Clinical Experiences with Technologies: Case Reports on the Use of Two Hydrofiber(R) Dressings

T he limitations of traditional wound dressings have long been recognized. Gauze, even when used with antiseptic solutions, adheres to wounds and can cause trauma on removal, with a deleterious effect on wound healing.1 Such wet-to-dry dressings cause mechanical debridement and remove necrotic and healing tissue in a nonselective manner when the dressing is changed. This can cause bleeding and injury to healthy tissue. Removing these dressings is also painful for patients. Microscopic examination of wounds managed in this way suggests that using gauze actually may encourage infection and slow normal healing.2 Cotton fibers from gauze are often left embedded in the wound, and these can potentiate and support the growth of infectious micro-organisms as well as cause inflammation. Desiccated tissue under gauze is a perfect medium for bacterial growth. All in all, gauze dressings may not enhance wound healing and can even damage healthy tissue and allow for infection (see Figure 1). Moist Wound Healing Modern wound dressings seek to counter the enemy of wound healing - desiccation. A moist wound environment is known to support wound healing, support autolytic debridement, and minimize damage to new cells. Modern dressings have demonstrated a better healing environment than gauze by retaining moisture while simultaneously managing wound exudate. Two types of modern dressings have been increasingly used in wound management: hydrocolloid-based and alginate-based dressings. Comparative studies suggest that hydrocolloid dressings offer some advantages over alginate-based dressings.3 New Hydrofiber(R) dressings (AQUACEL(R) and AQUACEL(R) Ag, both dressings from ConvaTec, a Bristol-Myers Squibb Company, Princeton, NJ)are proven to have greater absorbency than alginate- and hydrocolloid-based dressings. The dressings with Hydrofiber(R) technology gel quickly with controlled lateral wicking and bacterial sequestration into the Hydrofiber(R) fibers4,5 (see Figure 2). By forming a gel, the dressing is able to mould itself over the wound contours, maintaining a warm, moist environment conducive to healing. Clinical experience gained with two Hydrofiber(R) dressings - AQUACEL(R) , and the silver-containing antimicrobial dressing AQUACEL(R) Ag - supports use of this technology. Using Hydrofiber(R) Dressings in Clinical Practice Hydrofiber(R) dressings (AQUACEL(R) and AQUACEL(R) Ag)are available in sheet and ribbon form and are suitable for managing both acute and chronic wounds with moderate to heavy exudation. These dressings can be covered with an occlusive dressing or with gauze, which allows them to be left in situ for up to 7 days. The outer dressing can be changed more frequently as required. This means less disturbance of the wound, less discomfort for patients, and a reduced risk of wound infection. Because the dressings are easy to apply and remove, cause less pain on removal, and require fewer dressing changes, their use may reduce analgesic requirements. By supporting wound healing, use of these dressings may allow earlier patient discharge from care and also could help reduce the cost of wound management.6 These dressings can be used in acute, dehisced surgical wounds, and wounds left to close by secondary intention. They also can be employed to support wound healing in chronic wounds, including pressure ulcers, leg ulcers, and diabetic foot ulcers. The clinical benefits of these dressings in chronic wound healing reflect the key features of the dressing (see Table 1) and have been demonstrated in numerous clinical studies. Case Reports The clinical benefits of choosing a wound dressing based on Hydrofiber(R) technology are best illustrated through case examples using these products in clinical practice. As the following case histories demonstrate, these dressings can be used to manage patients at home or in hospital care settings, and offer practical and clinical benefits over many other approaches to wound care. Case report 1. A 60-year-old woman with diabetes mellitus and peripheral vascular disease developed a heel ulcer while in the hospital (see Figure 3a). Her wound initially was managed with standard dressings but she continued to present with a wound characterized by heavy, foul-smelling exudate, thick slough, erythema, and inflammation, suggesting heavy colonization and wound infection, which was confirmed by cultures. Surgical debridement was proposed, but the patient was averse to further hospitalization, preferring to be managed at home. After 2 weeks and two applications of the dressing, necrotic tissue was finally eliminated from the wound and a clean environment was created, facilitating subsequent wound healing (see Figures 3b and 3c). Using the Hydrofiber(R) silver-containing dressing helped facilitate management of this patient on an outpatient basis. No systemic pharmacotherapy was used. Case report 2. A 65-year-old female oncology patient who had undergone a pancreatectomy and required prolonged hospitalization subsequently developed abdominal wound dehiscence, resulting in a colostomy (see Figure 4a). She had marked abdominal wound dehiscence at the site of pancreatic resection, exposed sutures, and reported moderate to severe pain from heavily exuding wounds in close proximity to the site of a colostomy. The management challenge was to dress the extensive, vulnerable wounds and help support wound healing in a nursing home setting in a patient already severely compromised by underlying disease and surgical trauma. Vacuum-assisted (VAC(R)) therapy was contraindicated because of the retention sutures, nearby colostomy, and necrotic tissue in the wound. Dry gauze dressing also was discounted for fear of adhesion to sutures. The Hydrofiber(R) silver-containing dressing was used to pack and dress the exposed wounds. The dressing was left in place for 7 days, during which time the outer dressings were changed without disturbing the core wound dressing. Signs of gradual wound improvement appeared within 1 week (see Figure 4b). The patient reported reduced wound pain and the wound itself was visibly smaller with improved granulation. The patient continued to be managed with a further week of the silver-containing dressing, followed by the use of Hydrofiber(R) dressing. The patient showed good healing and wound progression despite exposed sutures and proximity of the wound to the colostomy exit site (see Figure 4c). Case report 3. A 72-year-old male patient with venous leg ulcers, long-standing venous stasis, and underlying diabetes with poor glycemic control (see Figures 5a and 5b) was noncompliant regarding leg wraps or leg elevation as part of ulcer management. Leg ulcers appeared to be heavily colonized and inflamed, and cellulitis was suspected. The Hydrofiber(R) silver-containing dressing was chosen to support an optimal wound healing environment and to provide a degree of local antimicrobial barrier protection. The use of this antimicrobial dressing was hoped to reduce the inflammation , but nevertheless cellulitis developed and systemic antibiotic therapy was initiated to ensure complete eradication of ulcer infection. This case demonstrates that while antimicrobial dressings can help control wound colonization at a local level, a combination of appropriate wound dressings and systemic antibiotics are vital to manage advanced infection. Case report 4.. An elderly male, wheelchair-bound nursing home patient had a long-standing diabetic foot ulcer (see Figure 6a) that had failed to heal with standard treatment. The ulcer was dressed with the Hydrofiber(R) dressing to support wound healing, but the ulcer continued to exude heavily and black necrotic tissue persisted, suggesting infectious colonization of the ulcerating tissue. The lesion was dressed with the silver-containing Hydrofiber(R) dressing to manage both the wound environment and the microbial infection. After 2 weeks and two dressing changes with the silver dressing, wound bed granulation noticeably improved (see Figure 6b). Outpatient management continued, and the use of these dressings did not preclude total foot casting or the use of pressure relief modalities. Conclusion Modern-day approaches to wound management that harness technological advancements based on sound scientific understanding of wound healing provide efficient and successful clinical outcomes for patients. Managing the wound micro-environment by controlling exudate maintains a moist atmosphere without undue threat to tissue repair, risk of tissue damage, or pain on dressing removal. A single application of a Hydrofiber(R) dressing that can be used in wounds for periods of up to 7 days allows undisturbed wound repair under near optimal conditions. The sequestration of bacteria into the silver-containing Hydrofiber(R) dressing offers a degree of control of the wound microbial ecosystem. The clinical experiences illustrated here, along with further clinical studies of these wound dressings, suggest that AQUACEL(R) and AQUACEL(R) Ag support wound healing, reduce pain during dressing changes, and show greater ease of use than standard gauze and other forms of wound dressings.5 The dressings also may help improve the cost effectiveness of wound care by reducing the need for frequent dressing changes, supporting wound healing, and potentially allowing patients an earlier discharge from care.

1. Turner T. Which dressing and why? Nursing Times. 1982;78(33)Suppl:45-48.2. Lawrence JC. Dressings and wound infection. Am J Surg. 1994;167(1A Suppl):215-245.3. Foster L, Moore P, Clark S. A comparison of Hydrofiber(R) and alginate dressings on open acute surgical wounds. Journal of Wound Care. 2000;9(9):442-446.4. Bowler PG, Jones SA, Davies BJ, Coyle E. Infection control properties of some wound dressings. Journal of Wound Care. 1999;8:499-502.5. Robinson BJ. The use of a Hydrofiber(R) dressing in wound management. Journal of Wound Care. 2000;9:32-34.6. Colwell JC, Foreman MD, Trotter JP. A comparison of the efficacy and cost effectiveness of two methods of managing pressure ulcers. Decubitus. 1993;6:28-36.