Dressings for topical wound management
Product POINTERS
Dressings for topical wound management
By Liza Ovington, PhD, CWS
President, Ovington & Associates
Fort Lauderdale, FL
There are many preclinical and clinical studies comparing wound management using semiocclusive dressings with wound management with conventional textile-based dressings such as gauze and petrolatum gauze. Typical outcomes show that semiocclusive dressings achieve improvements — including reduced costs, reduced pain, and reduced caregiver time — as compared with conventional dressing materials.
Literature review of randomized, controlled clinical studies of dressing products reveals there is no single type of semiocclusive dressing that performs better than another in any specific wound type. For example, the Agency for Health Care Policy and Research (AHCPR) guidelines for pressure ulcer treatment reviewed the wound healing literature from 1966 through 1992 and found no evidence of different healing outcomes in pressure ulcer treatment with different types of semiocclusive dressings. A recent update to these guidelines revealed no disputing data in the time period from 1992 to the present. The formal AHCPR recommendation is to "use clinical judgment to select a type of moist wound dressing suitable for the ulcer."
The controversy relating to dressing utilization centers on this last phrase. Marrying clinical judgment to selection of a moist wound dressing suitable to a wound requires a healthy working knowledge of the product as well as the wound. This product knowledge is not so easily assimilated. Topical wound management products continue to steadily proliferate, presenting a virtual jungle of choices for the health care professional. In order to avoid becoming entangled in the overgrowth, it becomes vital to see the forest rather than the trees.
It was once enough to be familiar with a limited number of material categories or species of dressings such as films, foams, hydrocolloids, and alginates. Now, with innovations in material categories such as hydrofibers, hydropolymers, and emulsions; clever marketing strategies ("alternatives to alginates," "cures for hydrocolloid headaches," and "one product does it all"); and the evolution of pharmaceutical and bioengineered products such as growth factors and skin substitutes, it is necessary to look beyond the form of the product and toward the function of the product.
Utilization of wound management products should be approached from the standpoint of product function and performance parameters needed/desired in promoting optimal healing. What does the wound require? What does the product do? What does it not do? Over what range of conditions does it perform? Is what it does what you need? Where is the evidence that it does it effectively?
Functions of an optimal dressing for wound management are multiple, depending on the nature and status of the wound in question. These functions may include:
• exudate management;
• conformability;
• adherence;
• pain control;
• odor control;
• cost-effectiveness;
• safety;
• healing;
• debridement;
• microbial barrier;
• antimicrobial activity;
• pressure distribution;
• compression;
• wound visibility;
• convenience;
• quality of life improvement for patient.
If one sets out to rate the performance of the existing dressing categories and materials in each of these functional areas, it could prove unwieldy. However, if certain assumptions are made, the list of functions may be pared down.
The first assumption is that the primary etiology of the wound being treated is addressed. The second is that the wound being treated has an adequate blood supply. The third is that all semiocclusive dressings are ostensibly safe and will foster healing if used appropriately and according to directions. Finally, it may be assumed that many functional benefits related to improving healing are consequences of a physiologically moist local environment (pain reduction, increased healing rate, autolytic debridement). In order to create and maintain a physiologically moist environment (as opposed to a dry or wet environment), the selected dressing must absorb in the case of excessive wound exudate, hydrate in the case of a dry wound, or protect/maintain in the case of an already moist wound.
Dressings initially could be rated as absorbing, hydrating, or protecting with regard to their function. Dressings could secondarily be rated as being adhesive or nonadhesive, indicating the need for a secondary dressing for attachment. Further, dressings could be rated as suitable for depth/contours or for superficial wounds regarding their ability to conform to the wound volume or to a challenging anatomical location. It also may be of interest to the clinician whether the dressing offers a physical barrier to liquids or bacteria, in terms of infection control and patient convenience.
A table accompanying this article gives examples of a four-point performance description of some common dressing forms or materials. (See table, p. 79.) Specific branded products are used for illustration because certain performance parameters such as adhesion may depend on the specific brand. If wound dressings were uniformly classified according to such a performance-based scheme, the task of understanding when to use what product might become simpler, despite new product names, innovative materials, and the sheer volume of available products. Assessment of the wound bed, drainage levels, periwound skin, and location would then guide the clinician to specific desired dressing functions.
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