By the WoundSource Editors
Chronic wounds pose an ongoing challenge for clinicians, and there needs to be a clearer understanding of the pathophysiology of wound chronicity and treatment modalities available.
By Marta Ostler, PT, CWS, CLT, DAPWCA
On June 28, 2018, I presented a webinar on the topic of wound dressing selection as part of WoundSource's Practice Accelerator series on Wound Dressings 101. Choosing an appropriate wound dressing for your patient can be a difficult task; however, understanding this important step in the wound healing cascade is integral to maintaining and achieving healing outcomes for our patients with chronic and acute wounds. During the informative presentation, I discussed such topics as:
Attendees of the webinar were able to ask questions during our Q&A segment. Following are responses to the top themed questions asked during the webinar related to wound dressings and treatment:
Most hydrocolloids have aggressive adhesives (and are too occlusive) that are not appropriate for skin tears. Do you agree?
I do agree for many hydrocolloids! However, sometimes it's really the wound's choice. My go-to dressing for skin tears that are minimally draining is a hydrocolloid. Certain hydrocolloids work well for minimum to scant drainage and can stay in place for weeks. For me, it's just picking the right wound/ulcer for the product.
Would a hydrocolloid be appropriate for a resident with a full-thickness sacrum ulcer with a twice-weekly alginate change to reduce the number of dressing changes to a hospice patient?
This method would not be my choice. If the wound care is palliative in nature and you need to reduce the frequency of the dressing changes, remember a hydrocolloid is not meant to absorb drainage. I would think an alginate or hydropolymer that will absorb a lot of drainage, covered by a super absorber, would fit better.
What would you recommend to cover a wound and provide cushion if foam is causing the edges of the wound to look macerated?
I would think that it would be good to look at something to protect the periwound prior to securing the foam in place. Also, I would want to look at a foam that would pull moisture from the wound away from the skin. I do like a medical-grade honey foam dressing and bacteriostatic foam dressings for that, myself.
What does MMP stand for?
Matrix metalloproteinases: they are a group of enzymes that degrade the extracellular matrix that a wound is trying to create during proliferation. This a good thing to put some study on.
What would be the best dressing for a patient who is extremely incontinent and has wounds to the coccyx area?
Maybe no dressing for a while. If the dressing is not staying in place, then it may be causing a pressure or shear issue. Maybe you can protect the wound and work to get the periwound improved. Also, ensure you have tried to deal with the incontinence. There are great skin adhesives that can be used when the periwound is intact.
Lymphedema with frequent cellulitis, hyperkeratosis treatment?
COMPRESSION, COMPRESSION, COMPRESSION. Also, if you can find a lymphedema therapist who will do some manual lymphatic drainage, that will help. Maybe a referral to physical therapy can also help, due to exercise intervention.
What dressing would you recommend for a hospice patient with extensive lymphedema and very fragile/thin skin who has a skin tear on the leg beside/below the knee?
Pick the dressing that is best for the patient, without any adhesives. Get a compression stocking and roll it on over the dressings. It is great for edema and lymphedema and will hold the dressings in place.
What wound cleansers would you recommend?
I tend to go for hypochlorous acid, as it is more specific to the body's own cleansing action. It is produced during inflammation to clean a break in the skin.
Could you please discuss native collagen vs. synthetic?
That can be a long discussion, and it may be best for a different venue. But, to be brief: native collagen typically has more crosslinking than synthetic collagen. However, there are many variables to consider. The cleansing process for collagen can be different; each process has its own procedure and some do change the native structure of the collagen. I really rely on my scientific network and company representatives to show me the information/data about a product. In my clinical experience, the native collagen is degraded more than synthetic. There is A LOT of literature on this subject out there on the specific aspects of collagen: I challenge you to dive into that data.
What do you think about instillation therapy with negative pressure wound therapy?
I really like this treatment opportunity. In fact, I have been making my own units for over 20 years. It is a great option for treatment. It has a lot of supportive data.
How do you suggest health care providers deal with Pseudomonas?
I have used antibiotics as the patient is able and have found success with vinegar soaks once to twice per day and some foam dressings.
Do you have criteria established for all the topical negative pressure devices when you use them?
I typically use the non-battery-powered device when drainage is not an issue and mobility is. I have used it a lot under compression as well. I don't operate with a protocol for this, specifically, because reimbursement is a factor.
How does the patient's insurance affect your decision in which specific product to use to manage/treat their wound?
Not a lot, unless the treatment I need is the ONLY option and is NOT covered. Then, I am upfront with the patient and we make the decision together about what they want to do. We can usually find a way around the issue. There are so many dressings on the market that I have never been told by a payer that I can't use a specific dressing.
How do you advise handling a patient who is refusing compression therapy?
I have had success telling the patient that the compression is "THE MEDICINE FOR THE WOUND/ULCER." I am not so sure why that works, but it can. Also, I believe it's okay, if the patient understands the situation and won't be accountable, to say I am sorry, I can't help you any longer. I know it's harsh, but it is real.
What are the recommendations for patients who are at risk of maggot exposure?
I like maggots, use them all the time. I had the not so clean maggots come into my office, having done a good job debriding the ulcer. However, yes, I understand your question. You have to keep the necrotic tissue covered because that is all the maggots want. Keeping the dressing sealed should be of help.
I don't really understand the concept of total contact casting. What exactly are they doing to a patient when that happens? Are they legit putting a cast on a wound to reduce pressure?
YES, legit putting a cast on; however the cast is put on to OFFLOAD THE ULCER, not protect a broken bone from movement. It is an immobilizing cast with extra padding to offload the ulcer. Please have a rep come and demonstrate that for you.
Have you ever used compression therapy synergistically with negative pressure therapy?
Many, many times. I have used the powered and the non-powered.
Can you comment on or are you aware of any studies regarding dressings altering the pH of the wound to stimulate healing?
There are many studies showing that wounds alter the pH of the wound base. These wound changes involve debridement, reduction in MMPs, as well as other cellular changes. Just search studies by Greg Schultz or other researchers who study these changes.
What is a reimbursable dressing for heavy weeping but no obvious wound?
If the skin is leaking, then to me, there is a wound. I measure the area that is draining and report that as the margins of the wound. Remember a wound is a break in the integrity of the skin. It becomes an ulcer after being open for four weeks or more. I do like diapers for these issues.
Where do pneumatic compression devices come into play in your wound healing strategy?
I use these only for management of lymphedema or deep venous insufficiency.
What would you recommend for a filler/primary dressing on a wound with light drainage and exposed tendon/bone?
Well, you need to cover the bone/tendon with something moist. I have used silver hydrogel or honey with a composite or contact layer. I like to keep viable structures moist!
How do you determine the correct amount of pressure to use with a negative pressure wound therapy device?
I tend to follow the manufacturer's guidelines. When I have questions, I use my representative for the product for help in deciding. I do that because the units out there are very different, and I know I can't know it all.
About the Author
Marta Ostler is the past Manager of Northeast Wyoming Wound Care in Sheridan, Wyoming, a department of Sheridan Memorial Hospital, where she has been for the past 24 years. She recently relocated to Billings, Montana and has joined St. Vincent’s Healthcare in their outpatient Physical Therapy Department. She is a Physical Therapist, Certified Wound Specialist, and Certified Lymphatic Therapist. Marta specializes in wound care and chronic wound management, as well as lymphedema treatment and management. She is a member of the American Academy of Wound Management, the American Professional Wound Care Association, the American Physical Therapy Association, and the American Board of Wound Healing. She also serves on the Board of the American Board of Wound Healing and the Association for the Advancement of Wound Care.
The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.