The Use of Cutimed Sorbact Ribbon to manage a complex infected orbital wound.
All wounds have some form of bacteria present although not all wounds are actively infected. It is those which are infected that can contribute to prolonged healing. With an increase in the use of topical antimicrobials there is an increasing concern with regards to antimicrobial resistance in patients with long term wounds (Cutting, 2011).
The patient in this evaluation is an 87 year old female who presented with an infiltrative extensive basosquamous cell carcinoma affecting the lateral canthus and invading her eye and surrounding tissues. The surgical team decided it was appropriate and necessary to remove the eye and perform a partial reconstruction of the socket with a combination of local flaps. The significant past medical history includes chronic kidney disease and hypertension, she is otherwise relatively fit and well.
She attended the dressing clinic one week post-operatively where the socket was moist and fragile. Due to the amount of exudate the wound was redressed with Aquacel Ag ribbon which was packed into the socket then an eye pad which was fixed with micropore tape. She attended the clinic three days later, at this point the wound was now heavily exuding and the flap was becoming macerated. She had positive swabs for Staphylococcus Aureus and was commenced on oral antibiotics at this stage.
The main issue with dressing this area was finding a primary dressing which would provide wound contact which was also non-adherent. Due to the complexity of the wound it was important to provide protection from infection longer term which was difficult. As this patient had a high exuding wound it also created the problem of adherence of the secondary dressing. The other issue with dressing this area is the practicality and the patient self image. This patient was concerned about not being able to wear her glasses as she required them for the other eye there for dressing had to be applied allowing her to do so. As the wound is on the face it was important for her not to have a bulky and obvious dressing in place so this was had to be taken into consideration also.
The aim for using this dressing regime was to help by treating infection, reduce exudate and prevent any further infection as exposed optic nerve evident.
Aquacel Ag ribbon was used for two weeks with minimal improvement and continued high level of exudate. The contributing factors of infection, location and the developed area of exposed optic nerve meant that treating and managing this wound became more of a challenge. This area is difficult to get dressings to stay in place generally however the contributing high exudate only added to the complexity.
The dressings were then changed onto Cutimed Sorbact ribbon at this stage with Cutimed Sorbion sachet multi star and skin tone micropore. The decision to do so was not taken lightly as the exudate was still the main problem and Cutimed Sorbact ribbon does not have the same absorbency as Aquacel. The Cutimed Sorbion sachet multi star was chosen as it was presumed that the Cutimed Sorbact Ribbon would not be able to manage the level of exudate produced by the wound. At this point it felt necessary to have a high absorbent dressing in place to cope with the exudates and lock it into the dressing to prevent visible strike through. The shape of the Cutimed Sorbion Sachet Multi Star was perfect to fold into the socket holding the primary dressing in place and preventing any bulk.
Cutimed Sorbact ribbon was used forfive weeks, as silver can only be used short term it was important to keep the wound free from bacteria and this was proving to be a long term wound. The bacteria binding action meant that this dressing could be used until it was no longer clinically required.
At the first dressing change the exudates levels had reduced drastically, previously the dressings were completely saturated which meant dressing changes three times a week, and occasionally more. The significant reduction in exudate meant that dressing changes could be reduced to twice per week. This change in exudate levels also impacted the secondary dressings, as there was not as much strike through it was possibleto change this to a smaller more comfortable option.
Within the five weeks of using Cutimed Sorbact ribbon the wound had dried out and optic nerve had granulated over and was no longer exposed, leaving only a superficial wound.
Discussion and Conclusion-
Cutimed Sorbact ribbon was an atraumatic dressing which tackled all bacteria in the wound causing a reduction in exudate which in turn meant that the frequency of dressing changes was reduced. The rapid reduction in the level of exudate meant that the period in which it took to get the wound healed was much quicker than expected.
As the optic nerve was exposed it was important to keep the area free from bacteria. Cutimed Sorbact ribbon meant that the wound could be kept free from infection and thus reduced the levels of exudate, in turn reducing the risk ofmaceration. The irreversible bacteria binding action means that the Cutimed Sorbact ribbon can be used for prolonged lengths of time and will not have an impact on toxicity to the healthy tissue resulting in effective use for infected wounds and prophylactic use (Probst et al, 2012) . Following the first course of antibiotics the patient did not require any further courses while the Cutimed Sorbact ribbon was in place. The conformability of the dressing meant that wound contact was almost guaranteed in the socket. Although the dressing was packed, the patient felt comfortable and unconcerned about exudate leakage or unsightly dressings.
Probst A, Norris R, Cutting KF. CutimedSorbactMade Easy. Wounds International 2012; 3(2)
Cutting, KF (2011) Catch or Kill? How DACC technology redefines antimicrobial management. BJN/BJCN