Using Hydrocolloids for Treating Pressure Ulcers - Essay Example

?Using Hydrocolloids for Treating Pressure Ulcers Pressure ulcers are also known as bedsores, pressure sores, and decubitus ulcers (Moore and Cowman,2010, p. 5). Pressure sores or ulcers are “localized areas of tissue damage, caused by excessive pressure, shearing or friction damage” (Moore and Cowman, 2010, p. 5, citing Nixon et al., 1999). The Agency for Healthcare Research and Quality definition of a pressure ulcer is that it is “a lesion caused by unrelieved pressure resulting in damage to underlying tissue” (Armstrong et al., 2001, p. 645). Pressure sores or ulcers usually happen in people who do not have the ability to reposition themselves (Moore and Cowman, 2010, p. 5). The elderly, the malnourished, and those with acute illness are the most vulnerable (Moore and Cowman, 2010, p. 5). Pressure ulcers are a serious problem for older people because of pain, osteomyelitis, sepsis, and mortality that can be associated with the condition (Graumlich et al., 2003, p. 147). Up to 18% of the hospitalized can have pressure sores or ulcers (Moore and Cowman, 2010, p. 5). In nursing homes, a prevalence of 24% was reported (Graumlich et al., 2003, p. 147). Among surgical patients, the incidence of pressure ulcers can be as high as 12 to 45% (Armstrong et al., 2003, p. 647). Pressure sores or ulcers arise when pressure from lying or sitting on a particular body area result to tissue damage and oxygen deprivation to the affected area (Moore and Cowman, 2010, p. 5). Because of continuous pressure, tissues are depleted of blood flow, waste products are not removed from the wound and the wound fails to get oxygen and nutrient supply that are all necessary for healing (Moore and Cowman, 2010, p. 5). According to Graumlich et al. (2003, p. 646), the pressure ulcers usually occur over bony prominences and the common ulcer sites include the scapula, occiput, sacrum, and heels; ears, shoulder, trochanter, medial knee, malleolus, and foot edge; and nose, forehead, chest, iliac crests, and toes. Pressure ulcers results when external pressure exceeds the tissue capillary pressure that is between 25 to 32 mm Hg (Graumlich et al., 2003, p. 646). According to Graumlich et al. (2003, p. 646), excess external pressure impedes blood flow for a period and causes tissue ischemia that results in the formation of an ulcer. In the United States, Graumlich et al. (2001, p. 645) estimated that the cost of treatment for pressure ulcers exceeded US$1 billion annually. Heyneman et al. (2008, p. 1165) reported based on the study of Severens and others in 2002 that the cost of pressure ulcers is about 1% of the health care budget. Of course, prevention is the cornerstone of care for pressure ulcer (Heyneman et al., 2008, p. 1165). However, when pressure ulcers already took place, there are several modes of treatments available. One of them is repositioning (Moore and Cowman, 2010). Another mode of treatment involves the use of collagen (Graumlich et al., 2003). Still another treatment involves the use of phenytoin (Hollisaz et al., 2004). Finally, another way is through hydrocolloids (Hollisaz et al., 2004; Belmin et al., 2002; Heyneman et al., 2008; Graumlich et al., 2003; and Thomas, 2008). The modes of treatments enumerated do not exhaust the modes of treatments feasible or possible on pressure ulcers but we focus on the use of hydrocolloids. Heyneman et al. (2008, p. 1165) reported that a wide range of treatment is available and the treatment methods can be subdivided into secondary prevention, topical products, surgical treatment and physiotherapy. The word “hydrocolloids” was coined in the 1960s in the development of mucoadhesives in the combination between carboxymethyl cellulose (CMC) with adhesives and tackifiers for treating mouth ulcers (Thomas, 2008, p. 602). Thomas (2008, p. 602) reported the term hydrocolloids was subsequently adopted to describe a new type of dressing based on the technology (Thomas, 2008, p. 602). The dressing technology identified as hydrocolloid, a hydrophilic gelable mass was applied in a semi-solid form into a flexible semipermeable carrier or dressing (Thomas, 2008, p. 602). As pointed out by Heyneman et al. (2008, p. 1165), hydrocolloids were patented in 1967 and were originally used for stoma (Heyneman et al., 2008, p. 1165). However, hydrocolloids were also used for both acute and chronic wounds (Heyneman et al., 2008, p. 1165). Based on the report of Cockbill and Turner in 2007, classical hydrocolloids consist of 40% polysiobutylene, 20% sodium carboxymethylcellulose, 20% gelatine and 20% pectine (Heyneman et al., 2008, p. 1165). According to Heyneman et al. (2008, p. 1165), hydrocolloids work this way: the dressing absorbs the wound fluid and is converted into a jelly-like mass, the polyurethane foam or film outside of the dressing enables exchange of water vapor and protects the wound against contamination. At the same time, however, besides the classic sheet form, hydrocolloids are available as a paste or granules that fill up the deep wounds (Heyneman et al., 2008, p. 1165). Thomas (2008, p. 602) reported that the first hydrocolloid dressing preparation was Granuflex that was launched in the United Kingdom in 1982 and then introduced in the United States as Duoderm in 1983 and as Varhesive in European markets. Citing the reports from several studies, Heyneman et al. (2008, p. 1165) explained that hydrocolloids are believed to aid healing by creating a moist environment and through intensifying the autolysis process, advance debridement. Further, hydrocolloid treatments have been believed to be comfortable and time/money saving because dressing changes can be less frequent (Heyneman et al., 2008, p. 1165). The Heyneman et al. (2008) study had sought to verify the efficacy of the hydrocolloid treatment and find out whether patients can indeed have cost-savings from the hydrocolloid treatment. Based on 29 publications dealing with 28 studies, Heyneman et al. (2008, p. 1164) confirmed that hydrocolloids have been frequently used on pressure ulcers grade 2-3. The publications assessed cover the studies available at that time in Pubmed, Embase, Cochrane Central Register of Controlled Trials, and the Cumulative Index to Nursing and Allied Health Literature (Heyneman et al., 2008, p. 1164). The studies covered by the publications included randomized controlled trials on the treatment of pressure ulcers with hydrocolloids as defined by the British National Formulary. Based on the studies, Heyneman et al. (2008, p. 1164) concluded that hydrocolloids are more effective than gauze dressings for the reducing the dimension of wounds. Compared to gauze dressings, hydrocolloids are favored based on absorption capacity, time needed for dressing changes, pain during dressing changes, and side effects (Heyneman et al., 2008, p. 1164). Heyneman et al. (2008, p. 1165) also found that hydrocolloids are less expensive compared to collagen, whether saline or providine are used for gauze soak. However, Heyneman et al. (2008, p. 1165 and 1170) pointed out that hydrocolloids are more expensive compared to hydrogel, polyurethane and collegenase. The overall conclusion of the Heyneman et al. (2008) literature review is that hydrocolloids are to be preferred to gauze dressings in the treatment of pressure ulcers grades 2 and 3 because hydrocolloids are more effective and less expensive than gauze dressings. In particular, Heyneman et al. (2008, p. 1170) pointed out that hydrocolloids are significantly more effective than gauze dressings with regard to the number of healed wounds. However, Heyneman et al. (2008, p. 1165) also concluded that “compared with alginates, polyurethane dressings, less-contact layers, topical enzymes and biosynthetic dressings, hydrocolloids are less effective.” Heyneman et al. (2008, p. 1171), however, were careful enough to point out that some of the studies on which they based their conclusions have methodological flaws like the absence of correct power calculations, correct randomization procedures, blinded assessments, and standard measuring methods. Nevertheless, despite the methodological flaws of some of the studies they have covered, Heyneman et al. (2008, p. 1171) had been able to conclude that hydrocolloids are more effective than gauze healing in terms of ulcer healing, pain involved, time savings involved in less wound dressings, absorption capacity, costs, and side effects. Nevertheless, Heyneman et al. (2008, p. 1171) recommended that deeper studies on hydrocolloids should be made in view of the wide range of topical treatments available in the modern era. Besides, Heyneman et al. (2008, p. 1171) expressed concern that research has to clarify “which products or combination of products are the most appropriate and generate positive effect on the wound bed”. In a track that is similar to Heyneman et al. (2008) and done contemporaneously with the mentioned scholars, Thomas reviewed the literature in the use of hydrocolloid dressings in the management of acute wounds (this is different from being simply pressure ulcers). He reported that his review suggested that the application of self-adhesive hydrocolloid dressings that are usually associated with the treatment of skin ulcer conditions such as pressure ulcers and leg ulcers are also beneficial for the treatment and management of acute wounds of all types (Thomas, 2008, p. 602). For example, Thomas (2008, p. 602) pointed out that the use of hydrocolloids for acute wounds decreased healing times by about 40% compared to traditional treatments. According to Thomas (2008, p. 602), the impermeable nature of hydrocolloids provides protection to the wound but permits washing or showering while helping to prevent the spread of pathogenic microorganisms. In addition, Thomas (2008, p. 602) pointed out that there are benefit-cost savings as well in the use of hydrocolloids. Thomas (2008, p. 602) pointed out however that recently hydrocolloid dressings are being replaced by products such as foam for treating heavily exuding wounds. Yet, at the same time, Thomas (2008, p. 602) pointed out that hydrocolloids continue to offer many practical advantages for lightly exuding wounds even if the hydrocolloids are being replaced in the market for acutely exuding wounds. In 2004 or 4 years earlier, Hollisacz et al. compared hydrocolloid, phenytoin cream and simple dressings for the treatment of stage I and II pressure ulcers. The study design used a randomized clinical trial among 83 paraplegic male victims of the Iran-Iraq war with mean age 36.65 6.04 years and mean weight 61.12 5.08 kilograms (Hollisacz et al., 2004, p. 1). Hollisacz et al. (2004, p. 1) concluded that among the three modes of treatment, the hydrocolloid dressing or HD is the most effective treatment for Stage I and Stage II pressure ulcers among young paraplegic men. According to Hollisacz et al. (2004, p. 1), complete healing of ulcers regardless of location and stage was better in the hydrocolloid dressing or HD group than the group that used phenytoin cream for treatment. Likewise, Hollisacz et al. (2004, p. 1) pointed out that complete healing of pressure ulcers was clearer in the hydrocolloid dressing or HD group than in the group that used simple dressing or SD. In 2003 or 5 years earlier, Graumlich et al. compared hydrocolloid versus collagen in treating pressure ulcers and found that the two modes of treatment have no significant differences in healing outcomes. However, Graumlich et al. (2003, p. 147) assessed that collagen was a more expensive treatment compared to hydrocolloid treatment and that collagen treatment offered no major benefits over hydrocolloid in treating pressure ulcers. The Graumlich et al. (2003) study was a randomized and single-blind controlled trial with an 8-week follow-up. The study was conducted in 11 nursing homes in Illinois, United States of America. In the study, 35 patients were allocated to topical collagen daily while 30 patients were allocated to hydrocolloid treatments that were done twice weekly (Graumlich et al., 2003, p. 147). The results of the Graumlich et al. (2003) study showed that there was complete treatment within 8 weeks. The mean healing time was assessed to be statistically similar or equal: collagen within 5 weeks and hydrocolloid treatment within 6 weeks (Graumlich et al., 2003, p. 147). In 2002 or 6 years earlier, Belmin et al. compared the efficacy of a sequential strategy combining calcium alginate dressings and hydrocolloid dressings treatment of grade III or IV pressure ulcers over a non-sequential strategy of using hydrocolloid treatment alone among the elderly. The study design used was open, nonrandomized, and multi-center parallel-group trial among twenty geriatrics hospital wards. Those in geriatrics wards belong to age 65 years old and older (Belmin et al., 2008, p. 269). Belmin et al. (2008, p. 269) concluded that for grade III or IV pressure ulcers among the elderly, a sequential treatment of using calcium alginate dressings first and then hydrocolloid dressings later promotes faster healing than treatment with hydrocolloid dressings alone. The Belmin et al. (2002) study that use calcium alginate dressings in addition to hydrocolloid dressing took off from the view that wound debridement is an important step in the treatment of pressure ulcers. However, Belmin et al. (2002, p. 270) pointed out that it can take a long time to debride a pressure ulcer completely, especially among older patients who frequently cannot undergo surgical debridement. Frank (2004, p. 1653) has emphasized that adequate debridement is especially important among the elderly to decrease the risk of infection and to promote healing. Thus, the idea of using calcium alginate in combination with hydrocolloid dressings because calcium alginate dressings have been shown by earlier studies to help in the debridement of pressure ulcers (Belmin, 2002, p. 270). The overall conclusion that is suggested by this review of literature is that hydrocolloid has not yet been replaced by other modes of treatment as the best treatment for pressure ulcers among the relatively young population but a sequential treatment using calcium alginate dressings and then hydrocolloid dressings appears to be the faster treatment among the older population. Nevertheless, even if hydrocolloid treatment is used alone and nonsequentially among the older population, the hydrocolloid treatment continues to be one of the more effective treatments in dealing with pressure ulcers. Of course, the current literature review also suggest that we may have to find out if there were studies that used or combined the use of calcium alginate with hydrocolloid treatment for pressure ulcers among the younger population. Until then, however, the conclusion articulated in this review holds. References Armstrong, D., Bortz, P., and Halter, M. (2001). An integrative review of pressure relief in surgical patients. AORN Journal, 73 (3), 645-674. Belmin, J., Meaume, S., Rabus, M., and Bobbot, S., (2002). Sequential treatment with calcium alginate dressings and hydrocolloid dressings accelerates pressure ulcer healing in older subjects: A multicenter randomized trial of sequential versus nonsequential treatment with hydrocolloid dressings alone. Journal of the American Geriatrics Society, 50 (2), 269-274. Frank, C. (2004). Approach to skin ulcers in older patients. Canadian Family Physician, 50, 1653-1659. Graumlich, J., Blough, L., McLaughlin, R., Milbrandt, J., Calderon, C., Agha, S., and Scheibel, W. (2003). Healing pressure ulcers with collagen or hydrocolloid: A randomized, controlled trial. Journal of the American Geriatrics Society, 51 (2), 147-154. Heyneman, A., Beele, H., Vanderwee, K., and Defloor, T., (2008). A systematic review of the use of hydrocolloids in the treatment of pressure ulcers. Journal of Clinical Nursing, 17, 1164-1173. Hollisaz, M., Khedmat, H., and Yari, F. (2004). A randomized clinical trial comparing hydrocolloid, phenytoin and simple dressings for the treatment of pressure ulcers. BMC Dermatology, 4 (18), 1-9. Moore, Z. and Cowman, S. (2010). Systematic review of repositioning for the treatment of pressure ulcer. EWMA Journal, 10 (1), 5-12. Nixon, J., et al. (1999). The diagnosis of early pressure sores: report of the pilot study.” Journal of Tissue Viability, 9, 62-66. Thomas, S. (2008). Hydrocolloid dressings in the management of acute wounds: A review of the literature. International Wound Journal, 5, 602-613. Read More