A Critical Analysis of the Effect of Silver versus Iodine Dressings in Chronic Wound Management - Essay Example

A Critical Analysis of the Effect of Silver versus Iodine Dressings in Chronic WoundManagement Janine Patching SID Number Word Count: 3923 MOD001947 Wound Management 2013/14 Fiona Downie Anglia Ruskin University A Critical Analysis of the Effect of Silver versus Iodine Dressings in Chronic Wound Management Introduction I have chosen to look at this topic as due to being a community nurse, wounds are a major part of my job with chronic wounds taking up most of my caseload. There are various classifications that are offered to wounds, but the most common are acute wounds and chronic wounds. These types of wounds behave differently, and this defines the reasons why different methods are used in management of acute and chronic wounds. According to Wysocki (2002), acute wounds are those that progress through normal phases of healing and characteristically reveal some signs of healing within weeks. On the other hand, Wunderlich and Orfanos (1991) observed that chronic wounds are those that do not follow the normal healing process in the sense that they may or may not show any signs of healing within a few weeks. According to Bryant and Nix (2011), acute wounds are categorized as those that are acquired through surgery, trauma and those that are attained through burning (Bryant & Nix, 2011: 23-34). The phases and time duration that is assumed for acute wounds is measurable, and this is supported by the four major phases of healing though they have been confirmed to be overlapping; hemostasis, inflammation, proliferation and maturation. This material aims at investigating the effects of silver dressing and iodine dressing in chronic wound management. This will be achieved through consideration of various stages that are involved in both techniques of managing chronic wounds, comparing the stages with respect to their effectiveness of the use of the methods, and making an evidence-based argument regarding the most appropriate technique to use in managing the chronic wounds. In collection of data significant in meeting the objective of the study, secondary sources of data will be relied on, where various articles addressing the aspect of iodine dressing and silver dressing will be critically analyzed. This will significantly aid in determination of the findings of previous researchers about the effectiveness and efficiency of each individual method in addressing chronic wounds. An evidence-based conclusion will be drawn regarding the effects of silver dressing and those of iodine dressing in chronic wounds management. Chronic Wounds Chronic wounds are categorized into venous ulcers, diabetic ulcers and pressure ulcers. The venous ulcers occur mostly in the legs, and are evident to be affecting mostly the elder people. Mostly, the venous wounds are caused due to improper functioning of tiny valves in the vein, and this consequently affects the flow of blood (Bryant & Nix, 2011: 23-24). The diabetic ulcers occur to people with advanced diabetes, where nerves are damaged and thus cause scratches and bruises on the legs and feet. Advanced diabetics cause individuals also to develop the peripheral article disease (PAD) which is considered to be another type of chronic wounds (White, 2001: 3-8). Other causes of PAD are smoking, obesity, and high pressure. White (2001) also found out that the other main type of chronic disease is pressure ulcers, and they usually occur in people whose mobility is severely limited (White, 2001: 3-8). Lack of blood circulation that is caused by pressure on tissue is evident to be greater than that in the capillaries, and this cuts off circulation. Trial, et al. (2010) observed that most of the chronic wounds begin as acute injuries but the healing process exceeds the normal anticipated process in the sense that it does not observe the normal healing phases (Trial, et al. 2010). They are mostly stuck in a prolonged inflammatory stage and this is caused by an overabundance of neutrophil permeation (Howell-Jones, Wilson, Hill, Howard, Price, & Thomas, 2005: 143-149). Some of the possible chronic wounds are with inclusion of diabetic foot ulcers and venous ulcers, but these types of wounds do not share common etiology but according to studies, they are observed to share some characteristics with respect to different levels of activity (Howell-Jones, Wilson, Hill, Howard, Price, & Thomas, 2005: 143-149). There are various ways of dressing the chronic wounds depending on the cause of the wound and the phase at which the wound has reached. One of the ways of managing the wounds is through the use of the silver dressings which are considered to be wound products that are manufactured to regulate infections and provide the injured region a favorable environment that is crucial to facilitate the healing process (Tammelin, Lindholm&Hambraeus, 1998: 435-437). However, various criticisms have been raised about the effectiveness of silver dressings in management of acute and chronic wounds, and this (Thomas & McCubbin, 2003: 305-308). As in the case of silver dressing, there are several arguments presented regarding the appropriateness of iodine dressing in management of acute and chronic wounds (Greener, Hughes, Bannister, et. al. 2005: 59-61). Chronic wounds have become common in the contemporary world irrespective of the technologies and innovations that have been made in the medical sectors. It has been confirmed by Thomas and McCubbin (2003) that due to chemicals that people use and some of the wound dressing techniques that people are currently using, the rate at which the acute wounds are turning to become chronic wounds is elevating (Thomas & McCubbin, 2003: 305-308). This implies that there is a great challenge in understanding the most appropriate technique to use in dressing both acute and chronic wounds, and this follows the observation that mismanagement of the acute wounds significantly drives to establishment of the chronic wounds (Flanagan, 2003). Wound bed preparation is an idea that aims at allowing health professionals to have diverse methods of dealing with wounds, monitor the progress of healing of the wounds and more importantly have diverse ways of interventions. Thomas and McCubbin (2003) confirmed that there are four components that are considered to be very essential in management of chronic wounds, and these are with inclusion of tissue management which entails understanding which tissues are affected (Thomas & McCubbin, 2003: 101-107). Tammelin, Lindholm and Hambraeus (1998) argued that inflammation and infection control are other components that are considered relevant in wound bed preparation and they involve understanding some of the infections causing the wound, and/or those measures that can be used to prevent infection from affecting the wound (Tammelin, Lindholm & Hambraeus, 1998: 435-437). The other component is moisture balance and lastly the epithelial advancement. The four components construct a framework called TIME (Cutting, 2011: 4-7). The ability of the medical professional to integrate and apply all procedures highlighted in each of the components has raised concerns, and this presents the problem that needs investigation. White (2001) observed that both silver dressing and iodine dressing wound management integrates these four components, and failure to follow the requirements of each component causes more harm to the injured persons (White, 2001: 3-8). Silver and cadexomer iodine are considered to be topical antimicrobial agents that are used for treatment and management of infected wounds such as the chronic wounds. They are all considered to be effective and efficient antimicrobials depending by the level of the chronic wounds and more importantly the carefulness of the person addressing the wound (Klasen, 2000: 117-138). Preparation of a wound bed is not an easy process, and it is the obligation of the trained member of nursing staff to involve appropriate skills and professionalism to ensure that success is attained during the wound management process (Cutting, 2011: 4-7). This chapter will integrate a critical analysis of individual antimicrobial, and establish the factors that are essential in using the agents such as the presence of biofilms in the agents and also presence of the wound inflammation as a result of the use of the agents (Lansdown, 2002: 125-130). The use of silver dressing in managing the chronic wounds has an important history in the sense that healthcare providers have seen success in the use of the antimicrobial agent. According to Cutting (2011), it is highly recognized for its use and its ability to line water vessels to preserve water in the ancient times, an indication that it can be considered to be a preservative (Cutting, 2011: 4-7). This feature was formulated and modified to an extent that the silver nitrate can be used to dress wounds irrespective of whether they are acute or chronic wounds (Lipski&Hoey, 2009: 1541-1549). The silver compounds provide a wide bactericidal spectrum activity which integrates various measures of effectiveness and efficiency against common wound pathogens. Additionally, it is observed to have great influence on the vancomycin-resistant enterococci (VRE) and more importantly it facilitates greatly to prevention of the wound from being infected by the extended-spectrum-lactamase producers that have been confirmed by medical professionals to be toxic to human body (Maillard & Denyer, 2006). Cutting (2011) found out that silver ions are very effective in killing bacteria, and they attain this through destroying the cell walls of the bacteria. The ions also kill the bacteria by destroying the membranes and the respiratory systems of the bacteria alongside various enzymes and ribonucleoproteins (Cutting, 2011: 4-7). However, it can be claimed that the effectiveness of the silver ions to kill the complex communities of bacteria before they are split to form microcolonies that lead to development of mature and toxic biofilm is not well described (Percival, Bowler & Russell 2005: 1-7). According to Percival, Bowler and Russell (2005), the silver ions can be termed as inactive in the environments of the wounds, and therefore the approach through which the silver ions are introduced to the wounds requires carefulness to ensure that the ions positively help in dressing and healing the wounds. The silver ions are characteristically released from dressing the wounds through the process of oxidation which takes place when the silver ions are in contact with the fluid from the wounds. In order to increase the antimicrobial activity, scientists and medical specialist manufactured the nanocrystalline silver agents that released smaller particles and at a faster rate (Wysocki, 2002: 382-397). This helped in ensuring that the efficiency and efficacy of admission of the silver dressing in management of the chronic wounds is achieved comprehensively. Percival, Bowler and Russell (2005) observed that due to differences in the effectiveness and appropriateness of the silver antimicrobial agent that are commercially available, there is need to use diverse silver ions when carrying out primary experimental tests alongside other factors that need to be considered. Systematic reviews have indicated that silver antimicrobial agents have lost their popularity due to lack of RTCs of acceptable quality (Percival, Bowler & Dolman, 2007: 186-191). These reviews offer the suggestion of the modest if not differing support that silver sulphadiazine (SSD) cream prevents infection. This is an indication that to some extent, the silver ions and their effectiveness in dressing chronic wounds are doubtable (Percival, Bowler & Woods 2008: 52-57). This triggers researchers and scientists to have more interest in identifying the possible methods that can be used to test the efficacy of silver as a chronic wound dressing agent because there is fear that poor admission of the silver ions negatively contributes to lengthening of the period to which the wounds take to heal. In the year 2001, Percival, Bowler and Woods (2008) found out that only the SSD cream that was appropriate in healing the chronic wounds and this follows the observation that all other products of silver ions were ineffective in dressing the acute and chronic wounds (Percival, Bowler & Woods, 2008: 52-57). According to the study, silver dressing was not recommended as a result of lack of confidence that health professionals had developed towards the antimicrobial agent. Additionally, there was a significant reduction in ulcer size that was observed after a short period of introduction of the silver ions to an acute wound. Dunn and Edwards-Jones (2004) found out that the early effectiveness of silver ions was still doubtable and was not sustained, and this was confirmed in a review that was conducted in 2007 considering three RCTs which included various antimicrobial with inclusion of the silver ions. However, after a four-week assessment, it was found out that there was a high rate of closure for the wound that was dressed using the silver ions as compared to that which was dressed using the calcium alginate dressing. Additionally, after six weeks follow-up when a silver dressing was administered to a wound as compared to when alternative dressings were used, OMeara, Cullum, Majid and Sheldon (2001) found out that the closure period for the silver dressing was faster as compared to others. This was one fundamental way of confirming the effectiveness of the silver ions as antimicrobial agents to dress chronic wounds. The most significant and substantial review was conducted in 2010, where Thomas & McCubbin (2003) tried different antimicrobial agents such as silver, and other non-silver agents (Thomas &McCubbin, 2003: 305-309). The study involved clients with wounds that revealed the sign of bacterial infection or burden, and according to the findings that were extracted from the study, it was revealed that the wounds that were not dressed with silver products took relatively longer period to close as compared to those that were coated with silver products. However, the long-term effects of the use of the silver products to dress chronic wounds were not established, and are until to-date not known (Thomas & McCubbin, 2003: 305-309). There was another study that was conducted in 2010 by Cutting, White and Hoekstra (2009), and the findings were not very different, and this follows the observation that irrespective of the fact that the researchers used different products, it was confirmed that the use of silver alginate products was more effective than carbon methylcellulose in reduction of the risks of infection. Generally, from the numerous reviews that have been conducted regarding silver ions and their effectiveness in dressing wounds that are chronic, it can be concluded that there is short-term effectiveness in contrast to other treatments. This implies that there is great need to have confidence in the silver-based products in healing of chronic wounds because from the systematic reviews evident above, it is more effective than other chronic wound management antimicrobial agents (Michaels, Campbell, King, Palfreyman, Shackley& Stevenson 2009: 1147-1156). In comparing silver ions and silver associated products in dressing chronic wounds, it can be argued that there is a proliferation of reviews comparing silver products with one another. In a study involving six silver containing dressings by Meaume, Vallet, Morere, and Teot (2005), it was found that there were some silver products that were more effective than others in dressing chronic wounds. This led the researchers to make conclusions that the nature of the dressing contributed immensely to the success of the silver coating to reduction of infections in the chronic wounds (Meaume, Vallet, Morere, & Teot, 2005: 411-419). It was also observed by Carter, Tingley-Kelley and Warriner (2010) that a combination of different silver products may have diverse impacts to the closure of the chronic wounds, and to the duration spent before the wounds show the trend of healing (Carter, Tingley-Kelley &Warriner, 2010: 668-679). Considering the element of the safety of silver treatment, it can be retrieved that the transient staining of the environment near the skin can take place with silver dressing. However, this assumption or hyper-pigmentation is not always considered to be permanent. This follows the results from a porcine study which revealed that discoloration was correlated with the duration of use and to some extent, there could be permanent discoloration. The argument presents some confidence that the materials or products from silver ions that are used in dressing wounds are effective and efficient (Chambers, Dumville & Cullum, 2007: 165-173). Reflecting on the element of cost effectiveness of the silver treatment, Chambers, Dumville and Cullum (2007) argued that silver treatments are expensive if comparison is done with other products used to dress chronic wounds. The high cost of the silver products is linked to the findings that the products are very effective as compared to other treatments in dressing chronic wounds (OMeara, Cullum, Majid, & Sheldon, 2001: 4-21). The labor that is used in manufacture of the silver treatments might also be considered to be higher, alongside other factors such as the skills and professionalism that is needed while dressing the wounds. Cadexomer iodine is another advanced antimicrobial that is used in treatment of chronic wounds and those wounds that are at high risks of being infected by the bacterial burden (Lipski & Hoey, 2009: 1541-1549). Irrespective of the positive results from the use of iodine in dressing chronic wounds, there has been limited research in ways that can be used to improve the effectiveness of the iodine antimicrobial agents. This might be considered to be an illustration that the effectiveness and efficiency of the iodine agent is confirmed, and thus there is no need of further research as evident in the case of silver products (Storm-Versloot, Vos, Ubbink&Vermeulen, 2010). There are various systematic reviews that have been conducted regarding iodine and other dressings with respect to human beings and other animals. The use of iodine has resulted to elevated wound healing as compared to the use paraffin gauze and hydrocolloid dressings. According to Lipski and Hoey (2009) zinc paste dressings were also considered to be less effective and efficient as compared to iodine products dressing. However, the efficacy of iodine was proven to be less as compared to those of gentamicin solution and the dextranomer beads. This does not imply that its use is not good in dressing the chronic wounds because, according to some researchers, the efficacy of the antimicrobial agent depends on the duration of application and the size of the wound (Lipski & Hoey, 2009: 1541-1549). It has also been observed that there are few cost effective researches that have been conducted regarding the use of iodine as a dressing agent for chronic wounds. However, it has been confirmed to be more expensive as compared to treatments such as the use of hydrocolloid dressing and the standard treatment. It has been observed that iodine is the most commonly used and accepted topical antimicrobial to control the dangers associated with risks of bacterial infection in chronic wounds (Klasen, 2000: 117-138). This observation has been confirmed experimentally because among the numerous antimicrobials that are used to dress wounds, iodine is more effective, but this does not imply it is the best of all. On the other hand, Klasen (2000) observed that the silver antimicrobials have been raising issues connected to their effectiveness and appropriateness in dressing chronic wounds. The validity of silver antimicrobials was arrived at following the observation that the silver ions responded positively to the burn injuries and that it is more effective in prevention of bacterial infections in chronic wounds as compared to other antimicrobials such as iodine among others (Thomas &McCubbin, 2003: 101-107). Most of the comparisons between the silver and iodine antimicrobials are not directed towards the quality of these agents in reduction of risks of bacterial infections in wounds, but on the cost effectiveness. According to reviews conducted on the cost effectiveness of silver and iodine antimicrobials, it was revealed that the product cost for iodine was less for chronic wounds that have not exceeded 12 weeks (Vermeulen, van Hattem, Storm-Versloot, Ubbink, &Westerbos, 2007: 1-45). The costs of nursing such wounds while using the iodine antimicrobial is less than when using the silver antimicrobial agent and this is due to the production cost of the agents and the professionalism needed while administering the dressing. Experiments by Wunderlich and Orfanos (1991) also reveal that there is relatively small difference in healing rate when any of the antimicrobial is used in dressing chronic wounds. However, it was noted that healing was quicker for silver in situations where there is low growth of the white blood cells (Wunderlich & Orfanos, 1991: 446-450). There are various reasons that are offered as to why chronic wounds stall in the inflammation phase, and these are with inclusion of the pro-inflammatory response being out of control. This condition is contributed due to factors such as local tissue ischemia and repeated trauma among other causes (Klasen, 2000: 117-138). The other reason is due to absence of activity of biochemical elements that are responsible for pro-inflammatory response (Meaume, Vallet, Morere, Teot, 2005: 411-419). It is in such situations when dressing is necessary to prevent entry of infections, and the selection of the appropriate antimicrobial depends on various factors such as availability, the duration of the wound and the size of the wound and contraindications. In situations where the wound has exceeded four weeks, it is advisable that silver antimicrobial is used to facilitate to faster closure and healing of the wound (Greener, Hughes, Bannister, et al. 2005: 59-61). However, there is great need to investigate on the clinical effectiveness of either silver or iodine antimicrobial agent in dressing the chronic wounds. It is the responsibility of the researchers and medical specialists to determine the appropriate measures that can be used to ensure that the antimicrobials are effective at any stage of wound healing (Trial, et al. 2010: 20-26). They need to make an evidence-based assessment of inflammation that is present at the time of dressing so as to know which antimicrobial is appropriate and at what level should it be applied. According to Trial, et al. (2010), the ability to recognize when a wound is colonized and when it has infections is crucial as it aids in determination of when to start dressing the wound using the antimicrobial agents such as silver and iodine products. As the wounds continue to expand and open, Trial, et al. (2010) observed that the chances of being infected by bacteria is very high, and the observation that the bacterial first stay at the solid environment before differentiating suffices to show that recognizing when there is presence of bacteria aids in killing them before they differentiate. Dowsett (2003) on the other hand found out that the amount of antimicrobial transfer to aid in fighting bacteria is dependent on the surrounding of the skin, and the risks of being infected. This implies that it is the obligation of the healthcare practitioners to understand the situations when there is need to administer the antimicrobial to prevent infection, especially for wounds that are considered to be chronic (Jorgensen, Price, Andersen, al. et. 2005: 64-73). Following the understanding established of the use of antimicrobial agents to heal chronic wounds, there is great need to make appropriate recommendation on the most appropriate dressing agent to use, and in which environments. According to Flanagan (2003), chronic wounds are prone to bacterial burden, and this is because they are mostly open and the chances of bacteria settling and reproducing in the wounds is very high (Flanagan, 2003). The following recommendations are effective for practice in the sense that they aid in determination of the best course of action to take while dressing a chronic wound (Munter, Beele, al. et. 2006: 199-206): a. The topical antimicrobial agents and treatments needs only to be administered to wounds that have the signs of critical colonization and systemic infections. Additionally, they need to be used for wounds that show the signs of local infection. This is an indication that they should not be used when there is reliable and positive progress of healing (Flanagan, 2003). In connection, when infection is suspected wounds should be swabbed and appropriate antibiotics used thereafter. b. Since both silver and iodine antimicrobials are recommended for use in dressing critical and chronic wounds, it is essential to follow the instructions and prescriptions offered by the manufacturers to avoid negative side effects (Dunn & Edwards-Jones, 2004). c. The fact that the effectiveness and efficiency of the silver antimicrobial productsvaries, the state of the wound needs to be considered while selecting the dressing product to use (Cutting, White & Hoekstra, 2009: 396-402). This is also true for the iodine antimicrobial. d. Both silver antimicrobial and the iodine antimicrobial have almost equivalent clinical efficacy to wounds that have exceeded four weeks, and thus it is the obligation of the medical practitioners to select the most appropriate dressing agent depending on the nature and size of the wound (Cutting, White & Hoekstra, 2009: 396-402). e. For wounds that have not exceeded four weeks, it is advisable to use the silver antimicrobials because they help in attainment of faster healing. f. Considering the element of research recommendation, it is essential for scientists and medical professionals to determine whether there is any scientific advantage that is linked to the suggestion that there is prophylactic responsibility for antimicrobial healing in chronic wound management (Carter, Tingley-Kelley & Warriner, 2010: 668-679). g. Local education and training for Wound Management should be mandatory for all staff that deal with wounds to ensure the best outcome for patients. In the main, it can be argued that both silver and iodine antimicrobial dressings have positive effects in treatment and management of chronic wounds (Bryant & Nix, 2011: 23-34). For management of wounds that have not exceeded four weeks, it is highly recommended that practitioners use the silver antimicrobial agents because they facilitate to faster healing as compared to iodine treatments among others. Considering the cost effectiveness of these treatments, studies have showed that silver antimicrobial treatment is more expensive as compared to iodine treatment. Generally, both the antimicrobial agents have diverse effects in reduction of the risks of bacterial infections to open and chronic wounds. Selection of the appropriate treatment product to use thus depends on the nature of the wound, the size, and more importantly the duration to which the wound has been in existence. References Bryant, R., & Nix, D. 2011. Acute and Chronic Wounds (4th ed.). British Journal of Nursing; 12(19): 23-34 Carter, M. J., Tingley-Kelley, K. & Warriner, R. A. 2010. 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A comparison of the antimicrobial effects of four silver-containing dressings on three organisms. Journal of Wound care; 12(3): 101-107. Thomas, S. & McCubbin, P. 2003. An in vitro analysis of the antimicrobial properties of 10 silver-containing dressings. Journal of Woundcare;12 (8):305-308. Trial, M. C. et al. 2010. Assessment of the antimicrobial effectiveness of a new silver alginate wound dressing: a RCT. Journal of wound care; 19(1):20-26. Vermeulen, H., van Hattem, J. M., Storm-Versloot, M. N., Ubbink, D. T. &Westerbos, S. J. 2007. Topical Silver for Treating Infected Wounds (Review). The Cochrane Database of Systematic Reviews (1):1-45. White, R. 2011. An approach to assessing evidence that can inform clinical decision-making. Journal of Wound Care, 20(3 The Silver Debate Supplement):15-19. White, R. J. 2001. An historical overview of the use of silver in modern wound management. British Journal of Nursing, 15(10 (silver supplement)):3-8. Wunderlich, U. & Orfanos, C. E. 1991. Treatment of venous ulceracruris with dry wound dressings: phase overlapping use of silver impregnated activated charcoal xerodressing [German]. Hautarzt, 42:446-450. Wysocki, A. B. 2002. Evaluation and managing open skin wounds: colonization versus infection. AACN Clinical Issues, 13(3):382-397. Read More