Case Study
INTRODUCTION
This case study follows the care and treatment of a patient and the management of a diabetic foot wound post debridement using V.A.C. VERAFLO™ with NPWTi-d (negative pressure wound therapy with instillation and a dwell time) to increase healing time. The patient is a 52-year-old 145kg male, long distance truck driver who presented with right foot pain because of recently hitting his foot while moving about the cabin of his truck; he hit the frame by the passenger seat and subsequently developed an injury. The injury was to the right foot, which led to ulceration and cellulitis in the indicated area of pain. He was initially seen in the ER on August 27, 2019 and six days later by his family physician in her office and sent directly to ER to see the surgeon that day. On admission to hospital September 3, 2019 the patient appeared to be septic from the wound site. He indicated there had been spreading redness to the ankle, ongoing fevers and chills leading him to seek medical attention. At the initial assessment by the surgeon the patient was afebrile with an obvious foul-smelling odor and a necrotic ulcer centered around the fifth metatarsal head. The wound was noted to be suspicious for osteomyelitis due to the extensive integumentary damage to the foot. The patients past medical history includes type 2 diabetes mellitus (treated with oral medication/insulin), hypertension, dyslipidemia, obesity with a high BMI, and smokes a pack and half cigarettes per day.
On August 27, 2019 the patient was initially seen in the emergency department having a fever of 38.4. His initial treatment by the ED physician at this visit was to start intravenous ceftriaxone 2G every 24 hours. As his condition was not improving the patient followed up with his family physician on September 3, 2019 were they started him on Cipro 400mg IV and Clindamycin 600mg IV and an urgent referred to see a general surgeon for potential debridement plus or minus amputation. As part of his care the infectious disease physician was consulted to review the swab and bone cultures. On September 3, 2019 the patient presented to the Emergency department to see the surgeon, who assessed the patient and initial treatment was to take the patient to the OR for debridement, amputation of the right 5th toe and a PICC line insertion for the antibiotic therapy. After surgery the patient was admitted to hospital to continue with IV antibiotics and dressing changes consisting of iodine soaked gauze twice a day. On September 4, 2019 it was noted that the wound was not responding to the treatment and discussion with the patient, his family and the care team a decision for further debridement and amputation of the 4th digit was made. There was discussion of a possible below knee amputation if the wound did not respond well to the treatment, which would have affected the patient quality of life.
| Figure 1 is the initial picture taken of the patient’s foot on September 4, 2019 prior to the V.A.C application post second debridement in the OR. Note the exposed bone and debris and shape of the wound. No pain was reported except at the dorsal side of the wound which was tender on palpation. The wound measured 9.5cm L x8.5cm W x 1.5cm D undermining 5.5cm – exposed bone 1.5cm x 0.5cm |
| Figure 1Figure 1 |
METHODS
On September 5, 2019 the V.A.C. VERAFLO with instillation of normal saline and dwell was initiated after observation and discussion with the surgeon and wound care nurse. The initial dressing with the V.A.C. consisted of a cleanse choice dressing using normal saline, instilling every 2 hours with a soak time of 5 minutes. The wound measurement following the debridement prior to commencing Veraflo™ was 9.5cm long x 8.5cm wide by 1.5cm deep with undermining of 5.5cm from 12 o’clock to 6 o’clock and 1.5cm x 0.5cm bone exposed at approximately 6 o’clock. It was noted that 12 hours post initiation of V.A.C. Veraflo™ the wound bed had holes filled with granulation tissue noted.
| Figure 2 was taken 12 hours after the application of the V.A.C. VERAFLOWTM with NPWTi-d. Note the rapid improvement in wound granulation. There are tissue buds already forming through the reticulated open cell foam dressing. |
| Figure 2Figure 2 |
The V.A.C. Veraflo TM treatment was continued after the second debridement on September 4, 2019 for 3 weeks as the patient remained in hospital. The dressings were changed every Monday, Wednesday and Friday with the continued treatment as described. With each dressing change the decrease in depth could be seen and measured as well debris was being removed with each dressing change, preventing having to continue to use sharp debridement on the wound. The potential for a below the knee amputation was no longer discussed as a plan of care for the patient to be discharge home on home and community care were put in place. These actions of decreasing the amount of foot amputated using the V.A.C. VERAFLOW TM did help to improve the quality of life for the patient.
| Figure 3 was taken on September 25, 2019, 15 days after the initial application of the V.A.C. VERAFLOWTM while the patient was still in the hospital showing the granulation buds filling in, debris gone and small piece of bone exposed. The wound measured 8.5cm L x 4.5cm W x 0.5cm D with no undermining. |
| Figure 3Figure 3 |
The management of this complex patient involved a multidisciplinary approach including the patient’s wife, dietary, physiotherapy, diabetic education, surgical services, wound care, infectious disease services, outpatient services, and home and community care. The patient and families involvement in the plan of care was essential in the patients healing journey. The patient’s wife who has a medical background was present during dressing changes and was taught the skill of changing the V.A.C. ™ therapy dressings. The dietary and diabetic education teams provided the patient with advice on the appropriate medications and diet to assist with maintaining the patient’s blood glucose levels to help facilitate the healing of the wound. As well, the Infectious disease physician closely monitored the antimicrobials to prescribe based on the patient’s microbiology reports and bone biopsy. Another key component that assisted with the healing progress of this patients wound was having the surgeon present during dressing changes to visualize the wound in order to provide sharp debridement if needed. Physiotherapy advised regarding appropriate off-loading foot wear of a lower leg air cast boot to allow the patient some mobility.
RESULTS
The patient was discharged home three weeks after his admission on September 25, 2019, and was able to transition to an ActiV.A.C.® negative pressure dressing and IV antibiotics that could be managed by home and community care. On discharge the patients wound measured 8.5cm long x 4.5cm wide x 0.5cm deep, with no undermining and 1.0cm long x 0.5cm wide of bone still exposed. The length of the wound had decreased by 1.0cm, the width of the wound had decreased by 4.0cm and the depth of the wound by 1.0cm. As part of the patients discharge plan an outpatient follow up in ambulatory care was arranged with the surgeon for every two weeks to monitor the wound until it is fully healed.
At the first outpatient visit two weeks post discharge on October 11, 2019 the wound was found to have good formation of granulation tissue with the lateral plantar edge of the wound needing to be debrided. The bone fragment that was noted in the wound at 6 o’clock released from the wound easily to reveal new granulation. At this time the wound continued to be a complex wound and the patient required continuation of the negative pressure dressing until the 0.5cm depth of the wound reaches 0cm as discussed with the healthcare team and patient. Once the wound has reached this 0cm depth, the healthcare team will then transition the wound to a conventional dressing for closure.
| Figure 4 was taken on October 11, 2019; two weeks post discharge at home, with the application of the ActiV.A.C. ®. Note the granulation and decrease in overall depth of the wound 7.5cm L x 4.5cm W x 0.3cm D. The maceration and rolled edge at the plantar side of the wound. This was debrided by the surgeon. Bone fragment released from the wound when cleansed. |
| Figure 4Figure 4 |
| Figure 5 was taken on October 25, 2019 four weeks post discharge with the application of the ActiV.A.C.® note the granulation and decrease in overall depth of the wound – 7.5cm L x 3.0cm W and the depth overall was 0.2cm. A decision in consultation with the surgeon was made to discontinue the ActiV.A.C. ® and apply a conventional dressing. |
| Figure 5HM Figure 5 |
DISCUSSION
The treatment choice of V.A.C. VERAFLO ™ for the patients wound was to prevent an alternative of a possible below knee amputation. Using V.A.C. VERAFLO™ with instillation and cleanse choice dressing stimulated wound granulation and removed debris from the wound that decreased the need for surgical intervention. There was a reduction of edema, excess fluid, and bacterial colonization in the wound thus decreasing the foul odour.
CONCLUSION
Using the V.A.C. VERAFLO™ with NPWTi-d (negative pressure wound therapy with instillation and a dwell time) helped to expedite the granulation process as evidenced in the photograph comparison at 12 hours., while the cleanse choice dressing debrided the wound of debris and decreased the bioburden which was as noted by the decrease in exudate and odour. The use of this dressing increased the healing time of this wound for the patient. The alternative treatment measure of a possible below the knee amputation which would have radically changed the patient’s life, his career and his body image was avoided. This dressing choice for wound care has provided the patient with a continued quality of life and ability to continue his career.