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Debridement is the removal of non-viable tissue from the wound bed and surrounding skin and is an important part of wound healing and wound bed preparation. Devitalised tissue, such as necrosis, slough and hyperkeratosis, interfere with the process of wound healing. When a wound fails to progress, there is a need to assess the wound bed and surrounding tissue and promote an optimum environment that encourages the formation of healthy granulation tissue (Young, 2014). Recent advances in debridement techniques using monofilament fibre technology can be practised by nonspecialist nurses and used safely and effectively in a patient’s home. In a recent audit, a dataset of 486 patients who had been newly prescribed a monofilament fibre debridement pad was obtained to validate clinical effectiveness and cost efficiency. The total cost of wound care prescribing fell by 14% or £101,723 in the six months after the intervention compared with the six months before. The average monthly expenditure per patient fell from £244 before the intervention to £209 after (Burnett et al, 2021). This evidence reinforces the National Institute for Health and Care Excellence (NICE) recommendations for use of monofilament fibre debridement in the community, based on evidence of its effectiveness and estimated cost savings (NICE, 2019).

Nanotechnology has opened a new area of scientific research. This field deals with materials within the dimensions of 1–100nm and a plethora of new technologies have emerged. In wound care, silver nanoparticles are used to aid wound healing as an antimicrobial agent, but also as an anti-inflammatory agent. The properties of silver nanoparticles differ from that of the material on a larger scale and their production can be controlled to give varied properties and characteristics that have different uses. These resultant properties are very important and differences in characterisation can alter their biological and physical attributes. All wound dressings have to undergo rigorous scrutiny around toxicity and safety when regulatory review is undertaken, yet some users still have concerns over long-term effects of silver nanoparticles in vivo. This review will address some of these concerns and reviews the current health and safety data associated with introduction of new products containing silver nanoparticles using Venus Ag dressings (SFM LTD, UK) as an example.

The treatment of chronic wounds presents a major challenge in medical care. In particular, the effective treatment of bacterial infections that occur in the form of biofilms is of crucial importance. To develop successful antibiofilm strategies for chronic wound treatment, biofilm models are needed that resemble the in vivo situation, are easy to handle, standardizable, and where results are readily transferable to the clinical situation. We established two 3D biofilm models to distinguish the effectiveness of wound dressings on important microorganisms present in chronic wounds. The first 3D biofilm model contains Staphylococcus aureus, Escherichia coli, and Acinetobacter baumannii, while the second is based on Pseudomonas aeruginosa. Bacteria are cultivated in a nutrient-rich agar/gelatin mix, into which air bubbles are incorporated. This results in a mature biofilm growing in clusters similar to its organization in chronic wounds. The models are convenient to use, have low variability and are easy to establish in the laboratory. Treatment with polihexanide and silver-containing wound dressings showed that the models are very well suited for antimicrobial testing and that they can detect differences in the efficacy of antimicrobial substances. Therefore, these models present valuable tools in the development of effective antibiofilm strategies in chronic wounds.

Aim:

82 year old man with diabetes, congestive cardiac failure and mixed arterial vascular insufficiency had been treated in the home for diabetic health management and a chronic history of leg ulcers.

Patient was suffering from hyperkeratosis and previous treatment was an elastic tubular bandage which was left on for 24 hours a day, 7 days a week.

Method:

A solution was required which would manage the hyperkeratosis, prevent further skin breakdown and prevent bacterial or fungal build up in the feet and legs. The solution had to be cost effective, gentle on skin and ensure quick, easy removal of excessive skin and debris.

A monofilament fibre debridement pad* was used to clean, remove and descale the hyperkeratosis without damaging healthy skin.

Results / Discussion:

After initial treatment with monofilament fibre debridement pad, there was visible improvement and reduction in hyperkeratosis, no itch and reduction in odour.

Once dead skin and hyperkeratosis was removed, patient was put on a structured skin care regime including cleansing, exfoliation and replenishing the skin barrier using emollients.

Conclusion:

Hyperkeratosis of the lower limb is a common skin condition that typically affects patients with chronic venous insufficiency. Patients are often embarrassed by the appearance of their skin, the hyperkeratotic scales and the unpleasant odour. The monofilament fibre debridement pad can be used by all healthcare professionals working in the community, and by patients. It’s effectiveness and ease of use may encourage patients or carers to take an active role in their care.

Aim: Stasis dermatitis is a common inflammatory dermatosis of the lower extremities. The mainstay is treatment of the underlying chronic venous insufficiency (CVI) with multimodal therapy, which is aimed at reducing oedema and venous hypertension. External compression with short stretch bandages, impregnated with zinc oxide, is used as first line therapy simultaneously reducing swelling and employing anti-inflammatory effects of zinc. Our aim was to compare two different short-stretch systems with zinc oxide, both from the patients and staff point of view.

Method: 10 patients with bilateral stasis dermatitis were included in the study. 2 patients had only CVI, while 8 patients had phlebolymphoedema. Both legs were treated simultaneously. Self-adherent two-layer bandaging system with zinc1 was applied on one leg and zinc paste bandage2 and adhesive short-stretch system3 was applied on the other leg for 7 days. A questionnaire with was filled out by the patients and the staff. Overall skin inflammation improvement was also assessed.

Results: Both systems proved to be easy and fast to apply. There were no differences in slippage or compliance during wear. Patients had no difficulties with mobility and wearing footwear while using either compression systems. 90% of patients reported that self-adherent bandaging system was at least as comfortable to wear as adhesive bandage. The skin condition was equally improved with both systems.

Conclusion: Both self-adherent and adhesive short-stretch systems with zinc proved to be suitable treatment of stasis dermatitis in patients with venous insufficiency and phlebolymphoedema.

Situation

Patient is a 73 year old lady who has been suffering with venous leg ulcers since 2016. On presentation, she had leg ulcers measuring more than 50cm2 which were very painful with high levels of exudate.

Action(s) taken/ treatment provided

Compression therapy was initially commenced with a long stretch compression bandage. This was changed to a 2 layer resuable short stretch system due to ease of use and patient comfort. This was a cost effective option as patient was able to wash, re-roll and reuse the bandages throughout her treatment from September 2019 to February 2020. The bandages were skin friendly and comfortable for the patient who is prone to dermatitis. The wounds were managed with alternate combinations of ionic gel dressing for pain relief, cadexomer iodine, antimicrobial dressings and biocellulose hydrobalance dressings.

Outcome(s)

In the first 4 weeks, the ulcers had reduced in size by 50% and after 6 months of treatment the wounds had fully closed.

Lesson(s) learned

In the absence of corrective surgery, compression therapy has been found to be the most effective treatment for venous leg ulcers (VLUs)1. Achieving healing rests on patients’ adherence to treatment and in this case it was found that compression bandages which are both cost effective and comfortable for the patient are more likely to encourage patient concordance. Compression therapy alongside effective wound care resulted in full healing for this patient after 4 years of suffering with venous leg ulcers.

Situation

Patient presented with a traumatic injury to left hand sustained while sailing. The wound was 3 weeks old and covered in hardened necrotic tissue.

Action(s) taken/ treatment provided

Upon advice from clinician, patient covered wound in plastic wrap overnight to soften and visited hospital the following morning. A monofilament fibre debridement lolly was used to mechanically debride outer necrotic eschar. An ionic hydrogel dressing was then applied for further autolytic debridement and deeper wound assessment. The dressing was removed after 24 hours and mechanically debrided again with monofilament fibre debridement lolly. After full wound assessment, decision was made to intervene surgically and patient received a skin graft within 24 hours.

Outcome(s)

After 3 months, the skin graft had healed and patient regained full use and movement of his hand.

Lesson(s) learned

The combination of mechanical and autolytic debridement using two simple, easy to use, community based products allowed for full assessment of the wound bed. The treating clinician was able to assess, dress, reassess and refer, resulting in a fast decision to send the patient for surgical intervention and improved overall clinical outcome.

Situation

Patient presented with bi-lateral leg ulceration and was being treated daily by a GP. Wounds had been present for the past 133 weeks and compression therapy was not part of the treatment regime.

Action(s) taken/treatment provided

Upon referral to the Nurse Navigator service at Princess Alexandra Hospital, routine vascular tests were carried out and he was deemed suitable for light compression therapy in addition to a wound care treatment plan, including wound bed preparation with monofilament fibre debridement pad. Compression bandaging is the gold standard treatment for those suffering from venous ulceration. The short-stretch bandage of choice delivers safe, light compression and is washable to help reduce the costs of ongoing treatment.

Outcome(s)

Wound healing progress was slow but consistent with the use of short stretch compression and the wound care treatment plan. Patient was adherent to care and found compression bandage to be comfortable, affordable, helped to reduce pain and improve quality of life. Leg ulcers fully healed after 32 weeks of treatment.

Lesson(s) learned

The Nurse Navigator supported patient care at GP practice to enable collaboration and education of those involved in ongoing care. This ensured a holistic approach to care allowing for systems improvement, patient centred care, improving patient outcomes and most importantly creating partnership between the GP practice and hospital.

Situation

76 year old lady with systemic pneumococcal infection was in ICU for 6 weeks and now being treated in community nursing and podiatry care. 9 toes were affected with necrosis.

Action(s) taken/ treatment provided

Patient had black, hard necrotic toes which required debridement of tips, nail beds and removal of exposed dead bones. Toes are difficult to dress and required moisture for autolytic debridement. Patient also required a solution which will relieve pain.

It was decided that a combined treatment of community nursing and podiatry would deliver the best outcome for this patient.

• Podiatry: Sharp debridement, removal of nails and removal of protruding dead bony toe phalanges

• Community nursing: Debridement with monofilament fibre pad (in combination with sharp debridement) and dressings for autolytic debridement and pain relief.

Outcome(s)

After 2 weeks of treatment on the left foot, black necrotic tissue has been softened to allow for further debridement. After 4 weeks of treatment, big toe almost healed and small amount of nail bed regrowth.

After 2 weeks of treatment on the right foot, evidence of granulation and epithelialisation of toes and nail bed areas.

Lesson(s) learned

Working as a multi-disciplinary team alongside allied health is vital for the healing process and can help to achieve the best possible clinical and patient outcomes, particularly for complex wounds.