Annals of Burns and Fire Disasters - vol. XIV - n. I - March 2001

ADVANTAGES OF AN ADHESIVE HYDROCELLULAR DRESSING IN THE TREATMENT OF PARTIAL-THICKNESS SKIN GRAFT DONOR SITES

Reali U.M., Martini L., Borgognoni L., Brandani P., Andriessen A.*

Plastic Surgery Division, Santa Maria Annunziata Hospital, University of Florence, Italy


SUMMARY. This study describes the effective performance of an adhesive hydrocellular dressing versus paraffin gauze in the treatment of skin graft donor sites. A total of 50 patients were included in the study, each patient acting as his/her own control. An equal half of the donor site was treated with the trial dressing; the other half was treated with paraffin gauze. Cost-effectiveness, time to complete epithelialization, ease of dressing application, ease of dressing removal, and pain upon removal were assessed. The trial dressing demonstrated a statistically significant faster healing time (p < 0.000001) and enhanced patient comfort, and was shown to be cost-effective.

Introduction

The wounds created by skin grafting differ from other wounds in that they are a uniform wound model with regard to the edges of the wound, the wound bed, and the bacterial environment. Partial-thickness grafts are usually 300-375 [tm thick. As elements of epidermal tissue remain in the base of sebaceous glands and hair follicles, the healing time with this method ranges from 10 to 14 days. Donor sites dressed with traditional dressings have a healing time ranging from 7 to 12 days. Partial-thickness skin graft donor sites are traditionally dressed with paraffin gauze dressing, as the wound contact layer, and an absorbent secondary dressing. A light compression bandage is applied in order to reduce postoperative bleeding. Typical disadvantages observed with this dressing regime are adherence of the dressing to the wound bed due to coagulation, damage, frictional trauma to the wound bed, and pain upon dressing removal.' The rationale that Allevyn Adhesive is known to be effective in the treatment of various wound types would suggest improvements in the treatment also of donor sites. This dressing is easy to use, reduces pain, and does not cause trauma to the wound bed on removal.

Material and method

Allevyn Adhesive is a new generation wound dressing. It is designed to manage moderate to high volumes of exudate and to maintain the essential moist wound-healing environment. The hydrocellular dressing is made up of three layers:

  • an outer polyurethane film, which prevents fluid and bacterial strike-through and helps maintain a moist wound healing environment
  • a hydrophilic core, for hydrocellular exudate management, high absorbency, controlled exudate uptake, and reduced risk of leakage
  • a polyurethane adhesive wound contact layer, for minimal disturbance to healing tissue and quick, less painful dressing changes

Paraffin gauze is a bleached cotton gauze which contains 175 g of paraffin per square metre of cloth. The purpose of this study was to evaluate and compare the performance of Allevyn Adhesive hydrocellular dressing with paraffin gauze dressing in the treatment of partialthickness skin graft donor sites. The trial materials were evaluated with regard to the following:

  • time to complete epithelialization of the donor site
  • ease of dressing use
  • ease of dressing removal
  • pain on removal
  • cost-effectiveness of the dressing regime

Allevyn Adhesive and the paraffin gauze dressing were used during the 7-day study period. The period was extended to 12 days when the wound had not healed. Wound assessment and dressing change took place after 4 days and at the end of the evaluation at 7 days. If applicable, a compression bandage was applied for the first 24 h post-operative. Patients fulfilled the following inclusion criteria prior to the evaluation: Inclusion criteria: patients of either sex who required partial-thickness grafts were considered suitable for inclusion in the clinical evaluation; willing and able to comply with treatment; willing and able to give consent; aged at least 18 yr.
Exclusion criteria: patients with clinically infected wounds (inflammation or cellulitis around wounds, purulent exudate, fever - such patients can be recruited once the infection has resolved); pregnant women; patients with a known history of poor compliance with medical treatment; plasma protein < 6 mg/100 ml; Hb < 10 mg/100 ml. Fifty patients were recruited, each patient acting as his/her own control. Half of the donor site was treated with the trial dressing; the other half was treated with paraffin gauze. Grafts were harvested manually with a dermatom. After harvesting of the graft, the donor site was prepared with saline soaks for approximately 10 min before the dressing was applied. If patients had a coagulation disorder or were receiving anti-coagulants, the donor site was prepared with an adrenaline/saline solution. The initial dressing was left in ,situ for 4 days, after which the dressing was changed and if applicable the same dressing regime was applied for a second period until the 7-day treatment was completed. Additional dressing changes took place only if required, i.e. when either the dressing was saturated or leakage occurred. The patients were treated with the Allevyn Adhesive vs paraffin gauze dressing regime until one of the following end points was reached:

  • maximum 7 days treatment; wound healed; patient withdrawn for other reasons
  • adverse event

Patient record form booklets were completed for initial assessment, at day 4 and day 7, and at the end of the treatment. If a patient presented with multiple donor sites, he/she was treated with the Allevyn/paraffin dressing regime; only the largest donor site was evaluated. At each dressing change we assessed the appearance and size of the wound bed, ease of dressing application, ease of removal, pain on removal, and durability of the dressing regime. For pain analyses, a 10 cm scale was used (Fig. 1). Upon each initial random dressing removal the patient was asked to rate the pain by giving a single stroke (/) on the line to indicate the level of pain the patient experienced. With regard to healing time, in order to obtain comparable data for variance analysis, further controls were made at days 10 and 12, when complete epithelialization had not been reached at the end point (day 7). Statistical analysis was performed by a chi-square (x2) test and a variance analysis method (one-way Anova). Cost-efficacy was evaluated with respect to cost per period of treatment, healing time, and clinical complications.

"No pain" (0)  _______________________  "Pain I cannot bear" (10)

Fig. 1 - Pain scale.

Results

Fifty patients, 28 females and 22 males, were enrolled in the study, of whom 44 were evaluated for the end results. The patients' ages ranged from 18 to 88 yr (mean, 59.6 yr). All grafts were taken from the thigh and harvested as partial-thickness skin grafts. The size of the donor site ranged from 20 to 71 cm' (mean, 43.4 cm'-). On each patient, 50% of the donor site was covered with Allevyn Adhesive and 50% was dressed with paraffin gauze. The trial site and the control site were the same size. A clinically manifest infection was recorded in the control site of six patients, who were removed from the study. With regard to pain assessment, at each initial random dressing removal the patient was asked to rate pain by giving a single stroke(/) to the line to indicate the level of pain experienced. In order not to skew the pain assessment a dressing that did not adhere was removed first. Compared with paraffin gauze, Allevyn Adhesive showed a significant difference in the pain reported by the patient on dressing removal. All 44 patients, on removal of the paraffin dressing, scored 10 ("pain I cannot bear"). Three patients, on removal of the Allevyn Adhesive dressing, scored 2 ("slight pain") and 41 patients scored 0 ("no pain").

Trial site, dressed with Allevyn Adhesive

After 4 days of treatment, the dressing was found to be easy to apply and remove and it adhered only slightly to the wound bed. The dressing was saturated with blood, even if the patient was at rest. There was no leakage during wearing time of the dressing and no pain was reported on removal of the dressing. At the end point of the study (7 days), 41 out of the 44 patients had complete epithelialization of the trial site, which was dressed with Allevyn Adhesive. Twenty-three had complete epithelialization of the trial site at 4 days, 18 at 7 days, and 3 at 10 days, with a mean of 5.64 days (SD 1.88).

Control site, dressed with paraffin gauze

At day 4, in all the patients (N = 44), the paraffin gauze dressing adhered completely to the wound bed and therefore was left in place. At day 7 the paraffin gauze was still adhering to the wound bed in 28 patients and removal of the dressing was not possible without causing damage to the wound bed. At the end point of the study (7 days), only 16 out of the 44 patients had complete epithelialization of the control site, dressed with paraffin gauze. Twenty-six had complete epithelialization of the control site at day 10 and two at day 12, with a mean of 9.0 days (SD 1.58). In the treatment of donor sites, Allevyn Adhesive, demonstrated a statistically significant faster healing time than paraffin gauze (p < 0.01). At day 7, the trial site in 41 patients treated with Allevyn Adhesive had reached complete epithelialization, as against 16 patients in the control site. Comparing the overall healing times, variance analysis shows a significant difference in favour of the trial sites treated with Allevyn Adhesive (p < 0.000001).

Cost analyses

Trial site Control site
Allevyn Adhesive,
saline solution
Cost: lire 10,900 (euro 5.63)
Paraffin gauze, gauze swabs,
saline solution, surgical tape
Cost: lire 7,716 (euro 3,98)
When the wound healed:
moinstening cream, gauze swabs
Cost: lire 4,600 (euro 2.38)
When the wound healed:
moinstening cream, gauze swabs
Cost: lire 4,600 (euro 2.38)

Table A - Material used

 

N = 23, patients healed at 4 days and needing one Allevyn Adhesive dressing
lire 10,900 + 4,600 = 15,500 x 23 = lire 356,500 (euro 184.12)
N = 18, patients healed at 7 days needing two Allevyn Adhesive dressings
lire 10,900 x 2 = 21,800 + 4,600 = 26,400 x 18 = lire 475,200 (euro 245.42)
N = 3, patients healed at 10 days needing two Allevyn Adhesive dressings
lire 10,900 x 2 = 21,800 + 4,600 x 2 = 31,000 x 3 = lire 93,000 (euro 48.03)
Total cost of materials for the trial site (N = 44): lire 924,700
(euro 477.57)
Cost of time for dressing changes:
We calculated 15 min per dressing change at a cost of lire 15,000 (euro 7.75)
112 dressing changes were performed in the trial site at a cost oflire 1,680,000 (euro 867.65)
The total cost of treatment in the trial site was lire 2,604,700 (euro 1,345.26)

Table B - Cost of treatment of trial site

 

N = 16, patients healed at 7 days needing one dressing with paraffin gauze
lire 7,716 + 4,600 = 12,316 x 16 = lire 197,056 (euro 101.77)
N = 26, patients healed at 10 days needing one dressing with paraffin gauze
Lire 7,716 + (4,600 x 2) = 16,916 x 26 = lire 439,816 (euro 227.15)
N = 2, patients healed at 12 days needing one dressing with paraffin gauze.
lire 7,716 + (4,600 x 2) = 16,916 x 2 = Lit. 33,832 (euro 17.47)
Cost of materials for the control site (N = 44) was lire 670,704
(euro 346.39)
Cost of time for dressing changes:
We calculated 15 min per dressing change at a cost of lire 15,000 (euro 7.75)
We performed 152 dressing changes in the control site at a cost of
lire 2,280,000 (euro 1,177.52)
The total cost for treatment in the control site was lire 2,950,704 (euro 1,523.91)
Six patients had a clinical infection in the control site and needed
two dressing changes with paraffin gauze and an additional four
other dressing changes
Cost: lire 7,716 x 2 + 4,600 x 4 = 33,832 x 6 = lire 202,992
(euro 104.86)

Table C - Cost of treatment of control site


Conclusions

Compared with paraffin gauze, Allevyn Adhesive demonstrated a statistically significant faster healing time (p < 0.000001). The dressing provided a clean, controlled, moist wound-healing environment that was beneficial to healing. Allevyn Adhesive was easy to apply and remove, without causing mechanical trauma to the wound bed, thus allowing faster, more comfortable wound healing. The patients reported only slight or no pain upon dressing removal with the trial dressing, as opposed to pain they could not bear with the control dressing. One Allevyn Adhesive dressing was sufficient for the treatment period of one donor site in 18 out of the 44 patients. In six patients, half the donor site dressed with paraffin gauze became infected and took up to 14 days to heal, compared with the other half dressed with Allevyn Adhesive which healed within 4 days. No infection occurred in the trial site, suggesting that the risk of infection was reduced when using Allevyn Adhesive for this treatment. The Allevyn Adhesive dressing was shown to be cost-effective.

 

RESUME. Les Auteurs out etudie le rendement effectif d'un pansement hydrocellulaire adhesif par comparaison avec la gaze paraffinee dans le traitement des sites donneurs de la peau. L'etude a considers 50 patients (chaque patient agissait comme temoin de lui-meme). La moitie du site donneur a ets traitee avec le pansement objet de 1'etude et Fautre moitie avec la gaze paraffinse. Les Auteurs out evalue Fefficacite-cout, le temps pour completer 1'epithelialisation, la facilite d'appliquer et de lever le pansement, et la douleur au moment de 1'enlevement. Le pansement hydrocellulaire a demontre un temps de guerison plus rapide statistiquement significatif (p < 0.000001) et une amelioration du confort du patient. En outre, le pansement hydrocellulaire avait un bon rapport efficacite-cout.


BIBLIOGRAPHY

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This paper was received on 8 September 2000.

Address correspondence to:
Prof. U.M. Reali, Plastic Surgery Division,
Santa Maria Annunziata Hospital,
University of Florence, Italy.

 

AWARD OF THE G. WHITAKER

INTERNATIONAL BURNS PRIZE FOR 2001, PALERMO, ITALY

At a meeting held on March 24th 2001, at the seat of the G. Whitaker Foundation, Palermo, after examining the scientific activity in the fields of research, teaching, clinical organization, prevention and cooperation presented by various candidates and in consideration of the high level of the candidates, the Adjudicating Committee unanimously decided to award the prize for 2001 to MANOHAR HARIRAM KESWANI, M.S., Hon. Plastic and Burns Surgeon in Charge, Eric I:haras Burns Research Unit, Masina Hospital, Byculla, Bombay Bai Jerbai Wadia Hospital for Children, Patel, Bombay. The prize is awarded with the following motivation:

  • Dr Manohar Hariram Keswani, M.S., has been a pioneer in the treatment of burns in a developing country, India, that has an elevated incidence of burn patients but lacks adequate scientific and technological support.
  • Despite the difficulties, he has for over 40 years dedicated his constant attention to the problem, and in particular to burns in children and their sequelae. Thanks to his commitment, it was possible to create in 1968 the first Department for Burns Care in India, which he himself directed, at the J.J. Hospital and Grant Medical College in Bombay. The year 1975 saw the inauguration of the first Paediatric Division for Burns at the Bai Jerbai Wadia Hospital Bombay, which still remains the only one in the whole country.
  • He later played a decisive role in the creation of the Kharas Memorial Burn Centre, Bombay, a small private structure of just 18 beds which is today considered the best burns unit in Bombay. He later made a decisive contribution to the creation of a hospital dedicated entirely to burns pathology, the Indian Burns Research and Training Institute, now in the course of completion, which will ultimately have 140 beds. The objective will thus be achieved of creating in his country a. decisive culture of prevention, treatment, rehabilitation, research, and training of medical and nursing staff. "Dr Keswani founded: The Burns Association of India, The Indian Burns Research Society, and India's First Skin Bank.
  • With modesty but with perseverance and passion, Dr Keswani has been the leading figure in the realization in his country of all the instruments necessary for tackling the grave problems of burns. The international scientific community has appreciated his continuous commitment by awarding him numerous prizes and honours of the highest prestige."



 

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