manage excessive exudate, thereby protecting peri-wound skin and facilitating wound healing.

Transcription

1 A clinicl cse-series evlution of supersorent dressing on exuding wounds l Ojective: To evlute the cpcity of supersorent dressing (DryMx Extr; Asorest AB) to mnge excessive exudte, therey protecting peri-wound skin nd fcilitting wound heling. l Method: Ptients with cute nd chronic wounds of vrious etiology were ssessed, nd tretment of their wounds with the supersorent dressing ws evluted. The strting point for this study ws the needs of individul ptients nd, therefore, the study includes ptients with exuding wounds of vrious etiologies, which were not progressing towrds heling with their previous tretment. l Results: Thirty ptients, ged yers, were included in this cse series, etween Decemer 2008 nd Septemer Dressings were chnged from dily to once week, sed on the clinicin s judgment nd the needs of the individul ptient. In mny ptients, frequent dressing chnges were needed initilly ut, fter while, the exudte levels decresed nd the dressing could e chnged t longer intervls. Inspection of the sturtion ws possile without removing the dressing. The soring efficiency of the dressing ws considered to e very good y the investigting clinicin, even under compression, nd lood, stool nd urine ws seen to e sored y the dressing. Prior to using the supersorent, mny ptients suffered from pinful wounds nd mcertion, irrittion, eczem nd itching in the surrounding skin, cused y the wound exudte. As the exudte levels decresed nd the wounds strted heling, the ptients felt less pin nd less itching in the surrounding skin. l Conclusion: This cse series suggests tht the supersorent dressing promoted wound heling in ptients with highly exuding wounds, where previous therpy hd filed. More reserch nd evlution compring the cpcities of vrious supersorent dressings in vitro nd in vivo nd the clinicl implictions of their specil properties is needed. l Declrtion of interest: These studies were sponsored y Asorest AB, mnufcturers of DryMx Extr. A. Hindhede is n independent consultnt who received fee for her contriution. F. Meuleneire completed clinicl cse-series in greement with the sponsor nd received funding for conduct of the study. The sponsors hd no role in study design, or collection or nlysis of the dt. exudte mngement; exuding wounds; peri-wound skin; supersorent dressing; ptient outcomes Wound exudte plys n essentil role in wound heling, y fcilitting the diffusion of vitl heling fctors nd the migrtion of cells cross the wound ed. 1 In heling wound the mount of exudte decreses with time; n increse in the mount of exudte my e sign of inflmmtion, cteril contmintion, lim dependency or other fctors. 1 If the wound does not hel, the composition of the exudte chnges, which my impede heling. 1 When too much wound exudte is produced, or it is of the wrong composition, multitude of prolems cn follow, cusing delyed heling, nd impcting on the qulity of life of ptients nd crers, including: l Lekge nd soiling l Peri-wound skin chnges (mcertion, skin stripping or erosion) l Odour l Discomfort, pin l Infection l Protein loss, fluid nd electrolyte imlnce l Psychosocil prolems ssocited with exudte. 1 When too much exudte is produced, it is importnt to ccurtely determine the underlying fctors, only then cn effective tretment e initited. Specilist referrl my e necessry. Vsculristion needs to e ssessed nd possily improved, necrotic tissue nd slough removed, oedem nd infection treted, nutrition enhnced, nd psychosocil support ensured. Successful exudte mngement cn reduce heling time, prevent exudte-relted prolems, increse ptients qulity of life nd improve tretment efficcy. 1 The choice of method for exudte control should e sed on the chrcteristics of the wound nd the requirements of the ptient. Aville methods include physicl therpies, such s A. Hindhede, 1 RN, BSc, Specilist in Wound Heling nd Dermtology; F. Meuleneire, 2 Tissue Viility Nurse Specilist; 1 Örero, Sweden; 2 St Eliseth Woundcre Centre, Zottegem, Belgium. Emil: nne.hindhede@ swipnet.se

2 Fig 1. Ptient outcomes t end of study* Tle 1. Bseline wound chrcteristics, nd tretment outcomes Wound etiology No. of Age Tretment Outcome wounds (yers) (dys) Arteril leg ulcer 3 80 (57 94) 70 (67 94) Less mcertion (n=2), heling (n=1) Almost heled (n=13; 43%) Heling (n=9; 30%) Fully heled (n=6; 20%) Less mcertion (n=2; 6.7%) Hemtom ulcer 3 60 (23 84) 49 (42 154) Heling (n=1), lmost heled (n=1), fully heled (n=1) Lymphtic lek Fully heled cused y trumtic leg wound Lymphtic ulcer Fully heled Mixed etiology Heling leg ulcer Postopertive 4 55 (30 78) 60 (56 63) Heling (n=1), wound lmost heled (n=2), fully heled (n=1) Posttrumtic wound Almost heled /venous hypertension Pressure ulcer 3 85 (78 85) 177 (18 196) Heling (n=2), lmost heled (n=1) Skin ter 2 71 (70 72) 30 (25 35) Almost heled (n=1), fully heled (n=1) Ulcer cused y Heling herpes zoster Venous leg ulcer (48 83) 77 (28 112) Heling (n=2), lmost heled (n=7), fully heled (1) Totl (23 94) 56 (18 196) Less mcertion (n=2), heling (n=9), lmost heled (n=13), fully heled (n=6) Unless otherwise stted, results presented s medin (rnge); Results presented s men (rnge) lim elevtion, 2 exercise, 3 compression therpy, 4 nd negtive pressure wound therpy (NPWT). 5 However, for mny ptients, these methods re unsuitle. 6 8 Accurte use of modern, dvnced dressings is key considertion for mnging exudte t wound level. 1 Fluid retention nd sequestrtion of exudte A dressing s efficiency in mnging wound exudte should not just e viewed in terms of the volume sored, ut lso in terms of its ility to retin the exudte within the dressing, even when externl pressure is pplied. Wound dressings tht only sor low volumes nd hve little or no * All wounds showed decrese in mcertion; however, some did not progress towrd heling cpcity to retin wound exudte re more likely to cuse mcertion nd/or excorition of the peri-wound skin. 9 Consequently, dressings tht sor reltively lrge quntities of exudte, ut lck the cpcity to sequester the exudte nd remin wet on the surfce, my e less efficient in the mngement of exuding wounds thn dressings tht sor less ut retin the exudte inside the dressing. 9,10 Use of crems or ointments in the wound re my interfere with sorency nd sequestering function of products. 11 Dressings tht ind proteses re not suitle for dry wounds or wounds with lethery eschr. Asorent wound dressings Simple sorptive dressings, such s cotton, foms, viscose or polyester textiles, hold fluid within spces in their structure, similr to sponge. When these mterils re plced under pressure, fluid is relesed from the spces nd my lek from the dressing. Mny sorent dressings lso llow moisture to evporte from the surfce of the dressing. This chrcteristic is quntified s the moisture vpour trnsmission rte (MVTR). 12 In recent yers, severl compnies hve introduced wound dressings tht contin so-clled supersorents, 13 which hve considerly higher sorption cpcities thn tht of other sorent dressings One such dressing is DryMx Extr (Asorest AB). The dressing hs core of cellulose nd supersorent polymers contined within polypropylene cover. Wound exudte is drwn verticlly into the dressing, where it lters the core to gel consistency. Fluid is ound within the gel, to prevent peri-wound mcertion nd retin humid surfce environment, to fcilitte tissue repir. The mnufcturers stte tht the dressing lso sors during pressure nd the fluid is retined inside the dressing, even under compression. The product is ctegorised s protese modultor nd hs een evluted in few documented oservtion studies This rticle descries cse series of ptients with cute nd chronic wounds of vrious etiologies, to evlute the cpcity of DryMx Extr to mnge excessive exudte.

3 ws lso evluted nd pin level ws evluted y using the visul nlogue scle (VAS). Tretment with the supersorent dressing continued until the clinicin considered tht the condition of the wound no longer wrrnted its use. Fig 2. Cse 6, venous leg ulcer on presenttion (), nd fter 12 weeks of tretment with the supersorent dressing () Fig 3. Cse 17, hemtom on the leg, cused y trum (), nd fter 5 months of tretment with the supersorent dressing () Method Ptients presenting t St Eliseth Woundcre Centre, specilist wound clinic in Belgium, etween Decemer 2008 nd Septemer 2009, were included in this cse series if their wounds were moderte to highly exudtive nd the treting clinicin considered tht progression towrds heling ws stlled due to lekge, mcertion, strikethrough or totl dressing sturtion. All ptients were treted y the sme nurse prctitioner (FM). No stndrd protocol ws pplied to ptients included in the study. The underlying cuse of the wound ws treted efore nd during the study nd ptients with venous leg ulcers continued to hve the sme compression tretment. The dressings previously used included lgintes, foms, Hydrofier nd nticteril dressings. Dressing chnges were scheduled sed on the clinicin s individul clinicl judgment. At dressing chnge, the clinicin recorded the soring efficcy of the dressing nd the condition of the wound ed nd the surrounding skin. Assessments regrding sorency were mde y inspection of the sturtion of the dressing, without removing the dressing, nd y compring the need for dressing chnge with tht of the previous tretment. The retention of lood, stool nd urine, s well s odour, pin, mcertion, irrittion nd itch, ws lso ssessed sed on the clinicin s nd the ptient s previous experience. Reduction of cteri ws determined y the clinicl signs of the wound heling process, such s decresing exudte levels, less pin nd odour, ppernce of grnultion tissue nd, in mny cses, epithelilistion. Comfort Results Overll, 30 ptients, of men ge 69 ± 16.2 yers (rnge yers), with cute nd chronic wounds of vrious etiologies, were ssessed (Tle 1), nd tretment of their wounds with supersorent dressing ws evluted. Eighteen of the ptients hd severely exuding wounds, nine hd firly lrge mounts of exudte nd three hd modertely exuding wounds. Dressings were chnged from dily to once week sis, sed on the clinicin s judgment nd the needs of the individul ptient. In over third of the ptients, frequent dressing chnges were needed initilly ut, fter while, the exudte levels decresed nd the dressing could remin in situ for longer intervls. Inspection of the sturtion ws possile without removl of the dressing. The soring efficiency of the dressing ws considered to e very good, even under compression, nd lood, stool nd urine were sored into the dressing nd did not sty in contct with the wound. Before tretment with the supersorent dressing, mny ptients (n=21) suffered from pinful wounds nd mcertion, irrittion, eczem nd itching in the surrounding skin, cused y the wound exudte. Eleven ptients reported woundrelted pin. Four of these cses concern venous leg ulcers (36%), one mixed rteril-venous ulcer (9.1%), two rteril ulcers (18%), two skin ters (18%), one lymphtic ulcer (9.2%) nd one herpes zoster wound (9.2%). As the exudte levels decresed nd the wounds strted heling, ptients reported less pin nd less itching in the surrounding skin. After the supersorent ws introduced, only one ptient required skin protection (Cse 6). One ptient reported pin due to the supersorent on removl, where the dressing would sometimes stick to the wound; however, this could e prevented y moistening the dressing with sline solution on removl. The supersorent ws continued until the clinicin considered tht the wound hd no further use for tretment with it. In four ptients (13%), other dressings were used in direct contct with the wounds t the sme time s the supersorent. The clinicin concluded tht the supersorent could e comined with n lginte or Hydrofier to ensure tht there is no cvity in the depth of wound. The reltively poor soring qulities of lgintes nd Hydrofiers re supplemented y the supersorent dressing, which sors the superfluous wound exudte.

4 The end results from the study re shown in Tle 1 nd Fig 1. A selection of five ptients re presented elow. These ptients were chosen to represent vriety of wounds with different etiologies nd photogrphs tht would illustrte the effects of the dressing. Cse 6 A 48-yer-old mn with chronic venous insufficiency nd pinful, severely exuding leg ulcer, which hd een treted with lgintes, foms nd severl ointments/crems, s well s compression therpy with long stretch ndges (Fig 2). Before strting tretment with the supersorent dressing, ointment remins, crusts nd deris were removed nd the leg ws wshed with povidoneiodine sop. The dressing ws fixed with short stretch ndges. Initilly, the dressing ws chnged every other dy; fter 5 weeks, the exudtion hd decresed, grnultion nd re-epithelilistion ws noted nd the dressing could e chnged every 3 dys. After 7 weeks, the wound continued to hel, skin protection spry or wound edge protection could e discontinued nd the ptient no longer experienced nightly pin. After 12 weeks, the chronic ulcer ws in the finl stge of heling nd compression therpy ws continued y use of n elstic stocking (Fig 2). Fig 4. Cse 18, hospitl-cquired pressure ulcer on heel (), nd fter 6 months of tretment with the supersorent dressing () Fig 5. Cse 23, wound fter open nkle frcture (), nd fter 6 weeks of tretment with the supersorent dressing () Cse study 17 An 84-yer-old femle presented with lrge hemtom on her leg, cused y impct with the edge of the ed. Initilly, the skin did not rek; however, n incision ws mde to drin the hemtom, fter 2 weeks (Fig 3). The wound ws wshed with poly hexnide (PHMB) solution nd the supersorent dressing ws plced in the wound cvity to sor the remining hemtom. After 2 weeks, necrotic skin ws clerly demrked from the vitl skin nd shrp deridement ws possile. A skin trnsplnt ws considered in order to close the defect quickly, ut the ptient s ge nd overll condition did not llow this surgicl procedure. At the strt of tretment, the dressing ws chnged every second dy; however, from week 16, the dressing could sty unchnged for week. Even when the mount of wound fluid decresed, the tretment ws continued. The chnging intervl ws extended nd the dressing could esily e removed, fter eing moisturised with sline solution. The wound heled slowly, ut without ny complictions (Fig 3). Cse study 18 An 85-yer-old womn with pressure ulcer on her heel, which developed while in hospitl for hip frcture. The fom dressing originlly used ws Fig 6. Cse 24, ulcer with comined rteril-venous etiology (), nd fter 10 weeks of tretment with the supersorent dressing () oversturted every dy nd wound culture showed resistnt Pseudomons eruginos (Fig 4). After 8 weeks of tretment with the supersorent, the wound surfce ws much smller. The wound ed ly deeper thn the wound edges, with the dressing no longer in direct contct with the wound ed. As there ws still lrge mount of exudte, n lginte dressing ws used to fill the wound cvity nd the supersorent dressing plced on top. To void pressure, the ptient s heel ws offloded with heel protector t night. Thin lyers of firin were curetted during wound cre nd PHMB solution ws used to preserve the cteril lnce. After 6 months of tretment with no complictions, reepithelilistion ws lmost complete (Fig 4). The clinicl signs of wound heling progression nd sence of signs of infection suggested tht cteri, toxins nd MMPs were removed nd did not ffect the wound. The supersorent dressing is s

5 ctegorised s protese modultor, nd toxins nd MMPs re thought to e removed through its ility to sor, retin nd sequester exudte contining cteri, including P. eruginos. Cse study 23 A 78-yer-old femle with wound on the right lower externl shin following n open nkle frcture. There were no clinicl signs of infection, with clerly-mrked wound edges nd stgnting heling process (Fig 5). Initilly, the supersorent dressing ws chnged every 4 dys. At the very first dressing chnge, wound ed grnultion nd fltter wound edges were noted. After 2 weeks, the wound edges were even fltter nd epithelilising. Within 6 weeks, the wound ws less thn third of its originl size nd in the lst phse of heling (Fig 5). Cse study 24 An 80-yer-old mle with n infected nd inoperle chronic comined rteril-venous ulcer on the inside of his right nkle (Fig 6). The ptient ws hevy smoker nd not willing to stop. The severely exuding ulcer hd foul odour. Locl nd systemic ntiiotics hve hd little effect on the wound prolem. Initilly, the supersorent dressing ws chnged dily. The production of wound exudte decresed only slowly, ut fter 3 weeks there ws fr less odour, the wound surfce ws reduced nd the ptient suffered less pin. After 5 weeks of tretment, there ws much less mcertion nd the wound ws well under control, with visile improvement in the surrounding skin. Progress slowly continued nd the lst picture ws tken fter 10 weeks of tretment with the supersorent (Fig 6). Discussion Mngement of wound exudte is key fctor in the wound-heling process. To prevent wound from prolonged inflmmtory process, sorption of excessive wound fluid contining toxins nd MMPs is crucil. The chllenge is to find wound dressing tht stisfies these needs in cost-efficient mnner, compred to other forms of tretment. According to clinicl results, supersorent dressings support the heling process in ptients with highly exuding cute nd chronic wounds. While soring excess wound exudte, they keep the wound surfce moist nd protect the peri-lesionl skin from pthologicl chnges. Intervls etween dressing chnges cn e prolonged, reducing wound pin, leving the wound undistured, fcilitting grnultion tissue formtion nd epithelilistion, resulting in fst improvement. The ptients enrolled in this prospective clinicl study were representtive of ptients in dily prctice setting. The men ge of the ptients in the study ws 69 ± 16.2 yers nd 27% (n=8) were over 80 yers old. Mny hd comoridities, such s rheumtic rthritis, circultory diseses or dietes nd some were treted with cortisone or nti-cogultion medicine, which my compromise wound heling. The results of this study suggest tht the supersorent dressing promoted wound heling in ptients with highly exuding wounds in which previous therpy hd filed. The dressing ws well tolerted y the ptients nd, ccording to the investigtors evlutions, esy to pply nd remove. The supersorent could e comined with hydrophoic dressing to tret wound infection, or n lginte or Hydrofier to ensure tht there is no cvity in the depth of the wound. The poor soring qulities of these primry dressings were supplemented y the supersorent, which sored the superfluous wound exudte. In this study, the peri-lesionl skin ws oserved to improve, suggesting tht the supersorent ws effective in protecting the wound orders from mcertion, oedem nd erythem. Limittions In this study, no rigid stndrd protocol ws pplied. As cse series, no inclusion nd exclusion criteri were imposed. Furthermore, specific dt on heling times nd concomitnt tretments were not collected in systemtic mnner. Undenily, this entils certin methodologicl limittions compred with rndomised controlled tril (RCT), where inclusion nd exclusion criteri im to crete more homogenous study popultions, rndom lloction to tretment minimises lloction is nd the exct sme follow-up of tretment groups ensures the vlidity of the evidence. However, RCTs commonly exclude ptients with wounds resulting from, or complicted y, vriety of concomitnt fctors, lthough these wounds my pose significnt therpeutic prolems, which need to e ddressed in dily prctice. 22,23 The strting-point for this study ws the needs of individul ptients nd, therefore, the study includes ll kinds of ptients with exuding wounds who were not helped y the previous tretment. Conclusion Although supersorents hve existed for lmost hlf century, their pplictions in wound dressings hve only just egun. This cse series suggests tht the supersorent dressing promoted wound heling in ptients with highly exuding wounds, where previous therpy hd filed. More reserch nd evlution compring the cpcities of vrious supersorent dressings in vitro nd in vivo nd the clinicl implictions of their specil properties is needed. n

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