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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 30002500 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.

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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.

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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

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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)

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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)

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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)

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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)

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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.

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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.

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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.

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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

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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.

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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)

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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)

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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

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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

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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

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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,

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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

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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

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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

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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

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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

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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

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