Email - October 15, 2004

Wound Care Information Network

October 15, 2004

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Previous email questions & their replies are listed below. Remember, replies have not been validated for accuracy or truthfulness.

Dear Dr. Freedline, I am 4 weeks post-op from having a Myomectomy. On my second day post-op, my incision ruptured open from a hematoma. I was diagnosed with a wound dihenses. My wound is still a dime size opening. My question is what is the swollen, hardness immediately above my wound and will it ever go away? Is it scar tissue or just surgical inflammation? Thank you from an unhappy patient in Ohio...	sorry, no replies
Hello, thank you for your information to me, Now i hope you may help me giving any information about banana's potential to cure wound and burns. That is why because, i live in Malaysia and many villagers in my area uses banana to cure wound. I hope you may deliver to me many specific information about the actual potential of banana in curing wound. That's all from me. Thanks for all. mior_malaysia	Mior I've heard about papaya, but not banana. But, maybe banana makes a nice moist healing environment, maybe an alternative to a hydrogel? Though I'd be concerned that the sugar content would promote bacterial growth, at least the anaerobes since it might be somewhat occlusive. Then again, the sugar content might be high enough to promote drawing water out of the wound to soften eschar or to absorb exudate, and to inhibit bacterial growth. I got curious just now, and checked out PubMed. There is a little on banana leaves for burn and donor sites. It seems to be about the same effect, but cheaper, than potato peels, and a lot better than vaseline gauze. There's a good amount looking at the effect of banana on gastric mucosa and gastric ulcerations. I found another article (Rao NM. Protease inhibitors from ripened and unripened bananas. Biochem Int. 1991 May;24(1):13-22) that shows protease inhibition (including trypsin and papain) by the bananas, both ripe and unripe. It varies by species of banana. So, maybe it's good in a wound you're trying to granulate, to keep the enzymes from the wound from damaging healthy tissue? Perhaps it affects MMPs as well, maybe binding them? Renee C., MSPT, MPH, CWS
how much salt to water for normal saline concentration? unsigned	Hi: Saline solution can be made at home as follows: Boil 1 quart of water for 5 mins. Add 2 tsp Non- iodized salt Stir until resolved let cool before use! Source: Wound Care Essentials practice and Principles 2004. Lippincott, William, Wilkins. Pg 105. Best Regards, Jamie B. Pinnock, RN
Dear WCIN, I work in a 25 bed rural hospital in Missouri. I am a registered nurse with some wound care experience. I am writing the skin care algorithim for our institution. I have done some research on the internet and I am not sure how I want to set it up. I would like to use Lanaseptic cream on stage I and superficial stage II ulcers, but am unable to locate it on the internet community. Please write back with some beginning input and any info on Lanaseptic. Thank you, Donna M. Powers R. N.	Donna I personally prefer Proshield for Stage I and Stage II pressure ulcers. But as far as your algorithim, check with the company that makes it....they usually have one already that you can adapt to your institution. Diane, RN, BSN, WOCN --- Laniseptic is a fine product. The one caution is that it contains lanolin, which many people are sensitive to. Renee C., MSPT, MPH, CWS --- Hi: have you tries going on the Lantiseptic web site? www.lantiseptic.com Sometimes- Wound Care companies have protocols already done for their products that you can mirror in your algorithms or use conjunctively. Best Regards, Jamie B. Pinnock, RN ---- Donna, I have some algorrhythms that are a part of our wound care policy and procedures that include lanaseptic and Xenaderm. I would be more than happy to send you a copy for your review. Just send me your email address at jeaton@lanefrosthealth.com. Good luck...Jan, Wound care Coordinator
My sister has a very serious open abdominal wound that occurred through an open surgery to clean her abdominal cavity of sepsis. The wound is not healing very well due to a leak from a feeding tube in her stomach which lets gastric juices and bile out into her abdominal cavity and it is affecting the ability of the wound to heal. A skin graph using Alloderm was used and the bile deteriorated the product and her cavity is open again. I am looking for products or therapies that will assist in her recovery. She does have granulation tissue and occasional bleeds due to what the surgeons think is bleeding tissue. I have researched magnetic (pulsed and static) and ultrasound therapy and wondered if you can offer any other additional information that could help us out. Regards, Pia	Hi: I can only imagine how difficult this wound must be difficult to manage. Is changing the tube feeding location an option? I don't think the wound is going to heal with gastric material contaminating it. I would suggest the answer lies in fixing the underlying problem first. Consider positioning, what is going on in the GI system- is there a problem there?- too much gastric secretions? Please update us on the progresson. Best Regards, Jamie B. Pinnock, RN --- Your sister sounds as though she may be a good candidate for VAC treatment....Vacuum Assisted Closure by KCI. The VAC system has been used very successfully with abdominal wounds and even when fistulas are present. My advice is to seek a wound care center or specialist in your area. You can learn more about the VAC on the following website: www.woundvac.com Good luck! DR, PT, CWS ----- the aim would be to prevent the digestive juices from remaining in contact with the surface -- the granulating area and the intact skin i would suggest applying zinc oxide paste on the intact skin and applying an absorbent pad which holds the moisture away as with Whisper Sanitary napkins. kumkum (Plastic Surgeon) ----- This may work, try to find an e- stim unit that will offer HPVC or diathermy. I have had greater results with placing the neg. electrode into the wound. remember, no matter what type of modality you use, you must clean the wound as much as possible. Using sterile water Vs normal saline may be the best option. Normal saline may dry out the wound. Tim Biggs PTA
Dear Sirs, Our nurses are having a discussion on what truly defines a "non-healing surgical wound." We would greatly appreciate your input on this matter, and any reference information you can point us toward. Thank you for your assistance. Sincerely, Susan Winokur	Hi: The question is very vague- can you clarify. A healing surgical wound: Healing ridge felt adjacent to incision line 2 weeks post procedure-- usually the least amount of time staples- sutures can be taken out. If your question is home health related to medicare visit wocn.org they have a section in MOO questions. Best Regards, Jamie B. Pinnock, RN ---- Susan, A healing ridge is a deposit of collagen underneath the approximated edges of a surgical wound. This is a normal occurence indicative of normal progression of and uncomplicated healing. It may feel like a roll of flesh following the incision line and should be evident within 5-9 days, the absence of which signals impending dehiscence. It should normally begin to flatten out by the 4th week post-op. Hope this helps, Maria Carunungan, DPT, CWS
hello I have a lot of trouble with leg ulcers .there is a lot of pain and I cant get it to heal .the one I have now I have a unna boot on it I have had this ulcer for three months.it is on my foot beside my ankle.I am under dr care but he says there is nothing I can do but the unna boot.can you help me please?iwould appreciate any help thank you very much pam	Dear Pam, Unna boot is usually used for venous ulcers which combines mild compression and medication (Unna boot is medicated paste). It controls edema (collection of fluid) like compression hose because the Unna boot hardens (although not as hard as cast material). It usually is left on for 5-7 days but people do chnage this sooner depending on the amount of drainage. Where in the leg/foot is your ulcer? (Is it above the malleoli or the two bony prominences on either side of your ankle? or is it below this area? Is it in the inner side of the leg?) I recommend you look for a wound care specialist who can check your wounds. Venous ulcers will heal with compression and are the type that heals slowly or won't heal when they are misdiagnosed and not managed well. However, there might be other factors too, like you might have arterial insufficiency (wounds don't get enough blood supply coming from the heart) and not just arterial insufficiency...or you might have an infection, or have other factors which can delay healing. A wound specialist will check to see what "delaying factors" you might have. And treatment will be geared to correcting or resolving these factors by many different means. You can plug in"wound specialist directory" on your browser and you'll get a listing of wound specialists in your area. Good luck! Maria Carunungan, DPT, CWS ---- Hi Pam: What exactly is your problem with the una boot? Is it uncomfortable? There are other options available for compression, however compression is more than likely necessary for the wound to heal. Remember that venous ulcers result from having problems with blood returning back to the heart from the legs- so it is necessary to have compression. Discuss other possible options such as a 4 layer wrap or modified four layer. There are also other specialty bandages available such as Surepress and Setopress (I believe these are Convatec products), and Circaid to name a few. Best Regards, Jamie B. Pinnock, RN --- Pam, would suggest, if your doctor has not already done so, that you determine that your arterial status is sufficient in your leg/foot to accomodate an Unna boot thereby making sure that your ulcer is due to a venous insufficiency alone and not to a lack of blood flow to the area. If and when your arterial status is deemed sufficient, I would suggest that if your leg swells and has other indicators of venous insufficiency that you be very compliant with the golden standard of compression and elevation to keep the swelling under control and promote healing. Best wishes. Becky, PT --- Pam, I am a wound care nurse in long term care, I take care of several residents with similar problems. Thus far the most effective treatment I have found is the Unnaboot, however the Unnaboot alone is not always enough. Recently we have started applying a product called Xenaderm to the leg/legs prior to wrapping (still only changing the dressing every three days). Chronic wounds that were taking months to heal have been closing in an average of 2 weeks. Xenaderm is a prescription so you will have to go back to the doctor. Tina (L.V.N. / treatment nurse) --- Pam if there is a lot of pain it may be an arterial ulcer and not a venous ulcer and the unna boot is contraindicated for an arterial ulcer, find a good wound care center or have your doctor do some vascular tests to determine if you have a good arterial flow to the area. Bryan Luster, PTA Wound Care Specialist lusterbryan@hotmail.com --- Pam, For many people, a multi-layer compression wrap such as Profore or Dynaflex is more effective. Also, make sure the circulation into your leg is good. If you have diabetes, manage your blood sugar. Make sure you nutrition is good. Walk a lot, avoid sitting and standing still, and keep your legs elevated as much as possible. Renee C., MSPT, MPH, CWS
We are treating a scalp wound that became infected after a full thickness graft was placed. It is MRSA positive and we have been using accuzyme with ns wet to dry dsg 2x's/day. What is your opinion of aquacel ag & silverlon? Thank You for your help Peg	Peg, In reguards to your question on the scalp wound. I am an Rn, in albany, n.y. area. Have been in home care for 18-19yrs. Nursing for 25 yrs. An M.D., probabely much more qualified. But here goes. First the MRSA, needs to be treated with antibiotics, which I am sure your all ready doing. Some times you get lucky and the culture is treated with oral antibiotics, other times it requires 6-8 weeks of I.V. therapy. The normal saline wet to dry, is an older form of therapy, still used by many people. My care curently involves patient's in home care, on a long term program. Cost is a factor. We use silver dsgs, silversorb, actisorb, acticoat. But done 1-2x week, absorbs minimal to heavy exudate. actisorb silver been use 10 years. used with MRSA, used with anti- biotics, as a two-pronded approach. Check on line www.actisorbsilver.com. can use it wet or dry, easily folds to pack or fit wounds. Clean with N.S., apply dressing, cover with gause, tape ect. Can change outer dressing,if copious drainage. Good luck, allen. --- Hi Peg: If the wound has MRSA then it needs to be treated systemically. There are some people who become chronic MRSA carriers and this obviously presents a problem with closure. Aquacel Ag is silver impregnated Aquacel- a synthetic alginate. May not be a bad idea or an antibiotic ointment. But the underlying cause must be treated. Best Regards, Jamie B. Pinnock, RN --- Dear Peg: The scalp is a very unusual place to have a poorly healing wound. This leads me to ask, has the cause been diagnosed? A good decision on treatment would be much easier if we knew the cause of the wound. Has it been biopsied? The scalp is a fairly common site of squamous cell carcinoma, which would present as a non-healing ulcer. Bryan Gibby, MSPT, CWS --- Peg, I do not see why accuzyme is used unless you have necrotic tissue. Need to consult physician and inquire about placing patient on IV antibiotic like Gentamycin to check the MRSA as unchecked, this can delay healing. Silverbased products like you mentioned as good antimicrobial but most often MRSA will require strong antibiotics delivered via IV. Maria Carunungan, DPT CWS --- The silver impregnated dressings are very good for a wide spectrum of bugs but generally will not resolve MRSA, we usually try an oral sulfa like Septra and if it does not decrease the bacteria you will have to use IV Vancomyacin. Bryan Luster, PTA Wound Care Specialist lusterbryan@hotmail.com --- Peg, The silver dressings are very good with infected wounds. You may not want to use the absorbent type if there is not a significant amount of drainage because you want to keep the graft moist to a certain extent. Becky, PT --- Peg, I love Aquacel AG. I find it very helpful, and have been able to decrease the antibiotic use in some. Iodosorb is another great product. Renee C, MSPT, MPH, CWS
Hi, I am a Clinical Nurse Specialist working in wound care. Recently I had a patient who developed a biofilm over a granulating cavity wound on his foot. After either manual or autolytic debridement the biofilm would reoccur within 24 hours. Finally after persistent washing with Chlorhexidene sponges for about 10 days the biofilm resolved. Oddly enough the presence of the film didn't hinder the healing of the wound. Anyone had any experience with biofilms? There is very little research available. Thanks for your help. Karen	Hi Karen: There is research available- whilst non has cracked the nut the information is useful. There was a lot of talk about biofilm at the most recent Symposium on wound care in Orlando Florida organized by HMP communications . Is the concept of biofilm amazing or what? bacteria are quite intelligent and evolve so much faster;) There are some really great articles on www.worldwidewounds.com there is a specific article on biofilm. Type in biofilm in the sites search box. Best Regards, Jamie B. Pinnock, RN --- Look for the name Pat Mertz when you do a lit search. She's a main person in the field. The only way we know about now to reduce biofilms is physical removal--ie: debridment. The matrix the bacteria form prevent chemicals and antibiotics from getting in. They are looking at adjuncts to increase penetration. Renee C., MSPT, MPH, CWS
I have been doing some research for non-invasive treatments for arterial ulcers, and have found a treatment that uses a compression machine called the Circulator Boot TM. Are you aware of this machine, and if so, can you direct me to some "unbiased" evaluation of the treatment? Thanks. Rick	Rick, Please go to www.circulatorboot.com for information on its working. Physiologically, it should be a good modality to aid arterial circulation but you need to be careful about using this on patients with known cardiac dysrythmia. Maria Carunungan, DPT, CWS ----- No comment on the boot, but there have been several articles in the last couple years on the effectiveness of electrical stimulation in arterial wounds. Renee C., MSPT, MPH, CWS
I'm a NP following a 38 y/o obese female with severe lymphedema. No hx of diabetes. Too large to get out of the house for massage therapy, cannot do compression tx. due to size. Is developing open wounds on legs. Clean not infected. The wound center recommended a wound vac due to extensive amount of drainage. Wounds keep getting larger. Albumin now < 2. Is this the most appropriate tx? Seems as if it is making the wounds larger and depleting protein. Any suggestions, recommendations? SWilliams	What about manual lymphatic drainage? Find a local lymphedema therapist and see if they can help her. Renee C, MSPT, MPH, CWS --- Hi: Perhaps you can research Lymphedema therapist who are willing to do home visits- but then again if the patient is not able to maintain then it may not be valuable for more than wound healing. Vac may be a good opton. Best Regards, Jamie B. Pinnock, RN --- Dear Ms. SWilliams, You are right. You have to watch the use of the vac as it can deplete protein. Protein have to be monitored and if necessary patient has to be given supplements. Also is the wound the only source of protein loss, or perhaps the patient is also losing protein in his urine? This has to be determined, especially if patient has hypertension. The vac is not a must use for all draining wounds. If they are on the gaiter area of an obese patient (above the ankles), and the patient has edema, most likely they are venous wounds which will not heal or slow to heal unless you offload fluid through compression.. The type of wound needs to be determined by its appearance, location, and pt's medical history can give you predisposition to certain wounds too. Does she have venous stasis discoloration (or hemosiderin staining where the legs below the knees down to ankles are discolored purplish brown or brown. If these are venous wounds, compression will help via Unna boot (which includes medication), by hose, or by compression machine. But you can't just put anyone on compression as the patient might have some arterial insufficiency as well. There are tests for these. Please consult a physician about vascular studies for "both arterial and venous insufficiency" as this can determine if patient's legs are safe to compress. Also you want to check about cardiac status when doing compression. Hope this helps, Maria Carunungan, DPT, CWS --- S, Recently had the same kind of patient...We used Calcium alginate in the wound bed coverd by Meplix foam to contain drainage. Wound is now ready for closure. Calcium alginate we have found not only absorbs drainage but has stimulated the granulation process. This wound was originally 3 cm in depth. We have now converted to a hydrogel wafer for closure but are looking into a dressing called Scarlet red which has a excellent record for wound closure. We also have all our wound patients on supplements of Z-gen once a day, Vitamin C 250 Qid and Vitamin E 400u daily along with a high protein diet. We have found that this increases the albumin and nutritional level for healing and so far has been very successful for us. Good luck, Jan , Wound Care coordinator --- You will not have any luck until the Albumin situation is resolved. Any hope of getting a dietary consult and suggestions for supplements? Then, of course, there is always the compliance issue....... I think I would hold off on the VAC until the protein levels increase because you are wasting your time and the insurance company may not authorize the use of the VAC if and when the appropriate time arises (i.e., albumin, total protein are WNLs) Becky, PT --- extreme about 70 degree elevation strong wrap-around pressure bandage portable ozone therapy to the limb may also help frequent change of dressings use of absorbant pads on the oozing areas -- whisper sanitary napkins kumkum (plastic surgeon) --- Here is a corrected version of the letter I sent a few minutes ago: This can certainly be one of the more challenging situations in wound healing. You say she is too large for compression. I am guessing you mean with stockings, as it is almost impossible to effectively use stockings in the very bad cases. Some ideas that have worked for me in cases of extremely large legs: 1. Zimmer compression wraps (used by some ortho surgeons post-op, available from Zimmer) work much better on these large legs than any type of Ace, Comprilan, or the other types of wraps. The wraps will move around and cause binding unless you use copious amounts of Micropore plastic tape (on the bandages only, not on her skin). 2. A next step up in aggressiveness would be to use Elastoplast wraps on top of cast padding or Kerlix. Too aggressive for use in most patients, but very useful for the biggest and most difficult edematous legs. 3. For the biggest legs I ever saw, 120 cm girth at the thigh, the only solution we could find was one hour b.i.d. home use of a Jobst compression pump with custom sleeves. The custom sleeves cost about $500. Insurance paid for the pump, but I don't know how much it was. This worked well for this case, a worst-case scenario. The VAC can be very useful in some cases, but these people tend to be far more susceptible to maceration and spreading breakdown than most other patients with wounds. This can be a problem, as maceration is one of the few drawbacks to the VAC. If the problem is not too bad, zinc oxide ointment to the periwound skin will help greatly to reduce the maceration. However, as the drape will not stick to the zinc oxide, you then need to use a bigger drape than before. While I love the VAC and use it frequently, I am not sure that I would use it in a case like this because of their extraordinary sensitivity to maceration, besides the possibility of contributing to the hypoalbuminemia. Hope that helps! Bryan Gibby, MSPT, CWS

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