Case Study
V.A.C. VeraFlo ™ Therapy with two different types of fillers in temporal succession in the management of an infected venous vascular lesion of the lower limb: V.A.C. VERAFLO CLEANSE CHOICE ™, V.A.C. VERAFLO ™ Dressing
Infected Venous Vascular Lesion of the lower limb
Colognese Stefano, Wound Care Specialist RN MSc
Azienda USL, Presidio Ospedaliero ASMN-IRCCS, Reggio Emilia, Italy, IT
Remote Pathological Anamnesis: 63-year-old male with chronic renal insufficiency with likely pre-renal genesis, acute urinary retention due to benign prostatic hypertrophy, chronic lymphedema of the lower limbs.
January 2018: admission to the Department of Infectious Diseases for “patient with extremely extensive ulcers infected at bilateral lower limbs, intensely smelly, with intense pain and erythema”. The numerous culture tests on lesions, were positive for: multi-resistant Pseudomonas aeruginosa, Staphylococcus aureus.
April 2018: further admission to the Department of Infectious Diseases for “suppuration of trophic ulcers in the lower limbs”. Even during this hospitalization all culture tests performed on the lesions were positive for multi-resistant Pseudomonas aeruginosa. I was contacted by the clinicians for two consecutive assessment of wounds.
Assessment:
1) Appearance of Wound bed: present fibrin, present slough, present necrosis (yellow/black), present bleeding granulation tissue, present friable granulation tissue, present granulation tissue easily flakable, present thick biofilmated matrix, suspected infection.
2) Wound color code: Green, Yellow.
3) Exudate quantity: abundant (the tissues are immersed in the liquid; the exudate may or may not be evenly distributed in the lesion; saturates more than 75% of the dressing).
4) Type of exudate: purulent (dense, viscous, turbid, milky). Exudate color: cyan-green (Pseudomonas aeruginosa).
5) Presence of Odor: Yes. Evaluation Odor: Likert point 3 (The odor is perceptible when the dressing is not covered).
6) Pain Assessment: Yes/Present. NRS (from 0 to 10, where 0 corresponds to the total absence of pain and 10 represents the worst pain imaginable by the patient): 7.
7) Edges: macerated, irregular, jagged, infected, reddened, in extension.
8) Perilesional skin conditions: infected, macerated, presence of erythema, hot, presence of edema, presence of cellulitis.
9) Signs of suspected local infection: Increased pain or new onset, erythema, edema, local heat, exudate increase, healing delay, bleeding granulation tissue, friable or easily flaked, bad smell/odor. Figure 1,2
Treatment of the lesion: after procedural pain control (morphine subcutaneous on medical prescription), and topical anesthetic (pack with Lidocaine hydrochloride cream 5%), kept in place for 15 minutes), debridement of all lesions is performed by dermatological curette. Subsequently, pack with 1% acetic acid (galenic preparation), kept in place for 5 minutes, followed by washing with physiological solution. Figure 3
Maintenance treatment:
Cleansing with: Prontosan® Wound Irrigation Solution (ready-to-use solution with polyiesanide/PHMB and betaine). Pack kept in place for 15 minutes. Primary medication with: Silver Sulfadiazine cream, spread in a thin layer on all lesions. Secondary medication with: Kerlix™ AMD Antimicrobial Gauze in roll + superimposed sterile gauze. Surface covering with: bandage with self-fixing cohesive gauze. Change medication: every 24 hours or early (as needed), based on the saturation of the dressings with the exudate product. The patient is discharged the following days and entrusted to home nursing assistance.
May 2018: yet another hospitalization for “infected ulcers of the lower limbs”. During admission “sharp worsening of trophic ulcers of the lower limbs already present for some months and medicated at home by home nursing assistance”. The clinicians and nurses decide to use the previous hospitalization treatment scheme and they do not activate the Wound Care Specialist nurse.
January 2019: new admission for “infected trophic ulcer of the leg in a patient with chronic lymphedema of the lower limbs. Clear worsening of the lesion, with increased secretions and pain intensity”. New assessment:
1) Appearance of Wound bed: present fibrin, present slough, present necrosis (yellow/black), present unstable eschar (soft, moist, fluctuating), present bleeding granulation tissue, present friable granulation tissue, present granulation tissue easily flakable, present thick biofilmated matrix, suspected infection.
2) Wound color code: Green, Black, Yellow, Red.
3) Exudate quantity: abundant (the tissues are immersed in the liquid; the exudate may or may not be evenly distributed in the lesion; saturates more than 75% of the dressing).
4) Type of exudate: purulent (dense, viscous, turbid, milky). Exudate color: yellow, cyan-green (Pseudomonas aeruginosa).
5) Presence of Odor: Yes. Evaluation Odor: Likert point 2 (The odor is clearly perceptible at a certain distance from the patient).
6) Pain Assessment: Yes/Present. NRS (from 0 to 10, where 0 corresponds to the total absence of pain and 10 represents the worst pain imaginable by the patient): 8.
7) Edges: macerated, irregular, jagged, infected, reddened, in extension.
8) Perilesional skin conditions: infected, macerated, presence of erythema, hot, presence of edema, presence of cellulitis.
9) Signs of suspected local infection: Increased pain or new onset, erythema, edema, local heat, exudate increase, healing delay, bleeding granulation tissue, friable or easily flaked, bad smell/odor.
Signs of Widespread/Systemic Infection (as for local infection, moreover: abundant presence of pus. Figure 4/4a
During this hospitalization I decided to use the NPWTi to manage wounds as an alternative to traditional treatment with advanced dressings.
At first the wound was cleaned with a 0.05% sodium hypochlorite-based solution using a pack held in place for 10 minutes.
An NPWTi with V.A.C. VERAFLO CLEANSE CHOICE™ technology was therefore positioned, according to the following method: 1) protection of perilesional skin with 3M™ Cavilon™ (protective film in liquid form), 2) additional protection of perilesional skin by packaging of “dam” (Advanced Drape – sterile transparent adhesive film), and exposure of the wound bed, 3) Filler: V.A.C. VERAFLO CLEANSE CHOICE™ Dressing – Medium, cut and shaped in mold, 4) Sealing of the Filler with V.A.C. Advanced Drape (sterile transparent adhesive film), and further reinforcement of the system with the same material (included in the Kit), 5) Central positioning of VeraT.R.A.C., 6) Type of solution instilled: 500 ml of Physiological Solution + 500 ml of 0.05% Sodium Hypochlorite, 7) Instillation volume: 100 ml per cycle (every 3 hours, for a total of 8 washes in 24 hours), 8) Infiltration time: 10 minutes, 9) Duration V.A.C. Therapy: 3 hours post-infiltration, 10) Target Pressure: 125 mmHg, 11) Intensity: Medium, Device: V.A.C.Ulta™ motor unit, Canister: V.A.C.Ulta™ (1000 cc). CHANGE MEDICATION: EVERY 2 DAYS.
After 2 days of treatment with V.A.C. VERAFLO CLEANSE CHOICE ™ (on January 30th 2019), the lesion appears to be clean and bleeding. Completely removed the fibrin, the unstable eschar, the pus and the slough present on 01/28/2019. Figure 5,6,7,8,9
Obtained the optimal cleansing and decontamination of the wound bed, the primary objective was to favor the growth of the granulation tissue, homogenizing the surface of the lesion: the filler was then changed, choosing V.A.C. VeraFlo™ Dressing. The same treatment settings were maintained.
After 2 days of treatment with V.A.C. VeraFlo™ Dressing (on February 1st, 2019), the lesion appears more cleansed and superficialized. Figure 10
Due to poor patient compliance the NPWTi was suspended and the lesion was managed with advanced dressings. At discharge from the hospital, clinicians write: “during the hospital stay, antibiotic therapy was performed with the combination of piperacillin-tazobactam and NWTi was performed with clear and obvious improvement of the local situation and pain “.
Conclusions: although “There is limited rigorous RCT evidence available, concerning the clinical effectiveness of NPWT in the treatment of leg ulcers”*(**), my clinical experience has shown that the treatment of infected venous vascular lesions of the lower limb by NPWTi has produced optimal results in extremely short times, reducing both the infection and the biofilm present on the wound bed. The V.A.C. filler VERAFLO CLEANSE CHOICE™ carried out a mechanical debridement of the wound bed that was less traumatic and less painful than the curette technique and avoided the reformation of the infected and biofilmated matrix. The subsequent use of V.A.C. VERAFLO™ Dressing made it possible to homogenize the growth of the granulation tissue, making the wound bed surface uniform, preparing the lesion to accommodate an appropriate advanced dressing.
*Dumville, J.C., Land, L., Evans, D., Peinemann, F. Negative pressure wound therapy for treating leg ulcers. Cochrane Database Syst Rev 2015; 7: 7, CD011354.
**Apelqvist, J., Willy, C., Fagerdahl, A.M. et al. Negative Pressure Wound Therapy – overview, challenges and perspectives. J Wound Care 2017; 26: 3, Suppl 3, S1–S113.
