Utilisation of negative pressure with instillation to prepare a thigh wound for skin grafting

Case Study

Mr Mark Kim, Clinical Nurse Educator, St Vincent’s Hospital

Introduction:

This case study highlights the effectiveness of negative pressure wound therapy with instillation in preparing a wound bed for skin grafting in a patient with poor wound healing ability.

Patient History:

51 yo male with chronic bilateral lower limb cellulitis and lymphoedema with poor compliance. He had a motorbike accident more than 5 years prior which resulted in an upper thigh wound that was skin grafted.  The grafted tissue was vulnerable to injury and a wound developed which became infected.  When the patient was admitted into hospital on the 24^th August, he presented with a deep thigh wound and multiple ulcers on his lower limbs.  The patient was septic with high fevers and was initiated on IV antibiotics. Patient had hypoalbuminaemia and a very poor nutritional status which affected his ability to heal.

The lower leg ulcers were treated with a non-adherent content layer and Zetuvit to control wound exudate and the upper thigh wound was managed conservatively with standard wound care dressings.

Wound Treatment:

The upper thigh wound was covered with thick slough and on assessment the surgical team booked him in for surgical debridement.  On the 8^th September, the patient was taken into theatre for debridement and application of negative pressure wound therapy.  Post debridement, the wound measured 15 x 10cm with a depth of 5cm.  Swabs were taken which confirmed that the wound was colonized with Pseudomonas.

On the 11^th September (Figure 1) the surgical team changed the treatment regime to negative pressure wound therapy with instillation and dwell (NPWTi-d), with a novel reticulated open cell foam dressing with through holes (ROCF-CC).  The negative pressure device was set to instill normal saline with a 10 minute soak time every 4 hours, with the aim of keeping the wound bed clean and enhancing granulation tissue.

The instillation solution was changed to Microdacyn on the 17^th September as there was concern of recurrence of Pseudomonas due to a mild odour from the wound at dressing change.

On the 27^th September (Figure 3), the depth of the wound bed was reduced significantly and measured 1cm with healthy granulation tissue.  The patient was continued with NPWTi-d with ROCF-CC, with only the solid cover layer used over the wound bed.

On the 7^th October (Figure 4) the wound was reviewed by the surgical team and deemed to be ready for a skin graft.  The patient was subsequently skin grafted 2 days later with negative pressure applied to the graft to ensure effective graft take.

Conclusion:

Considering the patient’s complex medical history, the utilization of NPWTi-d with ROCF-CC assisted to clean and granulate the wound for an effective graft take.

Figure 1: Prior to application of NPWTi-d with ROCF-CC

Figure 2: 23^rd September

Figure 3: 27^th September

Figure 4: 7^th October