Effective Wound Care: Use of Pioneer's Dressings PDF

Product Focus Effective wound care — the use of Pioneer’s dressings to optimise healing llThe remodelling phase (days 5 to 7 onwards post Abstract...

Product Focus Effective wound care — the use of Pioneer’s dressings to optimise healing llThe remodelling phase (days 5 to 7 onwards post Abstract injury) (Anderson, 1996). There are a wide number of wound dressing products available on the veterinary Each of the above phases rather than occurring at market, with each dressing having a specific function in wound healing. In order completely separate times as completely separate proc- to use these dressings appropriately, a sound understanding in the processes esses, in fact all overlap as they progress and hence of wound healing is essential, and therefore which dressing is most suited to influence the development and duration of the next the different phase, in order to optimise wound healing. Wound debridement is phase, meaning each phase is crucial to the end result. also a key aspect of wound management, and again, knowledge of the different techniques, and materials, which can be utilised is essential, in order to select the Early inflammatory phase most appropriate approach. The initial injury triggers coagulation and stimula- tion of the inflammatory cascade resulting in chemo- Key words: debridement, necrotic, epithelialisation, inflammatory, taxis and an influx of inflammatory cells. The magni- proliferative tude of the inflammatory response will be dependent on the severity of the trauma (O’Dwyer, 2007). T he treatment of small animal wounds will com- During the early inflammatory stage, wound man- monly require a staged approach. Definitive agement is commonly aimed at the debridement of treatment will often be delayed while emergency the wound, in order to remove necrotic tissue, and treatment of the patient and its wound, and initial sta- debris/foreign material, from the wound bed. The bilisation is performed. Analgesia and effective restraint mainstays of debridement in acute wounds are surgi- is often required, until the animal is stable enough for cal and mechanical debridement. Dressings at this sedation or a general anaesthetic (GA). Wounds can be time may include mechanical debridement dressings classified by their cause and the type of tissue damage such as wet-to-dry dressings, or the use of Debrisoft caused: incisional, abrasion, avulsion (or degloving), (supplied by Pioneer Vet Products). shearing, puncture or perforated, and burns. Regardless of the aetiology of the wound, the factor which has the Mechanical debridement single biggest impact on future healing is the presence Debrisoft of contamination and necrotic tissue. Debrisoft is a monofilament debridment pad that is Once the patient is stable a more thorough evalua- made up of more than 18 million specially angled fi- tion may be carried out. Appropriate chemical restraint bres. It is used to remove sloughy tissue, debris and may be required for examination. Diagnostic imaging necrotic/non-viable tissue from the wound bed. De- may be used to check for foreign material, penetrating brisoft can be used in conscious, as well as uncon- injuries, associated fractures, dislocations and tendon scious patients, and works rapidly (Figure 1). Its gen- or ligament damage. A management plan should take tle action means viable tissue within the wound bed, into account the wound’s location, size, damage to lo- i.e. granulation tissue and epithelial cells, remain in- cal structures and the amount of tissue loss. tact. Its simplicity, low cost and rapid results makes it a very viable option for debridement. Case study Wound healing phases 1, shows the product being used on initial presenta- There are three phases in wound healing tion and for the first few dressing changes to remove llThe inflammatory phase (immediate) necrotic tissue and sloughy material. llThe proliferative (repair) phase (days 3 to 7 post in- jury) Wet-to-dry dressing Wet-to-dry dressings are a useful tool in wound man- Louise O’Dwyer MBA BSc(Hons) VTS agement in veterinary practice. Their effectiveness (Anaesthesia/Analgesia & ECC) DipAVN relies on the adherence of the dressing to the wound (Medical & Surgical) RVN Clinical Support bed, which on removal lifts the debris and necrotic Manager, Vets Now Ltd tissue that becomes trapped in the mesh of the dress- ing (Figure 2). 94 March 2016 Vol 7 No 2 The Veterinary Nurse Downloaded from magonlinelibrary.com by 062.172.035.098 on May 24, 2021.  Product Focus Case study 1 Patient tissue surrounding the wound to allow for pad (Activa Healthcare supplied by Pioneer A 9-year-old Jack Russell Terrier. the use of a tie over (bolus) dressing. An Vet Products) is made up of more than 18 Presentation antimicrobial tie over dressing was applied million specially angled fibres that sweep The dog presented to the practice with and debridement with Debrisoft took place and bind debris and slough into the pad, an avulsion injury and a large ‘pocket’ in daily at dressing change, for the following effectively yet gently debriding the wound to her left hind limb following a road traffic 3 days, allowing for gentle yet rapid allow healthy granulation tissue formation. accident. Image 1. debridement and removal of necrotic and In this case Debrisoft allowed for the Presentation date sloughy material. Image 3. debridement of delicate tissue following the 29th December 2014. A staged approach to wound closure was initial surgical debridement and offered an Initial management taken in this case, with parts of the wound ongoing gentle debridement solution. Initially the wound was cleaned and being sutured closed while the main pocket Debrisoft offers veterinary professionals a lavaged and some surgical debridement was left open to granulate and heal by simple to use, gentle and rapid debridement was performed around the skin margins. second intention. Image 4. option where results can be seen in Debrisoft was then used to gently debride Outcome minutes. the sloughy material from the wound bed The wound went on to heal well without itself and the exposed muscle layers.  any complications and within 6 weeks from Case courtesy of Louise O’Dwyer, MBA, Image 2. initial injury had almost healed. Image 5. BSc (Hons), VTS (ECC), DipAVN (Med & Ongoing management Product Summary Surgery), RVN Clinical Support Manager, Stay sutures were placed in the healthy The Debrisoft monofilament debridement Vets Now Ltd Image 1. The wound at Image 2. Following Image 3. Good granu- Image 4. Extensive Image 5. 6 weeks post presentation. debridement with lation bed, allowing wound healing by 5 injury. Debrisoft. partial closure. weeks post injury. The application of wet-to-dry dressings involves moistening a sterile gauze swab using sterile saline or Hartmann’s solution, which is in contact with the wound bed; this is then protected by standard sec- ondary (cotton wool or dry swabs) and tertiary band- age layers. The moisture from the swab dilutes the exudates in the wound, which is absorbed into the secondary layer and the swab dries and adheres to the wound surface. The dressing needs to be changed at least daily before any strike through is noted; any delay leads to a delay in healing and increased risk of infection. Removal is often painful and sedation or anaesthesia is usually required. Surgical debridement Surgical (or ‘Sharp’) debridment will often be involved. This involves the cutting away of devitalised tissue Figure 1. Removal of sloughy material from a chronic wound using from the wound, which is a rapid and effective debri- Debrisoft. dement technique (Figure 3), as well as allowing the The Veterinary Nurse Vol 7 No 2 March 2016  95 Downloaded from magonlinelibrary.com by 062.172.035.098 on May 24, 2021.  Product Focus can be excised with a border of healthy tissue — in a similar fashion to removing a tumour with healthy margins in all planes. This is termed en-bloc debride- ment, ideal areas for this technique include the trunk or proximal limbs where there is plenty of available skin to close the deficit. The wound is usually packed with surgical swabs and sutured closed prior to exci- sion of the entire wound. Layered debridement More commonly when debriding a wound, devitalised tissue is removed gradually in layers, allowing conser- vation of tissue where possible; this may be important in areas such as the lower limbs and feet where there is Figure 2. Removal of a, well adhered, wet-to-dry dressing. inadequate skin to allow en-bloc debridement. Superficial tissue is removed first, followed by deb- ridement of deeper tissues. As debridement progress- es, instruments can be changed or disinfected and rinsed to prevent contaminating areas that have al- ready been debrided. Other forms of debridement Autolytic Autolytic debridement is a selective debridement brought about by the release of the patient’s own pro- teolytic enzymes (e.g. collagenase, elastase) and the activation of phagocytes. These enzymes soften and breakdown necrotic tissue, and are mostly produced by leucocytes. This is a natural process that occurs in all wounds, but its action can be enhanced by using products that promote and maintain an ideal moist wound environment, which promotes the activity of Figure 3. Extensive surgical debridement performed to remove necrotic leucocytes and macrophages. The moist environment tissue. also promotes the swelling of necrotic tissue, which loosens it from the wound bed. Assistance with auto- surgeon the opportunity to thoroughly explore, and as- lytic debridement may also be considered, which can sess the wound and underlying structures. As with any include the use of manuka honey, e.g. Manuka Fill as surgical procedure, debridement should be performed with Case study 2, Manuka IG Impregnated Gauze using strict aseptic technique, to prevent introducing dressing, hydrogels in combination with absorbent further bacterial contamination into the wound, so dressings such as Activheal Foam Non-adhesive, Ac- the surgical site should be draped, and the clinician tivheal Adhesive or Alleviate dressings (all available gowned and gloved. Pioneer Vet Products have a com- from Pioneer Vet Products), to absorb the exudate prehensive range of surgical protective wear including and sloughy material produced at the wound bed variable fenestration drapes, ideal as the aperture can (Figure 4). be adjusted to fit around individual wounds. Generally two approaches to surgical debridement Enzymatic can be used; ‘en bloc’ or layered debridement. The Enzymatic agents are relatively selective in loosening choice depends on the availability of surrounding tis- and removing necrotic tissue (Gregory, 1999). No vet- sue for closure, and therefore the need to preserve as erinary product exists in the UK, but in the USA an much skin as possible. ointment derived from bacteria (Bacillus subtillus), which contains the enzyme sutilain, is available and En bloc debridement can be used in wounds with minimal necrotic tissue. In areas where there is adequate normal tissue to A much wider range of proteolytic enzyme prepa- allow closure afterwards, the whole affected tissue rations are available for wound management in hu- 96 March 2016 Vol 7 No 2 The Veterinary Nurse Downloaded from magonlinelibrary.com by 062.172.035.098 on May 24, 2021.  Product Focus Case study 2 Patient management was pursued to encourage a and was practically healed 1 month after A female, medium-sized poodle cross. healthy granulation bed. Once granulating initial presentation. Presentation the decision could be made to either graft Dressing summary The dog was knocked down by a car and (although funds were short) or the wound Manuka Fill honey dressings (Pioneer presented with bilateral abrasions. could be allowed to close by second Vet Products) were used to assist with Presentation date intention. debridement — the osmotic action of the 19th March 2013. Ongoing management honey softens the necrotic tissue, assisting Initial management Manuka Fill Honey dressings were used autolytic debridement. These dressings also The dog initially presented to the veterinary to dress the wound and to assist with provided antimicrobial support to what was practice with a heavily contaminated debridement and dressings were changed a highly contaminated wound and helped wound to her left fore, she had suffered initially every 2 days, and then every 3 days to maintain a moist wound environment a severe abrasion which revealed tendon for the first 3 weeks. throughout the healing process. involvement, but no fractures. There Outcome was not enough skin available to close The wound went on to granulate and Case Courtesy of The Veterinary Wound the deficit immediately so open wound epithelise without any further complications Library and Nora Janossy Dr MedVet Image 1. 22nd March Image 2.2nd April Image 3. 5th April. Image 4. 19th April. Image 5. 25th April. mans, including enzymes derived from plants (e.g. Late inflammatory phase pineapple), bacteria and animals (e.g. Antarctic krill). Macrophages infiltrate shortly after inflammation is established and are crucial to the stimulation and Larval progression of the wound through the phases of the The use of maggots in wounds is an idea that has been healing. They debride necrotic or foreign material in around for hundreds of years. In human medicine the the wound and dispose of the platelet clot, dead cells, most commonly used maggot is that of the greenbot- bacteria and organic debris. Macrophages are derived tle fly (Lucillia sericata) (Gregory, 1999). Maggots are able to selectively debride necrotic tissue while spar- ing healthy structures; this technique is particularly Key Points advantageous when debriding wounds where vital Decreasing the presence of these impairments to wound healing will enable the ll structures exist and therefore surgical debridement is reduction of the level of contamination and the presence of necrotic tissue to a contraindicated. point where the closure technique chosen can be safely carried out. Debrosoft acts as an exciting new means of debridement, removing sloughy ll Hydrosurgery and necrotic tissue from the wound bed — its gentle action enables use in the Hydrosurgical units emit a very high-pressure stream of conscious patient. saline that cuts tissues. The Versajet (Smith and Neph- Each of the wound healing phases overlap as they progress and hence influ- ll ew) is the most commonly used unit in human hospitals ence the development and duration of the next phase. where they are used for debridement of wounds, chronic It is vital that veterinary staff have a good understanding of the processes in ll ulcers, and burns. Human reports suggest that Versajet wound management, so that an appropriate dressing can be matched for the is equally, if not more effective than conventional surgi- specific stage. cal debridement, by causing less damage to viable tissue. The Veterinary Nurse Vol 7 No 2 March 2016  97 Downloaded from magonlinelibrary.com by 062.172.035.098 on May 24, 2021.  Product Focus from the circulating monocytes and are stimulated by factors such as endotoxins, alginate, cytokines, fibrin, hypoxia and increased lactate concentrations. In monocytopenic patients, this stage is delayed or fails altogether (Anderson, 1996). If there is concern regarding infection at this point in wound healing, then dressings that have antimi- crobial activity may be considered, such products include manuka honey (e.g.Manuka Fill, Pioneer Vet Products), or dressings that contain silver (e.g. Supra- sorb A Ag, Pioneer Vet Products). Proliferative phase The proliferative phase marks the development of granulation tissue. Fibroblasts migrate into the wound from nearby skin. They lay down a new extracellular matrix after debridement has taken place, and manu- Figure 4. Use of manuka honey as part of the autolytic debridement facture and remodel collagen. Fibroplasia is almost process. entirely dependent on the inflammatory trigger and may be delayed if the inflammatory phase fails to oc- cur. However, once the fibroblast population is active, and in place, anti-inflammatory drugs will not halt the formation of normal scar tissue (Anderson, 1996). Epithelial cells are stimulated initially by the injury itself and subsequently by cytokines released by the other cells. They proliferate and flow over each other, then reattach to the granulation tissue underneath. This process is fastest when the wound is moist and the cells do not have to lyse necrotic tissue to get across the wound (e.g. migration under an eschar). The migrating and proliferating epithelial cells are fragile and highly susceptible to adverse conditions in the wound, desicca- tion or abrasion of the wound surface (O’Dwyer, 2007). epithelialisation. Wound Healing Figure 5. Application of sheet hydrogel dressing to a wound undergoing During epithelialisation, dressings should be selected which result in minimal disturbance of the wound envi- ronment, but also have the advantage of maintaining a 1.Blood Coagulation Hemostasis Wound Healing moist wound environment. Sheet hydrogels are an ex- Cyprofil Powder CHOOSE A DRESSING THAT ADDRESSES cellent option at this stage (Figure 5) (e.g. Actiform Cool, THE WOUND STAGE Pioneer Vet Products), as they allow epithelialisation to 4.Regeneration and Repair continue undisturbed, in a moist wound environment. Hydrogel ( with secondary) Actiform Cool Since they are composed of a solid sheet of hydrogel, Remodelling Phase Silicone Mesh (Mepitel) Demafilm with a film backing, they negate the additional cost of 2.Degerative Process having to use a secondary dressing to cover hydrogel, if Debrisoft Manuaka Fill Inflammatory Phase hydrogel was used for this same purpose. Hydrogel Sharpe Debridement Some wounds may fail to effectively reach prolifera- Maintain a Moist Environment Debride Devitalised tion and have an excessive inflammatory stage, during Tissue, Absorb Exudate and this time collagen degradation can become minimal Manage Contamination and or levels of matrix metalloproteinase can become 2a. Exudate Proliferation Phase Debrisoft elevated. Collagen dressing such as Cyprofil (Pioneer Suprasorb A+Ag 3.Granulation Flivasorb/Adhesive Cyprofil Collagen Vet Products) are effective in encouraging the forma- Possibly foam Foam Hydrogel tion of the extra cellular matrix, leading to the forma- Actiform Cool Silicone tion of a healthy granulation bed, wound contraction 01304 831 831 | www.pioneervet.co.uk and epithelisation, ultimately ensuring an effective Figure 6. Wound healing chart. proliferation phase. See Figure 6. 98 March 2016 Vol 7 No 2 The Veterinary Nurse Downloaded from magonlinelibrary.com by 062.172.035.098 on May 24, 2021.  Product Focus Case study 3 Patient progress. On the 18th April the wound was Product summary A male cat. debrided under sedation. The Cyprofil Collagen dressings (Pioneer Presentation Ongoing management Vet Products) were used to encourage the The cat first presented to the practice At this point additional advice was sought formation of a bed of health granulation following a suspected RTA and had severe via The Veterinary Wound Library and on tissue. The Cyprofil provides a scaffold trauma and degloving injuries to the medial the 12th May the wound was dressed with a and the protein fragments produced by aspects of both hind legs. X rays revealed Cyprofil collagen dressing. At the bandage degradation of the Cyprofil help to stimulate no fractures and the decision was taken change 1 week later ‘the improvement fibroblast proliferation, guide new collagen to allow the wounds to heal by second was amazing’ and although the tendon deposition and help to form extracellular intention. outline was still just about visible the wound matrix. This in turn allows for endothelial Presentation date was totally covered by granulation tissue cell proliferation, wound contraction and 18th March 2014. and had contracted well. The Cyprofil ultimately healing. ‘At the second bandage Initial management collagen dressings were continued, with the change the improvement was amazing A paraffin gauze was initially used as a bandages being changed every 3 days. with the tendon outline still just visible but primary dressing secured with a light Outcome totally covered by granulation tissue and the bandage and changed every 3 days. The Within a further 2 months the wound wound contracting down well’. majority of the wounds healed well but one was practically healed and required only was problematic. A wound on the dorsal a couple of further dressing changes, Case Courtesy of Francesca Braid MRCVS & aspect of the left hind was struggling to heal although there was a little bit of surrounding Catherine Darragh MRCVS, and at this point exposed extensor tendon soreness from some minor bandage rubs. Companion Care Tunbridge Wells and Hove was still visible and the wound was failing to and The Veterinary Wound Library Image 1.Tendon visible prior Image 2.1 week after Cypro- Image 3. Granulating well. Image 4. Healing well but to Cyprofil. fil. with some bandage irrita- tion. Remodelling phase in wound healing, along with good knowledge of The final phase is remodelling and restoration of the the actions of wound dressings, so that an appropri- This article was produced normal structure. The scar, however, will nearly al- ate dressing can be matched to the specific stage of using an educational grant ways be weaker than the surrounding uninjured skin wound healing process, in order to optimise wound from Pioneer Vet Products. (Anderson, 2003). healing. Wound management is an ever-evolving More information on their field so it is essential that staff remain up to date on range of products can be Conclusion the novel technologies.  VN obtained from: http:// In wound management, it is vital that veterinary staff www.pioneervet.co.uk have a good understanding of the processes involved Conflict of interest: none. Anderson D (1996) Wound Dressings Unraveled. In liams JM, editors. Manual Small Animal Veterinary As- mals: A Practical Guide for Management in Small Ani- Practice 25(2): 70–83 of canine and feline wound sociation: 13–23 Veterinary Nurses and Tech- mal Practice. In Practice Gregory CR (1999) Wound management and recon- O’Dwyer L (2007) The Process nicians. Elsevier, Philadel- 18(3): 115–28 healing and influencing struction. Shurdington, of Wound Healing. Wound phia, USA Anderson D (2003) Wound factors. In: Fowler D, Wil- Cheltenham (UK): British Management in Small Ani- The Veterinary Nurse Vol 7 No 2 March 2016  99 Downloaded from magonlinelibrary.com by 062.172.035.098 on May 24, 2021.