Practice development: Ensuring that the correct antimicrobial dressing is selected
Clockwise from top left: Figure 1 shows rapid debridement/cleansing effect in a pressure ulcer with wound cleansing and wound dressing containing PHMB. Figure 2 shows the healed wound after treatment. Figure 3 depicts modern debridement with Debrisoft moisturised with Prontosan. Slough and debris is ‘sucked’ into the monofilaments.
were contraindicated. However, recent research examining the presence of biofilms in wounds, suggests the use of more effective cleansing methods are needed[12]
. Antiseptic wound cleansing agents, which
are able to disrupt biofilms, have become increasingly used in clinical practice. One such wound cleanser is Prontosan® (B Braun), available both as a irrigation solution and as a gel in different viscosities. It contains betaine — a surfactant — which helps in breaking up the biofilm[13]
and polyhexanide, which is reported
to disrupt biofilms. Clinical experiences of this agent in heavily colonised/locally infected wounds are reported to be good. However, without repeated debridement, a biofilm often rapidly reforms[6]
. Other common antiseptic cleansing
agents include sodium hypochlorite solutions, chlorhexidene, dilute acetic acid and povidone iodine[14]
. Their use remains controversial — in
some areas, they are banned from use, while in others, they are considered standard care. In resource-poor settings they may represent the only available means of managing bioburden in chronic wounds.
Debridement Traditional techniques for debridement have included supporting autolytic debridement through dressing choices, enzymatic debridement using exogenous collagenase applied to the wound, conservative sharp debridement using
surgical instruments to remove non-viable tissue or more aggressive surgical debridement [Figs 1–3]. There are other options used for debridement, including hydrosurgery and ultrasound. These are expensive to use and require specific skills. Mechanical debridement with saline wet-to-dry dressings is not considered an effective debridement modality but irrigation with safe irrigating fluids can be used. In some settings, maggots are to used to reduce debris and bacterial burden[15,16]
.The effect is greater in the
removal of gram-positive bacteria, compared with gram-negative species[2]
. More recently, dressings that actively debride
the wound have become available. These work by actively sequestering exudate, bacteria, debris and inflammatory cytokines within the dressing. One such product for gentle and effective debridement is Debrisoft® (Activa). This product contains 18 million monofilaments. After moisturisation, it can be carefully wiped/stroked over the wound, ‘sucking’ debris, probably biofilm products and bacteria, into the monofilaments[16]
Similar products include Drawtex® (Beier Drawtex Healthcare) and Sorbion Sachet® (Sorbion).
Antimicrobial dressings Following thorough wound cleansing and debridement, appropriate wound dressings should be selected. The selection of such dressings is dependent on wounds status and the treatment goals for the patient [Table 4].
10. Woo K, Sibbald RG. A cross-sectional validation study of using NERDS and STONEES to assess bacterial burden. Ostomy Wound Manage 2009; 55(8): 40–8.
11. Fernandez R, Griffiths R. Water for wound cleansing. Cochrane Database Syst Rev 2012; 15(2): CD003861.
12. Cutting KF. Addressing the challenge of wound cleansing in the modern era. Br J Nurs 2012; 10-23; 19(11): 24, 26–9.
13. Andriessen A, Strohal R. Technology update: the role of PHMB: a topical approach to wound infection. Wounds Int 2010; 1(3):1–4.
.
14. Sibbald RG, Orsted HL, Schultz GS, Coutts P, Keast DH. Preparing the wound bed 2003: focus on infection and inflammation. Ostomy Wound Manage 2003 49(11): 24–51.
15. Gray D, Cooper P, Russell F., Stringfellow S. Assessing the clinical performance of a new selective mechanical wound debridement product. Wounds UK 2011; 7(3): 42–6.
www.woundsinternational.com
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Practice Development
Credit: Eva Robertsson and Christina Lindholm
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