Weeping Wounds: Effective Strategies for Managing Exudate
Drainage is no stranger to those of us whom observing wounds is a common occurrence, but identifying the source of the drainage, whether present in excess or at normal levels, offers important insight on the progression of the wound towards closure. Being able to accurately identify the type and source of the drainage that is present gives providers an advantage in mitigating the effects of excessive exudate and keeps wounds on track towards healing. “Exudate provides vital information on a wound’s condition — the volume, colour, viscosity and odour can all provide clues to factors that can impact on healing, such as bacterial load and infection” (Beldon, 2016).
“Problems with exudate production occur if the wound becomes ‘stuck’ in the inflammatory stage and the production of exudate is overstimulated. Exudate found in chronic wounds (those that fail to heal after six weeks) has a different makeup to that in acute wounds and is often produced in higher quantities. Chronic wound exudate does not have the active growth factors found in acute wound exudate and it can actually block the healing process, destroy the extracellular matrix (ECM) and become a ‘wounding agent’ itself, causing more damage than healing (Chen et al, 1992)” (Barrett, 2016).
Serous Exudate:
“Serous drainage is mostly clear or slightly yellow thin plasma that is just a bit thicker than water. It can be seen in venous ulceration and also in partial-thickness wounds. Generally, this is not one of the types of wound drainage that leaves much color on a bandage. Serous fluid contains sugars, white cells, proteins, and other chemicals that are vital in the healing process to move across the wound site. Therefore, serous is one of the normal types of wound drainage and often appears in the first 48 to 72 hours. Sometimes, a thin watery drainage appears that is tinged with pink from a small number of red blood cells. In the early stages of healing, this pink serous wound exudate is normal and is not necessarily an indication of either infection or slow healing” (Wound Source, 2017).
Dressing changes often reveal a wet bandage, but the bandage should not be overly saturated with fluid. If this is the case, it is often an indicator of increased bioburden and the presence of potentially harmful bacteria. Additionally, the appearance of copious amounts of serous drainage on an incision line, or fluid arising from the skin in areas where there is no trauma, can be a sign of a medical condition, such as severe edema. All excessive types of wound drainage should be carefully monitored for signs of infection or other health problems.
Sanguineous Exudate:
“Sanguineous wound drainage is the fresh bloody exudate which appears when skin is breached, whether from surgery, injury, or other cause. Sanguineous bloody drainage is bright red and somewhat thick in consistency, some compare to the consistency of syrup. It can be seen during angiogenesis in both full-thickness wounds and also in deep partial-thickness wounds. This type of drainage is a normal part of the inflammatory phase of wound healing, but it should lessen considerably over time and stop after a few hours in most instances. In some deeper wounds, sanguineous wound drainage may continue for a few days but should distinctly lessen in volume. This drainage has the features of added plasma, which makes the run-off appear pink in color” (Wound Source, 2017).
If sanguineous wound drainage persists, quickly saturates bandages, or reappears following initial cessation, that can be indicative of an issue in wound healing. There may be fresh trauma to the wound site, the patient may be too active after surgery, or there may be some kind of stress on the wound that needs inspection.
Serosanguinous Exudate:
“Serosanguinous drainage is the most common type of exudate that is seen in wounds. It is thin, pink, and watery in presentation” (Andronaco, 2016). Although serosanguinous exudate is commonly documented, it is not necessarily a good thing to see it present in a wound. The pink tinge is a result of red blood cells, often as a result of trauma from dressing changes. It is important to be mindful of this and utilize non-adherent dressings in order to prevent further damage to the wound bed. Capillaries close to the surface of the skin can be easily injured when the dressing on a wound is changed. That means a scrape or wound with a larger surface area may be especially likely to produce serosanguinous drainage.
A 2018 paper, published in Wounds UK, “…showed that 65% of the patients included in this audit with moderately-to-highly exuding wounds were treated with inappropriate wound dressings that failed to meet the clinical objective of exudate management. Adverse event sequelae such as skin maceration/excoriation occurred and, consequently, direct and indirect costs associated with treating these patients increased. Using a more appropriate wound dressing such as a [superabsorbent dressing] (e.g. Zetuvit plus) has demonstrated significantly reduced costs when compared to these audit costs” (Stephen-Hayes et al., 2018).
Purulent Exudate:
“Purulent drainage is not a characteristic of normal healthy wound healing. Exudate that becomes a like a thick, milky liquid or thick liquid that turns yellow, tan, grey, green, or brown is almost always a sign that infection is present. This drainage contains white blood cells, dead bacteria, wound debris and inflammatory cells. These purulent types of wound drainage are commonly called ‘pus’ and often have a foul or unpleasant smell. Additionally, they can increase an inflammatory response resulting in intense pain at the wound site and surrounding skin. Wound drainage with a foul odor in of itself does not indicate infection. All wound drainage contains bacteria which feed of byproducts in the drainage and this activity produces an odor” (Wound Source, 2017).
A balance must be struck in treatment between containing heavy drainage and preventing maceration and maintaining a moist wound environment. Responses should vary based on the need of the patient, the type and location of the wound and what stage of the healing process the wound is in. There are a variety of dressings available to allow for a correct pairing of dressing and wound needs. In wounds with venous insufficiency, compression and elevation may be helpful in assisting with blood return and suppressing exudate. Some heavy drainage may have an underlying cause which can be treated such as an infection. Some deeper or tunneling wounds with exudate may be suitable for negative pressure wound therapy (Wound Source, 2019).
Best Practices:
Utilizing a step-up, stepdown approach, which focuses on the needs of the wound at a particular time, rather than using a one-size-fits-all approach to dressing choice, has allowed nurses and providers alike to more effectively manage wound exudate through personalized care-specific to each patient- at any given point in time. This responsive approach to the levels of exudate being produced by a wound allows the caregiver to ensure that the wound bed has an optimal level of moisture and the wound has the best chances of healing, without over-spending on products that would be better suited to more problematic wounds. While it can be difficult to make a choice about which dressing to use because of the vast array available, it is important to match the dressing to the wound and use the most appropriate dressing for the levels of exudate being produced.
If you enjoyed this article, or have insights and experiences dealing with highly exuding wounds that you would like to share, please feel free to do so in the comment section below!
References:
Barrett, Simon. “Managing Exudate and Preventing Biofilms in Community Wound Care.” JCN, vol. 30, no. 1, 2016, pp. 36–39.
Beldon, Pauline. “How to Recognise, Assess and Control Wound Exudate.” JCN, vol. 30, no. 2, 2016, pp. 32–38.
Bajjada, Tracey. “Using a Step-up, Step-down Approach to Exudate Management .” JCN, vol. 31, no. 2, 2017, pp. 32–38.
Stephen-Hayes, Jackie, et al. “A Retrospective Audit of the Treatment of Wounds with Moderate to High Exudate Levels.” Wounds UK, vol. 14, no. 5, 2018, pp. 124–132.
“Identifying the Different Types of Wound Drainage.” WoundSource, 6 May 2020, www.woundsource.com/blog/identifying-different-types-wound-drainage.
“Wounds with Heavy or Purulent Drainage.” WoundSource, 24 Dec. 2019, www.woundsource.com/patientcondition/wounds-heavy-or-purulent-drainage.
“Wound Exudate: Assessment and Management Strategies.” WoundSource, 6 May 2020, www.woundsource.com/blog/wound-exudate-assessment-and-management-strategies.
Roland, James. “Serosanguinous Drainage: Types and Why Does It Matter?” Healthline, Healthline Media, 17 Oct. 2017, www.healthline.com/health/serosanguinous#serosanguinous-drainage.
Wound Care Advisor. “Wound Exudate Types.” Wound Care Advisor, 25 Feb. 2020, woundcareadvisor.com/wound-exudate-types/.
