Dressing adherence can be a real challenge when

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1 The use of Atrauman non-adherent wound dressing in tissue viability Jackie Stephen-Haynes Jackie Stephen-Haynes is a Nurse Consultant and Senior Lecturer in Tissue Viability at Worcestershire PCT and the University of Worcester [email protected] Dressing adherence can be a real challenge when managing wounds. Removal of adhered dressings can damage the wound bed and fragile granulation tissue, and cause unnecessary pain to the patient. In response to this problem, industry has developed a number of low or non-adherent primary dressings or wound contact materials for use on a range of wounds. These vary significantly in material structure, clinical function and price. Atrauman product properties Atrauman, produced by Hartmann UK, is a non-medicated tulle dressing consisting of a water repellent polyester tulle impregnated with neutral oil (fatty acids) and does not contain paraffin, it is conformable, non-adherent and permeable to wound exudate (Figure 1). The ingredients have been developed to avoid skin irritation or sensitization and are designed specifically for atraumatic wound care. The use of Atrauman can assist the health care practitioner in a wide variety of wounds and should be considered as a first line treatment. It is available in a range of sizes on NHS logistics and FP10 (Table 1). When using Atrauman, the health care practitioner should consider the appropriate dressing size; this dressing can be cut to size and can be left in place for up to 7 days, it may be applied to a variety of wounds in all healing phases, including: Cuts and lacerations Abrasions Pressure ulcers Burns Scalds Radiation therapy burns Abstract This product focus considers the characteristics and application of Atrauman, a non-adherent dressing, in relation to the different aspects of wound healing. Atrauman has many characteristics that make it an ideal dressing choice in a number of clinical scenarios, including: pain free removal; promotion of healthy granulation tissue; cost effectiveness and versatility. KEY WORDS Atrauman Non-adherent dressing No pain at dressing change Abscesses Toe nail avulsion Covering donor/recipient sites. ( Wound healing Since the work of Winter (1963) and Hinman and Maibach (1963) the maintenance of a moist wound environment for optimal wound healing, has been widely recognized as an objective of wound care. The wound healing process involves a series of very complex interconnected processes with each stage overlapping (Cutting and Tong, 2003). There are a number of models that describe wound healing. The stages of wound healing according to Dealey (2005) are: Inflammation Reconstruction Epithelialisation Maturation. This has implications for the use of Atrauman because appropriate dressing selection must be related to the stage of wound healing (Burton, 2004; Thomas, 2008). Acute wounds The healing of acute wounds is a well-defined co-ordinated process that includes wound formation with initial coagulation leading to inflammation, then cell proliferation and repair of the tissue matrix, ending with re-epithelialization and closure of the wound; over time there is remodelling of scar tissue (Ovington and Schultz, 2004). The atraumatic properties of Atrauman make this dressing very effective as a primary contact layer during the re-epithelialization phase of acute wound healing the delicate epithelial tissue does not adhere to Atrauman s non-adherent surface. Granulation tissue Reconstruction (Dealey, 2005) or proliferation (Timmons, 2006; Cutting and Tong, 2003) is the development of granulation tissue which takes place over approximately a 28 day period in acute wounds, with the formation of a loose extra cellular matrix (ECM) of fibrin, fibrinonectin, collagen and other agents (i.e. glycosaminoglycans and proteoglycans). The ECM supports the development of new blood vessel formation, termed angiogenesis, resulting in granulation tissue. Granulation tissue has a pink granular appearance with numerous capillaries with each granule

2 Atrauman is a suitable contact layer dressing during the granulating and epithelialization phase of wound healing, it can also be used to carry creams or medicaments such as hydrogels or topical silver sulfadiazine cream. If used in this way, an appropriate secondary dressing should be applied that is able to manage exudate (Thomas, 2008). Figure 1. Atrauman atraumatic primary dressing. containing a loop of capillaries. This tissue will bleed easily if traumatized and care should be taken when removing wound contact layers or dressings. Granulation tissue mainly consists of proliferating fibroblasts, capillaries and tissue macrophages in a matrix, so handling it carefully is important in achieving wound healing this tissue grows to fill and repair the wound. It is essential that the granulation tissue does not penetrate the dressing. Atrauman is made up of hydrophobic polyester fibres and therefore it avoids trauma on removal, thus protecting the granulation tissue. Atrauman has a 1mm diameter pore size which prevents granulation tissue from penetrating the dressing it does not contain Vaseline or paraffin, and so leaves the wound bed residue free. Following granulation tissue formation, epithelial tissue then develops further, closing over the granulated wound. Once fresh epithelium covers the wound, the clinical aim is to protect the newly formed skin while the tensile strength of the wound increases. Atrauman will not damage fragile epithelium on removal. Beneath the skin, moisture levels are controlled by a delicate interplay between fluid pressures in the tissues, capillary filtration and lymphatic drainage. Atrauman can assist in this process as it is permeable to air and water vapour. It is not occlusive and therefore does not contain fluid within the wound. Wound infection When a wound becomes infected the exudate can increase and become viscous and malodorous. Management should focus on treating the infection systemically, topically or both. Dressings with antimicrobial properties including silver, iodine or honey should be discontinued once the infection has been treated and the exudate level reduces to a normal level for the wound type (White and Cutting, 2006). Atrauman Ag is impregnated with metallic silver that has been proven to kill a wide range of micro-organisms. A study by Kapp (2005) used Atrauman Ag in the treatment of 600 patients and found that it was substantially less cytotoxic than other silver dressings, thus preventing potential damage to granulation tissue. While Atrauman Ag is indicated on locally infected or critically colonized wounds, Atrauman (without silver) may also be suitable for the management of infected wounds, where an occlusive dressing may be contraindicated. Although it will not combat the infection, it will permit the passage of topical antimicrobials as well as pus and exudate from the wound. Skin tears Skin tears are associated with older people as the skin becomes thinner, drier and more wrinkled with age. Indeed, patients over 65 years of age account for 88% of all reported skin tears with the largest proportion (41%) occurring in those aged years (Public Safety Advisory, 2006). Early recognition of skin fragility will enable the health care practitioner to take effective steps to avoid unnecessary trauma or damage. The older person with fragile skin requires extra care when selecting and using wound dressings and tapes. Wound/scar contraction Wound contraction is where the open wound margins are brought together by fibroblasts, and scar contraction is where Table 1. Atrauman product prescribing information Description Size Product Pack NPC Code PIP Drug tariff NHS logistics code code contact dressing 5 x 5cm pcs EKA pence 15 pence contact dressing 7.5 x 10cm pcs EKA pence 18 pence contact dressing 10 x 20 cm pcs EKA pence 36 pence 20 x 30 cm pcs EKA pence 104 pence contact dressing

3 shrinkage of the scar occurs, through collagen re-modelling. Scarring causes major psychological distress and can be disfiguring and aesthetically unpleasant. Scars can cause severe itching, tenderness, pain, sleep disturbance, anxiety, depression and disruption of daily activities (Bell et al, 1988). Hypertrophic scars present as a deep red/purple colour, they become more elevated, firm, warm to the touch, hypersensitive and itchy as the scar progresses over time. It is more efficient to prevent hypertrophic scars than treat them. Schmidt et al (2001), states that hypertrophic scars appear between 3 5 weeks after trauma, and notes that patients are frequently discharged without follow up that would have allowed for the monitoring of hypertrophic scarring. Therefore, Atrauman can be useful is this situation as it keeps wound edges supple and maceration free, potentially avoiding scar tissue contraction. Wound pain Hollinworth (2005) offers a practical template for pain assessment and proposes several interventions to reduce pain including: The use of warm cleansing solutions Careful dressing removal The use of time out The use of atraumatic dressings, reducing dressing changes as appropriate The correct application of bandages. More recently the World Union of Wound Healing Societies (2008) has identified factors that the health care practitioner should consider before, during and after dressing change. The factors included: Gentle cleansing of the wound Avoidance of abrasive wipes and cold solutions Analgesics should be used to minimize pain Dressings that minimize trauma and avoid maceration. The health care practitioner should always seek to assess and address the issue of pain, as this can have a major influence on patient concordance and healing. Importantly, selecting a non adherent dressing is important as it minimizes pain and trauma on removal. Traumatic wounds Acute traumatic wounds benefit from atraumatic dressings and are often in areas that are difficult to dress, for example, finger tips/toes. The range of dressing sizes available, particularly the availability of smaller sizes such as 5 x 5 cm, reduce the need to cut the dressing to size and reduces cost. Why select Atrauman? Dressing selection Thomas (2008) has defined the performance requirements of a wound dressing and makes the distinction between primary and secondary requirements as follows: Primary requirements are those that are common to most wound management materials. Secondary requirements relate to specific types of wounds or wounds in a particular condition or stage in the healing process. Primary requirements of the ideal dressing Maintains the wound and the surrounding skin in an optimum state of hydration (this implies the ability to function effectively under compression). If self-adhesive, forms an effective water-resistant seal to the peri-wound skin, but is easily removable without causing trauma or skin stripping. Forms an effective bacterial barrier (effectively contains exudate or cellular debris to prevent the transmission of micro-organisms into or out of the wound). Does not release particles or non-biodegradable fibres into the wound. Provides protection to the peri-wound skin from potentially irritant wound exudate and excess moisture. Produces minimal pain during application or removal as a result of adherence to the wound surface. Keeps the wound at the optimum temperature and ph. Free of toxic or irritant extractables Requires minimal disturbance or replacement. Secondary requirements of the ideal dressing Exhibits effective wound cleansing (debriding) activity Possesses antimicrobial activity capable of combating localised infection Has odour absorbing/combating properties Has ability to remove or inactivate proteolytic enzymes in chronic wound fluid Possesses haemostatic activity. It is important for the health care practitioner to consider the performance qualities that are needed when selecting and utilising a dressing. Atrauman offers several of these performance qualities including: maintenance of hydration, ease of removal; does not cause skin stripping; does not release particles into the wound; is free of toxic extractables and requires minimal disturbance in terms of dressing changes. Thomas (2008) does not advocate that all primary or secondary requirements are necessary in all dressings, rather

4 Figure 2. Initial abrasion. Figure 3. After initial treatment with Atrauman. Figure 4. Fast fading of the bruising. that the health care practitioner decides which ones are important in a particular clinical case. A wide variety of wound types demand a non-adherent dressing with a range of attributes as outlined in the primary category. Several issues are of particular clinical significance to Atrauman, including the protection of granulation tissue (and avoidance of over-granulation), the prevention of pain/trauma at wound dressing change, the importance of allowing the free passage of air and oxygen to and from the wound, and minimizing wound contraction and scar tissue formation. Atrauman case studies Figures (2 4) show a case study by Stephen-Haynes (2008), (unpublished) where Atrauman was applied to an acute traumatic wound on a 55 year old male to provide protection to the wound. Note the fading of the bruising and the maintenance of the largely intact skin. In this case study there was a requirement for a non-adherent dressing which would maintain moisture at the wound base, while protecting the fragile skin and allowing for monitoring. Atrauman proved to be an excellent dressing in this clinical scenario. Several authors have considered the use of Atrauman as a non-adherent dressing. Burton (2004) undertook a nonrandomized prospective study involving 52 patients with surgical or traumatic wounds. The aim was to evaluate the effectiveness and acceptability of 5 low adherent dressings, including Atrauman, in clinical practice over a 10 week period. The areas explored were: Ease of application and removal Comfort while wearing the dressing Patient comfort on removal How well the dressing stayed in place Frequency of dressing changes. The wound aetiologies included: Digit amputation Digit crush injury Toenail avulsion Skin tear Laceration Post surgical cellulitis Post-surgical incision Pre-tibial laceration. The study found that 88% of the patients healed or were healing at the end of the evaluation and specific advantages of Atrauman were highlighted: The ability of Atrauman to conform around digits No allergic reaction No maceration Value for money. Thompson (2005) undertook a study of 90 patients over a 2-year period being dressed with Atrauman with a variety of wounds, including: Abrasions Skin tears/lacerations Cellulitis with exudate management issues Vascular ulcers Orthopaedic lesions Post operative general surgery wounds Pressure ulcers: grade 2 3 (EPUAP, 1998) Grafts: donor and recipient Burns. Thompson reported that maceration of the peri-wound area never occurred when using Atrauman and suggested using a barrier film cream in addition to Atrauman to manage highly exuding wounds. Importantly, it was noted that hypergranulation did not occur. Thompson (2005) concluded that Atrauman was an effective primary dressing that allowed profuse low viscosity exudate to flow through the open weave onto the absorbent dressing and that its clinical efficacy and cost effectiveness led to it being listed as a formulary product. Gray (2005) reports two case studies where managing exudate was the main concern for both patients. Firstly, a patient with secondary lymphoedema who was leaking 600ml daily from their wound and secondly a patient with an infected wound with a high level of exudate. Atrauman was applied directly to the wound beds of both patients, with frequent changing of the Zetuvit absorbent wound pad (outer padding), while leaving the Atrauman in place. The study showed a good clinical

5 outcome and was cost effective. The non-adherent dressing allowed for the management of the exudate until the underlying pathology was resolved. Summary There are a number of non-adherent dressings available with a significant variance in price (BNF, 2009). It is essential for health care practitioners to select appropriate dressings with due consideration for the desired clinical outcome. Several case studies (Burton, 2004; Gray, 2005; Stephen-Haynes and Thonpson, 2008; Thompson, 2005) support the use of Atrauman as a non-adherent primary contact dressing. The atraumatic nature of Atrauman has meant that it is an excellent dressing choice in a wide variety of chronic and acute wounds. Atrauman has been shown to be beneficial in safeguarding granulation tissue, allowing free flow of air to the wound bed and allowing exudate freely out. Atrauman is both cost effective and versatile, and should be considered in daily clinical practice as a dressing of choice, especially where pain at dressing change is an issue. It has also been shown to be a useful dressing when managing scar formation. This usefulness in avoiding scar formation allows the practitioner to apply a dressing that is appropriate in the short, medium and longer term. BJCN Bell L, McAdams T, Morgan R, et al (1988) Pruritis in burns: a descriptive study. J Burn Care Rehabil 9(3): British National Formulary (2008) Available online at: Accessed Burton F (2004) An evaluation of non-adherent wound contact layers for acute traumatic and surgical wounds. J Wound Care 13(9): Cutting K, Tong A (2003) A wound physiology and moist wound healing booklet. Institute of wound management booklet, Johnson & Johnson Dealey C (2005) The Care of Wounds: a guide for Health Care Professionals (3rd ed) Blackwell Publishing, Oxford European Pressure Ulcer Advisory Panel (1998) Pressure Ulcer Prevention and Treatment Guidelines. EPUAP, available online at Gray D (2005) Managing highly exuding leg wounds. Forum Wound Care. Available online at: Hinman C, Maibach H (1963) Effect of air exposure and occlusion on experimental human skin wounds. Nature 26(200): Hollinworth H (2005) Pain at wound dressing-related procedures: a template for assessment. World Wide Wounds. Available on line at: Kapp H (2005) Atrauman Ag in the treatment of chronic wounds an application study on 624 patients. Aktulle Dermatologie 31(12): Ovington L, Schulz G (2004) The physiology of wound healing. In Chronic Wound Care - a problem-based learning approach. Morison M, Ovington L, Wilkie K (eds). Mosby Patient Safety Advisrory (2006) Skin tears: the challenge. Patient Safety Authority. Pensylvania. USA 3(3): 5 10 Schmidt A, Gassmueller J, Hughes-Formella B, Bielfeldt S (2001) Treating hypertrophic scars for 12 or 24 hours with a self-adhesive hydroactive polyurethane dressing. J Wound Care 10(5): Stephen-Haynes J and Thompson G (2008) The factors influencing the selection of low adherent dressings. Poster presentation, TVS Conference, Peterborough Thomas S (2008) The role of dressings in the treatment of moisture-related skin damage. World Wide Wounds. Available online at: Thompson G (2005) Case study: Atrauman: a descriptive evaluation by historical review and by specific case history. Woundcareforum, Spring 2: 6 8. Hartmann Ltd, Lancs Timmons (2006) Skin Function and Wound healing Physiology. Wound Essentials (1) Wounds UK, Aberdeen White R, Cutting K (2006) Modern Exudate Management a Review of Wound Treatments. Available online at: Winter G (1963) Formation of the scab and the rate of epithelialisation of superficial wounds in the skin of the young domestic pig. Nature 193: World Union of World Healing Societies (2008) Minimising pain at wound dressing related procedures - A consensus document. Available online at: www. wuwhs.com Hartmann medical (2009) Product information, available at: co.uk key points Atrauman, produced by Hartmann UK, is a non-medicated tulle dressing consisting of a water repellent polyester tulle impregnated with neutral oil (fatty acids), it is conformable, non-adherent and permeable to wound exudate. Atrauman dressings are used as a primary wound contact layer as well as being a carrier for other medicaments. Atrauman has been used on a variety of acute and chronic wounds including traumatic wounds and meets the remit of many key performance requirement of dressings. Atrauman is a clinically versatile and cost effective atraumatic dressing.