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Alginates and Hydrofibers

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This paper is aimed at reviewing the paper, “Randomised clinical trial comparing hydrofiber and alginate dressings post-hip replacement” by Ravnskog et al.(2011). It was published in the journal of wound care. Ample background information justified the need for the study. Wounds linked to implants form good breeding environments for microorganisms and hence wounds should be dressed properly.  Moreover, inappropriate dressing can lead to infection, persistent leaking and blistering. These blisters have been shown to cause delayed hospital stays, deep and superficial infection. It is therefore important to carry out a study to establish the most effective dressing.

Hydrofiber and alginate are variants of modern dressings and trial have been conducted to compare their efficacy to conventional dressings in form of gauze and pads. The findings support the superiority of modern dressings as wound healing is possible in an environment that is moist.  However, the researchers have not cited any sources to support the findings.  The researchers have also stated that some research studies have proven the efficacy of hydrofiber over alginate dressings. The latter afford patients more comfort in terms of less pain during removal, less adherence to the wound and easy application as well as removal. It is interesting that a separate trial established that there is no significant difference with regard to wound complications and patient comfort between pad and hydrofiber dressings. Another contradicting trial by Cutiplast and colleagues showed that hydrofiber dressings were superior to pad dressings. According to the study, hydrofiber dressings provided more patient comfort and blister care after patients underwent arthroplasty at the lower limb.  This literature review is wanting as the sample size of trial participants is not given. A large sample size would increase the reliability of the results. As it stands, it’s difficult to authenticate the research findings.  The authors should have stated the databases used for the study’s literature review. There is need to utilize studies from peer reviewed journals. 

The studies cited in the study’s background information do not provide conclusive evidence on the efficacy of modern dressings over conventional dressings. The researchers have presented contradicting studies on the efficacy of modern dressings versus conventional dressings.  Thus it’s hard to justify the use of modern dressings as there is no conclusive study proving their superiority. Modern dressings are more expensive than conventional dressings. Hence a study proving the efficacy was timely so as to vouch for their use.

Following the limited evidence based research on modern dressings, the researchers carried out a small-scale exploratory research before the main study. They studied the adverse effects in wound care following application of conventional dressing covered with fabric that was self adhesive. This was after patients had undergone hip arthroplasty. The wound infection rate was at a low of 0.4% but the rate of blister and skin injury was 42%.  Following the application of alginate dressings, the blister injury rate fell to 15%, and hence patient comfort.

The researchers received reports on the efficacy of hydrofiber dressings over alginate dressings. However, no trial had been conducted to compare the efficacy of hydrofiber dressings versus that of alginate dressings. This search was conducted on credible databases with peer reviewed journals. The databases included: British Nursing, Clinical Evidence, Cochrane, PubMed, Medline, Embase and Google scholar. Lack of evidence prompted the randomized clinical trial to investigate the efficacy of alginate dressings versus that of hydrofiber dressings. They formulated a null hypothesis, “there is no significant difference in skin status or wound complications following the use of either alginate or hydrofiber dressing.” This would be tested via quantitative statistic tests.

The sampling was purposive and the inclusion criteria used was appropriate. The study sought to recruit patients who had undergone hip arthroplasty. The research centre was the orthopedic hospital at Norway. Patients who had undergone primary hip arthroplasty in 2008 were eligible for the study. Ethical considerations were given due regard during the recruitment of study participants.  The exclusion criterion was refusal to participate in the study. Subjects were recruited after obtaining prior and informed consent.  Participants were informed on the goal of the study and the treatments to be administered. Authorization and ethical clearance was given by the regional Norwegian Ethics Committee.

The recruitment was successful and 200 participants were recruited for the study.  The trial comprised of two groups and 100 participants were allocated to each group. One group was given the alginate dressing while the other group was given the hydrofiber dressing. The trial was successful as there was no drop out case. All participants faithfully underwent their respective treatment. During follow up, a total of 8 patients did not fill the evaluation form. However, the effect of this anomaly on the results is negligible as an adequate number of 192 patients filled the evaluation form. 

In the study, the researchers used randomization and blinding to protect against bias and to ensure the collection of objective results. Randomization was carried out by hospital nurses who randomly applied either alginate or hydrofiber dressing. This was after incision during the hip arthroplasty operation in the theater. Single blinding was undertaken and the participants were not aware of the type of dressing applied.  According to the researchers, double blinding was not possible as the researchers were well aware of the dressing types. The dressings were uniformly applied and covered with transparent polyurethane film to prevent contamination and to allow viewing. The operations were conducted by 15 surgeons and their competency was uniform as described by the researchers. Hence, the healing was not influenced by the surgical procedure. In addition, the suction drain sites were independent of the wounds. Hence, removal of dressings at the suction drain site did not disrupt the wound dressing.

The outcomes evaluated by clinical staff comprised of registered skin damage in form of blisters, skin injury and erythema. Photos of the wound dressing were taken after the dressing and observations were made to monitor the wound healing. Skin damage was defined using pressure ulcer classification as provided in the ICD (International Classification of Diseases).

Data was collected by nursing students and nurses who had been trained. Patients evaluated outcomes were recorded after removal of dressings. They were required to report discomfort, itching, pain and burning. Recordings of yes/no were made. Visual analogue scales (VAS) were utilized. 0=no problems and 10 represented unbearable problems.

Statistical analysis comprised of various tests. Chi-square, a non parametric test was appropriate since ordinal data had been collected for the patient evaluation outcomes. Other tests comprised of t-tests to test for mean values, fishers test for differences in categorical variables, and regression analyses. The Kaplan-Meier method was used to assess the unchanged dressing proportion in the two groups. Skin status was better in the alginate group as compared to the hydrofiber group (p= 0.02). The damaged skin area was larger than the alginate group (p=0.05). There was no statistical significant difference in early skin reaction between the alginate and hydrofiber groups (p= 0.7). The logistic regression model that showed that there was a significant difference in patients who had removed the dressings in the 2 groups (p=0.01). With regard to patient evaluated outcome, there was no significant difference in the mean scores for burning pain, discomfort, itching and pain between these two groups.  Overall, there was no correlation in the occurrence of pain and skin damage after dressing removal in the two groups (p= 0.1).

The trial did not establish a clear cut difference in the application of hydrofiber and alginate dressings. Overall, patient comfort was similar as both groups exhibited positive outcomes.  However, the alginate group exhibited less pain and better skin status upon dressing removal as compared to the hydrofiber group. The researchers have made comparison of the study results with those obtained from similar, relevant trials. A Finland trial reported 24% skin damage after applying hydrofiber dressings after arthroplasties. This conforms to the study findings. The trial’s blister rates are higher than in other two studies. However these other studies investigated both knee and hip arthroplasties. Knee blisters are known to be rare. The researchers recommended both dressing types. However, further research needs to be carried out to evaluate if there exists a difference in the use of either alginate or hydrofiber dressings.


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