Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury - 37

CLINICAL PRACTICE GUIDELINE

Maggot debridement
Maggot debridement therapy (MDT) or the use
of maggots for debridement of wounds has been
approved in the United States by the Food and
Drug Administration as a medical device. Maggots
are precise in their debridement. The larvae
excrete through their oral, cutaneous, and fecal
matter, proteolytic enzymes, including collagenase,
that break down necrotic tissue. Maggots also
ingest bacteria along with liquefied necrotic tissue
subsequently killing them in their digestive tract.
They inhibit the pro-inflammatory responses of
human monocytes (van der Plas et al., 2009).
Medicinal maggots also stimulate healing, and
inhibit and eradicate biofilm (Sherman et al., 2009).
MDT has been shown to be significantly faster than
conventional treatment in debriding wounds (not
pressure ulcers) during the first week of treatment
(Opletalova et al., 2012) and faster than hydrogel
or autolytic debridement (Dumville et al., 2009).
Sherman et al. (2007) reported the successful use
of MDT in two SCI patients with wounds
unresponsive to conventional therapy, and where
surgical debridement was considered too risky.
Choice of a method of debridement is based
on the individual's clinical situation. Techniques
can often be combined. Although it is beneficial
to remove devitalized tissue as quickly as
possible, the clinical circumstances will determine
the most appropriate method. All methods of
debridement should be discontinued when the
necrotic tissue and/or biofilm has been removed.
S E L E C T I O N OF W OUND CA RE DRE S S ING ( TABL E 3)

16. Use a dressing that achieves a physiologic
local wound environment that maintains
an appropriate level of moisture in the
wound bed:

Control exudate

Eliminate dead space

Control odor

Eliminate or minimize pain

Protect the wound and the
periwound skin

Remove nonviable tissue

Prevent and manage infection

(Scientific evidence-I, II; Grade of recommendation-A;
Strength of panel opinion-Strong)

Dressings are topical products used for
protection of a pressure ulcer from contamination
and trauma, application of medication,
debridement of necrotic tissue, and optimally
provide a physiologic local wound environment. A
physiologic wound environment is a local

environment in which tissue hydration levels and
the viability of the wound tissue and various cells
within the wound space (growth factors, platelets,
etc.) are maintained by something other than the
skin. The wound dressing can be viewed as the
substitute skin.
Dressing selection should be based upon a
thorough wound assessment and history, dressing
interactions, patient and caregiver needs, as well as
cost (Baranoski, 1995; Krasner, 1997). It should be
noted, however, that caregiver time and the
associated labor costs required for wound care
significantly impact the overall cost of caring for
individuals with pressure ulcers and may exceed the
cost of wound management supplies (Bolton et al.,
1997). Therefore a dressing that may cost more on
a daily basis but does not need frequent dressing
changes may be the more cost-effective one in the
long run. Ultimately, the attributes of the dressing
should match the needs of the wound.
Control exudate
Exudate can be attributed to bacterial colonization and increased bioburden and therefore
can impair wound healing; thus, it needs to be
minimized. Although dressings should keep the
ulcer bed moist, they should not cause over
hydration leading to maceration of the surrounding intact skin. Excessive exudate causing
macerated surrounding tissue is associated with
prolonged healing time (Xakellis and Chrischilles,
1992). Excessive exudate can be managed by
using an absorptive wound dressing designed to
control exudate and avoid periulcer maceration.
Exudate should be absorbed away from the ulcer
bed (Bergstrom et al., 1994). A number of
techniques are used to protect the surrounding
intact skin from excessive moisture, including
applying moisture barrier creams, skin barriers,
or skin sealants. Changing the dressing if
excessive drainage is observed, keeping the
dressing in the wound bed and not on the intact
skin, and using a rectal pouch if fecal contamination is anticipated, are other techniques used to
protect the periulcer skin.
Sayag et al. (1996) compared an alginate
wound dressing to treatment with a dextranomer
paste. Reduction in wound size and the rate of
healing were better with the alginate group than
with the dextranomer paste. In an open-label, randomized, parallel group study, investigators compared the effects of a newly formulated
dextranomer paste with saline-soaked dressings.
Significantly greater improvement in ulcer drainage
(25%) was found with dextranomer paste compared to saline treatment (73% versus 13% of
treated ulcers) (Ljungberg, 1998).

Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury

Table of Contents for the Digital Edition of Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury