Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_764_Библиотеки_им_академика_М_И_Перельмана
.pdf
68
https://t.me/medicina_free
T. Pasquale and M. Maruccia
7.6 Sharp Debridement
Sharp debridement is a type of wound debridement that involves the use of sharp instruments,
such as forceps, scissors, or scalpels, to selectively remove nonviable tissues, foreign materials, and debris from the wound bed. This
technique is the fastest and most aggressive form
of debridement outside of surgery and is typically
performed by physicians, podiatrists, nurses, and
physical therapists. Sharp debridement is indicated for several conditions such as advancing
cellulitis or sepsis, necrotic tissues, eschars, calluses, or chronic wounds [24].
Examples of wounds that can benet from
sharp debridement include pressure ulcers,
venous ulcers, diabetic foot ulcers, and surgical
wounds. Sharp debridement is also used in burn
wound care to remove eschar and promote
healing.
The mechanism of action of sharp debridement involves the physical removal of nonviable
tissue, debris, and bacteria from the wound bed.
This promotes the formation of healthy granulation tissue and enhances the wound’s ability to
heal. Sharp debridement also helps to reduce the
bacterial load and prevent the spread of infection
to surrounding tissues. In addition, it allows for
better visualization of the wound bed, which
helps clinicians to identify signs of infection or
other complications [25].
It is important to note that sharp debridement should not be performed if the material
to be debrided is unidentified, pain is not adequately controlled for the patient, or the clinician’s competency is lacking. It is also not
indicated for non-infected ischemic ulcers
without adequate perfusion. Furthermore,
sharp debridement should be used with caution on patients who are thrombocytopenic or
those on anticoagulants.
During sharp debridement, scalpels and scissors should be applied parallel to the wound surface. The wound is debrided in layers, starting
with the most supercial layers, and rinsed with
saline to remove any remaining debris. After
debridement, the wound is reassessed for signs of
infection or other complications.
7.7 Surgical Debridement
Surgical debridement is a method of wound
debridement that involves the use of surgical
instruments such as scalpels, scissors, or lasers in
a sterile environment to remove nonviable tissues
from the wound bed. It is a fast and aggressive
method of debridement that is performed by a
physician or podiatrist who has advanced knowledge, skill, and training in surgical procedures.
Unlike other forms of debridement, surgical
debridement requires the use of anesthesia due to
the length of time required to debride the wound
and/or the extent of debridement required
(Fig.7.2) [26].
The goal of surgical debridement is to remove
all nonviable tissue from the wound bed, including necrotic tissues, foreign materials, and debris.
This is achieved by excising nonviable tissues
along the margin of healthy tissue and by exploring the wound to debride deeper structures such
as infected bones or nonviable tendons. Surgical
Fig. 7.2 Surgical debridement with Watson Dermatome
on burn wound. This gure demonstrates a surgical
debridement procedure performed on a burn wound using
a Watson Dermatome. The image showcases the precise
removal of necrotic tissue from the burn wound during the
intraoperative stage. The use of the Watson Dermatome
allows for controlled and effective debridement, ensuring
a clean and prepared wound bed for further treatment
7 Ulcer Debridement
https://t.me/medicina_free
debridement is indicated for a variety of conditions, including osteomyelitis, infectious arthritis, ascending cellulitis, extensive necrotic
wounds, wounds with extensive undermining,
foreign bodies, necrotic tissue near vital organs/
structures, and sepsis [27].
Surgical debridement techniques vary widely
depending on the type of wound and the type of
nonviable tissue to be removed. During the procedure, the physician performs a tissue biopsy to
better establish the presence and type of infection. This is followed by appropriate antimicrobial therapy. However, surgical debridement has
some disadvantages, including physical and emotional stress for the patient, high cost, and the risk
of infection associated with any surgical
procedure.
It is important to note that surgical debridement should not be performed on patients who
are unlikely to survive such a stressful procedure
or patients with palliative care plans. The use of
surgical debridement should also be approached
with caution when dealing with patients who are
thrombocytopenic or those on anticoagulants. It
is important to evaluate the patient’s overall
health status and comorbidities to determine
whether surgical debridement is appropriate.
7.7.1 Hydrosurgery
Hydrosurgery, also known as waterjet debridement, is a surgical tool used to remove nonviable
tissue, bacteria, and contaminants from wounds.
It is a precise and effective method of wound
debridement that uses a high-pressure stream of
sterile saline to remove unwanted tissue while
minimizing damage to healthy tissue. This system is especially useful for extensive wounds, as
it can quickly and thoroughly remove debris and
necrotic tissue from a large wound bed [20].
The hydrosurgery system consists of a specialized handpiece that produces a high-velocity
stream of saline. The handpiece is equipped with
a tiny jet nozzle that directs the stream of saline
onto the wound bed. As the saline stream hits the
wound bed, it dislodges and removes nonviable
69
Fig. 7.3 Hydrosurgical debridement. This gure illustrates the application of hydrosurgery for debridement
using a power-assisted system. This machine utilizes a
high-pressure uid stream to precisely and selectively
remove necrotic tissue, debris, and contaminants from the
wound bed. The image captures the moment of debridement, showing the controlled and thorough removal of
unhealthy tissue, while preserving the surrounding healthy
tissue. Hydrosurgery offers a minimally invasive and
effective method for debridement, promoting wound healing and preparation for further interventions
tissue and contaminants, leaving behind a clean,
healthy wound bed. The handpiece also has an
evacuation collector tube that collects the saline
and debris, which is then deposited into a waste
container (Fig.7.3).
One of the advantages of hydrosurgery is that
it preserves healthy tissue while removing only
the nonviable tissue. This tissue-preserving technique can reduce the time it takes for a wound to
heal and can also reduce the overall cost of treatment. In addition, because hydrosurgery is a minimally invasive procedure, it can be used to
debride wounds in sensitive areas of the body that
would be difcult or impossible to treat with
other methods [21].
However, hydrosurgery is not appropriate for
all wounds. It should not be used on deep tunneling wounds or on patients taking anticoagulants, as the high-pressure saline stream can
cause bleeding in these cases. It is also important to note that hydrosurgery produces an aerosolized mist that can contain bacteria and other
contaminants. As a result, both the patient and
clinician must wear appropriate barrier devices
during the procedure to avoid inhaling any
harmful particles.
70
https://t.me/medicina_free
T. Pasquale and M. Maruccia
7.8 Other Types ofDebridement
In addition to the main methods of debridement
mentioned earlier, there are other approaches that
can be explored in the management of ulcers.
These alternative methods offer additional
options for healthcare professionals to consider
when tailoring the debridement approach to individual patients.
7.8.1 Ultrasound Debridement
Surgical debridement with ultrasound is a relatively newer technique that utilizes the power of
ultrasonic energy to aid in the removal of necrotic
tissue. This method involves the use of lowfrequency ultrasonic waves delivered through a
specialized handpiece or probe. The ultrasonic
energy disrupts and breaks down the necrotic tissue, allowing for easier removal.
One of the advantages of surgical debridement
with ultrasound is its precision and selective targeting. The ultrasonic energy specically targets
and breaks down the necrotic tissue, minimizing
damage to healthy tissue. This technique can be
particularly useful in areas with delicate or hardto- reach ulcers, such as around bony prominences
or in deep wounds.
Moreover, surgical debridement with ultrasound is generally well-tolerated by patients and
may result in less pain compared to traditional
sharp debridement methods. It can also be performed at the bedside, making it a convenient
option for patients who may not be suitable for
more invasive procedures [28].
7.8.2 Laser Debridement
bed, effectively vaporizing and ablating the
necrotic tissue. The laser energy can be adjusted
to target specic types of necrotic tissue, providing a controlled and precise debridement
process.
One of the key advantages of laser debridement is its ability to promote hemostasis during
the procedure. The laser energy seals blood vessels as it removes the necrotic tissue, reducing
bleeding and improving visibility for the healthcare professional. Laser debridement also has the
potential to stimulate wound healing by promoting collagen synthesis and cellular activity.
It is important to note that laser debridement
may require specialized equipment and expertise,
and it is not widely available in all healthcare settings. Additionally, certain precautions must be
taken, such as proper eye protection for both the
patient and healthcare professional, to ensure
safe implementation of the procedure.
In conclusion, beyond the main methods of
debridement, debridement with ultrasound and
laser debridement present additional options for
healthcare professionals in the management of
ulcers. These techniques offer benets such as
precision, selectivity, improved visibility, reduced
bleeding, and potential wound healing stimulation. However, their utilization requires careful
consideration of factors such as patient suitability, available resources, and the expertise of the
healthcare team. Exploring these alternative
approaches expands the options for debridement
and contributes to comprehensive ulcer management strategies.
7.9 Factors toConsider
inChoosing
theDebridement Method
Laser debridement is another innovative approach
that utilizes the energy of laser light to remove
necrotic tissue from ulcers. In this technique, a
focused laser beam is directed onto the wound
Choosing the appropriate method of debridement
for a specic ulcer is a critical decision in wound
management. Several key factors inuence the
selection process, ensuring the most effective and
7 Ulcer Debridement
https://t.me/medicina_free
71
tailored approach to promote healing. By considering the size, depth, type of necrotic tissue, presence of infection, ulcer location, and patient’s
overall condition, healthcare professionals can
make informed decisions to optimize outcomes.
The size and depth of the ulcer play a crucial
role in determining the appropriate debridement
method. Larger and deeper ulcers often require
more aggressive debridement techniques to
remove extensive necrotic tissue and facilitate the
healing process. In contrast, smaller ulcers with
minimal necrotic tissue may benet from less
invasive debridement methods that focus on
selective removal, preserving healthy tissue.
The type of necrotic tissue present in the
wound bed is another essential factor. Different
debridement methods target specic types of
necrotic tissue, such as slough or eschar. For
instance, autolytic debridement using moistureretentive dressings is effective in promoting the
body’s natural enzymatic action to liquefy and
remove soft necrotic tissue. However, enzymatic
debridement employing topical enzymes may be
more suitable for thick eschar or brin deposits
that require enzymatic breakdown.
The presence of infection in the ulcer inuences the choice of debridement method. Infected
ulcers often necessitate more aggressive debridement approaches to eliminate bacterial burden
and facilitate effective wound healing. Sharp
debridement or surgical debridement may be
considered in these cases to achieve thorough
removal of infected tissue and reduce the risk of
further complications.
The location of the ulcer is a critical consideration when selecting the debridement method.
Some areas of the body, such as the face or near
vital structures, require more cautious approaches
to ensure minimal damage and optimal outcomes.
In these situations, less invasive methods such as
autolytic or enzymatic debridement may be preferred. However, in accessible areas, mechanical
debridement or sharp debridement can be
employed to achieve precise and thorough tissue
removal.
The patient’s overall condition and comorbidities must be taken into account when choosing the debridement method. Factors such as the
patient’s pain tolerance, mobility, vascular status, and ability to tolerate certain procedures
play a role in determining the most appropriate
approach. For instance, patients with compromised vascular supply may not be suitable candidates for surgical debridement due to the risk
of poor wound healing and complications. In
such cases, less invasive methods such as autolytic or enzymatic debridement may be more
appropriate.
The choice of debridement method for a specic ulcer is multifaceted and requires a comprehensive assessment of various factors.
Understanding the size, depth, type of necrotic
tissue, presence of infection, ulcer location, and
the patient’s overall condition enables healthcare
professionals to tailor the debridement approach
to optimize wound healing. By considering these
factors, clinicians can select the most suitable
debridement method and promote successful
wound bed preparation, setting the stage for
effective ulcer management and improved patient
outcomes.
Table 7.1 provides a comprehensive indication and recommendation on dressings and various debridement methods used in wound
management.
Table 7.2 provides a comprehensive comparison of various debridement methods used in
wound management.
72
https://t.me/medicina_free
Table 7.1 Debridement methods’ indication and recommendation
Debridement Types Indications Not recommended
Autolytic Hydrogels (e.g., Nu-Gel®,
Purilon®)
Hydrocolloids (e.g.,
DuoDERM®, Comfeel®)
Hydrobers (e.g.,
AQUACEL®)
Alginate (e.g., Algisite®) Wounds with moderate-to-heavy
Honey-based (e.g.,
Medihoney®)
Enzymatic Collagenase (e.g., Noruxol®,
Bionect®)
Papain-urea (e.g.,
Accuzyme®)
Trypsin (e.g., Granulex®) Chronic wounds with slough, burns,
Bromelain (e.g., NexoBrid®) Partial- to full-thickness wounds, burns,
Mechanical Wet-to-dry dressings,
hydrophobic dressing,
scrubbing, wound irrigation,
wound debridement pads
Surgical Sharp surgical instruments,
laser, hydrosurgery
Dry necrotic wounds, supercial
wounds, wounds with minimal exudate
Necrotic wounds, pressure ulcers, leg
ulcers, burns, wounds with granular
tissue
Cavity wounds, deep wounds, surgical
wounds, infected wounds
exudate, infected wounds, cavity
wounds
Infected wounds, wounds with
minimal-to-moderate exudate, burns,
surgical wounds
Partial- to full-thickness wounds,
wounds with necrotic tissue, and burns.
The presence of yellow, brous, or
thick slough indicates the need for
collagenase.
Chronic wounds with devitalized tissue,
pressure ulcers, diabetic foot ulcers, and
venous ulcers.
and traumatic injuries.
and wounds with necrotic tissue or
eschar.
Wounds with moderate-to-heavy
exudate
Necrotic or infected tissue, severe
burns, wounds with necrotic tissue or
eschar
T. Pasquale and M. Maruccia
Infected wounds, heavily
exuding wounds
Infected wounds, heavily
exuding wounds
Dry wounds
Dry wounds, wounds
with minimal exudate
Dry wounds, allergies to
honey
Clean, granulating
wounds, known
hypersensitivity to
collagenase
Clean, granulating
wounds
Clean, granulating
wounds
Clean, granulating
wounds
Granulating wounds,
newly formed tissue,
painful wounds
Granulating wounds,
newly formed tissue,
painful wounds
Table 7.2 Debridement methods’ comparison
Type Description Advantages Disadvantages
Autolytic
debridement
Enzymatic
debridement
Biological
debridement
Dressings, such as hydrogels,
hydrocolloids, and alginate, are
used to encourage the body’s
natural enzymes and moisture
to break down dead tissue.
Collagenase-based dressings or
ointments are applied to break
down collagen in necrotic
tissue.
Use of live y larvae to
consume necrotic tissue
Non-invasive, painless, and
can be used for a variety of
wound types.
Selectively targets necrotic
tissue, painless, and can be
effective for larger wounds
or those with heavy slough
or eschar.
Effective for heavily
necrotic tissue,
non-invasive
Can be slow and ineffective for
larger wounds or those with
heavy slough or eschar.
Can be costly, requires frequent
dressing changes.
Unappealing to some patients and
healthcare providers, requires
careful management and
monitoring, may be
contraindicated for certain
patients or wounds
7 Ulcer Debridement
https://t.me/medicina_free
Table 7.2 (contnued)
Type Description Advantages Disadvantages
Mechanical
debridement
Surgical
debridement
Wound irrigation or use of
specialized tools, such as
curettes or scalpels, to
physically remove necrotic
tissue.
Sharp surgical instruments are
used to remove necrotic tissue
and debris from the wound.
Rapid and effective for
larger wounds or those with
heavy slough or eschar, can
be combined with other
types of debridement.
Rapid and effective, can
remove debris and foreign
objects, can be combined
with other types of
debridement.
Can be painful and invasive, may
cause bleeding or damage to
healthy tissue, requires
specialized training and
equipment.
Invasive, requires anesthesia, may
cause bleeding or damage to
healthy tissue, can be costly, and
may require hospitalization.
73
References
1. Guest JF, Ayoub N, McIlwraith T, etal. Health economic burden that different wound types impose
on the UK’s National Health Service. Int Wound
J. 2017;14(2):322–30. https://doi.org/10.1111/
iwj.12603.
2. Schultz GS, Sibbald RG, Falanga V, etal. Wound bed
preparation: a systematic approach to wound management. Wound Repair Regen. 2003;11(Suppl 1):S1–28.
https://doi.org/10.1046/j.1524- 475x.11.s2.1.x.
3. Kirshen C, Woo K, Ayello EA, Sibbald
RG. Debridement: a vital component of wound
bed preparation. Adv Skin Wound Care.
2006;19(9):506–17.; quiz 517-519. https://doi.
org/10.1097/00129334- 200611000- 00011.
4. Kottner J, Cuddigan J, Carville K, etal. Prevention
and treatment of pressure ulcers/injuries: the protocol for the second update of the international clinical
practice guideline 2019. J Tissue Viability. 2019:28.
https://doi.org/10.1016/j.jtv.2019.01.001.
5. Maruccia M, Onesti MG, Sorvillo V, et al. An alternative treatment strategy for complicated chronic
wounds: negative pressure therapy over mesh skin
graft. Biomed Res Int. 2017;2017:8395219. https://
doi.org/10.1155/2017/8395219.
6. Atkin L. Understanding methods of wound debridement. Br J Nurs. 2014;23(12):S10-12., S14-15.
https://doi.org/10.12968/bjon.2014.23.sup12.S10.
7. Giudice G, Filoni A, Maggio G, et al. Use of the
stromal vascular fraction in intermediate-deep acute
burns: a case with its own control. J Burn Care Res.
2018;39(5):846–9. https://doi.org/10.1093/jbcr/
irx017.
8. Wolcott RD, Kennedy JP, Dowd SE.Regular debridement is the main tool for maintaining a healthy
wound bed in most chronic wounds. J Wound
Care. 2009;18(2):54–6. https://doi.org/10.12968/
jowc.2009.18.2.38743.
9. Atkin L, Rippon M. Autolysis: mechanisms of
action in the removal of devitalised tissue. Br J Nurs.
2016;25(20 Suppl):S40–7. https://doi.org/10.12968/
bjon.2016.25.20.S40.
10. Nuutila K, Eriksson E. Moist wound healing with
commonly available dressings. Adv Wound Care
(New Rochelle). 2021;10(12):685–98. https://doi.
org/10.1089/wound.2020.1232.
11. Ramundo J, Gray M. Enzymatic wound debridement. J Wound Ostomy Continence Nurs.
2008;35(3):273–80. https://doi.org/10.1097/01.
WON.0000319125.21854.78.
12. McCallon SK, Weir D, Lantis JC.Optimizing wound
bed preparation with collagenase enzymatic debridement. J Am Coll Clin Wound Spec. 2014;6(1-2):14–
23. https://doi.org/10.1016/j.jccw.2015.08.003.
13. Cigna E, Maruccia M, Sorvillo V, Parisi P, Palumbo F,
Onesti MG.The use of negative pressure therapy and
hyaluronic acid for the management of post-traumatic
lower limb injury. Int Wound J. 2013;10(5):534–8.
https://doi.org/10.1111/j.1742- 481X.2012.01011.x.
14. Sherman RA, Hall MJ, Thomas S. Medicinal maggots: an ancient remedy for some contemporary afictions. Annu Rev Entomol. 2000;45:55–81. https://doi.
org/10.1146/annurev.ento.45.1.55.
15. Qing C. The molecular biology in wound healing & non-healing wound. Chin J Traumatol.
2017;20(4):189–93. https://doi.org/10.1016/j.
cjtee.2017.06.001.
16. Kammerlander G, Andriessen A, Asmussen P,
Brunner U, Eberlein T.Role of the wet-to-dry phase
of cleansing in preparing the chronic wound bed for
dressing application. J Wound Care. 2005;14(8):349–
52. https://doi.org/10.12968/jowc.2005.14.8.26824.
17. Onesti MG, Fioramonti P, Carella S, Maruccia M.The
importance of periwound skin in the treatment of “difcult wound”. G Chir. 2011;32(1-2):83–8.
18. Choi JS, Lee JH, Kim SM, Kim YJ, Choi JY, Jun
YJ. Hydrogel-impregnated dressings for graft xation: a case series. J Wound Care. 2015;24(7):326–8.
https://doi.org/10.12968/jowc.2015.24.7.326.
19. Norman G, Atkinson RA, Smith TA, et al.
Intracavity lavage and wound irrigation for prevention of surgical site infection. Cochrane Database
74
https://t.me/medicina_free
T. Pasquale and M. Maruccia
Syst Rev. 2017;10(10):CD012234. https://doi.
org/10.1002/14651858.CD012234.pub2.
20. Onesti MG, Carella S, Maruccia M, Marchese C,
Fino P, Scuderi N. A successful combined treatment with dermal substitutes and products of
regenerative medicine in a patient affected by extravasation injury from hypertonic solution. In Vivo.
2012;26(1):139–42.
21. Morisaki A. A combination of hydrodebridement with pulsed lavage and negative pressure
wound therapies may enhance outcomes. J Card
Surg. 2022;37(9):2745–6. https://doi.org/10.1111/
jocs.16700.
22. Dijoux C, Ribal E, Téot L.Use of a moderate- pressure
irrigation system to effect debridement in the home
setting. J Wound Care. 2008;17(3):134–6., 138.
https://doi.org/10.12968/jowc.2008.17.3.28672.
23. Bath MF, Suresh R, Davies J, Machesney MR.Does
pulsed lavage reduce the risk of surgical site infection? A systematic review and meta-analysis. J Hosp
Infect. 2021;118:32–9. https://doi.org/10.1016/j.
jhin.2021.08.021.
24. Vowden KR, Vowden P.Wound debridement, Part 2:
Sharp techniques. J Wound Care. 1999;8(6):291–4.
https://doi.org/10.12968/jowc.1999.8.6.25888.
25. Bluestein D, Javaheri A.Pressure ulcers: prevention,
evaluation, and management. Am Fam Physician.
2008;78(10):1186–94.
26. Téot L. Surgical debridement of wounds. Soins.
2011;752:36–7.
27. Prodromidis AD, Charalambous CP. The 6-hour rule
for surgical debridement of open tibial fractures: a systematic review and meta-analysis of infection and nonunion rates. J Orthop Trauma. 2016;30(7):397–402.
https://doi.org/10.1097/BOT.0000000000000573.
28. Saggini R, Saggini A, Spagnoli AM, et al.
Extracorporeal shock wave therapy: an emerging
treatment modality for retracting scars of the hands.
Ultrasound Med Biol. 2016;42(1):185–95. https://doi.
org/10.1016/j.ultrasmedbio.2015.07.028.
Advanced Moist Wound Dressing:
https://t.me/medicina_free
Classication by Function
AlessandroGreco, MastronicolaDiego,
NatasciaMennini, andMagnoniCristina
8
The panorama of dressings for skin ulcers represents a continuum of products ranging from traditional gauze to bioengineered tissues. This
therapeutic baggage is enriched day after day
with new aids that often nd it difcult to be categorized according to the traditional product
classication used so far. In fact, there are dressings consisting of combinations of several individual components, each of which is characterized
by its own distinctive quality, but which combined together can acquire a completely different
one. Moreover, dressings belonging to different
product categories can actually perform the same
function once in contact with the wound bed.
Many new products are incorrectly inserted into
pre-existing categories dedicated to other products, due to the fact that they contain a particular
ingredient (as in the case of hydrocolloids), leaving numerous questions open on appropriateness
of use.
Currently, the effectiveness of appropriate
wound dressings on tissue repair process is
A. Greco (*) · M. Diego
Outpatient Wound Care Centre, Local Health Care
System, Frosinone, Italy
N. Mennini
Department of Chemistry, University of Florence,
Florence, Italy
e-mail: natascia.mennini@uni.it
M. Cristina
Unit of Dermatologic Surgery, University of Modena
and Reggio Emilia, Modena, Italy
widely accepted. It is well established that no
wound will heal if the factors that inhibit tissue
repair in each stage are not addressed properly.
The optimal choice of an advanced dressing is
based on two fundamental aspects: a precise
understanding of the mechanisms that underlie
the phases of the wound healing and a deep
knowledge of the properties of the different
dressing present on the market today.
To do this, clinicians need to be familiar with
the physical and chemical properties of dressing
components, the differences between products,
and their mechanism of action and synergy with
dressing’s scaffold. Since 1960, a multitude of
products have been designed to ideally create a
perfect wound environment. In 1991, Bolton [1]
rst introduced the important role played by
wound dressings in meeting clinical and biological needs, in order to achieve optimal results in
wound management. A precise wound assessment and an appropriate selection of wound care
products are of utmost importance.
Given the development of new advanced
dressings and systems, in 2006 Van Rijswik [2]
provided a review of wound dressings according
to their function instead of their material composition. In 2011, Cutting [3] urged for a revision of
wound dressing classication following clinical
objectives, again, based on a dressing’s function.
In 2014, T. Phillips [4] stressed the signicance of wound characteristics as a guide in
selecting the proper dressing, in order to achieve
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
M. Maruccia et al. (eds.), Pearls and Pitfalls in Skin Ulcer Management,
https://doi.org/10.1007/978-3-031-45453-0_8
75
76
https://t.me/medicina_free
A. Greco et al.
a faster wound healing. She suggested that wound
dressing selection should be guided by product
characteristics according to wound assessment:
supercial wound, wound with eschar, and exudating wounds.
To date, the literature classies dressing
based on their mechanisms of action or on the
concept of TIME.However, these classications
are only partially applicable, due to the increasing number of dressings, which are highly innovative but do not always t into existing
categories [5–8].
Clearly, there is a need to classify dressings
based on their function, but no attempts have
been successfully done till now in implementing
this new classication. This article would like to
present a classication of wound dressings based
on their function.
8.1 Classication by Function
“Status-Based”
Wound healing is an extremely complex process
involving several biological and molecular activities. The main physiological events in the
achievement of tissue restoration include coagulation, inammation, cellular proliferation and
migration, re-epithelialization, and remodeling.
Wound bed preparation is based on a precise
sequence of tissue repair processes that include
tissue homeostasis, infection control, exudate
balance, and progress to epithelialization of
wound margins [9].
It is important for the healthcare professional
to recognize the predominant clinical obstruction/sign, to identify the clinical condition of the
wound at that time.
The predominant (prevalent) sign
• It is dened as the most evident sign upon
clinical assessment of the wound and the sur-
rounding skin.
• The clinical sign (signs) determines the choice
of the most appropriate dressing at that spe-
cic moment.
It is possible to identify the main categories of
dressing by their functions and divide them
according to their main mode of action, by carefully examining the sequences of the tissue repair
process (status).
This paper aimed to offer the HCP a guide to
each type of dressing’s primary function and,
therefore, its main therapeutic indication.
Many technologically advanced dressings
have secondary, ancillary, or independent functions, in addition to the main function. The role of
these accessory functions can be decisive in specic clinical conditions.
The division by function consists of four main
categories: [10] (Fig.8.1)
Fig. 8.1 Four main categories of dressings classied according to function
8 Advanced Moist Wound Dressing: Classication by Function
https://t.me/medicina_free
Fig. 8.2 Category and subcategories of dressings that promote autolysis and debridement
77
1. Dressings that promote autolysis and
debridement.
2. Dressings that promote granulation tissue.
3. Antimicrobial dressings.
4. Dressings that promote epithelialization and
protect the surrounding skin.
8.1.1 Dressings that Promote
Autolysis andDebridement
The presence of slough, black necrotic tissue, or
devitalized tissue, in general, represents an obstacle to the healing process, in addition to being a
soil for bacteria [11, 12].
Some of the dressings can remove the necrotic
tissue by autolysis debriding. Analysis of these
dressings allows for their classication into two
groups, which represent their different mode of
action: physical-chemical and biochemical
(Fig.8.2).
The rst group consists of all the products of
which the primary function is to enhance the
body’s own phagocytosis process, so as to
remove, reduce, or soften the devitalized tissue
through the help of moistening, watering, or by
osmotic action. They range from propyleneglycol/glycerin or water-based polymers (amorphous or sheet hydrogels) to occlusive pasts or
sheets that are impermeable to uids or honey
dressing.
Autolytic debridement, one of the most commonly used methods, is based on the ability of
some dressings to stimulate the degradation
capacity of brin by endogenous enzymes activated in a moist environment [13].
The dressings capable of ensuring this primary function are uid and support hydrogels,
hydrocolloid paste and plaque, saturated polyacrylates, dextranomer, saline gauze, and hypertonic hydrogels.
Hydrogels are cross-linked polymers consisting mainly of water and available in the form of
plaques, amorphous gel, or impregnated gauze.
Thanks to their high water content, they are ideal
on dry lesions on which they perform their main
function, which is to hyperhydrate necrotic tissues and favorite endogenous lysis. An accessory
function commonly performed by hydrogels is to
soothe particularly painful ulcers [14, 15].
All products that have a similar functional
ability but are composed of enzymes and have
an enzymatic mode of action (collagenase, catalase, papain, non-specic proteases, bromelainbased, etc.) belong to the second group. They
act by penetrating and digesting non-viable tissue and brin without damaging healthy viable
tissue [16].
Соседние файлы в папке Библиотека им академика М.И. Перельмана