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Aim:

Although hosiery is the golden standard in the maintenance phase for treating lymphedema or venous leg ulcers, clinical challenges exist where hosiery may not be suitable due to unresolved edema or practical application issues. In this study a practical solution for this group of patients was implemented using a Leg Ulcer Hosiery Treatment System.*

Method:

9 patients, 5 males, 4 females aged between 45 – 87 years old. 7/9 edema, I erysipelas and I DVT. Previous treatment: 6/7 no treatment, 2 Tubigrip, 1 ill-fitting hosiery Referrals from the General Practitioner or Medical Specialists to the bandager Medical Stockings measurement. In all cases edema persisted and an alternative solutions was chosen using the new system for 4 – 6 weeks for treatment of the edema.

Results / Discussion:

After evaluation, there was an immediate effect reduction in edema, from 6 to 14%. Comfort and Donning was good to very good. Doffing was average to good. Patients were able to wear their own shoes, stay active and in some cases, continue working. They were measured for follow on Medical Stockings. The system was simple, effective, promoted self-care and was available off the shelf. Costs of bandager and community nurse time were reduced.

Conclusion:

Simple solutions such as the 2 layer Leg Ulcer System can help patients and caregivers for the treatment of edema with or without a wound. Benefits are self-management and cost efficiency instead of 2 – 3 x week bandaging. All patients could fit into their own shoes, and this motivates mobility.

Aim:

To review the evidence supporting the use of Monofilament fibre debridement technology (MFDT) in dermatological conditions.

Method:

MFDT has been successfully used for 7 years in the debridement and management of chronic wounds¹ and hyperkeratosis². In recent years clinicians have been utilizing the MFT in specific dermatological skin conditions.

Results / Discussion:

MFDT has been shown in case studies and case series to be a useful emerging treatment, especially when self-care is a priority, in the management of dermatological conditions resulting in:

 Varicose eczema

 Epidermolysis bullosa

 Chronic wounds in dermatological patients

 Dry, scaly and flaky skin conditions

 Hyperkeratosis associated with venous disease

 Secondary skin changes associated with chronic oedema and lymphoedema

 Actinic keratosis

 Prior to photodynamic therapy

 Acne vulgaris

The 18 million special monofilament fibres which have angled tips to reach uneven areas of the skin or wound bed are able to remove unwanted tissue, materials and skin, allowing other concurrent treatment to reach their target area without the barriers imposed by for e.g. devitilised tissue, dry, scaly and flaky skin and other debris and materials. This technology has received positive NICE guidance¹⁷ for use in acute and chronic wounds. MFDT is very soft, comfortable and gentle on patients. It is safe and easy to use and can also be used by patients for self-care.

Conclusion:

A review of the supporting evidence clearly supports the continued research and interest in MFDT related to dermatological conditions.

Aim:

A polyacrylate containing super absorbent dressing* can be used for patients with moderate-to-high exuding wounds. The study evaluated the performance of the superabsorbent dressing* in daily clinical practice.

Method:

German physicians from different specialisms participated: 23 general medicine, 13 surgery, 14 internal medicine and 3 other departments. Both the dressing and questionnaire were supplied by the sponsor. After dressing use the physicians scored on handling properties, absorbent capacity, user satisfaction and patient comfort. The super absorbent dressing* was used for at least 3 dressing changes in 171 patients (86 (50.3%) men, 78 (45.6%) women, 7 (4.1%) not scored).

Results / Discussion:

The centers used their current protocol. The patients had pressure ulcers (8 (4.7%), venous leg ulcers (113 (66%), diabetic foot ulcers (8 (4.7%), post-surgery (14 (8.2) and infected wounds (8 (4.7%). Dressing application was rated easy by 168 (95%) of the clinicians and the dressing demonstrated a good absorbent capacity as noted by 167 (98%) of the respondents. The dressing was rated easy to remove (168 (98.3%) and did not soil clothing according to 165 (97%) of the respondents. N=157 (94%) patients reported to be satisfied with the performance of the dressing as well as 166 (99%) of the physicians, who additionally reported (156 (94.6%) the dressing to be safe and reliable for the task at hand.

Conclusion:

The study design allowed for collecting data on the dressing in daily clinical practice. The evaluated dressing* was easy to use, comfortable and reliable for patients with moderate-to-high exuding wounds.

Compression, in the form of either a compression bandage or a compression stocking, has been touted as the gold standard for treatment of swelling and venous leg ulcers (VLUs). Adjustable Velcro wraps have been marketed as compression alternative. Although there is a growing body of evidence to support use of these products, there has not been a critical evaluation of the functionality of the devices to best matching product to patient presentation and ability to use the device effectively. Unlike compression garments, which are classified by compression category (class I/II or flat knit/circular), there is not an algorithm to direct health professionals to best match a specific adjustable Velcro wrap to an individual patient presentation. This small case series demonstrates that although each product performed as marketed in vitro, performance in clinical setting varied greatly dependent on patient presentation and functional skill level.

OBJECTIVE

The objective of this study was to analyze the effect of graduated compression stockings (GCS) on venous lower limb hemodynamics in healthy amateur runners.

METHODS

Ten runners were evaluated during rest and after a 10-km run without and with knee-high GCS of 20 to 30 mm Hg. Air plethysmography evaluated venous filling index (VFI), ejection fraction, and residual volume fraction (RVF) in both limbs. Capillary lactate level and heart rate were also measured.

RESULTS

Right VFI was 1.38 mL/s during rest, 1.98 mL/s without compression, and 1.32 mL/s with compression (P = .006). Left VFI was 1.35 mL/s during rest, 1.64 mL/s without compression, and 1.21 mL/s with compression (P = .006). In both limbs, ejection fraction was not different in the three situations. Right RVF was 22.35% during rest, 19.40% without compression, and 10.50% with compression (P = .006). Left RVF was similar in all situations. Capillary lactate level increased in runners without compression (P = .004) but kept stable in those wearing compression. The difference between after-run and before-run capillary lactate levels was similar in runners with and without compression. Rest, peak, and after-run heart rates were similar in runners with and without compression.

CONCLUSIONS

Healthy amateur runners had associated hemodynamic improvements when wearing knee-high GCS of 20 to 30 mm Hg during a 10-km treadmill run. VFI dropped in both limbs and RVF dropped at least in the right limb. There was no positive effect on calf muscle pump; capillary lactate variation; or rest, peak, and after-run heart rates.

Introduction

Non-healing, complex or stalled wounds fail to heal in the expected time required for tissue repair, in spite of their optimal wound management.1,2 Wound management requires addressing the etiologic causes and underlying disorders such as venous hypertension.2 A multidisciplinary approach to wound management including the whole chain of care is recommended. A project was developed in the Azienda USL, south east Toscana, Italy, a region of about 300 x 150 km, to improve quality of care for patients with wounds. The region has 8 hospitals and 13 nursing homes for a population of 850.000. Daily, on average 1200 community patients receive wound management. The project aimed to improve knowlegde and skills when delivering wound treatment in the community. The current study compared clinical efficacy and cost of autolitic, enzymatic and mechanical debridement using a monofillament pad and a pad with a hanle.

Method

Currently in the community enzymatic and autolytic debridement is used for patients with wounds that contain sloughy tissue. To address the need for mechanical debridement a monofilament debrider was proposed for its added value in terms of efficacy, safety, tolerability, results and ease of use.3-6 Eighty community patients with complex wounds of various etiologies containing sloughy tissue were included in the study and followed up for 15 days. Patients gave informed consent. Patients were allocated to the different treatment groups at random. At baseline patient's medical history, wound characteristics and privious treatment was recorded. During follow up visits a questionnaire was completed scoring wound condition, patient reported comfort/pain during debridement, time required for the procedure and product handling, using a 5-point Likert scale. Costs were calculated taking into account clinical efficacy, time to debridement, number of home visits, nursing costs, costs per product used.

Results

Debridement was effective and comfortable using all evaluated methods (on a 5-point Likert scale, the 2 types of monofilament products scored a mean of 4,9 and 4,8, enzymatic debridement sored a mean of 4,6 and autolytic debridement a mean of 3,6). The total costs for debridement using the monofilament pad and product with handle was Euro 58,67 and Euro 72,47 respectively. For enzymatic debridement the total costs were Euro 213,35 and for autolytic debridement total costs were Euro 98,67. Cost was significantly lower in the monofilament group due to a reduction in debridement time, number of visits and nursing time. Based on these results the monofilament product is proposed to be added to the list of products available for wound debridement in the community.

Discussion

Mechanical debridement is historically associated with the use of wet-to-dry gauze, which non-discriminatorily removes devitalized tissue, resulting in significant pain and damage to healthy tissue.1,2 Enzymatic and autolytic debridement may be slow and not suitable for wounds such as diabetic foot ulcers. In clinical studies mechanical wound cleansing and debridement using a monofilament polyester fiber product was effective, pain and trauma free.3-6 Our study showed the monofilament products to deliver better and faster debridement and a good patient tolerance. Both the number of visits and nursing time was reduced leading to a significant reduction in total cost of debridement.

Conclusion

The addition of the monofilament products to our debridement portfolio use for wound management in the community represents an essential added value in the range of dressings available for patients with complex wounds with appropriate use of tight resources.

Introduction

Exudate control is an important aspect of wound management of both acute and chronic wounds, where exudate can be an indicator on the wound bed condition, specifically inflammation. A polyacrylate containing super absorbent dressing can be used for patients with exuding wounds to successfully manage moderate-to-high exudate production. The dressing has the capacity to absorb large amounts of exudate and holds it within its core without the potential for reflection of fluid back onto the skin, thus preventing soiling of the patients clothing and/or bed sheets.

Methods

A survey was developed evaluating the performance of a superabsorbent dressing, suitable for the management of moderate-to-high exuding wounds, in daily clinical practice. The survey was conducted in Germany and participants comprised physicians from different specialisms: 23 general medicine, 13 surgery, 14 internal medicine, 1 vascular surgery, 1 podiatry and 3 dermatology. Both the dressing and questionnaire were supplied by the sponsor. After dressing use the physicians scored their findings on usability of the dressing, handling properties, absorbent capacity, user satisfaction and patient comfort on the provided questionnaire. The physicians used the super absorbent dressing for at least 3 dressing changes in 171 patients (86 (50.3%) men, 78 (45.6%) women, 7 (4.1%) not scored).

Results

Dressing change frequency was depending on the patient and wound condition and was at the discretion of the clinician. For wound cleansing and dressing application the centers current protocol was used. The included patients had various wound types, such as pressure ulcers (8 (4.7%), venous leg ulcers (113 (66%), diabetic foot ulcers (8 (4.7%), post-surgery wounds (14 (8.2) and infected wounds (8 (4.7%) such as after abscess drainage. Dressing application was rated easy by 168 (95%) of the clinicians and the dressing demonstrated a good absorbent capacity as noted by 167 (98%) of the respondents. The dressing was rated easy to remove (168 (98.3%) and did not soil clothing according to 165 (97%) of the respondents. N=157 (94%) patients reported to be satisfied with the performance of the dressing as well as 166 (99%) of the physicians, who additionally reported (156 (94.6%) the dressing to be safe and reliable for the task at hand.

Discussion

Effective management of exudate should shorten wound healing time, optimize resources and reduce the impact on the physical and psychosocial health status of the patient.1 Copious exudate production, especially in stagnating wounds, may cause maceration or even excoriation of the peri-wound skin, delaying wound healing.1 Patients may experience social isolation and anxiety due to leakage of the dressing. The evaluated super absorbent dressing for moderate-to-high exuding wounds can be applied as a primary and as a secondary dressing. Depending on the wound condition and the amount of exudate produced, on average dressing changes took place twice weekly. The absorbent properties of the superabsorbent dressing evaluated in the present survey enabled effective absorption, avoiding soiling of clothing.

Conclusion

The evaluated dressing was easy to use, comfortable and reliable for patients with moderate-to-high exuding wounds. In view of these results, superabsorbent dressings seem to be interesting for both clinicians and patients. Clinical studies are required to confirm these results.

Aim:

Clinical nurses specialist - Tissue Viability Nurses (TVNs) are no exceptions to significant change and challlenges in terms of their role and scope of practice. The use of advanced treatment modalities such as Conservative sharp debridement (CSD) and Negative pressure wound therapy (NPWT) are amongst the skill they posses for the healing of complex wounds. Debridement in wound bed preparation is a well recognised concept to aid wound bed prepation in order to facilitate wound healing. This can be an intergral part in the management of complex infected surgical wounds where devitalised tissue is present prior to application NPWT. Sharp debridment over a vital organ is high risk, costly and can be life-threatening if done under aneasthetic. And CSD over bowel can equally be a high risk procedure and this will demand a surgeons skill for precision and safety. However, if left untreated this can impead wound healing and lead to other serious complications. Many TVNs are competent to perform CSD but the associated risk and complications of CSD over bowel cannot be ignored. This case study will look at the efficacy of the use of a Monofilament Fibre Lolly (MFL) by a TVN to debride devitalised tissue over bowel in a high risk patient.

Method:

Patient BH is a 46 year old lady who was admitted with a wound infection two weeks after a midline incisional hernia repair with application of mesh. She has asthma and was also diagnosed with alcoholic liver disease . On admission, she was septic and was treated with intravenous antibitiotic and she was taken to theatre for wound debridement. She went to theatre twice for repeat debridement of necrotic tissue causing significant bowel exposure at wound bed with some loose mesh. NPWT was used post-operatively by the surgical team to manage the wound. TVN input was sought to complete a wound assessment and for the re-application of NPWT due to patients compromised medical condition. And she was deemed unfit for anaesthetic. The use of the MFL was chosen as part of a product evaluation by the TVN. MLF was deemed to be atraumatic and has the ability to reach deep undermined areas to an open abdominal wound. It was moistened with 10mls of normal saline and was used to gently lift the devitalised tissue over the bowel using a circular motion with light pressure. Two MFL were used to cover all areas of the wound bed to effectively remove all devitalised tissue and reduce bacterial bioburden. NPWT was applied with careful consideration and protection applied over all exposed bowel.

Results / Discussion:

With the TVNs knowledge and competence in CSD the use of a new debridement tool such as MFL over bowel at the bedside was performed safely and in a timely fashion. MFL for debridement showed significant reduction of bacterial bioburden through removal of devitalised tissue and infected loose mesh with no complications such as bleeding and trauma that

are associated with other forms of debridement. 40% of slough/infected loose mesh were removed using the MFL and 60% were loosened and softened).

Conclusion:

This case study is an example of the increasing complexity of cases and ithe wound management faced by TVNs. With the availability of a new debridement tool such as the MFL, high risk patients not fit for anaesthetic are able to receive timely and safe wound bed preparation. The MFL was found to be less invasive compared to CSD and can be safely used over bowel.

Based on experimental work, a practical definition of inelastic material is provided and some superior effects concerning an improvement of the venous haemodynamics are emphasised in this article. In contrast to elastic compression, this material can narrow the veins in the upright position and to exert beneficial haemodynamic effects by abolishing reflux and improving the venous pump. The main disadvantages are the fact that proper application is not easy and that these inelastic bandages lose pressure quickly. Most inelastic bandages are applied with a pressure that is too low. Training courses in which the sub-bandage pressure can be checked by adequate measuring instruments may improve this situation. Self-applied Velcro® devices where the pressure can be measured by the patient using simple measuring aids provided by some companies may be a valuable alternative. The patient feels which pressure is beneficial and can readjust the system whenever it is getting loose. Newly developed pumps are also of increasing interest.