I see lots of wound specialist providers ordering complex, multi-faceted dressing regimens.
Maybe it is the best possible treatment for the patient, but maybe not… Consider whether it can be simplified.
Why? You would be surprised how often dressing orders are not so much dictated by evidence but by a tendency to throw a little bit of this and a little bit of that in, hoping that the sum will be greater than its parts.
Unfortunately, the result is often just the opposite. Whereas intensive design and research goes into the development of many of our individual wound care formulary items, there is little or no testing of the myriad combinations of products that are ordered, “out in the wild.”
It is very popular these days to prescribe what I call the “Club Sandwich Dressing.” You know what I mean by this. It is like sandwiches with so many layers that you can’t get your mouth around them.
Those sandwiches may look mouthwatering, but dressings with multiple contact layers, and cover layers are often less effective than simple dressing regimens with one contact layer, one cover layer, and something to protect the periwound if necessary.
For example, here is a Club Sandwich Dressing regimen: Hydrofera Blue and Silvasorb over wound bed, covered with alginate and bordered foam. What’s wrong with this? Hydrofera Blue is an open-cell foam designed to remove bioburden from the wound bed as the open-cells in the foam adhere to the bioburden, which gets removed when the dressing is changed. It also contains two different antimicrobial components, Methylene Blue and Gentian Violet. Silvasorb is also designed to help remove bioburden by a different mechanism, namely autolytic debridement. As a hydrogel, Silvasorb delivers moisture in a controlled fashion to the wound bed, softening bioburden, which is either washed away during dressing changes or allowed to be more easily removed via sharps debridement. It also contains silver ions, which have an antimicrobial effect. How does this combination work out in practice?
The hydrogel will tend to clog the open cell foam pores in the Hydrofera Blue, preventing its action of adhering to bioburden. Additionally, the Silvasorb, being pulled into the open cell foam pores, can’t do its job well, either. Why not try one or the other? If the wound is relatively low in moisture, Silvasorb may be the better strategy. Hydrofera Blue may be the better choice if moisture is more moderate. However, together, they don’t add benefits. Why?
Here is my overall suggestion: give a single contact layer dressing a chance and modify it if it doesn’t give the results you expect after 5-7 days. I believe this approach will generate more predictable outcomes while saving money that can be used to enhance care in other ways and even add formulary choices if needed.
What about the cover dressings? The orders in the example above specified an alginate over the Hydrofera Blue, presumably to absorb excess moisture, but this is already part of the Hydrofera Blue’s job. If the provider who wrote the orders thinks that the wound moisture is too excessive to be dealt with by Hydrofera Blue, it may not be the correct choice for a contact layer. Maybe the provider thinks that the alginate will protect the periwound. If so, wouldn’t Marathon or Cavilon be a better strategy?
Finally, we have bordered foam on top, a dressing designed to provide moisture management and maintain optimal temperature characteristics. It is on top of three contact layers: Silvasorb, Hydrofera, and alginate.
This is just one example, and you see the point.
To summarize: A prudent dressing regimen should consist of:
- A single, optimal contact layer based on current wound conditions (moisture, bioburden, )
- Protection for the periwound, if needed, based on drainage and periwound skin conditions
- One cover dressing
Share your thoughts, please!
Marcus Gitterle, MD, FACCWS Chief Medical Officer