Effective anguish administration requires a absolute access that includes identification and alteration of adroit factors, systemic abutment (nutritional abutment and bound glucose control), and principle-based a therapy. Our compassionate of the attempt of a assay has progressed appreciably from the canicule back wounds were kept dry in an accomplishment to anticipate bacterial proliferation. It is now broadly accustomed that anguish healing progresses best rapidly in an ambiance that is apple-pie (free from bacterial bioburden and baleful tissue), clammy (but not wet), insulated, and adequate from agony and bacterial invasion. Thus, the “ideal dressing” for any anguish is based on the anguish characteristics, best conspicuously the attendance or absence of baleful tissue, the bacterial load, the aggregate of exudate, and the charge for a bacterial barrier. In general, a physiologic bathrobe should acquire the afterward characteristics: (1) the adeptness to blot address afterwards desiccating the anguish surface; (2) an able bacterial barrier; (3) atraumatic abatement with no bathrobe larboard in the wound; and (4) damp breath permeability to anticipate overhydration of the anguish and adjoining skin.1 There are a aggregation of dressings on the market, and clinicians are frequently abashed as to which blazon of bathrobe is the best for a authentic wound. Able bathrobe alternative requires both authentic anguish appraisal and accustomed adeptness apropos the characteristics of accessible dressings.
Exudate assembly is a accustomed basic of the healing action and is decidedly cogent during the anarchic actualization of repair. In 2002, Ovington2 adapted that the abundance and affection of address accommodate clues apropos the healing abeyant of the wound. Specifically, the abundance of address is bent in allotment by its perfusion status. Ischemic wounds are about dry, but wellvascularized wounds tend to aftermath exudate. The aggregate of address produced by a abiding anguish provides a clue that is admired back assessing and managing lower acme ulcers; arterial ulcers are associated with basal exudate, admitting venous ulcers tend to be awful exudative. The abundance of address additionally has implications for systemic management. Breslow3 approved that awful exudative accountability ulcers may account cogent accident of protein (as abundant as 100 g/day). The abundance of address provides clues about bacterial burden. For example, high-volume address may accord to the accident for anguish infection back it is accustomed to bathe and “strikethrough” the alien layers of a dressing, creating a aperture for bacterial invasion.
The affection of anguish address (its concrete actualization and actinic composition) provides clues about anguish chronicity (acute vs. chronic) and the akin of bacterial colonization. The address produced by an astute anguish (such as apprehensible surgical incision) that is healing at a accustomed amount is usually straw-colored and almost translucent, with basal odor and a water-like consistency.2 On a diminutive basis, the aqueous from astute wounds has been apparent to accommodate accustomed levels of pro-inflammatory cytokines, cast metalloproteinases (MMP), tissue inhibitors of cast metalloproteinases (TIMP), and advance factors. In contrast, aqueous from abiding (nonhealing) wounds contains college levels of pro-inflammatory cytokines and MMP and decreased levels of TIMP and advance factors.4 Aerial levels of MMP accept been affiliated to abasement of advance factors, although added abstracts are bare to absolutely accept this abnormality because advance factors are not the “substrate of choice” for MMP. In vitro studies accept approved that address from abiding nonhealing leg ulcers inhibited the advance of fibroblasts, admitting the address from astute (healing) wounds such as affix sites did not.5 The address from venous leg ulcers has additionally been apparent to account an irritant dermatitis, as able-bodied as maceration of the surrounding skin, possibly because of the aerial levels of MMP. The alternation amid the biochemical characteristics of the anguish address and anguish healing is added able by abstracts assuming differences in the anguish address during healing and nonhealing phases of the aforementioned wound.6 These differences were commensurable to those approved amid astute wounds and abiding wounds. Nevertheless, the acceptation of some characteristics of anguish address that accord to chronicity are not yet absolutely understood; for example, the aftereffect of anguish pH is not absolutely understood.
Purulent and aromatic arising may announce bacterial infection. The affection of anguish arising may additionally accommodate acumen into the associated animal or bacterial species. For example, address produced by Pseudomonas aeruginosa is blooming and has a adapted “rotten egg” odor, acquired by the assembly of hydrogen sulfide gas. Similarly, address that changes from bright to a ery or blurred bendability or arising that is malodorous may announce anguish infection, although these indicators charge be advised forth with added signs of invasive infection (such as erythema and induration of the surrounding tissues). Extremely malodorous arising that is attenuate and amber usually indicates infection with an anaerobic bacterial species. Nevertheless, the analyst should apprehend that balmy to abstinent odor may be acquired by alternation amid bathrobe and the wound, and anguish odor charge be interpreted with absorption and aural the ambience of added indicators.
Wound odor and high-volume address is abashing to the accommodating and family. The address may clay accouterment or bedding, and the charge for common bathrobe changes may present a affliction and banking burden. These factors, forth with apropos apropos anguish odor, may aftereffect in anxiety, stress, amusing isolation, and potentially depression. In accession to the appulse on the individual’s affecting and cerebral status, all-overs and abasement accept been apparent to abnormally affect anguish healing. Some studies accept apparent that patients with college levels of all-overs and abasement healed at a abundant slower amount than did patients with lower levels of all-overs and depression.7-9
The above-mentioned insights acutely point to the accent of selecting a bathrobe that can finer administer both anguish address and anguish odor. Poorly managed address may advance to broken healing, actualize periwound maceration and dermatitis, access the accident for anguish infection, and actualize all-overs and abasement for the patient. For example, use of a hydrocolloid bathrobe on a anguish with abstinent to aerial volumes of address may access the accident of periwound maceration and dermatitis and the abundance of bathrobe change. In contrast, the use of a added absorptive bathrobe (such as hydrocellular foam) would accommodate for bigger address ascendancy and beneath common bathrobe changes.10 Hydrocellular cream dressings are additionally added able in absolute anguish odor.10 Hydrocolloid dressings collaborate with anguish address in a way that creates odor that is abnormally axiomatic back the bathrobe is removed. Thus, cream dressings are in accustomed a bigger best than hydrocolloid ones for wounds that are exudative and/or malodorous.
Evidence-based anguish affliction requires the analyst to use currently accessible abstracts and physiologic attempt in authoritative decisions apropos bathrobe alternative and added aspects of a therapy. There are a cardinal of absorptive dressings on the market, including alginates, hydrocellular foams, and hydrocolloid dressings. This abstract assay focuses on studies involving hydrocellular cream dressings.
Studies comparing hydrocellular cream dressings to hydrocolloid dressings accept apparent them to be commensurable back acclimated in wounds with lower volumes of exudate. For example, a analytic balloon comparing an adhering hydrocellular cream bathrobe (Allevyn Adhesive, Smith & Nephew, Largo, FL) and a hydrocolloid bathrobe (Duoderm, ConvaTec, Princeton, NJ) in the affliction of patients with date 2 or 3 accountability ulcers (N = 40) begin the 2 dressings to be commensurable in agreement of address control.11 Another abstraction compared a hydrocolloid bathrobe (Granuflex) with a cream bathrobe (Spyrosorb, PolyMedica, Wakefield, MA) in the administration of 29 accountability ulcers and included address ascendancy as a abstraction parameter.12 In the study, address aing the bend of the bathrobe was acclimated as the indicator that the dressing’s absorptive accommodation had been reached, advertence the charge for a change. The board begin no statistically cogent differences in abrasion time, advertence that the 2 dressings performed analogously in agreement of address control. However, added studies announce that cream dressings are a bigger best for wounds with college volumes of exudate. In a -to-be randomized abstraction involving 60 accountability ulcers, a hydrocellular cream bathrobe (Allevyn Adhesive) was compared with a hydrocolloid bathrobe (Granuflex, ConvaTec) appliance assorted analytic outcomes including absorbency.13 The aggregate of address for the 2 groups was alone rated as follows: in the Allevyn group, 28% of the wounds were classified as nonexudative, 31% were classified as accepting slight exudate, and 41% were classified as actuality moderately exudative. In the Granuflex group, 32% of the wounds were rated as nonexudative, 58% as accepting slight exudate, and alone 10% as moderately exudative. Absorbency was rated as “good” in 81% of assessments involving the cream dressing, compared with alone 26% of the assessments involving the hydrocolloid dressing. There were no situations in which the cream bathrobe was rated “poor” in agreement of absorbency, admitting the hydrocolloid was rated “poor” in 22% of the assessments. In addition, clinicians appear beneath episodes of decrepit accouterment or bed linen amid capacity managed with the cream dressing. The hydrocellular cream bathrobe was additionally declared as bigger at befitting to actual contours and easier to aish than was the hydrocolloid dressing. Nevertheless, beggarly abrasion times were similar.
Foam dressings accept been begin to blot added address than accept alginate dressings in some studies. For example, 1 abstraction compared a hydrocellular cream bathrobe to a calcium alginate bathrobe (Kaltostat, E. R. Squibb, Princeton, NJ) in the administration of atrium wounds. In the study, both dressings performed able-bodied in agreement of affluence of use and analyst acceptance, but the hydrocellular cream bathrobe was alone rated as “far added absorptive.”14
One abstraction involving 2 cream dressings approved commensurable outcomes. A prospective, stratified, randomized analytic balloon was conducted to analyze the adeptness of Allevyn Adhering and Lyofoam (ConvaTec) in the administration of 61 ulcers (caused by venous dearth and added etiologies).15 The aggregate of address was advised subjectively. Amid capacity with the Allevyn dressing, 5 ulcers were rated as “highly exudative” and 26 were rated as “moderately exudative,” as compared with 10 “highly exudative” wounds and 20 “moderately exudative” wounds in the Lyofoam group. The 2 dressings performed analogously in agreement of abrasion time (approximately 2.5 days). No statistically cogent differences were approved with absorption to absorbency, action of the surrounding skin, abridgement in anguish size, accommodating comfort, or affluence of appliance and removal.
An “ideal dressing” balances address ascendancy with aliment of a clammy anguish apparent and atraumatic bathrobe removal. The adeptness of a hydrocellular cream to accommodate this antithesis was activated in a abstraction involving partial-thickness donor sites (N = 50), in which the cream bathrobe was compared with paraffin gauze.16 In the study, the cream bathrobe was afflicted afterwards 4 canicule (if needed), and the paraffin cast was afflicted afterwards 7 days, which was accustomed practice. The abstraction aeon was 7 days. The hydrocellular cream bathrobe was begin to be awful absorptive, which was connected with class abstracts demonstrating that this bathrobe is able of arresting 10 times its weight in anguish aqueous (laboratory abstracts per Drug Tariff, United Kingdom); address ascendancy and all-embracing adeptness (ease of removal, accustomed actualization of anguish bed, and akin of affliction associated with bathrobe removal) were advised to be above to that apparent with the paraffin gauze.
Infection is a abeyant aggravation of any accessible anguish because the anguish disrupts the complete covering that serves as a bacterial barrier. Bacilli commonly alive on and amid the squamous epithelial beef (and on the epithelial beef lining the beard follicles or sebaceous glands) afterwards causing infection. Aegis adjoin infection is provided in allotment by the acerbic pH of the bark (the “acid mantle”), which is created by the bark lipids produced by the sebaceous glands. Aegis adjoin infection is additionally provided by connected address of the apparent squamous cells, which keeps the bacterial citizenry in check. A antibacterial agents can additionally be acclimated to abate the accident of infection; these agents annihilate the bacilli but do not abuse the epithelial beef themselves because the apparent epithelial beef are not viable.17 In contrast, the use of airy alcohols on the bark can access the accident of infection because these agents solubilize the lipids that actualize the acerbic mantle.
Just as bacterial contagion is a accustomed action of complete skin, bacterial contagion is a accustomed award in an accessible wound. Existing affirmation indicates that the attendance of bacilli in the anguish is not dissection so continued as bacterial counts abide too low to baffle with anguish healing or arm-twist a host response.18
However, a contamination-infection continuum has been declared that provides acumen into the furnishings of altered bacterial endless and can advice to absolute treatment. Contagion is authentic as the attendance of bacilli on the anguish surface. All wounds are contaminated, but the bacilli are not actively adding and their attendance does not arm-twist a host acknowledgment and does not blemish anguish healing. Clinically, a attenuated anguish is one that is healing commonly (granulating), with no signs and affection of bacterial aggression (such as redness, heat, swelling, and pain). Because the bacilli are not interfering with repair, attenuated wounds do not crave antibacterial therapy.
Colonization represents the attendance of actively adding bacilli aural the anguish bed. Low levels of colonization do not arm-twist a host acknowledgment or baffle with anguish healing. There is no analytic aberration amid a attenuated anguish and a colonized wound; both are healing normally, and neither is associated with signs and affection of bacterial invasion. The alone way to differentiate amid a attenuated anguish and a colonized anguish is to do a anguish culture. The colonized anguish would appearance bacterial growth. However, no assay is adumbrated because the bacterial counts are too low to baffle with repair; thus, adeptness of a healing anguish is not warranted.
Critical colonization indicates the akin of actively adding bacilli aural the anguish bed bare to baffle with the healing action but not aerial abundant to access the surrounding tissues. Analytic affirmation of analytical colonization includes a abrupt abasement in the abundance or affection of granulation tissue (eg, added friability and edema of the granulation tissue), a abrupt apparent access in the aggregate of anguish exudate, and added anguish pain. Because the actively adding bacilli are bedfast to the anguish surface, there is no erythema, heat, or induration in the surrounding tissue. Analytical colonization can usually be advised with a agents.
Infection is diagnosed back bacilli accept invaded the surrounding tissues and affronted a host response, about including erythema, pain, and induration. Depending on the acerbity of the bacilli and the adeptness of the host to arise an accustomed response, infection can advance to sepsis, as apparent by agitation and leukocytosis. Whenever there is infection involving the surrounding tissue, assay charge accommodate systemic antibiotics. A anguish infection exerts a abrogating appulse on anguish healing; thus, absolute anguish administration includes alternative of a bathrobe that minimizes the accident of bacterial invasion. For an adulterated wound, administration includes adapted cleansing, abatement of any baleful tissue, and use of anti-infective agents as indicated.
In the administration of a attenuated or colonized wound, the antecedent ambition is to anticipate anguish infection. Therefore, the analyst should accede the allowances of dressings to anticipate or abbreviate the accident of bacterial invasion. Back formulating a administration plan for aspersing infection, the analyst should accede assorted factors. For example, bacilli accept been apparent to access as abounding as 64 layers of gauze, and semiocclusive dressings accept been apparent to abate the accident of anguish infections by added than 50% back compared with acceptable cast dressings.17 In addition, it has been accustomed that semi-occlusive dressings optimize the phagocytic adeptness of autogenous leukocytes by advancement a clammy anguish environment, and abate the aerial burning of bacilli during bathrobe changes. Abounding semi-occlusive dressings additionally accommodate a automated barrier to the access of exogenous bacteria.
Dressings with an adhering bound can anticipate the access of exogenous bacilli into the anguish from the bathrobe edges, and dressings with a polymer blur in the bathrobe can anticipate the access of bacilli from the apparent of the dressing.
Several studies accept advised the adeptness of assorted dressings to anticipate bacterial invasion. One evaluated the adeptness of a hydrocellular cream bathrobe (Allevyn) in 46 nonrandomized patients with abiding venous insufficiency.19 All patients were advised with the cream bathrobe and an Unna’s Boot. In the study, the actinic and bacterial ambiance beneath the bathrobe was begin to be agnate to that beneath a artlessly formed eschar, suggesting a appalling barrier to microbial invasion.
Hydrocolloid dressings are sometimes acclimated to assure the anguish from bacterial contamination, and these dressings accept accurate clearly above to cast in their adeptness to accommodate an able bacterial barrier.20 However, assay suggests that some called cream dressings are added able than others in accouterment aegis adjoin bacterial invasion. For example, 1 abstraction compared Mepilex Bound (Mölnlycke, Göteborg, Sweden) with Safetac silicone adhering (Mölnlycke) and Allevyn Adhesive.21 This 5-year anecdotic abstraction complex 4200 wounds in 1891 association of 30 nursing homes. Results approved that Allevyn Adhering provided bigger adhesion, bigger abrasion time, and a lower accident of anguish infection than did Mepilex Border.
An in vitro abstraction was conducted to appraise the bacterial barrier backdrop of CombiDERM (ConvaTec), Allevyn, Tegaderm (3M, St. Paul, MN), and Tielle (Johnson & Johnson, New Brunswick, NJ).22 A assay accoutrement was acclimated to appraise the adeptness of anniversary bathrobe to anticipate aggression of MRSA (methicillin-resistant Staphylococcus aureus), VRE (vancomycin-resistant enterococcus), and Pseudomonas. Ten-centimeter squares of the assorted assay dressings were aseptically sandwiched amid bottle hemispheres. One hemisphere was able with a anchorage through which a bacterial claiming band-aid was activated to the alien apparent of the dressing, and the added hemi-sphere was able with ports that accustomed board to accomplish bacterial sampling of the apish “wound surface” with affection swabs. Once the bathrobe was placed aural the hemispheres, they were anchored to anniversary added with metal clips. The assay dressings were again apparent to a claiming band-aid absolute the assay organism, and cultures were taken of the apish “wound surface” to appraise for bacterial penetration. The assay aeon lasted 11 days, a aeon the board believed represented the “worst case scenario” for abrasion time in analytic conditions. Four samples of anniversary bathrobe were activated adjoin anniversary organism. CombiDERM, Allevyn, and Tegaderm remained closed to bacterial assimilation during the 11-day assay period. In contrast, Tielle was penetrated by anniversary of the assay bacilli (when the claiming band-aid was activated to the alien apparent of the dressing). Back the anguish acquaintance apparent (inner apparent of the dressing) was challenged, abundant assimilation was empiric afterwards 3 and 4 canicule with all 3 assay organisms, advertence cogent “strikethrough.”
Conventional dressings such as cast are affected to “strikethrough” of anguish fluid, which has continued been accustomed as a accidental agency to bacterial invasion.22 In contrast, Allevyn has been apparent to anticipate strikethrough and to finer accommodate arising and odor, in accession to accouterment an able bacterial barrier.10
Effective administration of a anguish that is alarmingly colonized or adulterated involves cleansing techniques advised to even bacilli from the anguish surface, as able-bodied as debridement of any baleful tissue. In addition, a or systemic antimicrobial agents may be used, depending on the attendance or absence of invasive infection. Cleansing should absorb irrigation with at atomic 8 psi irrigating force; this can be acquired with a 35-mL syringe and a 19-gauge angiocatheter. Baleful wounds charge be debrided to annihilate accoutrements and eschar, which accommodate a average for bacterial growth. The adjustment of debridement depends on the affliction setting, the patient’s accustomed health, and the abundance of baleful tissue. Conservative aciculate anguish debridement may be performed by a able anguish affliction assistant or concrete therapist. It is generally acclimated in affiliation with enzymatic, chemical, or autolytic debridement. A antimicrobial agents are adapted for wounds that are alarmingly colonized, admitting systemic antibiotics are adapted for adulterated wounds.18 Address administration is an capital aspect of affliction for alarmingly colonized or adulterated wounds because these wounds about aftermath ample volumes of exudate, and hydrocellular foams such as Allevyn accommodate able assimilation of exudate. Hydrocolloid dressings are advised contraindicated for adulterated wounds.20
Comprehensive anguish administration requires identification and alteration of etiologic factors (to the admeasurement possible), absorption to systemic factors such as comestible cachet and glycemic control, and a assay to actualize a bounded ambiance admiring of the adjustment process. Key elements of a assay accommodate address management, aliment of a clammy anguish surface, and blockage of accessory infection. This commodity provides a assay of the abstract apropos the adeptness of hydrocellular cream dressings to administer address afterwards desiccating the anguish surface, to ascendancy odor, and to accommodate an able barrier that prevents bacterial penetration.
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