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UNIQUE THERAPIES FOR DIFFICULT WOUNDS | including undermined areas (Figures 1 through 3). It is important that the entire wound be filled with sugar because the wound’s osmolarity must remain high to effectively kill bacteria.2 3. Bandaging: The primary bandage layer should consist of an adherent contact layer (large amount ovÊÃÌiÀiliÊ>LÃoÀLinÌÊ}>ÕâiÊoÀÊl>«Êëon}iîÊFigure 4). A second layer should be used to hold the primary absorbent layer in place (Figure 5). This should be followed by a protective tertiary layer (Figure 6). 4. Bandage Changes: UÊ >n`>}iÃÊnii`ÊÌoÊLiÊVh>n}i`ÊvolloÜin}ÊWound Preparation steps 1 through 3) once to twice `>ilÞÊ`i«in`in}ÊonÊÌhiÊ>moÕnÌÊovÊiÝÕ`>ÌiÊ«Ào- duced or if strikethrough is found in the tertiary layer. UÊ vÊÌhiÊÃÕ}>ÀÊl>ÞiÀÊiÃÊÃ>ÌÕÀ>Ìi`]ÊL>n`>}iÊVh>n}iÃÊ need to take place more frequently. This is evi- dent when there is (1) a granular sanguinous layer and no sugar covering the wound or (2) a naked wound and complete absence of sugar. If either condition is present, perform bandage 6 PREVENTING TRANSMISSION OF BACTERIA WITHIN THE HOSPITAL 5P BWPJE TQSFBEJOH XPVOE CBDUFSJB HMPWFT IBUT GBDF TIJFMET BOE PS HPXOT TIPVME CF XPSO EVSJOH XPVOE MBWBHF *O BEEJUJPO BMM CBOEBHF NBUFSJBM SFNPWFE GSPN UIF QBUJFOU TIPVME CF QMBDFE JO B CJPIB[BSE SFDFQUBDMF Vh>n}iÃÊmoÀiÊ vÀiµÕinÌlÞÊÕnÌilÊ ÌhiÊÜoÕn`Ê iÝÕ- date diminishes. UÊ >À}iÊ >n`Ê inviVÌi`Ê ÜoÕn`ÃÊ >ÀiÊ i`im>ÌoÕÃÆÊ therefore, bandages for these wounds should be changed at least twice daily. These frequent ban- dage changes will help keep the osmolarity high within the wound. Severely infected wounds may take 5 or more days to become “clean.”2 UÊ ÃÊ }À>nÕl>ÌionÊ ÌiÃÃÕiÊ voÀmÃ]Ê ÌhiÊ vÀiµÕinVÞÊ ovÊ bandage changes may be decreased to once daily and eventually every other day. A general rule of thumb to follow is when white, dry, granulated sugar is still present, bandage changes can be less frequent. 5. Length of Treatment: Treatment with sugar should continue until pockets and undermined tissue are closed and debridement is complete. Presence of >Ê }À>nÕl>ÌionÊ Li`Ê >n`Ê i«iÌhili>liâ>ÌionÊ >ÀiÊ >lÃoÊ indicators that sugar treatment may be stopped (Figure 7).2 Once healthy granulation tissue is present, superficial infections are much less likely and a simple, nonadherent primary bandage layer can be used. Figure 6. A tertiary layer was applied to hold and protect the bandage. This layer must not be too tight. 7 Disadvantages Potential disadvantages of sugar bandages include: UÊ ivviVÕlÌÞÊinÊ>««lÞin}ÊÌhiÊ«Àim>ÀÞÊ>n`ÊÃiVon`>ÀÞÊ bandage layers to assure a 1-inch layer of sugar covers the entire wound. UÊ/hiÊ vÀiµÕinÌÊL>n`>}iÊ Vh>n}iÃÊ ÀiµÕiÀi`Ê voÀÊ ÌhiÃÊ mo`>liÌÞ°Ê nÊoÕÀÊiÝ«iÀiinViÊÃÕ}>ÀÊL>n`>}iÃÊnii`Ê to be changed more frequently than wet-to-dry L>n`>}iÃÊ `ÕiÊ ÌoÊ ÌhiÊ iÝÕ`>ÌiÛiÊ n>ÌÕÀiÊ ovÊ ÌhiÊ wounds and quickly saturating sugar layer. UÊ-Õ}>ÀÊL>n`>}iÃÊ loÃiÊÌhiiÀÊoÃmoÌiVÊ«ÕllÊonViÊ ÌhiÊ sugar starts dissolving, while wet-to-dry bandages wick away moisture and facilitate mechanical debridement. HONEY iÃÌoÀiV>lÊ `oVÕminÌ>ÌionÊ ÃÕ}}iÃÌÃÊ }Þ«Ìi>nÃÊ ÕÃi`Ê Figure 7. Preoperative picture of the metatarsal injury illustrating granulation, epithelialization, and lack of infection. This wound was successfully closed with a mesh graft. honey as a topical wound treatment for over 4000 years. Not until the past decade has interest in honey as an adjunct to wound therapy accelerated in medical practice. Honey has antibacterial activity and enhanc- iÃÊLoÌhÊ}À>nÕl>ÌionÊ>n`Êi«iÌhili>liâ>ÌionÊovÊÜoÕn`Ã°Ê July/August 2011 Today’s Veterinary Practice 13