Introduction

The purpose of this article is to bring to the attention of surgeons some of the literature on wound dressings and the concomitant lack of research base for their practice of utilizing wet-to-dry and gauze dressings. The aims of the research described here were to identify what actually constitutes a wet-to-dry dressing, explain why it is used, and describe how specialist nurses interpret this technique.

Review of Current Literature

Wet-to-dry and gauze dressings are the most widely used primary dressing material in the United States (US),[1] and there is evidence that they are used inappropriately.[2] Journals and texts in the US support the principle of moist wound healing, but in practice the use of gauze, particularly as a wet-to-dry dressing, does not ensure a moist wound environment.[3] The literature describes wet-to-dry dressings as a means of mechanical debridement,[4–6] although efficacy in removing debris is not indicated. The importance of ensuring damaged and dying tissue is removed from a wound has been demonstrated by several authors[7,8] who advocate sharp debridement. The Agency for Healthcare Research and Quality (AHRQ), formerly the Agency for Health Care Policy and Research (AHCPR), guidelines[4] have promoted the use of wet-to-dry dressing for debridement by stating that use is supported by expert opinion (rated as C on their scale of hierarchy of evidence). Some controversy exists regarding what type of gauze should be used[9] and whether the dressing should be dry or moist when removed.[10,11] The AHRQ4 guidelines only comment on the latter issue, stating that moistening before removal at least partly negates the object of the dressing. The references at this point in the guidelines (page 48) relate to the nonselectivity of the dressing and focus on the pain caused to the patient on removal, not on the efficacy of wet-to-dry dressings. The guidelines clarify that wet-to-dry dressings should not be used as a generally acceptable form of a moist gauze dressing. In taking this approach, AHRQ have essentially supported the use of wet-to-dry dressings for debridement of pressure ulcers and the continuing use of moist gauze for primary
dressings.

Ovington in a recent article[2] describes gauze as, “still the most widely used wound care dressing and may be erroneously considered a standard of care.”[2] The paper notes that ‘wet-to-dry’ and ‘wet-to-moist’ are often used in practice in a way that makes them indistinguishable. Coupled with the fact that neither are actually used ‘wet’ both the term and the technique start to take on questionable value. Impeded healing due to local tissue cooling, disruption of angiogenesis by dressing removal, and increased infection risk from frequent dressing changes, strike through, and prolonged inflammation are all mentioned by Ovington as good reason to abandon this traditional dressing technique.[2] Ovington also presents a cost-effectiveness argument for change. An illustration is given of costs over a four-week period comparing saline and gauze with an advanced dressing (Tielle®, Johnson & Johnson Wound Management, Somerville, New Jersey) being performed by a home health nurse. The largest contribution to cost is nursing time; even with the patient doing some of his or her own care the cost is reduced with the advanced dressing due to fewer dressing changes and shorter healing time. There are other important considerations when choosing a dressing, such as clinical outcome, quality of life issues, discomfort, disruption of daily routines, and coping with daily activities that can all be addressed by modern products.