- 1 - Welcome to the eleventh edition of the Dressings Times which contains the results of a survey of the dressings used by Plastic Surgeons together with an interesting account of some wound management problems encountered in Zanzibar. Pre- vious editions of the Dressings Times have included articles outlining some of the facts and arguments relating to the use of hypochlorite solutions and other antiseptic agents used in wound management. These have clearly been a source of concern if not irritation to some medical colleagues and this fact is reflected in the first article in this current issue. USE OF DRESSINGS IN PLASTIC SURGERY UNITS IN THE UNITED KINGDOM. Summary A questionnaire was sent to every Consultant Plastic Sur- geon in the U.K. requesting information on the range of dressings used in their units for the management of open contaminated wounds. An analysis of the replies revealed that; i. Betadine and Flamazine are the most widely used sub- stances, ii. Paraffin gauze is universally used as a dressing, iii. Hypochlorites are still used by more than half of those replying, iv. Traditional dressings such as acetic acid and honey, are still considered to have a place, v. Many of the newer products, which include the semi- permeable films, hydrogels, hydrocolloids and the al- ginates, have failed to gain widespread acceptance de- spite being aggressively marketed,. vi. In each of these different groups of products, a sin- gle product often takes a major market share. Introduction The `ideal' dressing for open wounds is still a matter for dispute. The concept of a moist environment for wound heal- ing has led to the introduction of many new dressings, whilst, at the same time, many old established products, such as the hypochlorites, are being branded as useless or even toxic. This is at a time when wound dressing policies are being formulated in many hospitals with no regard to what is being practised in specialist wound management cen- tres such as Plastic Surgery Units. Although there is a widely held belief that many of the older methods of treat- ment are still in common use in these centres, little hard information is available to support this view. A survey was therefore conducted in attempt to determine precisely what dressings are used. Methodology A questionnaire was prepared and sent to each of the 130 Consultant Plastic Surgeons in the United Kingdom. This contained, in alphabetical order, 53 substances and dress- ings available for wound management and each respondent was asked to provide an indication as to the usage of each one within their unit. The questionnaire also gave the respon- dents an opportunity to make any general comments they felt appropriate. Results The grades of staff who completed the questionnaire are shown in Table 1. Table 1: Staff who completed the questionnaire +------------------------+-----------------+----------------+ | Grade | Number | Percent | +------------------------+-----------------+----------------+ | Consultants | 28 | 47 | | Registrars-S.R. | 20 | 33 | | S.H.O's | 4 | 7 | | Nursing Staff | 6 | 13 | +------------------------+-----------------+----------------+ | Totals | 60 | 100 | +------------------------+-----------------+----------------+ From the 130 forms distributed, a total of 60 replies were received representing 35 of the 40 Plastic Surgery Units in the United Kingdom. In nine cases the replies covered the Unit as a whole, however, in some instances, Consultants from a single Unit expressed different and even contradicto- ry views. The information contained in the completed forms is summarised in Table 2 Table 2: Usage of specific dressings ------------------------------------------------------------- SUBSTANCE ALWAYS OFTEN SELDOM NEVER ------------------------------------------------------------- Acetic Acid 1 (2%) 13 (22%) 17 (28%) 29 (48%) Actisorb 0 (0%) 0 (0%) 11 (18%) 49 (81%) Aserbine 0 (0%) 11 (18%) 17 (28%) 32 (53%) Bactroban 0 (0%) 10 (17%) 11 (18%) 39 (7%) Betadine 9 (15%) 42 (70%) 6 (10%) 3 (5%) Cetrimide 1 (2%) 6 (10%) 11 (18%) 42 (70%) Dextranomers Debrisan 0 (0%) 0 (0%) 6 (10%) 54 (90%) Iodosorb 0 (0%) 3 (5%) 4 (7%) 53 (88%) Flamazine 13 (22%) 39 (65%) 8 (13%) 0 (0%) Furacine 0 (0%) 4 (7%) 18 (30%) 38 (63%) Gentian Violet 0 (0%) 0 (0%) 4 (7%) 56 (93%) Hydrocolloids Biofilm 0 (0%) 0 (0%) 0 (0%) 60 ( (100%) Comfeel 0 (0%) 1 (2%) 0 (0%) 59 (98%) Dermiflex 0 (0%) 0 (0%) 0 (0%) 60 (100%) Granuflex 0 (0%) 18 (30%) 27 (45%) 15 (25%) Hydrogels Bard Abs.Dr. 0 (0%) 0 (0%) 0 (0%) 60 (100%) Geliperm 0 (0%) 3 (5%) 9 (15%) 48 (80%) Scherisorb Gel 0 (0%) 10 (17%) 9 (15%) 41 (68%) Silastic.Gel.Sh 0 (0%) 9 (15%) 15 (25%) 36 (60%) Vigilon 0 (0%) 0 (0%) 1 (2%) 59 (98%) Hydrogen Perox. 3 (5%) 15 (25%) 18 (30%) 24 (40%) Hypochlorites Chloramine 0 (0%) 1 (2%) 1 (2%) 58 (96%) Chlorasol 0 (0%) 1 (2%) 1 (2%) 58 (96%) Eusol 1 (2%) 23 (38%) 8 (13%) 28 (47%) Eusol Paraf. 4 (7%) 24 (40%) 7 (12%) 25 (42%) Miltons Sol. 2 (3%) 26 (43%) 4 (7%) 28 (47%) Malatex 0 (0%) 1 (2%) 10 (17%) 49 (82%) Mercurochrome 1 (2%) 14 (23%) 8 (13%) 37 (62%) Proflavine BNF 1 (2%) 13 (22%) 11 (18%) 35 (58%) Sugar Paste/Honey 0 (0%) 5 (8%) 8 (13%) 47 (78%) Varidase 0 (0%) 4 (7%) 12 (20%) 44 (73%) Alginates Kaltostat 16 (27%) 18 (30%) 15 (25%) 11 (18%) Sorbsan 0 (0%) 5 (8%) 11 (18%) 44 (73%) Foams Allevyn 0 (0%) 0 (0%) 1 (2%) 59 (98%) Coraderm 0 (0%) 0 (0%) 1 (2%) 59 (98%) | | | | | | | | | | | | | | | Lyofoam 3 (5%) 2 (3%) 7 (12%) 48 (80%) | | Synthaderm 0 (0%) 0 (0%) 4 (7%) 56 (93%) | | | |Melolin 0 (0%) 14 (23%) 11 (18%) 35 (59%) | | | |Paraffin Gauze | | Bactigras 7 (12%) 25 (42%) 15 (25%) 13 (22%) | | Jelonet 14 (23%) 38 (63%) 8 (13%) 0 (0%) | | Paratulle 6 (10%) 12 (20%) 5 (8%) 37 (62%) | | | |Films | | Bioclusive 0 (0%) 0 (0%) 2 (3%) 58 (97%) | | Ioban-2 0 (0%) 0 (0%) 1 (2%) 59 (98%) | | Omiderm 0 (0%) 0 (0%) 6 (10%) 54 (90%) | | Opraflex 0 (0%) 1 (2%) 1 (2%) 58 (96%) | | Opsite 0 (0%) 16 (27%) 15 (25%) 29 (48%) | | Pharmaclusive 0 (0%) 1 (2%) 1 (2%) 58 (96%) | | Tegaderm 0 (0%) 9 (15%) 8 (13%) 43 (72%) | | Transigen 0 (0%) 0 (0%) 1 (2%) 59 (98%) | | | |Swabs | | Dry swabs 3 (5%) 10 (17%) 9 (15%) 38 (63%) | | Saline soaked 4 (7%) 33 (55%) 15 (25%) 8 (13%) | | | |Paste Bandages | | Icthaband 1 (2%) 0 (0%) 5 (8%) 54 (90%) | | Quinaband 1 (2%) 0 (0%) 6 (10%) 53 (88%) | +-----------------------------------------------------------+ In the main, the additional comments received, indicated that a survey designed to determine exactly what was being used in their units was welcomed by Plastic Surgeons. There was also a feeling of `being able to get it off one's chest' since a large number of Consultants still used products to which the nursing staff in their Units strongly objected, and which had been condemned in various scientific papers. For example, at least 43 papers have been published that condemn the use of hypochlorites, claiming them to be unre- liable as desloughing agents, and toxic to living tissue on the basis of in vitro studies only. The majority of Plastic Surgeons, however, reported that they find them very useful. They also feel frustrated and angry when pharmacists and in- fection control nurses dictate new rules banning the use of such materials. There was an overwhelming impression that in Plastic Surgery Units simple things come first and that the frequency of dressing changes together with a good nurs- ing standard are considered more important than the dressing itself. There was also the comment that anything cheap and useful is withdrawn by people with no direct clinical role. These are the feelings of the Consultants who feel that the introduction of new products may be more for the benefits of the manufacturer than for the patient. Nursing staff, on the other hand, seem more prone to accept the new products whilst rejecting well established substances such as mer- curochrome or the hypochlorites. Another point which emerged from the replies was that there is little place for rigid protocols in the management of open contaminated wounds. However, it is also obvious that Plastic Surgeons are playing a minor role in the decision making of Hospital wound management policies. As a result a Consultant can find himself in a position where a substance he wishes to use is unavailable or blacklisted. Faced with near univer- sal adoption of hospital wound dressing protocols, it is strongly advocated that all Plastic Surgery Units should ex- amine their own wound care procedures and seek to influence overall management of open wounds. Unfortunately compara- tive trials of wound dressings have rarely been published from Plastic Surgery Units. If these were to be done, then it is hoped that they would be proved scientifically that the methods adopted by Plastic Surgeons in the care of open contaminated wounds are both cheaper and more effective than those advocated elsewhere. Mr L. Chatzis, Registrar, Kingston General Hospital, Hull, Mr J.H. James, Consultant Plastic Surgeon, Shotley Bridge Hospital, Co.Durham. EXPERIENCES WITH SUGAR PASTE IN ZANZIBAR Granulated sugar and saturated sugar solutions have been used to treat wounds for many years.1,2 These promote heal- ing by keeping the wound surfaces moist, thereby allowing the natural regenerative processes of the body to take place4 whilst inhibiting the growth of bacteria and fungi as a result of their low water activity3. When dry granulated sugar is poured into an open wound, any surface moisture is taken up by osmosis and this drying ef- fect can lead to the formation of an intense burning sensa- tion. Hence sugar pastes which do not exert this effect are now preferred to dry sugar for wound treatment in Western Medicine.5,6 In Eastern Africa however, granulated sugar is still sometimes used. In Zanzibar it was found that, in the management of cavity wounds, provided the wound was clean, optimum results were achieved when sugar paste was left in situ for two days. Paste on deep burns was changed either daily or on alternate days. Frequent removal of paste covering tropical ulcers was found to retard the healing process. This is contrary to the view of Middleton1,6 who stated that the dressing should be changed twice a day because the sugar paste liqui- fied if left for a longer time. Provided that leakage from the dressings did not occur and the sugar concentration did not fall below 55%, which would permit the growth of certain bacteria,3 liquefication was generally not found to be a problem. Formulations. Two sugar pastes were prepared in Zanzibar. One contained 87% granulated sugar with 0.5% chlorbutol as preservative. This was found to be similar in action to sugar pastes con- taining approximately 0.15% hydrogen peroxide and 17% PEG 400 which are used in Northwick Park Hospital7. Chlorbutol was selected as a preservative because it was freely avail- able and considered to be less toxic than the peroxide/PEG combination used elsewhere. The other group of pastes contained 0.25% or 0.5% povidone iodine. These were formulated following a report from Greenville, Miss., USA6 where sugar pastes containing povi- done iodine have been used for some years to treat wounds. In spite of the assertion that povidone iodine is ten times more toxic to leucocytes than it is to bacteria7, and the possible adverse effect of absorbed iodine on thyroid function8, no adverse effects (other than pain lasting up to six seconds on application) were observed in any of our pa- tients treated with povidone iodine sugar pastes. Because of stability problems associated with high temperatures in Zanzibar, each batch of paste containing povidone iodine was given a maximum shelf life of six weeks. Method of use Originally, most wounds treated with sugar paste were cov- ered with conventional gauze dressings, but later polythene films were also used. The occlusive effect of polythene did not appear to impair wound healing when the dressings were changed every two days. Limbs were inserted in polythene tubes (which had been rinsed with sterile saline solution) and sealed with zinc oxide plaster tape or masking tape at their lower ends to hold the sugar paste in place. When the top ends were sealed, an air vent was formed by inserting a finger between the polythene and the patient's skin as the tape was applied. Effect upon wound healing rates Sugar paste containing 0.5% chlorbutol promoted the forma- tion of granulation tissue, but this sometimes became exces- sive and tended to inhibit the growth of epithelial tissue across the wound surface. With povidone iodine pastes, how- ever, some remarkable healing rates were achieved. Once granulation tissue had filled a cavity, epithelium grew in from the edges at approximately 2mm a day. This meant that a wound 10cm in diameter would be completely covered in about three weeks. Thomas9 states that, in full thickness burns, healing is very slow. But it was found that the rate of growth of ep- ithelial tissue across the backs of a nine year old boy's hands, which had sustained full thickness burns, was simi- larly 2mm a day. This could not be described as `very slow'. Sugar paste containing 0.2% povidone iodine was used on this patient whose hands were enclosed in polythene bags when it was found that gauze dressings removed newly-formed granulation tissue when the dressings were changed. Effect upon wound contraction Skin grafts were not required for patients treated with sugar pastes. Wounds treated with sugar pastes were more cosmetically acceptable than skin grafts because of the min- imal amounts of contraction which occurred, especially when povidone iodine sugar pastes were applied. When wounds were treated with 0.1% acriflavine solution or a similar antisep- tic, severe contractions frequently occurred. These obser- vations are not consistent with the view expressed by Sherif and Sato10 that extensive full thickness burns which heal by epithelialisation always result in major deformities. The problems that can occur with conventional treatments are il- lustrated by reference to the case of a patient who sus- tained severe burns to the whole of both hands and wrists. When, after 46 days, he left the hospital after an argument, good granulation tissue had formed and new epithelial tissue had covered his fingers. It was anticipated that this would continue to grow up across the back of his hands to meet ep- ithelial tissue growing down from his wrists, a process that it was estimated, would take two to three weeks. Eight weeks later he returned. In the intervening time he had re- ceived conventional treatment in a clinic and the backs of his hands had developed extensive severe contractions with the result that three of his fingers were pointing upwards at right angles to the dorsal surfaces of his hands. The result was that, although he had full use of all his fin- gers, he could not hold objects because of the contractions at the metacarpal/phalanges joints. After four weeks treat- ment with a 10% salicylic acid solution in propylene glycol, intensive physiotherapy and a minor operation to cut a liga- ment, full use of this hands was restored eight weeks after his return to the hospital. Treatment failures As might be expected, patients with ulcers associated with carcinomas did not respond well to treatment with sugar pastes and sugar paste treatment was also unsuccessful on a six year old diabetic boy who had a leg wound which was heavily contaminated with Pseudomonas aeruginosa. Number of patients treated During my stay on Zanzibar I was able to record particulars of only 25 patients treated in the general hospital, howev- er, the total number of patients treated with sugar pastes can be estimated from the fact that in the course of one year, approximately 50kg of sugar paste was prepared. Since most patients needed only small quantities of paste, in ex- cess of 300 must have been treated in that year. The pastes were used on tropical and decubitus ulcers, deep burns, gan- grenous wounds and deep lacerations from traffic accidents, fights (e.g., stoning of thieves) and falling coconut trees. In the case of less serious wounds, a cream made from co- conut oil was used. John Topham, Southsea, Hants. Acknowledgments I wish to thank Dr. Betty Burgess, Dr. Sam Cannata, Dr. Hassan Ahmed and in particular Dr. T. Abbass and the nursing staff of the General (formerly V I Lenin) Hospital, Zanz- ibar. References 1. Middleton K.R. and Seal D. Sugar as an aid to wound healing. Pharm. J. 1985,235,757. 2. Bhanaganada K. Kiettiphongthavorn V. and Wilde H. The use of super-saturated sucrose solution for chronic skin ul- cers (Resurrection of an old remedy). J. Med. Assn. Thai- land. 1986,69(7),358-365. 3. Loncin M.C. and Merson R.L. Food engineering - princi- ples and selected applications. London Academic Press 1979 195-202. 4. Hinman C.D. and Maibach H. Effect of air exposure and occlusion on experimental human skin wounds. Nature, 1963,200,377-378. 5. Knutson R.A. Merbitz L.A. Creekmore A.A. and Snipes H.G. Use of sugar and povidone iodine to enhance wound healing. Five years experience. South. Med.J. 1981,74(11),1329-35. 6. Middleton K. Sugar pastes in wound management. The Dressings Times, 1990,3,(2). 7. Gordon H. Middleton K. Seal D. and Sullens K. Sugar and wound healing. Lancet, 1985,Sep 21,663-412. 8. Rath Th. and Meissi G. Induction of hyperthyroidism in burn patients treated topically with povidone-iodine. Burns, 1988,14(4),320-322. 9. Thomas S. Wound management and dressings. The Pharmaceu- tical Press, London 1990, p5. 10. Sherif M.M. and Sato R.M. Severe hand burns - factors affecting prognosis. Burns, 1989,15(1),42-46. It is possible that both articles may stimulate some lively correspondence for a future edition of the Dressings Times. All letters will be published on a `first come - first served' basis! And finally A new dressing has recently been introduced which is un- likely to find favour in Plastic Surgery Units. It consists of a conventional adhesive gauze pad, with a central window area with up to 15 small sensing areas. One area is a pH- sensitive chemical, that changes colour with acidity. An ox- idase disc monitors bacteria, and cobalt chloride tells whether the flesh is wet or dry. Liquid crystal tape changes colour with temperature. A piezoelectric pad measures pres- sure, producing an electric signal and an electrochemical cell is activated by moisture. Both switch on small lights to warn of trouble below the dressing. It is not known if this can be used in conjunction with hypochlorite solution! The Dressings Times is produced by the Surgical Materials Testing Laboratory, (SMTL) Bridgend General Hospital, Quarella Road, Bridgend, Mid Glamorgan. Telephone No.(0656) 752820.