Preliminary observations on clotting under three hydrocolloid dressings

Dressings and topical agents for treating pressure ulcers

BACKGROUND

Pressure ulcers, also known as bedsores, decubitus ulcers and pressure injuries, are localised areas of injury to the skin or the underlying tissue, or both. Dressings are widely used to treat pressure ulcers and promote healing, and there are many options to choose from including alginate, hydrocolloid and protease-modulating dressings. Topical agents have also been used as alternatives to dressings in order to promote healing.A clear and current overview of all the evidence is required to facilitate decision-making regarding the use of dressings or topical agents for the treatment of pressure ulcers. Such a review would ideally help people with pressure ulcers and health professionals assess the best treatment options. This review is a network meta-analysis (NMA) which assesses the probability of complete ulcer healing associated with alternative dressings and topical agents.

OBJECTIVES

To assess the effects of dressings and topical agents for healing pressure ulcers in any care setting. We aimed to examine this evidence base as a whole, determining probabilities that each treatment is the best, with full assessment of uncertainty and evidence quality.

SEARCH METHODS

In July 2016 we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid Embase and EBSCO CINAHL Plus. We also searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies as well as reviews, meta-analyses, guidelines and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication or study setting.

SELECTION CRITERIA

Published or unpublished randomised controlled trials (RCTs) comparing the effects of at least one of the following interventions with any other intervention in the treatment of pressure ulcers (Stage 2 or above): any dressing, or any topical agent applied directly to an open pressure ulcer and left in situ. We excluded from this review dressings attached to external devices such as negative pressure wound therapies, skin grafts, growth factor treatments, platelet gels and larval therapy.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed study selection, risk of bias assessment and data extraction. We conducted network meta-analysis using frequentist mega-regression methods for the efficacy outcome, probability of complete healing. We modelled the relative effectiveness of any two treatments as a function of each treatment relative to the reference treatment (saline gauze). We assumed that treatment effects were similar within dressings classes (e.g. hydrocolloid, foam). We present estimates of effect with their 95% confidence intervals for individual treatments compared with every other, and we report ranking probabilities for each intervention (probability of being the best, second best, etc treatment). We assessed the certainty (quality) of the body of evidence using GRADE for each network comparison and for the network as whole.

MAIN RESULTS

We included 51 studies (2947 participants) in this review and carried out NMA in a network of linked interventions for the sole outcome of probability of complete healing. The network included 21 different interventions (13 dressings, 6 topical agents and 2 supplementary linking interventions) and was informed by 39 studies in 2127 participants, of whom 783 had completely healed wounds.We judged the network to be sparse: overall, there were relatively few participants, with few events, both for the number of interventions and the number of mixed treatment contrasts; most studies were small or very small. The consequence of this sparseness is high imprecision in the evidence, and this, coupled with the (mainly) high risk of bias in the studies informing the network, means that we judged the vast majority of the evidence to be of low or very low certainty. We have no confidence in the findings regarding the rank order of interventions in this review (very low-certainty evidence), but we report here a summary of results for some comparisons of interventions compared with saline gauze. We present here only the findings from evidence which we did not consider to be very low certainty, but these reported results should still be interpreted in the context of the very low certainty of the network as a whole.It is not clear whether regimens involving protease-modulating dressings increase the probability of pressure ulcer healing compared with saline gauze (risk ratio (RR) 1.65, 95% confidence interval (CI) 0.92 to 2.94) (moderate-certainty evidence: low risk of bias, downgraded for imprecision). This risk ratio of 1.65 corresponds to an absolute difference of 102 more people healed with protease modulating dressings per 1000 people treated than with saline gauze alone (95% CI 13 fewer to 302 more). It is unclear whether the following interventions increase the probability of healing compared with saline gauze (low-certainty evidence): collagenase ointment (RR 2.12, 95% CI 1.06 to 4.22); foam dressings (RR 1.52, 95% CI 1.03 to 2.26); basic wound contact dressings (RR 1.30, 95% CI 0.65 to 2.58) and polyvinylpyrrolidone plus zinc oxide (RR 1.31, 95% CI 0.37 to 4.62); the latter two interventions both had confidence intervals consistent with both a clinically important benefit and a clinically important harm, and the former two interventions each had high risk of bias as well as imprecision.

AUTHORS' CONCLUSIONS

A network meta-analysis (NMA) of data from 39 studies (evaluating 21 dressings and topical agents for pressure ulcers) is sparse and the evidence is of low or very low certainty (due mainly to risk of bias and imprecision). Consequently we are unable to determine which dressings or topical agents are the most likely to heal pressure ulcers, and it is generally unclear whether the treatments examined are more effective than saline gauze.More research is needed to determine whether particular dressings or topical agents improve the probability of healing of pressure ulcers. The NMA is uninformative regarding which interventions might best be included in a large trial, and it may be that research is directed towards prevention, leaving clinicians to decide which treatment to use on the basis of wound symptoms, clinical experience, patient preference and cost.

Autolytic debridement of a large, necrotic, fully occluded foot ulcer using a hydrocolloid dressing in a diabetic patient

OBJECTIVE

The aim of this article was to review the authors' experience with hydrocolloid dressings in foot ulcers, especially in diabetic patients. Engineered as part of stomal flange, hydrocolloid dressings established their presence in wound care management after successfully protecting peristomal skin. They are occlusive dressings and have been valued for their ability to support autolytic debridement, thus removing necrotic tissue--a barrier to healing--from the wound bed. These dressings have received negative attention, however, after a number of case reports indicated the products as a possible cause of wound deterioration, amputation, and death, when used on foot ulcers. Therefore, in general, their use has been discouraged in the treatment of foot ulcers. The authors present a case in which a hydrocolloid dressing was used to successfully debride a large, necrotic, fully occluded foot ulcer in a diabetic patient.

DESIGN

A case report.

SUBJECT

A 60-year-old man with diabetes, post-renal transplant, with a large necrotic lesion on the lateral ankle, likely secondary to a burn.

RESULT

There was complete resolution of the wound in 25 weeks. Consistent use of hydrocolloids over 10 weeks healed a fully necrotic wound bed to complete granulation and the initiation of epithelialization. Infection was not a complication in this case. The wound has remained closed after 12 months.

CONCLUSIONS

Removal of necrotic tissue from the wound bed was evident after using hydrocolloid dressing, thus expediting healing of the wound. It was accomplished with frequent monitoring and respecting contraindications to the use of this product. This treatment was invaluable in effectively liquefying necrotic material in the wound bed in a noninvasive manner. The authors recommend consideration of using this type of dressing for similar lesions to more effectively and hastily remove barriers to healing, provided that the wounds are not infected and patients do not have peripheral arterial disease and are not severely medically compromised. Frequent monitoring and dressing change are also mandatory.

Ingredient-based wound dressing classification: a paradigm that is passe and in need of replacement

Wound dressings are classified according to their ingredients, but in many cases dressings within the same group have different recommended uses and even ingredients. Should future classifications be based on dressing functions?

Wound microbiology and associated approaches to wound management

The majority of dermal wounds are colonized with aerobic and anaerobic microorganisms that originate predominantly from mucosal surfaces such as those of the oral cavity and gut. The role and significance of microorganisms in wound healing has been debated for many years. While some experts consider the microbial density to be critical in predicting wound healing and infection, others consider the types of microorganisms to be of greater importance. However, these and other factors such as microbial synergy, the host immune response, and the quality of tissue must be considered collectively in assessing the probability of infection. Debate also exists regarding the value of wound sampling, the types of wounds that should be sampled, and the sampling technique required to generate the most meaningful data. In the laboratory, consideration must be given to the relevance of culturing polymicrobial specimens, the value in identifying one or more microorganisms, and the microorganisms that should be assayed for antibiotic susceptibility. Although appropriate systemic antibiotics are essential for the treatment of deteriorating, clinically infected wounds, debate exists regarding the relevance and use of antibiotics (systemic or topical) and antiseptics (topical) in the treatment of nonhealing wounds that have no clinical signs of infection. In providing a detailed analysis of wound microbiology, together with current opinion and controversies regarding wound assessment and treatment, this review has attempted to capture and address microbiological aspects that are critical to the successful management of microorganisms in wounds.

Moisture-Retentive Dressings: A Review of the Current Literature

Moisture-retentive dressings allow rapid epithelialization, reduce pain, reduce fibrosis, reduce infection and yield better cosmetic results. Furthermore, occlusive dressings allow less painful debridement and stimulate granulation tissue. Despite these advantages, moisture-retentive dressings are still underused. Among the reasons for this underuse are confusion due to the variety of dressings available, fear of infection, and excessive cost. The studies reviewed here refute concerns that moisture-retentive dressings are associated with more infections or that they are too expensive to be practical. The issue of cost was addressed in several of the articles reviewed here, and while moisture-retentive dressings are certainly more expensive on a per unit basis, their overall cost-effectiveness can be more favourable than other more conventional dressings.

A study of hydrogen peroxide generation by, and antioxidant activity of, Granuflex (DuoDERM) Hydrocolloid Granules and some other hydrogel/hydrocolloid wound management materials

The effect of Granuflex Hydrocolloid Granules (0.01-0.50% w/v) on the rate of proliferation of murine (L929) fibroblasts was examined. The dose-response curve showed a significant (P < 0.02) pro-proliferant effect at 0.05%, and a significant (P < 0.02) antiproliferant effect at 0.50%, mirroring the dose-response curve produced by hydrogen peroxide in the concentration range 10(-9) - 10(-4) mol/l. The antiproliferant effect at 0.20% w/v was abolished by catalase, suggesting that the biological activity of Granuflex was mediated by the in situ generation of hydrogen peroxide. Formation of hydrogen peroxide by Granuflex was confirmed by performing the scopoletin-horseradish peroxidase assay in the presence and absence of catalase. The total concentration of hydrogen peroxide detected was about 8 x 10(-6) mol/l (using 0.5% w/v Granuflex) after 48 h at 37 degrees C. In contrast, when hydrogen peroxide itself was added to L929 cultures, a similar antiproliferant activity was observed at concentrations between 10(-4) and 10(-5) mol/l. These results suggested that Granuflex was undergoing autoxidation in the culture medium, and hence that it might possess antioxidant activity. In assays for antioxidant activity using 1,1-diphenyl-2-picrylhydrazyl (DPPH), Granuflex, and two other hydrocolloid dressings (Comfeel Powder and Bard Absorption Dressing) showed significant ability to reduce DPPH to DPPH2. These three dressings also displayed superoxide scavenging activity in a nitroblue tetrazolium reduction assay. We conclude that, in addition to providing a moist wound-healing environment, Granuflex and certain other hydrocolloids might contribute to the establishment and maintenance of the reducing environment necessary for energy production and hence cell division.(ABSTRACT TRUNCATED AT 250 WORDS)