Current Perspectives On Dressings, Tunneling Wounds And Infected Ulcers

Offering insights on dressing dispensing and obtaining a level of debridement with dressings, these panelists also share their thoughts on wounds ranging from deep tunneling wounds to infected ulcerations in the lower extremity.

Q:

Do you use mail order delivery or dispense dressings from your office to your patients?

A:

Kazu Suzuki, DPM, CWS, uses Byram Healthcare, a medical supply company that supplies wound dressings by billing Medicare and co-insurances. He adds that other companies provide similar delivery services. Dr. Suzuki says this is an option for patients who do not want home health services and prefer to change their dressing themselves. He does not dispense dressings in the office, calling it “bothersome to take inventory and keep records for the sales tax purpose.”

   John Steinberg, DPM, says mail order delivery services “provide great flexibility” in getting patients their dressing materials. He notes the medical assistants do most of the administrative work in ordering and then he signs off on the home delivery orders. “For the most part, these have been efficient and well received,” he notes.

   Desmond Bell, DPM, does not dispense durable medical equipment (DME) products directly. His practice had obtained a DME provider license a number of years ago but in running a small solo practice at the time, he decided not to dispense products. The main reason for this decision was the administrative time he needed to process the paperwork and other regulatory issues. Dr. Bell began using several DME companies to supply his patients with dressings. “The home delivery works well and it has been a ‘win-win’ for us,” he comments.

Q:

What do you use when you want to achieve debridement function with dressings?

A:

The majority of Dr. Steinberg’s debridement is with sharp instrumentation at the time of the visit and he generally repeats this every week or two.

   Throughout his career, Dr. Bell has used enzymatic agents as an adjunctive to surgical debridement of devitalized tissue. He notes any moisture retaining dressing should provide the additional benefit of autolytic debridement when one uses it properly. The autolytic debridement benefit crosses over categories of dressings so he says products including hydrogels, alginates and hydrocolloids can assist in the debridement process. If additional debridement is needed between visits or if the site is too painful for sharp debridement, Dr. Steinberg uses enzymatic debridement, applying collagenase topically with a dry dressing daily.

   Dr. Suzuki has been using a lot of medical honey dressing (TheraHoney Gel, Medline), which comes in gel and impregnated gauze, for topical debridement of wounds. He used to use a lot of Santyl collagenase ointment but notes the company increased its price this year. For a cheaper alternative, Dr. Suzuki suggests applying a hydrogel or hydrocolloid to the wound and creating an occlusive environment. He notes the human body naturally produces proteases and collagenase, which “debrides” the wound naturally and slowly.

Q:

What do you use when you see a deep tunneling wound?

A:

In some instances, Dr. Bell says negative pressure wound therapy (NPWT) is highly effective for deep tunneling. Dr. Suzuki also considers NPWT first for deep tunneling wounds.

   Dr. Suzuki uses VAC Therapy (KCI), SNaP (Spiracur) and Pico (Smith & Nephew) devices, saying each product has strengths and weaknesses. He will pick what is most appropriate for the particular wound. For example, Dr. Suzuki notes the disposable NPWT devices, such as SNaP and Pico, are definitely lighter than VAC therapy, and may be more appropriate if his patient is a frail person with a fall risk.

   Dr. Steinberg generally will bring patients with tunneling wounds to the operating room for surgical debridement and then use a NPWT device or packing with a silver impregnated strip.

   Dr. Bell advises DPMs to consider what anatomical structures may be in the proximity of the wound as well as the presence of infection. As he notes, alginates work well for deep tunneling wounds. If the infectious process is a concern, he says iodoform gauze packing is another standard until things settle down.

   “A key concept here is to monitor the wound closely to watch the trend of how things are responding,” says Dr. Bell. “Do not be shy about changing dressings as necessitated by the response of the wound.”

Q:

What do you use when you see highly draining, uninfected wounds?

A:

Dr. Bell emphasizes that it really depends on the wound location as well as the source of the drainage. For example, he says a heavily weeping or draining leg wound that has an underlying component of congestive heart failure or renal disease will not dry up because of a particular dressing. If heavy drainage is coming from a non-infected wound, he says negative pressure can be a great adjunctive therapy, stressing that the nature and location of the wound should help determine what dressing to use.

   Dr. Suzuki cites several super-absorbent dressings, such as Cutisorb Ultra (BSN Medical) and OptiLock (Medline), which are composed of hydropolymer that absorbs a lot of moisture, much like a baby’s diaper. He says those dressings work extremely well for non-infected, highly draining leg wounds, especially when combining them with multi-layer compression dressings, such as Jobst Comprifore (BSN Medical) or Profore (Smith & Nephew).

   For highly draining wounds, Dr. Steinberg emphasizes the need to determine a cause as this may indicate a need for debridement or surgery. He generally uses calcium alginate dressings for absorption of drainage.

Q:

What do you use when you see an infected wound?

A:

When faced with grossly infected wounds, Dr. Suzuki takes these patients to the operating room for thorough debridement. If he sees a slightly infected wound with copious discharge in the office, he may use something like Sorbact (BSN Medical) contact layer, a non-adherent plastic mesh with an antimicrobial coating. As he notes, Sorbact “does a nice job” of letting drainage pass through while keeping the secondary absorbent dressings from sticking to the wound bed.

   In the case of an infection, Dr. Bell will use any adjunctive method to complement the systemic antibiotics that the patient is hopefully already taking. If the wound is badly contaminated, he says the first goal should be to begin cleaning things up. Again, he says this is determined by the location and nature of the wound.

   That being said, Dr. Bell notes a diabetic foot wound with extensive necrotic tissue with significant odor would likely receive an order (after surgical debridement) of one-quarter or one-half strength Dakin’s solution. He will saturate an alginate dressing with the Dakin’s solution and change the dressing out once daily. As the infection decreases in intensity and the wound shows clinical signs of improvement, Dr. Bell may switch over to a compounded triple antibiotic solution of gentamicin-clindamycin-polymyxin with daily application to the wound with alginate as in the case of the Dakin’s solution.

   When it comes to infected wounds, Dr. Steinberg generally performs surgical debridement in tandem with inpatient management and infectious disease consultation. If there is a low level of concern, he would consider topical care with cadexomer iodine and an oral antibiotic. Other dressings Dr. Bell prefers for infected wounds include cadexomer iodine or iodoform gauze packing.

   Dr. Bell is a board certified wound specialist of the American Academy of Wound Management and a Fellow of the American College of Certified Wound Specialists. He is the founder of the “Save a Leg, Save a Life” Foundation, a multidisciplinary, non-profit organization dedicated to the reduction of lower extremity amputations and improving wound healing outcomes through evidence-based methodology and community outreach.

   Dr. Steinberg is an Associate Professor in the Department of Plastic Surgery at the Georgetown University School of Medicine in Washington, D.C. He is the Program Director of the MedStar Washington Hospital Center Podiatric Residency and the Co-Director of the Center for Wound Healing at the MedStar Georgetown University Hospital in Washington, D.C. Dr. Steinberg is a Fellow of the American College of Foot and Ankle Surgeons.

   Dr. Suzuki is the Medical Director of the Tower Wound Care Center at the Cedars-Sinai Medical Towers. He is also on the medical staff of the Cedars-Sinai Medical Center in Los Angeles and is a Visiting Professor at the Tokyo Medical and Dental University in Tokyo. He can be reached via email at Kazu.Suzuki@CSHS.org .