Managing Exudate Pooling: A Simplified Practical Guide

Effective wound management relies on identifying and managing underlying conditions, and the prevention and management of barriers to wounds healing. Exudate pooling is the collection of wound fluid in the wound bed that can hinder the healing process. Implementation of effective strategies to prevent and manage exudate pooling is important to help reduce the burden of chronic wounds on patients, caregivers, and health systems. This article, which is based on a review of published literature, consensus statements, and best practice guidelines, offers a simplified yet practical summary for the prevention and management of exudate pooling by using advanced wound dressings.

Exudate pooling is the collection of wound fluid in the wound bed. Wounds with irregular depth, pockets, or cavities can create a dead space between the dressing and the wound bed where exudate can accumulate.¹ Exudate pooling can also occur when the dressing does not have enough absorption capacity to manage the level of exudate, or when the dressing is not changed frequently enough. Once a wound with depth, tunneling, or undermining is identified, a dressing should be selected to help manage this dead space and keep close contact with the wound bed.¹

By definition, all wounds represent a break in the skin and therefore have some level of depth. In a study evaluating records from 1009 patients treated for varying types of wounds, the average wound depth was 0.77 cm.² The deepest wounds were postoperative wounds with delayed healing (1.39 ± 2.38 cm) followed by pressure injuries (1.06 ± 1.74 cm), fungating tumors (0.79 ± 0.27 cm), and diabetic foot ulcers (0.74 ± 0.84 cm).² Burns (0.18 ± 0.10 cm) were reported to be the shallowest wounds.² Nearly half (49.6%) of all wounds had depth beyond the epidermis (0.22 cm), a characteristic that increases the risk of exudate pooling.² In a United Kingdom study of 4772 patients, a review of retrospective data collected through 5 different National Health Service trusts compiled undermining data for 1927 chronic wounds. Of these, 12% were undermined by tunneling or cavities beneath the skin where exudate could pool.³

In wounds that are healing naturally, exudate supports the healing process by providing a moist wound environment, supplying nutrients and growth factors, separating damaged tissue through autolysis, and facilitating the migration of cells.⁴ While exudate production is a normal feature of healing wounds, overproduction of exudate can delay wound healing.¹ In chronic wounds, exudate slows down cell proliferation, interferes with growth factor availability, and contains higher levels of activated matrix metalloproteinase that lead to prolonged inflammation.¹ When exudate pools in the wound bed, there is also increased risk of bacteria growth that could lead to increased bioburden and wound infection.⁵ Finally, exudate pooling may cause wound fluid to make contact with the wound edge or surrounding skin, causing leakage and maceration that, in turn, could lead to skin breakdown and thereby enlarge the wound.^4,6

In summary, for effective wound management, dead space between the dressing and the wound bed should be avoided as this allows for exudate pooling. When exudate pools in the wound bed, this could lead to increased risk of infection or biofilm formation and maceration of the periwound skin, all of which negatively impact the healing process. Appropriate dressing selection can help manage exudate and avoid exudate pooling.

Holistic wound management includes a thorough wound assessment with strategies to manage underlying conditions. Excessive exudate production may be caused by a number of factors, including wound infection, foreign bodies in the wound, edema near the wound, or other systemic factors; each of these factors should be addressed accordingly.⁴ Likewise, the exudate itself should be assessed for signs of infection. In particular thick, odorous exudate with a milky, yellow, green, or brown color often indicates infection, in which case an antimicrobial strategy should be considered.⁴

The primary aims of effective exudate management are to create a moist wound healing environment, prevent dead space where exudate could pool, and protect the surrounding skin from moisture damage.^1,7 Most dressings are designed to create a moist wound healing environment by absorbing excess exudate without drying out the wound. A moist wound bed helps to deliver growth factors and supports autolytic debridement, a process where the body’s own enzymes and moisture act to soften and liquify devitalized tissue.⁴

Another important dressing feature to promote wound healing is the ability to maintain close contact with the wound bed.^1,7 Dead space between the dressing and the wound bed could lead to exudate pooling and delayed wound healing. Alginates and gelling fibers are commonly used as primary filler dressings that can be used in combination with a secondary dressing to manage wound depth. Alternatively, a new foam dressing solution is now available that conforms into the wound bed to match the shape and depth of the wound, acting as a primary and secondary dressing in one (Figure).

Finally, an effective dressing should keep wound exudate away from the wound edge and surrounding skin. Some dressings are efficient at absorbing exudate but allow it to spread across the dressing and onto the periwound skin. Wound exudate coming into contact with the surrounding skin may cause maceration, inflammation, or excoriation that can delay the healing process and cause discomfort for the patient.^4,6 Furthermore, wound closure in the last phase of healing occurs through cell migration that starts from the wound edge, and macerated or compromised skin could prevent this process from happening.^6,8

In summary, there are many factors to consider when selecting a dressing, including local availability, patient allergies, fluid-handling capacity, and ease of use—but it’s especially important to consider the features that will support an optimal wound healing process. Dressings that provide a moist environment, manage the dead space, and maintain close contact with the wound bed could help reduce the risks associated with exudate pooling.

In 2020, a consensus paper was published with best practice statements on how to manage dead space and exudate pooling.⁷ The facilitators used a modified Delphi approach with input from 84 wound specialists from 19 countries. The following key findings and best practices were taken directly from this paper:

“A gap between the wound bed and dressing should be avoided as it negatively influences wound healing and results in increased bacterial invasion.”

“Managing the gap is one of the best methods for promoting an optimal healing environment, and the best way is to use a dressing that conforms into the wound bed to create close contact.”

“Appropriate dressing selection can avoid exudate pooling, decrease the risk of infection, and prevent maceration of the periwound skin.”

These statements achieved consensus across a group of international wound care specialists to help manage chronic wounds and the risks associated with dead space and exudate pooling.⁷

Following a review of published literature on exudate management, the authors put their learnings into practice by translating the findings into a practical guide for dressing changes. When exudate management is the main treatment priority, the guide below could be used by nurses at all levels to help prevent and manage exudate pooling and associated risk factors.

Check the dressing

Why? Dressings play a key role in managing exudate and keeping it away from surrounding skin.

How? Check that the exudate has not spread across the dressing beyond the size of the wound.

What? Use a dressing with vertical absorption to protect the surrounding skin from exudate.

Check the wound

Why? Exudate pooling could lead to delayed wound healing, maceration, and risk of infection.

How? Check that there is no exudate pooling (including small pockets) after removing the dressing.

What? Use a primary filler dressing with minimal shrinkage or a foam dressing that conforms into the wound bed, or consider changing the dressing more frequently.

Wound cleansing

Why? Gentle cleansing removes nonviable tissue, debris, foreign matter, and excess exudate.

How? Depending on the stage of healing, irrigate the wound or perform gentle physical debridement by circular motion in the wound bed.

What? Use saline or a wound cleanser for irrigation and gauze or pad for gentle debridement.

Protect the skin

Why? Exudate coming into contact with the surrounding skin could cause maceration or excoriation.

How? Use a dressing with vertical absorption to protect the surrounding skin from exudate.

What? For skin that is already macerated, use a protective barrier film before applying the dressing.

Select appropriate dressing

Why? Some primary filler dressings shrink as they absorb exudate, and some foam dressings spread the exudate onto periwound skin.

How? Ensure you manage all dead space from tunneling, undermining, or wound depth by using dressings that keep in close contact with the wound bed.

What? Select a primary filler dressing with minimal shrinkage to pack the dead space loosely (plus secondary cover dressing) or a foam dressing that conforms into the wound bed.

Exudate pooling could lead to delays to the wound healing process, increased risk of infection, and damage to the surrounding skin from exudate leakage. It is important to manage the dead space between the wound bed and the dressing by selecting products that create close contact with the wound bed and prevent exudate from spreading onto the surrounding skin.

Emily Greenstein, APRN, CNP, CWON-AP, FACCWS¹; Maarten Vooijs, MSc²; and Sarah Norton, MSN, MBA, RN, CWCN³

¹Marketing Director, Wound and Skin Care, Coloplast Corp, Minneapolis, MN
²Wound and Ostomy Nurse Practitioner, Sanford Health, Fargo, ND
³Manager Clinical Specialists, Wound and Skin Care, Coloplast Corp, Minneapolis, MN

Address all correspondence to: Maarten Vooijs, MSc, Coloplast Corp. 1601 West River Road North, Minneapolis, MN 55411; email: gbmvo@coloplast.com

Emily Greenstein is a paid consultant and paid advisory board member for Coloplast Corp. Maarten Vooijs and Sarah Norton are employed by Coloplast Corp.