Management of superficial to partial-thickness wounds

Abstract

Reference/citation: Wiechula R. The use of moist wound-healing dressings in the management of split-thickness skin graft donor sites: a systematic review. Int J Nurs Pract. 2003; 9:S9-S17.

Clinical question: Do rates of healing, infection, and pain differ depending on whether nonmoist or moist dressings are used to manage superficial to partial-thickness wounds?

Data sources: Investigations were identified by CINAHL, MEDLINE, Pre-MEDLINE, Cochrane Library, Current Contents, Health STAR, EMBASE, Expanded Academic Index, and Dissertation Abstracts International searches. The search terms included skin, graft, and donor. Additional searches were performed with reference lists and bibliographies of retrieved studies.

Study selection: To be included in the review, each study had to fulfill the following criteria: it had to be an intraindividual or prospective randomized controlled trial of human subjects; it had to include patients with postharvest split-thickness skin graft donor sites; it had to evaluate the effectiveness of primary and secondary wound dressings; and it had to have outcome measures that included healing (objective), infection (subjective), and pain (objective).

Data extraction: Data extraction and study quality assessment procedures were developed specifically for this review based on Cochrane Collaboration, Centre for Reviews and Dissemination, and Joanna Briggs Institute protocols and were performed independently by the author. Details of the procedures were not fully explained. The principal outcome measures were healing (proportion of sites healed within the study period or time to complete healing), rate of infection, and pain scores. The studies were grouped according to broad dressing type (nonmoist and moist) and specific types of moist dressings (hydrocolloids and polyurethane semipermeable transparent films). When comparable, study results were pooled and analyzed with a fixed-effects model. Data within broader dressing categories (nonmoist and moist) were analyzed with a random-effects model. chi (2) analysis was used to determine heterogeneity among the studies. RevMan software (version 4.04; Cochrane Centre, Oxford, UK) was used for statistical analysis.

Main results: The searches identified 111 studies and 1 integrative review, of which 58 studies met the inclusion and exclusion criteria. Inconsistency and variation in outcome measures and incomplete reporting of results prevented analysis of many studies. Wound healing was measured by days to complete healing (when dressings could be removed without trauma and pain) and wounds healed by day X (removal of dressings at regular intervals). Wound infection was subjectively measured based on clinical signs of infection (edema, heat, pain, or smell). Visual analog scales were used to measure pain levels. Among the broad categories of nonmoist (sterile gauze, fine mesh gauze, Xerofoam [Tyco Healthcare Group LP, Mansfield, MA]) and moist (DuoDERM hydrocolloid [ConvaTec, Princeton, NJ], Tegaderm transparent film [3M Health Care, St Paul, MN], Opsite transparent film [Smith & Nephew, London, UK]) dressings, the outcomes of healing, infection, and pain were analyzed. In 6 studies, the findings significantly favored moist dressings, compared with nonmoist dressings, for days to complete healing (weighted mean difference [WMD] = -3.97, 95% confidence interval [CI] = -5.91, -2.02). In 9 studies, wounds healed by day X (day 7, 8, 9, 10, or 12) were analyzed. The results were varied and inconclusive because of a small number of trials and subjects. Among 10 studies, no significant difference was noted in infection rates between nonmoist and moist dressings (odds ratio [OR] = 0.41, 95% CI = 0.14, 1.18). Three studies using visual analog scales for the outcome of pain were converted into a uniform scale of 1 to 10 (10 representing most painful). The findings significantly favored moist dressings over nonmoist dressings (WMD = -1.75, 95% CI = -2.94, -0.56). Among nonmoist and specific types of moist dressings, a subset analysis was performed to examine the outcomes of healing, infection, and pain. For days to complete healing, 2 investigations significantly favored hydrocolloid dressings over nonmoist dressings (WMD = -2.19, 95% CI = -2.89, -1.49). Additionally, in 2 studies, hydrocolloid dressings were significantly favored over other moist dressings (semiocclusive hydrocolloid and transparent film) for days to complete healing (WMD = -1.45, 95% CI = -2.17, -0.74). In 3 studies, the data significantly favored polyurethane semipermeable transparent film dressings over nonmoist dressings for days to complete healing (WMD = -2.82, 95% CI = -3.58, -2.07). For infection rates, 4 studies significantly favored hydrocolloid dressings over nonmoist dressings (OR = 0.21, 95% CI = 0.07, 0.65). In 4 other studies, polyurethane semipermeable transparent film dressings were significantly favored over nonmoist dressings with regard to infection rates (OR = 0.28, 95% CI = 0.09, 0.91). For the outcome of pain, varied outcome measures and insufficient data prevented analysis among specific types of moist dressings.

Conclusions: Moist dressings decreased the days to complete healing and pain scores when compared with nonmoist dressings. Among the broad categories of nonmoist and moist dressings, no differences were found in infection rates. The data on specific types of moist dressings revealed that days to complete healing were decreased with hydrocolloid dressings compared with nonmoist and other moist dressings. Hydrocolloid dressings also decreased infection rates compared with nonmoist dressings. Polyurethane semipermeable transparent film dressings also decreased days to complete healing and infection rates compared with nonmoist dressings. Overall, the data indicated that hydrocolloid dressings are more effective than nonmoist dressings in terms of rates of healing, infection, and pain in the management of superficial to partial-thickness wounds. The variations in outcome measures among the included studies should be considered in interpreting these findings.

Keywords: abrasions; moist dressings.