Amber is 42 jaar en moeder van 3 prachtige kinderen. Van kleins af aan was ze al redelijk gezet en dat bleef zo ondanks veel pogingen om af te vallen. Haar vader is overleden vlak na haar geboorte, ook hij was veel te zwaar en had te hoge cholesterol waarden. Amber dacht: dit gaat mij niet gebeuren en ik ga hulp zoeken om af te vallen. Ze kwam in 2016 in het ziekenhuis in Almelo bij de internist terecht en kreeg daar allerlei onderzoeken inclusief een erfelijkheidsonderzoek in verband met haar vader. Tijdens de tweede afspraak bij de internist werd ze goed met haar neus op de feiten gedrukt. Amber: ‘Hij zei, er moet gauw iets gebeuren want anders wordt u geen 38 jaar oud. Hier schrok ik dus behoorlijk van. Mijn bloeddruk was te hoog, ik rookte, had diabetes en een super hoog cholesterol gehalte.’ Al snel kreeg Amber groen licht voor een gastric bypass. ‘Maar daarvoor moest ik wel een jaar lang een voorbereidend traject volgen’. De operatie vond uiteindelijk plaats in april 2017.

In recent years, the impact of biofilms on non-healing wounds has gained increasing interest and it has been reported that between 80% to 100% of non-healing wounds have a biofilm associated with them that impedes wound healing (Bjarnsholt et al, 2017; Malone et al, 2017). Biofilms consist of a complex community of microorganisms, which tend to attach to surfaces, and are encased within a matrix consisting of extracellular polymeric substances (EPS) (Malone et al, 2017). This matrix provides

the microorganisms with protection against antimicrobial treatment and an individual’s immune system. There is an increasing focus and awareness around the use of biofilm based wound care (BBWC) pathways, and they are recommended in several consensus documents (Bianchi et al, 2016; Shultz et al, 2017; Murphy et al, 2020; International Wound Infection Institute (IWII), 2022), This article will discuss the evidence behind BBWC and the potential for introduction of a BBWC pathway into the community setting.

Introduction:

The treatment of infected chronic wounds is a challenge in everyday clinical practice. In the treatment of these wounds polyhexanide (PHMB) is the antiseptic of choice [1]. Patients with difficult personal backgrounds further complicate the successful treatment of these wounds. Two case studies of infected chronic lower leg ulcers are presented. The treatment was carried out with an antimicrobial wound dressing made of cellulose containing PHMB*.

Method:

Patient 1: A 27-year-old male patient from the UK with an infected venous leg ulcer on the right lower leg that had been present for 11 months (size: 315 cm², depth: 0.1 cm). Moderate exudation, odour and pain of VAS=7 present. A deep vein thrombosis has recently occurred. In addition, the patient suffers from drug addiction (intravenous), alcohol addiction and mental disorder. The patient was previously treated with a hydrogel-impregnated antimicrobial wound pad and a medical-grade honey dressing. The new treatment consisted of cleaning with a monofilament fibre debridement pad**, the antimicrobial cellulose dressing, a sterile absorbent compress and a tubular dressing as a secondary dressing.

Patient 2: An 80-year-old male patient from Germany with a mixed gaiter ulcer on the right lower leg (size: 450 cm², depth: 1 cm). Before the patient was admitted for treatment, he had already had several inpatient hospital stays. Therapy with a split-thickness skin graft was unsuccessful. The wound is infected with multidrug resistant gram-negative bacteria (MDRGN bacteria). The patient has had several antibiosis. The patient showed a constant incompliance with regard to the therapy attempts. Finally, a healing attempt with medicinal clay took place on the advice of his alternative (non-medical) practitioner. The patient was taken over with a massive infection, severe exudation and odour formation. Wound and lower leg pain correspondent to 8 on the Visual Analogue Scale (VAS). The entire lower leg was oedematous and papular indurations were present in the area of the forefoot. The wound was covered with biofilm and partially with fibrin. The wound edges and the surrounding skin were inflamed. Individual lesions were present. The patient's hygiene was poor. The weekly treatment was as follows: The wound was first cleaned with a wound irrigation solution containing sodium hypochlorite and a monofilament fibre debridement pad. The primary wound dressing was the cellulose dressing with PHMB. A highly absorbent wound compress*** and a superabsorbent wound dressing‡ served as a secondary dressing. In addition, the edema was treated with a compression bandage‡‡.

Results:

Patient 1: After 14 days and 5 dressing changes, the wound pain had decreased significantly (VAS = 1). The wound odour was gone. While the beginning granulation of the previously stagnant wound was particularly positive from the point of view of the user, the patient was particularly pleased that the wound odour had disappeared and that wound exudate no longer penetrated the dressing. The treatment was continued accordingly.

Patient 2: After 3 weeks, not only had the wound pain (VAS = 6-7) decreased, but the wound odour and signs of infection had disappeared. Granulation tissue was visible. After 4 weeks, the wound pain (VAS = 5-6) decreased even more. Although the patient acknowledged the success of the therapy and the reduction in pain, he stopped the treatment on the advice of his alternative practitioner.

Discussion:

Although the two cases involved patients with longstanding chronic wounds and difficult personal backgrounds, the users were able to heal the wound within a short time with the help of the antimicrobial cellulose wound dressing and adequate modern wound care. For the two users, the rapid treatment success, in the form of the beginning healing, was gratifying. For the patients, it was primarily the pain reduction and the decrease in wound odour that were particularly well received. This is not surprising, as these two factors play a major role in the patient's quality of life.

Conclusion:

The antimicrobial wound dressing proved to be a suitable for the treatment of infected chronic wounds.

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.

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.

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

Intellectually disabled 54 year old man with diabetes, obesity and hypertension. The patient has peripheral neuropathy of feet and developed a diabetic foot ulcer. Surgical debridement was performed in OR and wound was initially treated with impregnated gauze ribbon changed twice daily and cleaned with PHMB solution.

Action(s) taken/ treatment provided

A review of treatment regime and dressings was conducted at 5 weeks post-operation due to deterioration of wound, odour and possibility of future amputation of foot. New treatment plan included cleansing and debridement with and monofilament fibre pad and use of biocellulose hydrobalance dressing dipped in PHMB solution to improve rate of healing.

Outcome(s)

After 9 days, wound was granulating with reduced level of exudate and odour. Total cost of dressings over 9 days of treatment was $114.51. Patient was able to be transferred to a rehabilitation facility and avoided amputation.

Lesson(s) learned

After 5 weeks using a wound dressing regime including gauze and time consuming twice-daily dressing changes, the wound had deteriorated, rather than progressed towards healing. The change of dressing plan resulted in granulation and wound progression in just 9 days. Dressings were cost effective and saved time as did not need to be changed so regularly.

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.