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A comparison of the use of polythene sheet and Jelone® as temporary dressings for excised wounds
British JournalofPIastic Surgery (1991), 44,612-614 0 1991 The Trustees of British Association of Plastic Surgeons
A comparison of the use of polythene sheet and Jelonet@ as temporary dressings for excised wounds V. Lees, S. Ilyas and C. D. Reid Department of Plastic Surgery, Frenchay Hospital, Frenchay, Bristol SUMMARY. This paper reports our experience of the use of polythene sheet as a temporary dressing for excised wounds. A prospective randomised double-blind trial was conducted to see whether or not polythene dressing was less painful to remove than our traditional dressing of Jelonet?. Polythene was found to be less painful (p < 0.01). Other advantages of the use of polythene are presented.
Considerable attention has been focused of late on reducing the pain associated with surgical procedures (Royal College of Surgeons of England, 1990). A number of studies have addressed the problem of painful dressings with most attention being directed towards the donor sites of split skin grafts (Townsend, 1976; Birdsell et al., 1979; Attwood, 1989; Owen and Dye, 1990). We had observed that patients suffered considerable pain when our traditional Jelonet@ dressing was removed from an excised wound. Polythene sheet is nonadherent and is impermeable to body fluids and could thus be anticipated to provide a moist wound environment. It had been our clinical impression that removal of a polythene dressing prior to delayed grafting was considerably less painful than removal of Jelonet’@dressing. In this study it was our intention to investigate whether or not patients experienced less pain with polythene dressing and this was done by means of a prospective randomised double-blind trial. Other nonadherent temporary wound dressings include calcium alginate dressings in the form of Kaltostat T and Sorbsan T whose use has been reported to facilitate pain-free dressing removal (Kelly et al., 1988). Aluminium foil has also been successfully used as a painless nonadherent dressing (Poole et al., 1979). We were not further concerned with these other dressings in the present study.
Patients were randomised at the time of surgery by drawing a sealed envelope allocating the patient to one of two groups. Group 1 had Jelonet@ dressing following the excision of lesion. Six layers of Jelonet@ were cut to overlap the defect and the whole wrapped around with three layers of broadstrip dressing gauze and crepe bandage. The purpose of using six layers of the Jelonet@ was to ensure preservation of a moist wound environment, this being the traditional practice in our unit. Group 2 patients had their wounds dressed with a single layer of polythene sheet cut to overlap the defect by l-2 cm and secured in position with adhesive tapes. Perforations were cut in the polythene to allow drainage of blood and serous fluid (Fig. 1).
Materials and methods The comparison of Jelone$ and polythene dressings was made as a prospective randomised double-blind trial of 20 consecutive patients. Polythene dressing was prepared by the hospital TSSU who obtained commercial polythene bags (Transatlantic Plastics) which were then single wrapped and sterilised by gamma irradiation. Patients between the ages of 18 and 75 who were to undergo wide excision of a benign or malignant limb lesion 24.0 cm and < 15.0 cm with delayed application of split skin graft were recruited to the trial,
Fig. 1 Figure l-Application lower limb.
612
of polythene
to an excised
wound
of the
A Comparison of the Use of Polythene Sheet and Jelonet@asTemporary Dressings for Excised Wounds The leg was wrapped around, as before, with three layers of broadstrip dressing gauze and a crepe bandage. All donor sites were dressed in standard fashion with Jelonet@, Surgipad and crepe bandage. Operations were performed either under local infiltration anaesthesia using lignocaine with adrenaline or general anaesthesia, but not with regional block. Postoperative analgesia consisted of one or two doses of intramuscular omnopon on the day of operation with co-dydramol tablets as an alternative where opiates were not required. No analgesia was given on the day of dressing change unless the patient specifically requested it. A record was made of all drugs administered. Skin graft was applied on the day following operation. Nursing staff performed removal of dressing and application of skin. Entonox was administered at the bed side to those patients who required analgesia. The administration of Entonox, where used, was recorded. The patient then answered a questionnaire on the pain he or she had experienced during the dressing change. The questionnaire was administered by an assessor who was a member of nursing staff not aware of the nature of the dressing. The assessment consisted of (a) a modified visual analogue scale modified after Melzack (1975), and (b) a list of words describing pain intensity from which one term was selected.
Results A formal assessment was made of the pain experienced by the patients during the first dressing change with the application of skin graft. On the linear visual analogue scale (the left extreme of the scale denoting no pain and the right extreme of
the scale denoting intolerable and excruciating pain) patients in the Jelonet@ group scored a mean of 4.45 (range 1.1-9.2), while patients in the polythene group scored a mean of 0.98 (range O-3.1). These results are significant to ~~0.01 (Mann-Whitney U test for determination of significance). The assessment in which patients were asked to choose the term which best described their pain showed a modal choice for the Jelonet@ group of “Severe” and a modal choice for the polythene group of “No pain” (Fig. 2). Assessment of the comparability of the two groups showed they were similar in terms of the age and sex of the patients, size of the excised defect, anaesthetic agents administered and postoperative analgesia on a weight/kg basis. Analgesia was not routinely given immediately prior to dressing change but all patients were offered Entonox. Four patients in the Jelonet* group and three patients in the polythene group used Entonox.
Discussion The purpose of this study was to assess the usefulness of polythene as a temporary dressing for excised wounds prior to the application of split skin graft. Our analysis confirms our previous clinical impression that the patients experience considerably less pain at the time of dressing change, as compared to our traditional Jelonet@dressing. Nursing staff have been enthusiastic about the improvement which this constitutes for the patient. They have also pointed out that the time required to perform a dressing change can be considerably less with a polythene dressing. Jelonet@ dressings can take up to 1 hour to remove when stuck to the wound, and traumatic removal of the Jelonet@ can induce wound bed bleeding which further delays
‘of.
-I-
9
8 +
.
MILD
MODERATE
SEVERE
Quality of pain experienced IZl~0Lmim~
t2 JEL~N~
Fig.2 FigureZ-Ratings of pain intensityby choice from a word list.
613
V. SEVERE INTOLERABLE
British Journal of Plastic Surgery
614 the application of a skin graft. These problems are avoided with polythene. In addition to the cases we have reported we have used polythene on other open wounds (where closure/ cover is by delayed grafting) e.g. free flaps, fasciotomy incisions, large excised wounds of the head, neck and trunk, and traumatic wounds, with similarly favourabie results. The use of transparent polythene facilitates inspection of wound beds/muscle flaps without repeated handling etc. Polythene dressing is cost effective, adding less than El to the cost of the procedure, and this is probably more than offset by reductions in use of nursing time and costs of analgesics. This dressing is considerably cheaper than commercially available nonadherent dressings.
Owen, T. D. and Dye, D. (1990). The value of topical lignocaine gel in pain relief on skin graft donor sites. British Journal ofHastic Surgery, 43,480. Poole, M. D., Kahs, A. M. and van Domarw, H. (1979). Aluminium foil as a wound dressing. British Journal of Plastic Surgery, 32, 14s _ ._.
Report of the Work&g Party on Pain after Surgery. The Royal Colleee of Smwoos of EmzIand~(19901. Ed: Commission on Pro&ion of SuTgical Servic&. The‘Royal College of Surgeons of England, pp. l-8. Towasead, P. L. G. (1976). The quest for a cheap and painless donor site dressing. Burns, 2,82.
Acknowledgements Consultant Staff of Frenchay Hospital for allowing their patients to be entered into the trial. Nursing staff for their help and cooperation. Mr S. Joumeaux for assistance in data collection.
The Authors References AtWood, A. I.(1989). Calcium alginate dressing accelerates split skin graft donor site healing. British Journal of Plastic Surgery, 42, 373. Birdsell, D. C., Heia, K. S. aad Liadsay, R. L. (1979). The theoretically ideal donor site dressing. Annals ofPlastic Surgery, 2,535. Kelly, S. A., Dickson, M. G. aad Shape, D. T. (1988). Calcium alginate as a temporary dressing prior to the delayed application of split skin grafts (letter). British Journal of Pfastic Surgery, 41, 445. Mehck, R. (1975). The McGill Pain Questionnaire: Major properties and scoring methods. Pain, 1,277.
Viviea Lees, MA, FRCS, Burghard Research Fellow, Royal College of Surgeons of England;.Honorary Registrar, Department of Plastic Suraerv. Addenbreoke’s Hospital, Cambridge. (Formerlv Senior House Officer in Plastic Surgery,‘ Departm&t of Pla& Surgery, Frenchay Hospital). Sayed Ilyas, MS, MCk, Senior House Officer in Plastic Surgery. Clive D. Reid, FRCS (Glass), Consultant Plastic Surgeon. Department of Plastic Surgery, Frenchay Hospital, Frenchay, BristolBS16 ILE. Requests for reprints to Mr C. D. Reid. Paper received 12 April 199I. Accepted 7 June 1991 after revision.
A comparison of the use of polythene sheet and Jelonet@ as temporary dressings for excised wounds V. Lees, S. Ilyas and C. D. Reid Department of Plastic Surgery, Frenchay Hospital, Frenchay, Bristol SUMMARY. This paper reports our experience of the use of polythene sheet as a temporary dressing for excised wounds. A prospective randomised double-blind trial was conducted to see whether or not polythene dressing was less painful to remove than our traditional dressing of Jelonet?. Polythene was found to be less painful (p < 0.01). Other advantages of the use of polythene are presented.
Considerable attention has been focused of late on reducing the pain associated with surgical procedures (Royal College of Surgeons of England, 1990). A number of studies have addressed the problem of painful dressings with most attention being directed towards the donor sites of split skin grafts (Townsend, 1976; Birdsell et al., 1979; Attwood, 1989; Owen and Dye, 1990). We had observed that patients suffered considerable pain when our traditional Jelonet@ dressing was removed from an excised wound. Polythene sheet is nonadherent and is impermeable to body fluids and could thus be anticipated to provide a moist wound environment. It had been our clinical impression that removal of a polythene dressing prior to delayed grafting was considerably less painful than removal of Jelonet’@dressing. In this study it was our intention to investigate whether or not patients experienced less pain with polythene dressing and this was done by means of a prospective randomised double-blind trial. Other nonadherent temporary wound dressings include calcium alginate dressings in the form of Kaltostat T and Sorbsan T whose use has been reported to facilitate pain-free dressing removal (Kelly et al., 1988). Aluminium foil has also been successfully used as a painless nonadherent dressing (Poole et al., 1979). We were not further concerned with these other dressings in the present study.
Patients were randomised at the time of surgery by drawing a sealed envelope allocating the patient to one of two groups. Group 1 had Jelonet@ dressing following the excision of lesion. Six layers of Jelonet@ were cut to overlap the defect and the whole wrapped around with three layers of broadstrip dressing gauze and crepe bandage. The purpose of using six layers of the Jelonet@ was to ensure preservation of a moist wound environment, this being the traditional practice in our unit. Group 2 patients had their wounds dressed with a single layer of polythene sheet cut to overlap the defect by l-2 cm and secured in position with adhesive tapes. Perforations were cut in the polythene to allow drainage of blood and serous fluid (Fig. 1).
Materials and methods The comparison of Jelone$ and polythene dressings was made as a prospective randomised double-blind trial of 20 consecutive patients. Polythene dressing was prepared by the hospital TSSU who obtained commercial polythene bags (Transatlantic Plastics) which were then single wrapped and sterilised by gamma irradiation. Patients between the ages of 18 and 75 who were to undergo wide excision of a benign or malignant limb lesion 24.0 cm and < 15.0 cm with delayed application of split skin graft were recruited to the trial,
Fig. 1 Figure l-Application lower limb.
612
of polythene
to an excised
wound
of the
A Comparison of the Use of Polythene Sheet and Jelonet@asTemporary Dressings for Excised Wounds The leg was wrapped around, as before, with three layers of broadstrip dressing gauze and a crepe bandage. All donor sites were dressed in standard fashion with Jelonet@, Surgipad and crepe bandage. Operations were performed either under local infiltration anaesthesia using lignocaine with adrenaline or general anaesthesia, but not with regional block. Postoperative analgesia consisted of one or two doses of intramuscular omnopon on the day of operation with co-dydramol tablets as an alternative where opiates were not required. No analgesia was given on the day of dressing change unless the patient specifically requested it. A record was made of all drugs administered. Skin graft was applied on the day following operation. Nursing staff performed removal of dressing and application of skin. Entonox was administered at the bed side to those patients who required analgesia. The administration of Entonox, where used, was recorded. The patient then answered a questionnaire on the pain he or she had experienced during the dressing change. The questionnaire was administered by an assessor who was a member of nursing staff not aware of the nature of the dressing. The assessment consisted of (a) a modified visual analogue scale modified after Melzack (1975), and (b) a list of words describing pain intensity from which one term was selected.
Results A formal assessment was made of the pain experienced by the patients during the first dressing change with the application of skin graft. On the linear visual analogue scale (the left extreme of the scale denoting no pain and the right extreme of
the scale denoting intolerable and excruciating pain) patients in the Jelonet@ group scored a mean of 4.45 (range 1.1-9.2), while patients in the polythene group scored a mean of 0.98 (range O-3.1). These results are significant to ~~0.01 (Mann-Whitney U test for determination of significance). The assessment in which patients were asked to choose the term which best described their pain showed a modal choice for the Jelonet@ group of “Severe” and a modal choice for the polythene group of “No pain” (Fig. 2). Assessment of the comparability of the two groups showed they were similar in terms of the age and sex of the patients, size of the excised defect, anaesthetic agents administered and postoperative analgesia on a weight/kg basis. Analgesia was not routinely given immediately prior to dressing change but all patients were offered Entonox. Four patients in the Jelonet* group and three patients in the polythene group used Entonox.
Discussion The purpose of this study was to assess the usefulness of polythene as a temporary dressing for excised wounds prior to the application of split skin graft. Our analysis confirms our previous clinical impression that the patients experience considerably less pain at the time of dressing change, as compared to our traditional Jelonet@dressing. Nursing staff have been enthusiastic about the improvement which this constitutes for the patient. They have also pointed out that the time required to perform a dressing change can be considerably less with a polythene dressing. Jelonet@ dressings can take up to 1 hour to remove when stuck to the wound, and traumatic removal of the Jelonet@ can induce wound bed bleeding which further delays
‘of.
-I-
9
8 +
.
MILD
MODERATE
SEVERE
Quality of pain experienced IZl~0Lmim~
t2 JEL~N~
Fig.2 FigureZ-Ratings of pain intensityby choice from a word list.
613
V. SEVERE INTOLERABLE
British Journal of Plastic Surgery
614 the application of a skin graft. These problems are avoided with polythene. In addition to the cases we have reported we have used polythene on other open wounds (where closure/ cover is by delayed grafting) e.g. free flaps, fasciotomy incisions, large excised wounds of the head, neck and trunk, and traumatic wounds, with similarly favourabie results. The use of transparent polythene facilitates inspection of wound beds/muscle flaps without repeated handling etc. Polythene dressing is cost effective, adding less than El to the cost of the procedure, and this is probably more than offset by reductions in use of nursing time and costs of analgesics. This dressing is considerably cheaper than commercially available nonadherent dressings.
Owen, T. D. and Dye, D. (1990). The value of topical lignocaine gel in pain relief on skin graft donor sites. British Journal ofHastic Surgery, 43,480. Poole, M. D., Kahs, A. M. and van Domarw, H. (1979). Aluminium foil as a wound dressing. British Journal of Plastic Surgery, 32, 14s _ ._.
Report of the Work&g Party on Pain after Surgery. The Royal Colleee of Smwoos of EmzIand~(19901. Ed: Commission on Pro&ion of SuTgical Servic&. The‘Royal College of Surgeons of England, pp. l-8. Towasead, P. L. G. (1976). The quest for a cheap and painless donor site dressing. Burns, 2,82.
Acknowledgements Consultant Staff of Frenchay Hospital for allowing their patients to be entered into the trial. Nursing staff for their help and cooperation. Mr S. Joumeaux for assistance in data collection.
The Authors References AtWood, A. I.(1989). Calcium alginate dressing accelerates split skin graft donor site healing. British Journal of Plastic Surgery, 42, 373. Birdsell, D. C., Heia, K. S. aad Liadsay, R. L. (1979). The theoretically ideal donor site dressing. Annals ofPlastic Surgery, 2,535. Kelly, S. A., Dickson, M. G. aad Shape, D. T. (1988). Calcium alginate as a temporary dressing prior to the delayed application of split skin grafts (letter). British Journal of Pfastic Surgery, 41, 445. Mehck, R. (1975). The McGill Pain Questionnaire: Major properties and scoring methods. Pain, 1,277.
Viviea Lees, MA, FRCS, Burghard Research Fellow, Royal College of Surgeons of England;.Honorary Registrar, Department of Plastic Suraerv. Addenbreoke’s Hospital, Cambridge. (Formerlv Senior House Officer in Plastic Surgery,‘ Departm&t of Pla& Surgery, Frenchay Hospital). Sayed Ilyas, MS, MCk, Senior House Officer in Plastic Surgery. Clive D. Reid, FRCS (Glass), Consultant Plastic Surgeon. Department of Plastic Surgery, Frenchay Hospital, Frenchay, BristolBS16 ILE. Requests for reprints to Mr C. D. Reid. Paper received 12 April 199I. Accepted 7 June 1991 after revision.