Wednesday, 9 August 2017

Metal Nurse: Pus, slough, silver, honey and maggots

As a nurse, I flit from one passion to another. All in all, my passion for good nursing has not diminished, but subjects tend to vary from one to the other. Whilst I was a student I had a very, very acute interest in diabetes. Especially how much being diabetic can affect and impact on nearly every single aspect of your life. I've dabbled a little bit in cardiac care. I still enjoy advocating for vaccines, especially for healthcare workers, mental health still remains at the forefront of my mind, I got extremely interested in stroke if only because my first job offer was within an acute stroke setting, and so on and so forth. All in all, I do generally enjoy almost every aspect of nursing. Currently, my biggest passion involves wound care. In all its gory and gooey glory. The sloughier, the better. The deeper the cut, the more I have fun. I am not saying that I want people to get hurt... But when they do, I want to be there. To help obviously...

Wound care has gone through some major changes over the years and will no doubt continue to do so, just like any other aspect of health. Wounds account for a huge portion of the NHS budget, a study published in the BMJ estimated that wound care along with associated co-morbidities accounted for £5.3 billion. This is on par with obesity which costs £5.1 billion, a little less than cancer which costs £5.6 billion. But considerably less than health tourism.

There are several myths that persist regarding wounds. The biggest one being "Let the wound breathe", it is one of those exceptionally persistent old wives tales that every (grand) parent tell their children when they fall and scrape their knees whilst being too busy playing on their mobile devices (I jest, I jest). The idea being that the air will dry it out and let it heal faster. This is just patently wrong. The best healing environment is a moist environment. Moist environment reduces the time it takes for the wound to heal, leads to less inflammation and necrosis, and also reduces scar formation. Leaving the wound open just increases the risk of infection, slows healing rate and scars more prominently.

Wounds tend to be fairly simple in of themselves. But any healing can be delayed by a lot of reasons. Present co-morbidities, certain medications, dietary intake, mobility, smoking, alcohol drinking, etc etc. One of the biggest factors that can delay healing is being diabetic. The reason for this is because diabetes oft leads to neuropathy, which in turn leads to blood circulation, which makes it difficult for the blood with it's associated macrophages, fibrinogens and platelets from reaching the wound area.


But enough about that. Due to increased prevalance of antibiotic resistant bacteria we have now started to look more at alternative ways of treating wounds. As can be imagined antibiotic resistant bacteria will wreak havoc on wounds and will turn acute wounds into chronic ones purely because we don't have the antibiotics to give either in IV, oral form or as a topical cream. The three major components that are being used more and more of are: SilverHoney and Maggots. Oh, and seaweed. We use a lot of seaweed in wound care. Sadly due to the lack of real hardcore double blinded studies it is hard to ascertain how effective these methods are in speeding up wound healing process. Anecdotally I have come across excellent results with maggot therapy, but more mixed experience with either silver or honey. Good wound care is more based on how cleanly the dressing is done, with minimal dressing changes. Plus also making sure that the patients holistic assessment is complete, because there are so many other factors that can affect wound healing mentioned previously. The key component being actually cleaning the wound before covering it up, now here is something that I personally found interesting but every community nurse knew but needs to be reiterated, using normal tap water is just as effective as using pods of normal saline.

Now those three things that I mentioned before, Silver, Honey and Maggots are largely on the rise because of antibiotic resistance. Which was first detected when antibiotics first came on the market, but has since been on the rise. Without effective antibiotics we are looking at a very bleak future indeed, hence the need to look beyond antibiotics for infected wounds.

Silver dressings had been on the rise until fairly recently when study after study found that it was not that effective in preventing infections in chronic wounds or increasing healing rate. There had been reports that silver inhibits bacterial growth in petri dishes, but human beings are not petri dishes and this unfortunately not been replicated properly in real life situations.  In fact in some cases it seemed to delay healing times. On the other hand it is quite effective in odour control, but in all honesty I'd rather stick with charcoal dressings as they do it even better and are overall cheaper. There are of course those in the "alternative medical" business who insist on pushing colloidal silver for everything. But beware of this quack remedy. It is not natural as claimed, nor is it effective. And as a side note, ingesting colloidal silver can and does lead to a condition called Argyria. Having said all of that, when/if antibiotic resistance becomes the overwhelming reality then we will have to reevaluate the use of silver in dressings and wound care.

Honey on the other hand has been showing some benefit in real life situations. Honey had been a stable in folklore and "natural" medicine, up until the 19th century when medical doctors decided to put it to the test. Today it isn't just any old honey that is used, it is manuka honey. This honey is generally derived from New Zealand and Australia, collected by bees that forage on tea tree. The oil of which has also been found to be a fairly effective antimicrobial agent, even against antibiotic resistant bacteria like MRSA. Though again most of the positive findings tend to be in vitro. These dressings have been found to be as effective in small scale studies, but (again) large scale studies need to be done in order to establish whether they are superior to traditional dressings. But on the whole honey dressings are good because the provide moist healing environment, debridement, deodorizing and are also anti-inflammatory, all factors that assist with good healing environment.

Maggot therapy is back in vogue, and in recent years has seen increase in usage on especially wounds that take a long time to heal for example diabetic foot ulcers, pressure ulcers and venous stasis ulcers. Whilst maggot therapy had been in fairly common usage up until 1930's, the advent of antibiotics made maggots look obsolete. It wasn't until the 1980's when the danger or antibiotic resistant bacteria started truly rearing it's ugly head when maggots were reconsidered for wound care. Just to be clear it can't just be any maggots. For preference the larvae of the green bottle fly is used. These little beauties are tiny and feast on necrotic flesh, which makes them perfect for debridement of wounds. They do their stuff by secreting enzymes that break down the necrotic tissues into juices from them to drink. These enzymes also have the added benefit being broad spectrum anti-microbial, making this therapy also suited for those whose wounds have been colonised by antibiotic resistant bacteria. They can come in either a teabag or loose, and left on the wound for up to three days. Along with cleaning out the wound, the larvae also stimulate the healing process, they managed that by stimulating fibroblasts which synthetize into collagen and extracellular matrix, and by providing those elements it supports other cells with wound healing.  A small randomized study done in 2000 that involved 12 patients did indicate that larval therapy could be more cost-effective than using the standard hydrogel. But as with an study like this it makes it hard to replicate and do on a larger scale.

As mentioned previously, the dressings that I have mentioned to have their place within the toolkit of wound dressings. None should be completely dismissed unless there has been a large scale studies performed in showing either ineffectiveness or in fact make the problems worse. For example, "letting the wound breath", just stop it.

 What is most important when dressing a wound is consistency, rather than any fancy pancy dressings.
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