Maureen Benbow

The expense of exudate management

While exudate may contain elements necessary for healing such as proteolytic enzymes, inhibitors of metalloproteinases, plasma proteins, immune defence blood cells, lactic acid, glucose, pH buffers and growth factors, the concentration and activity of these constituents will be altered in chronic wounds. This will change the consistency and volume of exudate and the effectiveness of dressings which, in turn, will necessitate careful consideration and choice of the most suitable dressing and/or therapy options. Selecting the correct dressing or therapy initially and dressings and therapies for ongoing management as the wound characteristics change, achieves the most effective, acceptable and economical solution to controlling excess exudate. To this end, dressings for exuding wounds should be able to absorb and retain fluid, control its evaporation and moisture vapour transmission rate and to trap harmful components (e.g. bacteria) away from the wound surface (WUWHS, 2007). Just as not all exudate is the same, not all dressings and therapies are capable of accomplishing these desirable actions and vary in their ability to effectively absorb exudate of dissimilar consistencies at different rates to maintain moisture balance. Vowden et al (2015) provide a useful table summarising the significance of types of exudate (adapted from WUWHS, 2007; Wounds UK Best Practice Statement (BPS), 2013) which demonstrates the wide-ranging types of exudate to aid identification and inform subsequent decision-making. What is also interesting is the varying consistencies of the types of exudate from thin, watery through viscous, sticky to viscous which is dependent on the amount of host fluid being produced and the concentration of white cells and bacteria in the wound (Romanelli et al, 2010). While most published guidance relates to the management of the thinner, less viscous exudate, the management and control of thicker, viscous exudate is more difficult and requires understanding of the nature of activity within the wound as its characteristics change over time. In addition, the properties and actions associated with the wide range of dressing products must also be understood. For example, a simple absorbent product absorbs fluid into itself by wicking into the material. A more sophisticated dressing material will absorb and hold fluid in a gel that forms on contact with exudate or specially designed fibres that absorb and lockin debris, bacteria and exudate components. Other dressing types are combinations designed One of the greatest clinical challenges in wound management is effective, acceptable and cost-effective containment of excessive wound exudate, particularly in non-healing or slow-to-heal chronic wounds and infected wounds. While moist wound healing is desirable, too little or too much exudate will adversely affect the rate of healing so achieving the right moisture balance is essential. Excess exudate and its ineffectual management will have a significant negative influence on patients’ quality of life due to discomfort, leakage and malodour, frequent dressing changes, skin stripping and soiling of their clothes. In terms of cost, the extended treatment period associated with sub-optimal management or mismanagement of wound exudate will inevitably lead to increased treatment costs for dressings, staff time and possibly extra costs associated with the management of peri-wound damage from maceration and/or excoriation, and antimicrobials. Again, this results in an increased risk of infection, unnecessary stress and inconvenience for patients. Comprehensive, current assessment of the patient and the wound is required to identify any underlying contributing factors followed by identification of the stage, status and condition of the wound. A focused team effort is then needed to tackle the problem in a systematic way using a multidisciplinary approach that includes the patient’s input where possible. With the annual UK cost of wound care to the NHS estimated to be in the region of £1.4£2.1 billion each year, representing up to 4% of total NHS expenditure (Dowsett and Shorney, 2010), we should all be concerned. However, as demonstrated by Drew et al (2007), evaluating costs and/or successful management is not just about dressings but also about the number of people affected, the duration of wounds and associated wound complications, NHS primary and secondary care staff workload and the use of hospital beds when complications occur. Exudate assists healing by providing the correct medium for tissue-repairing cells to migrate across the wound bed, supplying essential nutrients for cell metabolism, enabling diffusion of growth factors for wound healing and promoting autolysis (World Union of Wound Healing Societies (WUWHS), 2007; Gardner, 2012). These processes, however, may be impeded by the presence of necrotic or sloughy tissue, which will need to be debrided so that the extent of the wound can be seen and assessed. The expense of exudate management