The role of wound-bed preparation in managing chronic pressure ulcers

Therapeutic Ultrasound in Lower Extremity Wound Management

In medical practice, ultrasound (US) is used for diagnosis and therapy. High-frequency (1-4 MHz) and low-frequency (20-120 KHz) therapeutic US are relevant to wound healing. The heating effects of high-frequency US are important, whereas the mechanical effects of low-frequency US must be considered. The physiological effects of low-frequency US include metabolic enhancement, perfusion, wound cleansing, and the acceleration of wound granulation. The therapeutic efficacy of US depends on dose (W/cm2 time)and dosage (frequency of application, series). At adequate doses, high-frequency and low-frequency therapeutic US induce in vitro cell proliferation; protein synthesis; and the production of cytokines by fibroblasts, osteoblasts, and monocytes. The mechanical effects of low-frequency US cause transient cavitation in wound surfaces for soft and smooth wound cleaning, ulcer debridement, and the stimulation of granulation. These effects can be determined in clinical studies, though the quality of the studies done so far and of the evidence of the usefulness of US is poor. Nevertheless, high-frequency and low-frequency US may be reasonable options in the management of chronic wounds.

Wound bed preparation of difficult wounds: an evolution of the principles of TIME

In the last few years, considerable progress has been made in the treatment of chronic ulcers, thanks to new therapy methods. Wound bed preparation is a modern approach for the removal of local barriers to healing by optimising debridement, reduction of bioburden and exudate management through the TIME principles, which have been introduced by the International Advisory Board on Wound Bed Preparation. However, this protocol does not evaluate the state of the repair process and therefore does not suggest the ideal therapeutic choice for each single patient. The revised TIME-H concept considers also the supposed healing time, H, and gives a score that correlates the wound condition with the incidental concomitance with medical pathologies related to the therapeutic measures, thus guiding the clinician towards a practical and systematic approach in the treatment. By applying this scheme to our situation, the average healing time was considerably reduced. The formulation of the new protocol TIME-H for a critical assessment of treatment scheme, which also includes the general conditions of the patient, represents a more rational and adequate approach for an accurate prognosis and therefore for a more suitable therapeutic choice in the treatment of difficult wounds.

Larval therapy in wound management: a review

Debridement is an essential component of wound care as the presence of devitalised tissue can impede the healing process. Larval therapy has been used for the debridement of wounds for several hundred years. A plethora of literature is available on larval therapy, but many authors acknowledge the paucity of large-scale clinical trials supporting its effectiveness. While the exact mechanism of larval therapy remains unknown, it encompasses three processes: debridement, disinfection and promotion of healing. This literature review discusses the applications, benefits and disadvantages of larval therapy as well as the processes involved. The literature reviewed suggests that further comprehensive research into the mechanisms involved in larval therapy is required to ensure that it may be used to best medical advantage.

An evaluation of polyvinylidene film dressing for treatment of pressure ulcers in older people

OBJECTIVE

To compare the effectiveness of polyvinylidene (PVL) food wrap as a dressing material versus conventional ointments and gauze dressings for pressure ulcers in patients aged 60 years or over.

METHODS

A prospective open controlled trial was conducted. The severity of pressure ulcers in both groups was evaluated using the DESIGN system. Scores were compared at baseline, four, eight and 12 weeks.

RESULTS

Twenty-five patients were treated with the PVL film (test) dressings and 24 with the conventional treatment (control). The test group showed greater improvement in DESIGN scores than the control group throughout the observation period, and the difference reached statistical significance at 12 weeks (p < 0.05). The incidences of local wound infection in the two groups were not statistically different (p > 0.999).

CONCLUSION

The PVL film dressing was more effective than conventional treatment in the management of severe pressure ulcers.

Skin grafting of a chronic leg ulcer with combined Versajet?-V.A.C. therapy

A new method for surgical wound debridement is the Versajet hydrosurgery technique. This technique uses a high velocity jet of sterile saline with a speed up to 1,078 km/h (670 miles/h). By using the Venturi effect (fluid speeds up in a restriction, reducing its pressure and producing a partial vacuum), a simultaneous vacuum is created across the operating window of the handpiece. The application of this high velocity fluid jet to a chronic wound enables precise debridement without collateral tissue damage. The vacuum-assisted closure (V.A.C.) therapy is used for chronic wounds to induce faster wound healing. This system creates a vacuum-induced negative pressure to a specific wound area resulting in an accelerated formation of granulation tissue in the wound bed. We present a patient who experienced rapid wound healing when both of these techniques were combined to clean the wound. After split-thickness skin grafting, V.A.C. therapy was continued. The result was excellent graft acceptance with complete wound healing. This case is unique in that a combination of both therapies resulted in complete wound healing.

Effect of a new silver dressing on chronic venous leg ulcers with signs of critical colonisation

OBJECTIVE

To investigate the clinical performance and safety of a new silver-containing wound-contact layer, Physiotulle -Ag (Coloplast), in the treatment of chronic venous leg ulcers with delayed healing and signs of critical colonisation.

METHOD

This was an open prospective non-comparative multicentre clinical study. Patients were treated for four weeks with Physiotulle -Ag, which was covered by Alione Hydrocapillary Dressing (Coloplast).

RESULTS

Thirty patients were recruited into the study. One ulcer healed after three weeks of treatment. The mean relative ulcer area reduced by 55% after four weeks. Over the study period the mean amount of healthy granulation tissue increased from 26% to 62%, and the mean amount of fibrin decreased from 63% to 32%. The ratio of malodorous wounds was 50% at inclusion, 20% after one week and 3% after four weeks. The dressing was considered easy or very easy to apply in 100% and easy to remove in 89% of dressing evaluations. The dressing combination showed good exudate-management properties. Incidence and severity of maceration, erythema and eczema decreased during the study and no device-related adverse events were recorded.

CONCLUSION

Physiotulle -Ag is safe and easy to use in chronic venous leg ulcers in which healing is delayed and with signs of critical colonisation.

Bacterial and fungal absorption properties of a hydrogel dressing with a superabsorbent polymer core

OBJECTIVE

To study in vitro the micro-organism absorption properties of a hydrogel wound dressing, TenderWet.

METHOD

Microbial films on agar plates and suspensions with common wound bacteria (Staphylococcus aureus, Staphylococcus epidermidis and Pseudomonas aeruginosa) and a fungal strain (Candida albicans) were studied.

RESULTS

The hydrogel dressing reduced the number of micro-organisms significantly, both on the agar plate and in suspension. The in vitro data show that the hydrogel dressing absorbed the micro-organisms from the environment. Electron microscopic imaging clearly demonstrated that the germs were attached to the surface of the dressing's superabsorbent polymer core.

CONCLUSION

In vitro data show that the hydrogel dressing TenderWet attracts and retains micro-organisms and reduces the number of viable germs. Clinical experience underlines this fast cleansing and debriding effect of the hydrogel wound dressing.

Protocol for the successful treatment of pressure ulcers

Bed-bound patients with pressure ulcers are almost twice as likely to die as are those without pressure ulcers. If pressure ulcers are treated with a comprehensive regimen upon early recognition, nearly all stage IV ulcers can be avoided. Furthermore, such a regimen can significantly reduce the comorbidities, mortalities, and costs of treatments resulting from stage IV ulcers. The costs of treatments for comorbidities after the ulcer progresses to stage IV far outweigh the costs for early treatment of the ulcer before it progresses beyond the early stages. We describe herein the 4 stages of pressure ulcers, as well as the pathogeneses, costs, and complications associated with these wounds. A comprehensive 12-step detailed protocol for treatment of pressure ulcers is described; this includes recognizing that every patient with limited mobility is at risk for developing a sacral, ischial, trochanteric, or heel ulcer; daily assessment of the skin; objective measurement of every wound; immediate initiation of a treatment protocol; mechanical debridement of all nonviable tissue; establishment of a moist wound-healing environment; nutritional supplementation for malnourished patients; pressure relief for the wound; elimination of drainage and cellulitus; biological therapy for patients whose wounds fail to respond to more traditional therapies; physical therapy; and palliative care. Availability of the described treatment modalities, in combination with early recognition and regular monitoring, ensures rapid healing and minimizes morbidity, mortality, and costs.

Descriptive evaluation of Alione hydrocapillary dressing

It is widely recognized that a moist wound environment enhances epithelial migration and resurfacing, as well as promoting autolytic debridement of necrotic tissue, reducing pain, infection and scarring (Russell, 2002). However, an imbalance in the level of moisture can lead to delayed healing, or even wound extension (Kindlen and Morison, 1999). The type of wound itself can be influential in relation to the level of exudate produced. With such a diverse array of wound management products now available, the healthcare professional faces a constant dilemma in deciding what dressing is suitable for maintaining an optimal level of humidity in the wound environment. Alione, a new hydrocapillary dressing, manufactured by Coloplast, appears to overcome this impasse by being sufficiently versatile to manage varying levels of exudate in all types of wounds.