It sounds like you have too many treatments. Fibracol is used directly on the healthy wound bed, and left in place when still dry upon dressing change. Hydrogel is also used on healthy wound beds that need more moisture. Fibracol is used for less exudating wounds. How deep is the wound?

Linda, PT

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You have a lot of products with contradictory effects. A hydrogel adds moisture, fibracol absorbs while releasing collage, a foam is absorptive, and a DSD covers and absorbs. You shouldn't need a DSD with a foam. And, the hydrogel and foam are antagonistic to each other. Decide what is the most important thing to achieve-add moisture or absorb moisture, and pick the best product to achieve that goal. If you choose fibrocol, placing it on the whole wound bed is fine. It works as a matrix to form new tissue easier, and it provides extra collagen for the proteolytic enzymes to attack in the hopes of sparing the endogenous collagen.

Renee Cordrey, PT, PhD(c), MSPT, MPH, CWS
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I have never heard of applying a hydrogel followed by Fibracol. Fibracol "melts" when in contact with wound drainage and thus provides the moist wound environment that's needed. Hydrogel would not be necessary in this case.
Amy Pastor RN, DON CWS

Hi Lenora -

I would consider using an ostomy bag and treating the wound like a colostomy. Don't know of anything else that would accomplish both your goals.

Yvonne Asay LPN

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You could try pouching the fistula with a colostomy bag just to catch the drainage. You should then be able to avoid having to use any kind of gauze dressing, and nothing would directly touch the wound bed. You could still use petroleum to soothe if needed; there are also products available to seal around the edges of the colostomy wafer if seepage is a problem. Kathy, RN CHPN

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I had a pt who had a similar problem and she got some relief by using a colostomy bag over the opening instead of gauze.The bag prevented the leakage from getting on her clothes which was a big confidence boost along with being more comfortable than the gauze and changing dressings all the time,less irritation from tape etc.
T.Daugherty LPN

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Put an ostomy appliance on it

Pat Devine RN CWOCN

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Have you tried pouching the fistula? They can be easily managed and ulcerations to the skin can be prevented when you do it thus improving QOL. Meantime, try to consult an ET nurse nearby.There are lots of skin barriers that you can use to address the problem.
Thanks

Dale, WOCN

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Lenora,

Have you ever thought about "pouching" the fistula with ostomy products? May be tough to get a seal given the location but with some of the ostomy products on the market you might be able to get a seal and put a bag on it to collect drainage and keep it off her skin without the painful skin burning of gauze. I've had some success with this and some home health patients.

Rachael RN, BSN

PS a belt and some glue may be in order to help hold it in place

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After reading your issue, it is clear to me that the wound care should be focused on comfort rather that healing. I would recommend a product called "Hydrofera Blue". It comes in sheets 6 x 6 and can be cut to fit the area involved. You can activate it with sterile water or saline and secure it in place with a clear transparent dressing (Tegaderm). It can be left in place for up to 3-4 days and will relieve pain and absorb drainage. A regular foam dressing will do all of this but they do not have the pain relieving advanages. I hope this is helpful. Kathy Jean Flynn RN, WCC; Cape Coral, FL
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Perhaps a pouch--like what is use for an ostomy would work. This would allow you to drain it, but not have to change it more than every few days or so. There are some pouches that are designed for fistulas. Your local wound clinic or WOCN should be able to help you with managing this and acquiring pouches if that's what you decide on.
Beth
RN, BSN, WOCN

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I recommend that you talk with an ostomy nurse. She could develop a plan that might help your mother. Look at www.wocn.org to find someone in your area.

Renee Cordrey, PT, PhD(c), MSPT, MPH, CWS

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I would like to suggest packing the area with normal saline soaked packing. Also, check to see if a supportive mesh was used inside. I am not sure about the procedure used on the patient you are referring to; but in past I had a client that was allergic to the product (mesh) used and it had to be removed. Also, be sure gauze was not left inside. Would non-adhesive allevyn pad help keep the pressure off and absorb the fluid/moisture? Just suggestions. BEE Direct Service L.P.N.
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In my opinion, you have 2 options;

#1- Foam dressings (not gauze) are much more absorbant and comfortable, it also "wicks" away drainage so it prevents that burning of the skin and other skin problems.
Examples of foam dressings are Optifoam (Medline) Allevyn (Smith & Nephew)
#2- She can be fitted for and wear an ostomy bag that collects this drainage. The bag is emtied daily but stays adhered to the skin by a sticky "wafer". The wafer is only changed once a week.

Hope this helps...
Amy Pastor RN, DON, CWS

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Get her to a qualified wound care center. Preferably one in your area run by Diversified Clinical Services. The wound care physicians there can help her. There are all kinds of treatments better than "Gauze and lets watch it" Please seek out qualified wound care treatment Include Hyperbaric Oxygen Therapy and your mother will heal. Feel free to contact me if you need further help.

Robert W. Wilson, CHT
Integration and Operations Mgr.
Diversified Clinical Services
P-VM (318) 218-8231
 

Interesting questions. I would not use the hydrogel. Hydrogels are used to heal wounds that need moisture added - such as chronic wounds that are dry or have some slough or necrotic tissue that can be readily autolytically debrided. The scarring you are talking about could be a condition called hemisiderin (not sure of spelling) which is an actually staining of the tissue from accumulation of iron cells. However, you could use a cream or ointment that has vitamins as long as there is no alcohol (most lotions have alcohol base). It might help and it would prevent future injury as cellulitis is usually caused by a break in dry skin allowing a bacteria to enter. Hope this helps.

Debbie Harris, BSN, JD, RN, CWCN in Louisville, KY

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Accuzyme is an enzymatic debriding agent, and should be applied daily to wounds presenting with predominantly nonviable tissue. The wound vac is supposed to be used when most or all nonviable/necrotic tissue has been removed. If the wound requires debriding, that should be done first, then discontinue and go with the vac.

Sara, PT, WCC

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This would be a great questions for your healthpoint rep. Also, always read the Manufacturers insert, the product must be used as recommended by the manufacturer. I use accuzyme for wounds that have eschar or slough in the wound bed, but I have never used it prior to applying a wound Vac.
Yolanda, RN, WCC

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I have seen accuzyme used this way. Although the accuzyme is applied less frequently, there still seems to be benefit using it.
does the wound need some sharp debriding to?
Beth
RN, WOCN

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I am a wound care nurse in a nursing facility and have used accuzyme with my vacs and it works great
rr

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From the Accuzyme PI: “Daily or twice daily applications are preferred”.

L. Beck RN, BSN, CWS, FCCWS

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Accuzyme on slough prior to using the VAC is ok. It is in the guidelines for the VAC. The VAC will suck up the necrotic tissue that the Accuzyme loosens. Have used it for years on wounds. I found that after a few dressing changes the Accuzyme will not be needed. Only beefy red granulation tissue will be present then you can d/c the Accuzyme

Catherine RN,BSN,CWOCN
 

You mention the panifil dressing being changed once per week, but the manufacturer does not recommend every week changes. If I am correct, it should be changed every 2-3 days. The manufacturer is HEALTHPOINT. Sign onto healthpoint's web site and search for panifil, or contact a healthpoint rep. to ensure the product is be used correctly.
Yolanda, RN, WCC

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This is complicated situation and is best assessed in person. You can find a specialist near you at www.aawm.org and www.wocn.org.

Renee Cordrey, PT, PhD(c), MSPT, MPH, CWS

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Is there a way that a vascular surgeon can help? Is ortho going to replace the appliance? I would use mepitel and an island dressing. The mepitel can be left if the wound bed even when changing the outer dressing. I can also be removed and rinsed under the tap if necessary. It is made by a dutch company called Molnlycke (there are two dots over the o). It is made of silicone and helps heal as well as keep the wound from drying out. Debbie Harris, BSN, JD, RN, CWCN from Louisville, KY

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Trying asking them to try a wound vac. That should help the wound heal.
S.W.

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You don't say where the wound is and if the infection included osteomyelitis? I would suggest once those have been addressed, to use the following whether or not the surgeon goes back in: use a silver product on the wound base and negative pressure. As I am also a rep of BlueSky Verstatile 1 negative pressure as well as a wound care specialist, I want you to know that up front. I know it works, so it would be worth a try. Look at our webpage for more info - www.medastat.com Hope this helps, Debbie Harris, BSN, JD, RN, CWCN from Louisville, KY

Try the Skin Barrier cream from Coloplast, if not, try ostomy powder from Convatec, Hollister, Coloplast etc, They worked well for my patients.

Dale, WOCN
Manila,Philippines

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Topical vit A may be helpful.
Are the cracks draining alot?
A foam might be more comfortable and less expensive--like hydrasorb.
Calmoseptine is a decent barrier.
Beth
RN, WOCN

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There are two options - silvasorb ointment by Medline that lasts for 3 days or silverlon charcoal cloth that is used for a week and must be moistened every day with H20, but works well as it has the most silver ions. Since it is probably more expensive, but works longer, and has more ions, you need to make the decision. Debbie Harris, BSN, JD, RN, CWCN

Both techniques are acceptable. There have been no studies to my knowledge to compare the two. There was one case study I just read the abstract of (in the APTA Electrophysiology Section newsletter) where they treated two heel wounds of the same patient, one with each protocol. The indirect method did better. But, it was a single case, and more research needs to be done.

Renee Cordrey, PT, PhD(c), MSPT, MPH, CWS

You may possibly be dealing with an anal fistula or cancer lesion. Has the patient followed-up with the surgeon who performed the colostomy? Sound like he needs further evaluation. Have you applied a collection pouch to determine how much drainage your patient is producing daily? Just some suggestions.
Yolanda, RN, WCC

Angela,

There are a huge number of options available. Whenever someone asks me how to treat a stage IV, my response is: how deep is it, how much is it draining, is it infected, how much necrotic tissue vs granulation tissue, where is it, how long has it been there, and are there tracts or undermining? Those characteristics contribute to the treatment options much more than the stage alone. Another site you may want to check out is www.AdvancingThePractice.org.



Renee Cordrey, PT, PhD(c), MSPT, MPH, CWS