Breaking Up: Ending Comfortable Relationships with Standard Treatments

Gauze and Chicken Divan have some commonalities: both are easy, quick, inexpensive, and have French connections-- which somehow makes both seem perhaps better than they really are. But both Chicken Divan and gauze may be too easy and as such, create an unwillingness to try something new.

It was the Ancient Egyptians and Greeks who first used woven fabric as bandages for wounds thousands of years ago. However, the continued use of gauze is far more based on tradition than on its functionality. Ancient Egyptians were familiar with the classic signs of infection; however, it was not until the nineteenth century work of Louis Pasteur and Robert Koch that the link was made between infection and specific pathogenic microbes. Then, it wasn’t until the 1978 work of JW Costerton that the biofilm paradigm was discovered, named, and defined by this pioneer.  Ongoing research is now showing that effective treatment of a chronic wound requires aggressive treatment of biofilm.

The French connection comes from the French word “gaze” which means gauze and is linked to the concept of gazing through a gauze veil. It is this lattice work which allows bacteria to penetrate up to 60 layers of gauze. Further the gauze itself is a breeding ground for bacteria, allowing maturation of biofilm within access of host nutrition but above and separated from action of host immunity. Bacteria can be up to 1000 times more tolerant to antimicrobial treatment than planktonic/free floating microorganisms. The recalcitrance of biofilm cannot be effectively addressed by a simple gauze sponge therefore more advanced modalities must be added to routine treatment options. 

When it comes to topical wound and post op incisional management, gauze is used far too often. It is no longer considered the standard of care as a primary wound dressing. So why does it remain the go-to, top drawer tool for wound care providers? A simple answer is that wound care is not taught routinely in medical and nursing schools. Therefore, many providers are not aware that the science and practice has advanced to more sophisticated wound dressings which treat patients more effectively. There are times when gauze is exactly the right option. However, It can also be labor intensive, require ongoing monitoring and frequent change, can be painful to remove, can leave pieces behind in the wound, and increases the bacteria and bioburden in the wound area.

There are thousands of other options available and there are multiple options for each stage of wound healing. Some kill bacteria-causing infection and include antimicrobial agents. Others have electronic sensors that can indicate changes in the wound as it heals. Some are skin substitutes, others are regenerative material. These can decrease healing time, be cost effective, and improve a patient’s quality of life.

The current challenge is in selecting from among these myriad options. The acronyms NERDS & STONEES help with that determination. NERDS for Non-Healing, Exudate, Red Friable Tissue, Debris/Discoloration, and Smell; STONEES for Size Increasing, Temperature Elevation, OS (probe to bone), New Breakdown, Erythema/Edema, Exudate, and Smell. Is it topical? Or is systemic treatment necessary? Each wound requires careful assessment to determine proper care.

Like medicine and wound care, treatment options evolve and improve. Gauze, like Chicken Divan, is likely to remain an option in the arsenal of wound care. But like other recipes, it is no longer the only choice and wound care must continue to provide the highest level of evidence-based care to patients.
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