Case Study

Introduction: We often wait to start V.A.C. therapy or we hesitate about which option is the best for the patient. In this case, we used many of the available tools in the V.A.C. therapy continuum to optimize healing and to avoid more important consequences such as amputation.  After only 14 dressing changes, we were able to take a deep wound with bone exposed and necrotic tissue and make it superficial and with 100% granulation tissue. We also learned very quickly that stopping V.A.C. therapy for a conventional gaze dressing deteriorates the wound.

Methods:

A 52 year old male was admitted after a motorcycle accident. The patient had no prior medical history and did not take any medications or natural products. The patient is a non-smoking, occasional beer drinker, non-drug user. The patient was autonomous for ADL (activities of daily living) and IADL (Instrumental Activities of Daily Living).

At admission, the patient had multiple bilateral rib fractures, sternal fracture with myocardial contusion, left clavicle fracture, left tibial plateau fracture, multiple open fractures to the right leg (distal femur, tibia, and calcaneus). He was taken to the operating room for debridement and pulsed lavage of the femur and tibia with reduction of the femur and external fixators were applied. He was then hospitalized in the ICU for anemia, acute renal failure (ARF), hypocalcaemia, hypokalemia, and infection. The patient was given a transfusion, four liters of Ringer lactate for the ARF and started on Ancef 2 grams every 8hrs for the infection.

The patient first saw the plastic surgeon 3 days after admission for his right heel wound, but the course of action was conservative management related to his other more pressing co-morbidities.

The patient was taken to the OR for an open reduction internal fixation (ORIF) of the right femur, intramedullary rodding of the right tibia, ORIF of the left clavicle and most importantly debridement of the right heel. The wound was left with 70% granulation tissue, but the calcaneus was exposed and there was an important loss of substance. The surgeon notes that it is a ‘’complex wound with a high risk of amputation below the knee’’.

Bone cultures were taken during the operation and antibiotic therapy was adjusted to Entrapenem 1g every 24hrs for six weeks to treat the osteomyelitis. A consult with plastic surgery was asked.

Results:

Six days after the operation, the patient was seen by a plastic surgeon who writes that “the wound is too deep and not clean enough for any type of flap or skin graft“. A consult was done with the Wound, Ostomy and Continence nurse (WOCN) for V.A.C. therapy.

KCI V.A.C. Cleanse Choice was started on the same day. The wound on the right heel was 8cm x 16cm x 2 cm at deepest area with no undermining and 50% granulation/30% slough/20% bone. The settings used for instillation were 34 mL of NACL 0.9% for 8 minutes every 2.5hrs with negative pressure at -125mmHg.

Due to pain during dressing changes and significant improvement, we switched to KCI V.A.C. Veraflo after three dressing changes. The wound on the right heel was 7cm x 14.5cm x 0.7cm and 95% granulation tissue/ 5% slough.  The settings used for instillation were 26 mL of NACL 0.9% for 5 minutes every 2.5hrs with negative pressure at -125mmHg.

Three dressing changes later, settings used for instillation were adjusted to 24 mL of NACL 0.9% for 5 minutes every 2.5hrs with negative pressure at -125mHg.  Antibiotics were also changed from Entrapenem 1 gram every 24hrs to Clindamycin 900mg every 8hrs and Ceftriaxone 2 grams every 24hrs to finish the six week treatment of osteomyelitis.

The patient was seen by the plastic surgeon after a total of eight dressing changes later (three with V.A.C. Cleanse Choice and five with V.A.C. Veraflo). The wound was evaluated and had again significantly improved to 4.5cm x 14cm x 0.3cm and 100% granulation.

Following that appointment, a skin graft was planned for the next day and a wet gaze dressing was applied. Unfortunately, the skin graft was cancelled late in the day due to other emergency surgeries. The patient refused to have a conventional V.A.C. installed by the ward nurses  and kept his wet gaze dressing until the next day.

When the WOCN team saw the patient less than 48hrs after removal of the V.A.C. Veraflo, the wound had already deteriorated with a biofilm on the entire wound surface and 5% of new slough.  Conventional V.A.C. therapy started with a black sponge on continuous suction at -125mmHg. The skin graft was rescheduled for the next visit from the plastic surgeon in 10 days.

After only one dressing change with conventional V.A.C. therapy, the wound was back to 100% granulation tissue without a biofilm.  The skin graft was done as planned. V.A.C. therapy was installed after the skin graft and left in place for five days. Upon removal of the V.A.C therapy, the skin graft was well adhered to the wound.

Discussion:

The role of each V.A.C. therapy option was well defined in this case; in addition, to the importance of not stopping a treatment prematurely.  We were able to save a man’s foot with relatively few dressing changes, 14 in total from start to finish. Early initiation of negative wound therapy is proven to lessen healing time thus reducing costs (Baharstani, Houliston-Otto, Barnes, 2008) and I think we could have started the therapy even earlier had we known about the heel wound. The initial use of V.A.C Cleanse Choice helped establish a clean wound free of necrotic tissue and infected material. Although, pain was greater upon removal the reticulated open cell foam it did help remove the unwanted tissue. As seen in Téot, Boissiere & Fluieraru (2017), after only three dressing changes the wound was significantly cleaner and smaller.  We were then able to switch from V.A.C. Cleanse Choice to V.A.C Veraflo to continue wound closure.  We did learn that very quickly (less than 48hrs) our optimal wound bed for grafting became sub optimal with a gaze dressing; so much so that we were afraid that we would need to use Veraflo again. Luckily, since the wound was superficial and greatly reduced we were able to rapidly restore the wound bed to its former optimal site for grafting. We used 14 dressing changes and 37 days to save a man\’s foot and close the wound with a skin graft.

Conclusion:

Each technology has its independent role; the cleanse choice works best to help debride de wound, but did cause more pain, the Veraflo helped the wound granulate more rapidly and caused less painful dressing changes, the conventional VAC therapy was indicated while we were waiting for the skin graft and after skin grafting. Clinicians still need to learn when and where to use each one technology to optimize its purpose, but with this case and others we have seen a great difference in wound closure.

References:

Baharestani, M.M., Houliston-Otto, D.B., & Barnes, S. (2008). Early Versus Late Initiation of Negative Pressure Wound Therapy: Examining the Impact on Home Care Length of Stay. Ostomy Wound Management, 54(11), 48-53.

Téot. L., Boissiere, F., & Fluieraru, S. (2017).  Novel foam dressing using negative pressure wound therapy with instillation to remove thick exudate. International Wound Journal. doi: 10.1111/iwj.12719