Wound dressing where there is limitation of choice

Abstract

Background Many sophisticated dressings are available to the wound care practitioner in the developed countries. These materials are made from a wide range of products like polyurethane, salts of alginic acid and other gelable polysaccharides. The situation is different in the developing countries where what is commonly available to wound care provider are traditional agents such as sodium hypochlorite, hydrogen-peroxide, cetrimide solution, chlorhexidine and others. The aim of this study is to reappraise the problem of limitation of wound dressing selection in the developing countries and to sensitize the wound care practitioner on the use of the commonly available products based on the needs of a different wound or even the same wound throughout its healing course. Patients and methods Patients attending the General Outpatient Department (GOPD) of our hospital for wound dressing were used for the study. Five surgeons who are familiar with wound care management visited the dressing unit of the GOPD daily for one week in October 2005. A proforma was designed where information on each of the patient was recorded. Results Fifty-three patients attended the dressing unit of our GOPD during the study period. Twenty-six patients (49.1%) had their wounds dressed with hypochlorite solution (Eusol), seventeen patients (32.1%) had their wounds dressed with honey and two patients, wound were being dressed with hydrogen peroxide. Conclusion While we are still awaiting the availability of the newer products in the developing countries, we should make use of the traditional products that are readily available to us according to the need of a particular wound, by this, our choice of wound dressing will not be arbitrary, ineffective and wasteful both in terms of time and physical resources.

Full text

Nigerian Journal of Surgical Research
Vol 8 No 3 – 4 ,2006 ; 151- 154
Original Article
Wound dressing where there is limitation of choice
1G. A. Rahman, 2I. A. Adigun, 1I. F. Yusuf, and1 C. K. P. Ofoegbu
1Division Of General Surgery Division Of 2Plastic And Reconstructive Surgery, Department Of Surgery,
University Of Ilorin Teaching Hospital, Ilorin
Request for Reprints G A Rahman, Department of surgery University of Ilorin Teaching Hospital P.M.B 1459,
Ilorin, Kwara State Nigeria
E-mail: garahman1@yahoo.com
Abstract
Background Many sophisticated dressings are available to the wound care practitioner in the developed
countries. These materials are made from a wide range of products like polyurethane, salts of alginic acid
and other gelable polysaccharides. The situation is different in the developing countries where what is
commonly available to wound care provider are traditional agents such as sodium hypochlorite,
hydrogen-peroxide, cetrimide solution, chlorhexidine and others. The aim of this study is to reappraise
the problem of limitation of wound dressing selection in the developing countries and to sensitize the
wound care practitioner on the use of the commonly available products based on the needs of a different
wound or even the same wound throughout its healing course.
Patients and methods Patients attending the General Outpatient Department (GOPD) of our hospital for
wound dressing were used for the study. Five surgeons who are familiar with wound care management
visited the dressing unit of the GOPD daily for one week in October 2005. A proforma was designed
where information on each of the patient was recorded.
Results Fifty-three patients attended the dressing unit of our GOPD during the study period. Twenty-six
patients (49.1%) had their wounds dressed with hypochlorite solution (Eusol), seventeen patients
(32.1%) had their wounds dressed with honey and two patients, wound were being dressed with
hydrogen peroxide.
Conclusion While we are still awaiting the availability of the newer products in the developing
countries, we should make use of the traditional products that are readily available to us according to the
need of a particular wound, by this, our choice of wound dressing will not be arbitrary,
ineffective and wasteful both in terms of time and physical resources.
Key words: wound, dressing, types, developing countries.
Introduction
No one dressing agent is suitable for the management
of all types of wounds, and few are ideally suited for
the treatment of a single wound during all stages of
the healing cycle. Successful wound management
therefore depends upon a flexible approach to the
selection and use of products based upon an
understanding of the healing process combined with
knowledge of the properties of the various dressings
available. The process of dressing selection is
determined by a number of factors which includes the
nature and location of the wound, and the range of
materials available. In most situations the cost of
treatment is also a major factor1. In the developed
countries, many sophisticated dressings are available
to the wound care practitioner which are made from a
wide range of materials including polyurethane, salts
of alginic acid and other gelable polysaccharides such
as starch and carboxymethylcellulose. These materials
are combined to form products as diverse as films,
foams, fibrous products, beads, hydro gels and
hydrocolloid dressings2.

152 wound dressing Rahman GA et al
The situation is totally different in the developing
countries like ours where what is still commonly
available to wound care provider are traditional agents
such as sodium hypochlorite, hydrogen peroxide,
cetrimide solution, chlorhexidine and others. These
agents have been proven to be of limited efficacy and
may also have an adverse effect upon the healing
process3and therefore get out of favour4. Wound
healing is a dynamic process and the performance
requirement of a dressing can change as the wound
progresses towards healing. The aim of this study is to
re-appraise the problem of limitation of wound
dressing selection in the developing countries. This is
with the aim of sensitizing the wound care practitioner
on the use of the commonly little available products
based on the needs of a different wound or even the
same wound throughout its healing course.
Methods:
This study took place in a tertiary health institution
located in the North Central Zone of Nigeria. Patients
attending the General Outpatient Department (GOPD)
of the hospital for wound dressing of different
aetiologies were used for the study. The authors who
are surgeons familiar with wound care management
visited the dressing unit of the GOPD daily for a
whole week in October 2005. A proforma was
designed where information on each of the patient
was recorded. Information collected included: the age,
sex, occupation, type of wounds, frequency of
dressing, type of dressing, cost of care, and the cost
bearer among others. The data were entered into the
SPSS 11.0 software for analysis.
Results:
Fifty-three patients attended the dressing unit of our
GOPD during the six days of study. The age range
was between 1 year and 84 years The mean age was
38.7 years (SD-23.0). There were thirty-four males
and nineteen females with a male to female ratio of
1.8:1. Sixteen patients (30.2%) were traders, twelve
patients (22.6%) were students, eleven patients
(20.8%) were farmers and nine patients (17.0%) were
civil servants. For the purpose of this study, wound
managed were classified into six types as shown in
Fig. 1. Nineteen patients (35.8%) had surgical wounds
(from surgical operations) of different etiology while
thirteen patients (24.5%) were being managed for
traumatic wounds resulting from poorly managed
traumatic injuries. There were twelve patients (22.6%)
with chronic leg ulcer while only one patient (1.9%)
was being dressed for pressure sore. Fig. 2 shows
various dressing agents available for use in our centre.
The result showed that twenty-six patients (49.1%)
had their wounds dressed with hypochlorite solution
(Eusol), seventeen patients (32.1%) had their wounds
dressed with honey, two patients’ wound were being
dressed with hydrogen peroxide, two patients also had
sufratulle gauze dressing. The remaining six patients
(11.3%) had other agents such as cetrimide and
chorhexidine solution used for their dressing. The
frequency of wound dressing shows that of these fifty-
three patients; Twenty-three patients (43.4%) had a
daily wound dressing while twenty-eight patients
(52.8%) had an alternate day dressing of their
wounds.
The cost of care of these patients’ wound dressing per
week excluding transportation to hospital, showed
that twenty patients (37.7%) spent an average of five-
hundred Naira (N500.00) per week while thirty-one
patients (58.5%) spent an average of six hundred
Naira (N600.00) per week. The remaining two
patients were being exempted from payment
Fig i Fig ii
type of wound
6.00 / 11.3%
13.00 / 24. 5%
2.00 / 3.8%
12.00 / 22.6%
1.00 / 1. 9%
19.00 / 35.8%
others
traumatic ulcer
malignant ulcer
chronic leg ul cer
pressure sor e
surgical wound
type of dressing
11.3%
32.1%
3.8%
3.8%
49.1%
others
honey
suffratule
hydrogen peroxide
eusol
Discussion
Effective wound management requires an
understanding of the process of tissue repair and a
knowledge of the properties of the dressing materials
available. It is when these factors are considered that
the process of choice of wound dressing can be
undertaken in a logical and informed fashion. A single
dressing cannot address or correct the underlying
pathology of a wound, rather, it should be selected
based on the needs of the wound. This can be
achieved by thorough assessment of the wound in
terms of its dimension, the type of tissue present in
the wound bed, the quality and quantity of exudates,
condition of the surrounding skin and the microbial
status. This assessment should be performed on all
wounds before they are dressed. This study shows that
we are still using the traditional wound dressing
agents for dressing. Twenty-six patients (49.1%) had
their wounds dressed with Eusol, while 3.8% were
dressed with hydrogen peroxide. Seventeen patients
(32.1%) were dressed with honey .In 23 (43.4%)
patients wounds were dressed daily which can be
regarded as high frequency dressing. High frequency
dressing is expensive, uncomfortable to the patients

Wound dressing Rahman et al 153
and stressful to manpower. It is safer to choose
dressings that require changing less frequently,
thereby reducing risk of nosocomial infection, cost of
care, further tissue damage and patient discomfort 5 .
Majority of our patients spent between five-hundred
Naira (N500.00)($4 USD) and six-hundred Naira
(N600.00)($5 USD) per week on wound dressing. The
unavailability of varieties of wound dressing in our
environment has led those who must care for wounds
to resort to the use of traditional agents such as
sodium hypochlorite, hydrogen peroxide, cetrimide
,chlorhexidine and honey. Usually there may be no
room for choice of agent depends and the most
readily available agent is used . In the developed
countries, several modern wound dressing materials
are available to the practitioners and the choice of
dressing materials take into consideration the needs of
the wound at a particular stage in the healing process1.
These dressing materials are grouped according to
their performance. Some of these agents include
hydrocolloid, hydrogel, alginate, and polyurethane
foam. They are indicated for selected wounds or the
same wound for different roles at different phases of
wound healing. Some characteristics that distinguish
these recent products are fluid status, conformability,
nice scent, absorbing characteristics, handling and
adhesive properties, and the presence of antibacterial
and haemostatic activity . Others include the ease of
application and removal and the interval between
dress changes6. Before a clinician chooses a wound
dressing
agent it is necessary to identify the purpose or
principal aim of that particular treatment. In most
cases, it will be to facilitate cosmetically acceptable
healing in the shortest possible time. Occasionally,
however, priorities can change and the speed and
quality of healing may not be of primary importance.
For example, a patient with a large malignant wound,
it may be more important to concentrate on removal
or containment of both the odor and the copious
exudates produced by the discharging lesion. This will
improve the patient’s quality of life remakably7, 8.
Dressing agents may be chosen for 4 purposes.
Remove sloughy necrotic tissue, promote granulation
and epitheliasition of the wound, Bring about
autolytic debridement of dead skin over some
wounds. In our environment, we commonly use gauze
pads soaked in saline or other solutions such as
sodium hypochlorite (Eusol) or hydrogen peroxide
which may be time consuming. Honey is another
agent that is readily available to us in the developing
countries. It is a good debriding agent and it is
commonly used by clinicians in necrotic wounds9, but
the problem of frequent dressing and pain associated
with its use is a major disadvantage. The use of
hydrogel and hydrocolloid are advances in developed
would. A dressing such as Intrasite Gel, Granugel and
Sterigel where available is more attractive and very
convenient. The gel is simply placed on the wound
and covered with gauze till the next dressing.
Hydrocolloids high absorptive capacity that greatly
limits the rate of frequency of change of dressing.
When the necrotic covering eventually separates, it
frequently leaves behind a wound containing yellow,
partially liquefied material called slough such as in
,pressure sores , diabetic foot ulcers burns and
chronic leg ulcers . It has been shown experimentally
that slough and devitalized tissue will predispose a
wound to infection by acting as a bacteriological
culture medium and inhibiting the action of
leucocytes in the wound10, 11. For good healing rate,
such wounds should be properly cleansed or debrided.
This can be done with some of the recent agents such
as Debrisan. Debrisan are polysaccharide beads for
dressing was one of the first modern dressings used
for wound cleansing. When used on sloughy wounds,
the beads absorb fluid and progressively remove
bacterial and cellular debris away from the surface of
the wound12. Sloughy wounds which also produce a
degree of exudates may be dressed with alginate
dressings. Other materials which are sometimes used
to debride sloughy wounds include enzymatic agents
such as Varidase, crab collagenese and krill13.
Polysaccharides such as honey and sucrose have also
been used to facilitate wound cleansing. Granulated or
icing sugar has been used successfully14, 15 interest has
just been focused on the use of a sugar paste
containing polyethylene glycol 400 and hydrogen
peroxide16, 17, 18. A significant development of
dressing sloughy wounds is the use of larva therapy
(maggots) for the rapid removal of slough and
necrotic tissue from wounds such as leg ulcers,
pressure sores, and diabetic foot ulcer19. It has been
reported that larvae are of value in burns20 and plastic
surgery for cleansing wounds prior to grafting21. In a
granulating wound there is no single dressing that is
suitable for use in all situations. In the developing
countries, where there is limitation of materials for
wound dressing, these wounds are usually packed
with gauze soaked in saline, hypochlorite or
proflavine. In some studies, honey is used
continuously for dressing in this phase of wound
healing thus causing hyper granulation, This may
usually slows down the process of epithelisation. In
the developed countries such wounds will be dressed
with alginate fibre or hydrocolloid dressing if exudate
production is not a problem. The production of
granulation tissue continues until the base of the
original cavity is level with the surrounding skin. At
this stage, the process of epithelisation begins around
the wound margin. Except on few occasions,
superficial or epithelising wounds tend not to produce
large quantities of exudates. Traditionally, these
wounds have been dressed with paraffin gauze
covered with a layer of Gauze and Cotton tissue
(“Gamgee”) which is readily available in most centers
in developing countries but some centers have
reported that the use of both alginates22,23 and
hydrocolloids dressings24 offer significant advantages
in these situations. The later reducing the time to
healing of donor site to about 7 days compared to 10-
14 days for comparable wounds dressed with
conventional fabric dressings. Wound related factors

154 wound dressing Rahman GA et al
takes priority when considering choice of dressing for
a particular wound. Therefore, we should always ask
ourself, what type of wound are we dealing with? Is it
a superficial, full thickness or cavity wound? Is the
wound necrotic, sloughy, and granulating or
epithelising? What about its characteristics, is it dry,
moist, heavily exuding, malodorous, excessively
painful or liable to bleed? What about the bacterial
profile, is it sterile, colonized or infected? For
example, a superficial, granulating or epithelising
wound with minimal exudate should not be dressed
with agents like hypochlorite solution or hydrogen
peroxide. Rather, such wound may be dressed with
sofra-tulle covered with saline soaked gauze or even
dry gauze. In clinical practice, when considering
dressings for an acute wound, the emphasis should be
on prevention of infection and promotion of healing5
whereas in chronic wound-healing, the control of
wound infection is more important25
Conclusion while we are still hoping to acquire
newer agents for wound dressing, in the developing
countries, we have made an effort to discuss some
characteristics needed to make us choose wisely from
the limited variety of dressing materials to meet the
needs of our wounds for efficient wound care.
References
1. Lippincott Williams and Wilkins; Ovington L.
Wound care products: how to choose. Home
Healthcare Nurse 2001; 19: 224-32.
2. Evans H; A treatment of last resort. Nursing
Times, 1997; 93: 62-65.
3. Moore D; Hypochlorites: A review of the
evidence. Journal of Wound Care, 1992; 1: 44-
53.
4. Poon VK, Burd A. In vitro cytotoxicity of silver:
implication for clinical wound care. Burns 2004;
30: 140-147.
5. Burd A, Kwok CH, Hung SC, Chan HS, Gu H,
Lam WK, Huang L. A comparative study of the
cytotoxicity of silver-based dressing in
monolayer cell, tissue explant and animal model.
Wound repair and regeneration 2007; 15: 94-104.
6. Thomas S. Treating malodorous wounds,
Community Outlook, 1989, Oct, 27-29.
7. Thomas S; Pain and Wound Management,
Community Outlook, 1989, July, 11-15.
8. Adigun IA, Rahman GA. Honey as a wound
dressing agent: A better alternative in developing
countries. Nig J Plastic Surg 2006; 2 : 10-16
9. Hohu D.C., Host resistance to infection:
established and emerging concepts, ibid.
10. Jacobsson S, Rothman U, Arturson G, Ganrot K,
Haegar K, Juhlin I. A new principle for the
cleansing of infected wounds. Scand J Plast
reconstr Surg. 1976; 10: 65-72.
11. Bale S., A guide to wound debridement
techniques, Journal of Wound Care, 1997; 6(4):
179-182.
12. Sugar sweetens the lot of patients with bedsores.
JAMA, 1973; 223, 122.
13. Knutson RA, Merbitz LA, Creekmore MA,
Snipes HG. Use of sugar and povidone iodine to
enhance wound healing: five years experience,
Sth Med J. 1981: 74: 1329-1335.
14. Gordon H, Middleton KR, Seal D, Sullen K.
Sugar and wound healing, Lancet. 1985; 2: 663-
664.
15. Middleton K.R., Seal D; Sugar as an aid to
wound healing. Pharm J. 1985; 235: 757-758.
16. Archer HG, Barnett S, Irving S, Middleton KR,
Seal DV. A controlled model of moist wound
healing: comparison between semi permeable
film antiseptics and sugar past. J exp path. 1990;
75: 155-170.
17. Thoma S., Jones M., Shutler S., Jone S., Using
larvae in modern wound management. Journal of
Wound Care. 1996; 5: 60-69..
18. Groves A. R., Lawrence JC., Alginate dressings
as a donor site haemostat. Ann R Coll Surg.
1986; 68: 27-28.
19. Doherty C, Lynch G, Nobel S. Granuflex
hydrocolloid as a donor site dressing. Care of the
critically ill. 1986; 2: 193-194.
20. Lansdown ABG, Williams A, Chandler S,
Benfield S. Silver absorption and antibacterial
efficacy of silver dressings. J Wound Care 2005;
14: 155-160.

Wound dressing Rahman et al 155