Debridement of a Leg Ulcer with Honey Impregnated Dressing

Paula Reed Supervisor de Enfermeria (Nurse Co-ordinator), Anneke Integral Care Services

Introduction

Mr N is an 80 year old gentleman who was presented to me in October of this year due to a wound on his left tibial region. This stemmed from a road traffic accident he had in 1953. His previous medical history; cardiac insufficiency, cardiomyopathy, ventricular hyperkinesia (His cardiac insufficiency will have an impact on the wound healing process; Guo, DiPietro 2010).

This RTA has left him with a chronic non healing wound. At times the area is healed but then re opens. Over the years Mr N has been shown how to treat his wound at home. He moved to Spain in 2008. The wound re opened in September 2013 and he was unable to heal this himself. Unfortunately Mr N developed a severe infection which caused him to be hospitalised. These home circumstances permitted for colonisation of the wound which then became infected (Stotts 2007).

He was treated with IV antibiotics and bed rest. He was discharged home, no arrangements were made for him see a nurse in the community. He contacted a private doctor who contacted me to treat his wounds. He lives with his wife who is of poor health (A vascular assessment was performed in the hospital which demonstrated that a light compression therapy was necessary).

Method, My Visit

On first assessment of the wound bed it was extremely dry; the surrounding skin was cracked and pealing. The treatment for this wound while in hospital was betadine, an antimicrobial agent; this was soaked in gauze and applied directly onto the wound. One can see by the first photos taken the typical effect of this kind of agent as it dries out the wound and the surrounding skin. However in order for wounds to heal they need warmth and moisture (Schultz et al 2003a, Wigger-Alberti W. et al 2009).

The main wound was malodorous, typical of the bacteria pseudomonas. He was taking oral antibiotics on his discharge from hospital. There was tissue death (necrosis) in the centre of the wound bed. Some slough was present, the surrounding skin was red inflamed with peri wound maceration along with hyperpigmentation to the limb.

Cost was a real issue for my client as he was receiving the treatment privately therefore all dressings had to be kept to a minimum. I was well aware of the need for a good absorbent dressing for this man which was cost effective. Despite a couple of visits to his General Practitioner and the nurses at the Health Centre no further dressings were given, he was only treated with betadine, gauze and a bandage to cover.

I decided on an alginate dressing impregnated with honey (Algivon, Advancis Medical), covered by a double layer of tulgrasum which is similar to a jelonet type sterile dressing used in the UK to prevent adherence of dressings to the wounds. Followed by gauze swabs, sofftban bandage and a crepe bandage.

The proliferative stage was delayed due to the thick layer of necrotic tissue therefore I debrided the wound by sharp debridement. I firstly allowed the honey dressings to take effect and soften the eschar before I proceeded. This was something which was greatly considered as safety is the key issue and the risks and benefits carefully weighed before a decision was made, (Benbow 2001) in conjunction with Mr N, I was given his informed consent. I was aware of my professional limitations and accountability in terms of knowledge, training and competence (NMC 2013).

There was a large sloughy area beneath this leathery eschar and I was able to use the Algivon as it has the capacity to encourage autolytic debridement (White, 2005). Honey has a high osmolarity due to its sugar content, it is a supersaturated solution (Hampton, 2007) which inhibits microbial growth and releases hydrogen peroxide to cleanse the wound (Lay-Flurrie, 2008).

Method, My Visit

I decided to check the bandaging daily for strike through but initially to aim for a full change every third day. The main challenge was the strike through onto the dressing, high exudate levels and pain control. Pain is a common and often underestimated problem for patients (King, 2003;Ryan et al, 2003) and at dressing changes (Briggs and Torra i Bou, 2001).

Oral analgesia; tramadol was taken one hour before my visits. This helped to dull the pain. The pain subsided after one hour of carrying out the dressing change. Mr N reflected later that the pain was bearable as he knew after the dressing was once in place it remained comfortable.

There is evidence that honey stimulates nocioceptors (Al-Swayeh & Ali, 1998), which are nerve endings that create a pain sensation in response to heat, acidity and some organic chemicals such as those in ginger and chilli. The pain experienced from the honey normally lasts for about 10 minutes. If the healing potential is explained and the patient is warned there may be pain, then they will often tolerate it for the 10 minutes.

Over the Algivon I used an absorbent dressing. Unfortunately there was still maceration to the surrounding skin. I chose a zinc oxide based barrier cream to apply to the wound edges to reduce the maceration (Cameron & Powell, 1997).

Mr N had one out patient appointment to see the vascular consultant during my time in
treating him and he was given a 10cm crepe bandage and was told to continue with light
compression from toe to knee! No further instructions. He told Mr N. he was satisfied with the honey treatment and to continue. Unfortunately at the time of the appointment I was unable to attend due to other commitments with clients however the consultant was left my contact details and literature of the manuka honey and Advancis products.

Over the past six weeks i am now able to dress the wound twice weekly, there is less
exudate and the tissue is showing good signs of granulation. This is where we are at to date.

Conclusion

The wound continues to progress and is free of the bacteria pseudomonas. He is pain free and is more positive about the future. Cost-effectiveness must always be secondary to clinical effectiveness. Nevertheless, cost-effectiveness is an extremely important consideration. If a dressing is clinically effective because it heals faster, it can then be said to be cost-effective. At the same time, Algivon is extremely low cost when compared to other dressings designed for this type of wound. Therefore, given that bacterial loading is quickly reduced and healing rapidly achieved, Algivon is a very cost effective dressing.

Also we need to be aware as health care professionals that, antibiotics are becoming ineffective and nurses are increasingly using antimicrobial dressings to combat infection. The evidence available is extensive.

I am hoping that with this case study it will encourage many other practioners to consider the use of honey in wound healing. Using honey as a dressing here in Mainland Spain is a slow process with the added difficulty of obtaining these dressings. However with a newly appointed distributor and the recognition from clinicians in the use of honey in wound care here then there will be more acceptance from health care professionals and the clients themselves.

References

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Hampton. S. (2007) “Honey as the new ‘silver’ dressing in wound care”. Journal of Community Nursing 21;11:45-48. Available online at (accessed on 25th May 2009)
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NMC 2008, The code: Standards of conduct, performance and ethics for nurses and midwives
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Stotts NA, (2007) Wound Infection: diagnosis and management. In: Morrison MJ, Ovington LG, Wilkie K, eds (2007) Chronic Wound Care. A problem –based learning approach. Mosby London
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