limb
wounds are often secondary to
poor venous return or venous
hypertension. Without
compression these wounds fail
to progress84,85. Evaluate lower
limb wounds, ascertaining the
patient’s ankle brachial index
(ABI) and/or toe brachial index
before applying compression
wraps
6. What is the condition of the
peri-wound skin or the skin
surrounding the wound
(including the skin of a
recently closed wound)?
If the skin surrounding the
wound is compromised and/or
painful, avoid adhesives or use
great caution. Use of a
polymer skin preparation,
especially the no-sting
varieties86, before attaching
any dressing is helpful. This
will assist to strengthen and
protect the skin without causing
pain or discomfort. Also
consider using protective
products such as barrier creams
and adhesive removers to treat
this vulnerable skin with care.
Soap-free, pH balanced non-
cytotoxic cleansers should
additionally be used to gently
cleanser the area surrounding a
wound87. Remember, this is
the skin that will eventually
support the wound healing and
from where the epithelial cells
will migrate88.
7. Is the wound painful?
Identify whether or not the
wound is painful. Is the pain
constant or only during
procedures or dressing changes
or manipulation. It is also
important to assess when the
pain began since pain can be an
indicator of critical colonization.
See Managing Pain with
Dressings section for more
information about pain
management and dressings to
diminish discomfort. Default is
that all wound are painful.
Simple measures such as
selecting a dressing with
absorbency that matches the
exudates level of the wound,
considering a contact layer that
remains in contact with the
wound bed during dressing
change, helping to diminish
pain, and avoiding gauze, the
most painful dressing category,
should be followed.
8. Does the wound have odor?
Odor can be associated with a
variety of wounds including
pressure ulcers, venous leg
ulcers diabetic and neuropathic
wounds, fungating cancerous
ulcers, malignant lesions and
wounds with necrotic tissue89.
The first step to eradicating
odor is to identify the cause
and eliminate it. Then prepare
the wound bed, debride
devitalized tissue, increase
wound cleansing and consider
the use of a safe antimicrobial
cleansers with benzalkonium
chloride (BZK) or benzethonium
chloride (BC). Current
treatment options include
metronidazole (flagyl) to
reduce anaerobic infection and
ionic silver powder and gel,
which is effective against both
aerobes and anaerobes, gram
positive and gram negative
bacteria90.
9. Is the wound stalled out?
Despite prudent care, has
progress toward healing
ceased? Wounds fail to thrive
for a variety of reasons
including: poor nutrition, lack
of blood flow, unrelieved
pressure, poor care, systemic
disease with three local factors
that can be alleviated with
advanced dressings. Those
factors are: critical colonization
and infection, senescence and
increased proteolytic enzymes.
Advanced ionic silver, PHMB,
and cadexomer iodine dressings
can help bring the bacteria and
bioburden into check.
Advanced collagen dressings
can help to bind and soak up
the proeolytic enzymes such as
matrix metalloproteases
(MMPs) and Elastase, in
addition to providing a
structure for fibroblasts to
proliferate and offering a
sacrificial substrate as a “food”
source to the destructive
enzymes.
The second is based upon Ovington’s
methodology91. Goals, form, and
function is combined with a nursing
assessment of the wound and the
patient prior to dressing selection. The
dressing must match the patient, the
wound, and the setting. In Ovington’s
article11, she presents an all-purpose
performance-based approach to using
wound dressings by asking six basic
assessment questions when deciding
on a wound dressing:
What does the wound need?
Determined by a complete
assessment of the wound and
surrounding tissues.
Assessment is performed at
each dressing change, including
the initial. Apply the goals.
Anticipate that the needs of the
wound will change as the tissue
envelope normalizes and the
healing process progresses.
What does the product do? This
is the function. Read the
product literature and clinical
data available.
How well does it do it? Examine
clinical studies and laboratory
comparisons to other products
in the same category. Talk with
other clinicians. Evaluate it on
your patients. Does the
dressing perform how it is
stated? Not all dressings are
equal.
What does the patient need?
Comprehensive assessment of
the patient, including
psychosocial. Do they need a
dressing that doesn’t require
daily changes, do they need
protection from trauma, or is
there a large amount of
exudate?
What is available? Health
insurance coverage, facility
formulary and reimbursement?
What is practical? Examine the
goals of wound management.
Does the dressing choice satisfy
the goals? Is the dressing easy
to apply (patient/family), easy
to obtain and cost effective?
Cost effectiveness of the product
should be considered during the
selection process. This means
understanding indirect costs as well as
the direct cost involved in wound care.
Direct cost examples include, but are
not limited to the primary and
secondary dressings, pharmacy,
caregiver time, and diagnostic
procedures. Indirect costs are similar
to overhead costs, and include
examples such as increased length of
stays, treatment complications and
litigation. The clinician should read
published studies critically to take
cost-per-unit outcome into account to
determine if treatment measures are
indeed cost effective. Sometimes the
most expensive product can be less
expensive in the long run because it
leads to faster healing with a reduced
amount of complications.
In the United States, wet-to-dry and
gauze dressings are still the most
commonly used primary dressing
substance92. Many reasons for the
persistence of gauze and saline used
as wound management mainstays
WET-TO-DRY AND MOIST GAUZE
include: lack of knowledge from
physicians and nurses on advanced
dressings and how they work,
confusion due to the plethora of
advanced products, incorrect view that
advanced dressings come with a high
price, and gauze is a “one size fits all”
modality that is readily available,
perceived as inexpensive and the
dressings have been used throughout
history since the practice is
propagated in the medical school and
surgical training93. There is also
evidence that they are used
inappropriately94. Recent journal
articles, texts, as well as expert
opinion support the principle of moist
wound healing, but in practice the use
of gauze, predominantly as a wet-to-
dry dressing, does not guarantee a
moist wound environment95.
Wet-to-dry dressings are described in
the literature as a means of
mechanical debridement96.
Debridement is the mainstay of wound
bed preparation since devitalized
material harbors bacteria, delays
healing and increases the risk of
infection97. However, it is the opinion
of this author that wet-to-dry or moist
gauze does not constitute advanced
wound caring or advanced therapy.
Granted, wet-to-dry gauze is a form of
non-selective debridement, however, it
is painful if the patient is sensate and
can produce negative outcomes.
Gauze dressings are not an optimal
wound care choice for the patient, the
caregiver or the healthcare system and
facility. They do not support optimal
granulation and healing and are more
labor intensive to use than advanced
dressings such as polyacrylates,
transparent films, hydrocolloids,
alginates, hydrogels and foams.
Therefore, these archaic regimes
should be abandoned since they are
not considered standard of care
despite The Agency for Healthcare
Research and Quality (AHRQ),
formerly the Agency for Health Care
Policy and Research (AHCPR), Clinical
Practice Guidelines for Treatment of
Pressure Ulcers98 have supported the
use of wet-to-dry dressing for
debridement by maintaining that its
use is backed by expert opinion (rated
as C on their scale of hierarchy of
evidence).
Ovington describes gauze as the most
widely used wound care dressing and
may be erroneously considered a
standard of care99. Her article
comments that 'wet-to-dry' and 'wet-
to-moist' are frequently used in clinical
practice in a fashion that makes them
interchangeable. She describes
hampered healing due to local tissue
cooling, disruption of angiogenesis by
dressing removal, and increased
infection risk from frequent dressing
changes, strike through, and
prolonged inflammation as good
reason to abandon this ‘traditional’
dressing technique100. Ovington also
offers a cost-effectiveness argument
for change. She illustrates the costs of
saline and gauze compared with an
advanced dressing (Tielle, Johnson &
Johnson Wound Management,
Somerville, New Jersey), over a four-
week period, performed by a home
health nurse101. The largest
contribution to cost is nursing time;
even with the patient and/or family
doing some of his or her care, the cost
is decreased with the advanced
dressing secondary to fewer dressing
changes and better outcomes (less time to closure).
Another investigator, Coyne, examined
the cost-benefit of wet-to-dry
compared to another advanced
dressing, polyacrylate moist wound
dressing (TenderWet, Medline
Industries, Inc. Advanced Skin and
Wound Care, Mundelein, IL) in a
nationwide 65 location home care
agency (TLC/Staff Builders) realizing a
26% cost-savings alone annually,
pointing out that wet-to-dry
treatments additionally cause pain,
slower healing and an increased
infection rate102. There are other
important considerations when
choosing a dressing, such as clinical
outcome, quality of life issues,
discomfort, disruption of daily
routines, and coping with daily
activities that can all be addressed by
modern products103. A comparison of
wet-to-dry gauze and polyacrylate
moist wound and debriding dressing is summarized in the table below:
Polyacrylate Debriding Wound
Dressing
(TenderWet® Active)
Wet-to-dry
(saline and gauze)
Absorbs planktonic bacteria and disrupts
biofilm (Bruggisser, 2005)104 as well as
MMPs (Eming, et al, 2008)105
Increases the chances of external
contamination and infection as well as
cross-contamination.
Bacteria can travel through 64 layers of
gauze (Lawrence, 1994)106.
Maintains wound temperature for 24 hour
period
Frequent (T.I.D. and Q.I.D) dressing
changes lead to a drop in wound
temperature, causing vasoconstriction
and decrease in blood perfusion,
further drastically impairing the ability
of oxygen to clear bacteria from the
wound leading to an increase in tissue
infectability.
Preserves wound moisture and promotes
moist wound healing (Fleck and
Chakravarthy, 2009)107
Does little to impede fluid evaporation
and does not provide moist wound
healing unless kept continuously wet
Multiple literature and research sources to
prove efficacy
“Traditional” dressing, despite evidence
to the contrary
Cost-effective (Coyne, 2003108 and
Murano, 2004)
Cost prohibitive secondary to caregiver
time and frequency of change, etc.
Pain-free advanced dressing modality
(Konig, et al, 2005)109
Painful and barbaric dressing causing
substantial patient discomfort and
wound bed disturbance.
Effective selective mechanical
debridement (mean rate of 38%)
(Paustian and Stegman, 2003)110.
Non-selective mechanical debridement,
causing tissue destruction and injury at
each dressing change, delaying healing
Contains wound debris and bacteria
Dried dressing removal disperses
significant amount of bacteria into the
air (Lawrence, Lilly & Kidson, 1992)111
Anti-inflammatory dressing action Prolonged inflammatory phase of
wound healing (Ovington, 2000)112
Ease of patient compliance/adherence to
routine (Flemister, 2000)113 Poor patient compliance/adherence
(Sibbald et al, 2000)114
Isotonic (Ringer’s solution) homeostatic
dressing from application to removal,
promoting moist wound healing
throughout.
As saline evaporates, becomes
hypertonic and fluid from the wound is
then drawn into the dressing promoting
desiccation of the tissue. As the wound
dries, cell migration and proliferation
are impeded (Kim, et al, 2000)115.
© Cynthia A. Fleck
REFERENCES 1 Zimmerman, LM, Veith I. Great Ideas in the History of Surgery. Baltimore, MD: Williams and Wilkins, 1961. 2 Forrest RD. Early history of wound treatment, Journal of Royal Society Medicine 75: 198-205, 1982 . 3 Sinclair RD, Ryan TJ. A great war for antiseptics. Wound Management, 1993; 4(1), 16-18.
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