A Prescriber's Guide To Dressings & Wound Management Materials  (1996)

Introduction

The Value for Money Unit (VFM) commissioned the Surgical Materials Testing Laboratory, at Bridgend General Hospital, Bridgend, to undertake a detailed analysis of Welsh Prescribing Analysis and Cost data (PACT), now known as Prescribing Audit and Report Catalogue. The full report was published in October 1995 and distributed to the NHS in Wales in November 1995. The object of this second publication is to provide prescribers with simple guidelines to facilitate the cost-effective prescribing of dressings and wound management materials.

Most of the current recommendations have been drawn from the original study updated to include information on dressings introduced into the list of prescribable items since June 1994.

Prescriptions issued between July 1993 and June 1994 for wound management materials, cost the NHS in Wales a total of £5.5m. This study suggested that this expenditure could be reduced by up to £140k by the introduction of minor changes in prescribing patterns for some of these products with:

  • no reduction in the quality of care provided to patients
  • the use of products which are superior in performance terms to those items that are currently being prescribed.

More fundamental changes, involving the exclusion of some products of questionable efficacy could result in additional savings up to a maximum of £528k.

Disclaimer

The VFM Unit does not accept any responsibility for statements or recommendations contained within this guide. The VFM Unit's role in this project has been to co-ordinate the completion of the work and help to structure the guide into a user friendly format Any comments concerning the selection of the products and their use should be directed to: Dr S Thomas Director Surgical Materials Testing Laboratory Bridgend General Hospital Bridgend Mid Glamorgan, CF31 1JP

Summary of potential cost savings

A summary of the principal savings that could be achieved on an `All Wales' basis by making changes to current prescribing patterns is given in Table 1. Within this table, each suggested change is classified into one of four groups as follows.

 

 
Group A Changes which could be considered to be free of any clinical implications except perhaps to represent an improvement in the quality or performance of the dressings provided to the patient.
Group B Changes which would result in improved patient care.
Group C Changes which are possible on theoretical grounds but which may require confirmation in practice or some minor changes in local procedures.
Group D Major changes in prescribing to discontinue the use of products which are of limited value or questionable efficacy.
Table 1: Summary of potential cost savings
Recommendation Code Saving
    (£1000s)
Substitute Release for Melolin * A 32
Substitute nonwoven swabs for woven swabs A 48
Substitute K-Band for Kling and Crinx A 44
Substitute Tricotex for NA Dressing A 13
Substitute Tensopress for Blue and Red Line Webbing A 3
Sub-total   140
Rationalise the use of crepe and compression bandages B 26
Substitute Skintact for Release and Melolin * (see below) C 62
Substitute K-Band for other retention bandages C 92
Substitute Scanpor for Micropore C 50
Substitute cheapest brands for Tubigrip C 46
Substitute Cutifilm for Tegaderm C 45
Sub-total   601
Discontinue use of topical antibiotic powders D 94
Discontinue use of Varidase D 5
Sub-total   1301
Total maximum potential saving   528

 

Note: It is obviously possible to only make one of the savings marked "*"

Classification of wound management materials

The wound management materials available on prescription can be classified into broad performance-related groups as follows.

Primary wound dressings

Primary wound dressings are applied directly to a wound to absorb exudate, provide protection from external contamination and facilitate healing. They are available in many forms. Some are self adhesive and therefore do not require the application of secondary dressings or retaining bandages. Others act as low-adherent interface layers between the wound and a secondary absorbent layer placed upon the outer surface of the primary dressing.

Dressing packs

Dressing packs, sometimes also called procedure packs, provide the nurse practitioner with a selection of sterile wound care items conveniently packaged together. The most commonly used variety contain an inner wrap that opens out to form a sterile field. These packs are generally used when changing a dressing or carrying out some similar procedure.

Surgical absorbents

Surgical absorbents are products which, although not designed to be left in intimate contact with damaged tissue, may be used for cleansing purposes or as secondary absorbent layers over a primary dressing in the management of heavily exuding wounds.

Extensible/Bandages

The bandages in the Drug Tariff may be classified into groups according to their function and performance. Considerable financial savings may be achieved by ensuring that these are used appropriately.

Surgical Tapes

Surgical tapes are used to retain dressings and other medical appliances in position. A number of types are available with various backing materials and adhesive systems. Traditional woven products coated with a zinc oxide-rubber adhesive have been largely replaced by paper tapes bearing synthetic acrylic adhesives for general purpose use such as dressing retention. The majority of expenditure on surgical tapes is on the paper products. Micropore is brand leader within this group but substantial savings could be achieved by the use of alternative products if these are judged to be clinically acceptable.

Paste Bandages

Paste bandages are used for the treatment of eczema[Image-15K], dermatitis[Image-15K] and similar conditions. Paste bandages are also often applied in conjunction with compression bandages in the management of venous ulcers. The principal problem associated with the use of paste bandages is their tendency to induce skin reactions. This is largely due to the presence of parabens preservatives. A recent addition to the Tariff is Steripaste which is preservative free and is therefore claimed to be less likely to induce skin reactions.

Tubular Bandages and Stockinettes

The Drug Tariff contains several different types of tubular bandages and stockinettes. These are used to provide support, act as dressing retention materials or provide protection to clothing or bedding following the application of large quantities of ointments or creams for dermatological conditions.

Pharmaceutical Preparations

The pharmaceutical preparations used in wound management are to be found in Sections 13.10 and 13.11 of the Welsh Prescribing Catalogue. These may be subdivided into the followings groups.

 
Wound cleansing agents Solutions used during dressing changes for cleansing the surface of the wound or the surrounding skin.
Antibacterial agents Topical agents that are applied to open wounds to combat infection
Wound debriding agents Materials that are used to dissolve or degrade slough or necrotic tissue present in a wound.
Miscellaneous products

These include cyanoacrylate skin adhesive and various

lotions used in wound care.

Review of wound management materials

This sections contains a brief review of the dressings contained within the Drug Tariff, together with those pharmaceutical items in Section 13.10 and 13.11 of the Welsh Prescribing Catalogue that are used in wound management. This section is intended to provide users with background information on the products that are available in an easily understandable form and explain, where possible, how the physical properties of these materials influence their clinical applications as described in Section 4.

Primary wound dressings

Hydrocolloid dressings - Key features

Three hydrocolloid dressings are listed in the Drug Tariff, and these vary significantly in their composition and physical characteristics. The products differ in price, but in the absence of hard published data on their relative clinical effectiveness, it is not possible to make any recommendation on preferred usage.

  • Hydrocolloid dressings consist of a self-adhesive gel-forming mass which may contain sodium carboxymethylcellulose, gelatin and pectin, applied to a carrier such as a thin polyurethane film or foam sheet.
  • Used for light to moderately exuding wounds including pressure sores[Image-15K],minor burns[Image-16K] and traumatic injuries. Also used extensively in the management ofleg ulcers[Image-16K] where they appear to have advantages in the treatment of wounds that fail to respond to compression therapy alone.
  • In their intact state, hydrocolloids are initially virtually impermeable to water vapour and for this reason they are often used to facilitate rehydration and autolytic debridement of dry sloughy or necrotic wounds[Image-16K].
  • Because hydrocolloid dressings do not cause pain on removal, they are particularly useful in paediatric wound care for the management of both acute and chronic wounds.

 

Table 2: Hydrocolloid dressings
Product Size (cm) Cost (p)
Tegasorb (oval) (£24,269) 10 x 12 201
  13 x 15 379
Granuflex (£591,566) 10 x 10 212
  15 x 15 399
  15 x 20 435
  20 x 20 599
Comfeel (£241,056) 10 x 10 211
  15 x 15 419
  20 x 20 628


Figures in ( ) indicate expenditure for period July 1993-June 1994.

Semipermeable adhesive film dressing - Key features

There are currently four adhesive film dressings available on the Tariff. They are all made from a thin sheet of polyurethane coated with a layer of acrylic adhesive.

  • The dressings are permeable to moisture vapour and gases but impermeable to liquids.
  • Film dressings have a wide range of applications. Their use has been reported in burns, donor sites[Image-16K], surgical wounds and superficial pressure sores[Image-15K]. They are also used as secondary dressings in combination with alginates and hydrogels and are applied prophylactically to prevent damage caused by shearing forces to the skin of patients confined to bed.
  • Although the physical properties of the films from which the dressings are constructed are broadly comparable major differences exist in the application systems that have been developed.
  • Users often express a strong preference for a particular brand of film dressing because they have become familiar with its method of use. It is argued that a change to an alternative product with a different application system could lead to wastage and therefore increase rather than reduce costs.
  • Despite the `brand loyalty' shown to particular makes of dressing, significant savings are possible if prescribing practices can be changed.

 

Table 3: Semipermeable film dressings
Product Size (cm) Cost (p)
Cutifilm (£2,125) 10 x 14 106
  7.5 x 10 62
Opsite (£157,077) 10 x 12 116
     
Tegaderm (£331,306) 10 x 12 121
     
Bioclusive (£35,871) 10.2 x 12.7 128
     


Figures in ( ) indicate expenditure for period July 1993-June 1994.

Perforated film absorbent dressings - Key features

Three perforated film dressings are included in the Drug Tariff; These dressings are designed to combine a degree of absorbence with low-adherence for the management of lightly exuding superficial wounds.

  • They consist of an absorbent fibrous fleece covered with a plastic film containing a series of small holes arranged in a uniform pattern.
  • The plastic film is intended to prevent the dressing adhering to the surface of the wound and the holes are present to allow the passage of exudate through to the absorbent layer.
  • Perforated film absorbent dressings are widely used in the treatment of superficial wounds and are frequently applied in combination with hydrogels or alginates.
  • The ability of these dressings to absorb exudate is limited, and for heavily exuding wounds they are sometimes covered with a second absorbent pad. In these situations the absorbency of the dressing is less important than its low-adherent properties.

 

Table 4: Perforated film absorbent dressings
Product Size (cm) Cost (p)
Skintact (£879) 5 x 5 10
  10 x 10 17
  20 x 10 33
Release (£14,864) 5 x 5 11
  10 x 10 19
  20 x 10 36
Melolin (£308,008) 5 x 5 12
  10 x 10 20
  20 x 10 39


Figures in ( ) indicate expenditure for period July 1993-June 1994.

Alginate dressings - Key features

Alginate dressings are produced from the calcium and sodium salts of alginic acid, a polymer obtained from seaweed that is composed of mannuronic and guluronic acid residues.

  • Calcium alginate is insoluble in water but in the presence of sodium ions from wound exudate, a partial ion exchange reaction takes place resulting in the production of sodium alginate which forms a hydrophilic gel on the wound surface that is believed to facilitate healing.
  • The physical and chemical properties of the dressings depend upon the content of calcium and sodium ions and the relative concentration and arrangement of the mannuronic and guluronic monomers. Dressings rich in mannuronic acid, tend to react readily with sodium ions, forming soft amorphous gels. Dressings rich in guluronic acid gel less readily and form firmer less mobile gels.
  • Five alginate dressings are available on the Drug Tariff. Most consist of calcium alginate formed into textile fibres.
    • Sorbsan consists primarily of fibres of calcium alginate rich in mannuronic acid.
    • Kaltostat is produced from fibres of calcium/sodium (80:20) alginate rich in guluronic acid.
    • Tegagel is chemically similar to Sorbsan but more closely resembles Kaltostat in appearance.
    • Kaltogel, a new addition to the Tariff, is also rich in mannuronic acid but also contains 20% sodium alginate to facilitate rapid gelling.
    • Comfeel Alginate Dressing, rich in guluronic acid, is made by a freeze drying process and is therefore a fibre-free mass of calcium alginate which is supported on a nylon mesh net.
  • Alginate dressings are used primarily for the treatment of exuding wounds such as leg ulcers, acute surgical woundssinuses[Image-15K] and other cavity wounds such as pressure sores[Image-15K].
  • Alginates also have haemostatic properties, and one product, Kaltostat, has a product licence for this application.
  • The chemical and physical properties of the alginate dressings are very different and this has implications for the selection and method of use of the products concerned. Sorbsan and Kaltogel are soluble in 0.9% sodium chloride solution and is therefore easily removed from a cavity wound or sinus[Image-15K] by irrigation. Tegagel and Kaltostat are less soluble and therefore may be removed from the wound intact as may the Comfeel product.
  • Although there is some anecdotal evidence to indicate that at least one alginate, Sorbsan, may be of value in the management of sloughy, necrotic orinfected wounds[Image-16K] but this has not been confirmed in a clinical trial.

 

Table 5: Alginate dressings
Size Comfeel Kaltogel Kaltostat Sorbsan Tegagel
cm (No data) (No data) (£162,241) (£192,409) (No data)
5 x 5   0.70 0.72 0.87 0.72
6 x 4 0.69        
7.5 x 12     1.57    
10 x 10 1.44 1.45   1.54 1.50


Figures in ( ) indicate expenditure for period July 1993-June 1994.

Low-adherent wound contact layers - Key features

Low-adherent wound contact layers are used as interface layers to prevent a secondary absorbent dressing from adhering to the surface of a wound and causing trauma on removal. They are available both plain and impregnated with white soft paraffin which may also contain an antibacterial agent.

Unmedicated low-adherent wound contact layers

  • Knitted Viscose Primary Dressing BP, more familiarly known as NA Dressing or Tricotex, is a simple knitted fabric that is claimed to have limited adherence properties. This dressing is commonly used as the initial layer of the Four Layer Bandage system.
  • For many applications, NA Dressing and Tricotex have largely replaced paraffin gauze dressings (tulles), which, despite their greasy nature and description of `low-adherent dressings', often become firmly attached to the surface of a wound causing pain or discomfort upon removal.

 

Table 6: Plain, low-adherent wound contact agents
Product Size (cm) Cost (p)
N-A Dressing (£80,980) 9.5 x 9.5 23
Tricotex (£20,238) 9.5 x 9.5 28
Paraffin Gauze(£44,512)    
Individually wrapped 10 x 10 30
Bulk pack of 10 10 x 10 210

 

Medicated low-adherent wound contact layers

Paraffin gauze dressings can be medicated with antibiotics such as sodium fusidate and framycetin but these may cause sensitivity reactions and the development of resistant strains of micro-organisms.

  • Dressings such as Bactigras and Serotulle contain an antiseptic, chlorhexidine, instead of an antibiotic and are therefore generally considered to be free of these disadvantages.
  • Laboratory tests suggest that the chlorhexidine is not readily released from the hydrophobic paraffin base and therefore the antibacterial activity of these dressings is likely to be limited.
  • Inadine contains povidone iodine in polyethylene glycol which is hydrophilic and therefore better able to liberate the antimicrobial agent into wound exudate in order to exert a bactericidal effect.

 

Table 7: Medicated Low-adherent wound contact layers
Product Size (cm) Cost (p)
Inadine (£82,376) 5 x 5 25
  9.5 x 9.5 38
Chlorhexidine Gauze Dressing BP 5 x 5 21
(Bactigras, Serotulle, Chlorhexitulle) (£45,852) 10 x10 45
Fucidin Intertulle* (£2,363) 10 x 10 22
Sofra Tulle* (£18,148) 10 x 10 23


* The use of these dressings should be avoided where possible.

Hydrogel dressings - Key features

Hydrogels consists of insoluble polymers with hydrophilic sites which interact with aqueous solutions, absorbing and retaining significant volumes of water.

  • Intrasite gel, the only hydrogel is currently available in the Drug Tariff, contains approximately 1-2% carboxy-methylcellulose, 80% water, and 20% propylene glycol as a humectant and preservative.
  • The gel has the ability to absorb or donate liquid according to the state of hydration of the tissue to which it is applied.
  • Intrasite is also sometimes used as a carrier for metronidazole in the treatment of fungating and other malodorous wounds.
  • The primary indication for the use of the gel is the cleansing of sloughy and necrotic wounds[Image-16K] which it does by rehydrating dead tissue and encouraging autolytic debridement.
  • Intrasite gel can be used for the management of problem wounds such assinuses[Image-15K] and infected surgical wounds that may be difficult to dress with alternative products.
  • The gel has also been used with advantage in the treatment of extravasation injuries in neonates.
  • A generous layer of gel is applied to the surface of a wound and covered with a perforated plastic film dressing such as Melolin or Release or a semipermeable adhesive film depending upon the location and condition of the lesion.
  • On very dry wounds it is usual to change the dressing at least once per day.

 

Table 8: Hydrogel dressing
Product Size Cost (p)
Intrasite (£178,579) 15 grams 181


Figures in ( ) indicate expenditure for period July 1993-June 1994.

Polysaccharide bead dressings - Key features

Dressings made from polysaccharide beads were amongst the first `modern' products to be used in wound management. Two different types of beads are available which are used in a number of different formulations.

  • Debrisan consists of absorbent dextranomer microspheres about 0.2 mm in diameter. When introduced into a wound the beads absorb exudate and cellular debris and so assist with wound debridement
  • Because of practical problems associated with the use of the free flowing beads, they are also produced in the form of a paste in which they are mixed with polyethylene glycol.
  • Debrisan Absorbent Pads are textile bags containing Debrisan Paste that can be easily applied to, and removed from, an appropriate wound.
  • Iodosorb consists of microspheres of chemically modified starch which contain 0.9% elemental iodine which is released when the beads absorb water and swell.
  • Like Debrisan, Iodosorb is used for the treatment of moist sloughy wounds particularly when infection is present.
  • Also like Debrisan, Iodosorb is available in the form of a paste or ointment which is used in situations were application of the free flowing beads would be impractical.
  • Iodoflex, used in the management of relatively large shallow wounds, consists of a layer of Iodosorb ointment sandwiched between two pieces of gauze, one of which is removed before the dressing is applied to the wound surface.

 

Table 9: Polysaccharide bead dressings
Product Size (cm) Cost
Iodosorb range (£120,789)    
Iodosorb Powder 7 x 3 g sachet £13.50
Iodosorb Ointment 4 x 10 g sachet £18.05
  2 x 20 sachet £18.05
Iodoflex 5 x 5 g sachet £20.40
  3 x 10 g sachet £24.50
  2 x 17 g sachet £25.84
Debrisan range (£7,687)    
Debrisan Beads 10 x 4 g sachet £19.38
  60 g pot £29.01
Debrisan Paste 4 x 10 g sachet £19.89
  6 x 10 g sachet £29.93
Debrisan Pad 3 g pad £2.30


Figures in ( ) indicate expenditure for period July 1993-June 1994.

Polyurethane foam dressing - Key features

There are five polyurethane foam dressing included in the Drug Tariff which have very different performance characteristics and indication.

  • Lyofoam consists of an open-cell polyurethane foam sheet, one surface of which has been heat treated to collapse the cells of the foam and allow it to take up blood or wound exudate by capillarity. It is used in the management of a variety of different wound types including leg ulcers, traumatic wounds,minor burns[Image-16K] , and donor sites[Image-16K]
  • Unlike most absorbent dressings, Lyofoam transmits absorbed fluid laterally across the face of the dressing rather than from front to back. For this reason, a size of Lyofoam should always be selected which overlaps the edges of the wound by about 2-3 cm.
  • Allevyn is three component dressing consisting of a hydrophilic polyurethane foam layer about 3 mm thick sandwiched between a low-adherent net facing layer and a polyurethane film backing. The dressing is highly absorbent and is useful for the management of moderate-heavily exuding wounds such as legulcers[Image-16K] and fungating tumours.
  • Allevyn adhesive consists of a piece of Allevyn foam which is bonded to a piece of polyurethane foam to form an island dressing the surface of which is coated with adhesive.
  • Spyrosorb is thin sheet of polyurethane foam coated with adhesive. The dressing which is very conformable, has limited absorbent capacity but is highly permeable to moisture vapour. It is used for dressing relatively shallow, lightly exuding wounds or wounds in the final stages of healing.
  • Tielle is a sophisticated island dressing consisting of a piece of polyurethane film/foam, located in the centre of an adhesive moisture vapour permeable, polyurethane membrane. The dressing is highly permeable to moisture vapour which makes it suitable for application to moderately exuding wounds despite its limited absorbent capacity.

 

Table 10: Polyurethane foam dressing
Product Size (cm) Cost (p)
Lyofoam (£61,738) 7.5 x 7.5 83
  10 x 10 99
  17.5 x 10 154
  20 x 15 208
Allevyn (No data) 5 x 5 93
  10 x 10 185
  10 x 20 295
  20 x 20 495
Allevyn Adhesive (No data) 7.5 x 7.5 112
  12.5 x 12.5 202
  17.5 x 17.5 398
  22.5 x 22.5 579
Tielle (No data) 11 x 11 192
  15 x 20 399
  18 x 18 399
Spyrosorb (No data) 10 x 10 198
  20 x 20 565


Figures in ( ) indicate expenditure for period July 1993-June 1994.

Miscellaneous dressings

Miscellaneous wound management products that are included in the Drug Tariff are shown below.

 

Table 11: Miscellaneous dressings
Product Group Cost (p)
Airstrip dressing (£179) 30
Boil dressing pack (£14) 64
Standard dressing No 4 (£47) 54
Sterile eye pad (£2,310) 47


Figures in ( ) indicate expenditure for period July 1993-June 1994.

Dressing packs

Dressing packs, sometimes also called procedure packs, provide the nurse practitioner with a selection of sterile wound care items conveniently packaged together. Four different packs are included in the Drug Tariff.

  • Pack A, (Drug Tariff Specification 10), contains woven cotton swabs and a piece of gauze and cotton tissue (Gamgee).
  • Pack B (Drug Tariff Specification 35) contains nonwoven swabs and a proprietary dressing pad. Both packs also contain absorbent cotton balls, a paper towel and an inner wrap that opens out to form a sterile field. These packs are generally used when changing a dressing or carrying out some similar procedure.
  • Multiple dressing packs 1 and 2 contain absorbent cotton rolls, absorbent gauze and white open wove bandages. These items are intended to be used together to form a dressing. The precise indications for the use of these packs is uncertain but they are relatively expensive and as there can be little place for a dressing made from these three components in modern wound management, their use should be discontinued in favour of more cost effective alternatives.

 

Table 12: Wound dressing packs
Product Group Cost (p)
Dressing pack A (Spec 10) (£536,707) 69
Dressing pack B (Spec 35) (£74,186) 74
Multiple dressing pack (No 1) (£4,177) 300
Multiple dressing pack (No 2) (£276) 503


Figures in ( ) indicate expenditure for period July 1993-June 1994.

Note

The expenditure upon dressing packs quoted in the table above does not reflect the total sum spent in Wales on these items. At least one very large Authority purchases their packs from the hospital CSSD and this expenditure is not reflected in Table 12

Surgical absorbents

Surgical absorbents are products which, although not designed to be left in intimate contact with damaged tissue, may be used for cleansing purposes or as secondary absorbent layers over a primary dressing in the management of heavily exuding wounds.

Cotton/nonwoven swabs - Key features

  • Surgical swabs are traditionally produced from Gauze, a simple woven fabric made from absorbent cotton.
  • Developments in textile technology have led to the production of nonwoven fabrics manufactured principally from viscose which have a number of advantages over woven cotton.
  • Nonwovens are generally more absorbent and are less likely to shed fibrous material into the wound which may delay healing or predispose the wound to infection.They are also significantly cheaper.
  • Filmated swab contains a thin layer of absorbent cotton (cotton wool) which is included to improve the fluid handling properties, although the presence of the loose cotton fibres must increase the risk of particulate loss from the finished product.
  • Filmated swabs may be manufactured from either woven or nonwoven fabric but laboratory tests have shown that despite the presence of the fibrous cotton interliner, the filmated swabs available upon prescription are inferior in performance terms to the ordinary nonwoven product despite being significantly more expensive

 

Table 13: Non-sterile swabs
Non sterile swabs (100s) 10 cm x 10 cm Cost (p)
Nonwoven swabs (£11,584) 234
Cotton gauze swabs BP (£127,208) 498
Nonwoven filmated (Regal) (£15,930) 507
Cotton gauze filmated (£4,540) 620
Table 14: Sterile swabs
Sterile swabs (5s) (7.5 cm x 7.5 cm) Cost (p)
Nonwoven Swabs (£3,686) 20
Cotton Gauze BP (£34,103) 29

 

Figures in ( ) indicate expenditure for period July 1993-June 1994.

Gauze and cotton tissue - Key features

More familiarly known by its trade name of `Gamgee Tissue' it consists of a layer of absorbent cotton enclosed in a sleeve of cotton gauze.

  • Gamgee tissue is used to absorb exudate from heavily exuding wounds and should be applied over a primary wound dressing to avoid contaminating the wound with cellulose fibres.

Absorbent cotton rolls - Key features

  • Absorbent cotton (cotton wool) should not be used as a dressing material because of the problems of fibre loss.
  • The material available on the Tariff is not sterile and this should also preclude its use as a primary wound dressing.
  • Absorbent cotton is sometimes used as a padding material under bandages to prevent pressure damage to tissue over bony prominences, and for swabbing skin prior to injection.
  • Over 13 metric tons of absorbent cotton are prescribed annually in Wales.

Absorbent lint - Key features

  • Like absorbent cotton, lint sheds excessive amounts of fibrous material and therefore has no place in wound management.
  • Discussions with community nursing staff indicate that they never use it and therefore it must be assumed that it is provided direct to patients for some undefined purpose.

Absorbent gauze rolls - Key features

  • Absorbent gauze rolls, including ribbon gauze, are available in both the sterile and non sterile form.
  • Sterile ribbon gauze and the sterile version of the larger rolls product is sometimes used for packing wounds but there is no information to suggest what the non sterile material is used for.

Cellulose Wadding - Key features

  • Cellulose wadding consists of a layer of cellulose wadding in a tube of cotton gauze.
  • The product is not sterile and is used principally as an absorbent for non-surgical applications (e.g. incontinence). It should therefore not be regarded as a dressing.

 

Table 15: Surgical absorbents
Product Group No of items Expenditure
Gauze and cotton tissue rolls 25,376 130,778
Absorbent cotton rolls * 47,616 112,695
Absorbent lint * 7,650 34,374
Absorbent cotton gauze rolls * 23,507 34,004
Cellulose wadding 591 1,291

 

The items marked * in the table above are available in a range of sizes. The values quoted here for the number of items prescribed represent the sum of all sizes in each case.

Extensible/Bandages

The bandages in the Drug Tariff may be classified into groups according to their function and performance. Considerable financial savings may be achieved by ensuring that these are used appropriately.

Retention bandages -Key features

As their name suggests, these bandages are used to retain dressings in place. They should not be used to apply pressure as they are unsuitable for this purpose.

  • The first `retention bandage' was White Open Wove (WOW) a rigid fabric with extremely limited conformability that is available in a range of widths.
  • Because of the poor performance characteristics of WOW two softer more conformable bandages were introduced. These are Kling and Crinx the Cotton Conforming Bandages of the British Pharmacopoiea.
  • Recently, new lightweight bandages have been developed that have advantages over the simple cotton products. Some of these are included in the Tariff, and although they vary in performance and price, all of them are cheaper than the products they are designed to replace.

 

Table 16: Retention bandages
Bandage Type Cost (p)        
  2.5cm 5 cm 7.5cm 10 cm 15 cm
K-Band - 16 20 23 39
Easifix - 30 37 43 73
Stayform - 30 38 43 73
Slinky - 37 52 63 89
Crinx - 56 70 85 117
Kling - 58 75 91 120
White open wove 27 45 64 84 -

 

Support Bandages - Key features

Support may be defined as the retention and control of tissue without the application of compression. It is usually provided to prevent the development of a deformity or change in shape of a mass of tissue due to swelling or sagging.

  • The support bandages available on the Drug Tariff are Crepe Bandage BP, woven from cotton and wool, and Cotton Crepe Bandage BP - more familiarly known as Elastocrepe which is made entirely of cotton.
  • Both types of bandage have been used to provide support in the treatment of sprains and strains and to apply compression in the management of leg ulcers caused by venous insufficiency.
  • Numerous published studies have demonstrated, however, that the elastic properties of these bandages are such that they are unable to provide and maintain the levels of pressure that are required for this indication and therefore they should not be used for this purpose.
  • Competent compression bandages containing elastomeric yarns are much better suited for this application, and these are described in the following section.
  • It is likely that a significant proportion of all crepe bandages supplied are used inappropriately for dressing retention. This is not cost effective, for these bandages are much more expensive than the bandages described in Table 16.

 

Table 17: Support Bandages
Bandage Type Cost (p)      
  5 cm 7.5 cm 10 cm 15 cm
Crepe BP 79 110 146 208
Cotton Crepe - 251 325 -

 

Compression Bandages - Key features

Compression implies the application of clinically effective levels of external pressure, applied to modify or assist a physiological process - generally blood flow. The bandages in the Drug Tariff that are suitable for the application of high levels of compression are shown in Table 18.

  • The inappropriate use of compression bandages can have very serious consequences, resulting in extreme cases in necrosis and amputation[Image-0K]
  • It is vitally important that no form of high compression bandaging system is applied to a patient unless the possibility of arterial disease has first been excluded by some appropriate method.
  • Where crepe bandages are being used to provide compression, a change to a more effective product such as Setopress or Tensopress should be considered.
  • When crepe bandages are being used to apply compression, a change to a more clinically effective product will result in an increase in expenditure but an improvement in patient care.

 

Table 18: Compression bandages
Bandage Type Cost (p)  
  7.5 cm 10 cm
Tensopress 225 292
Setopress 229 296
Blue line with foot loop 402 -
Red line 2.5 m 318 -
Red line 3.5 m 384 -

 

Adhesive bandages Key features

Adhesive bandages are generally applied to provide support rather than compression. The adhesive coating helps to ensure that the bandages do not slip or become displaced.

  • Adhesive bandages are comonly used for strapping purposes and to provide support or compression in the treatment of sprains and strains.
  • Diachylon adhesive bandage, more commonly known as Lestreflex, is often used in place of bandages coated with a zinc oxide adhesive where skin sensitivity reactions are present or suspected.

 

Table 19: Adhesive Bandages
Bandage Type Cost (p)    
  5 cm 7.5 cm 10 cm
Elastic Adhesive Bandage BP (£24,828) 295 426 567
Elastic Diachylon Bandage BP (£41,391) - 321 -

 

Surgical Tapes

  • Surgical tapes are used to retain dressings and other medical appliances in position. A number of types are available with various backing materials and adhesive systems.
  • Traditional woven products coated with a zinc oxide-rubber adhesive have been largely replaced by paper tapes bearing synthetic acrylic adhesives for general purpose use such as dressing retention.
  • Plastic tapes such as Sleek and Blenderm are used where more long term adhesion is required, particularly in the presence of moisture as in the fixation of drains.
  • A finely woven tape coated with a synthetic adhesive, Leucosilk, is available where tensile strength and low sensitisation potential is important.
  • The majority of expenditure on surgical tapes is on the paper products. Micropore is brand leader within this group but substantial savings could be achieved by the use of alternative products if these are judged to be clinically acceptable.

 

Table 20: Surgical tapes
Tape Cost (p)      
  1.25 cm 2.5 cm 5.0 cm 7.5 cm
Lightweight `paper tapes' 5 metre roll        
Scanpor 39 63 109 -
Leukopor 42 66 116 -
Micropore 54 83 149 -
Hypal 2 58 88 163 -
Zinc Oxide Adhesive Tape BP        
1 metre roll - 34 - -
3 metre roll 53 79 - -
5 metre roll 74 107 182 276
Elastic Adhesive Tape BP        
1.5 metre stretched - 72 - -
4.5 metre stretched - 135 - -
Impermeable Plastic Adhesive Tape BP (Sleek)        
3 metre roll - 104 - -
5 metre roll - 156 198 287
Impermeable Plastic Synthetic Adhesive Tape BP (Blenderm)        
5 metre roll - 142 271 -
Permeable Woven Synthetic Adhesive Tape BP        
5 metre roll 61 89 157 -

 

Paste Bandages

Paste bandages consist of an open woven cotton fabric impregnated with a medicated paste or cream, most of which contain zinc oxide.

  • Paste bandages are used for the treatment of eczema[Image-15K], dermatitis[Image-15K] and similar conditions.
  • They are also often applied in conjunction with compression bandages in the management of venous ulcers
  • The principal problem associated with the use of paste bandages is their tendency to induce skin reactions. This is largely due to the presence of parabens preservatives.
  • A recent addition to the Tariff, Steripaste, is preservative free and is therefore claimed to be less likely to induce skin reactions.

 

Table 21: Paste bandages
Product Group Cost (p)
Zinc paste bandages BP  
Steripaste (15%) 288
Viscopaste PB 7 (10%) 297
Zincaband (15%) 281
Zinc Paste and Coal Tar Bandage BP  
Tarband 281
Zinc paste and ichthammol  
Ichthopaste (6/2%) 300
Icthaband (15/2%) 281
Zinc paste and calamine  
Calaband 290
Zinc paste, calamine and clioquinol  
Quinaband 290

 

Tubular Bandages and Stockinettes

The Drug Tariff contains several different types of tubular bandages and stockinettes (Table 22)

 

Table 22: Tubular bandages and stockinettes
Product Group Expenditure (£)
Elasticated tubular bandage 121,591
Lightweight elasticated tubular bandages 17,230
Plain stockinette 2,988
Foam padded elasticated tubular bandage 628
TOTAL 142,437

 

Elasticated Tubular Bandage

Available in a range of sizes from a number of manufacturers, Elasticated Tubular Bandage is applied in multiple layers to provide a degree of pressure and support and following soft tissue injuries. Despite the fact that it is commonly used in the treatment of venous legulcers[Image-16K], Elasticated Tubular Bandage it is not really suitable for this purpose as the pressure it produces falls far short of that which is required clinically. Although one brand has approximately 99% of the market, significant financial savings may be achieved by the use of alternative brands where direct substitutions are possible.. Some caution is required in this context, however, as the pressure profiles of the six products may vary.

Lightweight Elasticated Tubular Bandages

Two types of lightweight elasticated tubular bandage are included in the Tariff.

  • Tubifast is a lightweight elasticated stockinette that is particularly useful for holding dressings in place on digits and limbs.
  • Netelast has an open net-like structure and can be cut and fashioned into garments to retain dressings on awkward anatomical sites such as the head or groins region.

Plain Stockinette

Plain Stockinette is primarily used under orthopaedic casts and as a protective covering following the application of greasy ointments for the treatment of dermatological conditions.

Foam Padded Elasticated Tubular Bandage

  • Foam Padded Elasticated Tubular Bandage (Tubipad) consists of a length of Elasticated Tubular Bandage into which is sewn a piece of foam.
  • The bandage is used to provide padding and protection against physical damage particularly for elbows, knees etc.

Pharmaceutical preparations

A summary of expenditure on the pharmaceutical preparations used in wound management extracted from Sections 13.10 and 13.11 of the Welsh Prescribing Catalogue is shown in Table 23. Other products such as the polysaccharide bead dressings Debrisan and Iodosorb, which are also included in Section 13.11 of the Catalogue, do not appear in this table as these have been identified separately as `polysaccharide bead dressings' in Table 9

 

Table 23: Expenditure on pharmaceutical preparations
Product Group Products Expenditure (£000)
Wound cleansing agents Sodium chloride solution 312,715
  Chlorhexidine/cetrimide solution 16,650
  Chlorhexidine preparations 10,376
  Sterile water 57
  Sub total 339,798
Antibacterial agents Antibiotic powders 93,723
  Silver sulphadiazine cream 53,700
  Metronidazole preparations 52,814
  Povidone-iodine preparations 13,499
  Sub total 213,736
Wound debriding agents Enzymatic agents 5,047
  Hydrogen peroxide preparations 2,455
  Other proprietary preparations 1,364
  Sodium hypochlorite solutions 402
  Sub total 9,268
Miscellaneous Cyanoacrylate skin adhesive 702
products Proflavine cream 471
  Silver nitrate lotion 143
  Sub total 1316
  Total 564,119

 

Wound cleansing agents - Key features

Wound cleansing agents are solutions that are used to cleanse wounds prior to the application of a dressing. As such they should not be confused with debriding agents that are generally applied and left in-situ to facilitate removal of slough or necrotic tissue.

  • Most wound-care experts now agree that the routine use of antiseptic solutions has little place in wound management.
  • Antiseptics, particularly those which contain cetrimide, have marked cytotoxic properties and therefore should be avoided unless the wound is contaminated or shows clear evidence of infection.
  • For most applications, a sterile solution of normal saline is to be preferred for routine wound cleansing.

 

Table 24: Wound cleansing solutions
Cleansing solutions Cost (p)*
Sodium Chloride Solution  
Irriclens aerosol 250 ml 298
Normasol 25 ml sachets 23
Normasol 100 ml sachets 72
Sterac 150 ml 83
Sterijet 25 ml plastic amps 31
Steripod Blue 25 ml plastic amps 34
Chlorhexidine solution **  
Sterexidine 0.02%, 150 ml 83
Steripod pink 20 ml plastic amps 27
Unisept 25 ml 23
Unisept 100 ml 72
Chlorhexidine and cetrimide solution ***  
Steripod Yellow 25 ml plastic amps 27
Tisept sachets 25 ml 30
Tisept sachets 100 ml 72
Travasept 500 ml 74


* Rounded to nearest p, ** Not recommended for routine use ; *** avoid use where possible

Antimicrobial agents - Key features

Antimicrobial agents are used to prevent or combat local wound infection. Numerous preparations are available for this purpose as described in Table 23.

  • Antibiotic powders are used mainly in the treatment of infections in superficial wounds although some are also indicated for larger wounds. These products contain neomycin that is known to cause skin sensitisation and there is also a theoretical risk that their application can also lead to the emergence of resistant strains of bacteria. Antibiotic powders should therefore probably be avoided or used with extreme caution.
  • Silver sulphadiazine cream is used extensively in specialist centres for the treatment of extensive burns. Because the cream is active against a wide range of pathogenic organisms, it is also of value in the treatment of infected leg ulcers and other wounds.
  • Metronidazole preparations. Metronidazole is an antibiotic that is effective against pathogenic anaerobic bacteria often found in necrotic tissue. As such is a useful agent for combating the odour produced by malignant or sloughy wounds[Image-16K].
  • Povidone iodine preparations. Povidone iodine is a potent antimicrobial agent that is of value in the treatment of infected wounds[Image-16K]. Like other antiseptics, however, it should not be used once the infection is brought under control for it may have an adverse effect upon wound healing.

 

Table 25: Antimicrobial agents
Antiseptic/antibiotic preparations Cost (£)
Betadine dry powder spray 150 g 2.92
Betadine antiseptic paint 8 ml 1.06
Tribiotic 110 g 5.72
Flammazine  
50 g 4.30
500 g 20.40
Metrotop  
15 g 4.95
30 g 8.75

 

Wound debriding agents - Key features

Debriding agents are used to remove slough and necrotic tissue from wounds such as leg ulcers and pressure sores[Image-15K].

  • Much controversy surrounds the use of solutions containing hydrogen peroxide and sodium hypochlorite because they are claimed to delay wound healing and may also cause adverse effects upon the surrounding skin. Nevertheless, some practitioners still believe that their short term use may be justified for the cleansing of particularly dirty or sloughy wounds[Image-16K].
  • The continued use of enzymatic debriding agents is similarly questioned, for although they have been shown to have some benefit in the treatment of wounds containing semi-liquid slough and purulent exudate, they are ineffective against wounds containing deep hard necroses.
  • More wound care experts now tend to rely upon the use of Intrasite gel or hydrocolloid dressings to facilitate autolytic wound debridement.

 

Table 26: Wound debriding agents
Wound debriding preparations Cost (p)
Aserbine cream 100 g 117
Aserbine Solution 500 ml 176
Chlorosol 25 ml 36
Hioxyl cream 25 g 181
Hioxyl cream 100 g 565
Varidase Combi-Pack 820

 

Miscellaneous products

Cyanoacrylate skin adhesive is used as an alternative to sutures. Proflavine cream is an antimicrobial preparation of doubtful efficacy that has been used for many years to pack cavity wounds and sinuses[Image-15K]. As it also contains lanolin, it can cause skin sensitivity reactions in some patients. Silver nitrate lotion is sometimes used as an astringent antibacterial agent.

Guidance on Dressing Selection

Although wounds such as leg ulcers, pressure sores[Image-15K], burns and traumatic injuries have very different aetiologies, they can generally be classified into broad groups according to their physical condition and appearance. Such wound classification systems provide a useful starting point in the dressing selection process. (Table 27.) In is not intended that the recommendations in the following section should be followed in every case. It is envisaged rather that they should be used as a starting point in the dressing selection process. More detailed information on the selection of dressings and the use of specific product groups can be obtained from the references cited in the text of this booklet, copies of which can be obtained from the VFM unit.

 

Table 27: Summary of guidelines for dressing selection
Indication Recommended product/group
Sloughy or necrotic wounds[Image-16K]  
Dry sloughy or necrotic wounds[Image-16K] Hydrocolloid sheets or Intrasite gel covered with a semi-permeable film or perforated film dressing as appropriate.
Moist sloughy wounds[Image-16K] As above but also consider Sorbsan or Kaltogel covered with a perforated film dressing
Granulating wounds[Image-16K]  
Heavily exuding wounds For shallow large areas, Allevyn or Allevyn Adhesive. For deeper areas or cavities, Sorbsan or Kaltogel.
Moderately exuding wounds As above, but consider Lyofoam, or a hydrocolloid sheet or Tricotex
Lightly exuding or epithelialising wounds Semipermeable films, hydrocolloid sheets, unless over-granulation is a problem Lyofoam, Spyrosorb, or Perforated plastic film dressing.
Cavity wounds Alginate sheets cut into strips if necessary or Intrasite gel.
Infected or malodorous wounds Inadine Iodosorb, Sorbsan, and where appropriate, Metrotop or Flagyl, or Flammazine.
Skin/wound cleansing Non-woven swabs, 0.9% sodium chloride solution
Bandaging applications  
Venous leg ulcers (confirmed by vascular studies) Suitable primary dressing (as above) with competent compression bandage - Tensopress or Setopress
Dressing retention K-Band or similar. Tubifast or Netelast
Support for sprains and strains Support bandages or Elasticated tubular bandage

 

Dry sloughy and necrotic wounds[Image-16K]

If the blood supply to an area of tissue is interrupted for an extended period by the application of excessive pressure, the tissue will eventually die. The devitalised tissue will then become dehydrated and the epidermis will eventually take on a black leathery appearance. As it dries, the epidermis contracts, causing pain in the surrounding area. This necrotic material must be removed if normal healing is to take place. If surgical debridement is not an option, some method of reversing the process of tissue dehydration is required in order to facilitate autolytic debridement. This may be achieved in two ways. A dressing may be chosen that prevents the loss of water vapour from the dead tissue, or a product with a high water content may be applied to the area to rehydrate the tissue directly. Those dressings in the Drug Tariff that may be used in this way for the treatment of drynecrotic wounds[Image-16K] are described below.

 

Table 28: Recommended treatments for dry sloughy or necrotic wounds
Wound Type Recommended treatment
Small wounds of limited depth Hydrocolloid sheets
Large or deep wounds with undermining Intrasite gel covered with a Semipermeable Adhesive Film or a Perforated Plastic Film Dressing as appropriate.

 

Dry sloughy or necrotic wounds[Image-16K] (cont) - treatment with hydrocolloid dressings

Hydrocolloid dressings consist of a self-adhesive gel-forming mass, generally based upon carboxymethycellulose, applied to a carrier such as a thin polyurethane film or foam sheet. In their intact state hydrocolloids are virtually impermeable to water vapour and therefore retain moisture and thus facilitate rehydration followed by autolytic debridement of devitalised tissue. Depending upon the size and depth of the wound this process may take anything from a few days to several weeks to complete.

Method of use

A suitably sized dressing is selected, applied over the necrotic area and left in place for 3-5 days. It is then removed and the wound examined. This process may be repeated as often as required until debridement is complete.

Indications

Hydrocolloid dressings are particularly useful for relatively small, shallow areas such as `black heels' which can be covered completely by a single piece of dressing but they can also be used with good effect upon more extensive wounds on the sacrum or the buttocks.

 

Table 29: Hydrocolloid dressings
Sizes Tegasorb (oval) (£24,269) Granuflex (£591,566) Comfeel (£241,056)
10 x 10   2.12 2.11
10 x 12 2.01    
13 x 15 3.79    
15 x 15   3.99 4.19
15 x 20   4.35  
20 x 20   5.99 6.28

 

Figures in ( ) indicate expenditure for period July 1993 - June 1994

Dry sloughy or necrotic wounds[Image-16K] (cont) - treatment with hydrogel dressings

Hydrogels consists of insoluble polymers with hydrophilic sites which interact with aqueous solutions absorbing and retaining significant volumes of water. The only hydrogel dressing currently available upon prescription is Intrasite gel which contains approximately 1-2% carboxy-methylcellulose, 80% water, and 20% propylene glycol as a humectant and preservative. When applied to necrotic tissue, water is transferred directly from the gel to the tissue and thus facilitates rehydration and autolysis.

Method of use

A generous layer of gel is applied to the surface of the wound and covered with a Perforated Plastic Film dressing such as Release. If the wound is very dry a more occlusive covering may be used to reduce water vapour loss and prevent the gel from drying out. A Semipermeable Adhesive Film such as Cutifilm may be used for this purpose. On very dry wounds it is usual to change the dressing at least once per day.

Indications

Intrasite is particularly useful for cavity wounds, particularly where a degree of undermining is present, and in other situations where the use of hydrocolloid sheets would be inappropriate.

 

Table 30: Hydrogel dressings
Size Intrasite (£178,579)
15 grams 1.81


Figures in ( ) indicate expenditure for period July 1993 - June 1994

Moist sloughy or necrotic wounds[Image-16K]

Wounds such as leg ulcers and pressures sores sometimes develop a thick coating of viscous yellow slough. This acts as a potential source of infection and may delay healing unless it is removed mechanically or by some other means. The recommended products to facilitate debridement are described briefly below;

 

Table 31: Recommended treatments for moist sloughy wounds[Image-16K]
Wound Type Recommended treatment
Small wounds of limited depth Hydrocolloid sheets
Deeper wounds with undermining Intrasite gel covered with a Semipermeable Adhesive Film or a Perforated Plastic Film Dressing as appropriate.
Exuding sloughy wounds[Image-16K] As above but also consider Alginate dressings such as Kaltogel or Sorbsan covered with a Perforated Plastic Film Dressing.

 

In addition to the above, products made from polysaccharide beads and certain pharmaceutical preparations are also marketed for this indication. These are also described below. Moist sloughy wounds[Image-16K] (cont) - treatment with hydrocolloid dressings Hydrocolloid dressings consist of an adhesive mass which typically contains carboxymethycellulose, applied to a carrier such as a thin polyurethane film or foam sheet. In their intact state hydrocolloids are virtually impermeable to water vapour and therefore retain moisture and thus facilitate rehydration followed by autolytic debridement of devitalised tissue. If applied to an exuding wound, they have the ability to absorb liquid and form a gel, the nature of which depends upon the product selected, The moist conditions which exist beneath the dressing facilitate debridement followed by granulation tissue formation. Depending upon the size and depth of the wound this process may take anything from a few days to several weeks to complete.

Method of use

A suitably sized dressing is selected, applied over the sloughy area and left in place for 3-5 days. It is then removed and the condition of the wound examined. This process may be repeated as often as required until debridement is complete.

Indications

Hydrocolloid dressings are particularly useful for relatively small, relatively sloughy areas which can be covered completely by a single piece of dressing but they can also be used with good effect upon more extensive wounds on the sacrum or buttocks.

 

Table 32: Hydrocolloid dressings
Sizes Tegasorb (oval) (£24,269) Granuflex (£591,566) Comfeel (£241,056)
10 x 10   2.12 2.11
10 x 12 2.01    
13 x 15 3.79    
15 x 15   3.99 4.19
15 x 20   4.35  
20 x 20   5.99 6.28

 

Figures in ( ) indicate expenditure for period July 1993 - June 1994All Wales expenditure on hydrocolloid dressings during the period of the study was £856,891.

Moist sloughy wounds[Image-16K] (cont) - treatment with hydrogel dressings

Hydrogels consists of insoluble polymers with hydrophilic sites which interact with aqueous solutions absorbing and retaining significant volumes of water. The only hydrogel dressing currently available upon prescription is Intrasite gel which contains approximately 1-2% carboxy-methylcellulose, 80% water, and 20% propylene glycol as a humectant and preservative. When applied to sloughy tissue, water is transferred directly from the gel to the tissue and thus facilitates rehydration and autolysis.

Method of use

A generous layer of gel is applied to the surface of the wound and covered with a Perforated Plastic Film dressing such as Release. Alternatively, a more occlusive covering may be used to reduce water vapour loss and prevent the gel from drying out. A Semipermeable Adhesive Film such as Cutifilm may be used for this purpose. It is usual to change gel dressings at least once per day.

Indications

Intrasite is useful for cavity wounds, particularly where a degree of undermining is present, and in other situations where the use of hydrocolloid sheets would be inappropriate

 

Table 33: Hydrogel dressings
Size Intrasite (£178,579)
15 grams 1.81

 

Figures in ( ) indicate expenditure for period July 1993 - June 1994

Moist sloughy wounds[Image-16K] (cont) - treatment with alginate dressings

Alginate dressings consist principally of the calcium salt of alginic acid, a polysaccharide derived from seaweed. Calcium alginate is insoluble in water but in the presence of sodium ions from wound exudate, a partial ion exchange reaction takes place resulting in the production of sodium alginate which forms a hydrophilic gel on the wound surface. This helps to keep the surface of the wound moist and thus facilitate autolysis and eventually wound healing. The physical and chemical properties of the dressings depend upon the botanical source of the seaweed which in turn determines relative concentration and arrangement of the mannuronic and guluronic monomers which together make up alginic acid. The gelling characteristics are also influenced by the relative concentrations of calcium and sodium ions present in the dressing. Five alginate dressings are available on the Drug Tariff. Most contain a high concentration of calcium alginate formed into textile fibres, but one product, Comfeel Alginate Dressing, rich in guluronic acid, is made by a freeze drying process and is therefore a fibre free mass of calcium alginate supported on a nylon mesh net. Sorbsan consists primarily of fibres of calcium alginate rich in mannuronic acid. Kaltostat is produced from fibres containing a mixture of calcium/sodium alginate rich in guluronic acid. Tegagel is chemically similar to Sorbsan but the fibres have been hydroentangled, so that it more closely resembles Kaltostat in appearance. Kaltogel, a new addition to the Tariff, is also rich in mannuronic acid but also contains 20% sodium alginate to facilitate rapid gelling. similar to Sorbsan.

 

Table 34: Alginate dressings
Size (cm) Comfeel (No data) Kaltogel (No data) Kaltostat (£162,241) Sorbsan (£192,409) Tegagel (No data)
5 x 5   0.70 0.72 0.87 0.72
6 x 4 0.69        
7.5 x 12     1.57    
10 x 10 1.44 1.45   1.54 1.50

 

Figures in ( ) indicate expenditure for period July 1993-June 1994.

Moist sloughy wounds[Image-16K] (cont) - treatment with polysaccharide bead dressings

The polysaccharide bead dressings, Debrisan and Iodosorb, which are marketed for the treatment of sloughy wounds[Image-16K], are available in several different forms such as pastes which are intended to overcome the handling problems associated with the use of the free flowing spheres. Although Debrisan was one of the first `modern' debriding agents, its has now been largely replaced by Intrasite gel which is cheaper and easier to use.

 

Table 35: Polysaccharide bead dressings
Product Size (cm) Cost
Iodosorb range (£120,789)    
Iodosorb Powder 7 x 3 g sachet £13.50
Iodosorb Ointment 4 x 10 g sachet £18.05
  2 x 20 sachet £18.05
Iodoflex 5 x 5 g sachet £20.40
  3 x 10 g sachet £24.50
  2 x 17 g sachet £25.84
Debrisan range (£7,687)    
Debrisan Beads 10 x 4 g sachet £19.38
  60 g pot £29.01
Debrisan Paste 4 x 10 g sachet £19.89
  6 x 10 g sachet £29.93
Debrisan Pad 3 g pad £2.30


Figures in ( ) indicate expenditure for period July 1993-June 1994.

Moist sloughy wounds[Image-16K] (cont) - treatment with pharmaceutical preparations.

Traditionally, a number of pharmaceutical preparations been used to debride wounds. Much controversy surrounds the use of some of these materials, particularly those containing hydrogen peroxide and sodium hypochlorite. Most wound care experts recommend that they no longer be used because they are claimed to delay wound healing and may also cause adverse effects upon the surrounding skin. Nevertheless, some practitioners still believe that their short term use may be justified for the cleansing of particularly dirty or sloughy wounds[Image-16K]. The continued use of enzymatic debriding agents is similarly questioned, for although they have been shown to have some benefit in the treatment of wounds containing semi-liquid slough and purulent exudate, they are ineffective against wounds containing deep hard necroses. The pharmaceutical preparations offered for wound debridement are shown below.

 

Table 36: Pharmaceutical preparations used to debride wounds
Wound debriding preparations Cost (p)
Aserbine cream 100 g 117
Aserbine Solution 500 ml 176
Chlorosol 25 ml 36
Hioxyl cream 25 g 181
Hioxyl cream 100 g 565
Varidase Combi-Pack 820

 

Superficial granulating wounds[Image-16K]

If a wound involves a significant loss of dermal tissue, healing cannot occur unless the this damage is first repaired by the production of collagen-rich granulation tissue. During this process, particularly in the early stages, it is not unusual for the wound to produce significant quantities of serous fluid or exudate, the management of which may present considerable practical problems to the practitioner. As healing progresses, however, exudate production may diminish to the point at which a relatively impermeable dressing is required to ensure that the wound remains moist and in the optimum condition for rapid healing to take place. A range of dressing materials are available for this purpose, the choice of which will be determined by the site and nature of the wound as shown below.

 

Table 37; Recommended treatment for superficial granulating wounds[Image-16K]
Wound Type Recommended treatment
Heavily exuding wounds of limited depth Allevyn sheet dressing or Allevyn Adhesive
Heavily exuding deeper wounds or where undermining is present Alginate dressings such as Kaltogel or Sorbsan covered with a Perforated Plastic Film Dressing.
Moderately exuding superficial wounds As above but also consider Lyofoam, a hydrocolloid sheet or N-A dressing plus a suitable absorbent pad.
Lightly exuding granulating wounds[Image-16K] Lyofoam, or a hydrocolloid sheet (unless over granulation is a problem)

 

Superficial granulating wounds[Image-16K] (cont) - treatment with foam dressings

Allevyn is a highly absorbent dressing made from a hydrophilic polyurethane foam layer about 3 mm thick sandwiched between a low-adherent net facing layer and a polyurethane film backing. The dressing is highly absorbent and is useful for the management of most moderate-heavily exuding wounds. Allevyn adhesive consists of a piece of Allevyn foam which is bonded to a piece of polyurethane foam to form an island dressing the surface of which is coated with adhesive. Lyofoam consists of an open-cell hydrophobic polyurethane foam sheet, one surface of which has been heat treated to collapse the cells of the foam to allow it to take up blood or wound exudate by capillarity. Although the absorbency of Lyofoam is limited, it is very permeable to water vapour and may therefore be used on moderately exuding wounds. Tielle is a sophisticated island dressing consisting of a piece of polyurethane film/foam, located in the centre of an adhesive moisture vapour permeable, polyurethane membrane. The dressing is highly permeable to moisture vapour which makes it suitable for application to moderately exuding wounds despite its limited absorbent capacity.

Method of use

A suitably sized piece of dressing is chosen, applied to the wound and held in place with tape or a bandage as appropriate. Allevyn adhesive and Tielle clearly do not require the use of a secondary dressing. Unlike most absorbent dressings, Lyofoam transmits absorbed fluid laterally across the face of the dressing rather than from front to back. For this reason, a size of Lyofoam should always be selected which overlaps the edges of the wound by about 2-3 cm.

Indications

The Allevyn range can be used in the management of most heavily exuding wounds including leg ulcers, traumatic wounds,minor burns[Image-16K], donor sites[Image-16K] and malignant wounds. Lyofoam has been used for a similar range of applications when exudate production is reduced. Tielle may be used for most moderately exuding wounds because of its high MVTR.

 

Table 38: Polyurethane foam dressing
Product Size (cm) Cost (p)
Lyofoam (£61,738) 7.5 x 7.5 83
  10 x 10 99
  17.5 x 10 154
  20 x 15 208
Allevyn (No data) 5 x 5 93
  10 x 10 185
  10 x 20 295
  20 x 20 495
Allevyn adhesive (No data) 7.5 x 7.5 112
  12.5 x 12.5 202
  17.5 x 17.5 398
  22.5 x 22.5 579
Tielle (No data) 11 x 11 192
  15 x 20 399
  18 x 18 399
Spyrosorb (No data) 10 x 10 198
  20 x 20 565


Figures in ( ) indicate expenditure for period July 1993-June 1994.

Superficial granulating wounds[Image-16K] (cont) - treatment with alginate dressings

Five alginate dressings are available on the Drug Tariff. Most consist of calcium alginate formed into textile fibres. Sorbsan consists primarily of fibres of calcium alginate rich in mannuronic acid. Kaltostat is produced from fibres of calcium/sodium (80:20) alginate rich in guluronic acid. Tegagel is chemically similar to Sorbsan but more closely resembles Kaltostat in appearance. Kaltogel, a new addition to the Tariff, is also rich in mannuronic acid but also contains 20% sodium alginate to facilitate rapid gelling. Comfeel Alginate Dressing, rich in guluronic acid, is made by a freeze drying process and is therefore a fibre-free mass of calcium alginate which is supported on a nylon mesh net.

Method of use

A suitable size of dressing is chosen and applied to the surface of the wound. It is usually recommended that a Kaltostat is cut to the size and shape of the wound but this is not usual for the other products. The dressing is then covered with a secondary dressing such as a perforated plastic film or semipermeable film depending upon the amount of exudate that is anticipated. The chemical and physical properties of the alginate dressings are very different and this has implications for the selection and method of use of the products concerned. Sorbsan and Kaltogel are soluble in 0.9% sodium chloride solution and are therefore easily removed from the wound by irrigation. Tegagel and Kaltostat are less soluble and therefore may be removed from the wound intact as may the Comfeel product and Kaltogel - provided it is not saturated with saline.

Indications

Alginate dressings may be used for the treatment of most exuding wounds such asleg ulcers[Image-16K], minor burns[Image-16K], donor sites[Image-16K], surgical wounds, pressure sores[Image-15K] and malignant wounds. They also have haemostatic properties, and one product, Kaltostat, has a product licence for this application.

 

Table 39: Alginate dressings
Size (cm) Comfeel (No data) Kaltogel (No data) Kaltostat (£162,241) Sorbsan (£192,409) Tegagel (No data)
5 x 5   0.70 0.72 0.87 0.72
6 x 4 0.69        
7.5 x 12     1.57    
10 x 10 1.44 1.45   1.54 1.50


Figures in ( ) indicate expenditure for period July 1993-June 1994.

Superficial granulating wounds[Image-16K] (cont) - treatment with hydrocolloid dressings

Three hydrocolloid dressings are listed in the Drug Tariff, and these vary significantly in their composition and physical characteristics. The products differ in price, but in the absence of hard published data on their relative clinical effectiveness, it is not possible to make any recommendation on preferred usage. In the presence of wound exudate, the dressings absorb liquid and form a gel, the precise nature of which is determined by the product selected.

Method of use

The dressings are very easy to use. An appropriate size product is chosen, the backing removed and the dressing applied over the wound ensuring an overlap of about 2 cm all around to avoid leakage. The dressing may be left in place for a maximum of 5-7 days depending upon the nature of the wound.

Indications

Hydrocolloids are generally indicated for use in light-moderately exuding wounds including pressure sores[Image-15K], minor burns[Image-16K] and traumatic injuries. Also used extensively in the management of leg ulcers where they appear to have advantages in the treatment of wounds that fail to respond to compression therapy alone. Because hydrocolloid dressings do not cause pain on removal, they are particularly useful in paediatric wound care for the management of both acute and chronic wounds.

 

Table 40: Hydrocolloid dressings
Product Size (cm) Cost (p)
Tegasorb (oval) (£24,269) 10 x 12 201
  13 x 15 379
Granuflex (£591,566) 10 x 10 212
  15 x 15 399
  15 x 20 435
  20 x 20 599
Comfeel (£241,056) 10 x 10 211
  15 x 15 419
  20 x 20 628


Figures in ( ) indicate expenditure for period July 1993-June 1994.

Superficial granulating wounds[Image-16K] (cont) - treatment with low-adherent dressings

Low-adherent wound contact layers are used as interface layers to prevent a secondary absorbent dressing from adhering to the surface of a wound and causing trauma on removal. They are available both plain and impregnated with soft paraffin which may also contain an antibacterial agent. Most wound care experts would agree, however, that medicated products should be avoided unless there is clear evidence of clinical wound infection present. The most widely used low adherent dressings are now Knitted Viscose Primary Dressing BP, more familiarly known as NA Dressing or Tricotex, is a simple knitted fabric that is claimed to have limited adherence properties. This dressing is commonly used as the initial layer of the Four Layer Bandage system. For many applications, NA Dressing and Tricotex have largely replaced the paraffin gauze dressings (tulles), which, despite their greasy nature and description of `low-adherent dressings', often become firmly attached to the surface of a wound causing pain or discomfort upon removal.

 

Table 41: Plain, low-adherent wound contact agents
Product Size (cm) Cost (p)
N-A Dressing (£80,980) 9.5 x 9.5 28
Tricotex (£20,238) 9.5 x 9.5 23
Paraffin Gauze (£44,512)    
Individually wrapped 10 x 10 30
Bulk pack of 10 10 x 10 210

 

Cavity wounds

Cavity wounds are formed when significant damage to the dermis has occurred. Cavity wounds may be open and `boat-shaped' or may involve significant undermining of the surrounding tissue. In extreme cases this can result in the formation of a flask-shaped wound with a narrow opening leading into a chamber beneath the skin. Such wounds, like sinuses[Image-15K], can be very difficult to heal without surgical intervention. Unfortunately, at the present time, there are no cavity wound dressings available on the Drug Tariff and therefore the products available to treatment these often extensive complex wounds are very limited. Traditionally cavity wounds have been packed with absorbent fabric such as ribbon gauze, often soaked in hypochlorite or proflavine solutions. This technique has now largely fallen out of favour and most hospital-based practitioners now tend to use alginate ribbon or rope. As neither of these materials are available on the Tariff, the sheet forms of alginate dressings are commonly used for larger open wounds, cut into strips if required. For narrow wounds or sinuses[Image-15K]Intrasite gel is sometimes used.

 

Table 42: Recommended treatment for cavity wounds
Wound Type Recommended treatment
Heavily exuding open cavities or large deep wounds with undermining Alginate sheet dressings such as Kaltogel or Sorbsan covered with a suitable absorbent pad.
Narrow cavity wounds orsinuses[Image-15K] Alginate dressings such as Kaltogel or Sorbsan where practicable or Intrasite gel if the wounds are too narrow to permit the use of the alginates.

 

Cavity wounds - treatment with alginate dressings

Five alginate dressings are available on the Drug Tariff. Most consist of calcium alginate formed into textile fibres. Sorbsan consists primarily of fibres of calcium alginate rich in mannuronic acid. Kaltostat is produced from fibres of calcium/sodium (80:20) alginate rich in guluronic acid. Tegagel is chemically similar to Sorbsan but more closely resembles Kaltostat in appearance. Kaltogel, a new addition to the Tariff, is also rich in mannuronic acid but also contains 20% sodium alginate to facilitate rapid gelling. Comfeel Alginate Dressing, rich in guluronic acid, is made by a freeze drying process and is therefore a fibre-free mass of calcium alginate which is supported on a nylon mesh net.

Method of use

Alginate dressings may be used for the treatment of most cavity wounds providing that they can be easily inserted and removed. (It may be necessary to cut them into strips for some applications). The chemical and physical properties of the alginate dressings are very different and this has implications for the selection and method of use of the products concerned. Sorbsan and Kaltogel are soluble in 0.9% sodium chloride solution and are therefore easily removed from a wound cavity by irrigation with saline. Tegagel and Kaltostat are less soluble in saline and therefore must be removed from the wound intact using a forceps or gloved hand. The Comfeel product maintains its integrity because of the nylon mesh carrier and is also removed in one piece.

Indications

Alginates can be used for the treatment of most cavity wounds including abscesses, surgical wounds and pressure sores[Image-15K].

 

Table 43: Alginate dressings
Size (cm) Comfeel (No data) Kaltogel (No data) Kaltostat (£162,241) Sorbsan (£192,409) Tegagel (No data)
5 x 5   0.70 0.72 0.87 0.72
6 x 4 0.69        
7.5 x 12     1.57    
10 x 10 1.44 1.45   1.54 1.50


Figures in ( ) indicate expenditure for period July 1993-June 1994.

Epithelialising wounds

Epithelialisation is the final stage in the healing process and takes place when epithelial cells from the margin of the wound or hair follicles in the dermis proliferate and grow over the surface of exposed granulation tissue. At this stage of the healing cycle, the wound tends to be relatively dry and therefore a dressing is required which conserves moisture and prevents the exposed tissue from drying out. Although a number of different products can be used, most favoured are materials which form a moisture retaining protective covering over the wound surface.

 

Table 44: Recommended treatment for epithelialising wounds
Wound Type Recommended treatment
Epithelialising or lightly exudating wounds Semipermeable films, hydrocolloid sheets, Lyofoam, Spyrosorb, Perforated plastic film dressings.

 

Epithelialising/lightly exuding wounds (cont) - treatment with semipermeable films

There are currently four adhesive film dressings available on the Tariff. They are all made from a thin sheet of polyurethane coated with a layer of acrylic adhesive. The dressings are permeable to moisture vapour and gases but impermeable to liquids. They therefore provide protection to the wound but prevent it from becoming macerated .

Method of use

Although the physical properties of the films from which the dressings are constructed are broadly comparable, major differences exist in the application systems that have been developed for them. Users often express a strong preference for a particular brand of film dressing because they have become familiar with its method of use Basically, however, a suitably sized dressing is selected, the backing removed and the polyurethane film applied over the wound, taking care not to apply it under tension which could cause damage to the surrounding skin.

Indications

Film dressings have a wide range of applications. Their use has been reported in burns, donor sites[Image-16K], surgical wounds and superficial pressure sores[Image-15K]. They are also used as secondary dressings in combination with alginates and hydrogels.

 

Table 45: Semipermeable film dressings
Product Size (cm) Cost (p)
Cutifilm (£2,125) 10 x 14 106
  7.5 x 10 62
Opsite (£157,077) 10 x 12 116
Tegaderm (£331,306) 10 x 12 121
Bioclusive (£35,871) 10.2 x 12.7 128


Figures in ( ) indicate expenditure for period July 1993-June 1994.

Epithelialising wounds (cont) - treatment with perforated plastic film dressings

These dressings are designed to combine a degree of absorbence with low-adherence for the management of lightly exuding superficial wounds. They consist of an absorbent fibrous fleece covered with a plastic film containing a series of small holes arranged in a uniform pattern. The plastic film is intended to prevent the dressing adhering to the surface of the wound and the holes are present to allow the passage of exudate through to the absorbent layer.

Method of use

A suitably sized dressing is selected and held in place over the wound using tape or a bandage as appropriate. The ability of these dressings to absorb exudate is limited, and for more heavily exuding wounds they are sometimes covered with a second absorbent pad. In these situations the absorbency of the dressing is less important than its low-adherent properties.

Indications

Perforated film absorbent dressings are widely used in the treatment of superficial wounds such cuts and grazes and are frequently applied in combination with hydrogels or alginates for more heavily exuding wounds.

 

Table 46: Perforated film absorbent dressings
Product Size (cm) Cost (p)
Skintact (£879) 5 x 5 10
  10 x 10 17
  20 x 10 33
Release (£14,864) 5 x 5 11
  10 x 10 19
  20 x 10 36
Melolin (£308,008) 5 x 5 12
  10 x 10 20
  20 x 10 39

 

Epithelialising wounds (cont) - treatment with hydrocolloid sheets

Three hydrocolloid dressings are listed in the Drug Tariff, and these vary significantly in their composition and physical characteristics. The products differ in price, but in the absence of hard published data on their relative clinical effectiveness, it is not possible to make any recommendation on preferred usage. In the presence of wound exudate, the dressings absorb liquid and form a gel, the precise nature of which is determined by the product selected.

Method of use

The dressings are very easy to use. An appropriate size product is chosen, the backing removed and the dressing applied over the wound ensuring an overlap of about 2 cm all around to avoid leakage. The dressing may be left in place for a maximum of 5-7 days depending upon the nature of the wound.

Indications

Hydrocolloids are generally indicated for use in light-moderately exuding wounds including pressure sores[Image-15K], minor burns[Image-16K] and traumatic injuries but they can also be used for lightly exuding wounds if required. It has been observed that wounds dressed with hydrocolloid dressings sometimes tend to over-granulate. If this is noted a change to more permeable dressing such as a semipermeable film may be indicated

 

Table 47: Hydrocolloid dressings
Product Size (cm) Cost (p)
Tegasorb (oval) (£24,269) 10 x 12 201
  13 x 15 379
Granuflex (£591,566) 10 x 10 212
  15 x 15 399
  15 x 20 435
  20 x 20 599
Comfeel (£241,056) 10 x 10 211
  15 x 15 419
  20 x 20 628


Figures in ( ) indicate expenditure for period July 1993-June 1994.

Epithelialising exuding wounds (cont) - treatment with foam dressings

Of the five polyurethane foam dressing included in the Drug Tariff the products recommended for lightly exuding wounds are Lyofoam and Spyrosorb. The remaining products are generally used for more heavily exuding wounds Lyofoam consists of an open-cell polyurethane foam sheet, one surface of which has been heat treated to collapse the cells of the foam and allow it to take up blood or wound exudate by capillarity. It is used in the management of a variety of different wound types including leg ulcers, traumatic wounds,minor burns[Image-16K] , and donor sites[Image-16K] Spyrosorb is thin sheet of polyurethane foam coated with adhesive. The dressing which is very conformable, has limited absorbent capacity but is highly permeable to moisture vapour. It is used for dressing relatively shallow/lightly exuding wounds or wounds in the final stages of healing.

Method of use

A suitably sized dressing is chosen, applied to the wound and held in place with tape or a bandage as appropriate. Unlike most absorbent dressings, Lyofoam transmits absorbed fluid laterally across the face of the dressing rather than from front to back. For this reason, a size of Lyofoam should always be selected which overlaps the edges of the wound by about 2-3 cm. Spyrosorb being adhesive does not require a secondary dressing.

Indications

Lyofoam and Spyrosorb may be used for most lightly exuding wounds in the final stages of healing.

 

Table 48: Polyurethane foam dressing
Product Size (cm) Cost (p)
Lyofoam (£61,738) 7.5 x 7.5 83
  10 x 10 99
  17.5 x 10 154
  20 x 15 208
Allevyn (No data) 5 x 5 93
  10 x 10 185
  10 x 20 295
  20 x 20 495
Allevyn adhesive (No data) 7.5 x 7.5 112
  12.5 x 12.5 202
  17.5 x 17.5 398
  22.5 x 22.5 579
Tielle (No data) 11 x 11 192
  15 x 20 399
  18 x 18 399
Spyrosorb (No data) 10 x 10 198
  20 x 20 565

 

Infected or malodorous wounds

Wounds which contain large numbers of pathogenic bacteria may become clinically infected which will delay healing and may even lead to a life-threatening systemic infection. An appropriate form of topical treatment used as an adjunct to systemic antibiotics is likely to be of value in this situation. Other wounds, often those which contain significant quantities of slough or necrotic material, may become heavily colonised with proteolytic bacteria the metabolic processes of which can result in the formation of extremely unpleasant odours. This often occurs in pressure sores[Image-15K] and malignant wounds but it is also not uncommon in leg ulcers. There are two ways of dealing with this problem. Either a dressing containing activated charcoal can be applied to absorb the odour, or an appropriate treatment administered to kill the organisms that are responsible for causing the infection. At the present time, activated charcoal dressings are not reimbursable and are therefore not available to most practitioners in the community. The only alternative, therefore, is to use some form of medicated dressing or topical application until the infection is brought under control. Once the infection has been eradicated a change to an alternative dressing is probably indicated.

 

Table 49: Recommended treatment for infected or malodorous wounds
Wound Type Recommended treatment
Infected or malodorous wounds Dressings containing iodine such as Inadine, Iodosorb, Iodoflex. Paraffin gauze dressings containing antibiotics such as Sofratulle or Fucidin-tulle but only where specifically indicated. Pharmaceutical preparations such as Metronidazole gel Also consider Alginate dressings such as Sorbsan covered with a suitable absorbent pad.

 

Infected/malodorous wound (cont) - treatment with medicated tulles

Paraffin gauze dressings containing antibiotics such as sodium fusidate and framycetin have the potential to cause sensitivity reactions and the development of resistant strains of micro-organisms. For this reason they should be avoided unless they are specifically indicated following microbiological investigations. Dressings such as Bactigras and Serotulle which contain an antiseptic, chlorhexidine, instead of an antibiotic are generally considered to be free of these disadvantages. Laboratory tests suggest that the chlorhexidine is not readily released from the hydrophobic paraffin base and therefore the antibacterial activity of these dressings is likely to be limited. Inadine contains povidone iodine in polyethylene glycol which is hydrophilic and therefore better able to liberate the antimicrobial agent into wound exudate in order to exert a bactericidal effect.

Method of use

A suitably sized dressing is applied to the wound and covered with a secondary dressing such as a perforated plastic film held in place with tape or a bandage as appropriate. Depending upon the condition of the wound the dressing should be changed every 24-48 hours until the infection is brought under control.

Indications

Medicated paraffin gauze-type dressings are used in the treatment of wounds such as ulcers where clinical infection has been identified. If cellulitis is also present, consideration should also be given to the use of systemic antibiotics.

 

Table 50: Medicated Low-adherent wound contact layers
Product Size (cm) Cost (p)
Inadine (£82,376) 5 x 5 25
  9.5 x 9.5 38
Chlorhexidine Gauze Dressing BP 5 x 5 21
(Bactigras, Serotulle, Chlorhexitulle) (£45,852) 10 x10 45
Fucidin Intertulle* (£2,363) 10 x 10 22
Sofra Tulle* (£18,148) 10 x 10 23


* The use of these dressings should be avoided where possible.

Infected/malodorous wound (cont) - treatment with polysaccharide bead dressings.

Both the Debrisan and Iodosorb range are sold for the treatment of sloughy or infected wounds[Image-16K] but the Iodosorb products which contain elemental iodine have a clear theoretical advantage over non-medicated Debrisan in the treatment ofinfected wounds[Image-16K].

Method of use

Iodosorb ointment can be applied directly to a wound or placed upon the surface of a dressing which is then applied as normal. Iodoflex consists of a layer of Iodosorb ointment sandwiched between two pieces of gauze. Once a suitable size dressing has been selected, one piece of gauze is removed and the dressing is applied to the wound and covered with a secondary dressing such as a perforated plastic film.

Indications

Iodosorb ointment is indicated for the treatment of small infected cavity wounds whilst Iodoflex is most suitable for larger shallowinfected wounds[Image-16K] such as leg ulcers.

 

Table 51: Polysaccharide bead dressings
Product Size (cm) Cost
Iodosorb range (£120,789)    
Iodosorb Powder 7 x 3 g sachet £13.50
Iodosorb Ointment 4 x 10 g sachet £18.05
  2 x 20 sachet £18.05
Iodoflex 5 x 5 g sachet £20.40
  3 x 10 g sachet £24.50
  2 x 17 g sachet £25.84
Debrisan range (£7,687)    
Debrisan Beads 10 x 4 g sachet £19.38
  60 g pot £29.01
Debrisan Paste 4 x 10 g sachet £19.89
  6 x 10 g sachet £29.93
Debrisan Pad 3 g pad £2.30


Figures in ( ) indicate expenditure for period July 1993-June 1994.

Infected/malodorous wound (cont) - treatment with pharmaceutical preparations.

The antibacterial agents that may be used topically to prevent or combat wound infection are identified below. Antibiotic powders are used mainly in the treatment of infections in superficial wounds although some are also indicated for larger wounds. These products contain neomycin that is known to cause skin sensitisation and there is also a theoretical risk that their application can also lead to the emergence of resistant strains of bacteria. Antibiotic powders should therefore probably be avoided or used with extreme caution. Silver sulphadiazine cream, e.g. Flammazine, is used extensively in specialist centres for the treatment of extensive burns. Because the cream is active against a wide range of pathogenic organisms, including Pseudomonas sp., it is also of value in the treatment of infected leg ulcers and other wounds. Preparations containing the antibiotic metronidazole, e.g. Metrotop, are effective against the potentially pathogenic anaerobic bacteria often found in necrotic tissue. As such it is very useful agent for combating the odour produced by malignant or sloughy wounds[Image-16K]. Povidone iodine preparations are sometimes used in the treatment of infected wounds. Like other antiseptics, however, their use should be discontinued once the infection is brought under control, for povidone iodine may have an adverse effect upon wound healing.

 

Table 52: Antimicrobial agents
Antiseptic/antibiotic preparations Cost (£)
Betadine dry powder spray 150 g 2.92
Betadine antiseptic paint 8 ml 1.06
Tribiotic 110 g 5.72
Flammazine  
50 g 4.30
500 g 20.40
Metrotop  
15 g 4.95
30 g 8.75

 

Infected/malodorous wound (cont) - treatment with alginate dressings

A certain amount of anecdotal evidence is available to suggest that at least one alginate dressing, Sorbsan, may be of some value in the treatment of infected and necrotic wounds[Image-16K] although this has not been confirmed in a randomised controlled clinical trial. The reasons for this observed effect are not understood but it is possible that the activity may be associated with the gel-forming abilities of this particular dressing. If used in the treatment of infected wounds[Image-16K] the dressing should be changed regularly, at least every 48 hours.

Skin and wound cleansing

Surgical Swabs

Although there is now a general move away from routine mechanical cleansing of the surface of a wound, there are occasions when it is necessary to remove residues of slough or other debris from the wound or surrounding skin. The most commonly used materials for this purpose are cellulose swabs These are products which, although not designed to be left in intimate contact with damaged tissue, may be used for cleansing purposes or as secondary absorbent layers over a primary dressing in the management of heavily exuding wounds. Surgical swabs are traditionally produced from Gauze, a simple woven fabric made from absorbent cotton but developments in textile technology have led to the production of nonwoven fabrics manufactured principally from viscose which have a number of advantages over woven cotton. Specifically, they are generally more absorbent and are less likely to shed fibrous material into the wound which may delay healing or predispose the wound to infection. They are also significantly cheaper. Filmated swab contains a thin layer of absorbent cotton (cotton wool) which is included to improve the fluid handling properties, although the presence of the loose cotton fibres must increase the risk of particulate loss from the finished product. Filmated swabs may be manufactured from either woven or nonwoven fabric but laboratory tests have shown that despite the presence of the fibrous cotton interliner, the filmated swabs available upon prescription are inferior in performance terms to the ordinary nonwoven product despite being significantly more expensive

 

Table 53: Non-sterile swabs
Non sterile swabs (100s) 10 cm x 10 cm Cost (p)
Nonwoven swabs (£11,584) 234
Cotton gauze swabs BP (£127,208) 498
Nonwoven filmated (Regal) (£15,930) 507
Cotton gauze filmated (£4,540) 620
Table 54: Sterile swabs
Sterile swabs (5s) (7.5 cm x 7.5 cm) Cost (p)
Nonwoven Swabs (£3,686) 20
Cotton Gauze BP (£34,103) 29

Wound cleansing solutions

Wound cleansing agents are solutions that are used to cleanse wounds prior to the application of a dressing. As such they should not be confused with debriding agents that are generally applied and left in-situ to facilitate removal of slough or necrotic tissue. Most wound-care experts now agree that the routine use of antiseptic solutions has little place in wound management. Antiseptics, particularly those which contain cetrimide, have marked cytotoxic properties and therefore should be avoided unless the wound is contaminated or shows clear evidence of infection. For most applications, a sterile solution of normal saline is to be preferred for routine wound cleansing.

 

Table 55: Wound cleansing solutions
Cleansing solutions Cost (p)*
Sodium Chloride Solution  
Irriclens aerosol 250 ml 298
Normasol 25 ml sachets 23
Normasol 100 ml sachets 72
Sterac 150 ml 83
Sterijet 25 ml plastic amps 31
Steripod Blue 25 ml plastic amps 34
Chlorhexidine solution **  
Sterexidine 0.02%, 150 ml 83
Steripod pink 20 ml plastic amps 27
Unisept 25 ml 23
Unisept 100 ml 72
Chlorhexidine and cetrimide solution ***  
Steripod Yellow 25 ml plastic amps 27
Tisept sachets 25 ml 30
Tisept sachets 100 ml 72
Travasept 500 ml 74

* Rounded to nearest p, ** Not recommended for routine use ; *** avoid use where possible

Bandaging Applications

Venous ulcers and the role of compression

It has been estimated that in the United Kingdom, the prevalence of venousulcers[Image-16K] is about 0.15% of the adult population. Much research has demonstrated that the majority of these ulcers will respond favourably to compression therapy provide that clinically effective levels of pressure are applied and maintained over an extended period. Compression implies the application of clinically effective levels of external pressure, applied to modify or assist a physiological process - generally blood flow. It is currently believed that compression values of around 40 mm Hg at the ankle reducing progressively up the leg are suitable for this purpose. The Crepe-type bandages that have been used for many years for the treatment of venous leg ulcers are totally incapable of maintaining the levels of pressure required. More recently a new generation of bandages and bandaging systems have been developed that are capable of producing these required levels. A recently introduced British Standard that describes a performance-based classification system for elastic bandages has designated these compression bandages as Type 3c.The bandages in the Drug Tariff that are suitable for the application of high levels of compression are described below. The inappropriate use of compression bandages can have very serious consequences, resulting in extreme cases in necrosis and amputation[Image-0K] It is vitally important, therefore, that no form of high compression bandaging system is applied to a patient unless the possibility of arterial disease has first been excluded by some appropriate method, and that all nursing staff involved in compression bandaging have been properly trained in the theory and practical application of this technique.

 

Table 56: Compression bandages
Bandage Type Cost (p)  
  7.5 cm 10 cm
Tensopress 225 292
Setopress 229 296
Blue line with foot loop 402 -
Red line 2.5 m 318 -
Red line 3.5 m 384 -

Support Bandages

Support may be defined as the retention and control of tissue without the application of compression. It is usually provided to prevent the development of a deformity or change in shape of a mass of tissue due to swelling or sagging. Support bandages are available both plain and coated with adhesive.

Plain support bandages

The support bandages available on the Drug Tariff are Crepe Bandage BP, woven from cotton and wool, and Cotton Crepe Bandage BP - more familiarly known as Elastocrepe which is made entirely of cotton. Both types of bandage have been used to provide support in the treatment of sprains and strains and to apply compression in the management of leg ulcers caused by venous insufficiency. Numerous published studies have demonstrated, however, that the elastic properties of these bandages are such that they are unable to provide and maintain the levels of pressure that are required for this indication and therefore they should not be used for this purpose. Competent compression bandages containing elastomeric yarns are much better suited for this application, and these are described elsewhere. It is likely that a significant proportion of all crepe bandages supplied are used inappropriately for dressing retention. This is not cost effective, for these bandages are much more expensive than the bandages described in Table 59 .

 

Table 57: Plain Support Bandages
Bandage Type Cost (p)      
  5 cm 7.5 cm 10 cm 15 cm
Crepe BP 79 110 146 208
Cotton Crepe - 251 325 -

 

Adhesive support bandages

There are two adhesive bandages in the Drug Tariff. Elastic Adhesive Bandage BP, Elastoplast, which is coated with a zinc oxide adhesive, and Diachylon Adhesive Bandage, more commonly known as Lestreflex, which is used in place of Elastoplast where skin sensitivity reactions are present or suspected.

 

Table 58: Adhesive Bandages
Bandage Type Cost (p)    
  5 cm 7.5 cm 10 cm
Elastic Adhesive Bandage BP (£24,828) 295 426 567
Elastic Diachylon Bandage BP (£41,391) - 321 -

Retention bandages

As their name suggests, these bandages are used to retain dressings in place. They should not be used to apply pressure as they are unsuitable for this purpose. There are two basic types of retention bandages, flat or `roller' bandages and tubular bandages.

Flat bandages

The first `retention bandage' was White Open Wove (WOW) a rigid fabric with extremely limited conformability that is available in a range of widths. Because of the poor performance characteristics of WOW two softer more conformable bandages were introduced. These are Kling and Crinx the Cotton Conforming Bandages of the British Pharmacopoiea. New lightweight bandages have since been developed that have advantages over the simple cotton products. Some of these are included in the Tariff, and although they vary in performance and price, all of them are cheaper than the products they are designed to replace.

 

Table 59: Retention bandages
Bandage Type Cost (p)        
  2.5cm 5 cm 7.5cm 10 cm 15 cm
K-Band - 16 20 23 39
Easifix - 30 37 43 73
Stayform - 30 38 43 73
Slinky - 37 52 63 89
Crinx - 56 70 85 117
Kling - 58 75 91 120
White open wove 27 45 64 84 -

 

Elasticated Tubular Bandages

Two types of lightweight elasticated tubular bandage are included in the Tariff. Tubifast is a lightweight elasticated stockinette that is particularly useful for holding dressings in place on digits and limbs and Netelast has an open net-like structure and can be cut and fashioned into garments to retain dressings on awkward anatomical sites such as the head or groins region.


Conclusions  

The review of PACT data described in the original report indicated that significant financial savings could be achieved on an `All Wales' basis by making changes to prescribing patterns for surgical dressings. Although some of the proposed changes are relatively trivial, others may require medical and nursing staff to consider more fundamental modifications to their approach to wound management and the treatment of chronic wounds such as venous leg ulcers. Some changes may not be accepted for reasons which have been outlined in the text, but nevertheless it is conservatively estimated that it should be possible to reduce expenditure on wound management by at least £250,000 in material costs alone. These figures take no account of much larger, long-term savings which would result from an improvement in the healing rate of venousulcers[Image-16K] following the use of more effective types of compression bandages. It is therefore proposed that urgent attention be given to the development of research-based wound management formularies designed to limit the use of dressings to those items which meet accepted standards of safety and efficacy. The aim of such formularies should not be to exclude new developments but to ensure that the dressings which are available are used in a cost effective manner. This in turn implies a comprehensive programme of training and education for all those involved in wound care, for without such training the selection and use of dressings will continue to be unscientific and wasteful both in terms of time and physical resources. Dr S Thomas, Surgical Materials Testing Laboratory, Bridgend General Hospital, Bridgend.



  

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