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Figure 3. Traditional electrosurgical adapter, sample metalhubbed needles, and “pencil-type” electrosurgical handpiece (Valleylab). may be no substitute for the replacement of worn electrosurgical handles and/or their evaluation by biomechanical engineers. A small hole drilled in the distal shaft allows the spiral placement of a metal wire (of any diameter smaller than 0.5

mm) to enhance the fit into the handle. Spirallingthe wire down the shaft allows the modified electrosurgical adapter to be tightly screwed into virtually any loose electrosurgical device handle. The number of spirals determines the tightness of fit. The tightness may even be such that the modified electrosurgical adapter is totally impossible to remove from the handle with the lingers only. The modified electrosurgical adapter concept may facilitate needle removal, increase surety of fit into virtually any electrosurgical handle, and provide versatility of fit into worn handles that were previously unable to hold traditional or Luer-lok adapters.

Reference 1. Stegman S, Tromovitch T, Glogau R.The Bernsco adapter. J Dermatol Surg Oncol 1984;9:680.

A lgina tes A “New“ Dressing Alternative DANIEL PIACQUADIO, MD DONETTE B. NELSON, RN, BSN,CETN

BACKGROUND: Currently, a wide variety of bio-occlusive dressing materials are available. In general, these dressing materials provide a moist wound healing environment that has been shown to promote healing in both human and animal studies. To effectively use these dressings the clinician must have a full understanding of the properties of the materials as well as the pathophysiology of the particular wound. Most recently, a “new“ biosynthetic dressing material, the alginates, has become available. OBJECTIVE:To highlight proper use of alginate dressings for

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ne of the most recent additions to the family of bio-occlusive or biosynthetic dressings are the alginates. Although alginates were discovered more than a century ago, they are the least known of the bio-occlusivedressings.They were prominentlyintroduced as a

From the Division of Dermatology OP), University of California-San Diego and the Veterans Hospital-Sun Diego, and Mercy Hospital OBW, San Diego, California. Address correspondence and reprint requests to: Daniel Piacquadio, MD, Division of Dermatology, University of California -Sari Diego and the Veterans Hospifal-Sun Diego, 3350 La Jolla Village Drive, San Diego, CA 92161.

the management of acute and chronic wounds. METHODS:Case study and literature review. RESULTS: Alginates were shown to be effective

in a wide variety of acute and chronic wounds. CONCLUSION: Alginates possess several unique properties that should prove useful to the dermatologic surgeon as well as the dermatologist. Proper patient selection and use of this “new” dressing material, as well as a review of the literature is presented. J Dermatol Surg Oncol 1992; 18~992 -995.

wound dressing material in the 1950s, but because of product limitations and manufaduring difficulties, their use declined thereafter.’ However, recent innovations in the formulation and manufacturing of alginate dressings have resulted in renewed interest in them. Little has been written in the dermatologic literatureregarding this distinct material. Alginates possess several unique properties that should prove useful to the dermatologicsurgeon as well as the dermatologist. The ideal dressing material for a wound or surgicalsite is unfortunatelyunknown. However, the recent reintroduction of alginates brings us closer to an ideal dressing in some clinical settings. Alginate dressings are derived from “salts” of alginic acid. Various types of kelp or algae serve as the source for this com-

0 1992 by Elseuier Science Publishing Co., Inc. 0148-0812/92/$5.00

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plex polysaccharide (eggiant kelp Macrocystis pyrifera). When the material is extracted from the plant, it is in the soluble form of a sodium salt. Duringmanufacturing, ion exchange with elements such as Ca+, Mg+, Zn+,etc leads to the formation of alginate fibers. These fibers are then used in the manufaduring of the dressingmaterial. Overall, the material is best dassi6edas a gel. Table 1 characterizes the features of this dressing. Both clinical and scientific evaluations have shown that alginates facilitate wound Exudate from the wound is required to transform this material into a therapeutic gel matrix. Sodium in the wounds blood and exudate fluid provides the basis for the ionic exchange needed to form a soluble sodium alginate gel. It is hypothesized that this ionic exchange is the basis for the hemostaticproperties of the material.'" During this exchange free calcium ions are released, providing one of the essentialelementsof the clottingcascade.' Clinically, the hemostatic quality of this material can be particularly beneficial. Alginates may be considered the initial dressig of choice for full-thicknesswound defects. Their hemostaticproperties are of particular value postoperatively. Alginates provide an ideal moist wound healing environment. Hein et a16 showed that moist wound healing allowed Mohs full-thicknesssurgical defects to heal faster and with smaller, more aesthetic scars compared with conventional antibiotic gauze dressings. We have used alginates for this purpose and found similar benefits. Alginates have also been used as a dressing for split skin graft donor sites. Attwood3 studied 130 split skin graft donor sites and found significant reductions in healing time and patient comfort compared with traditional paraffin impregnated gauze dressings. At day 8'72% of alginate treated areas were totally healed compared with none of the traditionally dressed areas. In contrast, a study by Lawrence and Blake' showed no benefit compared with scarlet red dressings. However, the most common application for alginate dressings is in the treatment and management of decubiti and ulcers. Numerous investigators have shown the value of alginates in the treatment of these difficult cases of decubiti and ulcem8-I1Although alginates are not uniformly the dressings of choice, they have been successfulwhere many other treatments have Alginates have been shown to facilitate healing by promoting granulation and epithelizationof the wound. Patients using alginate dressings also uniformly note a reduction of pain associated with the wound and dressing changes. The only controlled study evaluating these dressings focused on their value in the management of leg ulcers in the ~ommunity.~ This study evaluated 81 patients, comparingalginate to par& impregnated gauze dressings. The study revealed superior healing rates as well as a greater percentage of wounds respondingto the alginates. Cost analysis, consideringboth material and nursing time, also favored the alginates. Overall, expenses for treatment were reduced by 30%. Alginates have also been used in the treatment of ingrown toenails.12Fraser and Gilchrist'* treated 10 patients with intractable ingrown toenails with hypergranulation tissue. After cleaning the nail groove, alginate dressing material was packed between the nail fold and nail plate to the nail groove. This packing extended over the hypergranulation tissue. The dressing was secured with Mefix. In all cases the hypergranulation

tissue subsided and there was a marked reduction of the lateral nail fold tissue. In many cases, this treatment eliminated the need for subsequent nail surgery. More recently, alginates have been used in the development of a new surgical ~ponge.'~ Evaluation of this "new gauze" was performed on 100 patients undergoing routine general surgical procedures(eg, cholecystectomy,mastectomy, etc). Each procedure was randomly assigned to either traditional gauze or the new alginate sponge. The new alginate based surgical gauze was more absorbent, and was associated with a decrease in surgical blood loss and operating time. Alginate dressingshave been shown to be effectivein a wide variety of clinical settings includingulcers, pressure sores,splitthickness graft donor sites, and full-thickness surgical defects. The unifying characteristic of these wounds is that they are all exudative. For less exudative wounds, wetting of the dressiig with saline may be done at the time of placement. If the wound dries and a moist environment cannot be maintained an alternate dressing material should be selected. Alginate dressings,if not properly hydrated, can be very irritating and will adhere to the wound bed? Clinically, alginatedressingsare easy to use and are available from several sources (Table 2). They readily conform to the underlying wound bed, and then are held in place by an overlying secondary gauze dressing. They may also be used in conjunction with other bio-occlusive dressings. We frequently use polyurethane film to hold alginates in place overlying splitthickness donor sites. The combination of alginates under an Unna boot for venous stasis ulcers improves absorption and yields accelerated healing in many cases. Alginate dressings should be changed when wound exudate "bleeds" through the secondary dressing or by day 7. When the dressing is changed, the material will appear as a yellow-brown gel over the wound site (Figure 1).It is important to recognize thischange and make patients aware of it so they do not confuse it with a purulent exudate from the wound. In addition to providing a moist environment the gel may also entrap bacteria, allowing them to be cleared from the wound site with dressing changes.' On occasion this gel/bacterial mixture may have a foul odor; however, this should not be of concern if there are no signs of true infection (tenderness,increased erythema, adenopathy,etc). As with the use of other biosyntheticdressings,the presence of bacteria is common and has not been shown to preclude the healing benefit of these materials." Because the gel is soluble, it can be readily removed by saline irrigation. Concomitant whirlpool

Table 1. Characteristics of Alginate Dressings Absorbent gel-forming alginic salt Soluble gel is nonadherent Appropriate for exudative wounds or surgical sites Maintains moist wound healing environment Hemostatic (damsalt) Dressing changes aided by ability to irrigate away old dressing with saline Reduces wound pain Conforms easily to wound bed

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Table 2. Alginate Dressings Algiderm (Viaderm Pharmaceuticals) Alginate Styptic Gauze (Pedinol Pharmaceuticals) Algosteril (Johnson& Johnson) Kaltostat (BritCair Ltd.) Sorbsan (Dow B. Hickman, Inc.)

therapy, if used, will not only promote wound cleansing and debridement, but will also remove the dressing. This no-touch technique can provide for almost pain-free dressing changes. Any trace material left behind need not be of concern because it will be broken down and metabolizedby the bod^.^,'^ Although there has been some question about the potential toxicity of alginates, the material has been used extensively over the past 40 years without d i f f i c ~ l t y . ~ ~ ' ~ One of the most difficult aspects of using biosynthetic dressings is determining which dressing type to use. In all cases, regardless of the dressing chosen, alginates as well as other biosynthetic dressings perform best when they are used on a stable, clean wound. However, alginates will provide some gentle autolytic debridement of the wound site. Alginates, as well as other biosynthetic dressings, have little role in frankly necrotic wounds prior to surgical debridement. Table 3 contrasts the features of alginates with other common biosynthetic dressings. It is clear that alginates have some distinct characteristics compared with these other materials. Alginates are only appropriate for exudative wounds irrespective of the wounds cause. However, because of the material's gel-forming action, it is able to absorb wound exudate more readily than most other biosynthetic dressings. This quality may be exploitedby combiningit with other dressing materials, which have other advantages. As previously noted, alginates can be used over venous ulcers and then held in place with an Unna boot. This minimizes exudativebleed-throughand combines the other benefits of alginates with the compressiveUnna boot dressing for the treatment of venous ulcers. Alginates can also be used with hydrocolloid dressings essentially as a replacement for the paste or granules in more exudative wounds. In some patients, as with the Unna boot combination, this combination yields better results than the hydrocolloid alone. Unfortunately,the true mechanismsof action of these materialsare not well understood and even less is known about these mechanisms when these materials are used in combination. The hemostatic properties of alginates also distinguishes them from the other biosynthetic dressings. Alginates essentially combine the benefits of Gelfoam with a moist healing environment. Because of this, alginates make an excellent dressing choice postoperatively for intradermal or full-thickness wounds where bleeding may be of concern. Its use may be continued as long as the site remains exudative. Alginates are also useful in deeper cavitary soft tissue exudative wounds or fistulas. The material may be readily packed into these sites and maintained by an overlying secondary dressing. Most of the other biosynthetic materials are not amenable to being packed into very deep wounds. The soluble nature of this

Figure 2. Leg ulcer with alginate gel overlying wound bed (arrow), periphery of wound shows a nonhydrated alginate gauze dressing (double arrow).

material is also advantageousfor cleansing and changing dressings in these deeper cavitarylesions because residue may just be rinsed away. Patients especially like this feature compared with other dressing options because it decreases the pain associated with dressing changes. However, for deeper wounds involving muscle or bone, alginates (as with other biosynthetic dressings) are usually not recommended. Unfortunately, there are no catch-all formulas to guide the clinician in his or her selection of the ideal dressing. There are often several reasonable choices for a given clinical setting. Dressing selection should be based on understanding of the characteristicsof the different materials, the pathophysiology of the wound, and clinical experience. Just as wound healing is a dynamic process, a wounds dressing needs may change over time. Practitioners should not be loath to change the type of dressing during therapy based on the patient's progress. The collectiveexperiencewith alginates to date would imply that these dressings have returned to stay. For exudative

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Table 3. Properties of Classes of Biosynthetic Dressings Characteristic Transmitsoxygen Transmitsmoishup Exdudesbacteria Absorbs fluid Transparent Adhesive Wound pain reduction

Films

++ +/-

+ + +

Hydrocolloids

Hydrogels

Alginates

-

Y?)

Y?)

+ +-

+ +

-(?I

+-

+/+/-

++ -

-

+

+

‘Adapted front Table I, Eagleetein Eaglestein WH. Experiences with biosynthetic dressings.~ArnAcadDmafol1985;12434-40,bypmissionofhfosby-Year Book, Inc.

wounds or surgical sites alginates create a unique highly absorbent, gel forming, hemostatic dressing that provides a nonadherent, moist wound healing environment. These dressings are of particular interest because of their malleable nature, which could eventually yield a “growth factor” delivery system in the future. Overall, given the distinct features and advantages of this family of materials, alginates deserve a place in the practitioner’s therapeutic armamentarium.

Acknowledgments. Viaderm Pharmaceuticals provided the dressing materials utilized in evaluating the alginates.

References 1. Thomas S. Use of a calcium alginate dressing. Pharm J 1985;235:188-90. 2. Barnett SE, Varley SJ. The effects of calcium alginate on wound healing. Ann R Coll Surg Engl 1987;69:153-5. 3. Attwood AI.Calciumalginatedressing acceleratessplit skin graft donor site healing. Br J Plast Surg 1989;42:373-9. 4. Jarvis PM, Galvin DAJ, Blair SD, McCollum CN. How does

calcium alginate achieve hemostasis in surgery?Mth International Congress of Thrombosisand Hemostasis, Brussels, July 1987;8-10. 5. Groves AR, Lawrence JC. Alginate dressing as a donor site hemostat. Ann R Coll Surg Engl 1986;68:27-8. 6. Hien NT, Prawer SE, Katz HI. Facilitated wound healing using transparent film dressing following Mohs micrographic surgery. Arch Dermatol1988;124:903-6. 7. Lawrence JE,Blake GB. A comparison of calcium alginate and scarlet red dressings in the healing of split thickness skin graft donor sites. Br J Plast Surg 1991;44:247-9. 8. Bamett AH, Odugbesan 0.Seaweed-baseddressingsin the management of leg ulcers and other wounds. Intens Ther Clin Mon 1988. 9. Bamett AH. Use of seawood-based dressing in management of leg ulcers in diabetics: a case report.Pract Diabetes 1987;4. 10. Gilchrist T, Martin AM. Wound treatment with Sorbsanan alginate fiber dressing. Biomaterials 1983;4:317-20. 11. Jeter KF,Tintle TE. Early experiencewith a calcium alginate dressing. Ostomy/Wound Manag 1990;28:75-81. 12. Fraser R, Gilchrist T. Sorbsan calcium alginate fiber dressings in footcare. Biomaterials 1983;4:222-4. 13. Blair SD, Jarvis P, Salmon M, McCollum C. Clinical trial of calcium alginate haemostatic swabs. Br J Surg 1990;77 568-70. 14. Hutchinson JJ. Occlusive dressings: a microbiologic and clinical review. Am J Infect Control 1990;18:257-68. 15. Burrows T, Welch MJ. The development and use of alginate fibres in nonwovens for medical end-users. In: Cusick GE, ed Nonwoven Conference Papers, UMIST 1983. 16. Chenoweth MB. The toxicity of sodium alginate in cats. Ann S ~ r g1948;1173-81. 17. Eaglestein WH. Experiences with biosynthetic dressings. J Am Acad Dermatol 1985;12:434-40.

Alginates. A "new" dressing alternative.

Currently, a wide variety of bio-occlusive dressing materials are available. In general, these dressing materials provide a moist wound healing enviro...
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