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I haven't seen actual studies but I have tried both and from 4 years experience... the Accuzyme works better... the generic is like using a little faster version of Santyl.
Tina (L.V.N./wound care nurse)

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I'm not sure if there is any documentation, but speaking from my own experience brand name accuzyme does work better then the generic. I had a patient that had a pressure ulcer on her ischium that was completely covered with slough/eschar. Generic ethazyme was ordered and did nothing until brand name was ordered. Within 2 weeks we had clean pink tissue and patient then began to heal.

Diane, RN, BSN, CWCN

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There are many schools of thought (and many reps pushing things) out there. I would suggest you do your own investigation. I have found case studies and smaller research studies that have used hydrogel for autolytic debridement that have worked better than the enzymatic debriders on the market by prescription. Also, another product has proved many times more effect in the harder, thicker eschars that any of the enzymatic debriders by prescription, and it is called hypergel. I personally rarely ever use enzymatic debriders unless the MDs are adamant. Then there are other nurses who swear by them. That is why I say, try and do your own investigation.

Deborah Harris, BSN, JD, RN, CWCS

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We tried the generic, didn't want to stick to the wound bed, we switched back to accuzyme and panafil in the spray bottles after Healthpoint demonstrated them and never looked back. Goes on easy sticks to wound, works better. Like it a lot with alldress as a top dressing if wound doesn't drain too much. Nick LPN WCC Wi Vets Home

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The type of dressing will depend on the following:
> stage of healing
> appearance of the wound (characteristics
such as color, odor, amount of drainage,
size)
> what type tissue are present (granulation,
eschar, slough?)

There are still a lot of people who use the old
"wet-to-dry" when other newer dressing types are
more appropriate. This isn't saying however that
wet-to-dry is outdated for wounds; it just depends
on what the wound needs.
Maria Carunungan, DPT, CWS

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Try mepiform by MoIlynke.

Deborah Harris, BSN, JD, RN, CWCS

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I would suggest backing off of the Santyl ointment. The hypergranulation could be a result of over active collagen production. If the wound bed is pink or beefy red tissue with no signs of infection, I would suggest a moist dressing covered with a dry dressing. ONLY the wound bed needs to be covered with the moist dressing & you can use a protective barrier ointment around the edges of the wound to prevent maceration. I have had really good results with a zinc-saline dressing such as Dermagran. They make a 2x2 impregnated gauze. This needs to be changed daily.
However, if the wound bed is not pink or red, then the whole treatment would need to change to another protocol.
Hope this helps!

Dianna Guidry RN, BSN, CRRN, WCC

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Not that my credentials are better then a doctors, but there are other options if hypergranulation is the only problem with the wound. You could have it treated with silver nitrate (burned) or have sharp debridment done. Both are fairly painful and could lead to other problems. However grafting is the fastest way to get from a wound with potential to get worse to no wound, all complications considered.
Tina (L.V.N./wound care nurse)

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First, why was collagenase used? This is often used
to debride the wound and can be discontinued once
red (granulation tissue) is predominant. The continued use of a debrider when no longer necessary can delay healing.

Also, look for other factors that can delay healing
such as peripheral circulation, presence of edema,
presence of infection, nutritional status, etc.

Some medications can also delay healing. Being arthritic, is she on steroids which by certain dosages can delay healing but effects can be countered by vitamin supplements.

Hypergranulation can be kept in check by different means such as using silver nitrate to remove the hypergranulation, or excision by a surgeon or other trained /experience specialists.Applying pressure on the hypergranulation can also control hypergranulation.

It is always better you consult with a specialist who can assess your wife's wound and look into other factors which can be causing the delay.

Good luck,
Maria Carunungan, DPT, CWS

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The delay in healing may be from the medications your wife is taking for her RA. Vitamin A does reverses the affects of steroids however can be toxic if to much is taken. Blood work does need to be done after about 10 days to check the vitamin levels. Keep in mind that reversing the affects of steroids will affect her healing and her pain. The hyper granulation is a result of either to much moisture in the wound or a bacterial presence. I am not familiar with the dressing that is currently being used or what is available in your location. I would look at the possibility of using one that contains growth factors. Michelle, PT, CWS

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Yikes!

sounds like you have lots of issues here! I think that before anything is done to make sure your wife has enough perfusion to heal the wound on her foot. Has she had a vascular work up done? Does she have palpable pulses or does she have edema?

If she doesn't have enough circulation she will never heal from any kind of surgery so that would be prioroty to check on.

Not sure why the MD is having you wrap the foot tightly. That doesn't sound quite right but since I'm not there to see and assess this is a difficult call. Usually with hypergranulation where the wound tissue is overgrowing above the level of the skin silver nitrate is used so not sure why santly would be prescribed.

Has she had a biopsy or wound culture done? I would get a 2nd opinion from a wound clinic or other MD

Hope this helps

Michele WCC in San Diego

gabian@cybermesa.com

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Go to google.com images - i find lots of useful things there

Deborah Harris, BSN, JD, RN, CWCS

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We should never limit debridement to certain wound types only as the appropriate criteria in determining the need for debridement is primarily "the presence of necrotic tissue" which if not removed can be a foci for infection and can lead to more serious complications including "sepsis" and even death by complications. For instance, if you have a diabetic wound on the sole of the foot which is callused will deepen the wound and without debridement can cause repeated trauma as the patient walks with this foot wound. Over the years, I have seen
firsthand the benefits of debridement to facilitate healing and the serious effects if debridement is delayed or not done at all.

There are diabetic wounds which have an arterial
insufficiency component and when wounds like these with dry eshcar are stable and below the level of the calcaneus, it is best left alone unless there are signs of infection.

The practitioners who might insist on limiting
debridement are perhaps not adequately educated
on the benefits of debridement and the risk of
non-debridement.

A good source of information which you can read
and later be comfortable sharing with these practitioners is any book on diabetic foot ulcers.

Maria Carunungan, DPT, CWS

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BEE Direct Service L.P.N.
Have you tried the normal saline compress debridment? Apply compress with just enough n/s to allow it to dry between changes and when removed it will debride. I have also seen where Elase ung mixed with antibiotic of choice( mixed )utilized. This was the only way the ulcer healed. Hope this is helpfull. Take care.

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Hi:

As far as I know the most recent and frequently used schools of thought call for sharp debridement of diabetic wounds, especially foot wounds that have callus formation. New cells can not migrate through dead dry skin. Callous and necrotic tissue send delay signals to the wound and significantly slows down/ halts the healing process. Callus also aide in breaking down tissue by acting as a point of pressure and friction. Abscess often form in and around diabetic wounds under callus. Callus like undermining in a wound, harbor bacteria. For an already compromised diabetic- this is a major source of infection. Your job is a difficult one, because the foot is as unique as a fingerprint and offloading is such a major issue with diabetics. I can understand why some my feel it best not to debride diabetic wound, I have heard numerous stories and have actually seen instances where patients loose their digits and require amputation after one debridement. But the cause of these misfortunes could probably be most attributed to poor practices, technique, and follow through. Some clinicians choose to treat the wound only and not the Pt. as a whole---and this easily steer down the wrong path. For example, making sure the limb is receiving adequate circulation is important before doing high level debridements. For specific articles on diabetic foot care-please contact me @ J.B.Pinnock@att.net.

Jamie RN, CWCN

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I can understand reluctance because diabetics in general have poor circulation. However, IF there is necrotic tissue, the wound bed cannot progress without debridement. If he/she does not want to surgically debride, there is autolytic, enzymatic, mechanical, bio-debridement [maggot],
conservative sharps debridement alternatives.

Deborah Harris, BSN, JD, RN, CWCS

If you become a wound care specialist, I think you would be covered; Unless there is some specific training the company who sells sterile maggots offers that would certify you.

Deborah Harris, BSN, JD, RN, CWCS

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In Texas an order from the doctor is sufficient because you are not cutting the wound, you are applying a chemical to the wound to get a desired out come, it's no different then applying Accuzyme.
Tina (L.V.N./wound care nurse)

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This is "selective debridement" and any form of
debridement should have a policy and procedure
for quality and infection control/liability issues.

Maria Carunungan, DPT, CWS

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As an RN, you would need to have further education in wound care (certification) & a competency skills check-off for your file (maybe signed off by the physician) before the practicing RN could complete this task. Otherwise I would suggest you have the physician take responsibility to complete the task.

Dianna Guidry RN, BSN, CRRN, WCC

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Hi Susan

This is a good question. I have heard it discussed before with no definitive answer. I know that using silver nitrate on a wound is considered chemical cautery in most cases. I suggest consulting your Nurse Practice Act, but regardless an M.D. order is necessary. It may be the same principle as conservative sharp debridement-some States allow this with special training, education, and certification with an M.D. order of course. I am also looking for responses to your question to better educate myself.

Jamie Pinnock R.N. CWCN

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It depends on what your licensure allows in the state you practice. As my license and certification dictates, I am permitted in the states I have
practiced; as they have all stated basically that one is permitted to practice the level of care you are trained in and have been duly certified/licensed. If your state says something similar, you would be able to do the MD order if you have been trained in that area.

Deborah Harris, BSN, JD, RN, CWCS
 

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Donna,
Being familiar with RA, there are many things
that can delay healing such as:
> stress which comes with the pain of RA
(Do you have adequate pain management?)
> medications which can suppress healing
such as steroids and other meds, even
Remicade
(There are vitamin supplements which
can be taken to counter the effects
such as vit C and vit A. This need to be
closely monitored and dose discussed
with your physician, esp. the use of vit A).
> your nutrition
> presence of other problems
(Have you been checked for other
conditions? Where is your wound located?
While the conditions that come with RA can delay
healing, you may have more important factors
influencing the wound to a greater degree, like
if you happen to have a venous stasis ulcer
which usually takes longer to heal; or if you
have a lot of edema).
It is best you consult a wound care specialist who
will look at your wound, your medical history
and check for other factors which can be causing
healing delays.
Good luck,
Maria Carunungan, DPT, CWS

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Hi Donna:

I am sorry to hear about your long suffering with your wound. I have taken care of patients like yourself in the past, and truthfully these wound are difficult, but not impossible to heal. Remicade is specific to RA and can’t be applied topically to wounds. RA can be such a debilitating disease and it affects the skin structurally as it does the bones. Caring for your wounds should be a collaborative effort between your current M.D., your Rheumatologist, and your Wound Specialist. I don’t know of research in this area- but I truly wish there was more information available on this specific topic. Engineered tissue grafts may be an option to try. Ask your Wound Care Specialist about this option. An example is a product called OASIS. Please contact me for more specific information.

Jamie Pinnock, R.N. CWCN
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That is a hard one to answer without more information. Since I imagine you
are on immunosuppressive drugs, those may be delaying your healing. I have
never had an ulcer I could not heal if treating the underlying problem i.e.
circulation or diabetes and then using good wound therapy. If remicade is
used to treat your RA, and if the side effects benefit the wound, go for it.

Deborah Harris, BSN, JD, RN, CWCS
Louisville, KY

nursingsupervisor@quarryville.com

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You can contact reps for wound care supplies
who will usually have ready protocols for your
staff's reference and some will actually let you
use these protocols (except if you adopt as your facility's). Some have wound care algorithms which are great to follow.
Good luck,
Maria Dulce Carunungan, DPT, CWS

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Hi

One of the best sources one can utilize for protocol development is a wound product company. Most companies like- 3M Healthcare-offer algorithms for different types of wounds and the best part is that they have specific products that are recommended for each type of wound. Protocols as far as institutional policy for the treatment of wounds is a bit different matter, but should involve consulting a wound care specialist who is familiar with incorporating approved guidelines into policy. Try contacting product reps and ask them about help with protocol development.

Jamie Pinnock, RN CWCN

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These protocols are things that are fairly generic, but should be generated by someone who is certified as a wound care specialist. If you do not have one on staff, I would hire someone for the job. It is fairly routine for the expert. Then I would have your medical director look over them and approve
them for general use.

Deborah Harris, BSN, JD, RN, CWCS