Exudate Management with Dressings

In local wound management, dressings are the main option for managing exudate. Following an integrated exudate assessment, the clinician will decide whether there is a need to change or maintain the current dressing regimen.

Strategy for achieving the desired moist wound environment

AIM	STRATEGY
Increase moisture	Choose dressing type to add or conserve moisture Use thinner version of current dressing Decrease dressing frequency change
Maintain wound moisture	Continue with current dressing
Reduce wound moisture	Use thicker (more absorbent) version of current dressing Change dressing type to greater fluid handling capability Use or add higher absorbency secondary dressing Increase frequency of dressing change

There are a vast number of different absorbent dressings, mainly because one of the most difficult tasks in wound management is the containment of exudate (Beldon, 2010). A number of dressing types are suitable for exudate management. These various products handle fluid in different ways. Some simply absorb the fluid at the point of contact with the wound, while others spread it laterally (wicking), making full use of the dressing’s total size.

There are those that rely both on absorbency and evaporation, measured by moisture vapour transmission rate (MVTR), as well as dressings that absorb vertically with a reduced lateral wicking action. Some gel-forming dressings also trap exudate components and microorganisms (WUWHS, 2019).

The main categories of dressing to choose from for exudate management are alginates, Hydrofiber, gelling fibres, super absorbents and foams.

There are several ideals for a dressing when looking at exudate management that should be considered:

Available in a range of shapes and sizes across care settings
Easy to apply
Require a secondary dressing
Comfortable/reduces pain/does not cause pain on application
Conformable
Prevents leakage and strikethrough
Absorbs odour
Stays intact and remains in place during wear
Suitable for extended wear (based on clinical need)
Suitable fluid-handling capacity relative to the wound exudate level
Retains fluid-handling capacity under compression therapy or when used with an offloading device
Atraumatic and retains integrity on removal
Unlikely to cause sensitisation or to provoke an allergic reaction
Cosmetically acceptable and available in a range of colours to match the patient’s request
Does not impede physical activity
Patient can shower with the dressing in situ
Incorporates sensors/alerts to feedback on dressing performance, need for change and wound condition
Inactivates factors that enhance inflammation (Matrix metalloproteases MMPs)
Cost-effective – considering factors such as the unit cost of dressing versus time taken to change, the potential impact on healing by use of cheaper dressings, how to make the case to procurement

(WUWHS, 2019)

Assess Exudate Colour
Clear/straw coloured Considered normal Lymphatic/urinary fistula	Cloudy/milky/cream A response to inflammation Possible infection	Red/pink Postoperative Traumatic dressing removal Possible infection	Green/yellow Bacterial infection Pseudomonas aeruginosa	Yellow/brown Infection/ possible infection Liquefaction of necrotic/ sloughy tissue Possible infection

Assess Exudate Colour

Clear/straw coloured

Considered normal
Lymphatic/urinary fistula

Cloudy/milky/cream

A response to inflammation
Possible infection

Red/pink

Postoperative
Traumatic dressing removal
Possible infection

Green/yellow

Bacterial infection
Pseudomonas aeruginosa

Yellow/brown

Infection/ possible infection
Liquefaction of necrotic/ sloughy tissue
Possible infection

Thin and watery	Assess Exudate Viscosity	Thick and sometimes sticky
Low Protein content Chronic oedema Venous or cardiac disease Malnutrition Urinary, lymphatic or joint fistula	Assess exudate odour Remove necrotic tissue if clinically indicated Reduce bioburden and manage underlying infection Review frequency of dressing change Some dressings may produce a charecteristic odour	High protein content Infection and/or inflammatory process Necrotic material Enteric fistula
Dry No visible moisture Not an ideal wound healing environment May be ideal for ischaemic wounds (consider vascular referral) Consider hydrating eschar Consider potential dressing adherence Surrounding skin may be scaly, atrophic and hyper-keratotic	Moist An ideal wound healing environment Dressing may be lightly marked Wound bed could appear glossy Reduced dressing change frequency Surrounding skin may be intact and hydrated	Wet Dressing may be extensively marked Potential fragmented areas of maceration Consider appropriate periwound protection Select dressing with appropriate fluid handling properties	Saturated Free fluid is visible Primary dressing is wet and strike through may occur If exudate escapes and/or frequent dressing changes are required, use high fluid handling capacity dressing Risk of macerated/ denuded periwound skin Use appropriate periwound protection	Leaking Free fluid is visible Dressings are saturated with exudate leaking from primary and secondary dressings High risk of extensive periwound maceration Superabsorbant products are necessary Use appropriate periwound protection/NPWT

Thin and watery

Assess Exudate Viscosity

Thick and sometimes sticky

Low Protein content

Chronic oedema
Venous or cardiac disease
Malnutrition
Urinary, lymphatic or joint fistula

Assess exudate odour

Remove necrotic tissue if clinically indicated
Reduce bioburden and manage underlying infection
Review frequency of dressing change
Some dressings may produce a charecteristic odour

High protein content

Infection and/or inflammatory process
Necrotic material
Enteric fistula

Dry

No visible moisture
Not an ideal wound healing environment
May be ideal for ischaemic wounds (consider vascular referral)
Consider hydrating eschar
Consider potential dressing adherence
Surrounding skin may be scaly, atrophic and hyper-keratotic

Moist

An ideal wound healing environment
Dressing may be lightly marked
Wound bed could appear glossy
Reduced dressing change frequency
Surrounding skin may be intact and hydrated

Wet

Dressing may be extensively marked
Potential fragmented areas of maceration
Consider appropriate periwound protection
Select dressing with appropriate fluid handling properties

Saturated

Free fluid is visible
Primary dressing is wet and strike through may occur
If exudate escapes and/or frequent dressing changes are required, use high fluid handling capacity dressing
Risk of macerated/ denuded periwound skin
Use appropriate periwound protection

Leaking

Free fluid is visible
Dressings are saturated with exudate leaking from primary and secondary dressings
High risk of extensive periwound maceration
Superabsorbant products are necessary
Use appropriate periwound protection/NPWT

Dressing options
Film Hydrogel Hydrocolloid	Adhesive foam Non-adhesive foam Contact material Clear absorbant acrylic	Adhesive foam Non-adhesive foam Alginate/ gelling fibre Clear absorbent acrylic Skin protectant: barrier film/ cream	Adhesive foam Alginate/ gelling fibre Super absorbant dressing Skin protectant: barrier film/ cream	Super absorbant dressing NPWT Skin protectant: barrier film/ cream

Any alteration in exudate levels and characteristics may indicate a change in wound status and as such wound management should be reassessed as necessary. Adapted from Wounds UK, 2013; WUWHS, 2019