Safety and effectiveness of an antiseptic wound cleansing and irrigation solution containing polyhexamethylene biguanide.

OBJECTIVE: There is currently a wide range of cleansing and irrigation solutions available for wounds, many of which contain antimicrobial agents. The aim of this study was to assess the safety of HydroClean Solution (HARTMANN, Germany), a polyhexamethylene biguanide (PHMB)-containing irrigation solution, in a standard cytotoxicity assay, and to assess its effect in a three-dimensional (3D) full-thickness model of human skin. METHOD: A number of commercially available wound cleansing and irrigation solutions, including the PHMB-containing irrigation solution, were tested in a cytotoxicity assay using L929 mouse fibroblasts (ISO 10993-5:2009). The PHMB-containing irrigation solution was then assessed in an in vitro human keratinocyte-fibroblast 3D full-thickness wounded skin model to determine its effect on wound healing over six days. The effect of the PHMB-containing irrigation solution on tissue viability was measured using a lactate dehydrogenase (LDH) assay, and proinflammatory effects were measured using an interleukin-6 (IL-6) production assay. RESULTS: The PHMB-containing irrigation solution was shown to be equivalent to other commercially available cleansing and irrigation solutions when tested in the L929 fibroblast cytotoxicity assay. When assessed in the in vitro 3D human full-thickness wound healing model, the PHMB-containing irrigation solution treatment resulted in no difference in levels of LDH or IL-6 when compared with levels produced in control Dulbecco's phosphate-buffered saline cultures. There was, however, a pronounced tissue thickening of the skin model in the periwound region. CONCLUSION: The experimental data presented in this study support the conclusion that the PHMB-containing irrigation solution has a safety profile similar to other commercially available cleansing and irrigation solutions. Evidence also suggests that the PHMB-containing irrigation solution does not affect tissue viability or proinflammatory cytokine production, as evidenced by LDH levels or the production of IL-6 in a 3D human full-thickness wound healing model. The PHMB-containing irrigation solution stimulated new tissue growth in the periwound region of the skin model.

Artificial intelligence in wound care: diagnosis, assessment and treatment of hard-to-heal wounds: a narrative review.

OBJECTIVE: The effective assessment of wounds, both acute and hard-to-heal, is an important component in the delivery by wound care practitioners of efficacious wound care for patients. Improved wound diagnosis, optimising wound treatment regimens, and enhanced prevention of wounds aid in providing patients with a better quality of life (QoL). There is significant potential for the use of artificial intelligence (AI) in health-related areas such as wound care. However, AI-based systems remain to be developed to a point where they can be used clinically to deliver high-quality wound care. We have carried out a narrative review of the development and use of AI in the diagnosis, assessment and treatment of hard-to-heal wounds. We retrieved 145 articles from several online databases and other online resources, and 81 of them were included in this narrative review. Our review shows that AI application in wound care offers benefits in the assessment/diagnosis, monitoring and treatment of acute and hard-to-heal wounds. As well as offering patients the potential of improved QoL, AI may also enable better use of healthcare resources.

Evaluation of patient-reported outcome measures in burn-specific tools: A systematic review.

INTRODUCTION: Patient-reported outcome measures (PROMs) are now well-established tools to evaluate the quality of patient-centred care. Due to the multi-faceted and multi-disciplinary nature of the practice of burn care, as well as the range of significant potential sequelae, PROM's should form a fundamental component of burn quality improvement programs. We aim to 1. Explore biological, psychological, and social considerations that are currently listed in burn-specific PROM tools, as well as their efficacy, 2. Evaluate biological, psychological, and social factors that are considered in new burn-specific PROM tools or those under development, and 3. Identify any opportunities with respect to burn-specific PROM tools, in order to inform future investigation in this area. METHODS: A search was performed of MEDLINE (Ovid), EMBASE, CINAHL, and the Cochrane Library databases. Two independent reviewers screened article titles/abstracts and then the full texts using Covidence. All studies were graded independently according to the Quality Rating Scheme for Studies and Other Evidences. RESULTS: The initial search yielded 552 references. Based on ab initio inclusion and exclusion criteria, 133 full-text studies were assessed for eligibility, and 21 articles were ultimately included in the systematic review. Due to study heterogeneity, a qualitative synthesis was conducted. Existing burn-specific PROMs covered a range of biological, psychological, and social factors affecting adult and paediatric patients with burn injury, but several studies required additional PROMs for a thorough evaluation. Burn-specific PROM tools under development are poised to fill this deficit. CONCLUSION: Major burn injuries are a unique form of trauma, requiring coordinated management that considers numerous factors not relevant to other patient populations. Further research is necessary to validate existing burn-specific PROM tools and to develop more comprehensive burn-specific PROM measures that more comprehensively incorporate the bio-psycho-social model of health.

Ambient Room Temperatures in a Burn Intensive Care Unit-A Quality Improvement Project.

Introduction: Patients with major burn injuries are particularly susceptible to hypothermia. The ability to maintain and rapidly increase ambient temperatures may reduce the impact of hypothermia and the hypermetabolic response. The purpose of this study was to determine ambient patient room temperatures in a burn intensive care unit (ICU) and to evaluate our ability to adjust these temperatures. Methods: The ambient temperatures of 9 burn ICU patient rooms were recorded hourly over a 6-month period in an American Burn Association-verified burn centre. Temperatures were recorded using wall-mounted smart sensors, transmitted to a mobile smartphone application via Bluetooth, and then exported to Excel for analysis. On 2 predetermined dates, thermostats in all rooms were simultaneously set to maximum, and monitored over 3 h. This represented a sound change initiative, and replicated a medical order to increase the ambient temperature during critical stages of patient care. Results: We recorded 4394 individual hourly temperature measurements for each of the 9 rooms. The mean ambient temperature was 23.5 ± 0.3 °C (range 22.8-24). After intervention 1, ambient temperatures increased <2 °C in 7 rooms and by only 2 °C-3 °C in the other 2 rooms. The overall mean increase in temperature over 3 h across all rooms was 1.03 °C ± 1.19 °C (range -0.88 to 3.26). Following intervention 2, temperatures could be increased by ≥2 °C in only 2 rooms with an overall mean increase in temperature of only 0.76 °C ± 0.99 °C (range -0.29 to 2.43) across all rooms. Conclusions: The burn ICU rooms were relatively cool and our ability locally to adjust ambient temperatures quickly was limited. Burn centres should have regular facility assessments to assess whether ambient temperatures can be adjusted expeditiously when required.

Introduction : Les patients ayant des brûlures importantes (>20% de la surface corporelle totale) sont particulièrement exposés au risque d'hypothermie. La capacité à maintenir et à rapidement augmenter la température ambiante peut réduire la répercussion négative de l'hypothermie et de la réponse hypermétabolique. L'objectif de cette étude était de déterminer la température ambiante des chambres de patients dans une unité de soins intensifs (USI) pour brûlés et d'évaluer notre capacité à ajuster ces températures. Méthodes : La température ambiante de neuf chambres de patients en USI pour brûlés a été enregistrée heure par heure pendant une période de 6 mois dans un centre pour brûlés vérifié par l'ABA. Les températures ont été consignées en utilisant des capteurs intelligents montés sur les murs avec transmission par Bluetooth à une application mobile pour téléphone intelligent, puis exportées dans un tableau Excel pour analyse. À deux dates prédéterminées, les thermostats de toutes les chambres ont été simultanément réglés au maximum et contrôlés pendant 3 heures. Cela représentait une initiative de changement réfléchie, répliquant une consigne médicale d'augmentation de la température ambiante pendant les phases critiques de soins aux patients. Résultats : Nous avons enregistré 4394 relevés horaires de la température pour chacune des neuf chambres. La température ambiante moyenne était de 23,5 ± 0,3 °C (écart : 22,8 à 24). Après la première intervention, les températures ambiantes ont augmenté de moins de 2 °C dans 7 chambres et de seulement 2 °C à 3 °C dans les deux autres chambres. L'augmentation moyenne globale pendant les 3 heures dans toutes les chambres était de 1,03 °C ± 1,19 °C (écart : −0,88 à 3,26). Après la deuxième intervention, les températures ont pu être augmentées de ≥ 2 °C dans seulement deux chambres avec une augmentation globale moyenne de la température de seulement 0,76 °C ± 0,99 °C (écart : −0,29 à 2,43) pour l'ensemble des chambres. Conclusions : Les chambres de l'USI pour brûlés étaient relativement fraîches et notre capacité à ajuster rapidement les températures ambiantes était limitée. Les centres pour brûlés devraient faire l'objet d'évaluations régulières d'établissement pour déterminer si la température ambiante peut être ajustée dans des délais très brefs en cas de besoin.

Experimental and clinical evidence for DACC-coated dressings: an update.

OBJECTIVE: To update the evidence in relation to the use of dialkylcarbamoyl chloride (DACC)-coated wound dressings in the prevention, treatment and management of wounds. METHOD: PubMed and PubMed Central databases were searched to identify articles published since 2020 describing the experimental and clinical evidence for DACC-coated dressings, and their antimicrobial effect, as well as their impact on the prevention and treatment of infected wounds. The identified articles were then narratively reviewed. RESULTS: The search yielded 113 articles (plus references from ad hoc sources), of which nine met the inclusion criteria. Of the nine included studies, five related to clinical aspects and four were laboratory studies. CONCLUSION: A number of new studies have provided further evidence for the mode of action of the antimicrobial effect of DACC-coated dressings and its wide spectrum effect (including World Health Organization-prioritised microorganisms). Additional clinical studies have provided evidence of new applications, such as in treating wounds in paediatric patients, and extended the evidence relating to their use in treating surgical site infections. Evidence also shows that DACC-coated wound dressings can aid in the binding of biofilms, and how this technology can align and support antimicrobial stewardship in the prevention of antimicrobial resistance.

Considerations for an ideal post-surgical wound dressing aligned with antimicrobial stewardship objectives: a scoping review.

OBJECTIVE: Most surgical wounds heal by primary or secondary intention. Surgical wounds can present specific and unique challenges including wound dehiscence and surgical site infection (SSI), either of which can increase risk of morbidity and mortality. The use of antimicrobials to treat infection in these wounds is prevalent, but there is now an imperative to align treatment with reducing antimicrobial resistance and antimicrobial stewardship (AMS). The aim of this review was to explore the published evidence identifying general considerations/criteria for an ideal post-surgical wound dressing in terms of overcoming potential wound healing challenges (including infection) while supporting AMS objectives. METHOD: A scoping review examining evidence published from 1954-2021, conducted by two authors acting independently. Results were synthesised narratively and have been reported in line with PRISMA Extension for Scoping Reviews. RESULTS: A total of 819 articles were initially identified and subsequently filtered to 178 for inclusion in the assessment. The search highlighted six key outcomes of interest associated with post-surgical wound dressings: wound infection; wound healing; physical attributes related to comfort, conformability and flexibility; fluid handling (e.g., blood and exudate); pain; and skin damage. CONCLUSION: There are several challenges that can be overcome when treating a post-surgical wound with a dressing, not least the prevention and treatment of SSIs. However, it is imperative that the use of antimicrobial wound dressings is aligned with AMS programmes and alternatives to active antimicrobials investigated.

Effectiveness of a polyhexamethylene biguanide-containing wound cleansing solution using experimental biofilm models.

OBJECTIVE: Antiseptics are widely used in wound management to prevent or treat wound infections, and have been shown to have antibiofilm efficacy. The objective of this study was to assess the effectiveness of a polyhexamethylene biguanide (PHMB)-containing wound cleansing and irrigation solution on model biofilm of pathogens known to cause wound infections compared with a number of other antimicrobial wound cleansing and irrigation solutions. METHOD: Staphylococcus aureus and Pseudomonas aeruginosa single-species biofilms were cultured using microtitre plate and Centers for Disease Control and Prevention (CDC) biofilm reactor methods. Following a 24-hour incubation period, the biofilms were rinsed to remove planktonic microorganisms and then challenged with wound cleansing and irrigation solutions. Following incubation of the biofilms with a variety of concentrations of the test solutions (50%, 75% or 100%) for 20, 30, 40, 50 or 60 minutes, remaining viable organisms from the treated biofilms were quantified. RESULTS: The six antimicrobial wound cleansing and irrigation solutions used were all effective in eradicating Staphylococcus aureus biofilm bacteria in both test models. However, the results were more variable for the more tolerant Pseudomonas aeruginosa biofilm. Only one of the six solutions (sea salt and oxychlorite/NaOCl-containing solution) was able to eradicate Pseudomonas aeruginosa biofilm using the microtitre plate assay. Of the six solutions, three (a solution containing PHMB and poloxamer 188 surfactant, a solution containing hypochlorous acid (HOCl) and a solution containing NaOCl/HOCl) showed increasing levels of eradication of Pseudomonas aeruginosa biofilm microorganisms with increasing concentration and exposure time. Using the CDC biofilm reactor model, all six cleansing and irrigation solutions, except for the solution containing HOCl, were able to eradicate Pseudomonas aeruginosa biofilms such that no viable microorganisms were recovered. CONCLUSION: This study demonstrated that a PHMB-containing wound cleansing and irrigation solution was as effective as other antimicrobial wound irrigation solutions for antibiofilm efficacy. Together with the low toxicity, good safety profile and absence of any reported acquisition of bacterial resistance to PHMB, the antibiofilm effectiveness data support the alignment of this cleansing and irrigation solution with antimicrobial stewardship (AMS) strategies.

Pressure in the Operating Room: A Potential Contributor to Hospital-Acquired Pressure Injuries.

Burn patients are at risk for hospital-acquired pressure injuries (HAPIs). An unexamined factor that may contribute to HAPI development is the effect of pressure from the operating table during surgery. The purpose of this study was to measure pressure on the buttocks and sacral area during burn surgery under general anesthesia (GA). Prospective study of consecutive adult burn patients admitted to an ABA-verified burn center who required surgery under GA between January 06, 2022 and December 08, 2022. We studied only cases that were supine, including those with both legs down (LD), one leg suspended (1LU), or both legs suspended (2LU). Interface pressures on the buttocks and sacral area were measured using a commercial sensor mat. Thousands of individual pressure measurements were integrated to show average and peak pressures over repetitive 10-minute intervals during the entire operation. Recordings were completed in 41 procedures among 28 patients (48.3 ± 16.9 years, % TBSA burn 19.2 ± 17.1, weight 80.2 ± 19.7 kg, BMI 26.7 ± 6.2). Both average pressure (Pave) and peak pressure (Ppeak) increased significantly with greater number of elevated legs (p < .001). During 2LU periods, Ppeak exceeded 100 mmHg for almost half the operative duration. Pave crept steadily upwards over time and had a positive relationship with weight, regardless of leg elevation. Prolonged moderate to high pressures are exerted on the sacral and buttock areas, especially with one or both legs suspended, during burn surgery. These novel observations suggest that pressure from the operating table could contribute to HAPI development.

Effectiveness of wound contact layers in enabling undisturbed wound management: a case series.

OBJECTIVE: Wound contact layers (WCLs) are intended to protect and support wounds during the healing process. An open, non comparative, case series clinical evaluation was undertaken to assess the impact of these dressings on establishing an undisturbed wound environment that supports effective wound management, and to allow the establishment of limits of duration of the wear time for the experimental WCLs. METHOD: The primary objectives of this clinical evaluation were to assess the ability of the WCLs to prevent tissue disturbance to the wound and surrounding skin and for the clinicians to have confidence to extend the wear time of the WCL dressings. For them to have confidence in leaving the dressings in place for extended periods, the assessment of the wound and periwound skin condition and an assessment of patient comfort was performed: assessment of wound and periwound condition in relation to tissue adherence of the dressing to the wound resulting in tissue damage/bleeding (to wound and/or periwound skin) and cellular infiltration into the WCL; assessment of patient wearing comfort and satisfaction; assessment of WCL wear time, relating to times between dressing changes as judged by the clinician. RESULTS: Based upon five parameters used to assess the extent to which the WCLs Atrauman, Atrauman Silicone and Atrauman Ag (HARTMANN, Germany) disturbed the underlying tissues-bleeding, wound tissue damage, periwound skin damage, tissue ingrowth and dressing adherence-the majority (>95%) of assessments indicated low or no disturbance of tissue. Over the 14 days of study assessment, the mean (±standard deviation) wear time was 7.3±1.2 days for the Atrauman group, 9.9±2.8 days for the Atrauman Silicone group, and 5.8±1.0 days for the Atrauman Ag group. All dressings were well tolerated by patients and rated highly in terms of in-use dressing performance. CONCLUSION: The results indicate that Atrauman WCLs are suitable for the management of a variety of wounds as they promote an undisturbed wound environment, including extended wear time.

Quality indicators in burn care: An international burn care professionals survey to define them.

INTRODUCTION: Quality indicators (QIs) are tools for improving and maintaining the standard of care. Although burn injuries are a major global health threat, requiring standardized management, there is a lack of worldwide accepted quality indicators for burn care. This study aims to identify the best burn care-specific QIs as perceived by worldwide burn practitioners. METHODS: The ISBI Burn Care Committee developed a survey to analyze which burn care- specific QIs were relevant to international burn care professionals. The questionnaire was based on the three dimensions of the Donabedian model (i.e., Structure, Process, and Outcome) to evaluate the quality of care. The study was conducted from April to September 2021 and analyzed and reported following the Checklist for Reporting Results of Internet E-Surveys (CHERRIES). RESULTS: According to the 124 worldwide respondents, the most relevant QIs were: access to intensive care, burn surgeons, and dedicated burn care nurses (Structure category), 24-hours access to burn services, local protocols based on documented guidelines (Process category), and in-hospital mortality and incidence of severe infections (Outcome category). CONCLUSIONS: Specific QIs related to structures, clinical processes, and outcomes are needed to monitor the treatment of burn patients globally, assess the efficiency of the provided treatment, and harmonize the worldwide standard of burn care.

Polyhexamethylene biguanide and its antimicrobial role in wound healing: a narrative review.

A wound offers an ideal environment for the growth and proliferation of a variety of microorganisms which, in some cases, may lead to localised or even systemic infections that can be catastrophic for the patient; the development of biofilms exacerbates these infections. Over the past few decades, there has been a progressive development of antimicrobial resistance (AMR) in microorganisms across the board in healthcare sectors. Such resistant microorganisms have arisen primarily due to the misuse and overuse of antimicrobial treatments, and the subsequent ability of microorganisms to rapidly change and mutate as a defence mechanism against treatment (e.g., antibiotics). These resistant microorganisms are now at such a level that they are of grave concern to the World Health Organization (WHO), and are one of the leading causes of illness and mortality in the 21st century. Treatment of such infections becomes imperative but presents a significant challenge for the clinician in that treatment must be effective but not add to the development of new microbes with AMR. The strategy of antimicrobial stewardship (AMS) has stemmed from the need to counteract these resistant microorganisms and requires that current antimicrobial treatments be used wisely to prevent amplification of AMR. It also requires new, improved or alternative methods of treatment that will not worsen the situation. Thus, any antimicrobial treatment should be effective while not causing further development of resistance. Some antiseptics fall into this category and, in particular, polyhexamethylene hydrochloride biguanide (PHMB) has certain characteristics that make it an ideal solution to this problem of AMR, specifically within wound care applications. PHMB is a broad-spectrum antimicrobial that kills bacteria, fungi, parasites and certain viruses with a high therapeutic index, and is widely used in clinics, homes and industry. It has been used for many years and has not been shown to cause development of resistance; it is safe (non-cytotoxic), not causing damage to newly growing wound tissue. Importantly there is substantial evidence for its effective use in wound care applications, providing a sound basis for evidence-based practice. This review presents the evidence for the use of PHMB treatments in wound care and its alignment with AMS for the prevention and treatment of wound infection.

The Africa Temporal Scalp Flap: A Novel Flap for Facial Reconstruction.

Although a number of flaps exist for nasal reconstruction, severe scarring of the forehead after burn injury led to the development of a novel two-stage flap based on the superficial temporal artery. The Africa Temporal Scalp (ATS) flap is composed of an axial ascending part on the superficial temporal artery, and a descending anterior extension for reconstruction of the midface. This is a retrospective analysis of all patients who underwent ATS flap surgery on the MV Africa Mercy. During the 7.5-year period, the ATS flap was applied to 45 facial reconstructions, with a median age of 28 years (range 19 months to 51 years). The main indications were previous burn injury (n = 27, 60%) and noma (n = 15, 33.3%). The majority of the flaps were used to reconstruct the lower third of the nose (n = 39, 86.7%), and the remaining six were for the lips or cheek. Experience allowed for earlier division than 3 weeks depending on the length of the flap, and the recipient site. There was one partial flap loss, one infection requiring revision, and two injuries to frontal branch of the facial nerve. The ATS flap is a novel two-stage flap that has proved especially versatile when forehead flaps are unavailable for nasal reconstruction due to extensive forehead scarring. The ATS flap reliably provides ample supple skin, and the donor site is effectively obscured from view, located in the periphery of the face.

An observational study of wounds treated with hydro-responsive wound dressings.

OBJECTIVE: Acute and hard-to-heal wounds are a significant burden to both a patient's quality of life and resources in healthcare systems. Here, we evaluate the outcomes of a non-comparative case series study in which Ringer's solution-preactivated polyacrylate dressings were used to treat acute and hard-to-heal wounds (the presence of Ringer's solution provides a wound dressing that allows, upon application, the immediate hydration of the underlying wound tissue). METHOD: Patients with acute and hard-to-heal wounds were enrolled into an open-labelled, non-comparative observational study. Patients were treated with Ringer's solution-preactivated polyacrylate dressings to enable wound debridement and wound cleansing for up to 12 weeks. RESULTS: A total of 303 patients were enrolled in the study and 278 were included in the analysis. Wound size decreased, from a median of 3.6cm2 (interquartile range (IQR): 1.2-9.3] at baseline to a median of 2.6cm2 (IQR: 1.1-7.8] at 84 days. Relative wound area reduction (WAR) was 43.1% at 84 days and estimated probability of achievement of a WAR of ≥40% and ≥60% was 68.7% and 53.4%, respectively. Median time to achieve a WAR of ≥40% and ≥60% was 54 days and 75 days, respectively. The median percentage of wound area covered by fibrin had decreased from 50.0% to 10% and granulation tissue had increased from 25% to 50% after 84 days. In addition, periwound skin condition, local signs of infection and pain all showed improvement. The majority of the wounds were assessed as 'healed' or 'better' at the conclusion of the evaluation period. CONCLUSION: Based on the findings of this study, the use of Ringer's solution-preactivated polyacrylate dressings in daily practice has the potential to improve clinical outcomes, including healing, in patients with acute and hard-to-heal wounds.

The importance of periwound skin in wound healing: an overview of the evidence.

DECLARATION OF INTEREST: The authors have no conflicts of interest.

HydroTac-a hydro-responsive wound dressing: a review of the in vitro evidence.

AIM: The aim of this review is to identify and summarise the key in vitro evidence available to support the use of HydroTac (HRWD-2) to address specific aspects associated with the treatment of both acute and hard-to-heal wounds. BACKGROUND: The provision of a moist wound healing environment to support optimal wound healing has been a basic tenet in wound care since the pioneering work on the benefits of occlusion to support wound healing. Modern wound dressings have adopted the benefits of moist healing through their innovative development. HRWD-2 has been shown in clinical studies to enable and support good healing outcomes and the in vitro evidence in support of this dressing is presented in this article. METHOD: An online literature search (supplemented with a manual search of resources not available online) was conducted to identify articles and studies describing in vitro evidence in support of HRWD-2 in aspects important for promoting a healing response in the clinical environment. RESULTS: In vitro studies showed that HRWD-2 contributes to balancing moisture levels and enhances the availability of growth factors known to be important for re-epithelialisation. Pre-clinical studies indicate that HRWD-2 enhances wound re-epithelialisation. Together these results suggest that HRWD-2 promotes a moist healing environment leading to the dressing supporting re-epithelialisation. In vitro data indicating an intrinsic lower in vitro adherence of HRWD-2 likely translate clinically to the benefits of an atraumatic wound dressing, including reduced pain (specifically at dressing change). CONCLUSION: The in vitro evidence presented in this review supports the successful clinical results reported for HRWD-2 in terms of fluid management, wound healing and pain reduction at dressing change.

The radial recurrent artery propeller flap for elbow coverage in an extensive burn.

Obtaining durable coverage of the elbow may be challenging when surrounding tissue as well as standard free flap donor sites are not available for use. Here we describe the application of the radial recurrent artery perforator propeller flap to good effect for the coverage of the elbow joint and ulnar nerve in the context of an extensive flame burn injury of over 80% of the body surface area. Despite few descriptions of its use in the literature, it is a relatively straightforward flap to elevate and inset, the donor area was effectively autografted and there were no postoperative complications.