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Use of Manuka Honey for Debridement in Necrotic and Sloughy Wounds.Pdf WOUND CARE Use of manuka honey for autolytic debridement in necrotic and sloughy wounds Theresa Mitchell wounds are managed in two stages The scientific and clinical focus on honey which has come about (Sibbald et al, 2011; Barrett, 2017). in the past 30 years has led to the classification of medical grade honey and the commercial availability of highly regulated products. Stage 1 Medical grade honey has proven antibacterial activity, traceability Full holistic assessment is undertaken of source, and lack of contaminants. It is gamma-irradiated to kill by a healthcare professional to bacterial spores that may be present in raw honey (Amaya, 2015; identify and establish any underlying Cooper, 2016). It is available in a wide range of products, including diseases or causes which might delay sterile tubes of honey ointment, honey impregnated tulles, alginates, an individual’s ability to heal in a gels and meshes. normal way. This includes common chronic conditions such as diabetes, heart, vascular or lung diseases, a KEYWORDS: poor immune system, or lifestyle Medical grade honey Antimicrobial agent choice, such as smoking or obesity. Autolytic debridement Activon® Manuka Honey Range Stage 2 The second stage examines local ebridement of slough barriers to healing within the wound and/or necrotic tissue ‘Honey is well-recognised itself. This involves removing non- Dis a key element of care as a safe and effective viable tissue, such as necrosis or associated with best practice and debriding agent, which slough, reducing oedema, exudate wound bed preparation (Atkin and the bacterial burden, and and Rippon, 2016; Barrett, 2017), possesses multifactorial choosing the most appropriate care as their presence is associated antimicrobial properties.’ pathway that will promote healing with an increased risk of infection and improve patient outcomes. and biofilms, especially if patients (MRSA) and Pseudomonas aeruginosa are frail, elderly or have a weak (P. aeruginosa); both of which have As said, debridement is a immune system (Grothier, 2015; been implicated in wound infection key component of wound bed Cooper, 2016; Halstead et al, 2016). and an increased risk of mortality preparation, as it helps to improve Honey is well-recognised as a (Jenkins, 2012; Leaper et al, 2015). conditions at the wound bed to safe and effective debriding agent, However, evidence, both in vivo and encourage healing (Dowsett, 2008; which possesses multifactorial in vitro, suggests that Manuka honey Strohal et al, 2013). The most antimicrobial properties (Carter et is effective at reducing bioburden and appropriate method of debridement al, 2016; Cooper, 2016; Ahmed et biofilms within a wound (Maddocks should be identified by the al, 2018). 2013; Bolognese et al, 2016; Cooper, healthcare professional during initial 2016; Malone and Swanson, 2017). assessment, as implementing best Recently, there has been practice in a timely manner is key. increasing concern about the rising WOUND BED PREPARATION number of antibiotic-resistant pathogens, particularly meticillin- Wound bed preparation was Practice point resistant Staphylococcus aureus developed and continually reviewed ▼ to deliver effective management Debridement is an important of chronic wounds and has been element of wound bed preparation accepted as best practice both and is defined as, ‘the removal nationally and internationally of foreign matter or devitalized, (European Wound Management injured, infected tissue from a Association [EWMA], 2004; Atkin wound until the surrounding healthy and Rippon, 2016; Barrett, 2017). tissue is exposed’ (Sibbald et al, 2011; Leaper et al, 2012; Madhok et Theresa Mitchell, specialist service lead, Mount In principal, wound bed al, 2013; Strohal et al, 2013). Gould Hospital, Plymouth; Queen’s Nurse preparation recommends that ?? JCN 2018, Vol 32, No 4 WOUND CARE WHAT IS AUTOLYTIC flavonoids, phenolic acids, and patients with chronic wounds DEBRIDEMENT? lysozyme (Ahmed et al, 2018). leading to embarrassment, isolation and depression (Grothier, 2015; Autolytic debridement describes The unique property of Manuka Dickinson, 2016; Jones, 2018). a normal healing process, which honey is attributed to the content Malodour is due to ammonia, amines makes use of the body’s own selective of methylglyoxal (MGO) — termed and sulphur compounds, which are ability to dissolve necrotic or sloughy the Unique Manuka Factor (UMF). produced when infecting bacteria tissue through phagocytosis. This is Manuka honey is assigned a rating metabolise amino acids from proteins done by the action of macrophages based on quantification of the in the serum and necrotic tissue and lymphocytes and provides a presence of MGO (Amaya, 2015; (Molan, 1999; Cooper, 2016). Some supportive environment without Cooper, 2016; Rabie et al, 2016). common wound pathogens have damaging healthy tissue. It is The activity of Manuka honey is distinctive odours, for example, P. important to remember that adequate aeruginosa produces a fishy smell, moisture is required at the wound and MRSA a cheesy smell (Cooper, interface to allow this process. ‘Manuka honey promotes 2016). However, sugars, such as those autolytic debridement by found in Activon® Manuka Honey, Manuka honey promotes autolytic drawing water from skin cells change the way in which bacteria debridement by drawing water metabolises, resulting in less odorous from skin cells via osmosis, which via osmosis, which rehydrates, wounds (Akhmetova et al, 2016). rehydrates, softens and liquefies hard softens and liquefies hard eschar and slough (Wounds UK, eschar and slough.’ MANUKA HONEY AS A 2013; Atkin and Rippon, 2016). This is DEBRIDING AGENT attributed to stimulation of plasmin activity in the wound, thus denaturing not inhibited by catalase, whereas Honey has been shown to be an fibrin which attaches slough to the peroxide activity is (Molan, 2009). effective antimicrobial debriding wound bed. This theory is based upon The level of MGO correlates to the agent on a variety of different wound the known effects of plasminogen level of antimicrobial activity and is types, including burns, leg ulcers, activator inhibitor (Cooper, 2016; measured as non-peroxide activity pressure ulcers, diabetic foot ulcers White, 2016). This mechanism is (NPA). An NPA rating of 10 or more and fungating wounds. consistent with autolysis, where is considered suitable for medical use, the creation of a moist wound for example, Activon® Manuka Honey THE EVIDENCE environment at the appropriate pH (Advancis Medical) is guaranteed leads to the removal of slough (Molan to have a minimum NPA of 10 and A recent 15-day evaluation by Barcic and Rhodes, 2015). Some patients may is usually higher. There is extensive et al (2014) compared a chemical experience discomfort or a drawing and well-established evidence for debriding agent against three sensation as the osmotic pressure Manuka honey’s antimicrobial different commercially available rises. The patient should be informed activity in vitro, including antibiotic- honey products in 20 patients of this and the most appropriate resistant species (Bolognese et al, presenting with diabetic foot ulcers, analgesia offered. 2016; Malone and Swanson, 2017). which had 100% fibrous sloughy tissue. Patients were divided into MANUKA HONEY’S Indeed, Manuka honey has been four groups. The chemical group ANTIMICROBIAL ACTIVITY shown to be clinically effective in had daily dressing changes, as per reducing bioburden and inhibiting manufacturer’s directions, and the As bees have different nutritional bacteria, including resistant strains other three groups were changed behaviour and collect nourishment such as antibiotic-resistant MRSA every three days. The rate of from various plants, honeys have and vancomycin-resistant enterococci debridement varied between each different compositions (Oryan et al, (VRE) (Gottrup et al, 2013). It has group. The chemical agent was the 2016). Manuka honey is derived from also been found to prevent biofilm slowest, with 90% of devitalised honey bees that forage on the nectar formation in a wide variety of tissue still present at the end of the of Manuka bushes (Leptospermum wound types in both adults and study. While the honey products did scoparium), which are indigenous neonates (White, 2016). Additionally, debride the foot ulcers, only one to New Zealand and Australasia. Manuka honey has been found to Honey has a complex chemistry be effective against organisms such which is dependent on its source and as P. aeruginosa and Escherichia coli ▼ Practice point processing techniques. As with all (E. coli), which are known to be honeys, Manuka honey can restrict involved in malodour (Cooper, 2016; Manuka honey can directly affect microbial growth due its acidic White 2016). bacterial cells embedded in a pH, osmotic effect of sugars, and biofilm and exhibits antiadhesive production of hydrogen peroxide REDUCING MALODOUR properties against common wound (H2O2) by peroxidase. Some non- pathogens (Bolognese et al 2016, peroxidase substances also support Wound odour can have a significant Maddocks 2013). antibacterial activity, including impact on the quality of life for ?? JCN 2018, Vol 32, No 4 WOUND CARE achieved 100% debridement. This was the honey which contained 100% pure medical grade Manuka honey with no additives or preservatives. A multi-centred retrospective study examined the safety and efficacy of Manuka honey in 115 neonates and paediatric wounds all Figure 1. requiring debridement (Amaya, 2015). Activon Tube.
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