Wound dressing performance: - BAP Medical

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— the formation of white, oedematous tissue frequentlyfound around highly exuding wounds.This tissue no longer offers a barrier to bacterialingress, and instead forms a microclimate in whichmoisture-loving bacteria can proliferate. 23 The tissuesbecome weakened and the wound increases insize. 23 Judicious care, and use of appropriate dressings,can avoid maceration and delayed healing.Vertical wickingVertical wicking occurs when exudate is taken upand held by the dressing within the wound areaimmediately above the wound, avoiding lateralspread to the periwound skin. (Lateral wickingoccurs when exudate is taken up by the dressingand spreads laterally across the dressing surfacebeyond the borders of the wound margin.)Bioburden management anddebridementWounds are contaminated with a variety of bacteria,so the potential for infection is always present. 24The warm, moist environment, together with aready supply of nutrients, offers an ideal setting forbacterial proliferation. Reducing bioburden is thereforean important aspect of wound management.The immobilisation of bacteria and the modulationof matrix metalloproteases (MMPs) is anindispensable performance parameter. This shouldnot affect the product’s absorption capacity, or itsretention properties and absorption kinetics. Thecombined effect is anti-inflammatory, which aidsdebridement and the progression towards healing.Concern has been raised about a possible associationbetween bacterial resistance and the widespreadand sometimes indiscriminate use of antimicrobials.25,26 Therapeutic management of woundbioburden through non-antimicrobial (passive)methods such as bacterial sequestration has notbeen vigorously pursued, despite the inherentadvantage of avoiding antibiotic resistance.It is widely recognised that an accumulation ofslough is consistent with slow/impaired woundhealing. To promote healing, this should be removedat regular intervals (debridement), even thoughthere are no clinical data to support this. 27 Approachesto debridement include autolytic, enzymatic, irrigation,larvae, sharp/surgical and wet to dry methods.The focus here is autolysis. Debridement may welltake on more significance as we learn more about itsbeneficial effects for healing.Matrix metalloprotease modulationWound repair and remodelling is influenced byMMP expression. Excess production of MMPs, inconjunction with reduced levels of TIMPs, results inan unbalanced destruction of the ECM and delayshealing. 28 Proteases produced by wound bacteriacompound the problem of tissue breakdown. MMPregulation is therefore important, and topical interventionshave proved beneficial in this respect. 29,30,31Impact on quality of lifeAdvanced wound dressings have improved the qualityof life of many patients. However, in somequarters these advances have not been fully accepted,and the lack of objective scientific evidence is oftencited as a reason for this.Horkan et al. examined 13 systematic reviews/meta-analyses that explored the effects of moderndressings on wound healing by secondary intention.32 His stark conclusion was that there appears tobe no consistent evidence that any one moist woundhealing dressing is better than another.Where does this leave the quest for advancedproducts and their use? Some clinicians appear socomfortable with outmoded practices, in spite ofabundant evidence, both empirical and objective,that they may not deliver optimal outcomes. Inorder to make a case for dressings that will achieve21st century outcomes, it is useful to consider therequirements of 21st century wounds.The health economics of highlyexuding woundsTraditional attempts to cope with highexudate levels required the use of high absorbencydressings. Simple cotton or cellulose-based productshave limited absorptive capacity. Once fibres areloaded with fluid, uptake is halted andleakage occurs.Later management techniques introduced the useof higher absorbency materials. Products such asalginates and Hydrofibers have the potential toabsorb higher volumes of fluid, but they also havea higher unit cost and generally require asecondary dressing, adding to the overall cost. Themanagement of heavy exudate can therefore beexpensive; frequent changing of saturated dressingsis required.In my experience, some clinicians may use simplewound interface materials, changing outer absorbentmaterials as required. However, this requiresfrequent health-care interventions. Dressings thatpromote a moist wound healing environment havebeen associated with faster healing rates and reducedpain and scarring. These features have improvedpatient satisfaction and decreased treatment costs. 338J O U R N A L O F W O U N D C A R E S O R B I O N S U P P L E M E N T 2 0 1 0
Other management techniques include the use ofNPWT. While effective in handling large volumes offluid, they can limit patient movement, require highlevels of expertise, have limited availability in thecommunity and are costly to operate.ConclusionTo perform the sum of absorbency, retention, preventionof maceration, vertical wicking, bioburdenmanagement, MMP modulation and debridement,an amalgamation of technologies specificallydesigned for collective maximum performanceis required.The efficient management of wounds, especiallyexudate output and its associated chronic inflammation,remains a challenge. However, this can be metif careful consideration is given to the overall woundcharacteristics, dressing selection and dressing performance.Finally, the product must be readilyavailable to clinicians in all health-care sectors at anaffordable unit price, with no hidden costs in theform of extra health-care interventions.References1 Kapadia, H.M. SampsonGamgee: a great BirminghamSurgeon. J R Soc Med 2002;95: 2, 96-100.2 Winter, G. Formation of thescab and the rate ofepithelialization of superfi cialwounds in the skin of theyoung domestic pig. Nature1962; 193: 293-295.3 Forrest, R.D. Early history ofwound treatment. J R Soc Med1982; 75: 3, 198-205.4 Turner, T.D. Semi-occluive andocclusive dressings. In: Ryan, T.J. (ed). An Environment forHealing: The role of occlusion.Royal Society of Medicine,1985.5 Morgan, D.A. The application ofthe ‘ideal dressing’ theory topractice. Nursing Scotland1998; July, 16-18.6 Thomas, S. The role of dressingsin the treatment of moisturerelatedskin damage. WorldWide Wounds, 2008. Availableat: www.worldwidewounds.com/2008/march/Thomas/Maceration-and-the-role-ofdressings.htmlAccessed 23February 2010.7 Reddy, M., Kohr, R., Queen, D.et al. Practical treatment ofwound pain and trauma: apatient-centered approach. Anoverview. Ostomy WoundManage 2003; 49: (4 Suppl),2-15.8 van Rijswijk, L. Ingredient-basedwound dressing classifi cation: aparadigm that is passé and inneed of replacement. J WoundCare 2006; 15: 11-14.9 Trengove, N.J., Stacey, M.C.,Macauley, S. et al. Analysis ofthe acute and chronic woundenvironments: the role ofproteases and their inhibitors.Wound Repair Regen 1999; 7:6, 442-452.10 Cutting, K.F. Wound exudate:composition and functions. Br JCommunity Nurs 2003; 8:(Suppl. 9), 4-9.11 Bishop, S.M., Walker, M.,Rogers, A.A., Chen, W.Y.Importance of moisturebalance at the wound-dressinginterface. J Wound Care 2003;12: 4, 125-128.12 Broughton, G. 2nd, Janis, J.E.,Attinger, C.E. The basic scienceof wound healing. PlastReconstr Surg 2006; 117:(Suppl. 7), 12S-34S.13 Katz, M.H., Alvarez, A.F.,Kirsner, R.S. et al. Humanwound fl uid from acutewounds stimulates fi broblastand endothelial cell growth. JAm Acad Dermatol 1991; 25:(6 Pt 1), 1054-1058.14 Kennedy, J.F., Bunko, K. Theuse of ‘smart’ textiles forwound care. In: Rajendran, S.(ed). Advanced Textiles forWound Care. WoodheadPublishing, 2009.15 Woodall, R.D. Tissue viability.Living with leg ulcers: apatient’s personal experience.Nurs Stand 1996; 10: 45, 52.16 Lamke, L.O., Nilsson, G.E.,Reithner, H.L. The evaporativewater loss from burns and thewater-vapour permeability ofgrafts and artifi cial membranesused in the treatment of burns.Burns 1977; 3: 3, 159-165.17 Alexander, S. Malignantfungating wounds: managingmalodour and exudate. JWound Care 2009; 18: 9, 374-382.18 Vermeulen, H., Ubbink, D.T.,Goossens, A. et al. Systematicreview of dressings and topicalagents for surgical woundshealing by secondary intention.Br J Surg 2005; 92: 6: 665-672.19 Thomas, S. Alginate dressingsin surgery and woundmanagement: part 3. J WoundCare 2000; 9: 4, 163-166.20 Snyder, R.J. Managing deadspace: an overview —eliminating these unwantedareas is a key to successfulwound healing. PodiatryManage 2005; 24: 8, 171-174.21 Cochrane, G. The severleydisabled. In: Bader, D.L. (ed.).Pressure Sores: Clinicalpractice and scientifi capproach. Macmillan, 1990.22 White, R.J., Cutting, K.F.Modern exudate management:a review of wound treatments.World Wide Wounds, 2006Available at: www.worldwidewounds.com/2006/september/White/Modern-Exudate-Mgt.html Accessed 12December 2009.23 Cutting, K.F., White, R.J.Maceration of the skin andwound bed. 1: Its nature andcauses. J Wound Care 2002;11: 7, 275-278.24 Bowler, P.G., Duerden, B.I.,Armstrong, D.G. Woundmicrobiology and associatedapproaches to woundmanagement. Clin MicrobiolRev 2001; 14: 2, 244-269.25 Russell, A.D., Tattawasart, U.,Maillard, J.Y., Furr, J.R. Possiblelink between bacterialresistance and use ofantibiotics and biocides.Antimicrob Agents Chemother1998; 42: 8, 2151.26 Tambe, S.M., Sampath, L.,Modak, S.M. In vitro evaluationof the risk of developingbacterial resistance toantiseptics and antibiotics usedin medical devices. JAntimicrob Chemother. 2001;47: 5, 589-598.27 Bradley, M., Cullum, N.,Sheldon, T. The debridementof chronic wounds: asystematic review. HealthTechnol Assess 1999; 3: 17,iii-iv, 1-78.28 Ma, C., Tarnuzzer, R.W.,Chegini, N. Expression ofmatrix metalloproteinases andtissue inhibitor of matrixmetalloproteinases inmesothelial cells and theirregulation by transforminggrowth factor-beta1. WoundRepair Regen 1999; 7: 6, 477-485.29 Chin, G.A., Thigpin, T.G.,Perrin, K.J. et al. Treatment ofchronic ulcers in diabeticpatients with a topicalmetalloproteinase inhibitor,Doxycycline. Wounds 2003;15: 10, 315-323.30 Kakagia, D.D., Kazakos, K.J.,Xarchas, K.C. et al. Synergisticaction of protease-modulatingmatrix and autologous growthfactors in healing of diabeticfoot ulcers: a prospectiverandomized trial. J DiabetesComplications 2007; 21: 6,387-391.31 Vin, F., Teot, L., Meaume, S.The healing properties ofPromogran in venous legulcers. J Wound Care 2002;11: 9, 335-341.32 Horken, L., Stansfi eld, G.,Miller, M An analysis ofsystematic reviews undertakenon standard advanced wounddressings in the last 10 years. JWound Care 2009; 18: 7,298-304.33 Metzger, S. Clinical and fi nancialadvantages of moist woundmanagement. Home HealthcNurse 2004; 22: 586-590.34 Vowden, K., Vowden, P.Understanding exudatemanagement and the role ofexudate in the healing process.Br J Comm Nurs 2003; 8: 11(Suppl), 4-13.All dressings should bechanged in line with themanufacturer’s instructionsfor use and clinicians shouldbe pragmatic aboutperformance expectationsJ O U R N A L O F W O U N D C A R E S O R B I O N S U P P L E M E N T 2 0 1 09
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