A comparison of dressings in the management of surgical abdominal wounds

Debridement for surgical wounds

BACKGROUND

Surgical wounds that become infected are often debrided because clinicians believe that removal of this necrotic or infected tissue may expedite wound healing. There are numerous methods of debridement available, but no consensus on which one is most effective for surgical wounds.

OBJECTIVES

To assess the effects of different methods of debridement on the rate of debridement and healing of surgical wounds.

SEARCH METHODS

In October 2021, we searched the Cochrane Wounds Specialised Register, CENTRAL, MEDLINE, Embase, and CINAHL. To identify additional studies, we searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies, reviews, meta-analyses, and health technology reports. There were no restrictions on language, date of publication, or study setting.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that enrolled people with a surgical wound that required debridement, and reported time to complete wound debridement or time to wound healing, or both.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed study selection, risk of bias assessment using the RoB 1 tool, data extraction, and GRADE assessment of the certainty of evidence.

MAIN RESULTS

In this fourth update, we identified one additional study for inclusion. The review now includes six studies, with 265 participants, aged three to 91 years. Five studies were published between 1979 and 1990 and one published in 2014. The studies were carried out in hospital settings in China, Denmark, Belgium, and the UK. Six studies provided six comparisons. Due to the heterogeneity of studies, it was not appropriate to conduct meta-analyses. Four studies evaluated the effectiveness of dextranomer beads/paste; however, each study used a different comparator (Eusol-soaked dressings, 10% aqueous polyvinylpyrrolidone, 0.1% chloramine-soaked packs, and silicone foam elastomer dressing). One study compared streptokinase/streptodornase with saline-soaked dressings, and one compared endoscopic surgical debridement with conventional 'open' surgical debridement. Five studies reported time to complete debridement (reported as time to a clean wound bed) and three reported time to complete healing. One study reported effect estimates (surgical debridement via endoscopy versus surgical debridement) for time to a clean wound bed and time to complete wound healing, and it was possible to calculate effect estimates for one other study (dextranomer paste versus silicone foam elastomer) for time to complete wound healing. For the other four studies that did not report effect estimates, it was not possible to calculate time to a clean wound bed or time to complete wound healing due to missing variance and participant exclusions. None of the included studies reported outcomes pertaining to proportion of wounds completely healed, rate of reduction in wound size, rate of infection, or quality of life. All studies had unclear or high risk of bias for at least one key domain. Dextranomer paste/beads (autolytic debridement) compared with four different comparators Four studies compared dextranomer paste or beads with Eusol-soaked gauze (20 participants), 10% aqueous polyvinylpyrrolidone (40 participants), 0.1% chloramine-soaked dressings (28 participants), or silicone foam elastomer (50 participants). There is very low-certainty evidence that there may be no clear difference in time to a clean wound bed between dextranomer beads and Eusol gauze. The study did not report adverse events. There is very low-certainty evidence that there may be no difference in time to a clean wound bed between dextranomer paste and 10% aqueous polyvinylpyrrolidone gauze. There was low-certainty evidence that there may be no difference in deaths and serious adverse events. There may be a difference in time until the wounds were clinically clean and time to complete wound healing between dextranomer paste and 0.1% chloramine favouring 0.1% chloramine, but we are very uncertain. There is low-certainty evidence that there may be no difference in deaths and serious adverse events. There is very low-certainty evidence that there may be no difference in time to complete healing between dextranomer beads and silicone foam elastomer. The study did not report adverse events. Streptokinase/streptodornase solution (enzymatic) compared with saline-soaked dressings One study (21 participants) compared enzymatic debridement with saline-soaked dressings. There is low-certainty evidence that there may be no difference in time to a clean wound bed or secondary suture between streptokinase/streptodornase and saline-soaked dressings. There is very low-certainty evidence that there may be no difference in deaths and serious adverse events. Surgical debridement via endoscopic ('keyhole') surgery compared with surgical debridement by 'open' surgery (the wound is opened using a scalpel) One study (106 participants) reported time to complete wound healing and time to a clean wound bed. There is low-certainty evidence that there may be a reduction in time to complete wound healing and very low-certainty evidence that there may be no difference in time to a clean wound bed with surgical debridement via endoscopy compared to 'open' surgical debridement. The study did not report adverse events. Overall, the evidence was low to very low-certainty for all outcomes. Five included studies were published before 1991 and investigated treatments that are no longer available. Worldwide production of dextranomer products has been discontinued, except for dextranomer paste, which is currently only available in South Africa. Furthermore, Eusol, used in one study as the comparator to dextranomer, is rarely used due to risk of harmful effects on healthy tissue and the enzymatic agent streptokinase/streptodornase is no longer available worldwide.

AUTHORS' CONCLUSIONS

Evidence for the effects of different methods of debridement on complete wound debridement and healing of surgical wounds remains unclear. Adequately powered, methodologically robust RCTs evaluating contemporary debridement interventions for surgical wounds are needed to guide clinical decision-making.

Wound, pressure ulcer and burn guidelines - 1: Guidelines for wounds in general, second edition

The Japanese Dermatological Association prepared the clinical guidelines for the "Wound, pressure ulcer and burn guidelines", second edition, focusing on treatments. Among them, "Guidelines for wounds in general" is intended to provide the knowledge necessary to heal wounds, without focusing on particular disorders. It informs the basic principles of wound treatment, before explanations are provided in individual chapters of the guidelines. We updated all sections by collecting references published since the publication of the first edition. In particular, we included new wound dressings and topical medications. Additionally, we added "Question 6: How should wound-related pain be considered, and what should be done to control it?" as a new section addressing wound pain, which was not included in the first edition.

A randomized controlled trial on the effect of a silver carboxymethylcellulose dressing on surgical site infections after breast cancer surgery

BACKGROUND

The incidence of surgical site infections (SSIs) after breast cancer surgery is relatively high; ranging from 3 to 19%. The role of wound dressings in the prevention of SSI after breast cancer surgery is unclear. This study compares a silver carboxymethylcellulose dressing (AQUACEL Ag Surgical (Aquacel) with standard wound dressing in SSI rate after breast cancer surgery.

PATIENTS AND METHODS

A single-centre randomized controlled trial among women ≥18 years, diagnosed with breast cancer, undergoing breast conserving or ablative surgery, was conducted in a combined in and outpatient setting. The intervention was the use of Aquacel, compared with standard gauze dressing. Primary outcome measure was SSI following CDC criteria.

RESULTS

A total of 230 patients were analysed: 106 in the Aquacel group and 124 controls. Seven patients (6.6%) developed SSI in the Aquacel group and 16 patients (12.9%) in the control group (RR 0.51 [95% Confidence Interval (CI): 0.22-1.20]; p = 0.112; adjusted OR 0.49 [0.19-1.25] p = 0.135)). Unplanned exploratory subgroup analysis of breast conserving surgery patients showed that SSI rate was 1/56 (1.8%) in the Aquacel group vs. 7/65 (10.8%) in controls; adjusted OR 0.15 [0.02-1.31] p = 0.087. The Aquacel group showed better patient satisfaction (median 8 vs. 7 on a Numerical Rating Scale, p = 0.006), fewer dressing changes within 48 hours(adjusted OR 0.12 [0.05-0.27] p<0.001), fewer re-operations (0% vs. 3.2%, p = 0.062), and lower mean wound-related treatment costs, both in a high (€265.42 (SD = 908) vs. €470.65 (SD = 1223) [p<0.001]) and low (€59.12 (SD = 129) vs. €67.55 (SD = 172) [p<0.001]) attributable costs of SSI model.

CONCLUSION

In this randomized controlled trial in women undergoing surgery for breast cancer, the use of AQUACEL Ag Surgical wound dressing did not significantly reduce the occurrence of SSIs compared to standard gauze dressing. The use of Aquacel resulted in significantly improved patient satisfaction, reduced dressing changes and reduced wound-related costs.

TRIAL REGISTRATION

www.trialregister.nl: NTR5840.

Antibiotics and antiseptics for surgical wounds healing by secondary intention

BACKGROUND

Following surgery, incisions are usually closed by fixing the edges together with sutures (stitches), staples, adhesives (glue) or clips. This process helps the cut edges heal together and is called 'healing by primary intention'. However, a minority of surgical wounds are not closed in this way. Where the risk of infection is high or there has been significant loss of tissue, wounds may be left open to heal by the growth of new tissue rather than by primary closure; this is known as 'healing by secondary intention'. There is a risk of infection in open wounds, which may impact on wound healing, and antiseptic or antibiotic treatments may be used with the aim of preventing or treating such infections. This review is one of a suite of Cochrane reviews investigating the evidence on antiseptics and antibiotics in different types of wounds. It aims to present current evidence related to the use of antiseptics and antibiotics for surgical wounds healing by secondary intention (SWHSI).

OBJECTIVES

To assess the effects of systemic and topical antibiotics, and topical antiseptics for the treatment of surgical wounds healing by secondary intention.

SEARCH METHODS

In November 2015 we searched: The Cochrane Wounds Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE and EBSCO CINAHL. We also searched three clinical trials registries and the references of included studies and relevant systematic reviews. There were no restrictions with respect to language, date of publication or study setting.

SELECTION CRITERIA

Randomised controlled trials which enrolled adults with a surgical wound healing by secondary intention and assessed treatment with an antiseptic or antibiotic treatment. Studies enrolling people with skin graft donor sites were not included, neither were studies of wounds with a non-surgical origin which had subsequently undergone sharp or surgical debridement or other surgical treatments or wounds within the oral or aural cavities.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed study selection, risk of bias assessment and data extraction.

MAIN RESULTS

Eleven studies with a total of 886 participants were included in the review. These evaluated a range of comparisons in a range of surgical wounds healing by secondary intention. In general studies were small and some did not present data or analyses that could be easily interpreted or related to clinical outcomes. These factors reduced the quality of the evidence.Two comparisons compared different iodine preparations with no antiseptic treatment and found no clear evidence of effects for these treatments. The outcome data available were limited and what evidence there was low quality.One study compared a zinc oxide mesh dressing with a plain mesh dressing. There was no clear evidence of a difference in time to wound healing between groups. There was some evidence of a difference in measures used to assess wound infection (wound with foul smell and number of participants prescribed antibiotics) which favoured the zinc oxide group. This was low quality evidence.One study reported that sucralfate cream increased the likelihood of healing open wounds following haemorrhoidectomy compared to a petrolatum cream (RR: 1.50, 95% CI 1.13 to 1.99) over a three week period. This evidence was graded as being of moderate quality. The study also reported lower wound pain scores in the sucralfate group.There was a reduction in time to healing of open wounds following haemorrhoidectomy when treated with Triclosan post-operatively compared with a standard sodium hypochlorite solution (mean difference -1.70 days, 95% CI -3.41 to 0.01). This was classed as low quality evidence.There was moderate quality evidence that more open wounds resulting from excision of pyomyositis abscesses healed when treated with a honey-soaked gauze compared with a EUSOL-soaked gauze over three weeks' follow-up (RR: 1.58, 95% CI 1.03 to 2.42). There was also some evidence of a reduction in the mean length of hospital stay in the honey group. Evidence was taken from one small study that only had 43 participants.There was moderate quality evidence that more Dermacym®-treated post-operative foot wounds in people with diabetes healed compared to those treated with iodine (RR 0.61, 95% CI 0.40 to 0.93). Again estimates came from one small study with 40 participants.

AUTHORS' CONCLUSIONS

There is no robust evidence on the relative effectiveness of any antiseptic/antibiotic/anti-bacterial preparation evaluated to date for use on SWHSI. Where some evidence for possible treatment effects was reported, it stemmed from single studies with small participant numbers and was classed as moderate or low quality evidence. This means it is likely or very likely that further research will have an important impact on our confidence in the estimate of effect, and may change this estimate.

Wound Dressings and Comparative Effectiveness Data

Significance: Injury to the skin provides a unique challenge, as wound healing is a complex and intricate process. Acute wounds have the potential to move from the acute wound to chronic wounds, requiring the physician to have a thorough understanding of outside interventions to bring these wounds back into the healing cascade. Recent Advances: The development of new and effective interventions in wound care remains an area of intense research. Negative pressure wound therapy has undoubtedly changed wound care from this point forward and has proven beneficial for a variety of wounds. Hydroconductive dressings are another category that is emerging with studies underway. Other modalities such as hyperbaric oxygen, growth factors, biologic dressings, skin substitutes, and regenerative materials have also proven efficacious in advancing the wound-healing process through a variety of mechanisms. Critical Issues: There is an overwhelming amount of wound dressings available in the market. This implies the lack of full understanding of wound care and management. The point of using advanced dressings is to improve upon specific wound characteristics to bring it as close to "ideal" as possible. It is only after properly assessing the wound characteristics and obtaining knowledge about available products that the "ideal" dressing may be chosen. Future Directions: The future of wound healing at this point remains unknown. Few high-quality, randomized controlled trials evaluating wound dressings exist and do not clearly demonstrate superiority of many materials or categories. Comparative effectiveness research can be used as a tool to evaluate topical therapy for wound care moving into the future. Until further data emerge, education on the available products and logical clinical thought must prevail.

Cavity wounds management: a multicentre pilot study

The objective of this study was to assess acceptability (based on pain at removal), efficacy and tolerance of an absorbent and cohesive rope(UrgoClean Rope, Laboratoires Urgo) in the local management of deep cavity wounds. This study was a prospective, multicentre (13), non comparative clinical study. Patients presenting with an acute or chronic non-infected cavity wound were followed up for four weeks and assessed weekly with a physical examination, in addition to volumetric,planimetric and photographic evaluations. Pain at removal was the primary criterion, assessed on a Visual Analogic Scale. The percentage of the wound surface area reduction and volumetric reduction were considered as secondary efficacy criteria. Forty three patients were included in this study. After one week of treatment dressing removal was painless and continued to be so throughout the period of the trial(four weeks). Median surface area at baseline was 7.74 cm2 and was reduced by 54.5% at week 4 (relative area reduction). Median wound volumetric value was noted 12 ml at baseline and was reduced by 72.7% by the end of treatment. The cohesiveness of the new rope was considered very good by health professionals. No residue was observed on the wound bed during the dressing change with the new rope. There were no adverse events related to the tested rope, during this trial.Pain-free removal associated with good efficacy and tolerance were observed with this new cohesive rope in the healing process of deep cavity wounds and could represent a therapeutic alternative to the usual ropes used in such indications.

Debridement for surgical wounds

BACKGROUND

Surgical wounds that become infected are often debrided because clinicians believe that removal of this necrotic or infected tissue will expedite wound healing. There are numerous methods available but no consensus on which one is most effective for surgical wounds.

OBJECTIVES

To determine the effect of different methods of debridement on the rate of debridement and healing of surgical wounds.

SEARCH METHODS

In March 2013, for this third update, we searched the Cochrane Wounds Group Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE; and EBSCO CINAHL.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) with outcomes including at least one of the following: time to complete debridement or time to complete healing.

DATA COLLECTION AND ANALYSIS

Two review authors independently reviewed the abstracts and titles obtained from the search, extracted data independently using a standardised extraction sheet and independently assessed methodological quality. One review author was involved in all stages of the data collection and extraction process, thus ensuring continuity.

MAIN RESULTS

Five RCTs (159 participants) were eligible for inclusion; all compared treatments for infected surgical wounds and reported time required to achieve a clean wound bed (complete debridement). One trial compared an enzymatic agent (streptokinase/streptodornase) with saline-soaked dressings. Four trials compared the effectiveness of dextranomer beads or paste with other products (different comparator in each trial) to achieve complete debridement. Meta-analysis was not possible due to the unique comparisons within each trial. One trial reported that dextranomer achieved a clean wound bed significantly more quickly than Eusol, and one trial comparing enzymatic debridement with saline-soaked dressings reported that the enzyme-treated wounds were cleaned more quickly. However, methodological quality was poor in these two trials.

AUTHORS' CONCLUSIONS

There is a lack of large, high-quality published RCTs evaluating debridement per se, or comparing different methods of debridement for surgical wounds, to guide clinical decision-making.

Debridement for surgical wounds

BACKGROUND

Surgical wounds that become infected are often debrided because clinicians believe that removal of this necrotic or infected tissue will expedite wound healing. There are numerous methods available but no consensus on which one is most effective for surgical wounds.

OBJECTIVES

To determine the effect of different methods of debridement on the rate of debridement and healing of surgical wounds.

SEARCH STRATEGY

For this second update we searched the Cochrane Wounds Group Specialised Register (searched 13 April 2011); the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 1); Ovid MEDLINE (2007 to March Week 5 2011); Ovid MEDLINE (In-Process & Other Non-Indexed Citations, April 11, 2011); Ovid EMBASE (2007 to 2011 Week 14); and EBSCO CINAHL (2007 to 8 April 2011).

SELECTION CRITERIA

We included randomised controlled trials (RCTs) with outcomes including at least one of the following: time to complete debridement or time to complete healing.

DATA COLLECTION AND ANALYSIS

Two review authors independently reviewed the abstracts and titles obtained from the search, extracted data independently using a standardised extraction sheet and independently assessed methodological quality. One review author was involved in all stages of the data collection and extraction process, thus ensuring continuity.

MAIN RESULTS

Five RCTs (159 participants) were eligible for inclusion; all compared treatments for infected surgical wounds and reported time required to achieve a clean wound bed (complete debridement). One trial compared an enzymatic agent (streptokinase/streptodornase) with saline-soaked dressings. Four trials compared the effectiveness of dextranomer beads or paste with other products (different comparator in each trial) to achieve complete debridement. Meta-analysis was not possible due to the unique comparisons within each trial. One trial reported that dextranomer achieved a clean wound bed significantly more quickly than Eusol, and one trial comparing enzymatic debridement with saline-soaked dressings reported that the enzyme-treated wounds were cleaned more quickly. However, methodological quality was poor in these two trials.

AUTHORS' CONCLUSIONS

There is a lack of large, high-quality published RCTs evaluating debridement per se, or comparing different methods of debridement for surgical wounds, to guide clinical decision-making.

A randomised controlled trial comparing eusol and sugar as dressing agents in the treatment of traumatic wounds

We conducted a randomized controlled trial comparing EUSOL (Edinburgh University Solution of Lime) and sugar as dressing agents in the treatment of traumatic wounds. Patients in both groups were matched for age and gender. We found EUSOL did better than sugar in terms of contraction of size of wound, presence of discharge, floor area covered with slough, formation of healthy granulation and early possibility of wound coverage.

Debridement for surgical wounds

BACKGROUND

Surgical wounds that become infected are often debrided because clinicians believe that removal of this necrotic or infected tissue will expedite wound healing. There are numerous methods available but no consensus on which one is most effective for surgical wounds.

OBJECTIVES

The aim of this review is to determine the effect of different methods of debridement on the rate of debridement and healing of surgical wounds.

SEARCH STRATEGY

We developed a search strategy to search the following electronic databases: Wounds Group Specialised Trials Register (searched 3/3/08) , Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, 2008, issue 1), MEDLINE (1950 to February Week 3 2008 ), EMBASE (1980 to 2008 Week 09) and CINHAL (1982 to February Week 4 2008). We checked the citations within obtained studies to identify additional papers and also relevant conference proceedings. We contacted manufactures of wound debridement agents to ascertain the existence of published, unpublished and ongoing trials. Our search was not limited by language or publication status.

SELECTION CRITERIA

We included relevant randomised controlled trials (RCT) with outcomes including at least one of the following: time to complete debridement, or time to complete healing.

DATA COLLECTION AND ANALYSIS

Two authors independently reviewed the abstracts and titles obtained from the search, two extracted data independently using a standardised extraction sheet, and two independently assessed methodological quality. One author was involved in all stages of the data collection and extraction process, thus ensuring continuity.

MAIN RESULTS

Five RCTs were eligible for inclusion; all compared treatments for infected surgical wounds and reported time required to achieve a clean wound bed (complete debridement). One trial compared an enzymatic agent (Streptokinase/streptodornase) with saline-soaked dressings and reported the time to complete debridement. Four of the trials compared the effectiveness of dextranomer beads or paste with other products (different comparator in each trial) to achieve complete debridement. Meta analysis was not possible due to the unique comparisons within each trial. One trial reported that dextranomer achieved a clean wound bed significantly more quickly than Eusol, and one trial comparing enzymatic debridement with saline-soaked dressings reported that the enzyme treated wounds were cleaned more quickly. However methodological quality was poor in these two trials.

AUTHORS' CONCLUSIONS

There is a lack of large, high quality published RCTs evaluating debridement per se or comparing different methods of debridement for surgical wounds, to guide clinical decision making.

Chronic wound pain: a conceptual model

PURPOSE

To present the wound care practitioner with a model for the assessment and treatment of wound-related pain.

TARGET AUDIENCE

This continuing education activity is intended for physicians and nurses with an interest in wound care and related disorders.

OBJECTIVES

After reading this article and taking this test, the reader should be able to: 1. Discuss the pathophysiology of chronic pain and the wound pain model. 2. Describe the patient's wound-related pain perspective. 3. Identify aspects of local wound care and their relationship to pain.

Minimising wound-related pain at dressing change: evidence-informed practice

Pain is a common concern in patients with chronic wounds. The purpose of this article is to inform clinicians of empirical evidence for practice based on a recent published consensus document on wound related pain. A team approach is needed to address the experience of living with wound related pain within a holistic framework. The importance of regular pain assessment and strategies to minimize traumatic during wound care are highlighted.

Systematic review of dressings and topical agents for surgical wounds healing by secondary intention

Background

The best dressing for postoperative wounds healing by secondary intention is unknown.

Methods

A systematic review was conducted to assess the effectiveness of dressings and topical agents on such wounds. Main endpoints were wound healing, pain, patient satisfaction, costs and hospital stay. Systematic methodological appraisal and data extraction were performed by independent reviewers.

Results

Fourteen reports of 13 randomized clinical trials on dressings or topical agents (gauze, foam, bead, alginate and hydrocolloid dressing) for postoperative wounds healing by secondary intention were identified; they were of weak methodological quality. In general, no statistically significant differences in wound healing were found for various dressing comparisons (11 of 13 trials). Patients experienced significantly more pain (four of six trials) and were less satisfied when gauze was used (three of six trials). Gauze was inexpensive, but its use was associated with significantly more nursing time than dressing with foam (two of three trials). No substantial differences in hospital stay were found (four of five trials).

Conclusions

Only small, poor-quality trials exist, rendering the evidence insufficient. Foam is best studied as an alternative to gauze and appears to be preferable in terms of pain reduction, patient satisfaction and nursing time.

Modelling the cost implications of using carboxymethylcellulose dressing compared with gauze in the management of surgical wounds healing by secondary intention in the US and UK

OBJECTIVE

To estimate the costs of using carboxymethyl cellulose dressing (CMCD; Aquacel* Hydrofiber) compared to gauze in managing surgical wounds healing by secondary intention in the US and UK.

STUDY DESIGN

This was a modelling study performed from the perspective of payers (i.e. the hospital and community sector in the US and the National Health Service (NHS) in the UK).

METHODS

Clinical outcomes attributable to managing surgical wounds healing by secondary intention with gauze were obtained from the published literature in the English language. There were no published studies on wounds healing by secondary intention with CMCD. Hence, the analysis conservatively assumed that wound healing rates associated with gauze would be the same for CMCD. These data were combined with resource utilisation estimates derived from a panel of clinicians enabling us to perform decision modelling. The models were used to determine the expected direct healthcare costs eight weeks after the surgical wounds were dressed by CMCD or gauze and left to heal by secondary intention in the US and UK.

RESULTS

All wounds are expected to heal within eight weeks, irrespective of dressing. Managing abscesses and other surgical wounds with CMCD instead of gauze in the US is expected to reduce costs by 4% in both wound types (i.e. $247 and $507 respectively) per patient over eight weeks. In the UK, managing abscesses and other surgical wounds with CMCD instead of gauze is expected to reduce costs by 30% (574 pounds) and 12% (581 pounds) respectively per patient over eight weeks. The lower cost of managing CMCD-treated patients is due to decreased nursing costs associated with a lower frequency of CMCD changes compared to gauze dressing changes.

CONCLUSION

Dressing surgical wounds healing by secondary intention with CMCD instead of gauze is expected to lead to a reduction in healthcare costs in both the US and UK. Hence, the purchase price of a dressing is not indicative of the cost effectiveness of a given method of surgical wound care.

Use of topical negative pressure therapy in postoperative dehisced or infected wounds

Animal and case studies suggest that topical negative pressure for subacute wounds can increase angiogenesis and local blood flow and reduce bacterial counts, but clinical trials into the technique have yet to be conducted.

A polymeric membrane dressing with antinociceptive properties: analysis with a rodent model of stab wound secondary hyperalgesia

The putative antinociceptive properties of a commercially available polymeric membrane dressing were tested by using a hind limb penetrating stab wound model in which secondary hyperalgesia could be evaluated from the hind paw. We examined the responses to mechanical and thermal stimuli applied to the hind paw remote to 2 small penetrating stab wounds of the calf. Application of the polymeric membrane dressing, but not gauze dressing, significantly reduced the development of both mechanical and thermal hyperalgesia induced by the penetrating stab wounds. In addition, animals with stab wounds showed a significant decrease in cage activity, and this decrease was prevented by application of the polymeric dressing. Analysis of spinal cord Fos expression demonstrated that the polymeric membrane, but not gauze, dressing significantly decreased stab wound-induced Fos expression in laminae I to VI of the ipsilateral L3-L5 cord segments. In addition, application of the polymeric membrane, but not gauze, dressing to the hind limb of naïve animals elicited Fos expression in laminae III and IV of the lumbar spinal cord. The data indicate that this model might be useful for evaluation of the mechanisms underlying deep tissue injury-induced secondary hyperalgesia, but they also demonstrate that the polymeric membrane dressing tested is capable of significantly reducing secondary hyperalgesia.

PERSPECTIVE

Surgery and other types of penetrating wounds cause pain that is not always relieved by opioids and/or less potent analgesics. The present results suggest that the polymeric membrane dressing tested here may be used alone or in conjunction with analgesics to relieve pain caused by penetrating tissue injury.

Dressings and topical agents for surgical wounds healing by secondary intention

BACKGROUND

Many different wound dressings and topical applications are used to cover surgical wounds healing by secondary intention. It is not known whether these dressings heal wounds at different rates.

OBJECTIVES

To assess the effectiveness of dressings and topical agents on surgical wounds healing by secondary intention

SEARCH STRATEGY

We sought relevant trials from the Cochrane Central Register of Controlled Trials, Cochrane Wounds Group Specialised Trials Register, MEDLINE, EMBASE, and CINAHL databases in March 2002.

SELECTION CRITERIA

All randomised controlled trials (RCTs) evaluating the effectiveness of dressings and topical agents for surgical wounds healing by secondary intention.

DATA COLLECTION AND ANALYSIS

Eligibility for inclusion was confirmed by two reviewers who independently judged the methodological quality of the trials according to the Dutch Cochrane Centre list of factors relating to internal and external validity. Two reviewers summarised data from eligible studies using a data extraction sheet, any disagreements were referred to a third reviewer.

MAIN RESULTS

Fourteen reports of 13 RCTs on dressings or topical agents for postoperative wounds healing by secondary intention were identified.

WOUND HEALING

Whilst a single small trial of aloe vera supplementation vs gauze suggests delayed healing with aloe vera, the results of this trial are un interpretable since there was a large differential loss to follow up. A plaster cast applied to an amputation stump accelerated wound healing compared with elastic compression, WMD -25.60 days, 95% CI -49.08 to -2.12 days (1 trial). There were no statistically significant differences in healing for other dressing comparisons (e.g. gauze, foam, alginate; 11 trials). PAIN: Gauze was associated with significantly more pain for patients than other dressings (4 trials). PATIENT SATISFACTION: Patients treated with gauze were less satisfied compared with those receiving alternative dressings (3 trials).

COSTS

Gauze is inexpensive but its use is associated with the use of significantly more nursing time than foam (2 trials). LENGTH OF HOSPITAL STAY: Four trials showed no difference in length of hospital stay. One trial found shorter hospital stay in people after amputation when plaster casts were applied compared with elastic compression (WMD -30.10 days; 95% CI -49.82 to -10.38).

REVIEWERS' CONCLUSIONS

We found only small, poor quality trials; the evidence is therefore insufficient to determine whether the choice of dressing or topical agent affects the healing of surgical wounds healing by secondary intention. Foam is best studied as an alternative for gauze and appears to be preferable as to pain reduction, patient satisfaction and nursing time.

Modern dressings: healing surgical wounds by secondary intention

There is a lack of robust research evidence on many aspects of wound care. The inaugural Professional Select Committee on Wound Care, held at the Royal College of Surgeons, explored the relative value of modern and traditional dressings in treating wounds healing by secondary intention. This article outlines its main findings.

Suitable dressings for toenail bed wounds: a literature review

This literature review considers potential dressing options for toenail avulsion. It forms part of the preparatory work for a prize-winning paper describing a qualitative study on pain experience, previously published in Journal of Wound Care.

A review of research investigating pain and wound care

Health-care professionals need to understand pain development and assessment, which should be undertaken at every treatment. This review outlines available research findings and highlights the problems that exist in measuring pain.

Pain at first dressing change after toenail avulsion: the experience of nurses, patients and an observer: 1

OBJECTIVE

Ingrowing toenails are often treated surgically by nail avulsion, with paraffin tulle gauze applied to the toenail bed afterwards. In one large city's primary care trusts, community nurses reported that patients felt pain when the gauze was removed postoperatively. This study looked at patients' general pain experience, and their pain during the first dressing change after toenail avulsion. Patients' perceptions of their pain were investigated, along with nurses' experience of redressing toenail beds, their technique and their interaction with patients, especially in relation to pain prevention.

METHOD

First an extensive literature review was conducted. Then a collective instrumental case study design was used. This allowed triangulation of data sources using patient and nurse interviews, and non-participant observation, from six cases recruited from the city's primary care trusts. Data were subjected to thematic content analysis, with two main categories identified. These were 'setting up of expectations' and 'a painful experience: but for whom?'

RESULTS AND CONCLUSION

This study provides a unique description of the type of pain patients experience. It raises serious issues about the adequacy of nurses' management of pain, including assessment, documentation and advice on pain-relief strategies. It supports discontinuing the use of paraffin tulle gauze as the postoperative dressing, and raises ethical issues about changing treatments and lack of communication with secondary care. Finally, it identifies a gap in knowledge of the most suitable dressing product to apply immediately after surgery. A randomised controlled trial is needed to clarify these preliminary findings.

Achieving value for money? Evaluation of two wound dressings

During the past three decades there has been dramatic increase in spending on wound dressing products in the UK. While the rise in costs in many ways reflects a rise in the performance of the products purchased, it remains vital that nurses charged with prescribing such products achieve value for money. This article describes a small study of the use of a primary dressing and a secondary wound dressing in 12 patients, representing a range of wounds. In each case a more expensive alternative would normally have been used. In each case observed, involving both primary and secondary dressings, no deficit in clinical performance was noted but potential cost benefits were identified. The authors conclude that these initial findings are encouraging and further studies are required to address this important area of wound management.

Secondary wound dressings: an evaluation of Alldress

Nurses are increasingly faced with the need to balance clinical efficacy with economic advantages when selecting wound management products. Compared to 20 or 30 years ago the money spent by the NHS in the UK on wound dressings has risen dramatically. It is also true that the rise in costs has, for the most part, been matched by an improvement in product performance. It is, however, important that claimed advances in wound management products are assessed critically to ensure they provide both clinical and economic benefits. In this article the authors explore the use of a secondary wound dressing. Using a case study methodology, the authors have conducted an evaluation aimed at identifying possible economic benefits associated with the study dressing as opposed to more expensive alternatives. In the case studies observed the dressing has been found to provide the required level of clinical performance at a considerable saving when compared to other modern wound management dressings. The authors conclude that these initial findings merit further investigation as they could, if replicated on a larger scale, result in considerable cost savings for the NHS without sacrificing clinical standards.

Review of an independent audit into the clinical efficacy of VACUTEX

An independent report was completed and analysed by Pharmaceutical Research Associates International in August 2001 (Pro-Tex, 2001). This company provides a service to carry out independent project work and research studies within the healthcare sector. The project involved 73 tissue viability nurses and 93 patients, whereby the performance of VACUTEX capillary action wound dressing was assessed on both acute and chronic wounds. The audit takes into account the varying cultures across England and Wales and demonstrates this rapid method of comparing previous dressings used on a multitude of wound types, with analysis focusing on the versatility and efficacy of the VACUTEX capillary action wound dressing. This article reviews the findings of the audit.

Alginate dressings in surgery and wound management--Part 1

Large quantities of alginate dressings are used each year to treat exuding wounds, such as leg ulcers, pressure sores and infected surgical wounds. Originally these dressings were a loose fleece formed primarily from fibres of calcium alginate. More recently they have been developed so that the fibres have been entangled to form a product with more cohesive structure, which increases the fabric's strength when it is soaked with exudate or blood. Some products also contain a significant proportion of sodium alginate to improve the gelling properties of the dressing in use. Other dressings have been produced from freeze-dried alginate. Once in contact with an exuding wound, an ion-exchange reaction takes place between the calcium ions in the dressing and sodium ions in serum or wound fluid. When a significant proportion of the calcium ions on the fibre have been replaced by sodium, the fibre swells and partially dissolves forming a gel-like mass. The degree of swelling is determined principally by the chemical composition of the alginate, which depends on its botanical source. Although it is recognised that the differences between the various brands of dressings may influence their handling characteristics--particularly when wet--it is generally assumed that these differences are of limited relevance to the dressing's performance clinically or at a cellular level. There is some evidence to suggest, however, that these assumptions may be wrong and that alginates may influence wound healing in a number of ways not yet fully understood. This three-part review of the literature encompasses the history, origin, structure, chemistry and clinical applications of alginates and alginate dressings. This review reveals that, despite their widespread use, alginates have been the subject of very few well-controlled clinical studies. There is fairly convincing evidence, however, that they do offer advantages over more traditional dressings for at least some clinical indications. It has also become obvious that there is a general lack of understanding about the importance of secondary dressing systems that must be used in with alginate dressings. Careful examination of the design and outcomes of the published studies suggests that the choice of both the primary alginate dressing and the secondary dressing can play a major role in determining treatment outcomes.

The management of chronic wounds: factors that affect nurses' decision-making

This study sought to determine how registered nurses make decisions regarding the management of chronic wounds. A self-administered questionnaire consisting of both Likert-type and open-ended questions was used to survey registered nurses working in hospitals and community services in a large Australian city. A total of 140 questionnaires were returned from a variety of clinical settings. The study revealed that registered nurses had a significant role in chronic wound management. However, they relied primarily on their own experience and that of colleagues for decision making in which they had varying degrees of autonomy. The authors conclude that nurses and medical staff require more objective, research-based education on wound assessment and management.

Adsorption of serum-derived proteins by primary dressings: implications for dressing adhesion to wounds

Using an in vitro immunolocalization technique, an exploratory study was carried out into the serum-derived protein adsorption capacity and the cell adherence of a traditional gauze dressing versus a new gelling fibre gauze dressing. We found that the traditional gauze dressing adsorbed protein more readily than the new dressing. The findings indicate that reduced binding of serum proteins to the surface of the gelling fibre dressing may help reduce the adherence characteristics for this type of dressing, minimising trauma and possibly reducing the acute pain experienced during dressing changes.