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MOIST
HEALING AND WOUND CARE INCLUDING BURNS
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(Advantages
and Current Approaches)
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Section
II. Part B ( Current Concepts Continued . . . )
B.
THE BURN WOUND
The
concepts of optimum burn wound management remained focused on
avoiding wound infection first with topical antibiotics and
more recently early excision and grafting. Infection has been
a much greater concern for the deep burn wound likely due to
the combination of impaired local immunity, with the
presence of dead tissue, and impaired systemic immunity
with a large injury.
The
role of moist wound healing has now been recently adopted for
the more superficial burn, skin grafts (mainly meshed grafts)
and a clean excised wound. (awaiting a graft)
The
current approach to the deep burn is antibacterial control
till excision. Surface desiccation using this approach is
inevitable as the topical creams are hyperosmolar. Also,
these agents do retard healing.
Burn
Wounds
Click
the Image to Enlarge
Burn
wound managed by exposure or open method. Note: Dry
surface with wound desiccation. This approach is no longer
considered appropriate.
ADVANTAGES
OF MOIST WOUND HEALING
Surface
drying not only impedes delivery of nutrients and immune
defenses to the wound surface but also markedly impedes the
ability of cells to migrate across the wound surface.
Epithelial cells need a moisture layer to migrate and spread.
For any re-epithelialization to occur on a dry surface, the
cells must burrow beneath the "scab" using a
controlled release of proteases.
Moisture
is required for:
The
optimum approach to maintaining a moist wound surface is the
use of occlusive dressings. These dressings include
polyurethane films, a variety of hydrocolloids and an
increasing use of adherent synthetic skin substitutes such as
Biobrane.
Advantage
of a Moist Wound Surface
Comparison
of Maintaining Moist Surface Versus Open Wound
C)
ADVANTAGES OF MOIST WOUND HEALING
Characteristics
of Moist Wound Healing
- Rapid
movement of epithelial cells across surface
- Decreased
surface inflammation
Click
the Image to Enlarge
Characteristics
of Healing on Wound
Without
Moisture Layer
- slower
epithelial movement as enzyme debridement thru eschar
required
- increased
wound inflammation (exudate)
Click
the Image to Enlarge
A
marker of the moisture retention on the wound surface has been
the water vapor transmission rate thru the dressing (WVTR in
g/m2/hr). The lower the WVTR, the more effective
the dressing or skin substitute is at maintaining wound
surface moisture.
Lower
WVTR Correlation
D)
WOUND MOISTURE AND ITS ROLE IN WOUND COMPLICATIONS
Infection:
Infection
or at least wound colonization has been considered to be a
potential complication, especially in a burn. However, on a
clean wound, moisture minimizes wound progression to
non-viable tissue. Injured tissue will increase organism
growth. In the presence of non-viable tissue, such as eschar
in a mid to deep partial or full thickness non-burn wound, a
solution with antibacterial properties can be used. However, a
topical cream is the
standard of care in deep burn wounds.
Antibacterial creams are still the mainstay in deep burns even
though desiccation and increased exudate and decreased healing
will likely occur.
Wound
Care Approach
Pain:
Pain
is a major complication of wound care. Removal of a dry
dressing on a partial thickness wound results in much greater
pain than removal or change of a moist dressing.
Moisture-retentive
dressings (or adherence skin substitutes left in place) cause
less pain.
Skin
Maceration:
The
concern over moisture and skin maceration relates mainly to exudate
which in increased amounts will lead to tissue maceration.
Wounds, moist or even wet with a solution (where exudate is
absorbed or removed) have been shown to actually increase
healing rate.
Hyper granulation:
Hyper granulation
is a complication of excess granulation tissue occurring in a
full thickness wound. This complication has been prevalent
well before the use of a moist wound environment and therefore
moisture is not the cause.
Recent
studies in acute wounds have indicated decreased inflammation
and less granulation tissue using moist healing.
Potential
Complications of Moist Wound Healing
Wet
Healing Environment
Of
major interest is the fact that a number of recent studies
have indicated that a wet wound surface (on a partial or deep
wound) further increases the rate of re-epithelialization of a
partial thickness wound.
Key
findings with wet surface
N.B.
All wet wound-healing studies have utilized a normal saline
solution with added antibiotics to avoid bacterial growth.
SUMMARY OF MOIST HEALING USE
ON BURN AND NON-BURN WOUNDS
E
) A CURRENT APPROACH TO BURN WOUND CARE
  
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