Debridement for surgical wounds.

BACKGROUND: Surgical wounds that become infected are often debrided because clinicians believe that removal of this necrotic or infected tissue will expedite wound healing. There are numerous methods available but no consensus on which one is most effective for surgical wounds. OBJECTIVES: To determine the effect of different methods of debridement on the rate of debridement and healing of surgical wounds. SEARCH METHODS: In March 2013, for this third update, we searched the Cochrane Wounds Group Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE; and EBSCO CINAHL. SELECTION CRITERIA: We included randomised controlled trials (RCTs) with outcomes including at least one of the following: time to complete debridement or time to complete healing. DATA COLLECTION AND ANALYSIS: Two review authors independently reviewed the abstracts and titles obtained from the search, extracted data independently using a standardised extraction sheet and independently assessed methodological quality. One review author was involved in all stages of the data collection and extraction process, thus ensuring continuity. MAIN RESULTS: Five RCTs (159 participants) were eligible for inclusion; all compared treatments for infected surgical wounds and reported time required to achieve a clean wound bed (complete debridement). One trial compared an enzymatic agent (streptokinase/streptodornase) with saline-soaked dressings. Four trials compared the effectiveness of dextranomer beads or paste with other products (different comparator in each trial) to achieve complete debridement. Meta-analysis was not possible due to the unique comparisons within each trial. One trial reported that dextranomer achieved a clean wound bed significantly more quickly than Eusol, and one trial comparing enzymatic debridement with saline-soaked dressings reported that the enzyme-treated wounds were cleaned more quickly. However, methodological quality was poor in these two trials. AUTHORS' CONCLUSIONS: There is a lack of large, high-quality published RCTs evaluating debridement per se, or comparing different methods of debridement for surgical wounds, to guide clinical decision-making.

[Conservative treatment of subcapsular hematoma in preeclampsia and HELLP syndrome: a case report]. / Tratamiento conservador del hematoma hepático subcapsular en pacientes con preeclampsia y síndrome de HELLP coexistentes: reporte de caso y revisión bibliográfica.

BACKGROUND: Liver hematoma is a rare and serious complication of pregnancy associated with preeclampsia-eclampsia and HELLP syndrome. CASE REPORT: 27 years old patient with two pregnancies, first pregnancy with eclampsia, admitted with 36.5 weeks of gestation, blood pressure of 140-100 mmHg, epigastric pain, shoulder pain without peritoneal irritation and increased tendon reflexes. The requested preeclamptic profile supports the diagnosis of severe preeclampsia and HELLP syndrome. It was decided to terminate the pregnancy by abdominal route. Male product was obtained alive, 2,060 g, Apgar 8/9, gestational age of 38.2 weeks Capurro. A review did not report liver parenchymal. The evolution during mediate puerperium was torpid, the patient presented epigastric pain and shoulder pain, and there was a rise in transaminases (AST 687 U/L, ALT 813 U/L), progressive thrombocytopenia (113, 103/ pL), decreased hemoglobin, proteinuria and hypovolemic shock. Abdominal CT scan was requested, and it confirmed a heterogeneous liver image (117 x 85 x 104 mm) with a volume of 694 cc, suggesting hepatic hematoma. Serialized control of abdominal CT indicated liver hematoma resorption after 25 days of hospitalization. Seven days after discharge transaminase levels were normal. CONCLUSION: To consider in the diagnosis of preeclampsia and HELLP syndrome the likelihood of liver hematoma as an acute complication; early treatment improves the prognosis.

Debridement for surgical wounds.

BACKGROUND: Surgical wounds that become infected are often debrided because clinicians believe that removal of this necrotic or infected tissue will expedite wound healing. There are numerous methods available but no consensus on which one is most effective for surgical wounds. OBJECTIVES: To determine the effect of different methods of debridement on the rate of debridement and healing of surgical wounds. SEARCH STRATEGY: For this second update we searched the Cochrane Wounds Group Specialised Register (searched 13 April 2011); the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 1); Ovid MEDLINE (2007 to March Week 5 2011); Ovid MEDLINE (In-Process & Other Non-Indexed Citations, April 11, 2011); Ovid EMBASE (2007 to 2011 Week 14); and EBSCO CINAHL (2007 to 8 April 2011). SELECTION CRITERIA: We included randomised controlled trials (RCTs) with outcomes including at least one of the following: time to complete debridement or time to complete healing. DATA COLLECTION AND ANALYSIS: Two review authors independently reviewed the abstracts and titles obtained from the search, extracted data independently using a standardised extraction sheet and independently assessed methodological quality. One review author was involved in all stages of the data collection and extraction process, thus ensuring continuity. MAIN RESULTS: Five RCTs (159 participants) were eligible for inclusion; all compared treatments for infected surgical wounds and reported time required to achieve a clean wound bed (complete debridement). One trial compared an enzymatic agent (streptokinase/streptodornase) with saline-soaked dressings. Four trials compared the effectiveness of dextranomer beads or paste with other products (different comparator in each trial) to achieve complete debridement. Meta-analysis was not possible due to the unique comparisons within each trial. One trial reported that dextranomer achieved a clean wound bed significantly more quickly than Eusol, and one trial comparing enzymatic debridement with saline-soaked dressings reported that the enzyme-treated wounds were cleaned more quickly. However, methodological quality was poor in these two trials. AUTHORS' CONCLUSIONS: There is a lack of large, high-quality published RCTs evaluating debridement per se, or comparing different methods of debridement for surgical wounds, to guide clinical decision-making.

The value of debridement and Vacuum-Assisted Closure (V.A.C.) Therapy in diabetic foot ulcers.

BACKGROUND: Treatment of diabetic foot ulcers includes a number of different regimes such as glycaemic control, re-vascularization, surgical, local wound treatment, offloading and other non-surgical treatments. Although considered the standard of care, the scientific evidence behind the various debridements used is scarce. This presentation will focus on debridement and V.A.C. Therapy, two treatments widely used in patients with diabetes and foot ulcers. METHODS: A review of existing literature on these treatments in diabetic foot ulcers, with focus on description of the various types of debridements used, the principles behind negative pressure wound therapy (NPWT) using the V.A.C. Therapy system and level of evidence. RESULTS: Five randomized controlled trials (RCT) of debridement were identified; three assessed the effectiveness of a hydrogel as a debridement method, one evaluated surgical debridement and one evaluated larval therapy. Pooling the three hydrogel RCTs suggested that hydrogels are significantly more effective than gauze or standard care in healing diabetic foot ulcers. Surgical debridement and larval therapy showed no significant benefit. Other debridement methods such as enzyme preparations or polysaccharide beads have not been evaluated in RCTs of people with diabetes. More than 300 articles have been published on negative pressure wound therapy, including several small RCTs and a larger multi-centre RCT of diabetic foot ulcers. Negative pressure wound therapy seems to be a safe and effective treatment for complex diabetic foot wounds, and could lead to a higher proportion of healed wounds, faster healing rates, and potentially fewer re-amputations than standard care. CONCLUSIONS: Although debridement of the ulcer is considered a prerequisite for healing of diabetic foot ulcers, the grade of evidence is quite low. This may be due to a lack of studies rather than lack of effect. Negative pressure wound therapy seems to be safe and effective in the treatment of some diabetic foot ulcers, although there is still only one well-performed trial that evaluates the effect.

Debridement methods in wound care.

Wound debridement is an essential part of effective wound care. There are many methods of debriding wounds and it is important that patients are involved in the decision so that they are able to give informed consent. To make effective clinical decisions and ensure patients are fully informed it is essential that nurses are aware of the different methods of debriding wounds. The nurse should also be aware of the professional requirements for competence and the risks and benefits of each method. A guideline for conservative sharp debridement has recently been published by the Tissue Viability Nurses Association (TVNA 2005), and this article reviews the issues related to the procedure and the alternatives available.

Varidase: the science behind the medicament.

Varidase is used throughout the world for the topical treatment of purulent and suppurating wounds. Its efficacy is centred on two enzymes, streptokinase and streptodornase. However, these represent only a small proportion of the bulked solid. This article gives an overview of the preparation and mode of action of Varidase, as well as showing some of the research and development that has gone into improving the assessment of its quality and composition.

Enzymatic debridement for necrotic wounds.

In a randomised, double-blind, controlled trial, a comparison was made of the relative efficacy of using streptokinase/streptodornase (Varidase) in a hydrogel (KY Jelly) or the hydrogel alone in the debridement of Grade IV pressure sores. Seventeen subjects aged 57-94 years (mean age 81) took part; 21 sores were studied, 11 of which were randomised to the enzyme treatment regime. Both treatments led to eschar removal; fewer days were needed in the hydrogel-only group (mean 8.1 days, sd 1.8) compared to the enzyme/hydrogel group (mean 11.8 days, sd 2.9), but this was not statistically significant. The results suggest that the use of hydrogel alone may be a cost-effective alternative to the use of streptokinase/streptodornase and hydrogel in the treatment of these wounds.

Cavity foot ulcers in diabetic patients: a comparative study of cadexomer iodine ointment and standard treatment. An economic analysis alongside a clinical trial.

Diabetic foot ulcers with exposure of tendon, muscle, or bone imply a high probability for deep infections and amputations. Delayed healing times are often described. The aim of this study was to compare the clinical effect and economic cost of cadexomer iodine with standard treatment in diabetic feet with cavity ulcers. Patients with deep, exudative foot ulcers were included in a 12-week open, randomised, comparative study. When ulcers stopped exudating, vaseline gauze was used in both groups until the end of the study. Costs were estimated for dressing material, staff and transportation. Clinically relevant improvement was seen in 12 patients treated with cadexomer iodine and in 13 patients treated with standard treatment. The average weekly cost was SEK 903 and SEK 1,421, respectively, of which the major part was costs for staff and transportation related to frequency of dressing changes. Treatment with cadexomer iodine ointment (Iodosorb) showed no clinical difference compared to topical treatment consisting of gentamicin solution, streptodornase/streptokinase, or dry saline gauze but was associated with considerably lower weekly treatment costs.

Uso de agentes fibrinolíticos em tromboses venosa e arterial / Fibrinolytic agents in venous and arterial thrombosis

Os fármacos fibrinolíticos representam um importante coadjuvante terapêutico para o cirurgiäo vascular em casos de trombose venosa e arterial. Há contudo muitos aspectos contraditórios. Seu uso em trombose venosa profunda näo tem aceitaçäo plena, apesar de alguns relatos de bons resultados. Quanto às patologias arteriais, sendo a correçäo cirúrgica difícil e limitada para as artérias de pequeno calibre, a fibrinólise pode representar uma alternativa ou um coadjuvante terapêutico. Deve ser lembrado que os efeitos colaterais induzidos pelos fármacos fibrinolíticos podem ser graves e limitar seu uso, havendo também suas contra-indicaçöes. Além disso, esta terapia exige uma adequada estrutura de UTI e laboratório para sua aplicaçäo

Low anti-streptokinase IgG concentrations following streptokinase-streptodornase treatment of leg ulcer patients.

We have evaluated whether neutralising anti-streptokinase IgG antibodies are produced following streptokinase-streptodornase therapy of leg ulcer patients. Serum anti-streptokinase IgG concentrations in 10 leg ulcer patients were determined before, and 1 week, 2 weeks, and 3 weeks following the treatment. We observed only a negligible increase in neutralizing anti-streptokinase IgG concentrations during the observation period, which was probably of no therapeutical significance.

A comparative study of ciprofloxacin and conventional therapy in the treatment of patients with chronic lower leg ulcers infected with Pseudomonas aeruginosa or other gram-negative rods.

Twenty-six elderly patients with chronic leg ulcers infected by Pseudomonas aeruginosa or other aerobic Gram-negative rods were randomised to two treatment groups. The control group (eight patients) received conventional local therapy and the other group (18 patients) was treated with oral ciprofloxacin for three months in addition to conventional local therapy. In the beginning of the study both groups were comparable with the age of the patients and the associated diseases including impairment of arterial and venous circulation in the lower legs. Also the size, duration and the severity of the inflammation reaction in the leg ulcers were comparable before the start of the therapy. Ciprofloxacin was clinically more effective than the standard therapy in reducing the size of the ulcer (p less than 0.05). Also the need of extra systemic antibiotics decreased significantly in the ciprofloxacin group compared with the controls. In three out of eighteen ciprofloxacin treated patients the leg ulcers disappeared completely during the three months' study period compared with none in the control group. However, ciprofloxacin resistant strains, mainly staphylococci, appeared in the leg ulcers in 67% of the ciprofloxacin treated patients compared with 0% in the control group (p less than 0.01). No significant side-effects due to ciprofloxacin except the resistant strains were noticed. We conclude that oral long-term ciprofloxacin therapy is effective in the treatment of chronic leg ulcer infections due to Gram-negative rods but selection of ciprofloxacin resistant strains is a problem in this patient group.

Comparison of saline and streptokinase-streptodornase in the treatment of leg ulcers.

In 31 patients with leg ulcers the wounds were randomly allocated to treatment either with a solution of streptokinase plus streptodornase in saline or physiological saline alone. The occurrence of pus and debris in the wounds was evaluated by a "blinded" investigator at the initiation of treatment and on Days 5, 10 and 15. In 12 out of 13 patients treated with the streptokinase-streptodornase solution and in 8 out of 16 saline-treated patients the wounds were clean by Day 10.

Proteases of Antarctic krill--a new system for effective enzymatic debridement of necrotic ulcerations.

The Antarctic krill (Euphausia superba) possesses an "over-dimensioned' digestive system, which is of vital importance for the survival of this euphaucean shrimp in the extreme marine environment. The isolated enzymes contain a well-balanced mixture of both endo- and exopeptidases, assuring fast and complete breakdown of proteinaceous material. These unique properties have now been shown to be extremely valuable for the effective removal of necrotic debris, fibrin or blood crusts in vitro. Therefore the krill enzymes should be considered as an important resource in the future management of necrotic wounds.

Enzymatic wound cleaning and absorbable sutures. An experimental study on Varidase and Dexon sutures.

The effect of an enzymatic preparation for wound cleaning (Varidase) on the mechanical properties of absorbable sutures (Dexon) was studied in vitro and in vivo in a rat model. In vitro the sutures demonstrated a significant decrease in strength (breaking strength and energy absorption) and extensibility after 12 days of incubation in saline. Incubation in Varidase, however, further decreased the mechanical properties significantly. The stiffness of the sutures was independent of treatment and time. In vivo changes of mechanical properties of the sutures resemble those of the in vitro study, except for a decrease in stiffness of the sutures. The sutures in a primary closed wound had the same strength (energy absorption) as the sutures of an open wound treated by saline, while the sutures of an open wound treated by Varidase tended to have a decreased strength (p = 0.08). This study supports the hypothesis that an enzymatic process may be involved in the degradation of Dexon. The continuous use of Varidase in Dexon-sutured wounds for a period longer than a few days is, therefore, questioned.

A double-blind randomized comparison of the effect and tolerance of Varidase versus saline when instilled in the urinary bladder in patients with catheter problems.

Thirty-eight patients with problems with their urinary catheters were randomly treated with Varidase or normal saline solution once a day for 10 days. Photographs were taken by using a cystoscope before treatment, at day 10 and day 24 after the commencement of treatment. The photographs were evaluated according to the occurrence of pus, debris, coagula and rubor. In the Varidase group the improvements from baseline to day 10 and day 24 were statistically significant (p less than 0.05) in all parameters while there were no statistically significant improvements in the saline group. Comparing the two treatment groups, regarding the changes from baseline to day 10 and day 24, it was statistically demonstrated that Varidase was significantly more effective than saline in all parameters (p less than 0.05). In conclusion, this study shows that Varidase effectively cleans the urinary bladder from pus, fibrin, necrotic tissue and blood clots.

A clinical study of Trypure or Varidase on minor burns.

A prospective double blind study using Varidase or Trypure on 2nd degree local burns in 18 patients was performed. No difference in cleaning or healing effect was revealed. In 6 out of 11 Trypure-treated and 1 out of 12 Varidase-treated patients treatment had to be discontinued because of intolerable pain. This difference was statistically significant.