y cuidados de heridas
Technol Assess 2000;4(21):1-237
Systematic reviews of wound care management: (3) antimicrobial agents
for chronic wounds; (4) diabetic foot ulceration.
O'Meara SO, Cullum N, Majid M, Sheldon T
NHS Centre for Reviews and Dissemination, University of York, UK.
BACKGROUND: Chronic wounds, including pressure sores, leg ulcers, diabetic
foot ulcers and other kinds of wounds, healing by secondary intention are
common in both acute and community settings. The prevention and treatment
of chronic wounds includes many strategies, including the use of various
wound dressings, bandages, antimicrobial agents, footwear, physical
therapies and educational strategies. This review is one of a series of
reviews, and focuses on the prevention and treatment of diabetic foot
ulcers and the role of antimicrobial agents in chronic wounds in general.
OBJECTIVES: To assess the clinical- and cost-effectiveness of (1)
prevention and treatment strategies for diabetic foot ulcers and (2)
systemic and topical antimicrobial agents in the prevention and healing of
chronic wounds. METHODS - DATA SOURCES: Nineteen electronic databases were
searched, including MEDLINE, CINAHL, Embase and the Cochrane Library.
Relevant journals, conference proceedings and bibliographies of retrieved
papers were hand-searched. An expert panel was consulted. METHODS - STUDY
SELECTION: Randomised and non-randomised trials with a concurrent control
group, which evaluated any intervention for the prevention or treatment of
diabetic foot ulcers, or systemic or topical antimicrobials for chronic
wounds (diabetic foot ulcers, pressure ulcers, leg ulcers of various
aetiologies, pilonidal sinuses, non-healing surgical wounds, and cavity
wounds) and used objective measures of outcome such as: (1) development or
resolution of callus; (2) incidence of ulceration (for diabetic foot ulcer
prevention studies); (3) incidence of pressure sores (pressure sore
prevention studies); (4) any objective measure of wound healing (frequency
of complete healing, change in wound size, time to healing, rate of
healing); (5) ulcer recurrence rates; (6) side-effects; (7) amputation
rates (diabetic foot ulcer treatment studies); (8) healing rates and
recurrence of disease, among others, for pilonidal sinuses. Studies
reporting solely microbiological outcomes were excluded. Decisions on the
inclusion of primary studies were made independently by two reviewers.
Disagreements were resolved through discussion. Data were extracted by one
reviewer into structured summary tables. Data extraction was checked
independently by a second reviewer and discrepancies resolved by
discussion. All included studies were assessed against a comprehensive
checklist for methodological quality. INCLUDED STUDIES - DIABETIC FOOT
ULCERS: Thirty-nine trials which evaluated various prevention and
treatment modalities for diabetic foot ulcers: footwear (2), hosiery (1),
education (5), screening and foot protection programme (1); podiatry (1)
for the prevention of diabetic foot ulcers; and footwear (1), skin
replacement (2), hyperbaric oxygen (2), ketanserin (3), prostaglandins
(3), growth factors (5), dressings and topical applications (9),
debridement (2) and antibiotics (2) for the treatment of diabetic foot
ulcers. INCLUDED STUDIES - ANTIMICROBIALS: Thirty studies were included,
25 with a randomised design. There were nine evaluations of systemic
antimicrobials and 21 of topical agents. QUALITY OF STUDIES: The
methodological and reporting quality was generally poor. Commonly
encountered problems of reporting included lack of clarity about
randomisation and outcome measurement procedures, and lack of baseline
descriptive data. Common methodological weaknesses included: lack of
blinded outcome assessment and lack of adjustment for baseline differences
in important variables such as wound size; large loss to follow-up; and no
intention-to-treat analysis. RESULTS - PREVENTION OF DIABETIC FOOT ULCERS:
There is some evidence (1 large trial) that a screening and foot
protection programme reduces the rate of major amputations. The evidence
for special footwear (2 small trials) and educational programmes (5
trials) is equivocal. A single trial of podiatric care reported a
significantly greater reduction in callus in patients receiving podiatric
care. RESULTS - TREATMENT OF DIABETIC FOOT ULCERS: Total contact casting
healed significantly more ulcers than did standard treatment in one study.
There is evidence from 5 trials of topical growth factors to suggest that
these, particularly platelet-derived growth factor, may increase the
healing rate of diabetic foot ulcers. Although these studies were of
relatively good quality, the sample sizes were far too small to make any
definitive conclusions, and growth factors should be compared with current
standard treatments in large, multicentre studies. Topical ketanserin
increased ulcer healing rate in 2 studies, while systemic hyperbaric
oxygen therapy reduced the rate of major amputations in 1 study.
Preliminary research into the effects of iloprost and prostaglandin E1
(PGE1) on diabetic foot ulcer healing suggests possible benefits. However,
good quality, large-scale confirmatory research is needed. Topical
dimethyl sulphoxide (DMSO) (1 trial), glycyl-l-histidyl-l-lysine:copper (1
trial) and topical phenytoin (1 trial) were associated with increased
healing. There is no good evidence in favour of any other dressing from 9
small trials, or for skin replacement dressings from 2 trials (the larger
of which suffered substantial loss to follow-up). RESULTS -
ANTIMICROBIALS: Thirty studies were included, 25 with a randomised design.
There were nine evaluations of systemic antimicrobials and 21 of topical
agents. RESULTS - ANTIMICROBIALS, VENOUS LEG ULCERS: DMSO powder produced
significantly higher healing rates than placebo, but was equivalent to
allopurinol powder. Results were conflicting for silver-based products
(silver sulphadiazine and silver-impregnated activated charcoal dressing).
There was no evidence in favour of systemic antibiotics, polynoxylin
paste, mupirocin 2% impregnated dressing or povidone iodine 10%. RESULTS -
ANTIMICROBIALS, MIXED AETIOLOGY WOUNDS: Systemic ciprofloxacin added to a
topical regimen produced increased healing rates in 1 trial. Levamisole
(primarily used to treat roundworm infection) was associated with
significantly higher healing rates than placebo (1 trial). The results for
benzoyl peroxide were equivocal. 1% silver-zinc allantoinate cream was
more effective than a variety of other topical preparations in a single
small study. No differences were found between a hydrocolloid dressing and
povidone iodine ointment for complete healing in patients with leg ulcers
(aetiology unspecified) or pressure ulcers. No differences were found
between an antiseptic spray (eosin 2% and chloroxylenol 0.3%) and an
alternative preparation in patients with diabetic foot ulcers or pressure
ulcers. RESULTS - ANTIMICROBIALS, PRESSURE ULCERS: There is no evidence in
favour of topical antimicrobials in pressure-sore prevention. Oxy-
quinoline ointment was significantly more effective than a standard
emollient for treating pressure sores in 1 study. No significant
difference was detected between a hydrocolloid dressing and povidone
iodine ointment, or between a gentian violet preparation and povidone
iodine/sugar ointment. RESULTS - ANTIMICROBIALS, DIABETIC FOOT ULCERS: No
beneficial effect of topical or systemic antibiotics was identified.
RESULTS - ANTIMICROBIALS, PILONIDAL SINUSES: Oral metronidazole given
after excision resulted in significantly shorter healing time (1 study).
Gentamicin-impregnated sponge produced significantly higher rates of
primary healing than no sponge. CONCLUSIONS: Much uncertainty remains over
the most effective interventions for the prevention and treatment of
diabetic foot ulcers. Certain treatments (e.g. growth factors and
off-loading techniques such as total contact casting) show promise but
need further, more rigorous evaluation. There is no existing evidence to
support the use of systemic antimicrobial agents for chronic wound
healing. Even with interventions that appear to be promising, further,
more rigorous evaluation is required before use becomes routine, as
existing trials are generally small and many have other methodological
problems. Several topical agents may be helpful, but again further
research is required to establish effectiveness. Until improved data on
relative effectiveness become available, considerations such as
cost-minimisation may be used to guide decisions on the use of
antimicrobial agents. IMPLICATIONS FOR FUTURE RESEARCH: It is likely that
most of the included trials have insufficient statistical power to detect
a true treatment effect. Most of this research requires replication in
larger, well-designed studies, with the incorporation of: adequate sample
size, clear inclusion criteria, true randomisation, assessment of baseline
comparability, blinded outcome assessment, objective outcome measurement,
intention-to-treat protocol and detailed reporting of withdrawals. Details
of concomitant interventions and an assessment of the adverse effects
associated with interventions should be provided.
J Accid Emerg Med 2000 Jul;17(4):254-6
Evaluating the use of computerised clinical guidelines in the accident
and emergency department.
Poncia HD, Bryant GD, Ryan J
Department of Accident and Emergency Medicine, Royal Sussex County
OBJECTIVES: To investigate the pattern and frequency of use of
computerised clinical guidelines (CCG) in an accident and emergency
department. METHODS: A software program was written to record information
on a central database each time the CCG were used. Data were collected
prospectively for a six month period. Users were blind to the study. The
date, time of use and guidelines consulted were recorded. RESULTS: 1974
individual sessions were logged comprising of 10204 "hits". The
CCG were used for a median of 10 sessions per day (range 1-38, SD 5.49). A
median of three subjects were accessed during each session (range 1-39, SD
5). The CCG were used most often during peak daily activity; 11 am (609
hits), 5 pm (678 hits) and 12 pm (604 hits) and on Sundays (1875 hits),
Thursdays (1770 hits) and Saturdays (1608 hits). The most frequently used
guidelines concerned orthopaedics and fracture management (1590 hits),
wound care (546 hits), poisoning (473 hits), medical emergencies (267
hits) and radiological policy (148 hits). CONCLUSIONS: In this department
CCG have become easily integrated as part of normal day to day working
practice. The CCG are accessible 24 hours a day. They can also be easily
updated according to best evidence, local policy or national guidelines.
The results of this study have helped the authors to focus education to
areas of clinical need.
Hand Clin 2000 May;16(2):215-24
Management of chemical injuries to the upper extremity.
Reilly DA, Garner WL
Division of Plastic and Reconstructive Surgery, University of Southern
California, Los Angeles, USA.
Chemical burns are interesting and challenging to treat. When the
practitioner is comfortable with the pathophysiology of chemical injury
and treatment based on these principles, most patients can be treated
effectively with good outcome (Fig. 2). Early treatment with water
irrigation, followed by diligent wound care, will allow our patients to
benefit to the maximum from our medical skills.
Health Technol Assess 1999;3(17 Pt 2):1-35 [Texto
Systematic reviews of wound care management: (2). Dressings and topical
agents used in the healing of chronic wounds.
Bradley M, Cullum N, Nelson EA, Petticrew M, Sheldon T, Torgerson D
NHS Centre for Reviews and Dissemination, University of York, UK.
Health Technology Assessment 1999; Vol. 3: No. 17 (Pt 1) [Texto
The debridement of chronic wounds: a systematic review
M Bradley, N Cullum, T Sheldon
Centre for Reviews and Dissemination, University ofYork, UK
Dermatol Nurs 1999 Feb;11(1):53-6, 60-3, 80
Traumatic wound care.
Dickerson P, Purdue GF, Hunt JL
Parkland Memorial Hospital, Dallas, TX, USA.
The scope and importance of traumatic wound care, assessment, debridement,
pre and postoperative management, and subsequent skin care during the
course of treatment cannot be over-emphasized, and indeed, are the most
important considerations for functional and cosmetic outcome. Care begins
in the emergent phase and continues through acute and convalescent phases.
Efforts are directed at methods and techniques which prevent infection,
facilitate wound healing, promote comfort, and at the same time, maintain
optimal function and minimize deformities.
Nurs Times 1999 Aug 25-31;95(34):72, 75
Wound care. Points of friction.
Royal Hospital for Neuro-disability, London.
This article aims to identify optimum management strategies for
hypergranulation of gastrostomy, tracheostomy and suprapubic catheter
sites. It discusses the aetiology of hypergranulation and gives an
overview of the available literature on existing treatments. It concludes
that the optimum choice of management may be to tape the tube to the body
to prevent friction and to use a polyurethane foam dressing with a high
moisture vapour transmission rate.
Nurs Clin North Am 1999 Dec;34(4):933-53, vii
Nursing management of chronic wounds: best practices across the
continuum of care.
Krasner DL, Sibbald RG
The Johns Hopkins University School of Nursing, Baltimore, Maryland, USA.
This article highlights the nurse's role within a holistic,
interdisciplinary approach to chronic wound management. Best practices for
chronic wound care are discussed, drawing on evidence-based science when
it is available. The fundamentals of chronic wound care, including
cleansing, irrigation, debridement, infection control, and topical
treatment are addressed. New devices and technologies are briefly
reviewed. Implementing these best practices across the continuum of care
will result in greater advances in the management of chronic wounds.
Nurs Clin North Am 1999 Dec;34(4):847-60
Pain management of wound care.
Pain Management Team, All Children's Hospital, St. Petersburg, Florida
33701-4899, USA. email@example.com
Children and adults still suffer pain during wound dressing changes
despite national guidelines. Assessing and managing pain are essential
components of comprehensive wound care. Developmentally sensitive pain
assessment tools are available to measure verbal, behavioral, and
physiologic responses to pain. Holistic pain assessment includes pain
intensity, location, description, relief measures, cultural background,
and the patient's developmental level and anxiety. Pharmacologic and
nonpharmacologic interventions should be combined to manage pain based
upon patient's response and nursing assessment. Nurses with a fundamental
knowledge of pain assessment and management provide their patients with
pain and symptom relief during wound care.
Ann Emerg Med 1999 Sep;34(3):356-67
Hollander JE, Singer AJ
Department of Emergency Medicine, University of Pennsylvania,
Philadelphia, USA. firstname.lastname@example.org
In 1996, almost 11 million lacerations were treated in emergency
departments throughout the United States. Although most lacerations heal
without sequelae regardless of management, mismanagement may result in
wound infections, prolonged convalescence, unsightly and dysfunctional
scars, and, rarely, mortality. The goals of wound management are simple:
avoid infection and achieve a functional and aesthetically pleasing scar.
Recent US Food and Drug Administration approval of tissue adhesives has
significantly expanded clinicians' wound closure options and improved
patient care. We review the general principles of wound care and expand on
the use of tissue adhesives for laceration repair.
Postgrad Med 1999 Jul;106(1):97-102 [Texto
Local wound care in diabetic foot complications. Aggressive risk
management and ulcer treatment to avoid amputation.
Carolina Podiatry Associates, Florence, South Carolina 29505, USA.
Techniques to prevent and treat lower extremity amputation in patients
with diabetes vary from simple foot inspection to complicated vascular and
reconstructive surgery. Early identification of risk factors, careful and
regular evaluation, and aggressive treatment in a multidisciplinary team
approach prevent amputation in most cases of diabetic foot ulcer. Suitable
treatment of these ulcers consists of minimizing pressure, resolving
infection, correcting ischemia, and maintaining a warm, moist, clean
environment to enhance wound healing. Success in these efforts not only
preserves quality of life for diabetic patients but also saves money for
the healthcare system.
Comment in: Postgrad Med 1999 Nov;106(6):27
Br J Nurs 1999 Feb 25-Mar 10;8(4):200-2, 204, 206 passim
Acute surgical wound care. 3: Fitting the dressing to the wound.
Foster L, Moore P
Department of Effective Healthcare, Scunthorpe Hospital, NHS Trust, North
The third article in this series on surgical wound care discusses the
types of dressings currently available, and selection of the correct
dressing for a particular wound type. There is an abundance of information
on the types of dressings available. Wound management for the individual
patient must be decided using best evidence and taking into account
patients' increased involvement in their care, new technology and the push
to mobilize early, leading to early discharge from hospital. The nurse
needs to have a good knowledge of the types of dressings available, the
properties of individual dressings and a sound understanding of wound
healing, in order to make an informed decision on wound management.
General factors such as safety, comfort, pain management and convenience
must be borne in mind when deciding which dressing is the best for
individual patients, given that dressings now have to be cost-effective as
well as clinically effective.
Am Fam Physician 1997 Oct 15;56(6):1643-6 [Texto
Nail gun injuries of the hand.
Hoffman DR, Jebson PJ, Steyers CM
University of Iowa Hospitals and Clinics, Iowa City, USA.
Nail gun injury of the hand is commonly encountered among workers in the
construction industry. Successful management requires a thorough
understanding of this unique injury, the recognition of nail shaft barbs,
and appropriate nail removal and wound care, with referral when indicated.
If barbs are encountered, nail removal involves cutting off the head of
the nail and extracting the nail in the direction of entry.
Nurs Clin North Am 1997 Jun;32(2):311-29
Management of the pediatric burn patient.
Cortiella J, Marvin JA
University of Texas Medical Branch, Shriners Burns Institute, Galveston,
Texas 77550, USA.
The care of children with burns represents a therapeutic dilemma for many
practitioners who periodically work with thermally injured patients. In
this article, the authors emphasize the pathophysiology of thermal injury
with special attention to the burned child. Within this framework, pain
control, resuscitation, wound care, and the importance of a "burn
care team" are discussed as important factors in the care of these
Mayo Clin Proc 1995 Aug;70(8):789-99
Pressure ulcers: prevention and management.
Evans JM, Andrews KL, Chutka DS, Fleming KC, Garness SL
Section of Geriatrics, Mayo Clinic Rochester, Minnesota 55905, USA.
OBJECTIVE: To describe important aspects of pressure ulcer prevention and
management, especially in elderly patients. DESIGN: We reviewed pertinent
published material in the medical literature and summarized effective
strategies in the overall management of the elderly population with
pressure ulcers. RESULTS: Pressure ulcers are commonly encountered in
geriatric patients. The development of a pressure ulcer is associated with
an increased risk of death. Certain well-recognized risk factors, such as
immobility and incontinence, may predispose to the development of pressure
ulcers; consequently, risk factor modification is an important aspect of
prevention and treatment. For existing lesions, various innovative patient
support surfaces and wound care products have been developed to alleviate
pressure and to facilitate wound healing. The use of a particular product
should be based on the clinical setting and the limited scientific
evidence available. With treatment, most pressure ulcers eventually heal.
CONCLUSION: Pressure ulcers are often, but not always, preventable. The
occurrence of such an ulcer signals the possible presence of chronic
comorbid disease and should prompt a search for underlying risk factors in
patients for whom ulcer treatment is considered appropriate.