VOL: 96, ISSUE: 36, PAGE NO: 15 Heather Newton, RGN, DipPSN, is clinical nurse specialist, tissue viability/wound care, Royal Cornwall Hospitals NHS Trust, Truro

Sugar paste, which has been used to dress wounds for decades, has largely been superseded by commercial preparations with improved wear times that are more readily available in both hospital and community settings.

But two years ago a British consultant orthopaedic surgeon visited Kenya, where he saw patients with gunshot wounds being treated effectively with sugar paste. On his return to England he suggested that sugar paste could be used on patients after orthopaedic surgery.

The trust’s nursing team was not sure about this suggestion. After both they and the consultant sought my advice as clinical nurse specialist for tissue viability, I initiated a literature search.

The literature search

Most clinical studies on sugar paste were done in the 1980s and most comparative studies contrasted its effectiveness with that of chlorinated lime and boric acid solution and gauze that had been soaked in povidone-iodine (Gordon et al, 1985; Trouillet et al, 1985).

On contact with the wound, sugar paste rapidly liquefies, enabling desloughing and assisting in the formation of granulation tissue (South Devon Healthcare NHS Trust, 1998). The literature shows that the osmotic effect of sugar also inhibits the ability of bacteria to reproduce (Loncin and Merson, 1979).

Seal and Middleton (1991) revealed that sugar paste was non-toxic and reduced the odour caused by anaerobic bacteria. And Archer et al (1990) showed that it resulted in the formation of granulation tissue and epithelialisation at a rate similar to that in wounds kept moist with a film dressing.

The evidence suggests that sugar paste dressings are most effective on sloughy, infected wounds, especially those that are infected after cardiothoracic surgery (Archer et al, 1990; Chirife et al, 1982; Gordon et al, 1985; Seal and Middleton, 1991; Trouillet et al, 1985).

In the presence of granulation tissue, wounds that have been treated with sugar paste have the potential to bleed. Accurate and regular reassessment of the wound is therefore crucial to the successful use of sugar paste (Seal and Middleton, 1991).

All these findings have been confirmed in a recent article by Topham (2000).

How to use sugar paste

The literature search produced enough evidence to support the use of sugar paste on specific types of wounds, so the next step was to obtain it in a form that was safe for use on patients.

The paste was available from a local pharmacy in both a thick and a thin formula. Both were recommended for use on wounds.

Thick sugar paste is highly viscous and is made up of caster and icing sugars mixed with polyethylene glycol and hydrogen peroxide.

Hydrogen peroxide is usually detrimental to wound healing, but in this case it performs a different function. The peroxide is added to the paste when it is being made up to reduce the bacterial contamination of the raw sugar. Oxygen is released during the process of chemical combination, destroying any bacteria and leaving a residue of water. Therefore no hydrogen peroxide is left in the sugar paste and, consequently, it is not toxic.

Thin sugar paste is a viscous liquid with the same constituents as thick sugar paste, but in different proportions.

Only pharmacists should make up these products. A 250g tub of thick paste costs £6.00 plus VAT, and a tub of thin paste costs £8.40 plus VAT.

It is recommended that sugar paste is used only on a named patient basis and there are no restrictions on discarding the contents of the tub once it has been opened.

A procedure for application has been drawn up to ensure that staff use the paste correctly (Table 1). It gives clear rationales for use. The procedure was ratified by the trust, and to ensure safe practice it was introduced to the clinical areas in conjunction with educational support for staff.

Clinical observations

Although sugar paste dressings had been used on only 10 patients in our unit at the time of writing, they appear to be an effective desloughing agent for infected cavity wounds.

The surrounding skin was occasionally prone to maceration as a result of the increased level of exudate, but this has not been a problem since barrier protection was implemented as part of the plan of care.

Dressing wounds on a daily basis is not usually cost-effective, especially in community settings. But as the wounds selected for treatment with sugar paste were infected and had high levels of exudate, they would probably have needed daily intervention, no matter which dressing regime was used.

Conclusion

Sugar paste has been classified as a medical device under European Union regulations. Licensing rules dictate that each tub, which is for the sole use of a named patient, must be disposed of if it has not been emptied within 24 hours of opening.

The paste is not in great demand across the pharmacy supply area and we have had difficulties obtaining raw materials that are of a sufficiently high quality for medical use.

This, together with the increased cost per application that will inevitably result from the 24-hour limit on its use, mean sugar paste is not likely to be seen as a viable alternative wound dressing unless strong evidence of its cost and clinical effectiveness can be identified.

CASE STUDIES

Groin abscess

Horace Edwards, 61, was admitted to hospital to have an abscess in his groin drained. The infection recurred five months later and he had extensive abdominal surgery to drain a large haematoma that extended to the symphysis pubis.

The cavity was at least 10cm deep, with a narrow opening that made it difficult to dress. After recurrent infections, the wound was also reluctant to heal.

Thick sugar-paste dressings were introduced two months after surgery (Picture 1). Two weeks later the depth of the wound had halved and there was no evidence of infection. Mr Edwards found the dressings comfortable and said he felt little discomfort during dressing changes. The position of the wound meant that the end stages of healing were slow. The sugar-paste dressings were discontinued and the wound was covered with a hydrocolloid dressing. Because of Mr Edwards’ medical history, oral antibiotics were continued throughout the healing process.

Three months after the sugar paste was first applied the wound had healed completely and there has been no evidence of wound breakdown or reinfection (Picture 2).

Road traffic accident

Ernie Wright, 31, fractured his left femur, fibula and tibia in a road traffic accident. The main problems were the frequent recurrence of infection and the amount of friable tissue in the wound bed (Picture 3). Proflavine pack dressings were used initially, but these were later replaced by a sugar-paste dressing. After two weeks there was a significant improvement in the levels of slough in the wound and there was no evidence of reinfection (Picture 4).

- The patients’ names have been changed.