Use of a superabsorbent dressing in wounds with moderate-to-high exudate volume

Use of a superabsorbent dressing in wounds with moderate-to-high exudate volume Jane Todhunter, Helen Greenhow, Anna McSkeane

To cite this article: Todhunter J, Greenhow H, McSkeane A (2024) Use of a superabsorbent dressing in wounds with moderate-to-high exudate volume. J Community Nurs 38(6)

WOUND CARE

Use of a superabsorbent dressing in wounds with moderate-to-high exudate volume Jane Todhunter, Helen Greenhow, Anna McSkeane The aim of this in-service evaluation was to assess the performance, safety, and usability of a superabsorbent polymer dressing in moderate to highly exuding wounds. An in-service evaluation was conducted for two weeks on 12 patients being treated for venous leg ulcers, postoperative wounds, diabetic foot ulcers and lymphoedema ulcers at an outpatient vascular clinic in England. Most of the patients (67%, n=8) required three or fewer dressing changes. The number of patients with maceration was reduced by 29% (n=2) from baseline (n=7), the mean pain score was reduced by 8% and no malodour was reported in 67% (n=8) of the patients by the end of two weeks. The dressing managed exudate well (50%) or very well (50%). The findings demonstrate the performance and safety of the dressing in managing exudate volume, wound odour and improving periwound skin condition without requiring a high frequency of dressing changes.

KEYWORDS:

 In-service evaluation  Superabsorbent dressings  Exudate  Maceration  Periwound skin  Frequency of dressing changes

T

he total number of patients with a wound in the UK in 2017/2018 was approximately 3.8 million. The annual National Health Service (NHS) cost for wound care was estimated to be £8.3 billion, 67% (£5.6 billion) of which was associated with management of almost 30% (1.1 million) of wounds that did not heal (Guest et al, 2020).

Minor wounds like abrasions, lacerations, burns and scalds are acute wounds that usually heal within a couple of weeks (Ousey et al, 2021).

Chronic or hard-to-heal wounds, such as diabetes-related foot ulcers (DFUs), venous leg ulcers (VLUs) and pressure ulcers (PUs) are challenging

Jane Todhunter, advanced vascular nurse practitioner; Helen Greenhow, vascular nurse specialist, both at North Cumbria Integrated Care NHS Foundation Trust; Anna McSkeane, research team leader, Clinical Research Department, Cumberland Infirmary, North Cumbria Integrated Care NHS Foundation Trust

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to treat and slow to heal as they fail to progress in the inflammatory stage of the healing process (Dissemond et al, 2022).

Both acute and chronic wounds may produce wound exudate, although the volume and rate of production varies between patients.

Wound exudate when present in the right quantity and right place has beneficial healing properties, including:  Maintaining a moist wound bed  Helping migration of skin cells  Providing essential nutrients to the wound  Encouraging autolysis (World Union of Wound Healing Societies [WUWHS], 2019).

However, excessive exudate can be detrimental to the wound and periwound skin thus delaying the healing process and causing a significant impact on patient quality of life (WUWHS, 2019). Poor

exudate management is associated with exudate leakage, wound odour, periwound skin damage, patient discomfort/pain and impaired healing rates (Barrett et al, 2018).

Superabsorbent dressings (SAP) are highly absorptive dressings intended for use on exuding wounds (WUWHS, 2019). They draw excess moisture away from the wound (O’Callaghan et al, 2020) and are able to prevent leakage and other exudaterelated complications (Hiskett, 2020).

The fluid absorption capacity of superabsorbent dressings is known to be very high (up to 100 times their own weight) (Eming et al, 2018). These dressings also have the potential to bind and sequester wound inhibitors, such as microorganisms, inside the dressing core, thereby protecting the tissue from further damage (Eming et al, 2008).

IN-SERVICE EVALUATION The dressing used in this in-service evaluation was a superabsorbent dressing, DryMax® Super, also known outside the UK as DryMax Soft and Absorbest Super (Absorbest AB).

The dressing is ultra-thin and highly conformable making it feasible for use on complex body extremities (Greenhow and Todhunter, 2024).

It consists of a white hydrophilic contact layer made of nonwoven polypropylene and a core made of superabsorbent polymers (sodium polyacrylate) between layers of viscose-polyester-material. Exudate is absorbed vertically by the hydrophilic contact layer of the dressing from which it is distributed evenly and retained in the core of superabsorbent polymers, thereby managing exudate volume in the wound bed to maintain a moist wound environment and

WOUND CARE

minimise the risk of leakage and periwound skin damage (Hindhede and Meuleneire, 2012).

The dressing has the ability to absorb and retain wound exudate under pressure. DryMax Super is available in several sizes and is designed to be applied with either side facing the wound. The aim of this in-service evaluation was to observe the performance of the dressing on moderate to highly exuding wounds under routine conditions of use.

Ethics

This in-service evaluation was conducted at North Cumbria Integrated Care NHS Foundation Trust after registering with the Trust’s audit department and obtaining the approval of the clinical research and development team. Since this was an in-service evaluation of a registered product within the instructions for use (IFU) and within routine clinical practice without any additional patient risk, review by an ethics committee was not required.

Methods and design

The in-service evaluation was conducted at the Trust’s outpatient vascular clinic by vascular nurse specialists between December 2022– March 2023. All the participants were outpatients. Patients were selected according to the indications and contraindications of the product’s IFU and clinician’s assessment of the appropriateness of a superabsorbent wound dressing for the patient and their wound. Routine wound care according to best practice guidelines of the Trust were carried out, which included the use of antimicrobial dressings and compression bandaging when appropriate.

Informed consent was obtained following the Trust’s procedures before initiating the in-service evaluation. The wounds were observed for a period of two weeks and assessments were performed at baseline (observation one) and at every dressing change.

Dressings were changed at the clinicians’ discretion depending on the wound condition. At every visit, patients were examined by the clinicians to assess possible adverse events. The final assessment of the

Table 1: Patient demographics Age

N=12

%

>80 71–80

3 1

25% 8.3%

Aetiology

N=12

%

Patient mobility score 1 2

N=12

%

Venous leg ulcer 8 66.7% 0 0% Postoperative 2 16.7% 1 8.3% wound 51–70 7 58.4% Diabetic foot ulcer 1 8.3% 3 7 58.4% 21–50 1 8.3% Lymphoedema 1 8.3% 4 4 33.3% ulcer * mobility score based on Braden scale: 1=completely immobile, 2=very limited, 3=slightly limited, 4=no limitations

wound was planned two weeks from the baseline visit.

The number of dressing changes of DryMax Super and the condition of the periwound skin at each dressing change were the primary endpoints.

The periwound skin was analysed on five parameters (macerated, erythematous, eczematous, friable, and healthy) at every visit during the evaluation period. Secondary endpoints were the clinicians’ assessment of:  Patient’s degree of comfort with the dressings measured on a visual analogue scale (VAS) scale of 1–5 (where 1=very uncomfortable, 5=very comfortable)  Level of wound pain measured on a VAS scale of 1–5 (where 1=no pain, 5=worst pain)  Level of malodour measured on five parameters (very strong, strong, moderate, slight, no odour)  Volume of wound exudate recorded both on the wound dressing and the wound after dressing removal on a scale of 1–5 (1=dry, 2=moist, 3=wet, 4=saturated and 5=leaking)  Assessment of overall ease of use of the dressings based on clinicians’ experience at dressing removal compared to other similar dressings used (much worse, worse, no change, better, much better), and their overall satisfaction with the superabsorbent dressings.

Results

In total, 12 patients were recruited to the in-service evaluation. Most patients (58.33%, n=7) were aged between 51–70, 25% (n=3) were aged above 80, and 8.3% (n=1) each were aged between 21–50 and 71–80. The participants of the inservice evaluation were reported to

have venous leg ulcers (66.7%, n=8), postoperative wounds (16.7%, n=2), diabetic foot ulcer (8.3%, n=1) and lymphoedema ulcer (8.3%, n=1) (Table 1).

Nine patients (75%) had an evaluation period of 14 days, one for 11 days and two patients for 18 days.

67% (n=8) of the patients required three (n=3) or fewer than three (n=5) dressing changes, while 16.7 % (n=2) required five dressing changes (Figure 1). One patient required a mean of three dressings at every dressing change owing to a larger wound size (see case report). The mean volume of exudate on the wound after dressing removal assessed on the five-point scale was 2.92 and 2.5, (i.e. ‘moist’ to ‘wet’), while wound exudate on the dressing was 2.7 and 2.5 at baseline and final assessment visit respectively. Strikethrough was a reason for dressing change only on one occasion, while routine planned visits were reported as the main reason for dressings being changed.

Healthy skin was reported in 50% (n=6) of the patients at the end of the evaluation period compared to 25% (n=3) at baseline. Maceration was reduced by 29% from baseline (58%, n=7) (see Figure 6 to note healing of periwound skin). The percentage of patients that still had maceration at the end of the study was 42% (n=5). At the end of the evaluation period, the number of patients with erythematous skin was the same as that at baseline (n=2; Figure 2). The percentage of patients with 100% granulating wound bed was 58% at the end of two weeks.

Patients reported a mean comfort score of 4.5 on a scale of 5 (5 being very comfortable) with the dressing at every visit (Figure 3). The mean pain scores at every visit ranged between JCN 2024, Vol 38, No 6

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face-to-face unstructured interviews to gather patient insights of their leg ulcer journey suggested that patients’ quality of life (social, physical and psychological) was adversely affected as a result of being affected by symptoms such as exudate, odour and pain which are typical to leg ulcers (Green et al, 2013).

14

12

Number of patients

12 10 8

5

6 4

3

2 0

1

2

3

2

2

4

5

Number of dressing changes Figure 1.

Dressing changes required by patients throughout the evaluation duration.

Surrounding skin condition at baseline

Surrounding skin condition at final visit 8%

17%

17%

25%

8%

50%

17% 58%

Healthy

Macerated

42%

Eczematous

Erythematous

Other

Figure 2.

Comparison of surrounding skin conditions between baseline and end of the evaluation.

More than one skin condition was reported per patient, hence each % reports the percentage of the total study population with that condition. The total of the segments sums up to more than 100%. Note: other=0% at baseline.

1–1.4 on a scale of 5 (1 being no pain).

The mean pain score at dressing change was reduced by 8% on the final visit from baseline (Figure 4).

At the end of the evaluation period, 67% of the patients had no malodour compared to 33% at baseline. The number of patients with slight, moderate, and strong odour was also reduced at the end of the evaluation period (Figure 5). On the final day, the clinicians reported that dressing changes with the subject dressing were better (67%), much better (25%), and as good as (no change 8%) similar dressings.

Overall assessment and satisfaction with the superabsorbent dressings was recorded as very good (75%) and good (25%). The dressing was JCN 2024, Vol 38, No 6

found to have managed the exudate well (50%) or very well (50%) at the end of the evaluation period and no adverse events were reported. The clinicians reported that the dressing was conformable with absorbency and a thin profile in their descriptive comments on the dressings.

DISCUSSION Inadequate exudate management can present a major challenge to patients and clinicians (Lindsay et al, 2017), as it is associated with exudate leakage requiring frequent dressing changes, wound odour, periwound skin damage, patient discomfort, pain, tissue destruction and delayed wound healing (Stephen-Haynes et al, 2018).

A study designed in the form of

DryMax Super is designed to address these threats. The hydrophilic contact layer absorbs the exudate and transports it vertically by capillary action to the solid core which forms a gel so that it does not move to the edges of the dressing.

The surfaces of the dressing which may be touching the periwound skin remain dry and so do not become a source of moisture causing maceration. The dressing has been shown to retain 83% of wound exudate when subjected to 40mmHg pressure during a retention test performed independently in the laboratory (Surgical Material Testing Laboratory [SMTL], 2020). The retention capacity of the dressing is comparable to other commercially available superabsorbent dressings tested under similar conditions (Singh et al, 2022), thus making it a suitable dressing for managing hard-to-heal ulcers, such as VLUs which are treated with compression bandages or compression hosiery. The absorptive capacity of the solid core and its retention of fluid are sufficient to permit intervals of three to four days between dressing changes of moderately exuding wounds, while maintaining a moist wound environment conducive to healing.

The ultra-thin profile of the dressing contributes to its conformability to the body and thus to patient comfort.

The results from this in-service evaluation indicate that the dressing under discussion meets the requirements of superabsorbent dressings in terms of its absorption and retention capacity. In a study on SAP dressings by Barrett et al (2018), the clinicians rated the SAP dressing’s fluid management capabilities as ‘very good’ (83%) or ‘good’ (13%) in managing different levels and types of exudate. Another SAP dressing in a study by Cutting was reported to have managed to

WOUND CARE

CASE REPORT OF A PATIENT WITH A COMPLEX WOUND A patient aged between 51–70 years with a history of venous leg ulcers for a period of three to six months with diabetes and venous insufficiency was included in the in-service evaluation. The patient’s leg was infected with Pseudomonas aeruginosa for which an antibiotic course had been completed four days before the baseline visit. The patient’s wound was managed with an antimicrobial dressing, superabsorbent dressing, gauze and compression bandaging before the start of the evaluation period with DryMax Super.

At baseline visit (visit one), the patient’s leg was reported to be wet with macerated toes. The wound size at baseline was 21cm2, which remained the same throughout the evaluation period. The patient required five dressing changes during the evaluation period with a mean of three dressings used to cover the wound at each dressing change. The volume of exudate on the dressing was between 3–5 (wet, saturated, and leaking) in the initial three visits (six days), which reduced to 2 (moist) in the last two visits. The periwound skin was macerated (50%) at baseline, however, no maceration was reported at the final visit (day 14) and the wound bed had 60% granulation tissue. During the evaluation, the dressing under discussion was used in conjunction with an antimicrobial dressing, compression bandaging, gauze, an analgesic and a skin protectant.

Clinicians reported that the dressing was conformable with a slim profile, folded well around toes, and was easy to bandage over. Its slim profile made it easier for the patient to put their shoes on. Overall, the dressing was assessed as effective in reducing exudate volume and improving periwound skin condition (Figures 6 and 7).

Figure 6.

One of the patient’s wounds at baseline (left) and final visit (right). Note healing of periwound skin.

Figure 7.

The patient’s wounds at baseline (left), after one week (centre), and at the end of the evaluation period (right), which required a mean of three dressings per visit.

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reduce exudate volume to moderate (n=9), light (n=6) or no exudate (n=5) in 22 (52%) of the 42 patients with highly exuding wounds at baseline (Cutting, 2009).

5.00

Comfort levels

4.50 4.00 3.50 3.00 2.50 2.00 1.50 1.00

Visit 2

Visit 3

Visit 4

Visit 5

Visit 6

Final evaluation

Visits Figure 3.

Mean comfort level of patients with DryMax Super, where 1=very uncomfortable and 5=very comfortable.

5.50 5.00 4.50

Pain scores

4.00 3.50 3.00 2.50 2.00 1.50

1.42

1.08

1.17

1.00 0.50

1

2

3

1.00

1.00

4

5

Visits Figure 4.

Mean pain scores on application of DryMax dressing, where 1=no pain and 5=worst pain.

Wound odour at baseline

Wound odour at final visit

8% 25%

17%

67%

17% 25%

No odour

Slight

Moderate

Strong

Very strong

Figure 5.

Level of malodour at baseline and end of the evaluation. Note: very strong=0% at baseline and final visit.

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These findings are consistent with a previous in-service evaluation with DryMax® which reported that its use was associated with marked improvement in both the wound bed and periwound skin with no reports of malodour. By the end of four weeks of the evaluation period, there was a significant reduction in the number of dressing changes required (Allymamod, 2011).

Improved comfort levels for patients were reported throughout the evaluation period.

LIMITATIONS

8%

33%

These findings are in line with this SAP dressing’s ability to effectively manage exudate volume, as recorded in the present evaluation and also a previous study on exuding wounds (Hindhede and Meuleneire, 2012).

Exudate volume on the wound and the dressing after removal were reduced at the end of the evaluation period. Only four (33%) patients required four or more dressing changes. No odour was reported in 67% of the patients’ wounds at the end of the evaluation period. The dressing also protected the wound borders and reduced the risk of maceration, erythema, eczema, and friability. At the end of the evaluation period, 50% of the patients were reported to have healthy periwound skin, with a mean reduction in wound size of 31%. The number of patients with healthy periwound skin doubled from baseline.

The in-service evaluation’s limitation is its observational design. As data collection was carried out during normal clinical practice there was only limited time for patient assessment. Evaluations of the periwound skin were subjective and not confirmed through assessments conducted by independent reviewers.

CONCLUSION This in-service evaluation demonstrates the suitability of

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Box 1

CPD reflexive questions

 What is your choice of dressing in managing moderate to highly exuding wounds in clinical practice?  Why do you think there is a correlation between periwound skin damage and delayed wound healing rate?  What clinical properties of superabsorbent dressings are responsible for favourable outcomes in wounds with excessive exudate?

DryMax Super dressings for its indicated use in a real-life situation.

The dressing was able to support the clinicians in treating moderate to highly exuding wounds of different aetiologies. The dressing application was associated with effective exudate management, reduced risk of periwound skin damage, and patient comfort. The dressing properties helped improve the periwound skin condition, as demonstrated by the increase in percentage of patients with healthy periwound skin at the end of the evaluation. The dressing was rated as having a better or much better ease of use compared to dressings previously used by the clinicians and they confirmed that they would continue to use it.

Controlled studies comparing superabsorbent dressing use in matched cohorts and investigating in more detail the relationship between patient comfort, frequency of dressing changes and dressing design are warranted. JCN

Declaration

The authors have no conflicts of interest to declare.

REFERENCES Allymamod A (2011) Evaluation of a 16-patient study using DryMax® Extra in four leg ulcer clinics. Wounds UK 7(4): 57–61. Available online: https://absorbest. se/lang/wp-content/uploads/2018/08/ Evaluation-of-a-16-patient-study-usingDryMax-Extra-in-four-leg-ulcer-clinics.pdf Barrett S, Callaghan R, Chadwick P, Haycocks S, Rippon M, Stephen-Haynes J, Simm S (2018) An observational study of a superabsorbent polymer dressing evaluated by clinicians and patients. J Wound Care 27(2): 91–100 Cutting KF (2009) Managing wound

exudate using a super-absorbent polymer dressing: a 53-patient clinical evaluation. J Wound Care 18(5): 200–5 Dissemond J, Malone M, Ryan H, Tanaka R, Ohura N, Wong KL, et al (2022) Implementation of the M.O.I.S.T. concept for the local treatment of chronic wounds into clinical practice. Wounds Int 13(4): 34–43 Eming S, Smola H, Hartmann B, Malchau G, Wegner R, Krieg T, Smola-Hess S (2008) The inhibition of matrix metalloproteinase activity in chronic wounds by a polyacrylate superabsorber. Biomaterials 29(19): 2932–40 Green J, Jester R, McKinley R, Pooler A (2013) Patient perspectives of their leg ulcer journey. J Wound Care 22(2): 58–66 Greenhow H, Todhunter J (2024) Improved clinical outcomes in the management of toe lymphorrhoea with a highly conformable superabsorbent dressing. Poster presentation, EWMA 2024 Guest JF, Fuller GW, Vowden P (2020) Cohort study evaluating the burden of wounds to the UK’s National Health Service in 2017/2018: Update from 2012/2013. BMJ Open 10(12): e045253 Hindhede A, Meuleneire F (2012) A clinical case-series evaluation of a superabsorbent dressing on exuding wounds. J Wound Care 21(11): 574–82 Hiskett G (2020) Shared care in wound management: a significant opportunity. J General Practice Nurs 6(3): 44–9 Lindsay E,Renyi R,Wilkie P, et al (2017) Patient-centred care: a call to action for wound management. J Wound Care 26(11): 662–7 O’Callaghan S, Galvin P, O’Mahony C, Moore Z, Derwin R (2020) ‘Smart’ wound dressings for advanced wound care: a review. J Wound Care 29(7): 394–406 Ousey K, Atkin L, Conway B, Gorton H, Laird J, Toner S, et al (2021) Wound Care and Dressing Selection for Pharmacy

Teams: Consensus Document. Wounds UK. Available online: https://pure.hud. ac.uk/en/publications/wound-care-anddressing-selection-for-pharmacy-teamsconsensus-do Singh G, Byrne C, Thomason H, McBain AJ (2022) Investigating the microbial and metalloprotease sequestration properties of superabsorbent wound dressings. Sci Rep 12(1): 4747 Surgical Material Testing Laboratory (SMTL), 2020: Data on file Absorbest Stephen-Haynes J, Rippon M, Callaghan R, Simm S (2018) A retrospective audit of the treatment of wounds with moderate to high exudate levels. Wounds UK 14(5): 124–33 World Union of Wound Healing Societies (2019) Consensus Document. Wound Exudate, effective assessment and management. Wounds International. Available online: https:// woundsinternational.com/world-unionresources/wuwhs-consensus-documentwound-exudate-effective-assessmentand-management/

KEY POINTS  Excessive exudate can be

detrimental to the wound and periwound skin, thus delaying the healing process and causing a negative impact on patient quality of life.  Superabsorbent dressings are

highly absorptive dressings intended for use on exuding wounds as they are able to draw and retain excess moisture away from the wound which helps prevent leakage and other exudate-related complications.  The findings from this case series

demonstrate the performance of the superabsorbent dressing in this evaluation (DryMax Super) in managing exudate volume, wound odour and improving periwound skin condition without requiring a high frequency of dressing changes.  The results of this case series

are comparable to the outcomes reported in previous studies with the same and other superabsorbent dressings.

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