Current Perspectives On Dressings, Tunneling Wounds And Infected Ulcers
Dr. Steinberg generally will bring patients with tunneling wounds to the operating room for surgical debridement and then use a NPWT device or packing with a silver impregnated strip.
Dr. Bell advises DPMs to consider what anatomical structures may be in the proximity of the wound as well as the presence of infection. As he notes, alginates work well for deep tunneling wounds. If the infectious process is a concern, he says iodoform gauze packing is another standard until things settle down.
“A key concept here is to monitor the wound closely to watch the trend of how things are responding,” says Dr. Bell. “Do not be shy about changing dressings as necessitated by the response of the wound.”
What do you use when you see highly draining, uninfected wounds?
Dr. Bell emphasizes that it really depends on the wound location as well as the source of the drainage. For example, he says a heavily weeping or draining leg wound that has an underlying component of congestive heart failure or renal disease will not dry up because of a particular dressing. If heavy drainage is coming from a non-infected wound, he says negative pressure can be a great adjunctive therapy, stressing that the nature and location of the wound should help determine what dressing to use.
Dr. Suzuki cites several super-absorbent dressings, such as Cutisorb Ultra (BSN Medical) and OptiLock (Medline), which are composed of hydropolymer that absorbs a lot of moisture, much like a baby’s diaper. He says those dressings work extremely well for non-infected, highly draining leg wounds, especially when combining them with multi-layer compression dressings, such as Jobst Comprifore (BSN Medical) or Profore (Smith & Nephew).
For highly draining wounds, Dr. Steinberg emphasizes the need to determine a cause as this may indicate a need for debridement or surgery. He generally uses calcium alginate dressings for absorption of drainage.
What do you use when you see an infected wound?
When faced with grossly infected wounds, Dr. Suzuki takes these patients to the operating room for thorough debridement. If he sees a slightly infected wound with copious discharge in the office, he may use something like Sorbact (BSN Medical) contact layer, a non-adherent plastic mesh with an antimicrobial coating. As he notes, Sorbact “does a nice job” of letting drainage pass through while keeping the secondary absorbent dressings from sticking to the wound bed.
In the case of an infection, Dr. Bell will use any adjunctive method to complement the systemic antibiotics that the patient is hopefully already taking. If the wound is badly contaminated, he says the first goal should be to begin cleaning things up. Again, he says this is determined by the location and nature of the wound.
That being said, Dr. Bell notes a diabetic foot wound with extensive necrotic tissue with significant odor would likely receive an order (after surgical debridement) of one-quarter or one-half strength Dakin’s solution. He will saturate an alginate dressing with the Dakin’s solution and change the dressing out once daily. As the infection decreases in intensity and the wound shows clinical signs of improvement, Dr. Bell may switch over to a compounded triple antibiotic solution of gentamicin-clindamycin-polymyxin with daily application to the wound with alginate as in the case of the Dakin’s solution.