Current Concepts in Wound Cleansing and Dressing Selection

Jane ODriscoll, PT, WCC, CLT Heidi Thielen, RNC, WOCN

Wound Bed Preparation

Four Major Components

1. Tissue Management

2. Inflammation and Infection control 3. Moisture Balance 4. Epithelial Edge Advancement

Tissue Management

Cleansing with mechanical force

Normal saline Commercial cleansers Lactated ringers Tap water

Debridement
Mechanical Sharp Autolytic Enzymatic

Infection Control

Choosing to cleanse with an antiseptic Topical Antiseptics (Cleansing)

Betadine gram +/ Dakins solution gram +/-; pseudomonas Acetic acid gram +/-; pseudomonas Hydrogen peroxide

Infection Control

Topical Antibacterial Dressings

Iodoform Aquacel Ag; Maxsorb Ag Silvadene Silverlon Acticoat Optifoam Ag
-

Silver Polymem Mepilex Ag Xeroform

Infection Control

Topical Antibiotics used for a limited time period when clinical infection is present
Muprirocin (Bactroban): MRSA, gram + Polymyxin: gram -; pseudomonas Bacitracin: wide spectrum gram + and

+ Oral and IV Antibiotics: vancomyicin; levaquin; sulfonamides (bactrim)

Epithelial Edge Advancement

Open wound edges Pack Dead Space

If epibole present, no healing will take place Silver nitrate Promotes healing from the bottom up Fill depth of wound with packing material Do not pack tightly Ex: wound fillers; gauze; alginates To determine what you use: do you want to absorb exudate or hydrate the wound bed this determines dressing choice

Dressings

Primary
The therapeutic or protective covering applied directly to the wound base

Secondary
Materials that serve as therapeutic or protective function and are used to secure the primary dressing i.e. keeps the dressing in place

Product Categories

Alginates primary dressing

Derived from brown seaweed Rope or flat dressing Sometimes impregnated with Ag Absorbs 333% its weight in fluid Becomes gel like when mixes with wound exudate Ex: Kaltostat, Kalginate, Sorbsan, Curasorb, Aquacel, Maxsorb

Product Categories

Collagens primary dressing

Freeze dried sheets of collagen, pastes, or gels usually derived from cowhide Encourages deposition/organization of new collagen & granulation Only use in proliferative phase Ex: Fibercol, Wondres, Nu gel, Medfil Pads, hyCure

Product Categories

Composites primary or secondary dressing

Combination of 2 or more different products Provides multiple functions autolytic debridement and vapor exchange Sometimes provides an absorptive function Ex: Covaderm, Alldress, Telfa Island, Stratasorb; Optifoam adhesive

Product Categories

Contact Layers primary dressing

Thin, non-adherent sheets placed in wound bed to protect against contact from other agents Provides protection Porous to allow fluid exchange Often used with fillers or topical medications Always used when bone or tendon is exposed Can leave in wound bed up to 7 days Ex: Tegapore, Dermanet, Mepitel, Telpha Clear, Curity Nonadherent, Vaseline Impregnated Gauze

Product Categories

Foams primary dressing

Semi-permeable polyurethane foam, nonadherent; waterproof outer layer Provides moist wound environment Best for maintaining temperature of wound bed Used on minimal to moderate drainage Ex: Allevyn, Curafoam, Flexzan, Hudrasorb, LYOfoam, Mitraflex, Polymem, Tielle, Mepilex, Biatain, 3M Heel Foam, Comfeel Ulcer Dressing, Optifoam

Product Categories

Hydrocolloids primary dressing

Contain hydrophilic colloidal particles in an adhesive compound laminated onto a flexible outer layer; is occlusive Can protect intact skin or newly healed wounds Cause autolytic debridement Use only on non-infected wounds Is somewhat absorptive of drainage Ex: Exuderm, Duoderm

Product Categories

Hydrogels primary dressing

Generally contain a 90% water gel base Comes in gel or sheets Donates moisture to a wound Ex: Wound gel filler: Curasol, Curafil, Intrasite, Solosite, Carrasyn, Normigel, Amerigel, Saf-gel Gel Sheets: Dermagel, Curagel, Kendall Island, NDM Island, MPM Med Gel Pad, Elastogel, Vigilon, Tenderwet Impregnated Gauze: CarraGauze, Transigel, Curasol, Dermagran Gauze

Product Categories

Specialty Absorptives primary or secondary dressing

Multilayered dressings consisting of highly absorptive layers Often made of cellulose, cotton, or rayon Use with heavy exudate Ex: Aquacel, Combiderm, Exu-Dry, Softsorb, Tendersorb Wet-Pruf pads, ABD pads

Product Categories

Transparent Films primary or secondary dressing

Transparent sheets with adhesive back Occlusive Cause autolytic debridement Use only on non-infected wounds Has no absorptive properties Ex: Tegaderm, Opsite, Polyskin, Mefilm

Product Categories

Wound fillers primary dressing

Agents that come in a variety of forms: thick paste, granules, powders, and beads Provide moist environment yet absorb some exudate Can be used on infected wounds Ex: Flexigel, Gold Dust Wound Filler, Iodoflex pads, Multidex

Tapes

Used to secure dressings Types

Foam Non woven cloth Fabric Paper

Plastic Cloth Silk

Gauze Dressings

Commonly known as 4x4s, 2x2s, packing strip, kerlix, conform, kling. Made of woven and non-woven fibers of cotton, rayon, polyester, or combination Moderately absorptive

Gauze Dressings

Some are impregnated

Mesalt: intended for heavily draining infected wounds Idoform: iodine impregnated gauze packing strip Xeroform: fine mesh gauze impregnated with petrolatum and 3% bismuth; deodorizes Vaseline: fine mesh gauze impregnated with vaseline Adaptic: fine mesh coated with light oil emulsion Kerlix AMD: coated with polyhexamethylene biguanide (bacteria killing polymer); extracts bacteria from wound

Skin Sealants

Liquid skin protectors that provide a plastic type film over skin Protects from moisture and tape damage Ex: Skin prep, NO-STING skin prep, Cavilon Barrier Film, Hollister Skin gel, Sure prep, Benzoin spray or sticks

Prescription Products

Accuzyme Papain-Urea Ointment

Provides enzymatic debridement Does not harm viable tissue Digests nonviable protein necrosis 1st choice until necrosis is <25% of wound bed

Collagenase Santyl
Provides enzymatic debridement Does not harm viable tissue Digests collagen necrosis

Prescription Products

Panafil Ointment
Provides enzymatic debridement Does not harm viable tissue Digests nonviable protein necrosis Use when there is <25% necrotic tissue present

Prescription Products

Other less common

Regranex Xenaderm Optase Gel Granulex Spray Biafine

Wound Types
Pressure, Venous, Arterial, Diabetic, Acute, Unusual

Pressure Ulcers

Rounded Crater like Regular edges Take on shape that caused the pressure The deeper the less likely they bleed Often peri-wound is non-blanchable erythema

Arterial Ulcers

Location
Between toes or tips of toes Over phalangeal heads Around lateral malleolus Areas subjected to trauma/rubbing footwear

Other skin characteristics

Thin, shiny, dry skin Hairless Thick toenails Dependent rubor Pallor on elevation - cyanosis - abnormal ABI - poor/absent pulses - decreased skin temp

Arterial Ulcers Continued

Characteristics Even wound margins Punched out appearance Pale, deep, wound bed Blanched peri-wound tissue Extreme pain Cellulitis

Gangrene/necrosis Dry gangrene

Unstable gangrene
Amputation required

black non-viable tissue Exclusive to the extremities Tx: paint with betadine or alcohol and dress with dry gauze

Diabetic Ulcers

Characteristics
Painless Even wound margins Rounded/oblong shape over bony prominence Deep Surrounding callous Cellulitis/underlying osteomyelitis

Venous Ulcers

Characteristics
Irregular wound margins Superficial Lumpy granulation tissue Generally painless Exudate is moderate to heavy initially Surrounding skin can be weepy Dermatitis vs. cellulitis

Venous Ulcers Continued

Treatment:
Cleanse and choose dressings for wound Compress Optimize contributing factors Elevate Establish a maintenance plan

Venous Ulcers Continued

Options for treatment

Unna boot Duke boot Circ-Aid Multilayer compression bandage

Can get manufactured in a premade kit

Dressing and compression wraps (dependent on pt mobility/independence)

Venous Ulcers Continued

Options for maintenance

Compression garments
Ted hose are NOT compression garments 20-30mmHg (recommended for arms) 30-40mmHg (recommended for legs) 40-50mmHg (recommended for severe swelling in legs)

Compression pumps

Treatment Considerations

Other considerations
Dry stable eschar: leave intact Unstable necrotic tissue: aggressive debridement Granulating wound bed: appropriate moist wound healing Infected wound: silver products; cadexomer iodine; use precaution with occlusive dressings Adjunctive therapies: Regranex (spendy); anodyne

Questions?

Thank you!