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.
Search Methods For Identification Of Studies
Four existing Cochrane Reviews were relevant to this NMA , and the protocol for this NMA complemented the protocols for these four reviews . We automatically included trials from these reviews in this NMA if they reported complete healing outcomes we planned to use the extracted data from these reviews where possible, supplementing if necessary which was required as some reviews had not been completed.
We conducted searches to identify relevant trials not covered by the four Cochrane Reviews as well as recently published trials. We crosschecked the identified trials against those in the 2014 NICE guideline and the 2013 US Agency for Healthcare Research and Quality guideline on treating pressure ulcers to further locate any additional trials we also checked the references of 24 systematic reviews identified by our search.
We searched the following electronic databases to identify reports of relevant randomised clinical trials:
the Cochrane Wounds Specialised Register
the Cochrane Central Register of Controlled Trials
EBSCO CINAHL Plus .
We also searched the following clinical trials registries:
WHO International Clinical Trials Registry Platform
EU Clinical Trials Register .
Searching other resources
How To Care For A Pressure Ulcer
Pressure Ulcer is a common occurrence among patients who are bed-bound or immobile. If you are a caregiver caring for a loved one who has pressure ulcers, you might want find out how you can manage the pressure ulcer wound and prevent it from deteriorating. Prevention is the key to ensure that your loved one does not develop another pressure ulcer wound. Read on to find out how to care for your loved ones wound properly and how you can get a change of wound dressing in the comfort of your home.
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What Are The Stages Of A Pressure Injury
There are four stages that describe the severity of the wound. These stages include:
- Stage 1: This stage is discolored skin. The skin appears red in those with lighter skin tones and blue/purple in those with darker skin tones. The skin does not blanch when pressed with a finger.
- Stage 2: This stage involves superficial damage of the skin. The top layer of skin is lost. It may also look like a blister. At this stage, the top layer of skin can repair itself.
- Stage 3: This stage is a deeper wound. The wound is open, extending to the fatty layer of the skin, though muscles and bone are not showing.
- Stage 4: This stage is the most severe. The wound extends down to the bone. The muscles and bone are prone to infection, which can be life-threatening.
Where To Buy Wound Dressing Online
Wound dressings are made of either natural or synthetic fibers, which help cover, protect, and heal a wound. The wound dressing is Used to control the bleeding, clean the debris, help remove necrotic tissue, prevent leakage or pooling of exudate, and protect the wound from external contaminants. At Shop Wound Care, we have a wide range of wound care dressings from top selling brands such as Medline, Smith & Nephew, Convatec, etc. Shop now!Other Useful Links:
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Do Scabs Heal Faster Dry Or Moist
According to the American Academy of Dermatology, keeping your wounds moist helps your skin heal and speeds your recovery. A dry wound quickly forms a scab and slows your ability to heal. Moistening your scabs or wounds can also stop your wound from getting bigger and prevent itchiness and scarring.
Pressure Ulcers: Debridement And Dressings
- Charles F von Gunten MD
- Frank Ferris MD
Background Fast Fact #40 discussed the staging and prevention of pressure ulcers this Fast Fact discusses their management. The first step in deciding how to manage pressure ulcers is an assessment of whether the wound is likely to heal. If the patient has a prognosis of months to years, adequate nutrition, and blood flow to the tissue, then healing is possible. If the patient has a prognosis of days to weeks, anorexia/cachexia, and/or the wound has inadequate perfusion, then symptom control alone is appropriate and uncomfortable/burdensome treatments are not appropriate.
Debridement Always provide adequate analgesia! Necrotic tissue must be removed for ulcer healing surgical debridement is the fastest and most effective method when there is healthy surrounding tissue. Note: If the patient is close to dying, and/or the wound will never heal, then debridement should not be attempted. Debridement gels are applied onto an ulcer under an occlusive dressing , are available for ulcers that do not require surgery or when surgical debridement is incomplete. These products come with or without enzymes to encourage autolytic or enzymatic debridement. For minimally necrotic ulcers, occlusive dressings such as DuoDerm, changed weekly, promote autolysis.
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Potential Biases In The Review Process
This was a sparse network and there may have been smallstudy effects which impacted on the network . The STATA routines have largely been developed for and tested on larger networks, and our work has contributed to modifications for sparse networks in the netweight routine. Other STATA routines can be modified by the user to take into account smallstudy effects, but we did not explore these approaches because there was too much uncertainty in the network for us to be confident of interpreting the results. Instead, we used the standard routines for NMA and adapted the recent approach to GRADE to bring in sparseness when assessing evidence certainty.
A further effect of the sparseness of the network may have been to hide any inconsistencies. The various statistical tests for inconsistency were generally not significant, but this may have been due to a lack of sensitivity of the tests and the wide CIs around the measures. Despite this, we found inconsistencies in the network for contrasts involving phenytoin. We cannot be sure that there are no other inconsistencies, but this may not matter given the already identified large uncertainties.
Clinical Case Presentation: Pressure Ulcer Management
Thorough wound assessments and sensible product selections are essential for preventing and treating wound infections, managing exudate and finally restoring skin integrity.
This is the clinical case presentation of Fernanda Cortes from Chile who explains step by step how she treated the stage 3 pressure ulcer of a 60-year-old family father. Through her commitment and the effective combination of Prontosan®, Askina® and Linovera® the patient eventually recovered.
Please note that the pictures in the video may be disturbing to sensitive persons.
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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.
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
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 .
Stage 4 Bedsore Causes
Stage 4 bedsores typically form if earlier-stage pressure injuries are not properly treated.
All when factors like pressure, shear, and friction cut off blood supply to the skin. Without proper treatment, the loss of blood can cause the skin to die and a wound to form.
Did You Know
A stage 4 bedsore is the worst-case scenario: the blood loss is so severe that the wound tunnels down through all layers of the skin and exposes bone.
Nursing home bedsores are often the result of improper care from staff.
Residents may develop bedsores if staff members:
- Cannot adequately care for every resident due to understaffing
- Dont treat dehydration or malnutrition, which can prevent healing or worsen sores
- Fail to notice or treat earlier stage sores due to skipped or rushed care
- Leave residents with mobility issues lying in beds or wheelchairs for hours on end
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Pressure Ulcer Treatment Services
Pressure ulcers present a significant economic, quality of life, and overall health care threat. Pressure ulcers were once a problem considered a side effect of aging has captured the attention of wound care surgeons. This is more commonly regarded as preventable and unacceptable as this is an indicator of the quality of life.
Pressure ulcers occur on any part of the body but are commonly seen over bony prominences, such as the occiput, sacrum, elbows, heels, hips, and the ischial tuberosities. One common pressure ulcer that occurs is on the feet due to rubbing of shoes, although most people do not recognize this as a chronic non-healing wound.
Pressure damages are predominantly caused by prolonged and unrelieved pressure from any external object against the skin like a bed, mattress, chair, clothing, footwear, medical devices, etc. Using a special mattress, moving, and changing of positions may reduce or relieve pressure. An appropriate wound care dressing can also help heal the ulcer. Patients who are immobile or have difficulty responding independently to pressure, or those who have a neurological deficit and cannot feel the effects of pressure are at immediate risk of developing pressure ulcers.
Treatment Of Stage 3 And Stage 4 Pressure Ulcers
The goal of treatment for stage 3 and 4 pressure ulcers, is to properly debride and dress the wound cavity, create or maintain moisture for optimal healing, and protect the wound from infection. The goal of properly unloading pressure from the area still applies. At these pressure ulcer stages, more emphasis should be placed on proper nutrition and hydration to support wound healing. If the extent of the pressure ulcer or other factors prohibit it from healing properly, surgery may be necessary to close the wound.
The following precautions can help minimize the risk of developing pressure ulcers in at-risk patients and to minimize complications in patients already exhibiting symptoms:
- Patient should be repositioned with consideration to the individualÃ¢s level of activity, mobility and ability to independently reposition. Q2 hour turning is the standard in many facilities, but some patients may require more or less frequent repositioning, depending on the previous list.
- Keep the skin clean and dry.
- Avoid massaging bony prominences.
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Appendix 2 Glossary Of Nma Terms
Armspecific outcomes/armlevel data: raw outcome data or risk) for each arm of the trial .
Assumptions for NMA: in common with all metaanalysis, the true treatment effect across trials is assumed to be described by a fixedeffect or randomeffects model. Additionally, transitivity is assumed and, concurrently, exchangeability and consistency.
Baseline risk: the absolute risk of the outcome in the ‘control’ group. This is affected by the presence of prognostic factors. Some authors have used the baseline risk as a proxy effect modifier, but in general the effect estimate is independent of the baseline risk on the other hand, the absolute risk difference depends on baseline risk.
Bayesian approach: the explicit quantitative use of external evidence in the design, monitoring, analysis, interpretation of a healthcare evaluation. In the Bayesian paradigm, prior beliefs about parameters in the models are specified and factored into the estimation. Posterior distributions of model parameters are then derived from the prior information and the observed data. In NMA, it is common to use noninformative priors for effect estimates.
Coherence/consistency: the direct effect estimate is the same as the sum of the indirect effect estimates.
Contrast/comparison/studylevel data: outcome data for the comparison .
Credible interval : the 95% credible interval is the range within which the mean value lies with posterior probability of 95%.
Studylevel data: see contrast.
How The Intervention Might Work
Animal experiments conducted over 40 years ago suggested that acute wounds heal more quickly when their surfaces are kept moist rather than left to dry and scab . A moist environment is thought to provide optimal conditions for the cells involved in the healing process, as well as allowing autolytic debridement , which is thought to be an important part of the healing pathway .
The desire to maintain a moist wound environment is a key driver for the use of wound dressings and related topical agents. Whilst a moist environment at the wound site has been shown to aid the rate of epithelialisation in superficial wounds, excess moisture at the wound site can cause maceration of the surrounding skin , and it has also been suggested that dressings that permit fluid to accumulate might predispose wounds to infection . Wound treatments vary in their level of absorbency, so that a very wet wound can be treated with an absorbent dressing to draw excess moisture away and avoid skin damage, whilst a drier wound can be treated with a more occlusive dressing or a hydrogel to maintain a moist environment.
Some dressings are now also formulated with an ‘active’ ingredient .
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Why It Is Important To Do This Review
The diversity of dressings and related materials available to health professionals for treating pressure ulcers makes evidencebased decisionmaking difficult when determining the optimum treatment regimen for a particular patient . With increasingly sophisticated technology being applied to wound care, practitioners need to know the relative effectiveness and costeffectiveness of these sometimes expensive dressings. Even where cost is not an issue, the most effective treatment may not be available or may be difficult or to use, so that information on the second and third best treatments is important too .
Current evidence syntheses include four Cochrane Reviews , two other systematic reviews , and two recent clinical guidelines . Each of these consists of a series of pairwise comparisons. No review finds clear evidence of any effect of one dressing compared to another in terms of assessed outcome measures, including complete wound healing.
In the absence of an overview or network metaanalysis, decisionmakers have to consider the findings of multiple pairwise randomised controlled trials simultaneously and qualitatively to judge, in the face of uncertainty, which dressing they might decide to use. It is extremely difficult to do this effectively, and this difficulty is compounded when the evidence comprises single small trials, about which decisionmakers may have little confidence.
A glossary of NMA terms is given in .
Criteria For Considering Studies For This Review
Types of studies
We included published and unpublished randomised controlled trials , irrespective of language of report. We did not identify any crossover trials, but we would have included them only if they reported outcome data at the end of the first treatment period and prior to crossover. We excluded studies using quasirandom methods of allocation . We highlighted trials in which three or more interventions were randomised.
Types of participants
We included studies that recruited people with a diagnosis of pressure ulcer, Stage 2 and above , managed in any care setting. We excluded studies that only recruited people with Stage 1 ulcers as these are not open wounds requiring dressings.
We accepted study authors’ definitions of what they classed as Stage 2 or above, unless it was clear that they included wounds with unbroken skin. Where authors used grading scales other than NPUAP, we attempted to map to the NPUAP scale.
Types of interventions
Interventions of direct interest
The interventions in this section were all those that can be directly applied as dressings or topical agents to open pressure ulcers. We presented results for these interventions and included them in summary tables. In the context of a network of competing treatments, there are no ‘comparators’.
Some of the interventions we considered were as follows:
Supplementary intervention set
Types of outcome measures
the proportion of wounds healed
time to complete healing .
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Where Can I Buy Treatment Options For Pressure Ulcers Or Bedsores
At Shop Wound Care, we have a wide range of products from top selling brands such as Medline, Smith and Nephew, Coloplast etc. that help in the treatment of decubitis.The treatment also includes the use of anti-bacterial and anti-fungal powders. Many medical professionals also recommend the use of moisturizing powders and creams so that the skin retains moisture and is not susceptible to friction-related ulcers. You can consult a medical professional for more information and advice on the topic. Shop Wound Care offers amazing discount and rewards on treatment options of Decubitus Ulcers. Shop Now!