Case reports using Appeel Sterile sachet

Case report 1 Case report 2 Case report 3 Case report 4 Case reports using Appeel Sterile sachet Case report 5 Pam Cooper, Fiona Russell and Sandra Stringfellow are Clinical Nurse Specialists; Kristine Duguid and Gail Pirie are Tissue Viability Nurses at the Department of Tissue Viability, NHS Grampian, Aberdeen Case report 6 Case report 7 Case report 8 Case report 9 Case report 10

Wounds UK, a Schofield Healthcare Media Company 2010 All rights reserved. No reproduction, copy or transmission of this publication may be made without written permission from the publishers The views expressed in this publication are those of the authors and do not necessarily reflect those of Wounds UK and CliniMed Ltd, Bucks, UK. Any products referred to should only be used as recommended by manufacturers data sheets 1233/0410

CoNTeNTS Case report 1: 50-year-old female with a wound to the dorsal aspect of the left foot 4 Case report 1 Case report 2 Case report 3 Case report 2: 85-year-old female patient with a sacral pressure ulcer 7 Case report 3: 52-year-old female patient with psoriasis extending around a large abdominal wound 10 Case report 4: 64-year-old male patient with pressure ulcers to his buttocks 11 Case report 5: 82-year-old male patient with a skin tear to his right hand 12 Case report 6: 16-day-old female baby with chemical burn to the back of her right hand 14 Case report 7: 95-year-old female patient with lower limb trauma 16 Case report 4 Case report 8: Seven-month-old baby with skin damage to the back of the neck 19 Case report 9: 40-year-old female with a small, painful chemical burn to her right wrist 20 Case report 5 Case report 10: 78-year-old male patient with a grade 4 pressure ulcer to the heel 22 Case report 6 Case report 7 Case report 8 Case report 9 Case report 10 3

CASE REPORT 1 In this case, following staff referral, a 50-year-old female presented to the department of tissue viability with a wound to the dorsal aspect of the left foot. She had been admitted with endocarditis and was awaiting cardiac surgery. However, she also presented with: non-insulin dependent diabetes, systemic lupus erythematosus (SLE), interstitial pulmonary fibrosis and vasculitis to both lower limbs. The vasculitis was attributed to SLE and had been successfully treated, but she had been left with a wound to her left foot. The wound presented as an area 2.5x1.2cm. The wound bed was covered in 100% yellow slough, and evidence of underlying granulation tissue. The patient reported pain at dressing change, which in the acute stages of vasculitis she found unbearable. Thirty minutes before dressing changes she would have tramadol to help reduce the pain. Hollinworth and White (2006) suggest that wound-related pain has become a... professional and humanitarian concern and that practice will only change if all professionals actively engage in care strategies to minimise trauma and pain in wound care. They propose that the starting point is, understanding the patient s experiences and the impact the pain has on their lives. Although the acute vasculitic episode had passed, this patient still experienced a high degree of pain and anxiety at dressing change. Figure 1. Mepore dressing covering the vasculitic lesion. Figure 2. Appeel Sterile lifting edge of Mepore dressing. The wound showed no evidence of infection, minimal exudate, and the periwound skin was intact with no redness or irritation. The wound was being dressed with a topical antimicrobial (Mesitran honey, Aspen Medical) and a small adhesive dressing (Mepore, Mölnlycke Health Care). She was happy with both dressings but required analgesia before any dressing change (Figure 1). Figure 3. Mepore dressing rolling back on itself due to the breakdown of adhesive. 4

CASE REPORT 1 cont. Appeel Sterile sachet (CliniMed Ltd, Bucks, UK) was applied to the top edge of the dressing (Figure 2) and then in steady drops around the edge to facilitate removal (Figure 3). This process was carried out across the whole dressing (Figure 4) until it was completely removed (Figure 5). Figure 5 clearly shows no stripping/trauma to the periwound area, with the patient herself reporting no pain at all at dressing removal. She continued to be treated with a topical antimicrobial (Flamazine, Smith & Nephew) and the Mepore dressing. She was reviewed 12 days later following extensive cardiac surgery to replace heart valves which had been damaged due to her endocarditis. Her dressings were being changed on alternate days, and she no longer required analgesia before dressing changes (Figure 6) a significant step forward for this lady. There was no evidence of skin stripping or irritation to the periwound skin. The use of Appeel Sterile sachet was continued at dressing changes and four weeks after her initial review and having had cardiac valve replacement surgery, her wound had made continuous improvement (Figure 7). There were no more reports of pain, and the periwound skin remained intact and healthy. Figure 4. Mepore dressing almost off. Figure 5. Initial dressing removed. Wounds UK, 2006,Vol 2, No 2 85 5

CASE REPORT 1 cont. Summary In this case the main challenge that the patient and clinician faced was pain management. Although the patient s acute episode of vasculitis had been successfully treated, a lesion to her foot remained. This caused a great deal of anxiety at dressing change, due to pain that the patient had previously experienced. Although she was being managed with analgesia, she was still worried when her dressing needed to be changed. Appeel Sterile sachet not only facilitated atraumatic dressing removal, but reduced any perceptions of pain to the point that the patient did not require analgesia before dressing changes. This was felt to be a significant clinical outcome for the patient. Figure 6. Two weeks later after using Appeel Sterile sachet. Hollinworth H, White R (2006) The clinical significance of wound pain. In: White R, Harding K, eds. Trauma and Pain in Wound Management. Wounds UK, Aberdeen: 3 16 Figure 7. Four weeks after initial review. 6

CASE REPORT 2 An 85-year-old female patient was admitted to a hospice for palliative care having being diagnosed with multiple myeloma. She also had a history of ischaemic heart disease and atrial fibrillation. She was in a poor condition with extensive weight loss, pain and a large, rapidly deteriorating sacral pressure ulcer. On admission, the initial priority was to improve her nutritional status and manage the considerable pain she was in due to her palliative condition. She was malnourished, with her body mass index (BMI) recording that she was underweight, with wasting muscle and fat layers within her adipose tissue. She was referred to the department of tissue viability for management of her sacral pressure ulcer. On initial assessment she presented with a black, necrotic stage 4 pressure ulcer (European Pressure Ulcer Advisory Panel- National Pressure Ulcer Advisory Panel [EPUAP-NPUAP], 2009), which was malodorous (Figure 1). This was conservatively debrided to remove devitalised tissue (Figure 2). She was started on a topical antimicrobial (Flamazine, Smith & Nephew) to facilitate debridement of necrotic tissue, remove odour and to help dressing changes to be pain free. Flamazine was liberally applied to gauze, which was lightly packed into the wound contours and secured with dressing pad and pants, as the surrounding skin was friable and there were concerns about trauma/skin stripping to the periwound area. The dressing was done daily. The patient was being cared for on a pressure-reducing mattress and was routinely repositioned. A morphine pump infusion effectively managed her pain. Her nutritional intake improved, with staff reporting that she had a very good appetite. She had previously been unable to cook and care for herself at home. Figure 1. Grade 4 sacral pressure ulcer at initial assessment. Figure 2. Sacral pressure ulcer following conservative debridement. Figure 3. Seven days after initial review. 7

CASE REPORT 2 cont. Autolytic debridement of the wound continued over two weeks through dressing intervention (Figures 3 and 4). It was decided to change the dressing to topical negative pressure (TNP) therapy ( Venturi, Talley Ltd) to promote granulation tissue and reduce the frequency of dressing changes. Appeel (CliniMed) Sterile sachets were to be used at each dressing change to remove film dressings and prevent pain or skin stripping (Figures 5 and 6). During dressing changes the patient was responding to questions being asked; however, on dressing removal, she reported that she was unaware that the adhesive dressing to her sacral area had been removed. She did not complain of any pain or discomfort. After seven days (Figure 7) and three dressing changes the wound had improved significantly. Staff reported that removal of the dressing was so much easier and faster. The patient reported no pain and in fact slept through dressing changes. Figure 7 shows that no trauma/stripping of the periwound skin had occurred. Figure 4. Two weeks after initial assessment, TNP therapy was introduced. Figure 5. Appeel Sterile sachet being used to help with the removal of the film dressing. Figure 6. Film dressing falling off. 8

CASE STUDY REPORT 2 cont. Conclusion Although this lady was admitted for palliative care, it was considered best practice to rapidly debride her pressure ulcer, start negative pressure wound therapy (NPWT) and promote healing. This reduced pain, odour and improved quality of life for both the patient and her visiting family members. The use of Appeel Sterile sachet enabled the healthcare staff to ensure that dressing removal was pain free, without causing any adverse effects to the periwound skin condition. European Pressure Ulcer Advisory Panel- National Pressure Ulcer Advisory Panel (2009) Pressure Ulcer Prevention and Treatment clinical practice guideline. NPUAP, Washington DC. Available online at: www.npuap.org Figure 7. Intact periwound skin after three dressing changes. 37 9

CASE REPORT 3 This 52-year-old female was admitted to an acute surgical ward for re-laparotomy and removal of exisiting mesh from an old hernia repair site in 2006. The patient had a large abdominal apron fold which hung down towards her groin area. She also presented with a body mass index (BMI) greater than 30, identifying that she was clinically obese. She was under the care of the dermatology department for ongoing management of psoriasis. This had not caused her any problems before admission. Following surgery, she developed wound dehiscence. Her wound measured 14x5x6cm. Adjacent to this was a smaller wound, measuring 5x1x8cm. On probing, these two wounds were connected with a small bridge of tissue. Due to the extent and depth of these wounds, negative pressure wound therapy (NPWT) (Venturi, Talley Ltd) was the treatment of choice. Appeel Sterile sachet (CliniMed) was used to help with removal of film dressings, as psoriasis had flared up in the abdominal area around the wound. On examination, her skin was red and irritated (Figure 1). The patient reported that previously pain at dressing changes had not been an issue, so no change was noted there. However, she did say that she felt more comfortable when Appeel Sterile sachets were used at dressing removal. There was no stripping or irritation to the skin, and no sting when in contact with areas of psoriasis. Both the patient and staff reported that the film dressing was easier to remove. Figure 1. Large abdominal wound with psoriasis extending extensively around wound edges. Conclusion As this lady s abdomen presented with large areas of psoriasis, the use of Appeel Sterile sachet was gentle, and did not cause any sting on application or further irritation to an already compromised skin integrity. 10

CASE REPORT 4 Mr X was a 64-year-old male patient who was admitted to the general vascular ward for bilateral, above-theknee amputation, due to advanced peripheral vascular disease and acute ischaemic pain. On admission, he was unkempt with a poor dietary intake. At home, due to reduced mobility and acute ischaemic pain, he tended to sit in his chair all day and night resulting in the development of pressure ulcers to both buttocks. Figure 1. Pressure ulcer to sacrum 100% yellow slough. He was placed on a dynamic alternating mattress and referred to the tissue viability department. The pressure ulcer to the left buttock measured 1.5x1cm, however the pressure ulcer on his right buttock was larger, measuring 6x3cm. The wound bed was covered with 100% yellow devitalised tissue which required debridement (Figure 1). The wound was dressed with Granuflex Bordered (Convatec Ltd) to facilitate debridement and prevent the risk of faecal contamination. Granuflex Bordered is an effective dressing which is widely used across the whole spectrum of acute and chronic wound aetiologies. It has a central area of hydrocolloid surrounded by an outer foam border. This foam border can become sticky due to heat and sweating of the patient s skin. Removal can be painful and residue of the border is sometimes left on the patient s skin. To facilitate removal of the Granuflex dressing, liquid from Appeel Sterile sachet (CliniMed) was used around the foam border edge. The foam edge came away easily, almost falling off, and left no residual dressing behind (Figure 1). Figure 1 clearly shows evidence of periwound redness and some skin stripping from previous dressing removals. However, Appeel Sterile sachet clearly disrupted the adhesive membrane, enabling the dressing to be removed without pain or periwound trauma. Figure 2. Pressure ulcer two weeks later. The patient continued to have the wound treated with Granuflex Bordered which was changed every 4 5 days, or according to exudate volume. Staff were actively encouraged to use Appeel Sterile sachet at each subsequent dressing change over the next two weeks. Mr X was reviewed two weeks later and had Granuflex Bordered removed, as before, using Appeel Sterile sachet (Figure 2). The image clearly demonstrates that the periwound condition had improved with no evidence of redness or periwound breakdown. The wound was improving and autolytic debridement was occurring. Conclusion Mr X and the staff reported that they were delighted with Appeel Sterile sachet and would continue to use the product for other patients. The feedback supported: Pain free dressing removal No periwound trauma Accelerated dressing change New opportunities to use adhesive dressings on more friable skin, which previously would not have been considered appropriate due to the risk of epidermal stripping. 11

CASE REPORT 5 Mr Y was 82 years old and still lived at home with limited external support. He was admitted to the care of the elderly emergency medical admissions unit after a fall. On admission, he had limited mobility, confusion and was generally in a poor condition. He was transferred to a care of the elderly assessment and rehabilitation ward with reported renal failure and poor health. Due to a skin tear to his right hand which had occurred when he fell at home, he was referred to the tissue viability department. On initial assessment the skin tear presented as an area of 2x1cm. Skin tears can roll up into themselves but with careful handling can be manipulated into position, however, this was not an option in this case. The patient presented with paperthin tissue which is associated with the elderly, due to the combined effects of thinning of the epidermis and a reduction in the elastin, and also in this case, as a result of the patient s poor condition and underlying medical conditions. This thin, friable skin can easily be damaged. The wound was dressed with Tegaderm Absorbent (3M Health Care), as it enabled the wound to be monitored, exudate absorbsion and supported a longer wear time between dressing changes. The dressing was to be changed weekly. On review seven days later, due to the friability of the skin, it was decided that Appeel Sterile sachet (CliniMed) should be used for dressing removal. Figure 1. Edge of dressing being lifted back. Figure 2. Appeel Sterile being dripped onto dressing edge. A small edge of the Tegaderm absorbent edge was lifted (Figure 1) and the sachet tip was placed in close proximity to allow managed drops of the silicone-based remover to drip onto the dressing (Figure 2) to change the surface chemistry of the skin, enabling removal of the dressing (Figure 3). 12

CASE REPORT 5 cont. The dressing was removed easily and efficiently by the ward manager. She recorded no pain expressed by the patient, or any redness/trauma to the periwound area (Figures 4 and 5). Figure 3. Tegaderm absorbent being peeled back. Conclusion The use of any adhesive dressing on elderly, friable skin is always a risk. The removal of adhesives can cause extensive stripping of the epidermal tissue due to the very nature of the skin s integrity. Appeel Sterile sachet opens up the use of a wide range of products which have generally been avoided or used with extreme caution in elderly patients. Both the patient and the staff reported positive outcomes, i.e: No pain No skin trauma Ease of dressing removal in friable compromised skin. Figure 4. Dressing removed. Figure 5. Intact periwound skin. 13

CASE REPORT 6 A 16-day-old female baby with a history of epilepsy presented with a chemical burn to the back of her left hand. This had been caused by phenytoin leaking into interstitial tissue when it was being administered via a cannula to her hand. On assessment by the tissue viability department, the wound measured 0.5x0.5cm. The wound was intact with 100% yellow tissue and a purple/dark red edge. There was low exudate and low viscosity with no clinical signs of infection. She initially presented with no dressings. Following assessment, ActiForm Cool (Activa Healthcare) was applied to the wound, secured by Tegaderm dressings (3M Health Care) to her hand. She was reviewed seven days later and the dressing was removed using Appeel Sterile sachet (CliniMed). There was no adherence of the film or hydrogel sheet dressings on removal. The baby did however cry. As this was the first dressing change, it was uncertain if this was due to wound trauma or the need to be fed. Thereafter, the baby was fed before dressing changes. The parents were advised to change the dressing every 2 3 days and they were supplied with Appeel Sterile sachets to assist with dressing removal at home. She was reviewed in clinic a week later (Figure 2), and the parents were keen to keep using Appeel Sterile sachet to facilitate dressing removal, as they felt it significantly helped to reduce pain and trauma. The slough in the wound bed was slowly beginning to debride and the dressing regimen was continued. Figure 1. Dressing removed using Appeel Sterile sachet. Figure 2. Film and hydrogel sheet dressing before removal using Appeel Sterile sachet. 14

CASE REPORT 6 cont. The baby was reviewed a further seven days later (Figure 3) and, again, the parents were positive about the use of Appeel Sterile sachet on the child s wound. They felt that this enabled fast dressing changes, with limited pain and trauma to their child. Conclusion Appeel Sterile sachet assisted in the removal of dressings in a very young baby. This liquid was used at each dressing change for three weeks. There were no clinical signs of skin trauma at dressing removal, assessment and re-application. The baby s parents and nurses were happy with the ease of dressing removal using Appeel Sterile sachet. The parents were able and willing to undertake dressing changes at home, as they were comfortable with the knowledge that the dressing change would be quick and efficient. Figure 3. Film and hydrogel sheet being removed using Appeel Sterile sachet. 15

CASE REPORT 7 This 95-year-old female was admitted to a care of the elderly ward from her sheltered housing unit following deterioration in her overall condition. On assessment she had a urinary tract infection which had caused her to become confused and go off her legs. She also had a history of hypertension and anaemia. She was immediately started on antibiotics for her urinary tract infection. She was an exceptionally pleasant and chatty lady who was quite happy to be in hospital, as she had been feeling poorly for some time. Her skin was friable and paper tissue thin, due to the natural thinning of the epidermis and reduction in elastin. The skin of the elderly is easily traumatised and, in this case, the patient presented with lower limb trauma resulting in a skin flap to her left tibial area. Due to her age and the friable nature of her skin, the staff were concerned that whichever dressing they used, by the very nature of her skin integrity, it might cause further trauma. They decided to refer the lady to the tissue viability department for advice and support on how to manage the wound. On assessment at the tissue viability department she presented with a skin flap measuring 6x0.5cm. An extensive area of skin had been sheared up and rolled in on itself. This was unrolled to provide full tissue coverage. There had been a build-up of serous exudate on the wound bed caused by the body s natural reaction to trauma. To prevent this from affecting the take of the skin flap, the skin flap was meshed using a scalpel to allow the exudate to drain through. As there was no sign of infection and the skin had provided full tissue coverage, the dressing selected was Mepilex Border (Mölnlycke Health Care). To help manage and reduce the oedema that she had in both legs, a regimen of blue line Tubifast, then Soffban and another layer of blue line Tubifast was applied toe-to-knee. Figure 1. Mepilex Border in place. Figure 2. Edge of Mepilex Border having Appeel Sterile sachet applied. 16

CASE REPORT 7 cont. At review seven days later, the dressing had remained intact (Figure 1). Due to the friable nature of the patient s skin, it was decided to use Appeel Sterile sachet (CliniMed) to aid dressing removal (Figure 2). The dressing literally peeled back on itself, aiding removal. The patient reported no pain at all, which she was surprised by as she had expected the dressing removal to be painful. There was no trauma to either the friable skin flap or periwound skin (Figure 3). Due to the nature of the skin, it was felt that the wound should be dressed with the Mepilex Border for a further week. Figure 3. Dressing removed. She was reviewed a further seven days later when, again, the dressing had been left in place for the full week. Appeel Sterile sachet was used to aid removal of the dressing (Figure 4). Figure 5 clearly demonstrates that Appeel Sterile sachet, which changes the chemical composition of the adhesive by making it inert when removing the dressing, results in no pulling or stretching of the skin at dressing changes. The dressing was completely removed revealing a complete take of the skin flap with no wound or periwound trauma (Figure 6). Figure 4. Appeel Sterile sachet aiding dressing removal. 17

CASE REPORT 7 cont. Conclusion The use of an adhesive dressing on friable, elderly skin which has already sustained trauma is always a risk. The removal of an adhesive dressing can stretch the skin, causing extreme pain and further trauma/stripping of not only the periwound skin, but also the wound itself. Appeel Sterile sachet not only ensured that dressing removal was entirely pain-free for the patient, but also prevented any further trauma to already identified friable tissue. Figure 5. Dressing falling off. Figure 6. Dressing completely removed. 18

CASE REPORT 8 This case report discusses the use of Appeel Sterile sachet (CliniMed) in the removal of adhesive dressings in a paediatric setting. The use of any adhesive wound dressing in paediatrics is made following careful consideration of the baby s medical and physical condition, with particular emphasis on skin integrity, type of wound, aim of dressing intervention, and frequency of dressing change. Baby A was a seven-month-old female with a history of prematurity and perinatal asphyxia. She had a tracheostomy performed to support her breathing. Due to babies natural behaviour of wriggling and trying to move around, it is difficult to ensure that life-supporting interventions such as tracheostomies do not fall out, or are pulled out. In the case of baby A, her tracheostomy was held in place using a soft ribbon which was tied at the back of the neck. Unfortunately, this tie caused skin damage to the back of her neck. Baby A was referred to the tissue viability department for management of this wound. On initial assessment she had a DuoDERM dressing (ConvaTec) in place. The tracheostomy ties had to be removed as they were still holding the tracheostomy in place. She was placed on her side for access, but this caused her colour to change necessitating a quick assessment procedure. Appeel Sterile sachet helped to reduce trauma at dressing changes. The liquid was dripped onto the DuoDERM to facilitate removal. No adherence occurred and the dressing literally fell off (Figure 1). There was no crying from the baby, suggesting that she had experienced no pain or trauma at dressing removal. The periwound skin was intact and no redness or irritation were evident. The DuoDERM dressing was reapplied and the tracheostomy collar was re-secured. Baby A s colour returned when she was repositioned on her back. Figure 1. DuoDERM having been removed from neck wound using Appeel Sterile sachet. There had been no previous wound management treatments and as frequency of dressing change was reduced, this treatment plan was continued. The management plan at this stage was re-application of DuoDERM every 4 5 days until fully healed. Conclusion Appeel Sterile sachet performed well in a situation where speed was required. Baby A s skin needed careful attention and caution due to its natural fragility and sensitivity. Appeel Sterile sachet provided the speed and delivery of care needed at this compromised moment of care, without causing any pain or trauma to a very vulnerable patient. 19

CASE REPORT 9 A 40-year-old female presented to the tissue viability department with a small, painful chemical burn to her right wrist. She had no previous medical history and was not on any medication. The burn was localised to underneath her watch, which she had been wearing regularly for over two years with no skin damage. However, she was aware that when gardening, some of the weed-killer spray that she had been using may have trickled off her gloved hands and got underneath her watch strap. On initial assessment she presented with a red area, measuring 6x2cm of epidermal tissue loss. Surrounding tissues were red and painful/sensitive to touch, but did not indicate the presence of infection. Figure 1. Hydrocolloid in situ. A small hydrocolloid dressing was applied to the wound and left in place for three days (Figure 1). Due to the sensitive nature of the surrounding irritation to the periwound skin and the original cause of the wound, it was considered appropriate to use Appeel Sterile sachet (CliniMed) at dressing removal. The patient was concerned about the possible irritant effect of Appeel Sterile sachet when coming into contact with skin that was already chemically irritated. She was reassured that this would not be the case and agreed to its use. A small edge of the dressing had some Appeel Sterile liquid dripped onto it, enabling the edge to be lifted. The nozzle of the sachet was then placed close to the dressing, allowing regulated drops of the Appeel liquid to be directed towards the dressing edge, facilitating its easy removal (Figures 2 6). Figure 2. Appeel Sterile sachet lifting dressing edge. Figure 3. Appeel Sterile sachet lifting dressing edge. The dressing was completely removed exposing a much improved wound with dimensions of 3x1.5cm and no surrounding skin erythema. (Figure 7). 20

CASE REPORT 9 cont. Figure 4. Appeel Sterile sachet lifting dressing edge. The patient reported no pain, stinging or any irritant effect when Appeel Sterile sachet came in direct contact with the broken skin. Conclusion Appeel Sterile liquid has been manufactured to aid the removal of adhesive dressings/devices in areas where pain, skin stripping and the risk of infection is high. However, one of the real concerns for patients is whether the solution will further exacerbate already broken, irritated painful skin. This case report clearly demonstrates that Appeel Sterile does not cause any stinging or further irritation of compromised skin integrity, and therefore can be used on all skin areas across the age spectrum. Figure 5. Appeel Sterile sachet lifting dressing edge. Figure 6. Appeel Sterile sachet lifting dressing edge. Figure 7. Dressing completely removed using Appeel Sterile sachet. 21

CASE REPORT 10 This 78-year-old male was initially admitted to the acute medical admission unit following a cardiovascular accident which left him with left-sided weakness. He was transferred to the stroke unit for rehabilitation, including physiotherapy, speech therapy, dietetic advice and occupational therapy support. He was determined and focused and, although struggling with his physical changes, was trying hard to improve his physical well being. Unfortunately, his condition deteriorated and he struggled to mobilise and became more dependent and bed-bound. He also became agitated, frustrated and at times restless. He used his right leg to push himself around the bed, which lead to the development of a large pressure ulcer to his heel, despite the immediate use of an alternating pressure-reducing mattress and specialist heel protectors. He was referred to the tissue viability department for management of the pressure ulcer to the heel. He presented with a grade 4 pressure ulcer (European Pressure Ulcer Advisory Panel-National Pressure Ulcer Advisory Panel [EPUAP-NPUAP], 2009). Due to the extensive nature of the pressure ulcer and the presence of malodorous necrotic tissue, larval therapy was applied. After obtaining patient consent, larvae were applied to his foot in the form of a BioBag (Zoobiotic Ltd), which is directly applied to the wound. The staff had applied Granuflex Bordered (ConvaTec Ltd) around the edge of the pressure ulcer in accordance with Zoobiotic s recommendation to prevent the periwound skin from maceration (Figure 1). Figure 1. Hydrocolloid dressing around pressure ulcer larval therapy having just been removed. Figure 2. Appeel Sterile sachet being used to remove hydrocolloid dressing. Appeel Sterile sachet (CliniMed) was used to speed up the removal the Granuflex Bordered dressing from around the pressure ulcer four days after application of the Biobag larval therapy (Figure 2). 22

CASE REPORT 10 cont. This pleased the patient, as he had found it uncomfortable when staff were holding and supporting his leg for any period of time to allow access to the wound. The hydrocolloid was removed without any pain to the patient or periwound trauma (Figure 3). Larval therapy was reapplied to promote further debridement. Conclusion This elderly gentleman had found having his leg elevated to allow staff access to the dressing uncomfortable. By using Appeel Sterile sachet the hydrocolloid template around the wound was quickly removed, thus reducing the time of leg elevation and without causing any pain or periwound trauma. European Pressure Ulcer Advisory Panel- National Pressure Ulcer Advisory Panel (2009) Pressure Ulcer Prevention and Treatment clinical practice guideline. NPUAP, Washington DC. Available online at: www.npuap.org Figure 3. Hydrocolloid removed, no periwound stripping. 23

He doesn t care that you re using the world s only sterile adhesive remover in a single-use sachet, to remove adhesive dressings quickly and conveniently. He just wants to know it won t hurt. For more information or a free sample of Appeel Sterile, please call the CliniMed Careline on 0800 036 0100 or visit www.clinimed.co.uk Essentials Helps H He lps remove pain pain i from from a dressing dressiing change h Appeel Sterile is available via NHS Supply Chain or direct from CliniMed. Appeel and CliniMed are registered trademarks of CliniMed (Holdings) Ltd. CliniMed Ltd, a company registered in England number 01646927. Cavell House, Knaves Beech Way, Loudwater, High Wycombe, Bucks. HP10 9QY. 2010 CliniMed Ltd. 1231/0410 STERILE Medical adhesive remover