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Dressings for ischemic diabetic ulcer?

Discussion in 'Diabetic Foot & Wound Management' started by OptimistPod, Nov 28, 2012.

  1. OptimistPod

    OptimistPod Member


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    Hi there,

    I am a third year Pod student and have been given a case study to look at.

    It involves a type 2 diabetic patient with an ischemic ulcer over the lateral aspect of 5th toe that has become infected, malodorous with exudation.

    With the vast amount of dressings on the market I would welcome any advice you guys have on the dressing type you would choose for this kind of wound.

    I understand you have little information on the wound but that's basically what we have been given. I also understand that there is limited evidence on dressing types and so am interested in hearing anyone's opinion on dressing choice.

    Thankyou in advance for any help you give.
     
  2. PostMortem

    PostMortem Active Member

    Hi OptimistPod,
    Before you get any answers to your question, you are going to have to put something forward first.

    1) What dressing would you use?
    2) What is the purpose of the dressing you propose to use?
    3) What are the properties of the dressing?
    4) What are the pros and cons of that dressing?
    5) What research have you done already?

    Without demonstrating that you have gone through this process as a starter, you are not likely to get much help.
     
  3. elenakash

    elenakash Welcome New Poster

    Look for Enluxtra.
     
  4. admin

    admin Administrator Staff Member

  5. elenakash

    elenakash Welcome New Poster

    OMG!... just ban me if it is not helpful. I wanted to help. Thanks and good bye.
     
  6. jos

    jos Active Member

    Ischaemic-> Doppler (for your info), send to GP to refer for Duplex scan, then referral asap to vascular surgeon. This toe can go black and drop off VERY quickly, if substantial blockage present.
    refer to Gp for antibiotics asap also. Xray to check for osteomyelitis, if infection has been present for a week or so (but not always conclusive).

    If it's infected it probably has pus and maybe biofilm- drain pus and wash well with sterile saline.
    Irrigate wound with Prontosan, apply iodosorb (or Sorbact), lyofoam to abosorb exudate and tape to secure. DO NOT TIE UP TOE TIGHTLY OR IT WILL DROP OFF!
    Will need daily change, especially if gooey. May need padding to deflect pressure from the ground? Open toe shoes to avoid pressure to toe.

    Their BGLS are probably up and all over the place also if there is infection present, so their diabetes will be all out of whack too, which doesn't help.. Watch our for systemic signs of infection-malaise, fever etc.

    Have a look at the AWMA site-they have some great research and info-the guidelines are very helpful!

    NOTE: I would not use Enluxtra as it (quote) "locks exudate"- this will seal in the infection and your toe/foot/limb will be gone in no time.
     
  7. markjohconley

    markjohconley Well-Known Member

    Goodaye Jos, would you send for a Duplex only if the doppler result indicated it?
    Slightly different, the wound care nurse practitioner here soaks with Prontosan for 10 minutes'ish rather than irrigate, and covers the Iodosorb with Atrauman to help hold it in place, all the best, mark
     
  8. jos

    jos Active Member

    Yes, would send if Doppler is poor or non existent! But the brief said 'ischaemic' so I would guess the Doppler would be poor anyway....

    Yep, sorry I said irrigate, meant soak. I usually wash away (irrigate) the debris with sterile saline first, if it is gooey, then prontsan it.

    Just googled Atrauman- is this a silver dressing? Why would you add it with iodosorb? Might they counteract each other??
     
  9. elenakash

    elenakash Welcome New Poster

    Completely wrong!!

    The Absorbing function is responsible for transportation of the exudate/microorganisms/slough components AWAY from the wound bed into the dressing. The Lock In function is responsible for prevention of returning of the absorbed infectious/corrosive stuff back to the wound bed or transferring to other parts of the wound or onto peri-wound skin. This mechanism is well known and you may see it used in gelling fiber dressings like Durafiber for example:

    http://www.smith-nephew.com/key-products/advanced-wound-management/durafiber/

    "Locks in Fluid and Bacteria 1,2,3,4,5 – helps to remove excess fluid and bacteria away from the wound bed and may reduce the risk of cross contamination on dressing removal"

    No, I do not work for S&N! :D

    Foam dressings have a fundamental flaw - they do not lock in exudate so the absorbed exudate and microorganisms can be easily squeezed onto other parts of the wound or peri-wound skin causing secondary ( or prolonged) infection and wound edge and skin maceration.
    Most foam dressings have very small pore size on the wound facing side. These small pores became quickly clogged by the viscous slough components. The clogged pores are impermeable for microorganisms leaving them on the wound.

    Some "gelling fiber" dressings ( alginates or cellulose fiber based) provide both functions - Absorbing and Lock In - only for as short time. The fibers near the wound bed disintegrate while absorbing the exudate and thus create a continuous gel layer that has poor permeability for microorganisms and slough components.

    Other dressing materials, that do not disintegrate while absorbing exudate, provide removal of the microorganisms and slough components for several days.
     
  10. markjohconley

    markjohconley Well-Known Member

    Jos, Atrauman also comes in non-Ag impregnated and that's what they use. Don't use much of the Ag impregnated Atrauman apparently as there's better products available, mark
     
  11. jos

    jos Active Member

    Oh, ok, when I googled it, the Ag form came up and I didn't realize there were other types!
     
  12. cperrin

    cperrin Active Member

    Prontosan is a surfactant biguanide acting almost like a wound bleach - if you have anything that has a very thick crust then soaking works a treat/but you could do this just as well with saline - but mainly for a sloughy wound the longer you soak it the more you will be able to debride off - in the same sense we have had mixed results using the prontosan wound gels. But for even for a standard A1 UoT wound we use prontosan instead of saline in clinics, reduces bioburden/colonisation a treat.
     
  13. OptimistPod

    OptimistPod Member

    Thankyou for all your replies, plenty of food for thought!

    So i gather the jists of it are to soak the foot in something as you say prontosan, and then just apply an absorbing dressing to take away the exudate?

    And yes Jos, the brief says evidence of lymphangitis and recent fever so i gather IV antibiotics are needed?

    Would the slough come away whilst soaking or would very fine debridement by needed, OR is debridement an absolute no no given the ischemic state? ( Sorry if this all sounds silly and naive, havent really been exposed to many wounds in clinic, the Uni seems to concentrate on biomechanics!!)

    How often would the dressing need changing also? given that strike through, i guess, wouldnt take too long given the amount of exudate?

    Thanks for all your help and suggestions though, i appreciate it!
     
  14. [Ulcers with exudate - I have never found anything better than 6% hydrogen peroxide to clean these types of wounds. It is an effervescent debrider, so bubbles up and lifts the exudate with it. It is a very safe solution, being only water and oxygen. It also promotes circulation, thereby enhancing healing. A goggle search supports this, as does the pharmaceutical manual. I suggest that the ulcer is cleansed daily with 6% hydrogen peroxide, then covered with a sterile dry non stick dressing. Keep affected foot elevated when seated too to promote better circulation to the area. The diabetes needs to be closely monitored too, as poor control increases the risk of ulcers. As does poorly fitting or unhygienic foot ware.]
     
  15. blinda

    blinda MVP

    H202 is cytotoxic and should NEVER be applied to an ulcer. Particularly on an `at risk` pt;

    http://www.ncbi.nlm.nih.gov/pubmed/19131809

    http://emedicine.medscape.com/article/1895071-overview

    http://www.webmd.com/a-to-z-guides/wound-care-10/diabetic-wounds


    Personally, I rather like the Covidien PHMB dressings, which I mentioned here;

    http://www.podiatry-arena.com/podiatry-forum/showpost.php?p=266381&postcount=3

    Cheers,
    Bel
     
  16. David Smith

    David Smith Well-Known Member

    I like to tell patients that we can't actually heal anything, we just try to create the optimum condition for the body to heal itself.

    Following that line of thought I love this analogy of wound conditioning compared to rebuilding a destroyed house.

    Probably our most useful role in this process is to help remove as much rubble and debris as we can, add some secodary scaffolding and temporary frame work and stop or retard invasion of pathogenic bacteria (the analogy falls down a bit on that front but that's the nature of analogies.) Maybe there's a security team a anti intruder fence and a sludge busting team there too.

    Imagine if we just had to create the right environment on a piece of wasteland and a house just built itself. (I did once make a den in a lightning tree):D

    4 Stages of Healing

    How Do Wounds Heal?
    Research work on acute wounds in an animal model shows that wounds heal in four phases. It is believed that chronic wounds must also go through the same basic phases. Some authors combine the first two phases.

    The phases of wound healing are:

    Hemostasis
    Inflammation
    Proliferation or Granulation
    Remodeling or Maturation

    Hemostasis:
    Once the source of damage to a house has been removed and before work can start, utility workers must come in and cap damaged gas or water lines. So too in wound healing damaged blood vessels must be sealed. In wound healing the platelet is the cell which acts as the utility worker sealing off the damaged blood vessels. The blood vessels themselves constrict in response to injury but this spasm ultimately relaxes. The platelets secrete vasoconstrictive substances to aid in this process but their prime role is to form a stable clot sealing the damaged vessel. Under the influence of ADP (adenosine diphosphate) leaking from damaged tissues the platelets aggregate and adhere to the exposed collagen. They also secrete factors which interact with and stimulate the intrinsic clotting cascade through the production of thrombin, which in turn initiates the formation of fibrin from fibrinogen. The fibrin mesh strengthens the platelet aggregate into a stable hemostatic plug. Finally platelets also secrete cytokines such as platelet-derived growth factor (PDGF), which is recognized as one of the first factors secreted in initiating subsequent steps. Hemostasis occurs within minutes of the initial injury unless there are underlying clotting disorders.
    Inflammation Phase:
    Clinically inflammation, the second stage of wound healing presents as erythema, swelling and warmth often associated with pain, the classic “rubor et tumor cum calore et dolore”. This stage usually lasts up to 4 days post injury. In the wound healing analogy the first job to be done once the utilities are capped is to clean up the debris. This is a job for non-skilled laborers. These non-skilled laborers in a wound are the neutrophils or PMN’s (polymorphonucleocytes). The inflammatory response causes the blood vessels to become leaky releasing plasma and PMN’s into the surrounding tissue. The neutrophils phagocytize debris and microorganisms and provide the first line of defense against infection. They are aided by local mast cells. As fibrin is broken down as part of this clean-up the degradation products attract the next cell involved. The task of rebuilding a house is complex and requires someone to direct this activity or a contractor. The cell which acts as “contractor” in wound healing is the macrophage. Macrophages are able to phagocytize bacteria and provide a second line of defense. They also secrete a variety of chemotactic and growth factors such as fibroblast growth factor (FGF), epidermal growth factor (EGF), transforming growth factor beta (TGF-__ and interleukin-1 (IL-1) which appears to direct the next stage.


    Proliferative Phase ( Proliferation, Granulation and Contraction):
    The granulation stage starts approximately four days after wounding and usually lasts until day 21 in acute wounds depending on the size of the wound. It is characterized clinically by the presence of pebbled red tissue in the wound base and involves replacement of dermal tissues and sometimes subdermal tissues in deeper wounds as well as contraction of the wound. In the wound healing analogy once the site has been cleared of debris, under the direction of the contractor, the framers move in to build the framework of the new house. Sub-contractors can now install new plumbing and wiring on the framework and siders and roofers can finish the exterior of the house. The “framer” cells are the fibroblasts which secrete the collagen framework on which further dermal regeneration occurs. Specialized fibroblasts are responsible for wound contraction. The “plumber” cells are the pericytes which regenerate the outer layers of capillaries and the endothelial cells which produce the lining. This process is called angiogenesis. The “roofer” and “sider” cells are the keratinocytes which are responsible for epithelialization. In the final stage of epithelializtion, contracture occurs as the keratinocytes differentiate to form the protective outer layer or stratum corneum.

    Remodeling or Maturation Phase:
    Once the basic structure of the house is completed interior finishing may begin. So too in wound repair the healing process involves remodeling the dermal tissues to produce greater tensile strength. The principle cell involved in this process is the fibroblast. Remodeling can take up to 2 years after wounding and explains why apparently healed wounds can break down so dramatically and quickly if attention is not paid to the initial causative factors.


    Regards Dave
     
  17. David Smith

    David Smith Well-Known Member

    Which brings me nicely to this point: The dressing is only the middle man there's preparation and protection and reinstatement on either side, i.e. removal of dirt, debris, foreign bodies, necrosis and callus and protecting the wound from pressure friction, and other trauma and reinstating vital supplies when possible.

    Dave
     
  18. David Smith

    David Smith Well-Known Member

    So from this evaluation of wound repair we might see that it may not be possible to select one dressing that does all the jobs required at the same and right time. This might be like getting a jack of all trades to rebuild your house instead of specialists employed at the right stage of progress. That approach may not be very successful. So you need the right contractors in at the right time and like a house rebuild (but more so) things don't go to set schedules and timings. If you look at the stages of healing and the processes within each stage you will see that they overlap considerably so the selection of appropriate dressiing at the appropriate time for optimum wound healing may be a very individual assessment case by case, although I have founds that different clinicians have favourite dressing selections, for the best outcomes, they probably should not be too rigid in their mode of application.

    Dave
     
  19. Tkemp

    Tkemp Active Member

    There's also patient education, so they dont remove the dressing to have a look or prod at it between appointments.
    Keeping the dressing clean, dry and in-situ is vital.
    Dressings with charcoal will aid in reducing the malodour. You have to bear in mind the social stigma some patients feel about having a malodourous wound - some can be very unpleasant!

    Remember to justify your choices of dressings in regards to the brief given.
    Good luck :)
     
  20. OptimistPod

    OptimistPod Member

    Thankyou for the analogy David, really works for me!

    I guess your right in that different types of dressings are needed at each stage, its just finding the evidence of which to use but all these suggestions are helpful so thanks guys!

    Tkemp, yeah part of the assessment is the hollistic approach to the patient so all those things are considered as he is feeling 'anxious' as he has already lost a toe on the other foot to gangrene. So lots to consider really!

    Thanks again
     
  21. mburton

    mburton Active Member

    You've had some interesting replies. Just one or two other things that may be helpful:-
    When blood supply is diminished ABs may not actually reach the area, so topical antibacterial dressings will be essential - I find Acticoat silver dressings usually work well.
    Osteomyelitis is very likely in this type of lesion - can you probe to bone? If so, for an ischaemic ulcer the prognosis is not great.
    Remember NOT to hydrate an ischaemic wound, if you do you will vastly increase the bacterial burden, although I agree with the other posters that Prontosan gel, used judiciously can be helpful in reducing bacteria and desloughing where there is reasonable potential for healing.
    Good luck - sometimes you need that as well!
     
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