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.
Risk Of Bias In Included Studies
Risk of bias for all included studies is summarised in . In order to represent ‘very high’ risk of bias, we have used two columns so very high risk of bias occurs when the cell is red in the final column .
Risk of bias summary: review authors’ judgements about each risk of bias item for each included study
We judged only one of the 51 studies to be at low risk of bias and ten to have unclear risk of bias . We judged 14 studies to be at very high risk of bias, that is, to have high risk of bias for two or more domains . We assessed the rest of the studies at high risk of bias. We grouped the low and unclear categories together.
*Studies marked with an asterisk were not included in the individual network.
Summary Of Main Results
We have successfully conducted a network metaanalysis of dressings and topical agents for healing pressure ulcers. Alongside the analysis we have applied a new method of GRADE assessment , which allows us to view the results in the light of our certainty in their findings. Using this approach, we found the majority of the evidence to be of low or very low certainty, and was mainly downgraded for risk of bias and imprecision . This level of uncertainty within the totality of the dataset impacts on all subsequent interpretation of its outputs.
This review includes 51 RCTs involving a total of 2964 participants, comparing 39 different dressings or topical agents for the healing of pressure ulcers. Most of the studies were in older participants, but four included participants with spinal cord injuries and one was in younger people said to be chronically ill or physically disabled. Seventeen studies included participants mainly with Stage 2 pressure ulcers and 15 mainly had Stage 3 pressure ulcers 13 studies investigated treatment of ulcers with a mean duration of less than three months.
We treated each topical agent as a separate intervention, but initially grouped dressings by class as described in the . The network involved 39 studies in 2116 participants, encompassing 21 different interventions in 27 direct contrasts and these informed 210 mixed treatment contrasts.
Biochemical Data For Nutrition Screening And Assessment
An important part of nutritional assessment is biological data analysis. While laboratory tests may help to assess nutrition problems in patients at risk or those who are actually affected by pressure ulcers, no laboratory test can exactly define an individual’s nutritional status. Therefore, at the moment, there are no ideal laboratory tests to detect malnutrition. Although serum albumin, prealbumin, transferrin, and retinol-binding protein as well as anthropometric measures such as height, weight, and body mass index and the other laboratory values may be suitable to establish the overall prognosis, still they might not well represent the nutritional status. Serum albumin is not a sensitive indicator of malnutrition because its levels are influenced by a variety of nutritionally unrelated factors such as protein-losing states, hepatic dysfunction, acute infection, and inflammation. Bluestein and Javaheri introduced some useful indicators that help to detect protein-calorie malnourishment in patients with pressure ulcers including involuntary weight loss of 5% or more in the previous month or of 10% or more in the previous 6 months, weight fewer than 80% of ideal body weight, serum albumin level < 3.5 g/dl , prealbumin level fewer than 15 mg/dl , transferrin level fewer than 200 mg/dl , and total lymphocyte counts fewer than 1500 per mm3 .
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 .
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What Is The Interest Of The Topical Application Route
Oral zinc sulphate supplementationis essential for healing in zinc-deficient patients. If normal levels exist, the conclusion of a systemic review of six clinical trials including leg wounds is that there is no benefit over placebo.3
On the contrary, its topical application has shown improvement at experimental and clinical level in patients presenting with both deficit and normal serum levels.
What Are Nursing Interventions For Dyspnea
Dyspnoea can be very frightening for patients and may result in increased anxiety, causing them to become more breathless. Nursing intervention can break this cycle. Allowing time with breathless patients, talking calmly to them and instructing them to breathe slowly, and breathing with them, can be highly effective.
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How Do You Promote The Healing Of A Pressure Ulcer
Caring for a Pressure Sore
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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The Formation Of Exudate
The normal wound healing response of inflammation leads to the development of local oedema. Histamine, released from damaged cells as a result of injury, causes plasma leakage from blood vessels and, as a consequence, oedema forms in adjacent tissues. This exudate seeps from the wound surface, initially taking the form of a clear, serous liquid. Later, it becomes more viscous and opaque, as it contains leucocytes and other constituents such as albumin, macrophages and cellular debris .
Although there is limited understanding of exudate formation, Thomas lists some of the factors that may influence its production .
When a wound deteriorates, it may exhibit an increase in exudate production, accompanied by soiling of clothes or bedclothes, a change in odour, and possibly leakage from dressings.
The optimal level of exudate for a wound – The optimal level of exudate required to facilitate healing has not yet been determined. In addition, it varies with different types of wound. Increased levels of wound exudate may promote bacterial wound colonisation , particularly in wounds that are not appropriately managed. However, despite the possibility of dressings becoming soaked and strike-through providing potential access for bacteria, there is little evidence to support the theory that this increases the risk of infection.
What Is Zinc Oxide
Zinc is a trace element very abundant in the body. While it is known that zinc deficiency can cause delayed wound healing, the actual role of zinc in wound healing was not known. A number of experimental studies and clinical trials have been conducted using zinc. Results showed that topical zinc oxide had increased wound healing, increased reepithelialization, decreased rates of infection and decreased rates of deterioration of ulcers. Topical zinc oxide has shown to improve the rate of wound healing in patients, regardless of their zinc status. Oral zinc supplementation in zinc deficient patients did not have the same effect.
The animal studies reviewed showed that zinc sulfate did not enhance wound healing, but delayed it. One of the major roles for zinc in wound healing was found that zinc oxide enhances the ability of matrix metalloproteinases to enzymatically break down collagen fragments. There are few clinical studies, but they have all shown a positive benefit for topical zinc oxide, and of interest, especially when used for debridement in burns.
Further research on the topic of zinc in wound management has been recommended, but for now, I would say use zinc oxide whenever possible. I certainly will continue using it in my wound care practice, especially now I know it is actively helping the wound.
Reference:Kogan S, Sood A, Granick M. Zinc and Wound Healing: A Review of Zinc Physiology and Clinical Applications.Wounds. 2017 29: 102-106.
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Research About Nutritional Status
Nutritional deprivation and insufficient dietary intake are the key risk factors for the development of pressure ulcers and impaired wound healing. A number of studies including The National Pressure Ulcer Long-Term Care Study revealed that weight loss and inadequate nutritional intake were associated with a higher risk of developing pressure ulcers. Stratton et al. in 2005 in a systematic review and meta-analysis investigated the advantages of nutritional support in patients at risk of developing pressure ulcers. Oral and enteral support was their main focus in bedsore prevention. Fry et al. described that preceding underfeeding and/or weight loss was a positive prognostic indicator for pressure ulcers. In Japan, Iizaka et al. observed that 58.7% of patients at age 65 or older with pressure ulcers receiving home care suffered from malnourishment. Blanc et al. showed that age, particularly 65 years and higher, is a risk factor for the development of pressure ulcer. Cox proposed that malnutrition is a state of disproportion in energy, protein, and other nutrients that leads to harmful effects on body structures and tissues.
What Do Pressure Sores Look Like
Symptoms: Your skin is broken, leaves an open wound, or looks like a pus-filled blister. The area is swollen, warm, and/or red. The sore may ooze clear fluid or pus.
After cleaning, apply an ointment to keep the area dry. Use underpads to keep the patient from soiling the bed and to make it easier to clean up. Dont use plastic underwear unless the patient is out of bed. If the skin has an open sore, ask about special dressings to help protect it.
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Prevalence Incidence And Health
In the USA, approximately 13 million people develop pressure ulcers each year, and more than 2.5 million patients in the United States acute care services suffer from pressure ulcers, and 60,000 each year die from the complications of such ulcers. In the United States between 1990 and 2000, the NPUAP reported a prevalence rate of pressure ulcer ranging from 10% to 18% in general acute care, 2.3% to 28% in long-term care and up to 29% in home care, and 0% to 6% in rehabilitative care. Pressure ulcers can diminish global life quality because of pain, management procedures, and increased length of hospital stay. Furthermore, they contribute to rapid mortality in some patients. Therefore, any intervention that may assist to avoid pressure ulcers or to treat them may be important to decrease the cost of pressure ulcer care and increase life quality of affected individuals. Pressure ulcer management costs are a major problem to healthcare organizations. In the UK, the cost is estimated at £1.4£2.1 billion annually and in the US is estimated at $1.6 billion. In Australia, budgets spent per each patient admitted to Intensive Care Units have been around $18,964. In the UK, the reported cost of care for pressure ulcers has been 4% of total healthcare costs.
Selecting The Right Dressing For Sacral Ulcer Management
A tremendous number of dressings are available for different types of wounds, and variousguidelines are available to help wound care professionals determine which type of dressing should be used in various circumstances. For example, petrolatum-impregnated dressings are nonadherent dressings that are useful in wounds with minimal exudate. Conversely, alginates and hydrofiber are moderately or highly absorbent, respectively, which makes them useful in wounds with excessive exudate production.
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How Is Topical Zinc Absorbed
Percutaneous zinc absorption depends on the integrity of the epidermal barrier and the amount of zinc transporters in the cell membrane of the keratinocytes.Topical application of zinc, as well as topical corticosteroids, increase the concentration of these transporters and, therefore, the absorption of zinc.
Absorption depends on the zinc concentration of the preparation and the vehicle. Zinc oxide, when in contact with a humid and acidic environment, is hydrolyzed and releases zinc ions, which are those that have biological activity . These ions progressively penetrate into the deep layers of the skin. Therefore, the application of zinc oxide products with a vehicle that promotes humidity and acidity, preferably in occlusion, optimizes the absorption of this ion. This explains the interest of bandages with zinc paste . On eczematous skin, a constant situation in venous ulcer patients, zinc paste bandages form a protective barrier that decreases skin inflammation.1
What Antibiotics Are Used For Pressure Ulcers
Amoxicillin-potassium clavulanate is a naturally occurring beta-lactam structurally similar to the penicillin nucleus. This antibiotic group of beta-lactam/beta-lactamase combination has demonstrated a broad-spectrum activity therefore, it is frequently used for the treatment of infected pressure ulcers.
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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 .
What Causes Bed Sores In The Elderly
The main cause of bedsores among seniors is nursing home neglect. Elders are at a higher risk of bedsores if they cannot easily move on their own. Bedsores typically develop when someone cannot reposition their body over a long period of time. Without movement, the skin loses blood flow and eventually decays.
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