Limited Access Dressing
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Limited Access Dressing (LAD): The Concept and Applications
How is LAD a combination of moist healing and negative pressure dressing? The Limited Access Dressing is a combination of intermittent negative pressure (for 30 minutes) and a moist wound dressing (for 31⁄2 hours without negative pressure) that is covered with a transparent polythene material (a total of 3 hours moist dressing and 21 hours negative pressure dressing in a 24- hour period). Negative pressure (up to -30 mmHg) is applied through tubing connected to a suction machine that is then placed under a polythene wound cover.
LAD designs. The material that contacts the wound LAD is classified into 2 groups:
B. Polythene sheet contacts the wound (LAD IB and LAD II, Figure 2)
Some may be skeptical as to whether a hydrocolloid material encountering the wound or negative pressure (LAD I) makes a difference. Liquefied hydrocolloid materials blocking the tube, and poor wound floor visibilityfor the initial few days until the suction removes any liquefied material, are two additional problems.
To avoid doubts and problems associated with LAD I, in LAD IB (Figure 2) a sterile polythene sheet separates the wound along with tubes from hydrocolloid and in the Hydrocoll® (Hartmann, Heidenheim, Germany) a central hole was made to improve visibility. LAD I and LAD IB was used for smaller wounds (up to 10 cm x 10 cm given that the maximum size of Hydrocoll was 15 cm x 15 cm).
In LAD II (Figure 3) wounds are covered with larger polythene sheets, polythene tubes, and polythene bags after placing tubes (as in other LAD designs) and when sealing is achieved with pieces of Hydrocoll and the adhesive polyurethane film (OpSite™, Smith & Nephew, Largo, Fla).
If required in critically ill patients, after taking out intravenous and other lines through the LAD polythene bag that covers the extremities, the puncture site may be sealed effectively.
How much intra-LAD negative pressure is effective? There is a general belief among most physiologists that true interstitial fluid pressure in loose subcutaneous tissue is slightly less than atmospheric pressure (average value of this pressure is negative in relation to atmospheric pressure and is approximately -3 mmHg).35
When the skin cover is absent in wounds,the pressure will rise to 0 mmHg (ie, equal to atmospheric pressure). These increases in interstitial tissue pressure from -3 mmHg to 0 mmHg will also cause the lymph flow to increase 20-fold35 and the re-absorption of fluid to increase through capillaries. Hence, the chances bacterial invasion and absorption of chemicals (toxins) through venules and lymphatics increases when edema increases the interstitial tissue pressure or produces an open wound that is not sutured.
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