Alginate Dressings For Treating Pressure Ulcers

Hydrofiber And Other Fiber Dressings

General Description and Physical Properties

Hydrofiber dressings are nonwoven sodium carboxymethyl cellulose spun into fibers . Hydrofiber dressings are a fiber rope or dressing that forms a firm gel when in contact with fluid and thus have some of the properties of alginates . They can absorb up to 25 times their own weight in fluid .

Forms and Products

Aquacel is an example of a hydrofiber dressing. Aquacel fibers form a gel on contact with exudate, which helps to maintain a moist wound environment . The vertical wicking of exudate helps to reduce maceration of periwound. Aquacel Foam and Aquacel Extra are other examples of this product. These dressings are more absorbent than alginates and promote nontraumatic dressing removal . There are other fiber dressings, polymer fibers that absorb exudate and are used in cavity wounds, e.g. Exufiber, Durafibee . Carboflex is a combination of a Calcium Alginate, a Hydrofiber and activated charcoal which is useful in exuding malodorous wounds .

Advantages and Disadvantages

The main advantages of the hydrofiber dressings are that they are highly absorbent and have no lateral wicking, which protects periwound . They also facilitate autolytic debridement . Hydrofiber dressings are nonadherent and require secondary dressings to keep them in place.

Indications and Method of Use

Hydrofiber dressings are used in the management of wounds with moderate to excessive exudate. They can be kept in place until the dressing is saturated .

Stage Iii And Iv Ulcers Full Thickness Skin Loss With Visible Underlying Tissues

Full thickness decubitus ulcers have underlying muscle, bone and/or adipose tissue visible and typically require highly absorbent dressings to manage exudate. Hydrofiber dressings are made from soft, absorbent material that transforms into a gel when it comes in contact with wound drainage. This gelling action traps bacteria and maintains optimal levels of moisture within the wound for healing. Calcium alginate dressings are made from seaweed fibers that have been formed into a loose fleece. The fibers are entangled so that the dressing becomes stronger when it becomes soaked with blood or drainage. Calcium alginate sheets can be placed on surface wounds while ribbons are used to pack deep tunneling ulcers. Both hydrofiber and calcium alginate dressings require a secondary dressing to hold them close to the wound bed .

How Do Alginate Dressings Work

There have been few studies of the effect of alginate dressings on the processes of wound healing.

The healing of cutaneous ulcers requires the development of a vascularized granular tissue bed, filling of large tissue defects by dermal regeneration, and the restoration of a continuous epidermal keratinocyte layer. These processes were modeled in vitro in one study, utilizing human dermal fibroblast, microvascular endothelial cell , and keratinocyte cultures to examine the effect of calcium alginate on the proliferation and motility of these cultures, and the formation of capillarylike structures by HMEC.

In the study, the calcium alginate increased the proliferation of fibroblasts but decreased the proliferation of HMEC and keratinocytes. In contrast, the calcium alginate decreased fibroblast motility but had no effect on keratinocyte motility. There was no significant effect of calcium alginate on the formation of capillarylike structures by HMEC. The effects of calcium alginate on cell proliferation and migration may have been mediated by released calcium ions.

These results suggest that the calcium alginate tested may improve some cellular aspects of normal wound healing, but not others.

Reference 1:Doyle JW, Roth TP, Smith RM., et al Effects of calcium alginate on cellular wound healing processesmodeled in vitro. J Biomed Mater Res 1996 Dec 32:561-568

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What Do The Studies Guidelines And Books Say About The Use Of Dressings With Calcium Alginate Fibres

Systematic reviews designed with the aim of comparing the benefit of different dressings in venous ulcers conclude that there is no evidence to suggest that any dressing is superior to the others in accelerating wound healing.3,4 However, the studies included in these reviews are few and of poor quality. Well-designed studies would therefore be needed to draw conclusions about the real impact of the use of the different wound dressings.

Given this lack of evidence, guidelines usually recommend thatthe dressing should be selected on the basis of exudate, perilesional skin, frequency of dressing changes, patient preferences and cost-effectiveness.5

And what do we find in the books? This is the most frequent list of indications for calcium alginate fibres:1

It is always highlighted that the frequency of dressing change will depend on the exudate. It is recommended that alginate fibres should not be used on wounds with little exudate and, if the sheet is dry and adhered to the wound bed, it should be moistened so that it gels and thus avoids a traumatic removal.

Alginate Dressings For Treating Pressure Ulcers

What are pressure ulcers, and who is at risk?

Pressure ulcers, also known as bedsores, decubitus ulcers and pressure injuries, are wounds involving the skin and sometimes the tissue that lies underneath. Pressure ulcers can be painful, may become infected, and so affect people’s quality of life. People at risk of developing pressure ulcers include those with spinal cord injuries, and those who are immobile or who have limited mobility – such as elderly people and people who are ill as a result of short-term or long-term medical conditions.

In 2004 the total annual cost of treating pressure ulcers in the UK was estimated as being GBP 1.4 to 2.1 billion, which was equivalent to 4% of the total National Health Service expenditure. People with pressure ulcers have longer stays in hospital, and this increases hospital costs. Figures from the USA for 2006 suggest that half a million hospital stays had ‘pressure ulcer’ noted as a diagnosis the total hospital costs of these stays was USD 11 billion.

Why use alginate dressings to treat pressure ulcers?

Dressings are one treatment option for pressure ulcers. There are many types of dressings that can be used these can vary considerably in cost. Alginate dressings are a type that is highly absorbant and so can absorb the fluid that is produced by some ulcers.

What we found

This plain language summary is up-to-date as of June 2014.

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Thin Flexible And Versatile

Designed to reduce the risk of further skin breakdown due to friction.

DuoDERM® Extra Thin Dressing can be used as a primary hydrocolloid dressing for dry to lightly exuding wounds.

It can be used as a secondary dressing to secure an AQUACEL® Dressing or an AQUACEL® Ag Dressing.

The European Pressure Ulcer Advisory Panel and The National Pressure Ulcer Advisory Panel guidelines recommend the usage of hydrocolloids for the management of pressure ulcers.1

DuoDERM® Extra Thin Dressing can be used to manage stage I and stage II pressure ulcers.

How Can Pressure Injuries Be Prevented

The development of pressure injuries can be prevented through careful observation of the skin and frequent repositioning in those who canât turn themselves. Tips to prevent pressure injuries include:

• Keeping the skin clean and clear of bodily fluids.
• Moving and repositioning the body frequently to avoid constant pressure on bony parts of the body.
• Using foam wedges and pillows to help relieve pressure on bony parts of the body when turned in bed.
• Maintaining a healthy diet to avoid malnutrition and to assist in wound healing.

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Compared With Scarlet Red

Twelve paired wounds were covered with either calcium alginate or scarlet red in seven patients with burns undergoing skin grafting. The rate of reepithelialization was assessed by optical planimetry for the calcium alginate and by time for sloughing of the scarlet red. This comparison failed to demonstrate objectively any difference in the rate of wound healing between these dressings however, calcium alginate did significantly reduce the pain severity and was favored by the nursing personnel because of its ease of care. Thus calcium alginate does appear to have clinical advantages as a dressing for skin graft donor sites .

Reference 1:O’Donoghue JM, O’Sullivan ST, Beausang ES et al. Calcium alginate dressings promote healing of split skin graft donor sites Acta Chir Plast 1997 39:53-55

Reference 2:Bettinger D, Gore D, Humphries Y Evaluation of calcium alginate for skin graft donor sites Burn Care Rehabil 1995 Jan 16:59-61

Appendix 11 Time To Event Data: Direct Evidence

The duration of followup ranged from 3 to 26 weeks, but the distribution was insufficient to allow modelling of time dependence in the network.

Seven studies reported timetoevent data. We calculated the hazard ratio using the method and spreadsheet from Tierney 2007 one study reported the hazard ratio directly, adjusted for exudate level. The timetohealing data are shown in Analysis 3.1 and summary statistics for the timetohealing and the proportion healed are compared in Table 22 for the studies that report both healing outcomes.

In the individual network, two studies in 95 participants suggested that the time to healing may have been quicker for hydrocolloid versus saline gauze there was no heterogeneity . One study in 24 participants suggested healing may have been quicker for collagenase ointment compared with hydrocolloid . In the other studies, the CI showed much uncertainty.

There was some suggestion of a time dependent effect because there were qualitative and quantitative differences between the HR and the RR: for shorter studies , the HR gave a smaller effect than the RR, but for the medium and longer term studies the HR gave a larger effect than the RR, suggesting that wounds that heal do so relatively quickly.

Analysis

Comparison 4 Direct evidence: group interventions, timetohealing data, Outcome 1 Timetohealing .

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Agreements And Disagreements With Other Studies Or Reviews

We have been unable to identify any network metaanalyses directed at healing pressure ulcers and incorporating both dressings and topical agents. The AHRQ guideline reviewed the evidence for dressings in a series of pairwise comparisons and stated that overall, they did not find substantial evidence to support certain local wound applications over others . The most recent NICE guideline on the prevention and management of pressure ulcers considered all RCT evidence on dressings and separately all RCT evidence on topical agents. NICE recommendations are to not use saline gauze dressings and for the health professional and adult to discuss the type of dressing to use, taking into account pain and tolerance, position of the ulcer, amount of exudate and frequency of dressing change. These recommendations rely heavily on consensus decisions, weakly supported by the evidence, and as such, agree with the findings of this review.

How Do Alginate Dressings Assist In Healing

When used to dress a wound which is exuding heavily, the calcium ions in the dressing interact with the sodium ions in the fluid of the wound. This reaction makes the fiber in the dressing to swell and partially dissolve into a gel. How much the alginate dressing swells depends on the chemical composition of the product and the botanical source

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Sensitivity Analysis By Risk Of Bias

The planned sensitivity analysis for risk of bias was to restrict the network to those studies at low or unclear risk of bias. Only 12 studies with 13 interventions remained and these formed three isolated loops.

Instead we conducted a sensitivity analysis which excluded studies that had high risk of bias for two or more domains we excluded seven studies from the joined network one further study was no longer joined into the network. This left 31 studies with 35 comparisons, including 18 interventions and 1513 participants .

The NMA results for interventions versus saline gauze are shown in Table 23 alongside the original data. There were only minor differences. The mean rank order was similar to the original data and the rankograms similarly indicated much imprecision.

Contributions Of Editorial Base:

Nicky Cullum: edited the protocol advised on methodology, interpretation and protocol content. Approved the final protocol prior to submission. Sally BellSyer: coordinated the editorial process. Advised on methodology, interpretation and content. Edited the protocol. Ruth Foxlee: designed the search strategy and edited the search methods section.

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Which Wound Dressing Is Best For Your Pressure Ulcer

Now that weve touched on some of the more common types of dressings used for pressure ulcers, you may be wondering which is the best for your particular situation. The answer will depend on multiple factors including where the pressure ulcer is located, how severe the bedsore is, and the degree of skin and tissue damage. Talk to your health care professional about any pressure wounds you notice on your body as soon as possible.

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Description Of The Intervention

This review includes RCTs of any dressings or topical agents applied directly onto or into wounds and left in situ, as opposed to products used to irrigate, wash or cleanse wounds and those that are only in contact with wounds for a short period.

Dressings

The classification of dressings usually depends on the key material used in their construction, and whether additional substances are added to the dressing. Several attributes of an ideal wound dressing have been described , including the ability of the dressing to:

• absorb and contain exudate without leakage or strikethrough, in order to maintain a wound that is moist but not macerated
• achieve freedom from particulate contaminants or toxic chemicals left in the wound
• provide thermal insulation, in order to maintain the optimum temperature for healing
• allow permeability to water, but not bacteria
• optimise the pH of the wound
• minimise wound infection and avoid excessive slough
• avoid wound trauma on dressing removal
• accommodate the need for frequent dressing changes
• provide pain relief and
• be comfortable.

There are numerous and diverse dressings available for treating pressure ulcers and their properties are described below.

Absorbent dressings are applied directly to the wound and may be used as secondary absorbent layers in the management of heavily exuding wounds. Examples include Primapore , Mepore and absorbent cotton gauze .

Topical agents

What Types Of Wound Dressing Can Be Used On Bed Sores

By Nursing Home Law Center

In order for bed sores to heal, attention must be paid to the removing dead tissue and protecting the wound from infection causing bacteria. Dressings are usually applied to help the body heal itself. The type of dressing and the frequency with which it is to be changed is ordered by a physician with the application and changes carried out by nurses.

Many patients with bed sores suffer additional harm when the staff responsible for caring for them fails to follow medical orders with respect to the frequency with which dressings are to be changed. If dressings are not changed according to orders set forth by a physician, the healing of the bed sores may be delayed and perhaps become infected.

The most commonly used dressings used to treat bed sores include:

Absorptive Dressings: These dressings are either applied directly to the wound or on top of other primary dressings. Absorptive dressings are intended to remove the drainage from the bed sore that may impede healing. Most absorptive dressings are changed on a daily basis. However, excessive drainage from a bed sore may require more frequent dressing changes.

Common types of Absorptive dressings include: Medipore, Silon Dual Dress, Aquacel Hyrofiber Combiderm, Absorbtive Border, Multipad Soforb, Iodoflex, Tielle, Telefamax, Tendersorb, Mepore and Exu-dry.

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Are Alginates Effective With Full

A prospective, randomised, controlled trial of 92 patients with full-thickness pressure ulcers set out to compare the efficacy of an alginate wound dressing with an established local treatment with dextranomer paste. During treatment, a minimal 40% reduction in wound area was obtained in 74% of the patients in the alginate group and in 42% of those in the dextranomer group. The median time taken to achieve this goal was four weeks with alginate and more than eight weeks in the control group. Mean surface area reduction per week was 2.39 cm2 and 0.27 cm2 in the alginate and dextranomer groups respectively . This difference was still highly significant when the sub-groups of almost completely healed subjects at the end of the study were considered.

This striking healing efficacy of an alginate dressing suggests it possesses pharmacological properties which require further investigation .

Reference 1:Sayag J, Meaume S, Bohbot S., Healing properties of calcium alginate dressings J Wound Care 1996 Sep 5:357-362

Summary Of Findings For The Main Comparison

NMA evidence for individual network: proportion with complete healing interventions versus saline gauze

1Majority of evidence at high risk of bias imprecision: very wide CI .2Imprecision: very wide CI .3Majority of evidence at high risk of bias imprecision: wide CI and direct evidence on collagenase from three studies, 11 events .4Majority of evidence at high risk of bias : imprecision: wide CI and direct evidence on dextranomer from one study, seven participants and four events .5Majority of evidence at high risk of bias imprecision: wide CI .6Majority of evidence at high risk of bias inconsistency: heterogeneity in direct evidence imprecision: wide CI .7Majority of evidence at high risk of bias inconsistency: significant difference between direct and indirect estimates imprecision: very wide CI .8Imprecision: wide CI .9Majority of evidence at high risk of bias : imprecision: wide CI and direct evidence on tripeptide copper gel from one study, six participants and five events .

In this section, we present the results for the individual NMA. Results for the group network are given in Appendix 5.

Interventions and comparisons

The individual network comprised 21 interventions: 13 eligible dressings six topical agents and two supplementary linking interventions .

Risk of bias for the individual network

We report risk of bias in three ways :

Network metaanalysis results

Ranking of treatments

Rankograms for each intervention individual network

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