Dramatically reduce wound pain with Hydrosorb® Hydrogel dressing ...

Case Study 1David Gray Tissue Viability Nurse, Grampian University Hospitals Trust, AberdeenManaging Highly Exuding Leg WoundsOccasionally wounds present with highlychallenging symptoms, which require afresh approach to their management. Themanagement of infected wounds on thelower limbs, which present with high exudatelevels, are one such example. In the two casestudies on this page, the level of exudateproduced by the wounds over a 12 hourperiod far exceeded the moisture handlingcapabilities of modern foam dressings.It was clear that in both cases moist woundhealing was not an achievable aim until thetwo underlying pathologies, oedema in study1 and infection in study 2, were removed.The clinician is then left with the problem ofmanaging the symptom until the underlyingpathology is removed and healing can proceed.During this time the level of exudate producedwould involve many dressing changes withthe potential for adhesives to irritate thesurrounding skin and maceration to develop.In these cases the management of the two casesinvolved the use of a non-adherent contactlayer, Atrauman and a secondary-dressing pad,Zetuvit. These dressings were held in placewith light tubular bandages. This combinationallowed the wound bed to be left undisturbedand the pad to be changed regularly withouttrauma to the surrounding skin. The ease withwhich the dressing could be changed allowedregular pad changes, thus reducing the risk ofmaceration around the wound.Study 1Image 1 and 2 portray a gentleman withwidespread lymphodema of both lower limbsdue to a malignant condition. There are twopuncture wounds, one on the left foot andone on the right leg.These wounds were leaking approximately50mls per 2 hours and elevating the limbsproved difficult due to his condition.These wounds were being treated usingfoam dressings that were being changed2-4 times per day, with large amounts ofleakage observed.As it was impossible to quickly reduce theoedema in the legs, the patient faced manydays/weeks of fluid leaking from his limbsand regular dressings changes. Even withthese dressings changes, it was not possibleto prevent fluid leaking across the healthyskin at the wound margins. The decision wastaken to dress the wounds with Atrauman,a non-adherent contact layer, covering withZetuvit, a dressing pad and securing with atubular bandage, applied from toe to knee.This combination allowed the patient to havethe oedema absorbed from the wounds intothe dressing pads. When the dressings padsneeded changing the tubular bandagewas rolled down and the pads changed.The presence of the Atrauman on thewound surface meant that the wound itselfwas not disturbed.Study 2Image 3 and 4 show a resolving case of cellulitusto the lower limbs. Both limbs have sufferedsuperficial skin loss due to blistering, associatedwith soft tissue infection. Due to the oedemapresent in the legs the application of a standardmoist wound dressing was contraindicated,due to the high levels of exudate and the needfor frequent dressing changes.Due to these factors the patient’s legs weremanaged with the same dressing regimeas that in study 1 (Atrauman, Zetuvit,tubular bandage).This regime was continued until the oedemain the legs and the leakage from the woundsreduced. At this point, a new moist woundhealingregime was introduced as the needfor regular [4-6] daily dressing was nolonger necessary.Image 3Image 4Image 1Image 2These wounds were unlikelyto heal until the oedema hadresolved, this was not likely tohappen for some days, possiblyweeks. The decision was takento manage the main symptom,oedema leakage, using thecombination described.ConclusionThese case studies demonstrate how theuse of relatively simple wound managementtechniques can reduce trauma to thesurrounding skin, manage high exudate levelswhile being economically effective. Using moreexpensive dressings to manage the exudatein the cases described could have resulted ingreater costs with no greater clinical outcome.It should be noted that due to the underlyingpathologies present at the time no healingcould have been reasonably expected.HARTMANN Wound Forum 5

Clinical Study 1Holger Kapp Department Clinical Application Studies, PAUL HARTMANN AG, HeidenheimClinical performance of a hydrogel dressingin the management of chronic wounds –a prospective application study in 81 patientsSUMMARYIn a prospective, multicentre, ambulantapplication study, 81 patients (average age67 years) were treated with the Hydrosorbcomfort hydrogel dressing. The majorityof the patients had chronic wounds,which were one year old on average. Atthe beginning and end of the study, thephysicians evaluated the condition of thewounds and the pain experienced by thepatients. They were treated with Hydrogelcomfort for an average of twelve days andthe dressing was changed every 4 days.The wound status improved markedly inthe course of the study. The proportionof the wound surface that was coveredwith slough fell from 62.7% to 23.1%.At the same time, the area covered bygranulation and epithelial tissue increasedby 11.9 and 15.1 percentage points,respectively. The wound area decreasedfrom 4.7 x 2.9 cm at the start to 3.7 x2.3 cm. Other parameters that improvedwith the Hydrosorb treatment were thedegree of exudation and the conditionof the perilesional skin. The patients alsoreported markedly less pain. Whereas29.6% of the patients reported no pain atthe beginning of the study, this proportionincreased to 56.3% at the final assessment.As the treating physicians emphasised,the documentation sheet provided withHydrosorb comfort proved to be helpful inmonitoring and documenting the course ofwound healing.Conclusion: chronic wounds can be treatedeffectively with Hydrosorb comfort. Thehydrogel dressing promotes the woundhealing process, reduces wound pain andthus improves the patients’ quality of life.IntroductionWhen the skin is injured, the body initiatesa cascade of processes that eventually leadto a re-epithelialisation of the wound areaand re-establishment of the skin’s barrierfunction (1). If the precisely coordinatedinterplay of inflammatory cytokines, mitogenicgrowth factors, extracellular componentsand enzymes such as proteases is disturbed,stagnation of the repair process can occur.The result is a chronic wound. The mostchronic wounds such as leg ulcers, pressureulcers and diabetic foot ulcers have anunderlying systemic disease process, whichpersistently interferes with biochemical andphysiological processes in the wound area.As a result, the healing process ceases in theinflammatory phase and becomesdeadlocked (2).Chronic wounds are of various origins andhave different aetiologies. Vascular causessuch as venous insufficiency, arterial occlusivedisease, diabetic angiopathy and neuropathy- sometimes in combination – are the mostcommon systemic disorders. At the local level,infections, and the presence of a foreignbody in the wound can delay wound healing.In addition, prevailing systemic diseasesinclude malnutrition, malignant cachexia,autoimmune diseases and systemicco-medication (3).Taking a systematic and disease-specificdiagnosis of these local and systemic factors isa prerequisite for successful wound treatment(4). Because of the complex pathophysiologyof a chronic wound, therapy should not bedirected only toward isolated local factors.Rather, a more holistical approach totreatment should be taken. The basis of everytherapy is causal treatment or ameliorationof the underlying disease, for instance,treatment of venous hypertension in chronicvenous insufficiency. Furthermore, only whendeficits of the macro- and microcirculationin the wound area are eliminated and blood,oxygen, and nutrient supply are optimallycorrected, can a wound dressing successfullysupport the healing process of an ulcer (5).Several parameters of the wound stateinfluence the choice of the appropriate wounddressing. Important parameters include sizeand location of the wound, the degree ofexudation, presence of slough, necrosis, andpossible signs of infection as well as thehealing phase of a wound at any given time.No single wound dressing can deal with allof these different parameters. Therefore,a number of different hydroactive wounddressings are available to the wound careprofessionals, most specifically tailored toensure a physiologically moist wound milieu,which promotes the repair process. During thetreatment, the condition of the ulcer shouldbe inspected regularly and the local andsystemic treatment should be adjusted if anychanges are diagnosed (6).Hydrogel dressings are indicated forchronic wounds which exhibit only slightexudation. Because of the high water contentof up to 90% of these dressings, they areable to keep granulation tissue and freshepithelial tissue moist and protect them fromexternal mechanical stress and provide abarrier to secondary infection fromthe environment (7).The present application study investigatedthe clinical efficacy and tolerability of theHydrosorb comfort hydrogel dressing onwound healing in patients who sufferedmainly from chronic ulcers that weredifficult to address therapeutically.6 HARTMANN Wound Forum

Table 1 Patient characteristics (n =81)Women 42 (51.9%)Men 39 (48.1%)Age66.8 years(±15.1 years;median 68.4 years;range 31.2 to97.7 years)Age of wound365 daysHydrosorb comfort is a transparenthydrogel dressing made of absorbentpolyurethane polymers containing about60% water. When applied to the wound,Hydrosorb supplies the tissue withmoisture. At the same time, the hydrogelabsorbs excess wound exudate and locksit into the gel structure. This ensuresmoisture balance in the wound andpromotes the production of epithelial andgranulation tissue.Because of the high proportion of water,Hydrosorb comfort is also indicatedwhen dry slough or necrosis has to beseparated from the base of the wound.The Hydrosorb comfort employed in thestudy is surrounded by a hypoallergenicadhesive film. The transparency of thehydrogel enables the condition of thewound to be inspected at any time. Theuser can also document changes in thewound size during treatment with a foil.After the wound dressing has been placedon the wound, the wound size can betraced on the film using a pen and the filmis then removed and stored in the patientfile. After several dressing changes, thetreating doctor can track the course ofhealing by comparing the respectivewound sizes.Material and methodsOutpatients with chronic or acute wounds ofdifferent aetiologies in 15 German medicalcentres (eight surgeons, four generalphysicians, one internal medicine office andtwo teaching hospitals) were eligible toparticipate in the prospective, multicentreapplication study. The requirement forincluding the patients in the study was thattreatment with the hydrogel dressing wasclinically indicated. One wound per patientwas treated in the study. No patients wereexcluded, in line with chronic woundsencountered mostly in daily practice. Theattending physicians were free to treat anypatient with chronic wounds, irrespective ofage, sex or comorbidities or the origin of thewound. Each patient was treated individuallyin the study according to their medicalhistory and diagnosis. Overall, three dressingchanges were documented. At the initialexamination, the investigators recorded thepatients’ age, sex, general health state andcomorbidities, age and size of the wounds aswell as previous local and systemic treatmentsand co-medications using a standardisedquestionnaire. At the beginning and endof the study, the investigators evaluatedthe condition of the wound by recordingthe proportion of slough, granulation andepithelial tissue, the extent of exudate, thecondition of the perilesional skin and patientreportedpain. At the final examination,the wound care professionals assessed theclinical efficacy, tolerability, and the handlingof Hydrosorb comfort. The patients werealso asked about their experiences with thehydrogel treatment.ResultsThe investigators documented the course oftreatment of 81 patients. 39 patients (48.1%)were male and 42 (51.9%) were female(table 1). The average age was 66.8 years(±15.1 years, range 31.2 to 97.7 years). Thegeneral health was assessed as very good in16 patients (20%) and age-appropriate in45 patients (55%). 20 patients (25%) had areduced physical state due to comorbidities.According to the attending physicians’Table 2 Aetiology of the wounds (n= 81Cause proportion in %Venous leg ulcer 19.8Arterial leg ulcer 7.4Mixed leg ulcer 12.3Decubitus ulcer 9.9Diabetic pressure ulcer 9.9Diabetic gangrene 7.4Acute traumatic wound 7.4Burn 8.6Other 17.3Wound conditionFig. 1 Condition of the wound before and after treatment with Hydrosorb comfort (n = 81)HARTMANN Wound Forum 7

description, 44 of the patients (54%) wereincluded in the study because previoustreatment of the wound had failed to achieveimprovement. For 30 (37%) the treatmentwith the hydrogel dressing was the firsttreatment of the wound. 6 patients (7.4%)were treated with the hydrogel because thephase of wound healing had changed.8 of the 81 patients withdrew from thestudy prematurely, two of them at the firstdressing change and 6 further patients at thesecond dressing change. The reasons weremaceration, in particular, and other adversereactions in the region of the wound margins.Aetiology of the woundsThe wound care professionals treated woundswith Hydrosorb that had arisen mainly becauseof vascular diseases (table 2). Venous andarterial ulcers were the most common woundtypes with 40%. The patients had suffered fromtheir ulcers for an average of 365 days (range 0days to 20 years, median 92 days).Fig. 2 Change in the degree of exudation in the course of the study (n = 81)ExudationPainPreviously used local wound dressingsTopical wound care consisted of foamdressings, silver-containing wound dressings,wound dressings with antiseptic and antibioticagents, ointment dressings and hydrocolloids,sometimes in combination, were mostcommonly applied in 46 patients prior toinclusion in the study.Co-medication and therapyAt the start of the study, 35 patients (43%)were on systemic medication. The patientswere taking anticoagulants, antibiotics,oral antidiabetic regiments, steroids andanalgesics in particular. In 8 patients (9.9%),the treating physicians combined the hydrogeldressing with another wound dressing: 3patients had an amorphous hydrogel, 2patients an alginate dressing and 3 patientshad a wound dressing containing silverapplied to their wounds. To treat the chronicvenous insufficiency, compression therapy waspre scribed for 24 patients. In 22 patients,measures to relieve the pressure on the woundwere employed and in a further 16 patientsthe doctors documented accompanyingmeasures such as wound debridement orelevation of the treated limb.Wound outcomesThe patients were treated with the hydrogeldressing for an average of 12.1 days anddressings were changed every 4 days. In thecourse of the study with the hydrogel theproportion of the wound area covered withFig. 3 Change in pain felt by the patients in the course of the study (n = 81)slough fell from 62.6 to 23.1%. At the sametime, the area covered with granulation andepithelial tissue markedly increased (fig. 1). Thewound size (length x width) fell from 4.7x 2.9 cmto 3.7 x 2.3 cm. Five wounds were completelyre-epithelialised at the end of the study.Apart from the condition of the wound, thedegree of exudation also improved (fig. 2).Table 3 Condition of the perilesional skin before and after treatmentwith hydrogel dressing (multiple nominations possible)The proportion of patients whose woundswere not exuding increased from 0% atbaseline evaluation to 22%. At the same time,the proportion of moderately and heavilyexuding wounds fell by more than half from47% to 23%. Fewer pathological symptomswere also diagnosed in the perilesionalskin (table 3).Diagnosis Initial examination Final ExaminationNo pathological findings 33 47Signs of inflammation 46 23Erythema 16 8Hyperthermia 11 3Oedema 10 8Infection 9 4Perilesional maceration 20 18Maceration 8 5Eczema 1 6Hyperkeratosis 10 7Blisters 1 0Other 2 88 HARTMANN Wound Forum

Assessment of Hydrosorb comfort treatment by the patientsFig. 4 Assessment of the wound treatment by the patients (n = 70)Patient-reported painThe number of patients reporting woundpain decreased markedly in the course of thethree dressing changes. Whereas 29.6% ofthe patients reported no pain at the start, thisproportion rose steadily to 56.3% at the finalevaluation (fig. 3). The number of patientswith severe pain was almost halved from11.1% to 6.3%.Dressing performance ratings byphysicians and patientsThe investigators assessed the hydratingcharacteristics, the ease of removal and thegood contact with the base of the woundas very good or good in over 90% of thetreatments (table 4). Good or very good skintolerability was recorded in over 90% of thetreated patients. The physicians had a goodor very good overall impression of thetreatment with the hydrogel in 83% ofthe treatment.In the opinion of the treating physicians,the condition of the wounds had improvedor markedly improved in over 85% of thepatients. The condition did not change in8.6% of the patients and it worsened in 6.1%.70 of the 81 patients assessed the tolerabilityand wearing comfort of the hydrogel (fig. 4).The overall impression was graded as verygood or good by over 85% and as satisfactoryby 5.7%.Documentation aid to assess the courseof healingThe investigators used the Hydrosorb comfortdocumentation aid at each dressing change in15 patients (18.5%). The documentation aidwas used partially in a further 40 treatments(49.4%). In every third wound treatment(32.1%), the aid was not used as otherdocumentation methods were preferred.If the documentation aid was used, its usewas de scribed in 54 of the 55 cases as veryeasy or easy and in one case as satisfactory.In 43 cases, the doctors assessed thedocumentation aid as helpful or very helpfulin assisting wound documentation.DiscussionThe prospective and multicentre applicationstudy showed that the hydrogel dressingpromotes production of granulation andepithelisation. Because this was a smallnonrandomised and non-comparative clinicalobservational trial, it can only give some firstinformation about the clinical performanceand tolerance of the treatment with thehydrogel dressing. It is not a proof of efficacy,but provides a real-world outcome evaluationof the wound care provided by medicalund nursing staff, in an unselected panelof patients, mostly reflecting non-healing,intractable wounds encountered in dailypractice. During the local treatment with thehydrogel, the proportion of the wound areaTable 4 Assessment of Hydrosorb comfort treatment by the physicians (results in %)very good good satisfactory adequate poor not assessableContact with the wound base 43.2 49.4 4.9 1.2 1.2 0.0Adjustment to the body modellability 45.7 49.4 13.6 2.5 1.2 0.0Exudate management 28.4 54.3 9.9 1.2 4.9 2.5Hydrating characteristics 54.3 40.7 1.2 2.5 0.0 1.2Skin tolerability 60.5 30.9 1.2 0.0 6.2 1.2Separation of necrosis 29.6 23.5 1.2 0.0 1.2 44.4Adhesion 46.9 32.1 12.3 1.2 6.2 1.2Removability 64.2 32.1 2.5 0.0 1.2 1.2Overall impression 46.5 37.0 6.2 3.7 6.2 0.0HARTMANN Wound Forum 9

covered with granulation tissue increasedfrom 25% to 37% and the proportion coveredwith epithelial tissue from 12% to 28%.These results are consistent with other studiesin which the local treatment with hydrogeldressings promotes the healing process ofchronic wounds (8, 9).Chronic wounds cause pain in many patients,which can interfere with quality of life (10,11).To relieve wound pain, the choice of a suitablehydroactive wound dressing is of crucialimportance (12). Hydrogel dressings hydrateand cool the wound and therefore have ananalgesic effect. This was shown by numerousstudies in which burn wounds, venousulcers and dermabrasions were treated withhydrogels (13). As they can also be removedwithout traumatising the wound bed, thecell vitality of the newly formed granulationand epithelial tissue remains intact (14). Thepain-reducing effects were also observed inthe patients who were treated with Hydrosorbcomfort in the current study. The number ofpain-free patients without pain increasedfrom 30% to over 56% while at the same timethe proportion with severe pain decreasedfrom 11% to 6%. The attending physiciansconfirmed that the hydrogel dressing can beremoved from the wound without difficultywhen the dressing is changed. They assessedthe removability as very good or good in over96% of the treatments.Another advantage of hydroactive comparedto traditional wound dressings is their costeffectivenessin the treatment of chroniculcers. Hydroactive wound dressings canbe left on the wound longer compared totraditional dressings and therefore haveto be changed less frequently. In thepresent application study, the wound careprofessionals changed the hydrogel dressingevery 4 days on average. Since the hydroactivedressing also provides a physiologicallymoist milieu, the wounds heal faster, whichagain shortens the treatment time. This alsoimproves the quality of life of the patients,who are often troubled by their chronicwound for months or even years. If the totaltreatment costs are compared (materialfor dressings and other aids, frequency ofdressing changes, staff costs etc.), hydroactivewound dressings are more cost-effective than,for instance, gauze dressings (15).In the treatment of chronic ulcers withhydrogel dressings, maceration in the woundarea can occur because of the constantwater release especially in the case of moreexudative wounds. The ability to absorbexcessive exudate is much lower comparedwith other hydroactive dressings such ashydrocolloids or foams (7). According to theinvestigators, this was also the main reasonfor discontinuation of the treatment with thehydrogel dressing. To avoid maceration, it istherefore important to inspect the wound andalso the perilesional skin regularly in order toidentify pathological changes promptly andadjust the local wound treatment accordingly(16, 17). Adequate care of the wound marginsmust also be ensured. Especially in elderlypatients, the skin around the ulcer is veryfragile and susceptible to maceration, oedemaand erythema (18). Closure of the defect ispossible only when the perilesional skin is alsointact as the proliferation and migration ofcells from which the epithelial and granulationtissue is produced are initiated by the skinsurrounding the wound (19). Skin protectioncreams have been proven as effective skincaremeasures (20). Nevertheless, hydrogeldressings have clear advantages when littlewound exudate is produced and the dressingchange intervals become longer. Here theirtransparency allows wound bed inspectionwithout the necessity to remove the dressing.This unique property avoids traumatic dressingchanges and adds cost benefits.ConclusionThe non-randomised, non-comparative trial inan unselected panel of 81 patients, who arecharacteristic for internist and general medicalpractices and outpatient clinics, suggeststhat chronic wounds, especially those ofvenous origin, can be treated effectively withHydrosorb comfort. By providing a moistwound environment, the hydrogel dressingpromotes the healing process, reduces woundpain and thus improves the patients’ qualityof life.References1 Martini P. Wound healing – aiming forperfect skin regeneration. Science 1997;276: 75-812 Scheithauer M, Riechelmann H. Reviewpart I: Basic mechanisms of cutaneouswoundhealing. Laryngo-Rhino-Otol 2003;82: 31-353 Izadi K, Ganchi P. Chronic wounds. ClinPlastic Surg 2005; 32: 209-2224 Grey JE, Enoch S, Harding KG. Woundassessment. Brit Med J 2006; 332: 285-2885 Schultz GS, Sibbald RG, Fallanga V, AyelloEA, Dowsett C, Harding K, Romanelli M,Stacey MC, Teot L, Vanscheidt W. Woundbed preparation: a systematic approachto wound management. Wound Rep Reg2003; 11: 1-286 Gillitzer R. Modern wound management.Hautarzt 2002; 53: 130-1477 Seaman S. Dressing selection in chronicwound management. J Am Podiatr MedAssoc 2002; 92: 24-338 Kaya, AZ, Turani N, Akyuez M. Theeffectiveness of a hydrogel dressingcompared with standard management ofpressure ulcers. J Wound Care 2005; 14:42-449 Hampton S. A small study in healing ratesand symptom control using a new sheethydrogel dressing. J Wound Care 2004; 13:297-30010 Ryan S, Eager C, Sibbald RG. Venous legulcer pain. Ostomy Wound Manage 2003;49: 16-2311 King B. A review of research investigatingpain and wound care. J Wound Care 2003;12: 219-22312 Moffatt CJ, Franks PJ, Hollinworth H.Understanding wound pain and trauma:an international perspective. In: EuropeanWound Management Association. Painat wound dressing changes: A positiondocument 2002: 2-7.13 Thomas S, Hay P. Fluid handling propertiesof hydrogel dressings. Ostomy WoundManage 1995; 41: 54-5914 Eisenbud D, Hunter H, Kessler L, ZulkowskiK. Hydrogel wound dressings: Wheredo we stand in 2003?. Ostomy WoundManage 2003; 49: 52-5715 Jones AM, Miguel LS. Are moderndressings a clinical and cost-effectivealternative to the use of gauze? J WoundCare 2006; 15: 65-6916 Ayello EA, Dowsett C, Schultz GS, SibbaldRG, Falanga V, Harding K, Romanelli M,tacey M, Teot L, Vanscheidt W. Time healsll wounds. Nursing 2004; 34: 36-4117 Hess CT, Kirsner RS. Orchestrating woundhealing: assessing and preparing thewound bed. Adv Skin Wound Care 2003;16: 246-25918 Fenske NA, Lober CWL: Structural andfunctional changes of normal aging skin. JAm Acad Dermatol 1986; 15: 571-58519 Cutting KF, White RJ. Maceration of theskin and wound bed 1: its nature andcauses. J Wound Care 2002; 11: 275-27820 Cameron J. Skin care for patients withchronic leg ulcers. J Wound Care 1998; 7:459-46210 HARTMANN Wound Forum

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