PATIENT CARE4fen±uraA4
Innovative dressings improve
wound care management
New treatment modes
bring enhanced healing
for patients
BY CYNTHIA A. FLECK, R.N.
N ew wound care technology is
paving the way for a different
kind of patient care. No longer are
wounds to be 'plugged and con-
cealed" but instead managed on a
cellular level. By improving the overall
healing process, clinicions save time,
organizations cut costs and the pain
associated with wounds is mitigated
for patients. "Smart' dressings treat a
variety of different waunds and pro-
mate the growth of healthy tissue; and
more cost-effective dermal reploce-
ments are just a few ways wound care
is odvancing.
2 4 MATERIALS MANAGEMENT IN HEALTH CARE february 2007 | matmanmog.com
W ound and skin care prod-
ucts have progressed dra-
marically in the last couple
of decades. The concept of moist wound
healing is ingrained and the trend of using
dressings that remain in and on the wound
for longer periods has proven to be het-
ter for patients in addi-
tion to saving money.
Thankfully, the days
of "plug and conceal'
are gone because ulcers
and skin conditions can
now be managed at the
cellular level, orchestrat-
ing the healing process every step of the
way. As with each aspect of health care,
it is necessary for providers and clinicians
to keep up with changes in technology
and maintain an awareness and under-
standing of what's new, how it works and
what's available. This article will provide
information on the latest wound and skin
products, thereby bringing solutions to
decision makers and offering better out-
comes, less pain, increased skin integrity,
odor control, decreased biohurdcn and
overall, more effective care. Incorporat-
ing these tools can help conserve capital
and resources while saving clinicians' time,
facility costs and patients, ache and
anguish. Also, using such key staff as a
certified wound specialist and/or certified
wound care nurse is recommended when
making decisions about wound care.
BIOBURDEN AND WOUND BED PREPA-
RATION. Wound bed preparation, includ-
ing debridement and biohurden control
are mainstays for effective wound heal-
ing. Silver dressings continue to be the
No. 1 advanced wound care product
choice available.
These innovative dressings continue to
gain widespread use, not just for the worst
wounds and sites but for safe, hroad spec-
trum prophylaxis of infection and
increased healing outcomes across the
spectrum of wound care.
Perhaps one of the safest and easiest
ways for clinicians to comhat bioburden
(the total population of bacteria, fungus
and viruses) within a wound is ro use ion-
ic silver. Ionic silver often can provide the
'kick start' that a stalled, chronic ulcer
needs to begin healing.
Look for dressings that deliver sus-
tained-release ionic silver over a period
of time (three to seven days or longer).
Because silver has tittle chance of devel-
oping clinically significant resistance (Jour-
nal of Hospital Infections, 2005), has very
limited sensitivity and is available over
the counter, it makes a wonderful dress-
ing choice.
Preventing a wound from entering into
critical colonization with silver dressings
allows complications, costs and discomfort
associated with infection to be avoided.
It also allows for potentially less frequent
dressing changes and reduced nursing
intervention and time, one of the most
expensive line items on the income state-
ment. These advanced silver dressings
afford more savings because they stay in
place and work effectively over the course
of several days.
The most versatile silver dressings are
recommended since they are applicable
to a variety of wounds and the changing
needs of those wounds.
Dressings rhat perform double or triple
duty are particularly popular, offering
nuiltiples uses. Some worthy products are
included in Fig. 1.
ULTRASONIC DEBRIDEMENT. A virtu-
ally pain^lree way to prcpiire a vvnund
bed is ultrasonic dehridcmciit.
rif<. I Versatile silver dressings on the market
• Calcium alginate/carboxymethylcel-
luiose silver combinations, which offer
superior absorption of wound fluid while
providing good wet strength and one-piece
removal in addition to sustained release of
safe, ionic silver (Chakravorthy D, Fleck CA,
Evaluation of two polyscccha ride-si I ver-bosed
high absorbency wound dressings, poster
presented at the Symposium on Advances
in Skin and Wound Core, Son Antonio, TX,
April 2006).
• Silver site dressings that provide pro-
tection from catheter-related blood stream
infections as well as those infections aris-
ing from other percutaneous tubes and
openings such as chest tubes. Unlike
chlorhexadine site dressings, silver is safer
and more gentle, causing fewer skin sensi-
tivities and can be used in children under
the age af 16, as well as having a broader
spectrum, covering Pseudomonas aerigi-
nosa, unlike chlorhexadine.
• Silver amorphous hydrogels, literally
meoning, "without form" or semi-liquid ge
silver. They're great for dry wounds, to fill
open spaces and to spread on other dress-
It allows a clinician to control the
amplitude (and thus, the level of pain
experienced by a patient), thereby increas-
ing the level of precision while having an
antimicrobial effect subdermally; and it
also will change the way bedside debride-
ment is performed.
These newly available devices offer
rapid results safely and efficiently while
providing exceptional granulation with
minima! or no bleeding. Tbe technology is
used within inpatient and outpatient clin-
ics throughout the country.
This relatively gentle wound bed prepa-
ration tool offers hope to patients whose
wounds have stalled out. This new equip-
ment introduces novel options for necrot-
ic wounds.
ings to give them ontimicrobial power
(CastellonoJJ, Mannari RJ, PoyneWG, Rob-
son MC. Comparison Evaluation of Silver
Contoining Antimicrobial Devices and Drugs,
poster presented at the 20th Annual John
A. Boswick Burn Conference, Maui, Hawaii,
2006). Think of them as " 2 i s t Century
wound core in a tube," cost-effective and
easy to use and remove from any wound
bed.
• Ionic silver powder (sprinkled in diffi-
cult-to-reach spats or anywhere you want
absorption and antimicrobial protection) is
olso a good choice since you can literally
make any dressing a "silver" dressing. Also
makes o wonderful addition to negative
pressure treatment such as the V.A.C.(r)
(K.C.I., San Antonio, Texas or the Versatile
1(tm) (Blue Sky Medical Group, Carlsbad,
CA) since it decreases pain, ador and poten-
tially days of theropy.
• Silver foams can easily be used as o
primary or secondary (for extra absorption)
dressing that provides a bit of cushioning
while pocking a broad-spectrum antimicro-
bial 'punch' that soaks up exudates.
matmanmog.com I /t^/^rwary 2007 MATERIALS MANAGEMENT IN HEALTH CARE 2 5
ODOR CONTROL. New innovations in
wound odor control using cyclodextrin
technology are taking the dressing mar-
ket by storm. Most odors are llpophilic
{oil loving).
New dressings that use cyclodextrins
(same technology as used in Febreze) use
a bucket-shaped conformation of the
bydrated cyclodextrin molecule to irre-
versibly capture lipopliilic odor molecules,
which then neutralizes the odor (see
Fig.2,p.26).
Cyclodextrins occur naturally and are
proven safe to use in modern wound care.
But how do tbe latest odor-elimination
dressings compare with the older technol-
ogy of charcoal-based dressings?
Cyclodextrins work optimally in the
presence of wound exudate and need the
wound moisture to work effectively. Both
moisture and serum proteins in the wound
exudates stabilize the 'bucket' shape
of the cyclodextrin molecule, allowing
odor to be captured and neutralized more
effectively.
Charcoal activity, on the other hand,
decreases in the presence of wound exu-
dates because serum proteins in tbe exu-
dates deactivate in the presence of wound
exudates. Additionally, cyclodextrins
intrinsically have a longer active time of
odor-absorbing function by nature of their
material.
Hydrocolloids, known to be the smelli-
est generic dressing category as well as
the most prevalently used advanced
wound management product, by nature
of their composition develop odor under
the occlusive seal they form.
Newly available bydrocolloids incor-
porate tbe cyclodextrin technology to dra-
matically reduce odor, making dressing
changes more comfortable for a patient
and caregiver.
PAIN CONTROL. The number of pain-
reducing dressings on the market that
combine silicones for gentle no-stick dress-
ing changes, as well as superabsorbent
foam materials for greater fluid handling,
PATIENT
will continue to increase because quality
of life is integral to wound care practice.
And, don't overlook other pain free prod-
ucts such as alcohol-free, nonstinging prep
wipes to protect the fragile periwound
skin from maceration and adhesive
stripping. These easy-to-apply copolymers
provide protection for the vulnerable epi-
dermis, without the pain and stinging sen-
sation that alcohol based ones historical-
ly have created.
home care at the patient's discharge.
Another plus is that this system is the
only dressing that does not require wound
cleansing, further reducing costs of saline
or wound cleansers. In addition, polyacry-
late moist wound therapy debrides just
as well as collagenase, according to an
article in the July 2005 issue of the Jour-
nal of Wound Care. It provides constant
cleansing of the wound bed by removing
devitalized material and biofilm., and
These products not only can improve
skin's appearance and texture., but can
help build collagen and develop skin's
resistance to damage. Sucb ingredients as
good quality silicones in advanced skin
care products provide protection through
the use of dimethicone, zinc oxide,
calamine and surfactant-free pbospho-
lipid cleansers that clean with derivatives
of vegetable oil instead of h;irmful, dry-
ing detergents or soaps.

GROWTH FAaOR DELIVERY NEGATIVE PRESSURE THERA-

Fig. 2 Bucket-shaped cyclodextrin (starch)
SYSTEMS AND SKIN SUBSTI- PY. Negative pressure or suction
malecule captures odar molecules, which
TUTES. Look forward to seeing is applied with a tube and scaled
neutralize odor.
more bioengineered 'smart' with an occlusive dressing. This
dressings (such as bioengineered technology 'stretches' cells
MOLECULAR STRUCTURE:
cellulose) that provide more tban involved in the healing process,
0 ring composed of glucose
one function, offering care for units releasing biochemical mediators
a variety of wound needs and of cell proliferation and pulls
growth factor delivery systems tbem together, healing tbe
and skin substitutes. These bio- Hydrophilic
wound. The vacuum effect evac-
(water-loving)
engineered in vitro cultured skin Lipophilic
exterior uates wound fluid, reduces ede-
(oil-loving)
cells begin as harvested neona- Interior ma and helps form new blood
tal foreskins and are grown in vessels and granulation tissue.
3-D SHAPE: The lipophilic
the lab. Negative pressure wound ther-
covity attracts and traps
Biiayered products are com- odor-causing molecules. apy is useful for large deficits
prised of a dermal equivalent Serum protein binding to and recalcitrant wounds.
and Type 1 bovine collagen that the outside wall stabilizes
Although not considered new,
the cyclodextrin bucket.
contains human dermal fibro- this equipment provides answers
blasts and an overlying corni- Source: Medline Advanced Skin ond Wound Care, 2006
for difficult-to-close wounds.
fied epidermal layer of ker-
atinocytes. Single-layer, living dermal debriding wounds at a mean rate of 38.11
COVERING THE FUTURE. Matrix metal-
replacement made of mesh Vicryl and percent per week, according to an article
loproteases (MMPs) Lire structurally relat-
human neonatal foreskin-derived fibrob-
in Ostomy Wound Management., 2003, ed, protein-degrading enzymes (proteas-
lasts and tbeir products work to produce
and an article in the October 2005 issue es) that alter the extra cellular matrix
an immediate cover and viable delivery
of the Journal of Wound Care. during tbe wound healing puxess. MMPs
system for key healing growth factors.
control platelet Liggregatlon, macrophage
ADVANCED SKIN CARE PRODUCTS, just and neutrophil function, cell migration
NOVEL DEBRIDING SYSTEMS. Polyacry as we require good nutrition to survive, and proliferation, neoangiogenesis and
late debriding systems provide quick, sim- our skin can be nourished from the out- collagen secretion and deposition. They
ple, safe and pain-free debridement in a side-in with advanced nutritional goods. 'turn on' or 'turn off matrix proteins,
trouble-free, user-friendly dressing that Skin care products containing specific, cytokines, growth factors and adhesion
provides 24-hour simultaneous rinsing specially treated amino acids, antioxi- molecules. Crucial for the inflammatory
and debriding (see Fig. 3, p. 28). dants, MSM (methylsulfonylmethane), a phase of wound healing are the same mol-
The dressing is activated by Ringer's naturally occurring anti-inflammatory ecules that, when produced in surplus,
solution, the most perfect physiologic flu- agent, and vitamin co-factors can nour- hinder healing in chronic wounds. Chron-
id. It is changed only once per day, mak- ish and strengthen skin, providing an ic wounds generally have high protease
ing it an ideal choice in acute care; and insurance policy against breakdown and levels (MMPs) and low protease inhibitor
changing it can be taught to a family for trauma, such as skin tears and wounds. levels compared with acute wounds. TTiere

2 6 MATERIALS MANAGEMENT IN HEALTH CARE february 2007 \ matmanmog.com

PATIENT CARE[fpnt..rPi]
24^hour rinsing effect will be an increase in the use of collagen
dressings with advanced native collagen.
based on state-of-the-art biomaterial sci-
ence and technology, which gives it the
ftinger's Wound Microorganisms Necrotic potential to alter the wound environment
solution debris tissue
biochemically, including MMPs and elas-
tase. There also will be more cost-effec-
tive dermal replacements, MMP modula-
tors, as well as other biologicals that tackle
various issues in the wound bed and sur-
rounding tissue and skin.
The wound and skin care industry will
continue to respond with products that
address the needs of the wound at a cellu-
lar level as well as growth in the area of
pain and odor relief. MMHC
CYNTHIA A. FLECK, R.N., \S A CERTIFIED
WOUND SPECIAtiST AND DERMATOL-
OGY ADVANCED PRACTICE NURSE,
FLECK ALSO IS VICE PRESIDENT OF
CLINICAL MARKETING AT MEDLINE
INDUSTRIES INC.'S ADVANCED SKIN
AND WOUND CARE DIVISION,
MUNDELEIN, ILL. SHE CAN BE CON-
TACTED AT CFLECKgnMEDLINE.COM.

Resources for increosing wound care knowledge

Prior to application into the wound, the
Associations
polyacrylate debriding system is activat-
Association for the Advancement of Wound Care, www.aawcone.org
ed with Ringer's solution.
Wound, Ostomy ond Continence Nurses Society, www.wocn.org
American Professional Wound Care Association, www.apwca.org
Notional Pressure Ulcer Advisory Panel, www.npuap.org

Certifying orgonizations
American Acodemy of Wound Monagement-multidisclplinary board certification,
wmv.oatvm.org
Wound, Ostomy and Continence Nurses Society, www.wocn.org

Helpful wound care sites

Due to the polyacrylate's higher affinity
for proteins than for solts, the obsorbent
core simultaneously takes up and binds
wound debris, necrotic tissue and
microorganisms in exchange far
Ringer's solution.
Advancing the Proctice, www.advoncingtheproctice.org
Wound Science, www.woundscience.com
World Wide Wounds, www.worldwidewounds.com
Medline Advanced Skin ond Wound Care, www.medline.com/woundcarB
Reference texts
Chronic Waund Care: A Clinical Source Book for Healthcare Professionals, 4th Edition. 2007.
ovailable this spring at www.hmpcommunications.com
Wound Care Essentials, 2004, available ot www.iww.com
Wound Care Practice. 2nd Edition, ovoilable later in 2007 at www.6esfpufc.com
Acute and Chronic Wounds. 3rd Edition. 2006, ovailoble at www.mosby.com

The 24-hour rinsing action rapidly estob-
lishes a clean wound bed, allowing for
active waund healing ta take place. There
is tissue growth, ongiogenesis and cellu-
lar migratian.
Source: Wedime Advonced Skin and Wound Core, 2002
Conferences
Americon Professional Wound Core Association's Annual Conference: April 19-22,
Philadelphio; www.opwco.org
Symposium on Advanced Waund Core: April 28-May 1, Tompo, Fla.; www.sawc.net
Wound, Ostomy and Continence Nurses Society Annual Conference: June 9-13, Salt Lake Gty;
www.wocn.org
Clinical Symposium on Advances in Skin and Wound Care: Oct. 11-14, Nashville;
www.symposiumonwoundcore. com
Wound Care Congress: Oct. 23-27, Dollas; www.waundcorecangress.com
Journals
Advances in Skin and Wound Care, published by Lippincott Willioms ond Wilkins,
wwwjww.com
Ostomy.^ound Monogement (O/WM), published by HMP Cammunications, www.o-wm.com
WOUNDS, published by HMP Communicotions, www.woundresearch.cam
Journal of Wound. Ostomy ond Continence Nursing, published by Lippincott Willioms and Wilkins

2 8 MATERIALS MANAGEMENT IN HEALTH CARE fehruary 2007 \ motmanmag.com