- Celebrating 15 years of best practice in wound management in Ireland 1996-2011 — By: Georgina Gethin - President of WMAI
- Journal Watch
- Larvae Therapy — a case report — By: Julie Jordan O'Brien
- Notices from WMAI Office
Dear members and colleagues,
As we see the spring bulbs start to peep up from the cold ground there is a sense of spring in the air. Spring brings with it a time of renewed growth, a fresh start, and sometimes places past events into the realms of a distant memory. Certainly we would like to place the challenges and difficulties of 2010 into a far distant memory but such events can often help us to refocus on what is important and to challenge us to improve into the future.
This is particularly so in wound management. Services have witnessed severe cutbacks and clinicians have often cited difficulties in obtaining dressings and devices necessary for optimal wound care. Yet, at the same time we have not properly debated the issue of clinical evidence in our choices of dressings or devices and the weight we place on such evidence.
Towards the latter part of 2010 we saw some debate around the need for RCTs in wound management and whether these are always necessary. Indeed it has been questioned whether RCTS are the appropriate method in which to obtain such evidence. There is some merit in this opinion as surely quality of life issues cannot be subjected to RCTs. In some instances there is a large body of evidence to support the use of certain devices or products and this has been gleaned from cohort studies, clinical trials and case studies involving thousands of patients.
These must be considered. However, as we move forward I would urge caution. Surely if we are to develop as a speciality and to be recognised as a speciality then we must strive to obtain the highest quality evidence that can be appraised through international peer-review. The challenge is not that RCTs are difficult but that we start to collaborate to conduct these RCTs so that high level evidence from large sample sizes can be achieved. To aim for less that this is to settle for less than what one expects in other disciplines.
In 2010 over 1,000 people attended education session delivered by the WMAI throughout the length and breadth of the country. We continued to work with our sponsors to promote wound management and have been actively involved nationally and internationally in areas of research in wound management.
This year, 2011, will bring some exciting developments. We will continue to work with the HSE in developing best practice in wound management through provision of education and dissemination of clinical practice guidelines. On 3rd and 4th October 2011 we will host our bi-annual conference.
This year the conference will be in the Galway Bay Hotel and promises to be our biggest and best yet. We will have workshops, symposium and plenary session. National and international speakers will deliver exciting lectures on current best practice and developments in wound management. We look forward to seeing you there and encourage you to submit an abstract of your work to the conference.
Finally may I wish you all the very best for 2011.
This is the first in a two part series in which the issue of pilonidal disease is explored. In part one, the background to the disease is outlined. This is a devastating condition which mainly affects young males with a male/female ratio of 4:1. Although exact prevalence rates are not available, in Northern Ireland alone 657 surgical procedures were carried out for this disease in the year 2000/1. The problems associated with the disease include embarrassment, time off work, and loss of income, in addition to having a significant impact on the quality of life of the individual. This is further compounded by the protracted duration of treatment and high recurrence rates. Treatment takes from 4 to 52 weeks. In this paper the author outlines the rationale and study design for a research study to explore the impact of this condition on the lives of 18 to 30 year old males with the condition. Hermeneutical phenomenology is being used to conduct the study. In part two, results of this study will be presented.
Note: Lilian Bradley was one of the founding members of the wound management association of Ireland. She was an inspirational person who dedicated her working life to improving the care of patients with wounds. She was actively engaged in dissemination and implementation of wound care guidelines. Sadly, Lilian passed away in 2006. This paper and the subsequent paper in part two represents her MSc thesis which she was awarded from Cardiff University.
We are familiar with prevalence rates of pressure ulcers in the elderly and those with reduced mobility such as wheelchair users. Little attention has been given previously to prevalence in children and more specifically in neonates. This research paper provides important data on the prevalence of pressure ulcers in neonates and should go some ways in highlighting the risk for such wounds in other less obvious groups. Data was collected from seven hospitals in Japan and included all infants (n=81) admitted to the neonatal ICUs during the study period. Thirteen infants had fourteen pressure ulcers. 50% (n=7) of all pressure ulcers occurred on the nose. Pressure ulcers were classified as grade 1 (n=3); grade 2 (n=11). The risk factors that were significant for pressure ulcer development were: low birth weight, skin texture, incubation temperature, incubator humidity, support surface, limited number of position changes and use of endotracheal tubes.
Negative pressure wound therapy (NPWT), has become widely used for the management of open abdomens and soft tissue wounds. A prospective observational study was conducted in surgical, trauma, or burn patients (8 patients with open abdomens and 9 patients with acute soft tissue wounds on NPWT). Exudate was assayed to characterize loss of protein, electrolyte, and immunoglobulins over multiple days of NPWT. 24-hour losses of proteins and electrolytes were greater in patients with open abdomens than soft tissue wounds. Mean total protein loss was 25 ± 17 g/d for open abdomens and 8 ± 5 g/d for soft tissue wounds. Conclusion: There are significant losses of proteins in wound exudate. As there is no significant difference in the concentration of total protein between wound type, the rate of loss may be calculated as 2.9 g/dL times the volume of wound exudate. Protein that is lost during NPWT must be taken into consideration when assessing the nutritional status and requirements of patients with wounds.
Larvae Therapy has been around for the last four hundred years and has mainly used for debridement of wounds (Grossman 1994). During the First World War Baer successfully used sterile larval therapy in the treatment of leg ulcers and osteomyelitis (Baer 1931). With the development of antibiotics and advanced surgical technique, larval therapy decreased and was only used in chronic wounds as a last resort (Evans 1995). However, there has been an growing interest in its usage in recent years due to the emergence of antibiotic resistant strains of bacteria, for example MRSA methicillin resistant staphylococcus aureus (Sherman et al 1996). Although it is not fully understood, its mode of action includes debridement of dead tissue, reducing bacteria and secretion of growth factors improving the wound bed environment (Parnes & Lagan 2007).
Larvae therapy is documented as being a cost effective debriding treatment that can reduce pain and malodour while promoting wound healing with little or no side effects (Kitching 2004). The therapy can be easily applied in any environment (inpatient/outpatient) and can be left in place for 3-5days (MacDougall & Rogers 2004).
Larvae therapy is not suitable for wounds with exposed vessels connecting to vital organs and wounds should never be allowed to close over larvae intentionally or otherwise. They are contra indicated for use near eyes, upper gastrointestinal tract and upper respiratory tract and patients with reported allergy to fly larvae, brewers yeast or soy bean protein. Care should be taken if the patient has a known risk or bleeding disorder and it may be necessary to use antibiotics in conjunction with the therapy (Snyder 2009).
The kit is delivered from a dedicated fly culture laboratory in Wales within 24 hours of ordering and can be stored refrigerated for up to 24 hours (Thomas et al 1998). They are available in a net bag called a Biobag, which contains the larvae therefore preventing escape and reduces the “yuk factor” for nurses who sometimes are hesitant in using them. The recommended dose of larvae is 5-10 larvae per square cm of wound surface. Upon arrival the larvae or bio bag should be inspected for activity and if there is none it should be reported to the manufacturer for replacement. The Biobag is placed directly onto the sloughy necrotic tissue. The surrounding skin is protected with zinc paste or Duoderm to reduce irritation to skin (Evans 2002).
The larvae feed on necrotic tissue and exudate within the wound therefore debriding it of devitalised tissue. The digestive juices secreted by larvae contain proteolytic enzymes, including trypsin-like and collagenase. The enzymes selectively debride necrotic tissue leaving viable tissue unharmed (Beasley & Hirst 2004).
The larvae ingest the liquefied tissue neutralising the bacteria in their gut (Brocklesby 2002). Additionally bacteria that are not destroyed within the acidic alimentary canal are contained within a tubular structure known as the peritrophic membrane thus preventing contamination (Snyder 2009). They also inhibit bacterial activity by producing inhibiting secretions. Steenvoorde & Jukema (2004) argue that adequate numbers of larvae are necessary to eradicate some gram-negative species such as Ecoli. The movement of the larvae stimulates exudate production thus increasing irrigation of the wound and assist in the removal of bacteria. This also alters PH of the wound therefore acting on the growth factors increasing oxygenation and promoting wound healing (Rayner 1999).
Accurate wound assessment is essential before any clinical treatment decision can be made. A thorough history taking and physical examination is necessary to ensure the right aetiology is obtained so that a plan of care can be established (Bates-Jensen 1995).
DM is an elderly man who sustained a grade four pressure ulcer to his right heel. The wound was 100% sloughy on admission and extended over the heel approx 4x5cms.The exudate was odorous and heavy and caused a lot of distress and pain for this man. Unfortunately DM had a lot of medical complications (Diabetes, Chest infection, renal impairment and congestive cardiac failure) and was therefore unsuitable for surgery. The biggest problem for DM was his immobility and he expressed a desire to get home, so it was important to get him walking as soon as possible so that he could avail of a home care package. The decision to use Larvae Therapy was made in conjunction with the team and the patient.
The treatment for DM was in progress over 4-5 days, with daily checks for activity and to change the secondary dressings. The only complaint DM had was some mild discomfort that resolved as soon as larvae therapy was removed. The Larvae are disposed of by double bagging and placed in bio hazardous waste bag. The reduction in slough was 100% in the 5 days, exposing a granulating wound bed. The wound was then treated with VAC (vacuum assisted closure therapy) enabling the patient to mobilise, and went on to heal.
DM reported that, overall, it had been a positive experience for him “The tiny miners from Wales excavated well and did their job”. “If it wasn’t for them I would not be able to walk around now”.
There is a re-emergence in the use of larvae therapy. The patients are becoming more interested in its availability and nursing staff are beginning to get used to the therapy (Margolin & Glatanella. 2010). DM was an elderly man with a complicated history who was discharged home promptly and mobile. The decision to use larvae therapy was an efficient way to debride, disinfect and stimulate healing in this wound. If the patient and staff are informed about larvae therapy, it can be performed easily and quickly, eradicating the discomfort of infection, malodour and necrosis in a safe and cost effective way (Waymen et al 2000)
Would you like to write a short paper for the WMAI newsletter or share your experiences or expertise with others? We would like to invite short papers for inclusion in future issues of the newsletter. Please send your submissions via email or post to the Office.
We are now accepting applications for the WMAI bursary 2012, for application information go to the Bursary page. Application must be made by 9th September 2011.