The Wound Situation
Recently, I had a very interesting and very sad case of a patient who underwent an I&D for a deep space abscess of his foot, a PICC Line placement for IV antibiotics, and a negative pressure device placed over the surgical site. The patient started with a simple Wagner grade I ulceration which appeared virtually harmless. However, over the course of just two weeks, the wound began to immediately decline. His blood sugars were uncontrolled, he was not changing his dressing, and he missed a few appointments to have the wound debrided. His life immediately changed with the loss of his wife and his overall appearance, health, and hygiene came to a standstill. It was extremely emotional for the patient since he depended on his wife for a number of years and now even the most menial of tasks such as taking his medication was an uphill climb.
I had interceded recognizing several shifts in the patients mental and physical state and once hospitalized, his chemistries began to equilibrate along with his white blood cell count and glucose levels. He underwent an incision and drainage (I&D) procedure along with a wash out in which a portion of the incision site was primarily closed and a large central deficit remained open. Deep cultures were taken in the operating room as well as bone cultures to rule out osteomyelitis and a preliminary MRI was also completed with contrast. Collaboration was attained with infectious disease and the patient was then discharged in a few days.
Since then, I have been following the patient very closely along with monitoring his overall medical state, home health, and his negative pressure device. Upon removal of his first wound vac change, the wound bed presented with granulation tissue with micro-deformation. Micro-deformation is simply taking the surface of the wound bed and increasing its area by creating raised areas of tissue (micro-villa) and thus increasing the rate of healing. However, Bioburden control is not a proven benefit of negative pressure according to Birke-Sorensen et al (Birke‐Sorensen H, Malmsjo M, Rome P, et al. Evidence‐based recommendations for negative pressure wound therapy: treatment variables (pressure levels, wound filler and contact layer) ‐ Steps towards an international consensus. J Plast Reconstr Aesthet Surg 2011;64:S1–16) and Moues et al. In another study, cultures revealed increased Staph aureus species with increased bacterial levels over time with the use of negative pressure.
As noted, the sponge was removed and I looked at the wound as I have done many times upon removal of a wound vac. The tissue presented with a pale red type of color commonly encountered as well as a distinctive odor. I then used the EZDebride Wound Instrument and gently debrided the wound bed and immediately noticed a bright red granular base immediately below the surface. I had actually debrided half of the wound intentionally and left the other half of the wound uninterrupted for comparison. It was a vast difference, not to mention the patient was also anti-coagulated and those who have debrided wound vac patients with scalpels or curettes immediate know the impact of how vascular these wounds are and how easily they will bleed. As mentioned, the surface of negative pressure wounds do accumulate a skin slough/bioburden which requires debridement and I have found that the EZDebride instrument provides an immediate solution. The wound following debridement was bloody, not bleeding which made the application of a new negative pressure dressing very easy and without any concerns.
Before the EZDebride, I recall that it was not uncommon to get a call from the patient and or home health nurse indicating that the wound vac cannister was full (usually blood) due to continued bleeding following the debridement of the wound bed with a curette. With bleeding, one can also decrease the effectiveness of the seal and with post complications of extreme maceration of the surrounding tissue.
The patient has done remarkably well in just 3 weeks and the wound has decreased in size significantly. I have not encountered any complications with bleeding of the wound, disruption of the pressure seal, and no maceration. In the past, the patient would often times present with bleeding through the dressing due to the uncontrolled depth of a curette debridement which would then linger for several days afterwards. With the use of the EZDebride, I have found those complications are now just a memory.
We will continue our discussion next time and delineate further the advantages of the EZDebride Wound Instrument in Wound Bed Preparation. Please check back often and until next time, fair winds and following seas
Dr. F. Derk