Comprehensive wound malodor management: Win the RACE
ABSTRACTComplex wounds that give off a foul odor are common in various patient care settings. Wound malodor has grave effects, both physical and psychological, and its management presents a serious challenge for caregivers. Multiple factors and processes involved in malodor production need to be considered in designing a comprehensive treatment plan described by the acronym RACE: removal of necrotic tissue, antibacterials, odor concealers, and education and support. Improving quality of life is the outcome of winning the RACE against malodor.
KEY POINTS
- Necrotic tissue is a substrate for bacterial growth and should be debrided. A variety of methods can be used.
- Malodor is most often from infection with anaerobic organisms, which topical metronidazole and other agents can help control.
- An absorbent dressing should be used either as a primary dressing, or over a layer of topical metronidazole and a nonadherent primary dressing.
- Foremost in formulating a patient- and family-centered malodor management strategy is to commit to controlling it as much as possible.
MALODOR ASSESSMENT: DO YOU SMELL SOMETHING?
Various ways to document wound malodor can prove useful in guiding assessment and treatment. Descriptions such as “foul,” “putrid,” “fishy,” or “filled the room” vividly portray the initial presentation. A 10-point numerical scale similar to a numerical pain scale or a visual analogue scale can be used as a subjective measure.
Other grading methods, which to the authors’ knowledge are not validated, may be helpful. In a study that focused on patients suffering from malodorous gynecologic malignancies, von Gruenigen et al20 used a 0-to-3 scale:
- 0 Absent
- 1 Not offensive
- 2 Offensive but tolerable
- 3 Offensive and intolerable.
A scale often adapted by other authors was devised by Baker and Haig,21 which clearly defines four classes:
- 1 Strong—odor is evident upon entering the room (6 to 10 feet from the patient) with the dressing intact
- 2 Moderate—odor is evident upon entering the room with dressing removed
- 3 Slight—odor is evident at close proximity to the patient when the dressing is removed
- 4 No odor—no odor is evident, even at the patient’s bedside with the dressing removed.
COMPREHENSIVE MANAGEMENT: HOW DO WE WIN THE ‘RACE’?
The acronym RACE outlines an approach to dealing with malodor. It stands for removal of necrotic tissue; antibacterials; odor concealers; and education and support (Table 1).
Remove necrotic tissue
An important step in eliminating malodor is to remove necrotic tissue. This starts with debridement, which decreases the incidence of infection and hastens wound closure.22,23 Table 2 compares the different types of debridement.
Sharp or surgical debridement involves the use of a scalpel or scissors. This type of debridement may increase the risk of bleeding, pain, and malignant cell seeding in fungating wounds.4,24
Enzymatic debridement employs chemicals with proteolytic action (eg, collagenase) to digest extracellular proteins in wounds.18,25
Mechanical debridement involves aggressive therapies such as forceful irrigation and hydrotherapy, which may fail to discriminate between necrotic and viable tissues.18,26
Biological debridement using maggots, which ingest bacteria and devitalized tissue, may cause increased wound bleeding and may be unacceptable for patients and families.24,27
Autolytic debridement is often recommended, particularly if complete healing is not the primary goal.17,24,28,29 Autolysis uses proteolytic enzymes and phagocytic cells present in the wound bed and wound fluid to clear devitalized tissue. It is easy, inexpensive, noninvasive, and painless,4 and it requires less frequent dressing changes relative to standard dressing or wet-to-dry dressing.
Autolytic debridement is commonly accomplished using hydrocolloid and hydrogel dressings.15,29 Hydrocolloids are adhesive, occlusive, and conformable dressings that are suitable for wounds with low to moderate amounts of exudate. Upon contact with the wound surface, the dressing absorbs the exudate, forms a gel layer, and maintains a moist environment. Hydrocolloids are not recommended for infected wounds or for those with copious exudate as they may lead to maceration around the wound. A disadvantage of hydrocolloid dressings is their tendency to generate brown, often malodorous exudate when removed.
On the other hand, hydrogels in amorphous gel, dressing, sheet, or impregnated gauze form are water-based products that create a moist environment similar to hydrocolloids. Aside from causing minimal trauma to the wound bed when removed, the dressing’s cooling effect may bring some pain relief. Hydrogels are appropriate for dry wounds and for those with minimal exudate.
After debridement, the wound is cleansed and irrigated. A number of cleansers and solutions are available, but normal saline is a cheap alternative. To irrigate, experts recommend an 18- or 20-gauge intravenous catheter attached to a 30- or 60-mL syringe.15 This technique provides 8 to 15 psi of pressure, enough to cleanse the wound without causing tissue trauma.
