Exudate Management Made Easy

exudate made management easy

facilitating the diffusion of vital healing factors (eg growth and immune factors) and the migration of cells across the Introduction wound bed5. It also promotes cell proliferation, provides Exudate production by open wounds is essential nutrients for cell metabolism, and aids autolysis of necrotic or for moist wound healing. However, when wounds damaged tissue. produce insufficient or too much exudate, and/or the composition of the exudate is harmful, a wide range of problems can occur that ultimately delay What affects rate of exudate healing, distress patients and consume considerable production? As healing occurs, the amount of exudate produced usually healthcare resources. This document builds on decreases5. It is important to recognise that the volume of the principles presented in the document Wound exudate is related to the surface area of the wound, and 1 exudate and the role of dressings , and focuses on how therefore large wounds such as burns, venous leg ulcers and a rigorous approach to exudate management can skin donor sites often produce higher volumes of exudate6. improve patient quality of life, promote healing and enhance healthcare effectiveness. Although a moist wound environment is necessary for optimal wound healing7, over- or under-production of exudate may adversely affect healing. Authors: M Romanelli, K Vowden, D Weir Full author details can be found on page 5. Any factor that increases capillary leakage or predisposes to the development of tissue oedema (eg inflammation, bacterial contamination or limb dependency) may boost What is exudate? exudate production. Low exudate production may indicate Exudate can be defined as fluid leaking from a wound. It plays a a systemic problem, eg dehydration, hypovolaemic shock, central role in healing. microangiopathy, or may be a feature of ischaemic ulcers1.

Exudate is mainly water, but also contains electrolytes, nutrients, When too much or too little exudate is produced, it is essential proteins, inflammatory mediators, protein digesting enzymes that the healthcare professional accurately determines and (eg matrix metalloproteinases (MMPs)), growth factors and evaluates the factors contributing to the problem. Only then can waste products, as well as various types of cells (eg neutrophils, effective management strategies be introduced. macrophages and platelets)2. Although wound exudate frequently contains micro-organisms, their presence does not necessarily mean that the wound is infected3. Exudate is usually Why does exudate sometimes cause clear, pale amber and of watery consistency4. In general, it is healing problems? odourless, although some dressings produce a characteristic odour In wounds not healing as expected (ie chronic wounds), that may be mistaken as coming from exudate. exudate appears to impede healing – it: n slows down or even prevents cell proliferation Wound exudate should be evaluated in the context of the n interferes with growth factor availability wound tissue type being treated. For example, exudate n contains elevated levels of inflammatory mediators and produced by a necrotic wound as a result of autolytic or activated MMPs8-10. enzymatic debridement would characteristically be opaque and tan, grey or even green (if the wound contains certain bacteria). The increased proteolytic activity of chronic wound exudate is This exudate may also present with a foul odour. implicated in perpetuating wounds, damaging the wound bed, degrading the extracellular matrix, and causing periwound skin problems11,12. What does exudate do? In healing wounds, exudate supports healing and a Alterations in the characteristics of exudate, eg in colour, moist wound environment. The main role of exudate is in quantity, odour or consistency, may have particular

1 exudate made management easy significance1,13. Any unexpected How do I know when What is the role of change in exudate characteristics exudate is not being dressings? may indicate a change in wound managed properly? In many cases, the overall aim of status or concomitant disease process Exudate is a problem when any of the exudate management is to achieve a and should prompt re-evaluation – following occurs: wound bed that is sufficiently moist for see: Wound exudate and the role of n leakage and soiling healing (see Table 1), but that does not dressings1. n periwound skin changes, eg cause problems such as maceration, maceration, denudation (skin whilst treating underlying contributory stripping or erosion) factors, enhancing patient quality of Why is it important to n delayed healing life, encouraging healing, addressing manage exudate? n odour exudate-related problems and Effective exudate management can n discomfort/pain optimising healthcare resource use1,14 reduce time to healing, reduce exudate- n infection (Figure 2). related problems such as periwound skin n protein loss/fluid and electrolyte damage and infection, improve patients’ imbalance Dressings are the main option for quality of life, reduce dressing change n need for frequent dressing changes managing exudate at wound level. frequency and clinician input, and so, n psychosocial problems – exudate- Table 2 presents dressing-related overall, improve healthcare efficiency. associated leakage, soiling, odour, strategies that can be employed to pain and the requirement for increase, maintain or reduce wound Comprehensive assessment underpins frequent dressing changes may moisture. effective exudate management, and distress patients and carers and ideally should be integrated into result in social isolation1. Where excessive exudate is a problem, or general wound assessment (Figure 1). where exudate composition is suspected Assessment should identify any wound- Insufficient exudate may be associated of impeding healing, removal of exudate related, local, systemic or psychosocial with delayed healing, delayed autolysis, from the wound bed is a priority. factors that may be contributing to dressing adherence and pain on exudate-related problems. dressing removal. How do I choose an appropriate dressing? There are numerous dressings Figure 1 Integration of exudate assessment (adapted from1) available, ranging from simple dressings consisting of one material, 7. Management to more sophisticated multilayered of exudate 1. Assess the dressings that combine several and related patient problems modes of fluid handling. The materials used in dressings vary in the way that they handle fluid and may 2. Assess the have other properties. Developing 6. Assess region of the periwound skin wound an understanding of how dressing materials function will assist clinicians in making appropriate dressing product choices according to individual patient’s 5. Assess 3. Assess needs. wound base current and edge dressing 4. Assess In addition to fluid handling exudate capability, the dressing selected should promote a wound

2 Table 1 Evaluation of dressing–exudate interaction (adapted from1) Status Indicators Wound bed Dressing Surrounding skin Dry Wound bed is dry; Primary dressing is unmarked; dressing may be adherent to Skin may be scaly, atrophic, there is no visible wound hyperkeratotic May be the moisture environment of choice for ischaemic wounds Moist Small amounts of Primary dressing may be lightly marked; dressing change Skin is likely to be intact, hydrated, no fluid are visible when frequency is appropriate lesions Aim of exudate dressing is removed; management in wound bed may many cases appear glossy Wet Small amounts of Primary dressing is extensively marked, but strikethrough does Initial fragmented areas of maceration fluid are visible not occur; appropriate dressing change frequency may be apparent when the dressing is removed Saturated Free fluid is visible Primary dressing is wet and strikethrough occurs; dressing Macerated or denuded periwound skin when the dressing is change is required more frequently than usual may encircle the wound removed Leaking Free fluid is visible Dressings are saturated and exudate is escaping from primary Periwound skin is likely to be macerated when the dressing is and secondary dressings onto clothes or beyond; dressing or denuded with extensive involvement removed change is required much more frequently than usual

Table 2 Strategies for achieving the desired moist wound environment (adapted from1) Aim Strategies* Increase wound moisture n Reassess patient management to ensure appropriate treatment is in place n Choose dressing type that conserves, maintains or adds moisture n Use thinner (less absorbent) version of current dressing n Decrease dressing change frequency n If problems continue or worsen, refer for specialist opinion

Maintain wound n Continue current dressing regimen if wound is making satisfactory progress towards treatment goals moisture n Reconsider dressing choice or consider specialist referral if progress towards treatment goals is unsatisfactory

Reduce wound moisture n Reassess patient management to ensure appropriate treatment is in place (eg systemic interventions, or elevation or compression where appropriate) n Use thicker (more absorbent) version of current dressing n Change to dressing type of greater fluid handling capacity n Add or use higher absorbency secondary dressing n Increase frequency of primary and/or secondary dressing change n If problems continue or worsen, refer for specialist opinion *It is important to review strategies regularly and to expect need for adjustment

environment that will encourage healing, prevent further n if used under compression, ability to retain fluid under problems and meet the patient’s individual needs15. Other pressure considerations will include: n cost-effectiveness. n ease of application, comfort, conformability n length of wear/frequency of dressing change required Only by careful assessment of the current dressing–wound n retention of exudate within the dressing interaction can appropriate decisions be made regarding future n avoidance of maceration/denudation dressing selection (Table 1). Any decisions made to change the n ease of removal dressing regimen need to be taken in the overall context of the n ability to reduce pain on application and removal and patient’s wound, concomitant conditions, psychosocial status during wear and wishes.

3 How do dressing materials retain fluid? Many dressing materials handle fluid Figure 2 Principles of effective exudate management (adapted from1) by absorbing it and/or allowing it to evaporate. Simple absorptive dressing Effective exudate management materials that take fluid up into spaces in their structure, eg cotton, viscose Treat underlying or contributory factors or polyester textiles and simple polyurethane or silicone foams, are not able to retain liquid under pressure. Some dressing materials, eg hydrocolloids, Wound-related factors Local factors Systemic factors Psychosocial factors carboxymethylcellulose (CMC) fibres (Hydrofiber® Technology) and, to an extent, alginates, can retain a high proportion of absorbed fluid when compressed by Optimise Remove/maintain/increase wound Enhance patient taking up liquid to form a gel16. wound bed moisture as appropriate quality of life

Dressing materials are frequently available in several different forms, eg Prevention and treatment of exudate-related problems flat sheets of varying thickness, pastes and ropes. Increasingly, individual dressing products combine layers or within the dressing16,17. This property For example, CMC fibres and some pockets of different types of dressing may help to protect periwound skin18,19. alginates, have been shown in vitro to materials. For example, dressings may trap bacteria and exudate components consist of a wound contact layer, an How can I increase wound such as proteolytic enzymes along with absorbent layer and a non-permeable or moisture? fluid20. semi-permeable backing. As a result, the In some situations, wound healing and fluid handling characteristics and usages autolysis are delayed because there Laboratory studies have also shown of individual dressings of the same is insufficient moisture in the wound. that some dressing materials, eg CMC, broad type may vary considerably1. Occlusive dressings (such as those with collagen/oxidised-regenerated cellulose a semi-permeable film backing or that and some forms of hyaluronan, are How do I avoid skin contain hydrocolloids) or those that able to reduce free radical activity21,22. maceration? donate moisture (such as hydrogels) can Free radicals are produced as part of Periwound skin changes have a number increase wound moisture content. Some the inflammatory process and have of causes including: contact with combination dressings are intended to been implicated in the perpetuation of exudate, dressing sensitivity/allergy or a maintain a moist wound environment wounds23. dermatological condition. The likelihood of whilst absorbing exudate. exudate-related changes can be reduced by minimising skin contact with exudate How do I know when by employing a dressing and regimen What do we know I have made the right appropriate to the level of exudate about the effects of choice? production, and, if appropriate, using dressings on exudate Regular comprehensive assessment a suitable skin barrier and atraumatic composition? and documentation of the wound are dressings and methods of fixation. It has been suggested that some essential for monitoring change and dressing materials have the potential aiding decision-making. Documented CMC fibres (Hydrofiber® Technology) to alter the composition of exudate in improvement of the wound and have been shown to form a gel that ways that may prove to be beneficial to progression towards treatment goals prevents lateral movement of fluid healing1. (usually healing) provide a clear

4 indication that the wound environment unhealthy and/or the wound is Management with fluid enhancement provided by topical extending collection devices interventions has been successful. n the wound bed shows signs of Fluid collection devices (eg wound increasing bacterial load management, stoma or urostomy bags) Indications that the right choice has n there is soiling outside the dressing are useful when exudate levels are been made and that the wound is n the patient has made adjustments high and draining from an area where progressing to healing include: to dressing arrangements to the surrounding skin can support an n healthy or improving periwound accommodate the exudate adhesive flange. Collection devices skin n dressing changes are very frequent are available that may be suitable for n healthy wound bed with no sign of n wound odour is uncontrolled a range of wound sizes, from small infection n wound pain is continuing. discrete wounds, eg small surgical n reduced dressing change wounds or drain sites, to large wounds requirements Management with topical such as dehisced abdominal wounds. n lack of or reduction in wound odour negative pressure n reduction in or lack of wound pain. In recent years, topical negative pressure wound therapy has revolutionised the management of Supported by an educational grant from When do I need to heavily exuding wounds24. In the ConvaTec. The views expressed in this think again? context of exudate management, it ‘Made Easy’ section do not necessarily The complications that may arise is especially useful when soiling and reflect those of ConvaTec. from poor exudate management are leakage pose significant problems Hydrofiber® is a registered trademark of significant. Regular reassessment is and when frequent dressing changes ConvaTec Inc. necessary to highlight continued or are very painful. It has been used in a emerging problems, and to prompt wide range of wound types, including adjustments in management. When diabetic foot ulcers and pressure ulcers there is lack of progress, reassessment and has proved particularly useful in Author details should include examination for factors the management of sternal and open M Romanelli1, K Vowden2, D Weir3. beyond the wound that may be abdominal wounds. 1. Consultant Dermatologist, Wound Research Unit, Department of creating a barrier to healing. In addition, Dermatology, University of Pisa, Italy specialist referral may be considered. Topical negative pressure 2. Nurse Consultant, Acute and Chronic wound therapy must be used Wound Care, Bradford Teaching Hospitals NHS Foundation Trust and University of Signs of lack of progress include: appropriately, giving consideration to Bradford, Bradford, UK n the patient’s quality of life is not contraindications, the type and location 3. Director, Wound Care, Osceola Regional Medical Center, Kissimmee, Florida, USA improving of the wound, resources required and n the periwound skin remains practitioner competencies24.

Summary Exudate production is a normal feature of healing wounds. However, when the exudate produced is too much, too little or of the wrong composition, a wide variety of problems can occur, ranging from psychosocial issues to delayed healing. Careful attention to contributory factors and to local management can help to reduce the likelihood of problems, encourage healing and avoid unnecessary health burden costs. To cite this publication M Romanelli, K Vowden, D Weir. Exudate Management Made Easy. Wounds International 2010; 1(2): Available from http://www.woundsinternational.com

SC–000115–MM 5 References 1. World Union of Wound Healing Societies proteases and their inhibitors. Wound 18. Vanscheidt W, Münter KC, Klövekorn W, (WUWHS). Principles of best practice: Repair Regen 1999; 7(6): 442-52. et al. A prospective study of the use of a non-adhesive gelling foam dressing on Wound exudate and the role of dressings. 10. Vowden K, Vowden P. The role of exudate exuding leg ulcers. J Wound Care 2007; London: MEP Ltd, 2007. Available from: in the healing process: understanding 16(6): 261-65. http://www.woundsinternational.com. exudate management. In: White, R 2. Cutting KF. Exudate: Composition and (ed). Trends in Wound Care: Volume III. 19. Parish LC, Dryjski M, Cadden S on behalf functions. In: White, R (ed). Trends in Salisbury: Quay Books, MA Healthcare of the Versiva® XC Pressure Ulcer Study Wound Care: Volume III. Salisbury: Quay Ltd, 2004; 3-22. Group. Prospective clinical study of new adhesive gelling foam dressing Books, MA Healthcare Ltd, 2004; 41-49. 11. Chen WY, Rogers AA. Recent insights in pressure ulcers. Int Wound J 2008; 5: 3. World Union of Wound Healing Societies into the causes of chronic leg ulceration 60-67. (WUWHS). Principles of best practice: in venous diseases and implications on wound infection in clinical practice. An other types of chronic wounds. Wound 20. Newman GR, Walker M, Hobot JA, international consensus. London: MEP Repair Regen 2007; 15: 434-49. Bowler PG. Visualisation of bacterial sequestration and bactericidal activity Ltd, 2008. Available from: http://www. 12. Gibson D, Cullen B, Legerstee R, et al. within hydrating Hydrofiber® wound woundsinternational.com. MMPs Made Easy. Wounds International dressings. Biomaterials 2006; 27: 1129- 4. Vowden K, Vowden P. Understanding 2009; 1(1): Available from: http:// 39. exudate management and the role of woundsinternational.com. 21. Moseley R, Leaver M, Walker M, et exudate in the healing process. Br J 13. Folestad A, Gilchrist B, Harding K, et al. al. Comparison of the antioxidant Community Nurs 2003; 8(11 Suppl): 4-13. Wound exudate and the role of dressings. properties of HYAFF-11p75, AQUACEL 5. Thomas S. Assessment and management A consensus document. Int Wound J 2008; and hyaluronan towards reactive oxygen of wound exudate. J Wound Care 1997; 5 (suppl 1): iii-12. species in vitro. Biomaterials 2002; 23: 6(7): 327-330. 14. Dowsett C. Exudate management: a 2255-64. 6. Thomas S, Fear M, Humphreys J, et al. The patient-centred approach. J Wound Care 22. Cullen B, Watt PW, Lundqvist C, et effect of dressings on the production of 2008; 17(6): 249-52. al. The role of oxidised regenerated exudate from venous leg ulcers. Wounds 15. Dowsett C. Managing wound exudate: cellulose/collagen in chronic wound 1996; 8(5): 145-50. role of Versiva® XC™ gelling foam repair and its potential mechanism 7. Okan D, Woo K, Ayello EA, Sibbald G. The dressing. Br J Nurs 2008; 17(11): of action. Int J Biochem Cell Biol 2002; role of moisture balance in wound healing. S38-S42. 34(12): 1544-56. Adv Skin Wound Care 2007; 20(1): 39-55. 16. Parsons D, Bowler P, Myles V, Jones 23. Salim AS. The role of oxygen-derived 8. Yager DR, Zhang LY, Liang HX, et al. S. Silver antimicrobial dressings in free radicals in the management of Wound fluids from human pressure wound management: a comparison venous (varicose) ulceration: a new ulcers contain elevated matrix of antibacterial, physical and chemical approach. World J Surg 1991; 15(2): metalloproteinase levels and activity characteristics. Wounds 2005; 17(8): 264-69. compared to surgical wound fluids. J 222-32. 24. European Wound Management Invest Dermatol 1996; 107(5): 743-48. 17. Waring MJ, Parsons D. Physico-chemical Association (EWMA). Position 9. Trengove NJ, Stacey MC, MacAuley S, characterisation of carboxymethylated Document: Topical negative pressure in et al. Analysis of the acute and chronic spun cellulose fibres. Biomaterials 2001; wound management. London: MEP Ltd, wound environments: the role of 22(9): 903-12. 2007.

Further reading World Union of Wound Healing Societies (WUWHS). Principles of best practice: Wound exudate and the role of dressings. London: MEP Ltd, 2007. Available from: http://www.woundsinternational.com. Gibson D, Cullen B, Legerstee R, et al. MMPs Made Easy. Wounds International 2009; 1(1): Available from: http:// woundsinternational.com. Krasner D, Rodeheaver GT, Sibbald RG (eds). Chronic wound care, 4th edition. Wayne, PA: HMP Communications, 2008.

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