Managing High Exudate Wounds: A How-to Guide

Contributor: Sarah Gardner, Clinical Lead, Oxford Health NHS Foundation Trust, Tissue Viability Service, Abingdon Hospital, Oxford

Exudate can be distressing for the patient, cause tissue damage and reduce quality of life. Inappropriate wound management and dressing selection can also contribute to the problem and lead to delayed healing. This ‘how to’ guide looks at the problems of excessive exudate and focuses on the use of superabsorbent dressings in a range of wound types.

What is exudate?

Wound exudate is produced as a normal part of the healing process to prevent the wound bed from drying out. Fluid in the wound bed also helps tissue-repairing cells to migrate and provides essential nutrients and growth factors for wound healing.

In a wound that is progressing normally, exudate production generally reduces over time, but in chronic wounds exudate is believed to prolong the inflammatory phase and be detrimental to healing. This exudate contains high levels of harmful substances that break down the cell-supporting extracellular matrix. By managing the amount of fluid produced, the detrimental effects of wound exudate can be minimised.

Why do some wound produce excessive exudate?

A wound healing by primary intention may produce a small amount of exudate and will heal without complication. However, some chronic wounds or surgically dehisced wounds healing by secondary intention, will produce large amounts of exudate. This may be related to:

• Size and position of the wound
• Underlying conditions that increase capillary leakage (eg cardiac, renal or hepatic failure)
• Pathology of the wound
• Failure of the lymphatic system
• Increased bacterial burden n Medications (eg steroids)
• The presence of oedema

If the quantity of exudate that is being produced cannot be explained by any of the above causes, it is important to consider other underlying factors.

Wounds that are typically affected include:

• Chronic venous leg ulcers
• Postoperative dehisced wounds
• Fungating wounds
• Burns
• Inflammatory ulcers such as rheumatoid ulcers or pyoderma gangrenosum
• Skin donor sites.

Problems associated with high exudate

If a wound produces high levels of exudate and is not managed appropriately, the wound bed will become overhydrated, causing moisture to leak out onto the periwound skin. Where this becomes trapped under the dressing, it can cause ‘softening’ or ‘sogginess’ (maceration), making the skin more prone to damage (Cutting, 2002). In addition, enzymes in chronic wound exudate may cause skin stripping (excoriation).

High exudate levels can also lead to:

• Malodour
• Wound pain
• Enlargement of the wound
• Protein loss/fluid electrolyte imbalance
• Delayed healing
• Local wound infection
• Soiled clothing and bedding.

Exudate-associated leakage together with malodour and pain can be distressing for patients and lead to social isolation (Int Consensus, 2012). If not managed effectively, exudate-related problems may lead to poor patient concordance due to a loss of confidence in the treatment. This may be related to the frequency of dressing changes, the type of dressing being applied (may become heavy and bulky), or a reluctance to sit for long periods with their legs elevated.

Aims of management

Moist wound healing involves maintaining a balance between excessive moisture and the wound bed becoming too dry. An understanding of the role of exudate in wound healing and the management options available is vital if goals are to be achieved.

An effective treatment plan should aim to improve clinical outcomes by treating the underlying cause or contributory factors, reducing exudate-related problems, reducing time to healing and improving patients’ quality of life.

Dressings are the main option for managing high exudate levels and are designed to handle fluid through various different mechanisms. Negative pressure wound therapy (NPWT) may also be useful when soiling and leakage pose a significant problem (Romanelli et al, 2010).

Management of excessive exudate

Robust holistic assessment (which includes the patient and the wound) underpins effective exudate management. Treatment decisions should be based on an accurate assessment of the exudate (WUWHS, 2007), including:

• Colour — may be indicative of bacterial growth or infection or contamination with blood or urine
• Consistency — exudate may be viscous (thick, sometimes sticky) or thin and runny
• Odour — exudate that is unpleasant smelling may be indicative of infection, necrotic tissue or sinus/enteric or urinary fistula
• Amount — the larger the size of wound, the greater the likely volume of exudate.

Use information obtained from the assessment to evaluate the performance of the current dressing and whether the exudate is being managed appropriately (WUWHS, 2007). Any change may indicate an alteration in the wound status or underlying condition and should prompt a review (Vowden and Vowden, 2003).

Treatments may be combined with appropriate compression to manage underlying conditions and/or antimicrobial therapy or systemic antibiotics to manage increased bacterial load.

Specific aims of management

1. Absorb exudate - Removal of exudate is a priority when managing high exudate wounds. Advanced dressings work by drawing the exudate up into the dressing and locking it in. NPWT works by actively removing exudate from the wound before it has time to spread onto the surrounding skin. 
2. Reduce bacterial count - Bacteria levels in the wound are reduced through absorption of the exudate into the dressing.
3. Avoid periwound maceration - When choosing dressings for exudate management it is important to protect the surrounding skin and to maintain a moist but not saturated wound environment. Consider the use of a topical transparent skin protectant for wounds related to pyoderma gangrenosum and vasculitic or rheumatoid ulcers.

It is important to select a dressing that is appropriate for the exudate level and to change the dressing as required.

How to protect the periwound skin

• Minimise skin contact with exudate
• Protect with a suitable barrier cream or film
• Use dressings with increased fluid handling capacity

Dressings coated with soft silicone may be used when it is important to prevent trauma to the wound or surrounding skin (Lloyd-Jones, 2011). They may also be indicated for elderly patients with fragile skin or where the patient complains of pain at dressing removal (WUWHS, 2004).