Académique Documents
Professionnel Documents
Culture Documents
Clinical innovations
Addressing the vertical and horizontal
aspects of the wound
Hyperbaric oxygen therapy as adjunctive
treatment for diabetic foot ulcers
Advances in wound dressing technology
Clinical update
Ten top questions and answers on the use of
dressings for pressure ulcer prevention
Case report
Use of honey to treat a necrotic wound after
laryngectomy and neck radiotherapy
Technology update
Using telehealth and photography for wound
assessment in Western Australia
Wound digest
Contents DECEMBER 2013
T
he International Wound Care The varied programme delivered by both
Conference in Kuala Lumpur on 18–20 international and local speakers reflected
October was attended by more than these advances in wound care practice, while
800 delegates from Malaysia and the Asia emphasising the importance of collecting
Pacific region. The theme of the conference accurate data to ensure appropriate use
was ‘Global wound care made local‘, and of products. Over the 3 days, Wounds
throughout there was an emphasis on International, with the support of Professor
sharing experiences from different regions Keith Harding and Jacqui Fletcher (UK), The opening ceremony,
around the world. This was echoed by the delivered three plenary sessions on the International Wound Care
deputy director general from the Malaysian science of pressure ulceration, elevated Conference, Kuala Lumpur.
Ministry for Health, who opened the protease activity in wounds (supported by
conference with the launch of World Wound Systagenix) and wound infection, resistance
Week, an initiative of the Malaysian Society and the role of topical antimicrobials —
of Wound Care Professionals (MSWCP), World the latter delivered in association with the
Union of Wound Healing Societies, and the International Wound Infection Institute. In
Asian Academy of Wound Technology. addition to the morning presentations, there
The conference has been an important were a number of afternoon workshops
step in the development of wound care in and free paper sessions. These were all well
Malaysia. In the past year, all state hospitals attended and offered delegates a choice of Delegates attend a plenary session.
in the country have appointed wound care topics and a greater level of interaction.
teams as part of a government directive. This Wounds International is delighted to
has not only raised awareness of wounds, have had this opportunity to work with
but is also helping to standardise wound Dr Harikrishna Ragavan Nair, President of
care in Malaysia. However, these teams MSWCP, and his unstinting efforts to build
require leadership through education and an a collaborative wound care community for
understanding of the size of the problem to both doctors and nurses working in the Asia
ensure judicious use of money. Pacific region. Thank you to the speakers for
Of course, it is not just about the cost of providing such interesting sessions — it has
managing the patient, but the cost to the been a pleasure working with you. We would
patient, which Geoff Sussman (Australia) also like to thank all those who attended (L–R) Kathy Day, Rob Yates, Harikrish-
eloquently stated in his presentation on and for sharing the excitement about what na K.R. Nair, Jacqui Fletcher.
‘Advances in dressing technologies and the future holds for wound care in Malaysia
innovations’. Saving limbs and reducing the and the wider Asia Pacific region. Wounds
impact of living with a wound is important. International looks forward to continuing
Next-generation dressings need to be smart this important collaboration and supporting
— to address the cause, the needs of the clinicians in their day-to-day practice. n
patient and the wound.
It is an exciting time with new advances
in wound care, including stem cells, growth Kathy Day
factors and pharmacological interventions. Publisher, Wounds International
For Malaysia and some parts of the Asia
Pacific region, the process of registration is
fairly simple with early adoption of wound If you would like further information about the
care products. In Kuala Lumpur, this was resources available on Wounds International Professor Keith Harding delivers a
evident from the range and number of and how these can be used to support ongoing presentation.
companies exhibiting at the conference, education and best practice, please contact Kathy
with over 30 stands in the exhibition and Day, the Publisher of Wounds International, at:
hospitality areas. kathy.day@woundsgroup.com
I
nterest in wound care and the need for n Second, it created a political platform
expertise and specialist knowledge is to provide a greater emphasis on
In this guest editorial, growing in epic proportions worldwide. wound care, where governments,
Harikrishna K.R. Nair The interest in wound care in the Asia non-governmental organisations,
Pacific region can be seen by the increase the industry and the public are made
discusses the launch of the in wound healing societies, such as for aware of the need for a standardised
World Wound Care Week burns and diabetic limb problems. There and comprehensive care in managing
is a huge variety of advanced dressings, wounds.
from 11–18 October and innovations, technologies and clinical n Third, we were able to share our
the World Wound Care guidelines available, and there is continual knowledge with subspecialties and learn
potential for growth. With the increasing about new breakthroughs in wound
Day on 18 October, and prevalence of diabetes there is an increase management, such as growth factors,
the hope that this will in diabetic foot wounds, as a quarter of all stem cells, new advanced dressings,
people with diabetes develop diabetic foot new diagnostics in wound care and scar
encourage international complications[1]. Furthermore, the number management.
collaboration. of amputations has also increased, and the n Fourth, initiatives and plans will be set
International Working Group on the Diabetic in motion to make new products and
Foot has noted that every 20 seconds a limb innovations accessible, affordable and
is being amputated somewhere in the world available to all patients, and to meet the
as a result of diabetes[2]. objectives set out by the various wound
References This is the reason the Malaysian Society of care organisations attending.
1. Singh N, Armstrong DG, Lipsky Wound Care Professionals launched the World In addition, the International Wound
BA (2005) Preventing foot Wound Care Week from 11–18 October 2013 Conference 2013 was launched officially
ulcers in patients with diabetes. in Kuala Lumpur Hospital, Kuala Lumpur, on the 18 October, which was designated
JAMA 293: 217–28
Malaysia. It was a unique event, and there as the World Wound Care Day. Participants
2. Bakker K, Apelqvist J,
was an exhibition, industry booths and a included delegates and distributors from
Schaper NC on behalf of
the International Working special presentation of wound care kits 33 countries. The World Wound Care Week
Group on the Diabetic Foot equipped with advanced dressings to wound and Day were endorsed by the World Union
Editorial Board (2012) Practical care teams from various hospitals and of Wound Healing Societies, the Ministry of
guidelines on the management
health centres under the Ministry of Health, Health of Malaysia, the Academy of Wound
and prevention of the diabetic
foot 2011. Diabetes Metab Res Malaysia, in support of their contribution to Technology, the Asian Academy of Wound
Rev 28(Suppl 1): 225–31 wound management. Furthermore, various Technology and Wounds International.
programmes were organised, which included Incidentally, World Wound Care Day also
workshops, seminars, talks and surgical falls on St Jude’s Day; St Jude was a patron
sessions with consultants from various saint of physicians. Finally, we have a day
disciplines and from numerous countries, in the year that is designated for wound
including Japan, France, South Korea, USA, care, which can and will be celebrated
Australia and China. throughout the world by all wound care
This was a very significant event, with four professionals.
Harikrishna K.R. Nair is key themes emerging: The aim is that the initiative and the
Head, Wound Care Unit, n First, the week was accepted momentum put into place to support wound
and Hospital Wound Care internationally and endorsed by the World care will continue, and will spur greater
Coordinator, Kuala Lumpur Union of Wound Healing Societies. The collaboration and cooperation between
Hospital, and President, aim was to celebrate wound care in the the various specialists and the nations in
Malaysian Society of region and share new initiatives. Various achieving advanced and timely wound
Wound Care Professionals, programmes were organised to meet care for all who need it. It is hoped that the
Kualar Lumpur, Malaysia. this objective and bring people from a international community will embrace and
number of locations together who have a support the World Wound Care Week and the
common goal. World Wound Care Day. n
At Smith & Nephew our observational Find out how ALLEVYN Life can help
research revealed all the reasons why you bring your patients out of hiding
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Wound management
Wounds International's clinical innovations section presents recent developments in
wound care. This issue, we focus on innovations in wound management discussed
in presentations given at the recent Wounds International conference held in Kuala
Lumpur on 11–18 October 2013.
Addressing the vertical NPWT facilitates the drainage of excessive fluid and debris
negative pressure
Morykwas[2,3] suggested that –125 mmHg is the optimal
negative pressure to increase blood flow, and has now
growth factors
Various modes of NPWT have been introduced,
namely continuous and intermittent. A third option is
the cyclic mode, which operates its negative pressure
A
ny wound can be simplified in a style similar to a sine wave by oscillating between
into the vertical and horizontal the designated negative pressures (Curasys®, Curavac®;
aspects of defect[1]. The vertical Daewoong Pharmaceutical). Once it hits the upper target
wound depicts the defect from the skin pressure of –125 mmHg, the system shuts off and the
and down (dead space), whereas the pressure slowly drops until the lower target pressure is
horizontal wound depicts the actual reached, regardless of the time frame. As the change in the
skin loss. It is our goal to address these intralesional pressure is measured, the falling velocity of
two issues in order to achieve wound the pressure is closely associated with the defect volume
healing. in the cyclic mode. In other words, the larger the volume of
In cases with both a vertical and defect, the shorter the time taken for completing one cycle
Author: horizontal wound, it is preferable to of the system. Thus, the pressure movement is regulated
Joon Pio Hong reconstruct with a flap that provides by the preset pressures and the volume of defect, not
sufficient tissue to obliterate the dead by a specific time frame. It has the same efficacy as the
space, and at the same time a flap that has a skin paddle intermittent mode, but with reduced pain as the pressure
to cover the skin loss. A three-dimensional reconstruction is not dropped to 0 mmHg [Hong et al, in press].
can achieve positive results in complex wounds. However, Although there has been debate about the
in cases where microsurgery/flap surgery is not available, microvascular perfusion at the wound edge and wound
alternative options must be found. healing, it is generally believed that the improved
microvascular blood flow at the wound edge achievable
Negative pressure with NPWT has beneficial effects on wound healing[5].
wound therapy NPWT’s effect on increased tissue perfusion is thought to
Negative pressure wound therapy (NPWT) was introduced be beneficial, especially for treating ischaemic wounds.
in 1997 and its use has been extended to managing Therefore, when microsurgical reconstruction is not
many types of wounds, including diabetic foot ulcers, an option, NPWT is an efficient way to stimulate the
pressure ulcers, the open abdomen, chest wounds, skin production of granulation tissue to reduce wound depth.
grafts and traumatic lower extremity wounds[2,3,4]. It is now In patients presenting with loose skin margins, serial
considered to be one of the major advanced treatments sutures to pull the wound margins inward while applying
for difficult wounds. NPWT can be an effective method to reduce the wound
The mechanism of action of NPWT in wound healing width, as well as fill the vertical defect with granulation
is not fully understood, but numerous studies have tissue. NPWT is also useful in cases where amputation
attempted to show its effects in many scenarios. Broadly, stump sites are difficult to close or have dehisced after
6 Wounds
Wounds International Vol 2 | Issue 2 | ©Wounds International 2010 International Vol 4 | Issue 4 | ©Wounds International 2013 | www.woundsinternational.com
Clinical innovations Wound management
repair. Often, there is a small dead space where fluid of practice. EGF is also used in cases where NPWT has
collects and eventually drains through the repaired site. successfully achieved granulation but epithelialisation
NPWT can stimulate granulation to fill the dead space. (horizontal healing) becomes a priority.
During any application of NPWT, the end-point is when
granulation tissue has filled the vertical aspect of the Conclusions
wound or covered all pre-exposed vital structures in Wounds need to be addressed in both the vertical and
the wound. Once this has been achieved, the horizontal horizontal aspects. The vertical aspect depicts the dead
aspect should be treated. space underneath the skin, where the wound can affect
Once NPWT has been successfully administered, a flap muscles, tendon and bones. NPWT provides an efficient
or skin graft can be applied. In small or moderately sized way to enhance healing by increasing granulation,
wounds, secondary intention healing can be pursued. thus improving the vertical aspect of the wound. Once
In cases where secondary intention will take too long or granulation is reached at the skin level, the horizontal
in cases when a skin graft is not available, or to expedite aspect (epithelialisation) must be adressed. EGF can
healing for secondary intention or grafting, growth lead to rapid, effective skin closure by enhancing
factors can be considered to promote healing. keratinocyte activity. This combination can be used in
cases where the wound is of moderate size to avoid skin
Epidermal growth factor grafts and to achieve efficient healing. n
Epidermal growth factor (EGF) — which is produced by
platelets, macrophages and monocytes — interacts with AUTHOR details
EGF receptors on epidermal cells and fibroblasts[6]. EGF Joon Pio Hong is Professor of Plastic Surgery,
primarily acts to stimulate epithelial cell growth across Department of Plastic Surgery, Asan Medical Centre,
the wound, and also acts on fibroblasts and smooth University of Ulsan, Seoul, Korea.
muscle cells. A number of studies have demonstrated
the effects of EGF on wounds through the shortening References
of healing time, increasing the tensile strength of the
skin and reducing unfavourable tissue effects[7,8]. EGF is 1. Pappalardo J, Plemmons B, Armstrong DG (2013) Wound healing
simplification: a vertical and horizontal philosophy illustrated. J
also known to positively feedback to increase the EGF
Wound Technol 19: 38–9
receptors.
2. Argenta LC, Morykwas MJ (1997) Vacuum-assisted closure: a new
Debridement of necrotic tissue, infection control, method for wound control and treatment: clinical experience. Ann
maintaining a moist wound environment and providing Plast Surg 38: 563–76; discussion 577
abundant oxygenation to the tissue are all essential
3. Morykwas MJ, Argenta LC, Shelton-Brown EI et al (1997) Vacuum-
elements of wound care. However, despite these efforts, assisted closure: a new method for wound control and treatment:
chronic wounds may still be resistant to treatment. One animal studies and basic foundation. Ann Plast Surg 38: 553–62
reason for delayed healing in chronic wounds despite the
4. Morykwas MJ, Simpson J, Punger K et al (2006) Vacuum-assisted
implementation of good wound care practices may be closure: state of basic research and physiologic foundation. Plast
found in lack of growth factors[9]. Reconstr Surg 117: 121S–6S
The author studied this hypothesis in a crossover
5. Borgquist O, Ingemansson R, Malmsjö M (2010) Wound edge
study[10] (a longitudinal study where subjects received microvascular blood flow during negative-pressure wound therapy:
a sequence of different treatments), in which diabetic examining the effects of pressures from –10 to –175 mmHg. Plast
foot ulcers of >6 months’ duration were debrided and Reconstr Surg 125: 502–9
treated with hydrocolloids or composite dressings (i.e. 6. Nanney LB (1990) Epidermal and dermal effects of epidermal growth
foams, Versiva [ConvaTec] or Aquacel® foam [ConvaTec]), factor during wound repair. J Invest Dermatol 94(5): 624–9
depending on the condition of the wound. If treatment
7. Brown GL, Curtsinger L 3rd, Brightwell JR et al (1986) Enhancement
effect was minimal using advanced dressings for 3 weeks, of epidermal regeneration by biosynthetic epidermal growth factor. J
patients were switched to twice-daily treatment with Exp Med 163(5): 1319–24
0.005% EGF and advanced dressings. Among the patients, 8. Epstein JB, Gorsky M, Guglietta A, Le N, Sonis ST (2000) The
21 showed improvement using hydrocolloid or composite correlation between epidermal growth factor levels in saliva and the
dressing alone, and 68 were crossed over to treatment severity of oral mucositis during oropharyngeal radiation therapy.
with EGF and advanced dressing. Among the EGF-treated Cancer 89(11): 2258–65
patients, complete healing was noted in 52 patients 9. Gary Sibbald R, Woo KY (2008) The biology of chronic foot ulcers in
within an average of 46 days (range, 2–14 weeks). persons with diabetes. Diabetes Metab Res Rev (Suppl 1): S25–30
The approach to wait for good standard of care to take 10. Hong JP, Jung HD, Kim YW (2006) Recombinant human epidermal
effect and use EGF only in cases where wound healing growth factor (rh-EGF) to enhance healing for diabetic foot ulcers.
is delayed over several weeks has become the standard Ann Plast Surg 56: 394–8
Hyperbaric oxygen after 4 weeks of HBOT. For grade 4 ulcers, improvement was
considered to be the separation of gangrene from the ulcer
therapy as adjunctive below with the presence of granulation tissue. If extirpation
was above the ankle, it was categorised as major amputation.
treatment for diabetic RESULTS
foot ulcers The recommended minimum number of HBOT session for
people with diabetes and foot ulceration is 30[6]; the minimum
number of hyperbaric treatments included in this study was
T
Authors: he gold standard for diabetic five sessions, and the maximum number of treatments was 30
Luinio Tongson, foot ulcer treatment includes (giving an average of 13 treatments). Thirteen patients were
Danielle L. Habawel, debridement of devitalised wound excluded from the study because they received less than
Rachelle Evangelista, tissue, management of any infection, five sessions of HBOT. Of the remaining 41 individuals, 24
John Lerry Tan revascularisation procedures when were male and 17 female, with an age range of 39–97 years
indicated and offloading of the ulcer. (average age, 65 years).
Hyperbaric oxygen therapy (HBOT) has been promoted as an A total of 88% (36/41) of the participants showed an
effective adjunctive treatment for diabetic foot wounds[1]. The improvement in their condition, while 12% underwent major
effects of HBOT on improving wound tissue hypoxia make amputation. Of those 36 patients whose condition improved
it a useful adjunct in clinical practice for diabetic foot ulcers. with HBOT, 86% (31/36) had complete healing of their
It may reduce the risk of lower-extremity amputation and diabetic foot ulcer and 14% had partial healing, where there
improve healing in people with diabetes with foot ulcers[1]. was granulation tissue in the wound bed but the wound had
Diabetic foot ulcers are one of the most significant and not fully epithelialised by study end. Figures 1–2 show two
devastating complications of diabetes. The prevalence of examples of diabetic foot ulcer healing after receiving HBOT.
foot ulceration in the diabetic population is 4–10%[2]. It is Table 1 shows outcomes in relation to the number of HBOT
estimated that about 5% of all people with diabetes present sessions. Of those patients who had 5–10 sessions of HBOT,
with a history of foot ulceration, and the lifetime risk of these 85% (12/14) with a Wagner grade 3 ulcer and 80% (8/10) with
people developing this complication is 15%[2,3,4]. In the study a Wagner grade 4 ulcer showed wound improvement and did
by Moxey et al, 70% of all non-traumatic amputations of the not require a major amputation; thus, the amputation rate
lower limbs occurred in patients with diabetes[5]. was 15% (2/14) in those with a Wagner grade 3 ulcer and 20%
The aim of the authors’ study was to evaluate the effects (2/10) in those with a Wagner grade 4 ulcer.
of systemic HBOT on the healing course of diabetic foot In those patients who received 10–20 sessions of HBOT,
wounds and the amputation rate relating to foot ulcers in there was an improvement in 85% (6/7) and 100% (4/4) in
people with diabetes. patients with Wagner grade 3 and 4 ulcers, respectively. There
was a 15% (1/7) amputation rate among those with a Wagner
METHODs grade 3 ulcer. After 21–30 sessions of HBOT there was a 100%
Between March 2012 and July 2013, 54 diabetic foot patients improvement of both Wagner grade 3 (1/1) and 4 (5/5) ulcers.
with either Wagner grade 3 or 4 wounds who underwent
HBOT at the Dr James G. Dy Wound Healing and Diabetic DISCUSSION
Foot Centre, Chinese General Hospital and Medical Centre, The amputation rate for people with diabetes and
Manila, Philippines, were included in the study. The protocol foot ulcers is 15–70 times higher than of the general
for the diabetic foot wounds was HBOT at 2.5 absolute population[7]. Ischaemia, infection and retarded wound
atmospheres, administered once a day, 5 days a week, with healing are the most common causes of amputation.
each session lasting 90 minutes. Alongside HBOT, standard Wound healing is oxygen dependent and is limited by its
care included debridement, modern moist dressings and availability at the cellular level. Elevated tension of oxygen
negative pressure therapy if indicated, as well as metabolic in plasma causes upregulation of growth factors, down-
and nutritional management. regulation of inflammatory cytokines, increased fibroblast
The study end point was ulcer healing and determining activation, angiogenesis, antibacterial effects and enhanced
the amputation rate of those patients who underwent HBOT. antibiotic action[7,8,9].
A Wagner grade 3 ulcer was considered healed when it was Treatment with HBOT involves the intermittent
completely epithelialised and remained so until the next visit administration of 100% oxygen at a pressure greater than
in the study. Wagner grade 4 ulcers were considered healed that at sea level. It is performed in a chamber with the
when the gangrene had separated and the ulcer below was patient breathing 100% oxygen while the atmospheric
completely epithelialised. An improved grade 3 wound was pressure is increased to 2–3 absolute atmospheres. This
defined in this study as the presence of granulation tissue results in an increase in the concentration of oxygen in
8 Wounds
Wounds International Vol 2 | Issue 2 | ©Wounds International 2010 International Vol 4 | Issue 4 | ©Wounds International 2013 | www.woundsinternational.com
Clinical innovations Wound management
Figure 1a. Diabetic foot ulcer (Wagner grade 3), which had Figure 1b. Surgical debridement was performed and the
been a non-healing wound for 2.5 months. There was a dressing changed daily; a broad-spectrum antibiotic was
black, hard covering on the wound site with foul, purulent given, and granulation was noted after five sessions of
discharge oozing from the wound. hyperbaric oxygen therapy (HBOT).
Figure 1c. Two weeks after 10 sessions of HBOT, with Figure 1d. Improved wound post-skin graft after
autolytic debridement and daily dressing changes, 2.5 months of treatment and adjunctive therapy.
granulation and epithelialisation were observed.
Figure 2a. A diabetic foot ulcer (Wagner grade 4), which had
not healed for 3 months; necrosis and slough were noted. Figure 2b. Transmetatarsal amputation was performed,
and granulation was observed after five sessions of HBOT.
Table 1. Number of hyperbaric oxygen therapy sessions and their effect on the healing of
diabetic foot ulcers
the blood and an increase in the diffusion capacity to amputation in 61% of patients who received conventional
the tissues. The partial pressure of oxygen in the tissues therapy alone.
is increased, which stimulates neovascularisation and Chen et al[17] found that HBOT significantly improves
fibroblast replication and increases phagocytosis and healing of diabetic foot ulcers in a dose-dependent manner.
leukocyte-mediated killing of pathogens in the wound. They compared the efficacy of <10 HBOT sessions with
There is strong evidence that fibroblasts, endothelial cells >10 HBOT sessions for the treatment of diabetic foot ulcers.
and keratinocytes replicate at higher rates in an oxygen-rich The investigators found that in the group that had <10
environment[10]. Based on these data, the concept is that HBOT sessions, limbs were preserved from amputation
the administration of oxygen at high concentrations and in 33.3% of the group; in those patients who had >10
pressures might accelerate wound healing in diabetes. HBOT sessions (mean, 22.8 sessions), 78.3% had their
The Undersea and Hyperbaric Medical Society’s feet preserved from amputation. In the present study,
indications for the use of hyperbaric oxygen in wound the likelihood of wound healing and limb preservation
care includes the treatment of Clostridial myositis and increased with the number of HBOT sessions received.
myonecrosis (gas gangrene), crush injury, compartment HBOT is recommended in Wagner 3 or higher diabetic
syndrome and other acute traumatic ischaemias, arterial foot wounds and is initiated at the authors' institution
insufficiencies, enhancement of healing in selected when 1 month of standard therapy fails to achieve results.
problem wounds, soft tissue infections, refractory The authors found no data on the effect on healing and
osteomyelitis, delayed radiation injury, compromised amputation in patients with earlier treatment of HBOT.
grafts, and flap and acute thermal burn injury[11]. Additional HBOT may be unnecessary for the great majority of patients
indications recommended by the 2004 European Consensus who respond to appropriate standard wound care; however,
Conference on Hyperbaric Medicine[12] are surgery and for those patients at risk of amputation, their wound needs
implant in irradiated tissue, post-vascular procedure to be healed promptly with available adjunct therapies,
reperfusion syndrome and limb replantation. In the USA, such as HBOT.
the new Medicare- and Medicaid-approved indication is
diabetic wounds of the lower extremity with the following CONCLUSION
criteria: patients with type 1 or type 2 diabetes with a lower Treatment of diabetic foot wounds with an aggressive,
extremity wound as a result of diabetes; wounds that are multidisciplinary therapeutic protocol in conjunction with
Wagner grade 3 or higher; and patients that have failed a HBOT is effective in decreasing major amputations. It seems
30-day course of standard, conventional wound therapy[13]. that HBOT improves healing of diabetic foot ulcers in a dose-
Meanwhile, the Wound Healing Society has given HBOT a dependent manner. The preliminary results are promising,
level I evidence rating in their Guidelines For The Best Care Of but large randomised controlled trials are necessary to
Chronic Wounds[14]. establish the efficacy of HBOT in the treatment of diabetic
In the study by Faglia et al[15], HBOT was associated with foot ulcers. n
a reduction in amputation rates among patients who were
at risk of below-knee or above-knee amputation because AUTHORs’ details
of severe ischaemia, underlying osteomyelitis, or both. Luinio Tongson is Head, Dr James G. Dy Wound Healing and
In the analysis of Heyneman and Lawless-Liday[16] on the Diabetic Foot Centre, General Surgeon and Wound Care
different clinical trials assessing the usefulness of HBOT Specialist, Danielle L. Habawel, Rachelle Evangelista and
for the treatment of diabetic foot ulcers, amputation was John Lerry Tan are HBOT and Wound Care Nurses, Dr James
prevented in 82–95% of patients. HBOT resulted in a mean G. Dy Wound Healing and Diabetic Foot Centre, Chinese
limb salvage rate of 89%, compared with prevention of General Hospital and Medical Centre, Manila, Philippines.
10 Wounds
Wounds International Vol 2 | Issue 2 | ©Wounds International 2010 International Vol 4 | Issue 4 | ©Wounds International 2013 | www.woundsinternational.com
Do you need to demonstrate
that a wound care intervention
offers value for money?
A new international
consensus can help
Understand what is meant
by ‘cost-effective wound
management’
Appreciate the different
types of economic analysis
used in healthcare
Interpret information
on cost and cost-effective-
ness of wound care
modalities and protocols
Set up systems to collect
the data for analysis
Make an appropriate case
for cost-effective wound
management
12 Wounds
Wounds International Vol 2 | Issue 2 | ©Wounds International 2010 International Vol 4 | Issue 4 | ©Wounds International 2013 | www.woundsinternational.com
*
1-2
42%
(n=15/36)
&
View references
News
Clinical Wounds
Clinical
Clinical
Clinical updateupdate
innovations
innovations
innovations
is absorbed into the wound and does not need to be innovative developments
removed at dressing change[6,8]. These are some examples of innovative developments for
The matrix is also available as a hydrogel (Keragel™; advanced wound management. These interventions offer
Keraplast Technologies LLC), which is designed for promising additions and new possibilities, and suggest
use in chronic dry wounds, acute wounds and for the that the future is bright for improved wound healing as we
treatment of certain skin conditions, such as epidermolysis uncover the mystery of tissue repair and develop new ways
bullosa[10–12]. Keragel provides moisture to a dry wound of restoring tissue balance. n
as well as a keratin-rich environment to encourage cell
growth, leading to excellent healing outcomes[13]. The AUTHOR details
author has used both forms of the keratin matrix with good Geoff Sussman is Associate Professor, Faculty of Medical
results at the Wound Clinic, Austin Hospital, Heidelberg, and Health Science, University of Auckland, Auckland,
Australia. New Zealand and Faculty of Medicine, Monash University,
Melbourne, Victoria, Australia.
Pharmacological therapies
The adjunctive use of pharmacology also has benefits References
in wound management, with some interesting agents
1. Queen D et al (2004) Int Wound J 1(1): 59–77
being used including angiotensin-converting enzyme
2. Expert Working Group, Wounds International (2011) International
(ACE) inhibitors, monoclonal antibodies, topical
consensus. The role of proteases in wound diagnostics. Available at:
immunosuppressants and xanthine oxidase inhibitors. http://bit.ly/1bcAhdK (accessed 03.12.2013)
An example was presented at the European Cardiology
3. Dissemond J et al (2013) EPA made easy. Available at: http://bit.
conference held in Munich, August 2013, by Ahimastos ly/1d1VaqZ (accessed 05.12.2013)
et al[14], whose randomised controlled trial demonstrated
4. Vu T et al (2007) Fam Practice 24(4): 372–9
that ACE inhibition improved walking ability and quality
of life in patients with peripheral arterial disease; an 5. Expert Working Group, Wounds International (2013) International
consensus. Making the case for cost-effective wound management.
improvement that impacts on wound healing and is Available at: http://bit.ly/1k6g7Dg (accessed 03.12.13)
substantially beyond that reported with conventional
6. Pechter PM et al (2012) Wound Rep Reg 20: 236–42
medical therapies.
Biologics, including monoclonal antibodies and in 7. Davis S et al (2009) J Am Acad Dermatol 60(3, Suppl 1): AB201
particular tumour necrosis factor alpha-antagonists, 8. Tang L et al (2012) Exp Dermatol 21(6): 458–60
are now being extensively evaluated in the setting of 9. Perez R et al (2009) Evaluation of the effects of two keratin
chronic wound healing. Preliminary studies and case formulations on wound healing and keratin gene expression in a
reports provide evidence of the clinical potential of these porcine model. Presented at the Symposium on Advanced Wound
Care Conference, 26–29 April, Dallas, TX
compounds in treating Pyoderma gangrenosum[15,16].
The author’s facility has used calcineurin inhibitors such 10. Kirsner R (2009) J Am Acad Dermatol 60(3, Suppl 1): AB202
as tacrolimus successfully for the induction or maintenance 11. Arbuckle A (200) A case study series of the management of
of remission in immune and inflammatory disorders, such Epidermolysis bullosa using Keragel T. Society of Paediatric
as Pyoderma gangrenosum, necrobiotic xanthogranuloma Dermatology, Portland, OR, USA
and vasculitic wounds[17–19]; it is applied topically as a 0.1% 12. Balance K et al (2008) Improved healing of a diabetic foot ulcer using
ointment. Topical tacrolimus does not negatively impact new keratin dressing technology. Australian Wound Management
Association Conference Proceedings, 7–10 May, Darwin, NT
acute cutaneous wound healing[20].
Tacrolimus promotes melanocyte and melanoblast 13. Hammond C et al (2010) Wound Pract Res 18(4): 189–95
growth and creates a favourable milieu for cell migration 14. Ahimastos AA et al (2013) JAMA 309(5): 453–60
via keratinocytes, which are possible mechanisms of how 15. Fonder MA et al (2006) J Burns Wounds Nov 20; 5:e8. Available at:
tacrolimus ointment induces repigmentation in patients http://1.usa.gov/1aPcoVw
with vitiligo[21]. 16. Juillerat P et al (2007) Dermatology 215: 245–51
Tacrolimus forms complexes with cytoplasmic
17. Altieri M et al (2010) Ostomy Wound Management 56(9): 32–6
immunophilins, which block the action of calcineurin
in activated T-cells. This prevents the production of 18. Tzellos TG, Kouvelas D (2008) Eur J Clin Pharmacol 64: 337–41
interleukin-2 and other cytokines, which normally 19. Khurrum Baig M et al (2004) Colorect Dis 6: 250–3
stimulate T-cell proliferation and differentiation. Tacrolimus 20. Namkoong S et al (2013) Exp Dermatol 22(5): 369–71
is used for the prevention of solid organ transplant
21. Lan CC et al (2005) Br J Dermatol 153(3): 498–505
rejection and the prevention and treatment of graft-versus-
host disease in stem cell transplants[22,23]. It is normally 22. Dayton JD et al (2011) J Heart Lung Transplant 30(4): 420–5
administered intravenously or orally. 23. Watkins KD et al (2012) J Heart Lung Transplant 31(2): 127–31
14 Wounds
Wounds International Vol 2 | Issue 2 | ©Wounds International 2010 International Vol 4 | Issue 4 | ©Wounds International 2013 | www.woundsinternational.com
International best practice
for DFU wound management
Implementing a
global wound care
plan for DFUs
� Effective debridement
and wound cleansing
� Appropriate dressing
selection
� Importance of an
integrated approach
Review group:
Jan Apelqvist, Sweden; Mariam Botros, Canada; Giacomo Clerici,Italy; Jill Cundell, Northern
Ireland; Solange Ehrler, France; Michael Hummel, Germany; Benjamin A Lipsky, USA;
José Luis Lázaro Martinez, Spain; Rosalyn Thomas, Wales; Susan Tulley, United Arab Emirates
How to...
Ten top questions and answers
Author:
C. Tod Brindle
on the use of dressings for pressure
ulcer prevention
P
ressure ulcer (PU) prevention remains a a change in patient status will prevent PU
struggle for clinicians around the globe development. However, PUs continue to
and across all transitions of care. In most plague patients and the clinicians that care for
situations, the use of evidence-based practice them globally, and experts agree that not all
and established PU prevention guidelines PUs are avoidable[4,5].
provide the necessary interventions to protect In high-risk patients, implementing
patients from these devastating injuries. standards of practice may either not be
However, these same standards of practice possible or not sufficient to adequately
are not always enough for high-risk patients, protect the patient. For example, how
leaving clinicians to investigate adjunctive do the standard recommendations for
therapies to add to their PU prevention turning patients at least every 2 or 4 hours
protocols. The recent rise in evidence depending upon the surface used[6] apply
supporting the use of prophylactic dressings to the patient who is undergoing a long
for PU prevention has been supported by operating theatre procedure without the
two randomised controlled trials (RCTs) possibility of repositioning, or to the severely
demonstrating efficacy of a particular dressing haemodynamically unstable patient who does
in preventing PUs[1,2]. This article serves as a not tolerate turning despite techniques to
brief recap of the use of these dressings for PU turn the sickest individuals[7]? Moreover, what
prevention by answering the top ten questions of the patient in severe respiratory distress
regarding the evidence and their use. who requires head-of-bed elevation close
to 45 degrees, and therefore is unable to be
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Wounds International Vol 2 | Issue 2 | ©Wounds International 2010 International Vol 4 | Issue 4 | ©Wounds International 2013 | www.woundsinternational.com
Clinical Update Ten top questions and answers
(n=219) differed only in the application of a wound care dressing has the capability of truly
prophylactic sacral dressing (Mepilex® Border protecting the tissue from the forces of pressure,
Sacrum; Mölnlycke Health Care) and heel shear, friction and microclimate. Researchers
dressings (Mepilex® Heel; Mölnlycke Health showed in-vitro evidence that the physical
Care). The patients were assessed and randomly deformation of tissue secondary to the forces
assigned in the ED; this occurred specifically applied during a loading event were likely
because of emerging evidence that suggests more damaging than the resulting ischaemia or
the triage time carries a high prevalence and hypoxia that occurred[14]. Therefore, if repetitive
incidence of PU development[12,13]. insults to the tissues could be potentially
After 1 year, the researchers reported less avoided by diverting the forces applied to the
PUs in both the sacral and heel regions for the tissues away from the bony prominence or
intervention group when using dressings as through dissipation of the intensity, the skin
an adjunct to prevention (sacral — two PUs in may be protected from injury.
the dressing group versus eight in the standard Nakagami et al[15,16] looked at this possibility
of care group, P=0.05; heel — five PUs in the when they compared the use of a transparent
dressing group versus 19 in the standard of film versus a hydrocolloid-ceramide wound
care group, P=0.002). The use of dressings dressing to decrease PUs on the heel. The
resulted in a 10% reduction in incidence for the authors concluded that while they showed
intervention group with a hazard ratio of 0.19 the dressings did in fact reduce shear and
(P=0.002), indicating that the application of a friction, the dressings did not have an impact on
dressing to high-risk patients in the ED/ICU was pressure, and therefore could not substitute for
superior to standard PU practices alone. heel floating. In this case it could be suggested
A second study by Kalowes[2] evaluated that the physical properties of the dressings
whether the use of a sacral soft silicone foam allowed for mitigation of two forces, but did not
dressing (Meplex Border Sacrum, Mölnlycke encompass pressure or microclimate.
Health Care) would significantly lower PU Further studies looking at the role of foam
incidence. In this prospective, experimental dressing in decreasing pressure in patients with
study, 367 medical-surgical/surgical trauma diabetic foot ulcers during walking provide
and cardiac care ICU patients were randomised more insight[17,18,19]. Four commercially available
into: a control group (n=184) receiving a dressings were tested and all showed minor
standard care intervention bundle, including reductions in impact pressures. The studies
a pressure redistribution surface, turning indicated that each dressing performed
protocol, incontinence prevention and nutrition differently and some dressings were less efficient
management; and an intervention group (n=183) when wet. A dressing will never be capable of
receiving the same standard of care interventions, reducing pressure to the level of redistribution
but with the addition of the sacral dressing. found in a specialist mattress; but in order for a
Over the 11-month study, seven PUs dressing to be an additional preventive measure,
(unstageable, deep tissue injury and stage II) the dressing construction must be capable
developed in the control group (4.21%) versus of mitigating and redistributing load as this
one PU (deep tissue injury) in the intervention subsequently impacts shear.
group (0.6%); these results were found to be As a result of the success of using the five-
statistically significant (P=0.001). The researchers layer silicone sacral dressing, as reported by
subsequently implemented the use of a Santamaria et al[1] and Kalowes[2], in-vitro studies
prophylactic sacral dressing to their standard of were completed to assess how the dressing’s
care bundle for high-risk ICU patients. construction provided benefit, and importantly
how similar dressings compared based upon microclimate on the sacrum, these forces are
“Intensive care their unique construction. Call et al[20] describe dramatically less under medical devices such as
patients have long an in-vitro comparison of nine competitor sacral tracheostomies or noninvasive positive-pressure
been identified dressings currently on the market. They assessed ventilation (NIPPV) masks.
how well the dressings reduced the coefficient of Medical device-related PU prevention is
for their increased
friction, reduced shear transmission through the primarily rooted in skin assessment under the
risk of pressure
dressing to the skin surface, and how much load device, proper fitting and routine repositioning
ulcer development could be deflected over the area of the dressing. of the device. Fletcher[24] outlines new
secondary to the In these studies, they determined that dressing techniques to help reduce or prevent skin
underlying comorbid materials and structure changed the impact of damage beneath medical devices. Additionally,
conditions, decrease shear and loading forces, and that dependent on device manufacturers are often unaware of
in tissue tolerance structure and function the dressings may or may the potential harm caused by their products,
and the therapeutic not be well suited for prevention. making clinician reporting of these events back
interventions used by Further, the management or maintenance of to the manufacturers vital.
clinical staff.” an appropriate microclimate (relative heat and
humidity) is an important measure to assess.
Especially in critically ill patients and those
with obesity, cardiac conditions or on certain
5
ICU
Who is at risk and when should dressings be
considered as part of the prevention strategy?
medications, perspiration and insensible fluid Intensive care patients have long been
loss is a known contributor to altered skin identified for their increased risk of PU
integrity via the impact of moisture-associated development secondary to the underlying
skin damage[21]. Thus if a dressing is to be used comorbid conditions, decrease in tissue
for prevention, it must be known how the tolerance and the therapeutic interventions
dressing manages moisture vapour transmission used by clinical staff[25–27]. In the author’s facility,
and responds to heat retention. after using sacral silicone foam dressings for
Call et al[22] evaluated eight commercially over 5 years and seeing the profound reduction
available sacral dressings and looked at the in PUs, the decision was made by the critical
amount of moisture held under the dressing, the care nursing council to begin applying the sacral
amount that was capable to be transmitted out dressing to all admitted, non-ambulatory adult
of the dressing and the amount of heat that was ICU patients. This decision came in part because
trapped at the skin surface. Clinicians should of the high acuity of the patients in an academic
question the evidence of the chosen dressing’s trauma centre, and because of the complexity
performance in these areas before using as an of PU aetiology, where tissue insult may far
additional intervention for PU prevention. precede cutaneous manifestation.
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Wounds International Vol 2 | Issue 2 | ©Wounds International 2010 International Vol 4 | Issue 4 | ©Wounds International 2013 | www.woundsinternational.com
Clinical Update Ten top questions and answers
the sacral dressing and the same dressing in more adept at load deflection over their increased
different shapes on non-traditional sites during surface area. The dressing needs to be larger than “The most difficult
operative procedures. In prone neurosurgical the bony prominence it means to protect. aspect of using a soft
patients they evaluated the preprocedural silicone foam dressing
application of sacral soft silicone foam dressings
to 104 patients and compared their outcomes
with 114 standard of care patients undergoing
7 Application and assessment: how do we implement?
The most difficult aspect of using a soft
silicone foam dressing to protect the sacrum
to protect the sacrum is
the proper application
the same surgery. They reported no PUs is the proper application of the dressing to
of the dressing to
developing in the preprocedural dressing group, the body, as well as the technique used for the body …”
while 12/114 developed pressure injuries in the skin assessment. In the author’s setting the
standard of care group. Mepilex Border sacrum dressing is used, and
the following advice relates to this product. The
Emergency department (ED) challenge for successful product application
The ED is an often overlooked area of hospital stems from the anatomical variability of each
PU prevention measures, simply because of patient and the need to place the dressing so
the complexity of providing consistent care, that it is fully protecting the bony prominence.
available equipment and merging prevention For incontinent patients, proper application
with initial triage assessment and stabilisation. is key to prevent undermining. The dressing
Naccarrato and Kelechi[32] describe this dilemma is occlusive and therefore, when applied
well, and provide insight via a literature appropriately, urine and stool can be wiped
review and recommendations for developing off of the top of the dressing without resulting
emergency nurse PU prevention guidelines. strike through. Clinicians should be careful not
The use of dressings may be beneficial for to position the dressing too close to the anus
prevention in high-risk patients who are waiting and ensure the distal pole of the dressing is well
to be admitted via the ED and have known sealed to the skin during application to further
risk factors impacting tissue tolerance, such as prevent undermining.
patients with spinal cord injury or those patients The clinician should remember that the
who may be transported directly to the operating primary area of protection is the sacrum, and this
theatre from the ED. Cubit and colleagues[33] should be the first focus of dressing application;
evaluated the application of Mepilex Border in some patients, a prominent coccyx or the
Sacrum to men and women >65 years who had a proximal portion of the gluteal cleft may also be
Waterlow Scale Risk Assessment score indicating protected from intertriginous injury. The dressing
a high risk or very high risk for pressure injury orientation should also be considered when
in an Australian ED. Subsequently, the authors evaluating the width of the surrounding bordered
reported that patients who were not allocated edge of the dressing. If during application it is
a dressing during their ED stay were 5.4 times noted that the bordered edge alone is covering
more likely to develop PUs than those who had a portion of the bony prominence, the dressing
the dressing applied as part of their prevention may be flipped upside down, as the more narrow
protocol. They concluded that the application of edge of the proximal portion of the dressing may
a dressing in the ED seemed to be beneficial for allow for more coverage.
elderly and ‘at-risk’ patients. When applying the dressing, it is easiest
In the author’s facility, patients entering the to remove the centre backing layer, fold the
trauma bay have a dressing applied to their dressing in half and focus on the application of
sacrum during primary assessment, as many the distal pole of the dressing to the area around
of these patients inevitably are sent to the the sacrococcyxgeal junction; this is the area
operating theatre or the ICU directly. The risk of dressing application that is of the greatest
of PU development in the ED and the benefit importance to maintain a proper seal. The skin
of prophylactic dressing use was additionally should be clean and dry and free from skin
highlighted in the RCT by Santamaria et creams and barriers, as their use will interfere
al[1], as all patients were randomised and the with the dressing’s adhesive technology and
intervention dressings applied in the ED. negate the preventive benefit. Thus clinicians
are encouraged to cleanse and dry the skin
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Clinical Update Ten top questions and answers
References dressings for reducing shear force on the heel. J 31. Castelino ID, Mercer DM, Calland
Wound Ostomy Continence Nurs 33(3): 267–72
JF (2012) Reducing Perioperative
1. Santamaria N, Gertz M, Sage S et al (2013) A
17. Chokalingam N, Ashford R (2004) A pilot study of the pressure ulcers in thoracic,
randomised controlled trial of the effectiveness of soft
silicone foam multi-layer dressings in the prevention of reaction forces at the heel during walking with the cardiovascular and spinal
sacral and heel PUs in trauma and critically ill patients. application of four different wound dressings. J Tissue surgery patients: achieving ZERO
Int Wound J doi: 10.1111/iwj.12101. Available at: Viability 14(2): 63–6 incidence is possible! Available at
http://1.usa.gov/19bN2F6 (accessed 9.12.12) http://bit.ly/1ewRNtP (accessed
18. Ashford RL, Feear ND, Shippe JM (2001) An in-vitro
study of the pressure-relieving properties of four 26.11.13)
2. Kalowes P (2013) Impact of 5-layered bordered
foam dressing on ICU patients’ sacral pressure ulcer wound dressings for foot ulcers. J Wound Care 10(2): 32. Naccarato Mk, Kelechi T (2011)
incidence. Am J Crit Care ( in press) 34–8 Pressure ulcer prevention in the
3. European Pressure Ulcer Advisory Panel and National 19. Chokalingam N, Ashford RL, Dunning D (2001) The emergency department. Adv
Pressure Ulcer Advisory Panel (2009) Prevention and influence of four wound dressings on the kinetics of Emerg Nurs J 33(2): 155–62
Treatment of Pressure Ulcers. NUAP, Washington DC human walking. J Wound Care 10(9): 371–4
33. Cubit K, Mcnally B, Lopez V
4. Black JM, Edsberg LE, Baharestani MM et al; National 20. Call E, Pedersen J, Bill B et al (2013) Enhancing pressure (2012) Taking the pressure off
Pressure Ulcer Advisory Panel (2011) Pressure ulcers: ulcer prevention using wound dressing: what are the in the emergency department:
avoidable or unavoidable? Results of the National modes of action? Int Wound J doi: 10111/iwj.12123 evaluation of the prophylactic
Pressure Ulcer Advisory Panel Consensus Conference. application of a low shear, soft
Ostomy Wound Manage 57(2): 24–37 21. Gray M, Black J, Baharestani M et al (2011)
silicon sacral dressing on high-risk
Moisture-associated skin damage: overview and
5. Wound Ostomy Continence Nurses Society (2009) pathophysiology. J Wound Ostomy Continence Nurs medical patients. Int Wound J 10(5):
Position statement on avoidable versus unavoidable 38(3): 233–41 579–84
PUs. J Wound Ostomy Continence Nurs 36 (4): 378–81
22. Call E, Pedersen J, Bill B, Oberg C, Ferguson-Pell M 34. Brindle CT, Santamaria N (2013)
6. Defloor T, Grypdonck M, De Bacquer D (2005) The Dressings for pressure ulcer
(2013) Microclimate impact of prophylactic dressings
effect of various combinations of turning and pressure prevention: implementation into
using in-vitro body analog method. Wounds 25(4):
reducing devices on the incidence of PUs. Int J Nurs clinical practice. Ostomy Wound
94–103
Stud 42(1): 37–46
Management (in press)
23. Black J, Alves P, Brindle CT et al (2013) Use of wound
7. Brindle CT, Malhotra R, O’Rourke S et al (2013)
dressings to enhance prevention of PUs caused by 35. Santamaria N, Liu W, Gerdtz M et
Turning and repositioning the critically ill patient
medical devices. Int Wound Journal doi:10.1111/ al (2013) The cost benefit of using
with haemodynamic instability: a literature review
iwj.12111. Available at: http://1.usa.gov/IfAsdj soft silicone multilayered foam
and consensus recommendations. J Wound Ostomy
(accessed 26.11.13) dressing to prevent sacral and
Continence Nurs 40(3): 254–67
24. Fletcher J (2012) Device-related pressure ulcers made heel pressure ulcers in trauma and
8. Brindle CT (2009) Outliers to the Braden Scale:
easy. Wounds UK 8(2). Available at: www.wounds-uk. critically ill patients: a within-trial
identifying high-risk ICU patients and the results of
com/pdf/content_10472.pdf analysis of the Border Trial. Int
prophylactic dressing use. WCET J 30(1): 11–18
Wound J doi:10.1111/iwj.12160.
9. Brindle CT, Wegelin J (2012) Prophylactic dressing 25. Nijs N, Toppets A, Defloor T, Bernaerts K, Milisen K, van Available at: http://bit.ly/1cvWGTI
application to reduce pressure ulcer formation in den Berghe G (2008) Incidence and risk factors for PUs
(accessed 9.12.12)
cardiac surgery patients. J Wound Ostomy Continence in the intensive care unit. J Clin Nurs 18: 1258–66
Nurs 39(2): 133–42
O
tolaryngologists from the Portuguese This patient was diagnosed with a laryngeal
Oncology Institute perform an tumour (T2N0M0). As he represented a serious
average of 100 laryngectomies per surgical risk, he was treated with radiotherapy
year in the treatment of laryngeal cancer. in November 2010. Failure of the primary
Common challenges faced include haematoma treatment led to laryngectomy and bilateral
formation, wound infection, wound dehiscence selective neck dissection in June 2011.
and pharyngocutaneuous fistula. Persistent Ten days later, extensive supra-tracheostomy
non-healing wound dehiscence is relatively necrosis developed. This is common in
Pedro Ângelo frequent despite antibiotic coverage and patients with head and neck cancer because
local wound care, because of the underlying of the aforementioned ‘bad condition of the
bad condition of the skin and the severe skin’. The risk increases in patients submitted
comorbidities of the patients. The skin of the to radiotherapy before surgery, since
neck is usually in a bad condition because radiotherapy itself can cause severe lesions to
patients requiring a laryngectomy frequently the skin. Mechanical debridement and daily
have a poor nutritional status and are silver dressings (Atrauman®, Hartmann) were
immunocompromised (because of the cancer). performed. One week after this, no significant
Ligia Ferreira Additionally, a significant number of them are improvement had occurred.
submitted to local radiotherapy before surgery.
The management of such situations is Method
difficult, expensive and both time- and resource- After receiving the patient’s consent, the
consuming, often involving repairing surgical authors introduced a honey-based ointment
Sonia Pereira is Otolaryngology flap coverage, which is not always successful. (L-Mesitran®; Triticum) on 11 July 2011. The
resident of the CHLC — More effective treatments are needed for these surgical wound was cleaned with saline, and
Hospital de São José, Lisbon, patients, which accelerate healing and diminish L-Mesitran was applied daily in a thin layer,
Portugal, and a Navy physician wound infection in a quicker manner than then covered with an absorbent hydrofiber
working with hyperbaric current local and surgical treatments. dressing (Aquacel®; Convatec). The surrounding
oxygen at Centro de Medicina skin was treated with a hypoallergenic, semi-
Subaquática e Hiperbárica, Case Report permeable barrier cream (Cavilon®; 3M) to
Lisbon; Pedro Ângelo is A 64-year-old man presented with progressive, avoid friction and the development of lesions
Otolaryngology resident at long-term dysphonia. He was a heavy smoker on the healthy skin. The primary dressing was
the CHLN — Hospital Pulido and a recovering alcoholic. He also suffered covered and fixed with a self-adherent dressing
Valente, Lisbon; and Ligia from hypercholesterolemia and chronic made of apertured, non-woven polyester
Ferreira is Otolaryngologist obstructive pulmonary disease. At physical fabric coated with a layer of an acrylic adhesive
at the Portuguese Oncology examination, a flexible laryngoscopy showed (Mefix®; Mölnlycke Health Care). The patient
Institute, Lisbon. lesions of both vocal cords with extension to did not experience any pain during dressing
the anterior commissure and subglottis. The changes. There were no fetid odours and no
neck exam was negative for adenopathies. antibiotics were prescribed.
22 Wounds
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A hive of
Activity
The Advancis Medical honey
range has expanded...
NEW!
Figure 1. 7 July 2011 — supra-tracheostomy necrosis Figure 2. 11 July 2011 — start of honey treatment.
post-laryngectomy.
24 Wounds
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Case report The use of honey in cervical necrosis after laryngectomy and neck radiotherapy
Case report
2. Hornig JD (2013) Supraglottic cancer. Available at:
failed to respond to radiotherapy, which http://emedicine.medscape.com/article/852908-
led to a total laryngectomy salvage. Early overview (accessed 22 November 2013)
complications following this procedure are
haematoma formation, wound infection, 3. Torrente MC, Rodrigo JP, Haigentz M Jr et al (2011)
wound dehiscence and pharyngocutaneous Human papillomavirus infections in laryngeal
fistula[1,2,5]. cancer. Head Neck 33(4): 581–6
Previously irradiated patients have a
higher risk of postoperative complications, 4. Stephen JK, Chen KM, Shah V et al (2012) Human
such as wound dehiscence and/or infection, Papillomavirus outcomes in an access-to-care
as a result of poor wound healing and soft laryngeal cancer cohort. Otolaryngol Head Neck
tissue fibrosis, frequently worsened by poor Surg 146(5): 730–8
nutritional status and other comorbidities.
The treatment of such wounds requires local 5. Johnson JT (2012) Malignant tumors of the larynx.
care with daily dressings and, sometimes, Available at: http://emedicine.medscape.com/
article/848592-overview (accessed 22 November
surgical closure, along with a longer length
2013)
of stay in hospital[1,2,5].
In this case, the patient developed an
6. Jull AB, Rodgers A, Walker N (2008) Honey as a
extensive wound dehiscence, which did
topical treatment for wounds. Cochrane Database
not respond to standard local wound care. Syst Rev Oct 8(4)CD005083. Available at: http://
Silver dressings had been tried and were www.ncbi.nlm.nih.gov/pubmed/18843679
not considered suitable in this case, because (accessed 22 November 2013)
of the need for prolonged use.[6,7,8] Honey-
based products may accelerate healing as 7. Thomas GW, Rael LT, Bar-Oh R et al (2009)
a result of their anti-inflammatory[9] and Mechanisms of delayed wound healing by
debriding action[10], antibacterial activity[11,12] commonly used antiseptics. J Trauma 66(1): 82–90,
and fibroblast stimulation effect[9,13]. In this discussion 90–1
case, the regeneration of tissue was evident
and was completed within 2 months. 8. Bradshaw CE (2011) An in-vitro comparison of the
antimicrobial activity of honey, iodine and silver
Conclusion wound dressings. Bioscience Horizons 4(1): 61–70
T echnology update :
Using telehealth and photography for
wound assessment in Western Australia
T
elehealth has been described as frequently taken and sent during separate
“the use of telecommunication time frames from related videoconferences
technologies to provide healthcare — allowing flexibility in timing for capturing
services across distances”[1]. One-quarter and transmitting images.
of the population of Western Australia live
in remote and rural sites and, according Image quality
to Moffatt and Eley[2], rural Australians When associated with comprehensive
have benefited from telehealth because patient histories, good-quality wound and
it has increased access to health services trauma images can validate and enhance
and improved the skills of healthcare wound assessment[3]. Images that provide
professionals, which in turn has decreased “an objective view of the wound” can be used
disparities in rural and urban health. to track wound healing[4], and images that
The Plastic Surgery Telehealth Service was incorporate environmental factors, such as
established at the Royal Perth Hospital (RPH) seating or mobility devices, can help clinicians
to provide equitable and timely expert review detect the factors that may inhibit healing.
for all Western Australians. Delivery of this Swann[5] discusses the importance
interdisciplinary telehealth service relies on of achieving sharp, clear images and
two basic forms: standardising images to achieve uniform
n Videoconferencing. size or quality, allowing for comparison of
n Store and forward. the wound over time. Photographic skills of
Videoconferencing lets clinicians discuss nurses and patients vary, affecting the quality
and observe in real time with remote patients of the images produced, but the requisite
and staff. Despite the benefits offered by this skills can be acquired and improved through
immediacy and interactivity, videoconference practice[4].
images frequently lack the crisp, clear High-resolution wound images may even
perspective required for effective wound show more detailed views of wounds[6], which
Beth Sperring is Acting assessment, necessitating the use of store can improve assessment and lead to more
Clinical Nurse Consultant, and forward. effective management. In a teledermatology
Plastic Surgery Telehealth Store and forward refers to technologies study in which image colour and sharpness
Service, Royal Perth Hospital, and processes that allow clinical data, X-rays were nearly always rated “good to excellent”,
Perth, Western Australia, and digital images be captured, stored locally Krupinski et al[7] reported 83% concordance
Australia. and transmitted securely to another site, between in-person and digital diagnoses and
where the information is reviewed. Store 76% concordance between biopsy results and
and forward is asynchronous — images are digital diagnoses.
26 Wounds
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Technology update Using telehealth and photography for wound assessment
Sikka et al[8] studied images taken on manage plastic surgery trauma patients at
mobile phones and although image quality a distance. Informed consent was obtained
was described as moderate (and not all from both patients.
clutter.
n The best size and format to enable image
CLINICAL APPLICATIONS
Digital photography is a relatively
cost-effective way of documenting the
progression of a wound, can be easily
incorporated into nursing practice[15]
and can aid in diagnosis[16]. As such,
digital photography is an important tool
in determining treatment options. The Figure 1. Wound presented at a videoconference. It was established that the debris
following case studies illustrate the use of around the skin flap was dressing-product residue, and a treatment plan was given via the
videoconferencing and store and forward to videoconference to the regional nurses and rural patient.
Case study 2
Mr B is a 62-year-old man who sustained a
crush injury to his left hand while working at
home, 400 km northeast of Perth. The Royal
Flying Doctor Service transferred him to RPH,
Figure 3. After sustaining a crush injury this patient was transferred to hospital for surgical
where surgical repair included a groin flap to
repair with a groin flap covering the deficit skin of his left hand.
cover the skin deficit to the dorsum of the left
hand (Figure 3).
Postoperative review was undertaken via
videoconference and the use of photography;
photos of the groin flap were taken weekly
and shared with the tertiary site using a secure
network. The images were used to assess the
colour and positioning of the flap. Further
assessment, including the warmth and texture
of the flap, was made in discussion with the
regional nurse and patient.
Clinical problem-solving, discussion of
the wound care options and the planning
of readmission for flap division were all
undertaken during videoconference sessions.
After division of the groin flap (Figure 5), the
patient's rehabilitation, including wound
review, scar management and range
Figure 4. Videoconferencing and digital photography were used to monitor wound healing
of movement, were supervised using
after flap division to allow the patient to be discharged to his rural home.
videoconferencing and digital photographs.
28 Wounds
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Technology update Using telehealth and photography for wound assessment
Wound digest
This digest summarises some important papers published on wound care.
2. Avoidable antibiotic exposure for Cullen Gill E, Moore Z (2013) An exploration of fourth-year
uncomplicated skin and soft tissue infections undergraduate nurses’ knowledge of and attitude towards
in the ambulatory care setting.
pressure ulcer prevention. J Wound Care 22(11): 618–9, 620, 622
3. Negative pressure wound therapy for treating
foot wounds in people with diabetes mellitus
(Review)
4. Feelings of powerlessness in patients with
2 Avoidable antibiotic exposure for
uncomplicated skin and soft tissue
infections in the ambulatory care setting
venous leg ulcers. Readability a a a
5. Current practice in the management of wound Relevance to daily practice a a a a
odour: An international survey. Novelty factor a a a a
1 An exploration of fourth-year
undergraduate nurses’ knowledge of and
attitude towards pressure ulcer prevention
The authors undertook a retrospective cohort study to
assess current prescribing practices and frequency of
avoidable antibiotic exposure.
n A total of 364 cases were analysed, comprising children
Readability a a a a
and adults treated in the ambulatory care setting for
Relevance to daily practice a a a
uncomplicated cellulitis, wound infection or cutaneous
Novelty factor a a a a
abscess between 1 March 2010 and 28 February 2011.
n As student nurses will become future qualified healthcare n The authors found that of 292 total cases where complete
staff, it is imperative that during their 4 years of training prescribing data were available, 46% of these cases
they receive education and develop skills pertaining to encountered avoidable antibiotic exposure. Furthermore,
the prevention and management of pressure. However, it was discovered that use of short-course, single-
there is insufficient time allocated to wound care in antibiotic treatment strategies would have decreased
university programmes and a lack of education on prescribed antibiotic days by 19% to 55%.
pressure ulcer prevention. n It was concluded that approximately half of
n The authors undertook a quantitative, cross-sectional uncomplicated skin infections are associated with
survey (a total of 60 fourth-year undergraduates were avoidable antibiotic exposure. Through the promotion of
given questionnaires) to determine the extent of single-antibiotic treatment approaches, total antibiotic
undergraduate nurses’ knowledge of, and attitudes use could be substantially decreased.
towards, the prevention of pressure ulcers.
n It was found that the participants, while displaying a Hurley HJ, Knepper BC, Price CS et al (2013) Avoidable
positive attitude towards pressure ulcer prevention, had antibiotic exposure for uncomplicated skin and soft tissue
a poor knowledge of pressure ulcer prevention. infections in the ambulatory care setting. Am J Med 126(12):
n Ninety-seven percent of participants felt confident 1099–106
in their ability to prevent a pressure ulcer and had a
moderate to high level of competency.
n The authors discovered that having a high level of
competency corresponded with having a positive
3 Negative pressure wound therapy for
treating foot wounds in people with
diabetes mellitus (Cochrane Review)
attitude towards pressure ulcer prevention, but did Readability a a a
not equate to possessing knowledge of pressure ulcer Relevance to daily practice a a a
prevention.
Novelty factor a a a
n In fact, attitude and knowledge had an inverse
relationship. The participant who obtained the highest n Negative pressure wound therapy (NPWT) can be used to
attitude score of 47 had one of the lowest knowledge treat wounds in people with diabetic foot ulcers (DFUs).
scores of 10. Conversely, the participant who had the This Cochrane systematic review aimed to provide clear
lowest attitude score of 31 obtained one of the higher clinical guidance to facilitate decision making regarding
knowledge scores of 18. its use.
30 Wounds
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Wound digest
n To assess the effects of NPWT, compared with standard study reported total PAT scores ranging from 51–60,
care or other adjuvant therapies, the review authors while 32% had scores from 41–50.
looked at published or unpublished randomised n There were no significant differences in terms of
controlled trials (RCTs) that evaluated the effects of any feelings of powerlessness between sexes, smokers
brand of NPWT in the treatment of DFUs, irrespective of and non-smokers, alcoholics and non-alcoholics, and
publication status or language of publication. different age groups. However, the authors found
n The authors reviewed five studies with a total of 605 that the presence of wound exudate and malodour
participants. Two studies (502 participants in total) had a significant impact in the study population
compared NPWT with standard moist wound healing. (P=0.004).
The three remaining studies were small with limited data. n The authors conclude that assessment of feelings of
n The authors found that there is some evidence to powerlessness may help to plan intervention that can
suggest that NPWT is more effective in healing DFUs minimise the impact of living with a VLU.
(in terms of reducing time-to-healing and reducing risk
of amputations) compared with standard moist wound Salomé GM, Openheimer DG, de Almeida SA et al (2013)
healing. This relates to postoperative amputation Feelings of powerlessness in patients with venous leg ulcers. J
wounds , as well as chronic, debrided DFUs. Wound Care 22(11): 628, 630, 632–4
n However, it was noted that these studies could be at risk
of bias. The limitations in current RCT evidence would
point to a need for further trials to be conducted. The
authors conclude that any potential change in practice
5 Current practice in the management of
wound odour: an international survey
Readability a a a a
regarding the use of NPWT must be informed by clinical
Relevance to daily practice a a a a
experience and acknowledge the uncertainty around this
Novelty factor a a a a
decision owing to data quality.
n Malodour has been regularly cited by patients and
Dumville JC, Hinchliffe RJ, Cullum N et al (2013) Negative carers as one of the most distressing and socially
pressure wound therapy for treating foot wounds in people isolating aspects of their wounds, which is detrimental
with diabetes mellitus (Review). Cochrane Database Syst Rev to their quality of life.
17(10): CD010318 n There is no standardised approach to assessment and
management of wound odour. To collect baseline