Article originally featured on General Surgery News
In this issue, we feature Part 2 of Wound Care: The Wild, Wild West. (Part 1 was published in the October 2020 issue, page 13). This is a relatively new topic for our On the Spot column but a relevant one to most practices, since there is some element of wound care in every surgical specialty. Some of the questions we tackle are the following:
Is the bar too low for bringing wound products to the marketplace based on classification as devices and not drugs?
Is it fair to say that often physicians do not know how to stage pressure injuries correctly by National Pressure Injury Advisory Panel guidelines?
Do topical antibiotics have a role in wound care?
Do Dakin’s solution, vinegar and saline still have a vital role in wound care?
Read on to see what these experts think!
Topical antibiotics have a role in wound care.
Dr. Park: On the fence. A wound is a culture dish on which you want tissue to grow and infectious microbes to die. Topical antibiotics are not suitable for infection, but can potentially aid in decontamination without the systemic toxicity of antibiotic therapies, but are ineffective as substitutes for surgical debridement and therapies for infection—which is different from contamination.
Dr. Cordova: Disagree Topical antibiotics play no significant role in wound care. Studies have failed to show a benefit of topical antibiotics in preventing infections. A comparison of bacitracin ointment and white petrolatum revealed no significant difference in the rate of infection [JAMA 1996;276(12):972-977]. Furthermore, on rare occasions, antibiotic ointment use is associated with contact reactions or dermatitis that can hinder wound healing. It is most likely the moist wound environment provided by ointments, i.e., Vaseline or petrolatum, that promotes wound healing. What does render a big impact on wound healing is irrigation, which removes particulate matter and decreases the bacterial count. In addition, comorbidities and conditions such as diabetes, renal insufficiency, obesity, vascular disease, immunodeficiencies, malnutrition and smoking may play a bigger role in wound complications, and their presence needs to be prioritized and optimized.
Dr. Wollheim: Disagree This is because I am concerned that the routine use of topical antibiotics in chronic wound care might be setting the stage unnecessarily for antibiotic resistance. There are many effective topical non-antibiotic antimicrobials available to use instead. Since a chronic wound’s bioburden [bacterial load] is usually protected in a biofilm environment, the use of a topical antibiotic might have an overall decrease in its effectiveness while at the same time increasing its risk for the development of resistance.
It is fair to say that often physicians (and other disciplines of health care) do not know how to stage pressure injuries correctly by National Pressure Injury Advisory Panel guidelines, creating regulatory, legal and reimbursement vulnerabilities.
Dr. Park: On the fence. There are severe biases involved in staging that are driven by reimbursement and penalties. These are useful tools to guide therapies, but are most often used for quality metrics and billing.
Dr. Cavaliere: Agree. Physicians and other health care providers receive limited wound care education and training. Pressure injury staging is not difficult; however, if not used on a regular basis, the stages are easy to forget. Correct documentation of pressure injury presence and stage upon admission are necessary to allow hospitals to report and track patient safety and quality. A pressure injury that is not documented within 24 hours of admission may be considered hospital-acquired and the hospital will not be reimbursed for the cost of caring for the pressure injury.
In many hospitals, evaluation and treatment of pressure injuries is considered a nursing responsibility with limited physician involvement. Pressure injuries typically develop in patients suffering from severe illness and patients with multiple comorbidities. Physician involvement in wound evaluation and management is essential to ensure the extent of the wound is considered in the context of the patient’s overall health. Discussion with patients and family members regarding overall condition and prognosis should include a review of the status of the wound.
Dr. Wollheim: Disagree, since I would not characterize the frequency of incorrectly staging a pressure injury as “often.” There are many health care clinicians who stage correctly. However, I do agree with the concept that if a pressure injury is incorrectly staged, this could have negative regulatory and/or legal implications.
Dr. Cordova: Disagree. I believe that most physicians and other health care providers are familiar with and understand the pressure injury staging system as described by the National Pressure Injury Advisory Panel. However, the staging does lend itself to a level of subjectivity among providers, and this fact may lead to regulatory, legal and reimbursement vulnerabilities. In addition, although the ulcer management may be addressed, some details in the documentation may be overlooked. Considering these patients often have numerous comorbidities and active medical and social issues requiring attention, the provider may be distracted in a detailed description of findings while addressing the continued abundance of documentation, charting and reporting.
Dakin’s solution, vinegar and saline still have a vital role in wound care.
Dr. Cavaliere: Agree. “Wound” is an incredibly broad diagnosis and therefore wound treatment must be tailored to the specific wound. Over the past several years, moist gauze dressings or “wet to dry” dressings have been denounced in favor of “advanced wound dressings.” Many of these “advanced” dressings are absorptive—meant to be changed less frequently—and may be relatively expensive. A large, infected wound with necrotic tissue needs to be washed/irrigated, the necrotic tissue needs to be removed, and more frequent dressing changes may be needed.
These solutions can be used for irrigation and/or packing and can help debride necrotic tissue, making them a valuable tool. Even with use of advanced wound dressings, these products can be used to irrigate and clean a wound. More concentrated solutions may irritate the tissue or slow healing; however, dilute solutions are well tolerated. The solutions are relatively inexpensive and can be prepared in the kitchen, making them accessible to patients who have limited resources or lack insurance coverage for dressing supplies.
Dr. Park: Agree. Changing the chemical environment of a wound, irrigation, decontamination—all of these agents have a role and have over a century-long track record. That they are cheap and not reimbursed may be one of the reasons why they have been discarded.
Dr. Wollheim: On the fence. Saline definitely still has a role in modern wound care except in the neonate. The pendulum is shifting away from utilizing Dakin’s and dilute acetic acid (vinegar) as antimicrobial agents and replacing them with newer, other commercial products. However, Dakin’s and acetic acid are still being used. If so, they should be used correctly. Dakin’s is only effective against gram-positive organisms and needs to be applied twice a day. Acetic acid is effective against both gram-positive and gram-negative organisms, especially Pseudomonas, and needs to be applied three times a day.
Dr. Cordova: Agree. Dakin’s, vinegar and saline play a vital role in wound care. Dakin’s and vinegar have proven bactericidal and fungicidal properties. However, their use should be for a limited period of time as it may cause fibroblast cytotoxicity and paradoxically impair wound healing. It is important to know that these products are available in different concentrations, and those that are more dilute still remain effective and have a safer profile while promoting antisepsis with a lesser degree of cytotoxicity. Saline is a simple, more physiologic, and efficacious solution that provides a moist environment conducive for adequate wound healing. These solutions are all highly accessible, cost-effective and successful in debridement. Despite the plethora of wound care products on the market, these continue to perhaps be the most cost-effective and have proven the test of time.
The bar is too low for bringing wound products to the marketplace based on classification as devices and not drugs.
Dr. Park: Agree, having seen tiny tubes of unguents sold for thousands of dollars, only to be discredited, with many patients having paid out of pocket. Simple, cheap and effective therapies always lose out to the “latest, greatest” thing.
Dr. Cavaliere: On the fence. There are numerous wound-related products with grand efficacy claims and limited data. This scenario makes choosing products challenging and puts frustrated physicians and suffering patients in a vulnerable position. Products that are low risk and relatively inexpensive may be appropriate to try even with limited data. Unfortunately, many patients assume economic hardship with the hope that a fancy new product will help them heal. A more rigorous and uniform process to evaluate wound products and to assess comparative efficacy would promote more cost-conscious wound care and improve outcomes.
Dr. Wollheim: Disagree. If a new product is not a medication and does not need to undergo the scrutiny of a drug, then I think the nondrug product should be made available for the clinician’s use. All wounds are different, and maybe a newer product might have a unique quality to heal the wound in comparison with other established products in the same category. The clinician should follow the trajectory of healing regardless of if the product is new or old to the marketplace. In general, the clinician should see a positive response within two weeks, such as a 10% per week decrease in the wound’s cross-sectional area, a decrease in the amount of nonviable tissue compared with viable tissue in the wound bed, and/or maybe less pain, among other parameters. If there is no improvement, then the clinician should consider moving on to a different therapy, be it from an old or new product/therapy.
Access to hyperbaric therapy for acutely sick patients is a problem with no real solution in sight.
Dr. Park: On the fence. There is not enough data to understand if a wound would have healed with optimal vascularity, surgical management and excellent wound care, with or without afternoons spent in a tank.
Dr. Wollheim: Agree. Hyperbaric oxygen therapy [HBOT] clinics are very expensive to establish, and the administration of the therapy requires its own unique expertise. Although it would be great for all patients to readily have access to HBOT, not all geographic areas can support its use. For the acutely ill patient who does not live in a region where HBOT is readily available, this might require them to be transferred to a hospital, long-term acute care hospital or long-term care facility, with an admission lasting several weeks. This could create a hardship for family members, too. “No real solution in sight” might be an understatement.