LA CONSULTA SEMANAL

NOVIEMBRE 2000

CONSULTA

Health Technol Assess 2000;4(21):1-237
Systematic reviews of wound care management: (3) antimicrobial agents for chronic wounds; (4) diabetic foot ulceration.
O'Meara SO, Cullum N, Majid M, Sheldon T
NHS Centre for Reviews and Dissemination, University of York, UK.
BACKGROUND: Chronic wounds, including pressure sores, leg ulcers, diabetic foot ulcers and other kinds of wounds, healing by secondary intention are common in both acute and community settings. The prevention and treatment of chronic wounds includes many strategies, including the use of various wound dressings, bandages, antimicrobial agents, footwear, physical therapies and educational strategies. This review is one of a series of reviews, and focuses on the prevention and treatment of diabetic foot ulcers and the role of antimicrobial agents in chronic wounds in general. OBJECTIVES: To assess the clinical- and cost-effectiveness of (1) prevention and treatment strategies for diabetic foot ulcers and (2) systemic and topical antimicrobial agents in the prevention and healing of chronic wounds. METHODS - DATA SOURCES: Nineteen electronic databases were searched, including MEDLINE, CINAHL, Embase and the Cochrane Library. Relevant journals, conference proceedings and bibliographies of retrieved papers were hand-searched. An expert panel was consulted. METHODS - STUDY SELECTION: Randomised and non-randomised trials with a concurrent control group, which evaluated any intervention for the prevention or treatment of diabetic foot ulcers, or systemic or topical antimicrobials for chronic wounds (diabetic foot ulcers, pressure ulcers, leg ulcers of various aetiologies, pilonidal sinuses, non-healing surgical wounds, and cavity wounds) and used objective measures of outcome such as: (1) development or resolution of callus; (2) incidence of ulceration (for diabetic foot ulcer prevention studies); (3) incidence of pressure sores (pressure sore prevention studies); (4) any objective measure of wound healing (frequency of complete healing, change in wound size, time to healing, rate of healing); (5) ulcer recurrence rates; (6) side-effects; (7) amputation rates (diabetic foot ulcer treatment studies); (8) healing rates and recurrence of disease, among others, for pilonidal sinuses. Studies reporting solely microbiological outcomes were excluded. Decisions on the inclusion of primary studies were made independently by two reviewers. Disagreements were resolved through discussion. Data were extracted by one reviewer into structured summary tables. Data extraction was checked independently by a second reviewer and discrepancies resolved by discussion. All included studies were assessed against a comprehensive checklist for methodological quality. INCLUDED STUDIES - DIABETIC FOOT ULCERS: Thirty-nine trials which evaluated various prevention and treatment modalities for diabetic foot ulcers: footwear (2), hosiery (1), education (5), screening and foot protection programme (1); podiatry (1) for the prevention of diabetic foot ulcers; and footwear (1), skin replacement (2), hyperbaric oxygen (2), ketanserin (3), prostaglandins (3), growth factors (5), dressings and topical applications (9), debridement (2) and antibiotics (2) for the treatment of diabetic foot ulcers. INCLUDED STUDIES - ANTIMICROBIALS: Thirty studies were included, 25 with a randomised design. There were nine evaluations of systemic antimicrobials and 21 of topical agents. QUALITY OF STUDIES: The methodological and reporting quality was generally poor. Commonly encountered problems of reporting included lack of clarity about randomisation and outcome measurement procedures, and lack of baseline descriptive data. Common methodological weaknesses included: lack of blinded outcome assessment and lack of adjustment for baseline differences in important variables such as wound size; large loss to follow-up; and no intention-to-treat analysis. RESULTS - PREVENTION OF DIABETIC FOOT ULCERS: There is some evidence (1 large trial) that a screening and foot protection programme reduces the rate of major amputations. The evidence for special footwear (2 small trials) and educational programmes (5 trials) is equivocal. A single trial of podiatric care reported a significantly greater reduction in callus in patients receiving podiatric care. RESULTS - TREATMENT OF DIABETIC FOOT ULCERS: Total contact casting healed significantly more ulcers than did standard treatment in one study. There is evidence from 5 trials of topical growth factors to suggest that these, particularly platelet-derived growth factor, may increase the healing rate of diabetic foot ulcers. Although these studies were of relatively good quality, the sample sizes were far too small to make any definitive conclusions, and growth factors should be compared with current standard treatments in large, multicentre studies. Topical ketanserin increased ulcer healing rate in 2 studies, while systemic hyperbaric oxygen therapy reduced the rate of major amputations in 1 study. Preliminary research into the effects of iloprost and prostaglandin E1 (PGE1) on diabetic foot ulcer healing suggests possible benefits. However, good quality, large-scale confirmatory research is needed. Topical dimethyl sulphoxide (DMSO) (1 trial), glycyl-l-histidyl-l-lysine:copper (1 trial) and topical phenytoin (1 trial) were associated with increased healing. There is no good evidence in favour of any other dressing from 9 small trials, or for skin replacement dressings from 2 trials (the larger of which suffered substantial loss to follow-up). RESULTS - ANTIMICROBIALS: Thirty studies were included, 25 with a randomised design. There were nine evaluations of systemic antimicrobials and 21 of topical agents. RESULTS - ANTIMICROBIALS, VENOUS LEG ULCERS: DMSO powder produced significantly higher healing rates than placebo, but was equivalent to allopurinol powder. Results were conflicting for silver-based products (silver sulphadiazine and silver-impregnated activated charcoal dressing). There was no evidence in favour of systemic antibiotics, polynoxylin paste, mupirocin 2% impregnated dressing or povidone iodine 10%. RESULTS - ANTIMICROBIALS, MIXED AETIOLOGY WOUNDS: Systemic ciprofloxacin added to a topical regimen produced increased healing rates in 1 trial. Levamisole (primarily used to treat roundworm infection) was associated with significantly higher healing rates than placebo (1 trial). The results for benzoyl peroxide were equivocal. 1% silver-zinc allantoinate cream was more effective than a variety of other topical preparations in a single small study. No differences were found between a hydrocolloid dressing and povidone iodine ointment for complete healing in patients with leg ulcers (aetiology unspecified) or pressure ulcers. No differences were found between an antiseptic spray (eosin 2% and chloroxylenol 0.3%) and an alternative preparation in patients with diabetic foot ulcers or pressure ulcers. RESULTS - ANTIMICROBIALS, PRESSURE ULCERS: There is no evidence in favour of topical antimicrobials in pressure-sore prevention. Oxy- quinoline ointment was significantly more effective than a standard emollient for treating pressure sores in 1 study. No significant difference was detected between a hydrocolloid dressing and povidone iodine ointment, or between a gentian violet preparation and povidone iodine/sugar ointment. RESULTS - ANTIMICROBIALS, DIABETIC FOOT ULCERS: No beneficial effect of topical or systemic antibiotics was identified. RESULTS - ANTIMICROBIALS, PILONIDAL SINUSES: Oral metronidazole given after excision resulted in significantly shorter healing time (1 study). Gentamicin-impregnated sponge produced significantly higher rates of primary healing than no sponge. CONCLUSIONS: Much uncertainty remains over the most effective interventions for the prevention and treatment of diabetic foot ulcers. Certain treatments (e.g. growth factors and off-loading techniques such as total contact casting) show promise but need further, more rigorous evaluation. There is no existing evidence to support the use of systemic antimicrobial agents for chronic wound healing. Even with interventions that appear to be promising, further, more rigorous evaluation is required before use becomes routine, as existing trials are generally small and many have other methodological problems. Several topical agents may be helpful, but again further research is required to establish effectiveness. Until improved data on relative effectiveness become available, considerations such as cost-minimisation may be used to guide decisions on the use of antimicrobial agents. IMPLICATIONS FOR FUTURE RESEARCH: It is likely that most of the included trials have insufficient statistical power to detect a true treatment effect. Most of this research requires replication in larger, well-designed studies, with the incorporation of: adequate sample size, clear inclusion criteria, true randomisation, assessment of baseline comparability, blinded outcome assessment, objective outcome measurement, intention-to-treat protocol and detailed reporting of withdrawals. Details of concomitant interventions and an assessment of the adverse effects associated with interventions should be provided.

J Accid Emerg Med 2000 Jul;17(4):254-6
Evaluating the use of computerised clinical guidelines in the accident and emergency department.
Poncia HD, Bryant GD, Ryan J
Department of Accident and Emergency Medicine, Royal Sussex County Hospital, Brighton.
OBJECTIVES: To investigate the pattern and frequency of use of computerised clinical guidelines (CCG) in an accident and emergency department. METHODS: A software program was written to record information on a central database each time the CCG were used. Data were collected prospectively for a six month period. Users were blind to the study. The date, time of use and guidelines consulted were recorded. RESULTS: 1974 individual sessions were logged comprising of 10204 "hits". The CCG were used for a median of 10 sessions per day (range 1-38, SD 5.49). A median of three subjects were accessed during each session (range 1-39, SD 5). The CCG were used most often during peak daily activity; 11 am (609 hits), 5 pm (678 hits) and 12 pm (604 hits) and on Sundays (1875 hits), Thursdays (1770 hits) and Saturdays (1608 hits). The most frequently used guidelines concerned orthopaedics and fracture management (1590 hits), wound care (546 hits), poisoning (473 hits), medical emergencies (267 hits) and radiological policy (148 hits). CONCLUSIONS: In this department CCG have become easily integrated as part of normal day to day working practice. The CCG are accessible 24 hours a day. They can also be easily updated according to best evidence, local policy or national guidelines. The results of this study have helped the authors to focus education to areas of clinical need.

Hand Clin 2000 May;16(2):215-24
Management of chemical injuries to the upper extremity.
Reilly DA, Garner WL
Division of Plastic and Reconstructive Surgery, University of Southern California, Los Angeles, USA.
Chemical burns are interesting and challenging to treat. When the practitioner is comfortable with the pathophysiology of chemical injury and treatment based on these principles, most patients can be treated effectively with good outcome (Fig. 2). Early treatment with water irrigation, followed by diligent wound care, will allow our patients to benefit to the maximum from our medical skills.

Publication Types:
  Review
  Review, tutorial

Health Technol Assess 1999;3(17 Pt 2):1-35 [Texto completo]
Systematic reviews of wound care management: (2). Dressings and topical agents used in the healing of chronic wounds.
Bradley M, Cullum N, Nelson EA, Petticrew M, Sheldon T, Torgerson D
NHS Centre for Reviews and Dissemination, University of York, UK.
Publication Types:
  Review
  Review literature

Health Technology Assessment 1999; Vol. 3: No. 17 (Pt 1) [Texto completo]
The debridement of chronic wounds: a systematic review
M Bradley, N Cullum, T Sheldon
Centre for Reviews and Dissemination, University ofYork, UK

Dermatol Nurs 1999 Feb;11(1):53-6, 60-3, 80
Traumatic wound care.
Dickerson P, Purdue GF, Hunt JL
Parkland Memorial Hospital, Dallas, TX, USA.
The scope and importance of traumatic wound care, assessment, debridement, pre and postoperative management, and subsequent skin care during the course of treatment cannot be over-emphasized, and indeed, are the most important considerations for functional and cosmetic outcome. Care begins in the emergent phase and continues through acute and convalescent phases. Efforts are directed at methods and techniques which prevent infection, facilitate wound healing, promote comfort, and at the same time, maintain optimal function and minimize deformities.
Publication Types:
  Review
  Review, tutorial

Nurs Times 1999 Aug 25-31;95(34):72, 75
Wound care. Points of friction.
Nelson L
Royal Hospital for Neuro-disability, London.
This article aims to identify optimum management strategies for hypergranulation of gastrostomy, tracheostomy and suprapubic catheter sites. It discusses the aetiology of hypergranulation and gives an overview of the available literature on existing treatments. It concludes that the optimum choice of management may be to tape the tube to the body to prevent friction and to use a polyurethane foam dressing with a high moisture vapour transmission rate.
Publication Types:
  Review
  Review, tutorial

Nurs Clin North Am 1999 Dec;34(4):933-53, vii
Nursing management of chronic wounds: best practices across the continuum of care.
Krasner DL, Sibbald RG
The Johns Hopkins University School of Nursing, Baltimore, Maryland, USA. dlkrasner@aol.com
This article highlights the nurse's role within a holistic, interdisciplinary approach to chronic wound management. Best practices for chronic wound care are discussed, drawing on evidence-based science when it is available. The fundamentals of chronic wound care, including cleansing, irrigation, debridement, infection control, and topical treatment are addressed. New devices and technologies are briefly reviewed. Implementing these best practices across the continuum of care will result in greater advances in the management of chronic wounds.
Publication Types:
  Review
  Review, tutorial

Nurs Clin North Am 1999 Dec;34(4):847-60
Pain management of wound care.
Senecal SJ
Pain Management Team, All Children's Hospital, St. Petersburg, Florida 33701-4899, USA. senecals@allkids.org
Children and adults still suffer pain during wound dressing changes despite national guidelines. Assessing and managing pain are essential components of comprehensive wound care. Developmentally sensitive pain assessment tools are available to measure verbal, behavioral, and physiologic responses to pain. Holistic pain assessment includes pain intensity, location, description, relief measures, cultural background, and the patient's developmental level and anxiety. Pharmacologic and nonpharmacologic interventions should be combined to manage pain based upon patient's response and nursing assessment. Nurses with a fundamental knowledge of pain assessment and management provide their patients with pain and symptom relief during wound care.
Publication Types:
  Review
  Review, tutorial

Ann Emerg Med 1999 Sep;34(3):356-67
Laceration management.
Hollander JE, Singer AJ
Department of Emergency Medicine, University of Pennsylvania, Philadelphia, USA. jholland@mail.med.upenn.edu
In 1996, almost 11 million lacerations were treated in emergency departments throughout the United States. Although most lacerations heal without sequelae regardless of management, mismanagement may result in wound infections, prolonged convalescence, unsightly and dysfunctional scars, and, rarely, mortality. The goals of wound management are simple: avoid infection and achieve a functional and aesthetically pleasing scar. Recent US Food and Drug Administration approval of tissue adhesives has significantly expanded clinicians' wound closure options and improved patient care. We review the general principles of wound care and expand on the use of tissue adhesives for laceration repair.
Publication Types:
  Review
  Review, academic

Postgrad Med 1999 Jul;106(1):97-102 [Texto completo]
Local wound care in diabetic foot complications. Aggressive risk management and ulcer treatment to avoid amputation.
Muha J
Carolina Podiatry Associates, Florence, South Carolina 29505, USA. jmamem@aol.com
Techniques to prevent and treat lower extremity amputation in patients with diabetes vary from simple foot inspection to complicated vascular and reconstructive surgery. Early identification of risk factors, careful and regular evaluation, and aggressive treatment in a multidisciplinary team approach prevent amputation in most cases of diabetic foot ulcer. Suitable treatment of these ulcers consists of minimizing pressure, resolving infection, correcting ischemia, and maintaining a warm, moist, clean environment to enhance wound healing. Success in these efforts not only preserves quality of life for diabetic patients but also saves money for the healthcare system.
Publication Types:
  Review
  Review, tutorial
Comments:
  Comment in: Postgrad Med 1999 Nov;106(6):27

Br J Nurs 1999 Feb 25-Mar 10;8(4):200-2, 204, 206 passim
Acute surgical wound care. 3: Fitting the dressing to the wound.
Foster L, Moore P
Department of Effective Healthcare, Scunthorpe Hospital, NHS Trust, North Lincolnshire.
The third article in this series on surgical wound care discusses the types of dressings currently available, and selection of the correct dressing for a particular wound type. There is an abundance of information on the types of dressings available. Wound management for the individual patient must be decided using best evidence and taking into account patients' increased involvement in their care, new technology and the push to mobilize early, leading to early discharge from hospital. The nurse needs to have a good knowledge of the types of dressings available, the properties of individual dressings and a sound understanding of wound healing, in order to make an informed decision on wound management. General factors such as safety, comfort, pain management and convenience must be borne in mind when deciding which dressing is the best for individual patients, given that dressings now have to be cost-effective as well as clinically effective.
Publication Types:
  Review
  Review, tutorial

Am Fam Physician 1997 Oct 15;56(6):1643-6 [Texto completo]
Nail gun injuries of the hand.
Hoffman DR, Jebson PJ, Steyers CM
University of Iowa Hospitals and Clinics, Iowa City, USA.
Nail gun injury of the hand is commonly encountered among workers in the construction industry. Successful management requires a thorough understanding of this unique injury, the recognition of nail shaft barbs, and appropriate nail removal and wound care, with referral when indicated. If barbs are encountered, nail removal involves cutting off the head of the nail and extracting the nail in the direction of entry.
Publication Types:
  Review
  Review, tutorial

Nurs Clin North Am 1997 Jun;32(2):311-29
Management of the pediatric burn patient.
Cortiella J, Marvin JA
University of Texas Medical Branch, Shriners Burns Institute, Galveston, Texas 77550, USA.
The care of children with burns represents a therapeutic dilemma for many practitioners who periodically work with thermally injured patients. In this article, the authors emphasize the pathophysiology of thermal injury with special attention to the burned child. Within this framework, pain control, resuscitation, wound care, and the importance of a "burn care team" are discussed as important factors in the care of these children.
Publication Types:
  Review
  Review, tutorial

Mayo Clin Proc 1995 Aug;70(8):789-99
Pressure ulcers: prevention and management.
Evans JM, Andrews KL, Chutka DS, Fleming KC, Garness SL
Section of Geriatrics, Mayo Clinic Rochester, Minnesota 55905, USA.
OBJECTIVE: To describe important aspects of pressure ulcer prevention and management, especially in elderly patients. DESIGN: We reviewed pertinent published material in the medical literature and summarized effective strategies in the overall management of the elderly population with pressure ulcers. RESULTS: Pressure ulcers are commonly encountered in geriatric patients. The development of a pressure ulcer is associated with an increased risk of death. Certain well-recognized risk factors, such as immobility and incontinence, may predispose to the development of pressure ulcers; consequently, risk factor modification is an important aspect of prevention and treatment. For existing lesions, various innovative patient support surfaces and wound care products have been developed to alleviate pressure and to facilitate wound healing. The use of a particular product should be based on the clinical setting and the limited scientific evidence available. With treatment, most pressure ulcers eventually heal. CONCLUSION: Pressure ulcers are often, but not always, preventable. The occurrence of such an ulcer signals the possible presence of chronic comorbid disease and should prompt a search for underlying risk factors in patients for whom ulcer treatment is considered appropriate.
Publication Types:
  Review
  Review, tutorial