EUROPEAN  TISSUE  REPAIR  SOCIETY

Mrs Deborah Hofman
Clinical Nurse Specialist, Dept of Dermatology,
Churchill Hospital, Oxford OX3 7LJ, England

It is generally believed, though not proven, that wounds need to be free from slough in order to heal. It has been stated that slough acts as focus for infection and prevents wound contraction.¹ Wounds which contain necrotic tissue are often malodorous due to the presence of anaerobic bacteria, and this may be distressing to the patient and relatives, moreover, it is impossible to establish the severity/depth of a wound until necrotic tissue has been removed.

There are many agents that a nurse can use to facilitate debridement from scalpel blade and scissors, to larvae, saline soaks and dressings which enhance wound autolysis. Before undertaking wound debridement and choosing a method the nurse should consider:

1. The desired outcomes and whether debridement is necessary.
2. Patient comfort and well being.
   In clinical practice some wounds appear to heal without ever achieving a healthy granulating bed.
   It is important to establish the difference between ne-crotic tissue, slough and fibrinous tissue.
   Punch grafting is a technique performed by some nurses. As with any grafting technique a healthy wound bed with a low bacterial load is vital for a successful outcome.²

A Study presented at the 8th EWMA conference looked at pre- and post-operative presence of bacteria in punch-grafted wounds.³ Results of this small study did not show that the presence of bacteria had any effect on the final outcome. However, the loss of grafts in two cases and the subsequent deterioration of the wound could be directly linked to infection.

References:

1. Wound Debridement, ETRS Consensus Document, January 1995.
2. Teh BT, Why do skin grafts fail? Plastic Reconstr. Surg. March 1979, 323–331.
3. Hofman DM and Cherry GW, Punch grafting: a technique for speeding the healing of leg ulcers. Proceedings 8th European Conference on Advances in Wound Management. April 1998.

Mrs Debra Sibbald
Dept of Medicine, University of Toronto,
Toronto, Ontario M5G 2C4, Canada

Dressings and cleansers are two critical components in preparing the wound bed to heal. It is difficult for providers to choose an appropriate product for the individual patient from the vast array currently available. Critical objective data comparing one product to another is lacking. The clinician is faced with a host of issues to examine when comparing dressings that extend beyond absorbency, wear time and ability to debride. A systemic process for analysing and evaluating key pharmaceutical and clinical considerations in the selection of both dressings and cleaners is presented. This approach facilitated the assessment of dressing categories by an interdisciplinary Canadian consensus team and their results in applying this method is reported.

Dr Carita Hansson
Associate Professor, Dept of Dermatology, Sahlgrenska University Hospital,
Sahlgrenska, 41345 Goteborg, Sweden

Iodine is a well known topical germicidal agent effective against a wide spectrum of organisms including bacteria, fungi and protozoa. Iodine is available as solutions and alcoholic tinctures and iodophors. Iodophors were developed because iodine tinctures caused skin irritation, severe hypersensitivity reactions and systemic absorption of iodine. Iodophors are compounds of iodine linked to carriers for iodine and only a small amount of iodine is released minimising toxicity but preserving germicidal activity. One of the most used iodophors is the complex of polyvinylpyrrolidone (povidine) and iodine.

Cadexomer iodine (Iodosorb/Iodoflex) was first registered in 1981. It has different characteristics to the povidine iodine preparations. The cadexomer starch is a carrier of 0.9% iodine. There is no chemical bond between the carrier and active agent. Cadexomer polysaccharide beads are small and in the presence of moisture the iodine is slowly released in low concentration. Iodine inactivation by protein absorption in the wound is overcome by the slow release. Cadexomer iodine is biodegradable. Beside the effect of cadexomer iodine being antimicrobial it also has a high rate of fluid absorption for exudating ulcers. Many studies have been made to investigate other modes of action of cadexomer iodine on wound healing. It has been shown in animals that not only cadexomer iodine but also the cadexomer in itself has positive effects on re-epithe-lialisation.

Cadexomer iodine decreases the microbial load which is especially useful in wounds colonised or infected with MRSA (methicillin-resistant Staphylococcus aureus), Pseudomonas or Candida albicans.

One of the most important effects for cadexomer iodine is probably in wound debridement where it helps clean the ulcer bed from slough and exudate. The first formulation for cadexomer iodine was in a dry powder followed by an ointment and a dressing with polyetylenglycol.

If the instructions for correct use are followed (persons should not be treated if they are known to be allergic to iodine or if they have or are under investigation for thyroid disease, and a total ulcer area over 300 cm² should not be treated) cadexomer iodine is a safe and effective therapy cleaning the ulcer and promoting healing.