Algorithm for the use of Drawtex® in a Tertiary Adult Burn Centre, … · 2017. 6. 19. · Hilde...

Algorithm for the use of Drawtex®

in a Tertiary Adult Burn Centre,

Tygerberg Hospital South Africa

Wayne George KleintjesMBChB (Stell), Mmed(Plast)(Stell), FCS(Plast Surg), PhD (Plast) (Stell)

Plastic & Reconstructive SurgeonHilde Du Plooy

(B.Pharm, MBA, BSc Anatomy Hons, MBChB (2022), CRA.Cape Town, South Africa

6- 9 June Addis Ababa, Ethiopia

Introduction

Retrospective Analysis

February to May 2016

Spongy / foam dressing with Leva Fibres

Allows the exudate to move away from wound

Developed in SA 1986

DRAWTEX ® POSITIONING

Need Identified

• Controversy (Couch, 2012; Ortiz et al., 2012)

• Problem: Where Drawtex® fits ?

• SOP TBH: sloughy, exudating wounds: Intrasite® gel and Bactrazene® (silver sulphadiazene)

• How does Drawtex® compare to the SOP?

Aim

1. Identify wounds for controls in the same patient that

could be used for comparison.

2. Identify the effectiveness of Drawtex® on fresh burns

3. Calculate cost-effectiveness

4. Propose an algorithm for the use of the dressing

Material & Methods

Study Subjects

Data Collection

Application Methods

Photographic Analysis

Statistical Analysis

Materials and Methods

A: Study Subjects: Criteria

Inclusion Criteria Exclusion Criteria

• Drawtex® on wounds • Skingrafted areas

• No operation in 48 hours; • Operation < 24h

• Other wounds for comparison

Materials & Methods

B: Data Collection

Parameters

• Demographic dataAge, sex

• Clinical wound analysisTBSA%, burn mechanism, area affected, treatment days

• Wound change: initial application vs later

For the wound assessment the following scale was used to measure: Slough, biofilm, exudate, epithelium, infection and wound moistness.

Other wound assessments included change in wound size, colour, odour and swab test needed.

Materials & Methods

Wound Assessment Scale Value Description

0 None

1 Mild

2 Moderate

3 Severe


C: Application Methods

DRAWTEX® GROUP CONTROL GROUP (BURN UNIT SOP)

Primary Dressing: Drawtex® Primary Dressing: Intrasite®& Bactrazine®

No secondary dressing was used, only bandages.

Secondary Dressing: Telfa®, followed by bandages.

Frequency of change: Every 48 hours Frequency of change: Every 24 hours

Cleansing and disinfection of wounds: Water, chlorhexidine and alcohol solution.MRSA: chlorhexadine soap or 1% acetic acid with pain protocol.


• Patients who had good photo records were used for comparison.

• The protocol:

iPhone camera of 10 megapixels

Photo should be taken 30 cm from the wound

A ruler must be included in the photograph

D: Photographic Analysis


• McNemar Chi square tests

• Means, standard deviation, ranges, 95 % confidence intervals

• Other statistical analysis (IBM SPSS version 23 will be used to analyse the data)

• A two-tailed p value < 0.05 = statistically significant

E: Statistical Analysis

Study Subjects

Description Number of Patients

Total number of patients admitted to burn unit of Tygerberg Hospital 100

Total number of patients available 39

Number of patients selected (N) 36

Drawtex ® patient sample (n) 36

Control patient sample (n) 8

Total number of areas to be treated in 36 patients 48

Drawtex ® areas treated out of 48 areas 40

Control areas treated out of 48 areas 8

Results

Results

Demographic data:

AGE Range Value

Minimum 17

Maximum 78

Average 33

SEX Description Number of Patients Percentage

Male 28 78%

Female 8 22%

Results

TBSA % Range Value

Minimum < 1%

Maximum 55%

Average 23%

Burn Mechanism Description Number of Patients Percentage%

Boiling Water 5 14%

Flame 29 81%

Electrical 2 6%

Paraffin 1 3%

Clinical data:

Results

Burn Area LocationNumber of Cases per

AreaPercentage %

Arms 27 56%

Legs 14 29%

Back 5 10%

Abdomen / Chest 10 21%

Head 7 15%

Treatment days Range Days

Minimum 1

Maximum 6

Average 2.6

Clinical data:

Results

GROUP DRAWTEX® n=8 CONTROL n=8

Description Initial Follow up % Change Initial Follow up % Change

Slough 17 3 -82% 16 17 6%

Biofilm 2 0 -100% 2 6 200%

Epithelium 7 16 129% 6 7 17%

Exudate 14 3 -79% 14 17 21%

Infection 2 0 -100% 2 3 50%

Moistness 15 5 -67% 15 18 20%

Wound Assessment: Parameters

ResultsTotal Wound Assessment:

Patient Number Group Initial Follow Up Difference

Patient 1 Drawtex ® 7 2 5

Control 5 6 -1


Control 7 10 -3


Control 9 10 -1


Control 8 10 -2


Control 9 7 2


Control 5 12 -7


Control 7 6 1


Control 5 7 -2

Results

Drawtex ® n=40

Variable Initial Follow up % Change

Slough 69 27 -61%

Biofilm 11 3 -73%

Epithelium 35 68 94%

Exudate 62 25 -60%

Infection 11 0 -100%

Moistness 59 28 -53%

General Results: Drawtex ® (n=40 wounds)

In general, the 40 wounds treated with Drawtex ® had:• Reduced slough with 61 %, • biofilm by 73 %, • enhanced epithelial growth with 94 %, • reduced the amount of exudate with 60 %, • reduced the rate of infection 100 % and • moisture with 53 %.

Result

Drawtex ® (n=8) Control (n=8)

Wound Colour

Initial

Assessment Follow Up Change %

Initial

Assessment

Follow

Up Change %

Green 1 0 -100% 1 0 -100%

Red 2 5 150% 0 0 0%

Yellow 3 1 -67% 4 6 50%

Yellow and Red 1 3 200% 3 2 -33%

Yellow and Green 1 0 -100% 0 0 0%

Yellow, Red and Black 1 0 -100% 0 0 0%

• When comparing the results in the follow up assessment based on the colour of the wounds:

• Those treated with Drawtex ®had an increase in red (healthy) wound tissue in five of the subjects compared to none in the control group.

• The amount of yellow (slough) tissue was significantly reduced by 67 % in the Drawtex ® group. In the control group, slough (yellow) increased with 50 %.

Results: Cost- effectiveness(C-E)

TREATMENT REGIMEN

DRESSING SKU

MEDIUM WOUND

APPLICATION 10-20 cm

TOTAL COST(24 HOURS)

TOTAL COST MEDIUM(48 HOUR

TREATMENT)

COST COMPARISON

Drawtex ® Drawtex® 20 20 x 20 x 1 N/A 102.828 102.828

Other

Intrasite® 25 g 0.5 17.91 35.82

111.35

Melolin® 10 cm x 10 cm 3 7.44 2.48

Telfa® 0 3 0 0

Bactrazine® 50 g 0.5 21.885 43.77

Bandage 0 1 0 0

Gauze Swab

0 4 14.64 29.28

Discussion: Controls & Results

• Low number of controls a.r.o. poor record keeping

• Limited – single permanent Dr/specialist

• Enquiry: clinical evidence Drawtex® more effective removing slough from wounds

• Unethical to continue doing control areas

• Drawtex®: subjectively clearly better than SOP

Patient 1: 1st Follow-up

CONTROL DRAWTEX

Patient 1: 2nd Follow-up (3 days)

CONTROL DRAWTEX


CONTROL DRAWTEX


CONTROL DRAWTEXCONTROL


CONTROL DRAWTEX

BACTERIA TRAPPED IN DRAWTEX

A B C

A: Drawtex with E.coli.

B: Drawtex® with MRSA.

C: Drawtex® with Candida albicans.(Edwards-Jones, V., Vishnyakov, V. & Spruce, P. 2014).

Discussion: Effectiveness on fresh burns:

• There was a clear decrease in moisture on the wounds.

• The question then arises: On which fresh burns will this moisture reduction be most beneficial.

• From the wound assessment data it seems that fresh burns with slough will have the best benefit from the use of Drawtex ®

Discussion: Effectiveness

• The clean fresh burn, superficial to mid-partial thickness has the most benefit from a skin substitute of which there are many available.

• Even though the SOP also removed slough it took much longer than Drawtex ®.

• One could make an argument for the presence of more pseudo-slough with the Intrasite® and Bactrazene®, but the clinical evidence in the photos were very convincing.

Discussion: Mechanism of Action

The question remains as to the mechanisms responsible for the actions seen with Drawtex in wound treatment.

The three mechanisms: Capillary, Hydroconductive and Electrostatic actions.

These proposed mechanisms may not totally explain the actions of Drawtex due to the difficulty of applying

physicochemical theory to biological systems.

A B

A: Scanning electron micrograph (SEM) of Drawtex® at 1000 times magnification. B: Drawtex hydrated under SEM at 1000 times magnification

(Edwards-Jones, V., Vishnyakov, V. & Spruce, P. 2014).


1. ABSORPTION WITHIN THE FIBRES

Capillary/Tubular Arrangements


2. NEGATIVE SUCTION EFFECT WITHIN FIBRE GAPS

Venturi Effect: Fluid between Tubules


2. NEGATIVE SUCTION EFFECT WITHIN FIBRE GAPS


3. DIFFUSION GRADIENT

Transectional View Fluid Absorbtion


4. ELECTRICAL CHARGE AND GRADIENT


5. STEPLADDER (ZIG ZAG) MOVEMENT OF WATER

LM, 4x magnification; Trypan Blue

LM, Trypan Blue, 4x magn


6. HYDROPHYLLIC PROPERTIES


7. MECHANICAL REMOVAL OF SLOUGH

Mechanical Removal: Adherence

Discussion: Cost-effectiveness

• The Drawtex® was mostly changed every two days (average data analysed was 2.6 days –without error correction)

• The cost of physical labour we did not include in the calculation, but it is a significant factor

• In a nursing staff shortage climate that must also be considered.

• Therefore the overall benefit of having effective slough removal every 2nd day with Drawtex ® was a huge benefit in the Burn Centre.

Proposed Algorithm

Burn Injury

Exudate

Colour

Wound Swab High (Old Wound) Low (New Wound)

Red or PinkYellow

Drawtex ® Skin Substitute

Proposed Acronym: Wound parameter assessment

BE ME SIC SOS B: Biofilm;

E: Epithelium;

M: Moistness;

E: Exudate;

S: Slough;

I: Infection;

C: Colour;

S: Swab;

O: Odour;

S: Size.

Conclusion

• Based on the current literature, the efficacy of Drawtex ®hydro-conductive dressings has not been described in a tertiary burn unit, specializing in adult burn care, such as Tygerberg Hospital.

• The study found that Drawtex ® delivers better results compared to the control group and therefore Drawtex ® is recommended for moderate to highly exuding wounds with slough.

• The proposed algorithm can be applied in burn wound assessments in both public and private tertiary institutes.

• Knowledge regarding the understanding of the efficacy thereof will contribute to the effective treatment management and protocol development for tertiary burns.

Limitations and Future Research

LIMITATIONS:• The sample size might be too small to derive meaningful conclusions,

however the limitation thereof will be determined based on the results

obtained from the data collected.

• Some data from the patient files may be inconclusive or not meet the

selection criteria.

• The selection was based on the quality, positioning, lighting, measurement

ruler as well as the similarity between compared areas.

AREAS OF FUTURE RESEARCH: • Application to skin graft procedures, to determine the efficacy thereof

when covering meshed skin grafts.

• Odour: improvement by selecting appropriate patients.

Algorithm for the use of Drawtex® in a Tertiary Adult Burn Centre, … · 2017. 6. 19. · Hilde...

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