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For enzymatic debriding I really like Gladase (Smith- Nephew). Any of the Papain-Urea Debriding Ointments seem to be about the same, but I simply like that particular one. After cleansing the area with saline bid simply apply to necrotic tissue and use the appropriate dressing for the amount of drainage. Good luck. Donna Cameron RN WCC

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Santyl is my number one choice. It rarely causes any burning or stinging sensation and can be used until the ulcer is healed. It must be applied to the wound bed and must be nickel thickness. Do this treatment daily. Make sure what ever cover dressing you use is not an absorbant or it will suck the santyl up into the dressing fibers. I usually put a non stick dressing than a cover dressing. I have used Gladase but have had patients complaining about the burning and have had one patient that sustained a burn from it. Santyl will not harm good skin but you should still do a skin prep on the periwound. You could also jump start wound healing by using a silver product for a couple of weeks. Keep in mind that silver products should be stopped when you need has been accomplished.
de BSN RN

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I think you have to first consider all possible factors which may be contributing to the chronic status of the wound, some of which include: elucidating the cause, identifying comorbid states/conditions and addressing them, determining whether the wound is suffering from infection or heavy bioburden (silent or overt), assessing nutritional status, ascertaining that appropriate dressings are being used to create a moist, warm healing environment, etc.

After that, if you are wanting to debride a wound, there are several different ways. Sharp conservative, mechanical, autolytic (via the appropriate dressing) and enzymatic (Accuzyme is a good prescription ointment), and biosurgical (via sterile maggots) are all methods that can be used.

Sara, PT, WCC

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Accuzyme works good, as well as Santly. It depends on if there is infection as well. What are the other characteristics of the wound. You need to determine why the wound is not healing or stalled and treat the whole body, not just the wound.

Sonja Whittredge, RN, BSN, NHA, WCC

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First eliminate the cause of the wound
second there are at least a dozen deriding agents on the market
check out ... www.woundsource.com for the latest in wound care products
also check Smith & Nephew and Health Point for the latest debriefing agents.

Pat Devine RN CWOCN

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Hi, I know the best debriding agents there are. Maggots! I repeatedly tell everyone that I am not professional, but I am a former patient and now a patient advocate , who knows what saved my feet from amputation. I have had diabetes for 43 years, and have been on immuspressants for 26 years (Kidney transplant) I had diabetic ulcers, Stage lV. I also had osteomyelitis in both heels. Amputation was my only choice, when I found out about maggot therapy. It is FDA approved, cost effective and works better than "everything" else, I tried. Maggots eat only the dead infected tissue, they kill the bacteria and they also excrete enzymes to promote healing. My feet have been totally healed for over four years now. Please do the research and become a patient advocate as I did to help others know "all" their options.

Pam Mitchell
Patient Advocate

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A good assessment must be done to try to determine why the wound is stalled. Is it granulated but carrying a heavy bacterial load? Then a silver dressing might be the answer. If it has eschar or slough, then you do need a debrider. I use papain/urea agents on really dirty wounds, and then when I have about 50% granulation, I often go to the combos with chlorophyllin like Panafil, Gladase-C, etc which may have some effect to encourage granulation. Also, remember, these agents usually can be used with vacuum dressing (VAC and Blue Sky) if that’s appropriate. In our state, Medicaid will only pay for Blue Sky. Good Luck.

Vicki, MSPT, CWS
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Hi:

Please keep in mind this information is general considering that the asker does not specify his or her capacity as a lay person or a clinician. I don’t recommend trying ointments without consulting a wound care specialist- who is able to evaluate the wound properly..

There are many options in debridement depending on the amount of dead/ necrotic tissue in the wound. Some well known topical debriding agents are Accuzyme and Panafil ointments that both contain powerful debriding agents. A hydrogel can be an effective debrider when applied to wound and covered with an occlusive or semi-occlusive dressing and allowed to stay in place in consideration of the wound drainage etc. Choice of debridement really depends on the patient, the wound, etc.

Best Regards,
Jamie Pinnock RN, CWCN

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Hi Kate, I am British, born in Yorkshire and as you see living and working in the States. With my diabetic foot ulcers I either sharp or chemically deride and then use the wound VAC from KCI. Wonderful and works fantastic. I know you have KCI in the UK. Just go under KCI.com. Hope that you have success.

Julie Palmer RN
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 Hi, I am sending the same info I sent to an earlier request, Maggots! As they saved my feet from amputation. I repeatedly tell everyone that I am not professional, but I am a former patient and now a patient advocate, who knows what saved my feet from amputation. I have had diabetes for 43 years, and have been on immuspressants for 26 years (Kidney transplant) I had diabetic ulcers, Stage lV. I also had osteomyelitis in both heels. Amputation was my only choice, when I found out about maggot therapy. It is FDA approved, cost effective and works better than "everything" else, I tried. Maggots eat only the dead infected tissue, they kill the bacteria and they also excrete enzymes to promote healing. My feet have been totally healed for over four years now. Please do the research and become a patient advocate as I did to help others know "all" their options.

Pam Mitchell

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dont foget to do ABI ON the leg to check the blood flow. thanks roopa lothe
PT,RN,CWS

For Mona: Chemical debridement can definitely be done at home. I have taught many patients to apply it. They just need the prescription to get the medicine, and need to be taught how to apply it, like they would for any other home dressing change.

Renee C.

Renee C.

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I am a direct care nurse working in rural Manitoba. I have used betadine liquid and white sugar often for ulcer healing. The only indication is be careful the client is not diabetic. It really works. Sugar has been used to treat coccyx ulcers also. Make a pouch to pour it into and tape. Honey has also been used on ulcers. Of course these tx’s need to be ordered by your physician.

I use a sterile urine bottle to make the mixture b/c there are no real ratios. I like it to be a soft paste mix. It will thicken as time goes on. Spread with a tongue blade. Good luck. BEE L.P.N.
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Sugar and honey have both been used to dress wounds. I am aware of no studies showing evidence that they are effective. By contrast, there are so many dressings with evidence to back their effectiveness, that could be used to treat such a scrape.

As they are not recognized by the FDA as wound dressings, especially in the highly regulated SNF/NF industry, the use of anything other than approved wound dressings could, especially if things did not go well and the wound did not heal or developed complications resulting in any kind of litigation, put both the doctor who ordered the dressing, the nurses or staff who applied them as well as the facility, in a precarious legal position.

Sara, PT, WCC

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NO indication whatsoever. Call the State Regulatory BOard and make a complaint.

Jeri

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I have heared of sugar as a home remedy for healing wounds,

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You didn't say what percentage had the slough, but my choice would be to d/c the e-stim and go to a wound vac. KCI will come to your facility and present a very good inservice. E-stim usually works but it a slow healer. The wound vacs are a great way to heal any wound with depth. They cannot be infected and you can only have minimal bone exposed. You change the dressing three times a week and the machines are portable. The negative pressure pulls body fluids to the wound and bathes it , warms and heals. If needed you can use their product with a silver impregnated sponge. I think you would be more pleased with the vac then e-stim.
de BSN RN

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transfer to The Vac by KCI
it will stimulate healing
Pat Devine RN CWOCN

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No matter how much E stim you do , the wound won't heal without either chemical or conservative sharp debridment. Try a pulse lavage or wound cleanser in a spray to lossen the slough before applying the debriding agent, then gently pat it dry. If that dosent work send him for a surgical consult to clean it out in the OR. You might consider calling Johnson and Johnson and investigate Prisma for use after the wound is clean. It will not only bind up the MMP's in this chronic wound but will help with the drainage as well. The rep will be happy to explain the properties of this amazing product.You must make the dressing larger than the wound so you can secure the dressing on to the undamaged surrounding skin Protect the periwound areas with vaseline or Calmoseptine ointment, or one of Medlines good skin products (on the skin, not in the wound)The wound should be packed lightly with fluffed up 4 x 4's. There must be something holding on the ABD's Protect the macerated areas with one of the products I mentioned and place as many ABD's over the area as needed to cover the area and tape down over the ABD to the skin that is not macerated A good foam in a large size (6x8 inches) might be better than a ABD. It will absorb more drainage.

When the wound is clean and stops draining (the Prisma will do that) and starts granulating, hydogel gauze followed by the same covering and protection of the periwound area will get the wound to granulate and hopefully finally fill in and close

J Means RN

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Dorinda,

First of all you have to be sure this gentleman is
eating the right food, high in protein and is he
really absorbing all the necessary elements for
woundhealing? 3 years is a long time. The wound needs to be debrided, for this wounds sounds like "death". I would use sharp debridement or maybe an agressive chemical debrider. Then I would use a calcium alginate to absorb the exsudate. For the surrounding skin I would use a zinc oxide paste, the "dry" one to protect the skin, you can even use Desitin for rash. Once the wound is nice beefy red you might want to put a VAC on to speed up the healing proces. I assume you already have all the other necessary factors reviewed like no pressure on the wound, lab controles etc.

Good luck,
Marloes van Kouwen

Have a nice day :)
Marloes van Kouwen

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I am not familiar with e-stim for wound healing. As long as the wound has slough present it will not heal. What is this patients pre-albumin? Being
S/P gastric bypass may affect his absorption for nutrition. Skin protective barrier film (skin prep) and stomahesive paste may be used to protect the
peri-wound tissues. A debriding agent may be used to reduce the slough, panafil ointment or spray may help with the debridement and the healing. Are
pressure relieving measures in place and used appropriately? Nutrition concerns addressed. The entire cavity needs to filled with some type of
dressing, fill dead space. Has anyone considered Vacuum Assisted Closure? KCI is a national company that provides the equipment and the supplies and is billable to insurances and Medicare. Also a pressure ulcer is not down scaled, once a person has a Stage IV it is always a Stage IV. The wound may be granulating and healing but would not become a Stage III. Any time there is not progress over a two week period, some type of change is needed in the wound care regimen. Although the wound does not appear infected could it be overcolonized? This would impede progress, some type of local antimicrobial may be indicated.
Laurie Ellefson, RN, WOC Nurse, CFCN

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I am sure after 3 years all underlying factors have been ruled out. With the gastric bypass I am not sure about the absorption of nutrients that may be a factor, he may not be getting the nutrition into his system that he needs for wound healing, lab work should be able to determine this. Has anyone tried the wound VAC? I have 10 years experience with the VAC in the Home health care setting. If you can get the peri-wound tissue to the condition where the drape will seal you can use enzymatic debriding ointment prior to the VAC dressing change. (It also depends on how much slough tissue is in the wound bed, I have used the VAC along with debriding ointment on all kinds of wounds with slough tissue) The Vac will manage the drainage and stop the maceration, the challenge will be getting the peri-wound tissue dry enough to seal, but trust me, there are ways! Call KCI at 1-800-ASK-4-KCI for more info on if the VAC is appropriate and good luck. You can also try talking to a CWOCN in your area, they are wonderful and always willing to help when it comes to wounds!
Sandie LPN

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I forgot to give you this info. You can locate a CWOCN in your area by going to these sites. www.aawm.org or www.wocn.org.
Sandie-LPN