I have posted below a question we received on Wound Management, and the response by Wayne Naylor (author of the 'Wound Management in Cancer and Palliative Care' course on this site). All other responses / comments would be welcomed.
Question: "I have just been consulted about a fungating, cancerous wound on a man's lower back. Odor and heavy exudate are the main management options. Do you have any definitive answer about which product is the most absorbant. Also do you have any experience with irrigating with flagyl, or use of metrogel with a fungating wound? Charcol drsgs and aquacell are being used, as well as "kitty litter"
in the room."
Response: "Firstly, with regard to absorbent dressings, there are several options you can try, depending on availability and cost. For heavy exudate I would use one of the following approaches depending on other wound characteristics.
- Aquacel is a good dressing as it is very absorbent and is easy to remove from the wound, as it turns into a gel on contact with exudate or water/normal saline. This dressing will help with wound debridement as well. Alginates can also be good but are not as absorbent, however they do help with light surface bleeding.
- Foam dressings with or without another dressing underneath. For example Allevyn, Tielle Plus, Lyofoam Extra, Mepilex - there can be issues of surface contact with foam dressings, which may allow exudate to escape. I tend not to use foams on proliferative tumours that protrude above skin level.
- Non-adherent wound contact layer, Mepitel for example, a silicone coated net dressing from Molnlycke, covered with an absorbent pad. The Mepitel can be left on for several days and the outer dressing changed as needed, this makes it more cost effective. The pads I would choose to use are Mesorb (also from Molnlycke) as they have an impermeable backing, but standard combine/gamgee pads are also OK. I also occasionally use adult incontinence pads for very heavy exudate, as these pads are designed to absorb and retain a large volume of fluid, and they are quite cheap (compared to many dressings!).
- I also use EXU-DRY (Smith & Nephew), which is a burn dressing that is very absorbent and has a low-adherent layer, but also good for other wounds with heavy exudate.
- A good dressing for exudate and odour management is CarboFlex (ConvaTec), which combines good absorption with an activated charcoal dressing. It is limited by size though, the largest is 15x20cm (about 6"x8").
Overall, my preferred dressing is the Mepitel (or Mepilex Transfer) and a secondary pad. This dressing is comfortable and quite versatile to fit different wound shapes and locations. The Mepitel is designed to be atraumatic on removal so helps reduce wound pain and trauma, which leads to bleeding. I also use EXU-DRY quite a lot, as it comes in a good range of large dressing sizes. More often now I also use the incontinence pads.
Now, odour, a very tricky problem. There are again several approaches to this problem.
- If possible debride any necrotic tissue away, as this reduces the bacterial burden, the main cause of wound malodour. But do not attempt
surgical or sharp debridement unless there is very loose easily removed necrotic tissue, as these wounds tend to bleed very easily and not stop bleeding very easily! Autolytic debridement with appropriate dressing is the most common approach.
- Next I use topical Flagyl (metronidazole) in a gel formulation (0.75 to 0.8% W/W). This is my preference because it is made for application to open wounds. Other people use crushed tablets/oral solution in a gel carrier, such as a wound hydrogel, I also do this sometimes, but there is debate about using an oral formulation on an open wound, and also exposure of healthcare professionals to dust from crushing the tablets. That said, it still works. The use of IV Flagyl to irrigate the wound is not common practice, as you do not get a high enough concentration on the wound surface and not long enough exposure. I also use oral Flagyl to combat the malodour "from the inside out". This is particularly helpful for wounds with deep cavities or that extend into body cavities, such as the vagina, when you cannot apply topical gel easily. In order to prevent side-effects from the oral Flagyl I recommend a reduced dose, 200mg TDS (instead of the usual
- Activated charcoal dressings are also effective, so long as you have a good seal around the wound to prevent odour escaping from under the
dressing. I usually use these in combination with Flagyl gel, as the charcoal dressings get rid of the odour quite quickly while the Flagyl takes a couple of days to have an effect.
- I have heard of boxes of 'good quality' kitty litter or charcoal blocks being placed under patient's beds with mixed success. In theory they should work to attract odour molecules and get them out of the air, but I am not sure they work that well. Other options we sometimes use are aromatherapy oil diffusers. The citrus oils are most effective at hiding wound related odour (such as Bergamot, lemongrass etc - Bergamot is my favourite).
I hope this is of some help, please also consider registering for the online Wound Management in Cancer and Palliative Care course on CancerNursing.org if you have not already done so, as the course has a lot of information on managing fungating wounds."