Local Wound Care for Malignant and Palliative Wounds – an Article Review

Updated 3/2017-- photos and all links (except to my own posts) removed as many are no longer active and it was easier than checking each one.

Wounds in palliative care patients may be related to their underlying malignancy or to skin breakdown (poor nutrition, advanced age, poor perfusion, etc).  Wounds and associated skin changes that develop in palliative patients are generally considered as nonhealable. 

Therefore, the goal is refocused in an attempt to reduce emotional distress to patients and their families as well as reduction of  local physical wound issues.  The article defines these issues using the mnemonic HOPES:    Hemorrhage, Odor, Pain, Exudate, and Superficial infection.

The article reminds us that malignant wounds (due to cutaneous mets) have been estimated to affect 5% to 19% of patients with metastatic disease.  The chest, breasts, and the head and neck, followed by the abdomen, are the most common sites for these metastatic malignant wounds.

Regardless of the cause, if the wound has been determined to be a non-healable wound, then the goals remain as above—reduce the patients emotional distress and address the “HOPES.”

H: Hemorrhage (or bleeding)
May be due to granulation tissue or to tumor erosion into a blood vessel. 

For minor bleeding, agents such as calcium alginates are readily available as a wound dressing. Calcium, as part of the alginate, is released into the wound in exchange for sodium, potentially triggering the coagulation cascade. The sodium alginate then converts the fiber to a hydrogel, promoting local comfort and protection. In severe cases, suturing a proximal vessel, intravascular embolization, laser treatment, cryotherapy, radiotherapy, and electrical cauterization may be necessary.

O: Odor

Unpleasant odor and putrid discharge are associated with increased bacterial burden, particularly involving anaerobic and certain Gram-negative (eg, Pseudomonas) organisms.  

Topical application of metronidazole is readily available as a gel and cream. ….. Some patients derive the greatest benefit if the metronidazole is administered orally.

Activated charcoal dressing has been used to control odor with some success. To ensure optimal performance of charcoal dressing, edges should be sealed, and the contact layer should be kept dry.

If topical treatment is not successful or practical, putting odor-absorbing agents such as kitty litter or baking soda (not charcoal; only works as a filter) beneath the bed may reduce odor.

P: Pain

Pain is frequently experienced during dressing changes. 

Careful selection of dressings with atraumatic and nonadherent interfaces, such as silicone, has been documented to limit skin damage/trauma with dressing removal and minimize pain at dressing changes.

In addition to the choices of dressing supplies, when possible the frequency of dressings can be reduced.  Gentle technique can also reduce the pain of dressing changes.

For severe pain, clinicians may need to consider oral agents combining long-acting narcotics (oral, patch), as outlined in the World Health Organization Pain Ladder, with adjunctive agents for the neuropathic component and short-acting agents for breakthrough. In resistant cases, clinicians may consider using general anaesthesia, local neural blockade, spinal analgesia, or general anesthesia or using mixed nitrous oxide and oxygen

E: Exudate

Exudation is promoted by inflammation that may be associated with infection. Excessive moisture creates an ideal wound environment for bacteria to proliferate, especially when the host defense is compromised.

Moisture is contraindicated in nonhealable wounds; hydrating gels and moisture-retentive dressings (hydrocolloids) should be avoided. 

To contain and remove excess exudate from the wound, a plethora of absorbent dressings has been developed. Major categories of dressings include foams, alginates, and hydrofibers, along with superabsorbent products based on diaper technology

S:  Superficial infection

All chronic wounds contain bacteria:  contamination or colonization.   Preventing infections is important for palliative care patients.

Debridement is a crucial step to remove devitalized tissue, such as firm eschar or sloughy material, which serves as growth media for bacteria. …….

Topical antimicrobial products are available, but no one product is indicated or suitable for all patients…….

In nonhealable wounds where bacterial burden was more of a concern than tissue toxicity, antiseptics including povidone-iodine, chlorhexidine, and their derivatives are propitious treatment options (Table 5).

Other topical antimicrobial agents are summarized in Table 6. If the infection is promulgated systemically, systemic agents must be administered. Prophylactic use of antibiotics has not been demonstrated to facilitate wound healing.

REFERENCE
Local Wound Care for Malignant and Palliative Wounds; Woo, Kevin Y., Sibbald, R.Gary; Advances in Skin & Wound Care. 23(9):417-428, September 2010

Care of Pressure Ulcers in Palliative Care Patients

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one.

I’d like to recommend this article (full reference below) to anyone involved in the care of palliative care patients, as well as anyone who does wound care.  It is a thoughtful and well written consensus paper from the National Pressure Ulcer Advisory Panel.

The article begins by pointing out the difference in goals between palliative care patients and the usual patients with pressure ulcers (PrU).

Usual care of a PrU is designed to promote healing; however, healing or closing the ulcer in patients receiving palliative care is often improbable. Therefore, the focus of care is better directed to reduce or eliminate pain, odor, and infection and allow for an environment that can promote ulcer closure, as well as improve self-image to help prevent social isolation.

 

There is a significant risk of PrUs in terminally ill patients.   Many develop Stage III and IV PrUs.  Advanced age, malnutrition, immobility, friction and shear forces, and increased exposure to moisture (ie incontinence, diarrhea, etc) are common.

In 1 study, the majority of PrUs in a hospice sample occurred in the 2 weeks before death,  not unexpected as body systems physiologically begin to shut down 10 to 14 days prior to death.

For individuals who are actively dying, prevention and treatment of a PrU should be superseded by comfort needs.  This means that if it is too painful to be turned and repositioned, then those preventive activities are minimized in an effort to give comfort/pain relief.

 

Pressure ulcers are often unpleasant smelling wounds due to the bacteria that thrive on the wound exudates and  devitalized tissue.  We’ve agreed that it is not likely we will heal the PrU in pallitive care patients, so what can we do to decrease the smell?  The paper has these recommendations to control wound odor:

Cleanse the ulcer and periwound tissue, using care to remove devitalized tissue.

Assess the individual and the ulcer, with a focus on comorbid conditions, nutritional status, cause of ulcer, presence of necrotic tissue, presence and type of exudates and odor, psychosocial implications, and so on.

Assess the ulcer for signs of wound infection: increasing pain; friable, edematous, pale dusky granulation tissue; foul odor and wound breakdown; pocketing at base; or delayed healing.

Use antimicrobial agents as appropriate to control known infection and suspected critical colonization.

Consider use of properly diluted antiseptic solutions for limited periods of time to control odor.

Consider use of topical metronidazole to effectively control PrU odor associated with anaerobic bacteria and protozoal infections.

Consider use of dressings impregnated with antimicrobial agents (eg, silver, cadexomer iodine, medical-grade honey) to help control bacterial burden and odor.

Consider use of charcoal or activated charcoal dressings to help control odor.

Consider use of external odor absorbers for the room (eg, activated charcoal, kitty litter, vinegar, vanilla, coffee beans, burning candle, potpourri).

 

The article list these products and dressings as odor-controlling:

Metronidazole,  an antimicrobial agent effective against anaerobic bacteria and protozoal infections such as Trichomonas. Topical metronidazole gel (0.75%-0.80%) is frequently used directly on the wound once per day for 5 to 7 days or more often as needed.  Metronidazole tablets can be crushed and placed onto the ulcer bed.

Cadexomer Iodine, an antiseptic that allows for low-concentration release of iodine over time and promotes an acid pH that enhances the antimicrobial action of the iodine.  

Charcoal -impregnated dressings have been found to minimize wound odor. Activated charcoal attracts and binds wound odor molecules.

Dakin Solution. Odor can also be controlled using Dakin solution 0.25% (sodium hypochlorite) saturated onto gauze packing and placed into the ulcer.  Dakin solution produces its own odor and can be irritating to the respiratory system, especially if the patient is in isolation or rooms with limited ventilation. Dakin solution may cause some pain in the wound when used.

Povidone Iodine. Odor can also be controlled using povidone solution.

Silver Dressings. Silver dressings are effective in countering some infections in the wounds and thereby controlling odor.

Other Odor-Control Methods. To control odor in the room, kitty litter can be placed under the bed. Vinegar, vanilla, coffee beans, or a candle in the room are also helpful in controlling odors.   External odor absorbers in the room are effective but, at times, the smells they create can be overwhelming themselves.

 

 

 

 

 

REFERENCE

Pressure Ulcers in Individuals Receiving Palliative Care: A National Pressure Ulcer Advisory Panel White Paper(C); Advances in Skin & Wound Care. 23(2):59-72, February 2010; Langemo, Diane K.; Black, Joyce; and the National Pressure Ulcer Advisory Panel