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1 exudate maagemet made easy Itroductio Exudate productio by ope wouds is essetial for moist woud healig. However, whe wouds produce isufficiet or too much exudate, ad/or the compositio of the exudate is harmful, a wide rage of problems ca occur that ultimately delay healig, distress patiets ad cosume cosiderable healthcare resources. This documet builds o the priciples preseted i the documet Woud exudate ad the role of dressigs 1, ad focuses o how a rigorous approach to exudate maagemet ca improve patiet quality of life, promote healig ad ehace healthcare effectiveess. Authors: M Romaelli, K Vowde, D Weir Full author details ca be foud o page 5. What is exudate? Exudate ca be defied as fluid leakig from a woud. It plays a cetral role i healig. Exudate is maily water, but also cotais electrolytes, utriets, proteis, iflammatory mediators, protei digestig ezymes (eg matrix metalloproteiases (MMPs)), growth factors ad waste products, as well as various types of cells (eg eutrophils, macrophages ad platelets) 2. Although woud exudate frequetly cotais micro-orgaisms, their presece does ot ecessarily mea that the woud is ifected 3. Exudate is usually clear, pale amber ad of watery cosistecy 4. I geeral, it is odourless, although some dressigs produce a characteristic odour that may be mistake as comig from exudate. Woud exudate should be evaluated i the cotext of the woud tissue type beig treated. For example, exudate produced by a ecrotic woud as a result of autolytic or ezymatic debridemet would characteristically be opaque ad ta, grey or eve gree (if the woud cotais certai bacteria). This exudate may also preset with a foul odour. What does exudate do? I healig wouds, exudate supports healig ad a moist woud eviromet. The mai role of exudate is i facilitatig the diffusio of vital healig factors (eg growth ad immue factors) ad the migratio of cells across the woud bed 5. It also promotes cell proliferatio, provides utriets for cell metabolism, ad aids autolysis of ecrotic or damaged tissue. What affects rate of exudate productio? As healig occurs, the amout of exudate produced usually decreases 5. It is importat to recogise that the volume of exudate is related to the surface area of the woud, ad therefore large wouds such as burs, veous leg ulcers ad ski door sites ofte produce higher volumes of exudate 6. Although a moist woud eviromet is ecessary for optimal woud healig 7, over- or uder-productio of exudate may adversely affect healig. Ay factor that icreases capillary leakage or predisposes to the developmet of tissue oedema (eg iflammatio, bacterial cotamiatio or limb depedecy) may boost exudate productio. Low exudate productio may idicate a systemic problem, eg dehydratio, hypovolaemic shock, microagiopathy, or may be a feature of ischaemic ulcers 1. Whe too much or too little exudate is produced, it is essetial that the healthcare professioal accurately determies ad evaluates the factors cotributig to the problem. Oly the ca effective maagemet strategies be itroduced. Why does exudate sometimes cause healig problems? I wouds ot healig as expected (ie chroic wouds), exudate appears to impede healig it: slows dow or eve prevets cell proliferatio iterferes with growth factor availability cotais elevated levels of iflammatory mediators ad activated MMPs The icreased proteolytic activity of chroic woud exudate is implicated i perpetuatig wouds, damagig the woud bed, degradig the extracellular matrix, ad causig periwoud ski problems 11,12. Alteratios i the characteristics of exudate, eg i colour, quatity, odour or cosistecy, may have particular 1

2 exudate maagemet made easy sigificace 1,13. Ay uexpected chage i exudate characteristics may idicate a chage i woud status or cocomitat disease process ad should prompt re-evaluatio see: Woud exudate ad the role of dressigs 1. Why is it importat to maage exudate? Effective exudate maagemet ca reduce time to healig, reduce exudaterelated problems such as periwoud ski damage ad ifectio, improve patiets quality of life, reduce dressig chage frequecy ad cliicia iput, ad so, overall, improve healthcare efficiecy. Comprehesive assessmet uderpis effective exudate maagemet, ad ideally should be itegrated ito geeral woud assessmet (Figure 1). Assessmet should idetify ay woudrelated, local, systemic or psychosocial factors that may be cotributig to exudate-related problems. Figure 1 Itegratio of exudate assessmet (adapted from 1 ) 6. Assess periwoud ski 7. Maagemet of exudate ad related problems 5. Assess woud base ad edge 4. Assess exudate How do I kow whe exudate is ot beig maaged properly? Exudate is a problem whe ay of the followig occurs: leakage ad soilig periwoud ski chages, eg maceratio, deudatio (ski strippig or erosio) delayed healig odour discomfort/pai ifectio protei loss/fluid ad electrolyte imbalace eed for frequet dressig chages psychosocial problems exudateassociated leakage, soilig, odour, pai ad the requiremet for frequet dressig chages may distress patiets ad carers ad result i social isolatio 1. Isufficiet exudate may be associated with delayed healig, delayed autolysis, dressig adherece ad pai o dressig removal. 1. Assess the patiet 2. Assess the regio of the woud 3. Assess curret dressig What is the role of dressigs? I may cases, the overall aim of exudate maagemet is to achieve a woud bed that is sufficietly moist for healig (see Table 1), but that does ot cause problems such as maceratio, whilst treatig uderlyig cotributory factors, ehacig patiet quality of life, ecouragig healig, addressig exudate-related problems ad optimisig healthcare resource use 1,14 (Figure 2). Dressigs are the mai optio for maagig exudate at woud level. Table 2 presets dressig-related strategies that ca be employed to icrease, maitai or reduce woud moisture. Where excessive exudate is a problem, or where exudate compositio is suspected of impedig healig, removal of exudate from the woud bed is a priority. How do I choose a appropriate dressig? There are umerous dressigs available, ragig from simple dressigs cosistig of oe material, to more sophisticated multilayered dressigs that combie several modes of fluid hadlig. The materials used i dressigs vary i the way that they hadle fluid ad may have other properties. Developig a uderstadig of how dressig materials fuctio will assist cliicias i makig appropriate dressig product choices accordig to idividual patiet s eeds. I additio to fluid hadlig capability, the dressig selected should promote a woud 2

3 Table 1 Evaluatio of dressig exudate iteractio (adapted from 1 ) Status Idicators Woud bed Dressig Surroudig ski Dry May be the eviromet of choice for ischaemic wouds Moist Aim of exudate maagemet i may cases Wet Saturated Leakig Woud bed is dry; there is o visible moisture Small amouts of fluid are visible whe dressig is removed; woud bed may appear glossy Small amouts of fluid are visible whe the dressig is removed Free fluid is visible whe the dressig is removed Free fluid is visible whe the dressig is removed Primary dressig is umarked; dressig may be adheret to woud Primary dressig may be lightly marked; dressig chage frequecy is appropriate Primary dressig is extesively marked, but strikethrough does ot occur; appropriate dressig chage frequecy Primary dressig is wet ad strikethrough occurs; dressig chage is required more frequetly tha usual Dressigs are saturated ad exudate is escapig from primary ad secodary dressigs oto clothes or beyod; dressig chage is required much more frequetly tha usual Ski may be scaly, atrophic, hyperkeratotic Ski is likely to be itact, hydrated, o lesios Iitial fragmeted areas of maceratio may be apparet Macerated or deuded periwoud ski may ecircle the woud Periwoud ski is likely to be macerated or deuded with extesive ivolvemet Table 2 Strategies for achievig the desired moist woud eviromet (adapted from 1 ) Aim Strategies* Icrease woud moisture Reassess patiet maagemet to esure appropriate treatmet is i place Choose dressig type that coserves, maitais or adds moisture Use thier (less absorbet) versio of curret dressig Decrease dressig chage frequecy If problems cotiue or worse, refer for specialist opiio Maitai woud moisture Reduce woud moisture Cotiue curret dressig regime if woud is makig satisfactory progress towards treatmet goals Recosider dressig choice or cosider specialist referral if progress towards treatmet goals is usatisfactory Reassess patiet maagemet to esure appropriate treatmet is i place (eg systemic itervetios, or elevatio or compressio where appropriate) Use thicker (more absorbet) versio of curret dressig Chage to dressig type of greater fluid hadlig capacity Add or use higher absorbecy secodary dressig Icrease frequecy of primary ad/or secodary dressig chage If problems cotiue or worse, refer for specialist opiio *It is importat to review strategies regularly ad to expect eed for adjustmet eviromet that will ecourage healig, prevet further problems ad meet the patiet s idividual eeds 15. Other cosideratios will iclude: ease of applicatio, comfort, coformability legth of wear/frequecy of dressig chage required retetio of exudate withi the dressig avoidace of maceratio/deudatio ease of removal ability to reduce pai o applicatio ad removal ad durig wear if used uder compressio, ability to retai fluid uder pressure cost-effectiveess. Oly by careful assessmet of the curret dressig woud iteractio ca appropriate decisios be made regardig future dressig selectio (Table 1). Ay decisios made to chage the dressig regime eed to be take i the overall cotext of the patiet s woud, cocomitat coditios, psychosocial status ad wishes. 3

4 How do dressig materials retai fluid? May dressig materials hadle fluid by absorbig it ad/or allowig it to evaporate. Simple absorptive dressig materials that take fluid up ito spaces i their structure, eg cotto, viscose or polyester textiles ad simple polyurethae or silicoe foams, are ot able to retai liquid uder pressure. Some dressig materials, eg hydrocolloids, carboxymethylcellulose (CMC) fibres (Hydrofiber Techology) ad, to a extet, algiates, ca retai a high proportio of absorbed fluid whe compressed by takig up liquid to form a gel 16. Figure 2 Priciples of effective exudate maagemet (adapted from 1 ) Woud-related factors Optimise woud bed Effective exudate maagemet Treat uderlyig or cotributory factors Local factors Systemic factors Remove/maitai/icrease woud moisture as appropriate Psychosocial factors Ehace patiet quality of life Dressig materials are frequetly available i several differet forms, eg flat sheets of varyig thickess, pastes ad ropes. Icreasigly, idividual dressig products combie layers or pockets of differet types of dressig materials. For example, dressigs may cosist of a woud cotact layer, a absorbet layer ad a o-permeable or semi-permeable backig. As a result, the fluid hadlig characteristics ad usages of idividual dressigs of the same broad type may vary cosiderably 1. How do I avoid ski maceratio? Periwoud ski chages have a umber of causes icludig: cotact with exudate, dressig sesitivity/allergy or a dermatological coditio. The likelihood of exudate-related chages ca be reduced by miimisig ski cotact with exudate by employig a dressig ad regime appropriate to the level of exudate productio, ad, if appropriate, usig a suitable ski barrier ad atraumatic dressigs ad methods of fixatio. CMC fibres (Hydrofiber Techology) have bee show to form a gel that prevets lateral movemet of fluid withi the dressig 16,17. This property may help to protect periwoud ski 18,19. How ca I icrease woud moisture? I some situatios, woud healig ad autolysis are delayed because there is isufficiet moisture i the woud. Occlusive dressigs (such as those with a semi-permeable film backig or that cotai hydrocolloids) or those that doate moisture (such as hydrogels) ca icrease woud moisture cotet. Some combiatio dressigs are iteded to maitai a moist woud eviromet whilst absorbig exudate. What do we kow about the effects of dressigs o exudate compositio? It has bee suggested that some dressig materials have the potetial to alter the compositio of exudate i ways that may prove to be beeficial to healig 1. Prevetio ad treatmet of exudate-related problems For example, CMC fibres ad some algiates, have bee show i vitro to trap bacteria ad exudate compoets such as proteolytic ezymes alog with fluid 20. Laboratory studies have also show that some dressig materials, eg CMC, collage/oxidised-regeerated cellulose ad some forms of hyaluroa, are able to reduce free radical activity 21,22. Free radicals are produced as part of the iflammatory process ad have bee implicated i the perpetuatio of wouds 23. How do I kow whe I have made the right choice? Regular comprehesive assessmet ad documetatio of the woud are essetial for moitorig chage ad aidig decisio-makig. Documeted improvemet of the woud ad progressio towards treatmet goals (usually healig) provide a clear 4

5 idicatio that the woud eviromet ehacemet provided by topical itervetios has bee successful. Idicatios that the right choice has bee made ad that the woud is progressig to healig iclude: healthy or improvig periwoud ski healthy woud bed with o sig of ifectio reduced dressig chage requiremets lack of or reductio i woud odour reductio i or lack of woud pai. Whe do I eed to thik agai? The complicatios that may arise from poor exudate maagemet are sigificat. Regular reassessmet is ecessary to highlight cotiued or emergig problems, ad to prompt adjustmets i maagemet. Whe there is lack of progress, reassessmet should iclude examiatio for factors beyod the woud that may be creatig a barrier to healig. I additio, specialist referral may be cosidered. Sigs of lack of progress iclude: the patiet s quality of life is ot improvig the periwoud ski remais uhealthy ad/or the woud is extedig the woud bed shows sigs of icreasig bacterial load there is soilig outside the dressig the patiet has made adjustmets to dressig arragemets to accommodate the exudate dressig chages are very frequet woud odour is ucotrolled woud pai is cotiuig. Maagemet with topical egative pressure I recet years, topical egative pressure woud therapy has revolutioised the maagemet of heavily exudig wouds 24. I the cotext of exudate maagemet, it is especially useful whe soilig ad leakage pose sigificat problems ad whe frequet dressig chages are very paiful. It has bee used i a wide rage of woud types, icludig diabetic foot ulcers ad pressure ulcers ad has proved particularly useful i the maagemet of steral ad ope abdomial wouds. Topical egative pressure woud therapy must be used appropriately, givig cosideratio to cotraidicatios, the type ad locatio of the woud, resources required ad practitioer competecies 24. Maagemet with fluid collectio devices Fluid collectio devices (eg woud maagemet, stoma or urostomy bags) are useful whe exudate levels are high ad draiig from a area where the surroudig ski ca support a adhesive flage. Collectio devices are available that may be suitable for a rage of woud sizes, from small discrete wouds, eg small surgical wouds or drai sites, to large wouds such as dehisced abdomial wouds. Supported by a educatioal grat from CovaTec. The views expressed i this Made Easy sectio do ot ecessarily reflect those of CovaTec. Hydrofiber is a registered trademark of CovaTec Ic. Author details M Romaelli 1, K Vowde 2, D Weir Cosultat Dermatologist, Woud Research Uit, Departmet of Dermatology, Uiversity of Pisa, Italy 2. Nurse Cosultat, Acute ad Chroic Woud Care, Bradford Teachig Hospitals NHS Foudatio Trust ad Uiversity of Bradford, Bradford, UK 3. Director, Woud Care, Osceola Regioal Medical Ceter, Kissimmee, Florida, USA Summary Exudate productio is a ormal feature of healig wouds. However, whe the exudate produced is too much, too little or of the wrog compositio, a wide variety of problems ca occur, ragig from psychosocial issues to delayed healig. Careful attetio to cotributory factors ad to local maagemet ca help to reduce the likelihood of problems, ecourage healig ad avoid uecessary health burde costs. To cite this publicatio M Romaelli, K Vowde, D Weir. Exudate Maagemet Made Easy. Wouds Iteratioal 2010; 1(2): Available from SC MM 5

6 Refereces 1. World Uio of Woud Healig Societies (WUWHS). Priciples of best practice: Woud exudate ad the role of dressigs. Lodo: MEP Ltd, Available from: 2. Cuttig KF. Exudate: Compositio ad fuctios. I: White, R (ed). Treds i Woud Care: Volume III. Salisbury: Quay Books, MA Healthcare Ltd, 2004; World Uio of Woud Healig Societies (WUWHS). Priciples of best practice: woud ifectio i cliical practice. A iteratioal cosesus. Lodo: MEP Ltd, Available from: woudsiteratioal.com. 4. Vowde K, Vowde P. Uderstadig exudate maagemet ad the role of exudate i the healig process. Br J Commuity Nurs 2003; 8(11 Suppl): Thomas S. Assessmet ad maagemet of woud exudate. J Woud Care 1997; 6(7): Thomas S, Fear M, Humphreys J, et al. The effect of dressigs o the productio of exudate from veous leg ulcers. Wouds 1996; 8(5): Oka D, Woo K, Ayello EA, Sibbald G. The role of moisture balace i woud healig. Adv Ski Woud Care 2007; 20(1): Yager DR, Zhag LY, Liag HX, et al. Woud fluids from huma pressure ulcers cotai elevated matrix metalloproteiase levels ad activity compared to surgical woud fluids. J Ivest Dermatol 1996; 107(5): Tregove NJ, Stacey MC, MacAuley S, et al. Aalysis of the acute ad chroic woud eviromets: the role of proteases ad their ihibitors. Woud Repair Rege 1999; 7(6): Vowde K, Vowde P. The role of exudate i the healig process: uderstadig exudate maagemet. I: White, R (ed). Treds i Woud Care: Volume III. Salisbury: Quay Books, MA Healthcare Ltd, 2004; Che WY, Rogers AA. Recet isights ito the causes of chroic leg ulceratio i veous diseases ad implicatios o other types of chroic wouds. Woud Repair Rege 2007; 15: Gibso D, Culle B, Legerstee R, et al. MMPs Made Easy. Wouds Iteratioal 2009; 1(1): Available from: woudsiteratioal.com. 13. Folestad A, Gilchrist B, Hardig K, et al. Woud exudate ad the role of dressigs. A cosesus documet. It Woud J 2008; 5 (suppl 1): iii Dowsett C. Exudate maagemet: a patiet-cetred approach. J Woud Care 2008; 17(6): Dowsett C. Maagig woud exudate: role of Versiva XC gellig foam dressig. Br J Nurs 2008; 17(11): S38-S Parsos D, Bowler P, Myles V, Joes S. Silver atimicrobial dressigs i woud maagemet: a compariso of atibacterial, physical ad chemical characteristics. Wouds 2005; 17(8): Warig MJ, Parsos D. Physico-chemical characterisatio of carboxymethylated spu cellulose fibres. Biomaterials 2001; 22(9): Vascheidt W, Müter KC, Klövekor W, et al. A prospective study of the use of a o-adhesive gellig foam dressig o exudig leg ulcers. J Woud Care 2007; 16(6): Parish LC, Dryjski M, Cadde S o behalf of the Versiva XC Pressure Ulcer Study Group. Prospective cliical study of ew adhesive gellig foam dressig i pressure ulcers. It Woud J 2008; 5: Newma GR, Walker M, Hobot JA, Bowler PG. Visualisatio of bacterial sequestratio ad bactericidal activity withi hydratig Hydrofiber woud dressigs. Biomaterials 2006; 27: Moseley R, Leaver M, Walker M, et al. Compariso of the atioxidat properties of HYAFF-11p75, AQUACEL ad hyaluroa towards reactive oxyge species i vitro. Biomaterials 2002; 23: Culle B, Watt PW, Ludqvist C, et al. The role of oxidised regeerated cellulose/collage i chroic woud repair ad its potetial mechaism of actio. It J Biochem Cell Biol 2002; 34(12): Salim AS. The role of oxyge-derived free radicals i the maagemet of veous (varicose) ulceratio: a ew approach. World J Surg 1991; 15(2): Europea Woud Maagemet Associatio (EWMA). Positio Documet: Topical egative pressure i woud maagemet. Lodo: MEP Ltd, Further readig World Uio of Woud Healig Societies (WUWHS). Priciples of best practice: Woud exudate ad the role of dressigs. Lodo: MEP Ltd, Available from: Gibso D, Culle B, Legerstee R, et al. MMPs Made Easy. Wouds Iteratioal 2009; 1(1): Available from: woudsiteratioal.com. Kraser D, Rodeheaver GT, Sibbald RG (eds). Chroic woud care, 4th editio. Waye, PA: HMP Commuicatios,

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