Silver dressings--do they work?

Pressure ulcer following circumferential head dressing

PURPOSE

To report four patients with forehead pressure ulcer (PU) following encircling head dressing and review the literature.

METHODS

Uneventful endoscopic forehead lift procedure was performed with moderate skin elevation in three patients. Left upper eyelid crease incision was made to remove the sub-brow dermoid cyst uneventfully in one patient. All procedures were performed under general anesthesia. Mixed topical antibiotic and steroid ointments were placed on the incision sites before putting the encircling forehead dressing (using gauze and elastic bandage). The dressing was then removed on the first postoperative examination.

RESULTS

Forehead and eyebrow PUs were observed on the first follow-up visit (16-72 h) after removing the dressing. Patients were otherwise healthy. They did not have significant pain or burning postoperatively. Management included pressure release, wound debridement, daily dressing, topical antibiotic and steroid, and silicone-based anti-scar cream. None had infected ulcer and all except one ended up with atrophic scar in the last follow-up (2-14 months). External pressure and shearing forces were assumed to be the main causative factors, even though reperfusion injury could contribute in the development of PU.

CONCLUSION

Encircling head dressing can cause PU and result in scar formation in healthy immunocompetent patients. If there is a low risk of postoperative hematoma, encircling dressing should be avoided. Early loosening of the dressing and frequent examination of the skin are the best preventive and diagnostic measures. Treatment includes pressure removal, daily debridement, and topical medications.

Review of the Current Management of Pressure Ulcers

Significance: The incidence of pressure ulcers is increasing due to our aging population and the increase in the elderly living with disability. Learning how to manage pressure ulcers appropriately is increasingly important for all professionals in wound care. Recent Advances: Many new dressings and treatment modalities have been developed over the recent years and the goal of this review is to highlight their benefits and drawbacks to help providers choose their tools appropriately. Critical Issues: Despite an increased number of therapies available on the market, none has demonstrated any clear benefit over the others and pressure ulcer treatment remains frustrating and time-consuming. Future Directions: Additional research is needed to develop products more effective in prevention and treatment of pressure ulcers.

Extending the TIME concept: what have we learned in the past 10 years?(*)

The TIME acronym (tissue, infection/inflammation, moisture balance and edge of wound) was first developed more than 10 years ago, by an international group of wound healing experts, to provide a framework for a structured approach to wound bed preparation; a basis for optimising the management of open chronic wounds healing by secondary intention. However, it should be recognised that the TIME principles are only a part of the systematic and holistic evaluation of each patient at every wound assessment. This review, prepared by the International Wound Infection Institute, examines how new data and evidence generated in the intervening decade affects the original concepts of TIME, and how it is translated into current best practice. Four developments stand out: recognition of the importance of biofilms (and the need for a simple diagnostic), use of negative pressure wound therapy (NPWT), evolution of topical antiseptic therapy as dressings and for wound lavage (notably, silver and polyhexamethylene biguanide) and expanded insight of the role of molecular biological processes in chronic wounds (with emerging diagnostics and theranostics). Tissue: a major advance has been the recognition of the value of repetitive and maintenance debridement and wound cleansing, both in time-honoured and novel methods (notably using NPWT and hydrosurgery). Infection/inflammation: clinical recognition of infection (and non infective causes of persisting inflammation) is critical. The concept of a bacterial continuum through contamination, colonisation and infection is now widely accepted, together with the understanding of biofilm presence. There has been a return to topical antiseptics to control bioburden in wounds, emphasised by the awareness of increasing antibiotic resistance. Moisture: the relevance of excessive or insufficient wound exudate and its molecular components has led to the development and use of a wide range of dressings to regulate moisture balance, and to protect peri-wound skin, and optimise healing. Edge of wound: several treatment modalities are being investigated and introduced to improve epithelial advancement, which can be regarded as the clearest sign of wound healing. The TIME principle remains relevant 10 years on, with continuing important developments that incorporate new evidence for wound care.

Extremity Trauma, Dressings, and Wound Infection

The manner in which high-energy transfer limb injuries are dressed can alter the wound environment through manipulation of the bacterial burden, thus minimizing tissue degradation and influencing healing potential. Infection is the principal complication of such wounds, and antiseptic soaked gauze is accepted in early coverage of extremity wounds despite a lack of evidence to support this practice. There has been resurgence in the use of silver in acute wounds, through dressings manipulated to deliver sustained elemental silver to the wound interface. In vitro and in vivo experimentation of silver dressings are characterized however by methodological compromise, primarily through lack of similarity of models to the physiology of the healing wound. Results from in vitro studies caution against the use of silver because of evidence of cytotoxicity, but this is not reproduced in in vivo or clinical experimentation, leading to ambiguity. Review of silver dressing application in burns and chronic wound studies fails to support its use over other dressing systems. Similarly, evidence for the use of silver in acute limb wounds is lacking. This article provides a comprehensive overview of the use of silver dressings in acute wound care and highlights in particular the paucity of evidence regarding its routine use in extremity injury.

Expert opinion on the management of infections in the diabetic foot

This update of the International Working Group on the Diabetic Foot incorporates some information from a related review of diabetic foot osteomyelitis (DFO) and a systematic review of the management of infection of the diabetic foot. The pathophysiology of these infections is now well understood, and there is a validated system for classifying the severity of infections based on their clinical findings. Diagnosing osteomyelitis remains difficult, but several recent publications have clarified the role of clinical, laboratory and imaging tests. Magnetic resonance imaging has emerged as the most accurate means of diagnosing bone infection, but bone biopsy for culture and histopathology remains the criterion standard. Determining the organisms responsible for a diabetic foot infection via culture of appropriately collected tissue specimens enables clinicians to make optimal antibiotic choices based on culture and sensitivity results. In addition to culture-directed antibiotic therapy, most infections require some surgical intervention, ranging from minor debridement to major resection, amputation or revascularization. Clinicians must also provide proper wound care to ensure healing of the wound. Various adjunctive therapies may benefit some patients, but the data supporting them are weak. If properly treated, most diabetic foot infections can be cured. Providers practising in developing countries, and their patients, face especially challenging situations.

A systematic review of silver-containing dressings and topical silver agents (used with dressings) for burn wounds

Silver preparations are commonly used for burns, but evidence of their effectiveness remains poorly defined. The aim of the study was to evaluate the effectiveness of silver-containing dressings and topical silver for preventing infection and promoting healing in burns wounds through a meta-analysis of the available evidence. The Cochrane Central Register of Controlled Trials and relevant databases were searched. Drug companies and experts in this field were also contacted. Randomised controlled trials (RCTs) of silver dressings or topical silver (used with dressings) compared with non-silver dressings were eligible for inclusion. We identified 14 RCTs involving 877 participants. One small trial of a silver-containing dressing showed significantly better healing time compared to the control [MD -3.6; 95% CI -4.94 to -2.26 for partial thickness burns and MD -3.9; 95% CI -4.54 to -3.26 for superficial burns]. Topical silver showed significantly worse healing time compared to the non-silver group [WMD 3.96; 95% CI 2.41-5.51] and showed no evidence of effectiveness in preventing wounds infection [WMD 2.48; 95% CI 0.39-15.73]. Our review suggests that silver-containing dressings and topical silver were either no better or worse than control dressings in preventing wound infection and promoting healing of burn wounds.

An overview of the evidence on the efficacy of silver dressings

While there is a plethora of clinical and anecdotal evidence on the efficacy of silver dressings, there is no rigorous RCT data to support this. This has led procurement managers to defer the inclusion of silver dressings on wound formularies, despite its clinical popularity. This article gives an overview of the evidence on topical antimicrobials, in order to determine whether there is a case for such a stance.

An approach to assessing evidence that can inform clinical decision-making

Following the Cochrane meta-analyses findings, doubts are being expressed about efficacy of silver dressings. However, the need for topical antimicrobials has not diminished, and the evidence for non-silver agents is no better than that for silver. This article describes an alternative system to Cochrane for analysing the evidence base, and suggests a practical approach to making a case for silver to procurement managers.