WoundBlog.com

Matthew…great blog and great wound info!! Tell me – what has been your experience with using VAC on a venous stasis ulcer? Any tricks for helping to keep the seal with the weeping? Also do you apply light compression over the VAC? I have never had a good experience with this and spend most of my time patching the seal,, but thought you might have some creative tips. I appreciate it…thanks so much!

A

Dear A, Great Question.  The first decision I make when choosing negative pressure (VAC) for venous etiology wounds is which types of venous wounds I would exclude. Limiting conditions or symptoms include:

1. Infection, or an inflammatory reaction along the periwound or the extremity itself.

Note: while infection of venous wounds does occur it is often mistaken as the lone cause of redness along the extremity or peri-area of the wound. More commonly, this redness (erythemia) is related to an inflammatory process common with venous wounds (see a great explanation below*). If this problem is preventing the application of Wound Vac therapy then I recommend a Medrol dose pack which typically does this trick in reducing the inflammatory process.

2. Fragile or weeping skin tissue proceeding from the borders of the wound out to the greater part of the lower extremity (disallowing adhesion of wound vac drape or duoderm thin without the further opening of wounds along the extremity).

This being said, you can treat fragile or weeping skin just a few inches away from the wound with a few simple tricks.

First, on outright weeping skin a recommend a layering process that starts with the application of Non-sting skin prep followed by anti-fungal powder.  Alternatively repeating (at least 10 repeated applications) the application of these two products achieves two goals as the weeping areas are covered in a way that limits their drainage and the skin prep provides a great tacky surface for which the wound drape to adhere.

Second, along the edges beyond the weeping or fragile skin tissue place a Duoderm thin (ConvaTec). I have found that Duoderm Thin is about the only dressing that prevents the fluid from working its way under it a high draining wound with or without NPWT.  I also recommend placing stoma paste (ConvaTec) in the trenches of skin that the Duoderm Thin can’t secure to (See the following image). Once hardened place the Duoderm Thin over the Stoma Paste.

Finally, at this point place the VAC Foam in the wound bed. I recommend the  the V.A.C.® GranuFoam™ Bridge Dressing (See Picture Below). This dressing allows you to concisely weave the pre-sized bridge dressing through the multilayer compression dressing. When applying the wound drape place skin prep to skin (that is intact) and over the Duoderm Thin to provide a more wound drape dressing.

“Venous reflux (or valve failure) or other vein conditions can lead to increased pooling of blood, causing venous hypertension (increased pressures in the veins of the lower leg), which leads to the pooling of blood. These venous conditions may come from more superficial veins (like varicose veins), deeper veins (related to deep vein thrombosis or DVT) or from perforator veins, which connect the veins of the superficial and deep vein systems. When these high pressure conditions exist, fluid can leak out into the surrounding tissues, inflammation of the tissues occurs, and the normal transfer of nutrients and oxygen to the tissues is impaired. Over time, the diminished level of nutrients and oxygen and the inflammation created causes damage to the surrounding tissues, which can result in skin discoloration and tissue death” (retrieved from www.veintreatment.com).

Intended use of Total Contact Casts

Total Contact Casts are typically intended for diabetic planter ulcers.

Hold or don’t initiate a Total Contact Cast if:

1. Infection
2. Critical limb ischemia Tcom < 30mmHg
3. Major illness / Unstable patient
4. Frail / Bad hip or back
5. Non-compliance (overactive)

Quick Fixes for Total Contact Cast Complications:

1. Heavy Drainage – Biweekly changes
2. Toe Drainage – Open toe cast
3. Discomfort – Add padding
4. Chafed skin -  Add padding
5. Pre-ulcerated lesion on pressure point – offload pressure point
6. New ulcer – offload pressure point

Consider a DH Walker if you are unable to control for:     

1. Discomfort with extra padding
2. Chafed skin with extra padding
3. New ulcer formation continues regardless of offloading
4. Lower extremity joint problems

Note: DH Walkers are hard to ambulate in for patients with a weak gait. If this is the case consider a walker. If it is still difficult for the patient to ambulate consider a wedge shoe (Darco).

Note: Consider a Crow Boot for patients who have a rocker bottom (Charcot) foot deformity.

Research indicates that 67% of diabetic foot ulcers remain unhealed after 20 weeks of care. (Note: Average healed at 20 weeks is 33%)

Kantor J, Margolis DJ. Expected healing rates for chronic wounds. WOUNDS. 2000;12(6):155-158

RESULTS—Wound area measurements at baseline and after 4 weeks were performed in 203 patients. The midpoint between the percentage area reduction from baseline at 4 weeks in patients healed versus those not healed at 12 weeks was found to be 53%. Subjects with a reduction in ulcer area greater than the 4-week median had a 12-week healing rate of 58%, whereas those with reduction in ulcer area less than the 4-week median had a healing rate of only 9% (P < 0.01). The absolute change in ulcer area at 4 weeks was significantly greater in healers versus nonhealers (1.5 vs. 0.8 cm2, P < 0.02). The percent change in wound area at 4 weeks in those who healed was 82% (95% CI 70–94), whereas in those who failed to heal, the percent change in wound area was 25% (15–35; P < 0.001).

Percent Change in Wound Area of Diabetic Foot Ulcers Over a 4-Week Period Is a Robust Predictor of Complete Healing in a 12-Week Prospective Trial Peter Sheehan, MD1,Peter Jones, MSC2,Antonella Caselli, MD3 John M. Giurini, DPM3 and Aristidis Veves, MD3

10.2337/diacare.26.6.1879 Diabetes Care June 2003 vol. 26 no. 6 1879-1882

Nutrition

“Basic principles of nutritional management of a patient with diabetes mellitus to control glucose, hyperlipidemia, and hypertension should be applied to the patient who has developed neuropathic foot ulcers.”

Level of Evidence=C

WOCNS, 2004. Guideline for Management of Wounds in Patients with Lower-Extremity Neuropathic Disease. Pg. 24

“Ensure adequate offloading of pressure through wound closure. Utilize assistive devices to provide support, balance, and offloading of the affected site.”

Recommendation

WOCNS, 2004. Guideline for Management of Wounds in Patients with Lower-Extremity Neuropathic Disease. Pg. 17

TCOM

A transcutaneous oxygen monitor study “is indicated to assess tissue perfusion when the lower extremity wound is not healing or an ABI or toe pressures can not be done due to incompressible arteries” (Grolman et.al. 2001: Hopf et al., 2006: Stalc & Poderos, 2002).

Level of Evidence = A

WOCNS, 2008. Guideline for Management of Wounds in Patients with Lower-Extremity Arterial Disease. Pg. 14

Negative Pressure Wound Therapy  “has been demonstrated to be effective for the treatment of neuropathic/diabetic ulcers and skin graft and donor sites.”

Level of Evidence = B

WOCNS, 2004. Guideline for Management of Wounds in Patients with Lower-Extremity Neuropathic Disease. Pg. 27

Skin Substitutes have the potential to stimulate, through topical activation the normal or enhanced activity of mechanisms involved in tissue repair.

(Gentzkow, Iwasaki, Hershon, Mengel, Prendergast, Ricotta et al., 1996; Gentzkow, Jensen, Pollak, Kroeker, Lerner, Lerner et al., 1999; Marston, Hanft, Norwood & Pollak, 2003)

Level of Evidence = 1b

“Hyperbaric oxygen therapy may be clinically effective in treating patients with limb-threatening diabetic wounds of the lower extremity (Wagner grades III and IV)

Level of Evidence = A

WOCNS, 2004. Guideline for Management of Wounds in Patients with Lower-Extremity Neuropathic Disease. Pg. 27

Five ways to build the ideal wound clinic

1. Build a large referral base

A. Become an expert in wound care and hyperbarics (do research and publish)

B. Get in front of as many doctors as possible and share what you know. Become well connected in the hospital and the hospitals system.

C. Let them know that you are an adjunct to their care and that you will be working to keep them informed of patient progress.

D. Maintain active communications with the referring physicians.

2. Recruit all types of specialists to work as wound physicians.

A. This includes Vascular, General Surgery, Trauma, Plastics. ID, Internal Med, Podiatry. etc…

B. Make sure that there are open cross referral patterns between these doctors.

C. With this in mind, recruit doctors that have an us (not me) mentality as sharing referrals can improve patient outcome and better outcomes means more referrals.

3. Provide Advanced Wound Care

A. Have physicians who can manage complex wound etiologies such as micro-occlusive and autoimmune disorders.

B. Insure that you have physicians available who can provide surgical interventions such as complex flaps.

4. Provide a process driven wound care environment

A. Benchmark wound healing outcomes by etiology, with goals for how to improve lower preforming healing outcomes.

B. Create evidence based protocols for the care of your patients.

C. Foster staff / clinician / physician  process improvement committees which drive improvements such as clinic development, patient safety, and new product review.

5. Create accurate and seamless documentation

A. Invest in a wound care related electronic medical record (EMR).

B. Insure that the EMR company has on the ground training that not only trains towards the EMR, but also how the EMR should fit into your clinic process (I recommend Well Care Strategies TPS Full Ambulatory Solution).

NPWT

Negative Pressure Wound Therapy increases rate of closure in stage 3 and 4 pressure ulcers

(Ubbink, Westbos, Evans, Land, & Vermeulen, 2008)

Level of evidence B

Guideline for Prevention and Management of Pressure Ulcers, WOCN Clinical Practice Guideline Series 2, 2010,  Pg 34

Support Surfaces

Individuals at risk should be placed on a pressure redistribution surface.

(RNAO, 2005; NICE, 2005)

Level of evidence B

Guideline for Prevention and Management of Pressure Ulcers, WOCN Clinical Practice Guideline Series 2, 2010,   Pg 18

Nutrition

Early nutritional assessment is critical to identify patients at risk for malnutrition

(Dorner, Posthauer, & Thomas, 2009)

Level of evidence C

Guideline for Prevention and Management of Pressure Ulcers, WOCN Clinical Practice Guideline Series 2, 2010, Pg 10

Surgical Intervention

Evaluate the need for surgical interventions with stage 3 and 4 pressure ulcers that don’t respond to conservative pressure ulcer treatments.

(Sorensen, Jorgensen, & Gottrup, 2004)

Level of evidence C

Guideline for Prevention and Management of Pressure Ulcers, WOCN Clinical Practice Guideline Series 2, 2010,  Pg 35

Co-morbidities related to delayed healing in Pressure Ulcers

Pressure Ulcer healing is complicated by co-morbid conditions including malignancy, diabetes, CVA, heart failure, renal failure, pneumonia.

(Berlowitz & Wilking, 1989)

Level of evidence C

Guideline for Prevention and Management of Pressure Ulcers, WOCN Clinical Practice Guideline Series 2, 2010, Pg 12

Wound Conditions related to delayed healing in Pressure Ulcers

Wounds that are larger, deeper, infected, had large amount of exudate, and /or covered with slough or eschar are less likely to heal with in 3 months and likely to heal after five to six months of treatment.

(Jones et al., 2007)

Level of evidence C

Guideline for Prevention and Management of Pressure Ulcers, WOCN Clinical Practice Guideline Series 2, 2010, Pg 12

Benchmark for Pressure Ulcers greater than 4 square cm

The median days to healing is 73 days for large (>4cm2) ulcers

(Bergstrom et al., 2008)

Level of evidence: Level 4 study

NPUAP & EPUAP. Prevention and t6reatment of pressure ulcers: clinical practice guideline. Washington DC: National Pressure Ulcer Advisory Panel; 2009. Pg 54.

Benchmark for Pressure Ulcers greater than 4 square cm

The healing rate for stage 3 pressures was 31.5% and 23.3% for stage 4 pressure ulcers in the first 3 months (12 weeks).

(Brandeis et al., 1990)

Level of evidence: Level 4 study

NPUAP & EPUAP. Prevention and t6reatment of pressure ulcers: clinical practice guideline. Washington DC: National Pressure Ulcer Advisory Panel; 2009. Pg 54.