A new global perspective of evidence-based wound protocols.
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Congresses as Topic↗
Biomedical subjects
R Gary Sibbald
Publications and source records attributed to R Gary Sibbald.
Increased bacterial burden and infection: the story of NERDS and STONES.
PURPOSE: The purpose of this article is to provide practitioners with an overview of wound infection/inflammation and bacterial balance and to offer a guide to assessment and treatment of chronic wounds. TARGET AUDIENCE: This continuing education activity is intended for physicians and nurses who assess and treat wound infections. OBJECTIVES: After reading this article and taking this test, the participant should be able to: 1. Discuss factors associated with infection of the chronic wound, including the concept of bacterial balance and burden. 2. Identify signs of infection in the chronic wound and applicable diagnostic tests. 3. Describe appropriate treatment for the infected chronic wound.
Abbreviations as Topic↗
Guest editorial: it takes a village to heal a wound.
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Congresses as Topic↗
The silver-releasing foam dressing, Contreet Foam, promotes faster healing of critically colonised venous leg ulcers: a randomised, controlled trial.
The study compared the effect of a sustained silver-release foam dressing (Contreet Foam) with a foam dressing (Allevyn Hydrocellular) without added silver in critically colonised venous leg ulcers with delayed healing. The study was a multicentre, open, randomised, controlled study lasting for 4 weeks. Ulcer area and healing were assessed weekly. Odour, maceration, absorption capacity and leakage were evaluated at dressing changes. All adverse events were recorded. One hundred and twenty-nine patients were included (Contreet Foam: 65, Allevyn Hydrocellular: 64). The two groups were comparable in all respects. After 4 weeks, there was a significantly greater reduction in ulcer area in the Contreet Foam group (45%) than in the Allevyn Hydrocellular group (25%). After 1 and 4 weeks, odour was present in significantly less of the ulcers in the Contreet Foam group (17% and 19%, respectively) compared with the Allevyn Hydrocellular group (47% and 39%, respectively) and at the final visit there were significantly fewer leakages in the Contreet Foam group (19%) compared with the Allevyn Hydrocellular group (49%). Also, less maceration was observed after 1 and 4 weeks in the Contreet Foam group (34% and 37%, respectively) compared with the Allevyn Hydrocellular group (55% and 48%, respectively). The occurrence and cause of adverse events were equally distributed between the study groups. The present study provides evidence of the superior performance of the silver-releasing dressing, Contreet Foam, compared with a traditional moist foam wound healing dressing in the treatment of critically colonised, chronic venous leg ulcers. The results of this randomised, controlled study suggest an important role of sustained silver-releasing dressings in the treatment of critically colonised chronic wounds.
Adult↗
A liquid film-forming acrylate for peri-wound protection: a systematic review and meta-analysis (3M Cavilon no-sting barrier film).
To undertake a systematic review of all reliable evaluations of the clinical performance and cost-effectiveness of a film-forming liquid acrylate in the protection of the chronic ulcer peri-wound skin. Results from searches were scrutinised by two reviewers to identify possible randomised controlled trials and full reports of these were obtained. Details of eligible studies were extracted and summarised independently by two reviewers using a data extraction sheet. Meta-analysis was used to combine the results of trials where the interventions and outcome measures were sufficiently similar. A total of nine eligible studies were identified. The review reveals that a liquid-film forming acrylate (Cavilon no-sting barrier film, 3M, Minneapolis, MN, USA) is a safe and effective skin barrier to protect the peri-wound area of chronic ulcers. There is no difference between the protective properties of different barrier methods that are used to protect the peri-wound skin around chronic ulcers. Compared with no treatment or a placebo, this liquid film-forming acrylate has a significant impact on the integrity of the peri-wound skin. In addition, it has significant benefits in terms of pain control and patient comfort, and its use may reduce nursing time.
Acrylates↗
The effect of a silver-containing Hydrofiber dressing on superficial wound bed and bacterial balance of chronic wounds.
The treatment of chronic wounds represents a major cost to society and has a profound effect on the participant's quality of life. Chronic wounds may have an increased bacterial burden that can impair healing without all the clinical signs of infection. Silver dressings may provide an alternative topical method to control bacterial burden. The primary aim of this study was to evaluate the clinical improvement in chronic wounds through the effect on wound size, maceration, resolution of surface slough and conversion to healthy granulation during a 4-week application of the silver-containing Hydrofiber dressing. This was a single centre, open-label case series study which included a total of 30 evaluable participants: four with diabetic neuropathic foot ulcers, 13 venous stasis ulcers, four pressure ulcers and nine miscellaneous wounds that did not fit any of the previous categories. All participants had adequate vascular supply, indicating the potential to heal. The wounds were stalled or had the signs and symptoms consistent with critical colonisation. The underlying cause of the ulceration was identified and corrected, or the symptoms and signs were treated. This was followed by the application of silver-containing Hydrofiber dressings for a period of 4 weeks. The majority of wounds treated decreased in size (70%) with decreased exudate, decreased purulence and resolution of surface slough (75%). There was an increased quality and quantity of healthy granulation tissue. Unlike some silver dressings, the Hydrofiber and silver combination dressing was unlikely to cause burning and stinging on application. Peri-wound maceration was present in 54% of participants at baseline, and 85% of these resolved with this dressing. A desloughing action was seen in those patients with pre-existing slough at baseline and its removal will lower the bacterial burden of the wound.
Adolescent↗
Using a dermal skin substitute in the treatment of chronic wounds secondary to recessive dystrophic epidermolysis bullosa: a case series.
Epidermolysis bullosa is a family of genetic disorders that cause blistering and shearing of the skin from even the mildest trauma. Care generally focuses on preventing infection, protecting the skin against trauma, attending to nutritional deficiencies and dietary complications, minimizing deformities and contractures, and providing psychological support for the entire family. One approach to the treatment of chronic wounds in Epidermolysis bullosa involves tissue engineering, where cells similar to those of the skin, grown on a three-dimensional scaffold, are used to induce healing. Charts of six young people (ages 8 years to 23 years; four girls, two boys) with recessive dystrophic Epidermolysis bullosa who received applications of a dermal skin substitute to persistent erosions at multiple body sites (55) at successive clinic visits were reviewed. Each patient received between seven and 32 skin substitute applications to between six and 19 sites; patients were followed for at least 8 weeks. At weeks 1 to 2, epidermal coverage ranged between 80% and 100%. Some sites had persistent coverage but others experienced breakdown. Four patients had hand surgery and the living skin substitute was used postsurgically to provide coverage for the epidermal defects. Overall in these six cases, the dermal skin substitute proved advantageous to wound protection, healing, and symptom relief. Compassionate care combined with optimal wound care and advancing technology may offer an effective antidote to the wounding and pain of this devastating disease.
Chronic Disease↗
Chronic wound pain and palliative cancer care.
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Bandages↗
TIME heals all wounds.
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Abbreviations as Topic↗
The International Interdisciplinary Wound Care Course at the University of Toronto: a 4-year evolution.
The International Interdisciplinary Wound Care Course at the University of Toronto was designed to emphasise interdisciplinary collaboration, examine the evidence base and develop wound care opinion leaders across Canada and internationally. There is a need to translate the new wound care evidence base for diagnosis and treatment into patient care and ultimately improve patient outcomes.
Curriculum↗
Rheumatoid arthritis-associated inflammatory leg ulcers: a new treatment for recalcitrant wounds.
Patients with rheumatoid arthritis may develop leg ulcers of varied aetiologies, including venous disease, infection and inflammation (vasculitis or pyoderma gangrenosum). The leg ulcers in rheumatoid arthritis patients may involve several of these aetiological factors and are often difficult to heal. Both the ulcers and the treatments are often painful, and these ulcers may be present for years. A new oxidised regenerated cellulose and collagen dressing has been developed for slow-to-heal wounds and may have a role in the management of superficial inflammation that may persist in many of these ulcers, although clinically it is difficult to distinguish this from critical colonisation or frank infection. Venous disease requires compression therapy. Deep compartment infection should be treated with systemic antimicrobials, and inflammatory processes extending beyond the superficial wound base require disease-specific systemic anti-inflammatory agents. Four patients with recalcitrant wounds resistant to best practice were treated successfully with this new dressing combined with a strategy to control bacterial burden.
Aged↗
Is bed rest an effective treatment modality for pressure ulcers?
Despite the well-documented medical, physical, and psychological complications associated with this care management option, bed rest remains a frequently prescribed treatment modality for conditions such as pressure ulcers. Cognitive and psychosocial complications of bed rest include depression, learned helplessness, perceptual changes, and fatigue. Physically, complications can include contractures, muscle atrophy, osteoporosis, pathologic fractures, urinary tract infections, decreased cardiac reserve, decreased stroke volume, resting and post-exercise tachycardia, orthostatic hypotension, pulmonary embolism, deep venous thrombosis, pneumonia, anorexia, constipation, and bowel impaction. Furthermore, the literature does not contain evidence supporting the use of bed rest to facilitate healing of pressure ulcers. More suitable approaches to pressure ulcer care include limiting bed rest, initiating occupational therapy, integrating meaningful tasks into daily activities, increasing outside stimulation, involving patients in care decisions and addressing their concerns, optimizing nutritional status, and managing pressure and shear throughout daily activities. Recommendations for implementing alternatives to bed rest are addressed.
Activities of Daily Living↗
Comparing a foam composite to a hydrocellular foam dressing in the management of venous leg ulcers: a controlled clinical study.
Venous leg ulcers are the most prevalent form of chronic wounds in the Western world. The principles of moist wound healing coupled with the use of graduated compression bandaging have become the cornerstone of treatment for venous leg ulcers but not all moist dressings are alike. To compare the attributes of a foam composite dressing with those of a hydrocellular foam dressing in the management of venous leg ulcers, a prospective, randomized, comparative 12-week study was conducted in 15 centers in the US, Canada, France, Germany, and the UK. Dressings were changed and compression bandages applied per manufacturer recommendations and dressing performance was assessed at every dressing change and at the final evaluation. Patients with venous ulcers were randomized to treatment for 12 weeks with either hydrocellular foam (n = 52) or foam composite (n = 55) dressing. Healing differences between the groups were not statistically significant, with 36% of patients using foam composite dressing healed in a mean of 66 days and 39% of patients using hydrocellular foam dressing healed in a mean of 73 days. However, the foam composite dressing performed significantly better than the hydrocellular foam dressing with regard to condition of the periwound skin - 55% of patients in the foam composite group having healed or markedly improved surrounding skin compared to 37% of patients using hydrocellular foam (P = 0.03). The foam composite dressing was rated significantly better than the hydrocellular foam dressing ("very good" to "excellent") in level of satisfaction with conformability (87% and 75%, respectively, P = 0.05); being non-sensitizing (73% and 52%, respectively, P = 0.02); and ease of application (93% and 81%, respectively, P = 0.01). The findings reported in this study suggest that the foam composite dressing offers significant improvements in the quality of life of patients with venous leg ulcers as well as for their caregivers.
Adult↗
Wound bed preparation: a systematic approach to wound management.
The healing process in acute wounds has been extensively studied and the knowledge derived from these studies has often been extrapolated to the care of chronic wounds, on the assumption that nonhealing chronic wounds were simply aberrations of the normal tissue repair process. However, this approach is less than satisfactory, as the chronic wound healing process differs in many important respects from that seen in acute wounds. In chronic wounds, the orderly sequence of events seen in acute wounds becomes disrupted or "stuck" at one or more of the different stages of wound healing. For the normal repair process to resume, the barrier to healing must be identified and removed through application of the correct techniques. It is important, therefore, to understand the molecular events that are involved in the wound healing process in order to select the most appropriate intervention. Wound bed preparation is the management of a wound in order to accelerate endogenous healing or to facilitate the effectiveness of other therapeutic measures. Experts in wound management consider that wound bed preparation is an important concept with significant potential as an educational tool in wound management. This article was developed after a meeting of wound healing experts in June 2002 and is intended to provide an overview of the current status, role, and key elements of wound bed preparation. Readers will be able to examine the following issues; the current status of wound bed preparation; an analysis of the acute and chronic wound environments; how wound healing can take place in these environments; the role of wound bed preparation in the clinic; the clinical and cellular components of the wound bed preparation concept; a detailed analysis of the components of wound bed preparation.
Cell Proliferation↗
Practical treatment of wound pain and trauma: a patient-centered approach. An overview.
Chronic wound pain is distressing and influences the patient's ability to function. One of the failures of modern medicine is the inadequate assessment and treatment of pain. The clinician's approach to chronic wound pain combines the "preparing the wound bed" paradigm with chronic wound pain models. A holistic approach must include the diagnosis and treatment of the underlying cause, identification and correction of patient-centered concerns, and the three major components of local wound care (debridement, bacterial balance/prolonged inflammation, and moisture balance). The Krasner pain model defines chronic (persistent), noncyclic acute, and cyclic acute wound pain. Chronic persistent wound pain without an event or trigger often relates to the cause of the wound that needs to be corrected to relieve the pain. Noncyclic acute pain is often experienced with a surgical procedure such as sharp debridement. Cyclical acute pain may occur repeatedly with removal or application of new local wound dressings. Securing a thorough pain history focusing on pain patterns will help healthcare professionals develop specific pain relief initiatives. Pain is a component of quality of life. Patient-centered concerns need to address pain control measures until the cause of the pain can be corrected. Controlling pain, however, may not always improve quality of life scores. Each of the components of local wound care also may be responsible for the production of pain; strategies need to be implemented to ensure adequate patient comfort.
Acute Disease↗
Venous leg ulcer pain.
Venous disease and venous leg ulcers are frequently painful. The pain experienced may be constant or intermittent. Constant pain can originate from vascular structures (superficial, deep phlebitis), pitting edema, collagen (lipodermatosclerosis), infection, or scarring (atrophie blanche). Ulcer region pain is often episodic and may be due to surgical or other debridement procedures. Intermittent pain is often related to dressing removal or recent applications of new dressings. An approach to pain control will consider the cause of pain and utilize local measures, regional approaches to edema control, and systemic medication aimed at constant, episodic, or intermittent pain triggers.
Adult↗
Pain in diabetic foot ulcers.
People with diabetes who have foot ulcers require adequate vasculature, infection control, and pressure offloading to heal. Pain is uncommon in diabetic foot disorders, but it may herald the onset of limb-threatening complications such as deep infection, Charcot change, or critical ischemia. Although neuropathy is most commonly painless, a minority of patients experience disturbing burning, stinging, stabbing, or shooting sensations. Using the "preparing the wound bed" model, the cause of pain in the person with diabetic foot problems can be diagnosed systematically and important therapeutic measures can be instituted in an attempt to prevent potential complications, including amputation.
Diabetic Foot↗
Pain in pressure ulcers.
Integrating pain management into a treatment paradigm for pressure ulcers can lead to improved outcomes. An approach to wound bed preparation that addresses the cause and patient-centered concerns--as well as local wound care factors of moisture balance, debridement, and bacterial balance--can be integrated with the Krasner model of chronic wound pain. The risk factors for pressure ulcers are well known, but pain may be an important contributor to immobility and the development of pressure ulcers. Pain is also an important signal of wound-related infections. Strategies must be developed to control the cyclic acute pain of dressing changes and the noncyclic acute pain of wound debridement. Spinal cord injured and elderly, cognitively impaired patients with pressure ulcers present special challenges in pain management.
Aged↗