… For example, some hydrocolloid and alginate dressings may result in wound drainage that mimics purulent exudate (Bates-Jensen & Ovington, 2007). 144 Table 7: Types of wound exudate (Cutting & White, 2002; Bates-Jensen et al, 2012; Wounds UK, 2013; Vowden et al, 2015) Type Colour/opacity Consistency Comments Serous Clear, amber Thin, watery ■ Normal during inflammatory and proliferative phases of healing or straw- ■ An increase in serous exudate may be a sign of infection coloured ■ In excessive amounts may be associated with congestive cardiac failure, venous disease, malnutrition or be due to fluid draining from a urinary or lymphatic fistula Serosanguineous Clear, pink to Thin, slightly ■ May be considered normal during inflammatory and proliferative phases light red thicker than of healing water ■ Pinkish due to the presence of red blood cells ■ May also be found post-operatively or after traumatic dressing removal Sanguineous Red Thin, watery ■ Reddish due to the presence of red blood cells ■ May indicate new blood vessel growth or disruption of blood vessels ■ May be associated with hypergranulation Seropurulent Cloudy, Thin ■ Serous exudate containing pus creamy, yellow ■ May also be due to liquefying necrotic tissue or tan ■ May signal impending infection Fibrinous Cloudy Thin, watery ■ Cloudy due to the presence of fibrin strands ■ May indicate inflammation, with or without infection Purulent Opaque, Often thick ■ Mainly pus (neutrophils, inflammatory cells, bacteria) and may include milky, yellow, slough/liquefied necrotic tissue tan or brown; ■ Indicates infection sometimes ■ Green colouration may be due to infection with Pseudomonas aeruginosa green ■ May be associated with odour Haemopurulent Reddish, milky, Thick ■ Mixture of blood and pus opaque ■ Often due to established infection Haemorrhagic Red, opaque Thick ■ Mostly due to the presence of red blood cells and indicative of increased capillary friability or trauma to the wound ■ May indicate bacterial infection 155 W O R L D U N I O N O F W O U N D H E A L I N G S O C I E T I E S CONSENSUS DOCUMENT Table 8: Clinical methods of assessment of wound exudate production Method Details Wound Extent of control Exudate amount Dressing requirement exudate score Wound Exudate Score 1 Full None/minimal No absorptive dressings required. … Patients/carers undertaking dressing changes will need to be educated about hand hygiene, cleansing and dressing change techniques, as well as dressing disposal. 184 Figure 3: Exudate management in the context of comprehensive and individualised wound management Comprehensive structured wound assessment Devise and document comprehensive wound management plan agreed with patient/carers • Short-term and long-term goals of treatment • Further investigations/specialist referrals • Planned interventions and rationale for each • Reassessment schedule Optimise patient Provide patient/ Management of the wound and the exudate condition and carer education quality of life • Reassure • Ensure psycho- • Explain rationale Manage factors Optimise wound bed Manage exudate to social support for goals of care contributing to and periwound skin achieve wound bed • Enhance nutrition • As appropriate, the wound and to moisture level • Optimise manage- explain moist abnormal exudate • Debride/cleanse appropriate for ment of comor- wound healing and quantity or as appropriate to treatment goals bidities, including mode of action of composition remove necrotic referring for additional treat- material and • Apply as appropri- specialist input as ment modalities, • See Table 5 slough ate: appropriate e.g. compression • Local factors – • Manage peri- • Dressing(s) • Address patient therapy, and risks e.g. infection or wound skin • Negative pres- concerns, includ- of non-compliance biofilm, venous problems – e.g. sure wound ing management • When and how to disease, sinus/ maceration, therapy (NPWT) of pain seek help fistula erosions • Fluid collection • For self care – • Systemic factors – devices – e.g. hand hygiene, e.g. cardiac failure ostomy/fistula cleansing, dressing • Practical factors appliances change technique, dressing disposal Prevent and treat other exudate-related problems • Leakage and soiling • Dressing adherence issues • Protein loss • Odour • Fluid and electrolyte imbalance Monitoring and reassessment of the patient and the wound Patient deteriorating and/or wound not Wound healed healed or deteriorating • Reassess • Implement preventative measures and • If the wound is not healing despite optimal management, follow up as appropriate consider second-line treatments 195 W O R L D U N I O N O F W O U N D H E A L I N G S O C I E T I E S CONSENSUS DOCUMENT EXUDATE The aims of exudate management are to: MANAGEMENT ■ Optimise wound bed moisture level as appropriate for the patient ■ Protect the surrounding skin ■ Manage symptoms and improve patient quality of life. … Table 11: Methods of wound debridement and desloughing (Strohal et al, 2013; Atkin, 2014; Percival & Suleman, 2015; Wounds UK, 2017) Type of Mode of action Comments debridement Autolytic/ ■ Devitalised tissues are ■ Aided by dressings that manage exudate or donate enzymatic softened and liquefied moisture to produce a moist wound environment by enzymes occurring ■ Can be used before or between other methods of naturally in the wound debridement ■ Slow, but ease of use may lead to overuse and delay more appropriate method of debridement Mechanical ■ A swab, cotton gauze, or ■ Easy to use monofilament pad is used ■ Patients can use for self-care under supervision on the wound surface to detach devitalised tissue Sharp ■ Devitalised tissue is ■ Quick and selective; useful on hard eschar removed using a scalpel, ■ Requires specialist training scissors and/or forceps Surgical ■ Non-viable tissue and ■ Useful for hard eschar and to debride large areas wound margins are ■ Requires specialist training and usually requires excised to achieve a anaesthesia and an operating theatre bleeding wound bed Larval ■ Green bottle fly larvae are ■ Reduces pain, bacteria and odour placed loose or bagged ■ Unsuitable for dry, excessively moist or malignant in the wound where they wounds, or wounds that communicate with a body ingest devitalised tissue cavity/organ and microbes ■ Patients may decline Ultrasonic ■ Ultrasound is used to ■ Quick break up devitalised tissue ■ Requires specialist training Hydrosurgical ■ A high-pressure jet of ■ Requires specialist training saline is used as a cutting implement 204 Figure 4: Wound bed Management of infection/biofilm moisture level A sudden increase in wound exudate and pain are indicative of wound infection. …