SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA
w w w . r b o . o r g . b r
Original
article
The
use
of
negative
pressure
wound
therapy
in
the
treatment
of
infected
wounds.
Case
studies
夽
Daniel
de
Alcântara
Jones
∗,
Wilson
Vasconcelos
Neves
Filho,
Janice
de
Souza
Guimarães,
Daniel
de
Araújo
Castro,
Antonio
Marcos
Ferracini
HospitalSãoRafael,Servic¸odeOrtopediaeTraumatologia,Salvador,BA,Brazil
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Articlehistory:
Received7March2016 Accepted4April2016
Availableonline2November2016
Keywords:
Negative-pressurewoundtherapy Woundhealing
Woundsandinjuries Infection
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Objective:Toevaluatetheresultsandbenefitsobtained fromthetopicaluseofnegative pressurewoundtherapy(NPWT)inpatientswithinfectedwounds.
Methods:Thiswasaretrospectivestudyof20patients(17malesandthreefemales,mean age42years)withinfectedwoundstreatedusingNPWT.Theinfectedwoundswerecaused bytrauma.ThetreatmentsystemusedwasVAC.®(VacuumAssistedClosure,KCI,San Anto-nio,UnitedStates)appliedtothewoundincontinuousmodefrom100to125mmHg.The parametersrelatedtothewounds(location,numberofVACchanges,thesizeofthedefects inthesoftparts,andtheevolutionofthestateofthewound),lengthofhospitalstay,length ofintravenousantibiotictherapy,andcomplicationsrelatedtotheuseofthistherapywere evaluated.
Results:Themeanlengthofthehospitalstay,useofNPWT,andantibacterialtherapywere 41days,22.5days,and20daysrespectively.TheuseoftheVACledtoameanreductionof 29%inthewoundarea(95.65–68.1cm2;p<0.05).Onlyonepatientdidnotshowany improve-mentinthefinalappearanceofthewoundwithcompleteeradicationoftheinfection.No complicationdirectlycausedbyNPWTwasobserved.
Conclusion:NPWTstimulatesinfection-freescartissueformationinashorttime,andisa quickandcomfortablealternativetoconventionalinfectedwoundstreatmentmethods.
©2016SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora Ltda.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http:// creativecommons.org/licenses/by-nc-nd/4.0/).
夽
StudyconductedatHospitalSãoRafael,Salvador,BA,Brazil.
∗ Correspondingauthor.
E-mail:[email protected](D.A.Jones). http://dx.doi.org/10.1016/j.rboe.2016.10.014
Aplicac¸ão
da
terapia
por
pressão
negativa
no
tratamento
de
feridas
infectadas.
Estudo
de
casos
Palavras-chave:
Tratamentodeferimentoscom pressãonegativa
Cicatrizac¸ão Ferimentoselesões Infecc¸ão
r
e
s
u
m
o
Objetivo: Avaliarosresultadosebenefíciostrazidospelaaplicac¸ãotópicadaterapiapor pressãonegativa(TPN)empacientescomferidasinfectadas.
Métodos: Estudoretrospectivodesériedecasoscompostapor20pacientes(17homense trêsmulheresemédiade42anos)comferidasinfectadastratadaspelaTPN.Asferidas infectadasemsuamaioriaforamdecausatraumática.Osistemadepressãoavácuousado foioVAC®(VacuumAssistedClosure,KCI,SanAntonio,EstadosUnidos),aplicadoàferida
emmodocontínuonaordemde100a125mmHg.Nacasuística,osparâmetrosrelacionados àferida(localizac¸ão,quantidadedetrocasdoVAC,tamanhosdosdefeitosdepartesmoles, evoluc¸ãodograudaferida),otempodeinternamento,otempodeantibioticoterapiavenosa eascomplicac¸õesrelacionadasaousodaterapiaforamavaliados.
Resultados: Otempomédiodeinternamento,usodaterapiaavácuoeantibioticoterapia foi,respectivamente,de41,22,5e20dias.OusodoVACpromoveuumareduc¸ãomédia daáreadasferidasde29%(95,65cm2 para68,1cm2;p<0,05).Apenasumpacientenão obtevemelhoriadoaspectofinaldaferida,comerradicac¸ãocompletadainfecc¸ão.Nenhuma complicac¸ãoatribuídadiretamenteaousodaTPNfoiobservada.
Conclusão: A terapia por pressão negativa, por facilitar a formac¸ão de um tecido de cicatrizac¸ãoausentedeinfecc¸ãolocalnumcurtointervalodetempo,representaumaopc¸ão rápidaeconfortávelaosmétodosconvencionaisnotratamentodeferidasinfectadas.
©2016SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevier EditoraLtda.Este ´eumartigoOpenAccesssobumalicenc¸aCCBY-NC-ND(http:// creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction
The association of infection with loss of soft tissue, one ofthe most complex complicationsof extremitiessurgery, leads to difficult problems, such as exposure of implant hardwareand sensitivestructuressuchastendons,nerves, and bone.1,2 Some ofthesurgical optionsfor thisproblem describedintheliteratureincluderotationflaps, skin graft-ing, use of colloids, and flap transfers, among others. All thesesurgicalchoicesare madeafterdebridementof devi-talized tissue and copious irrigation of the injured area.3 Treatmentisusuallylongandleadstocomplicationsinmany cases,themostcommonbeingseverepainduringdressing changes.4
Onetherapeuticoption,termednegativepressurewound therapy(NPWT),alsoknownasvacuumassistedclosure(VAC) dressing,providesthefollowingbenefits:controlofdrainage offluids,reductionoflocaledema,reductionofbacterialload, and earlydevelopment ofgranulationtissueby angiogenic stimulation.5–7InitiallydescribedbyArgentaandMorykwas,8 this therapy has become an important and effective tool for fighting infection in complex wounds, by acting topi-callywithlow complicationrate,providinggreater comfort tothe medicalteamand patient, aswell asreducing time ofhospitalization,useofantibiotics,andnumberofdressing changes.8–11
Thepurposeofthisstudywastoevaluatetheresultsand benefitsbroughtbythetopicalapplicationofNPWTinpatients withinfectedwounds.
Material
and
methods
BetweenJanuary2012andDecember2013,27patientswith infectedsurgicalwoundsweretreatedinahighcomplexity hospital inSalvador (BA)using the vacuum dressing tech-nique (VAC® Vacuum Assisted Closure, KCI, San Antonio, UnitedStates).Thefollowinginclusioncriteriawereadopted: presence of positive culture, use of vacuum drainage for over fivedays, purulentlocaldrainage,andtissuenecrosis. For the present study, a sample composed of 20 patients (Table 1) was selected and retrospectivelyassessed by col-lectionofdatarecordsafterapprovalofthehospital’sethics committee.
Allpatientshadaminimumfollow-upofsixmonths(6–26). Meanagewas42years(16–75);therewere17menandthree women.Trauma(Fig.1)wasthemaincauseofhospitalization (nine patients),followedbyinfection indiabeticulcer (four cases)andvaricoseulcers(fourcases).Inthegroupoftrauma patients,eighthadfractures,sixinthefootandankle(four treatedwithexternalfixatorandtwowithplateandscrews), oneinthetibia(treatedwithexternalfixation),andoneinthe distalradius(treatedwithintraosseouswires).
Table1–Clinicalseries:dataregarding20patientsbeforeandafterVAC.
Patient Age Etiology Site Degree
after
Areabefore Areaafter Daysof VACuse
Additionalprocedure
1 42 Diabeticfoot Foot 1 5 2 18 No
2 58 Diabeticfoot Foot 1 33 25 22 No
3 76 Vascularulcers Foot x 300 294 5 Amputation
4 63 Vascularulcers Foot 1 28 22 18 No
5 59 Diabeticfoot Foot 1 25 19 13 No
6 61 Diabeticfoot Foot 1 6 4 19 No
7 40 Motorcycleaccident Foot 1 29 18 13 No
8 52 Carcrash Forearm 2 261 163 22 Skingraft
9 43 Pressureulcer Sacrum 1 173 121 26 V-yflap
10 55 Vascularulcers Ankle 2 68 44 49 V-yflap
11 35 Motorcycleaccident Ankle 3 6 4 11 Musclerotation+skingraft
12 32 Motorcycleaccident Leg 1 222 153 19 Skingraft
13 38 Motorcycleaccident Foot 2 157 109 50 Skingraft
14 48 Osteomyelitis Ankle 1 32 17 35 No
15 57 Vascularulcers Ankle 1 112 83 26 Skingraft
16 28 Motorcycleaccident Leg 1 332 204 20 Skingraft
17 49 Pressureulcer Sacrum 1 38 25 32 Skingraft
18 25 Motorcycleaccident Ankle 1 29 19 28 Skingraft
19 37 Postoperativeinfection Ankle 1 15 8 9 No
20 55 Fall Foot 1 42 28 20 Skingraft
Fig.1–Patientvictimofmotorcycleaccident.(A)Presenceofexposedanklefracture;(B)Externalfixationoftheankleand presenceoflocalinfection;(C)Appearanceafter28daysofVACtherapy;and(D)Skingrafting.
causativeagentwasfoundtobeStaphylococcusaureus(Table2). After diagnosis, all patients underwent surgical treatment (debridementand localwoundirrigation),followedbylocal treatmentoftheinjurywithNPWT.
Technique
Table2–Distributionofthebacteriacausingthe infection.
Etiologicalagent Numberofpatients %
Staphylococcusaureus 9 45
Pseudomonasaeruginosa 3 15
Escherichiacoli 3 15
Acinetobacterbaumannii 2 10
Others 3 15
multiporouspolyurethanesponge.Under sterileconditions, thespongewascuttopreciselycovertheextentofthewound, applied directly on it (covering the entire extension), and sealedwithatransparentadhesiveandvapor-permeablefilm. Thisensemblewasconnectedtothereservoirthrougha suc-tiontube,allowingforthecontrolofthevolumeofsecretion suctionedandanegativelocalpressureincontinuousmode, ontheorderof100–125mmHg(Fig.2).TheNPWTsystemwas changedevery3–4days;thefirstapplicationwasinthe oper-atingroomandtheremaining,mostlyatbedside.Accordingto patient’sclinicaldevelopment,whennecessary,dressingwas changedintheoperatingroomafterformaldebridement.The useofdressingwasdiscontinuedafterhealthygranulation tis-suewaspresent.Additionalprocedures,suchasskingrafting andflaprotation,weresometimesrequiredforfinalcoverage. Thefollowingwound-related parameterswereanalyzed: location,amountofdebridement,numberofVACexchanges, andsizeofsofttissuedefect(measuredwiththeaidofagraph paper;Fig.2)beforeandaftertheapplicationofthedressing. Thecomparativeevolutionofthewounddegreeatthe begin-ningandendoftherapywasassessed,dividedintofivegroups
Fig.2–Patientwithapictureofinfectionontheleg.(A) Measurementoftheevolutionoflesionareaduring dressingchange;and(B)VACmounting(consistingoffoam, transparentfilm,reservoir,pump,andsuctiontube).
Table3–Scoreusedtoclassifythedegreeofthewound.
Score(grade) Woundstatus
0 Closedwound
1 Skindefect
2 Bone,implant,ortendonexposure(onlyone) 3 Bone,implant,ortendonexposure(twoormore) 4 Presenceoflocalinfection
basedonthedegreeofexposureandthepresenceofinfection, asshowninTable3.12Thedurationofhospital-stayand intra-venousantibiotictreatmentwerealsorecorded,aswellasthe complicationsrelatedtotheuseoftherapy.Thecollecteddata werecollineatedonExcel(Microsoft)andanalyzedwiththe helpofStatview®software.
Results
In thepresent study,thepatients remainedinthe unitfor mean41days(17–75),butwithmean20daysofintravenous antibiotictherapy(8–42).Themediandurationoftherapywas 22.5days(5–50);onaverage,thedressingwaschangedevery 3.4days.Thesepatientsweretaken82timestotheoperating roomforwounddebridement(meanfourtimesperpatient); the totalnumber ofdressing changeswas133,72ofwhich tookplaceatbedside.
Almostallpatientsachievedanimprovementinthefinal appearanceofthewoundsite,withinfectioneradication.One patient,whohadaninfectedvaricoseulcer,hadan unfavor-ableevolution,progressingintosepsis;anamputationatthe leveloftheproximaltibiawasperformed.Thispatienthad undergoneonlyonedressingwiththetherapyinquestion.
A 29% mean reduction of wound area was observed, from95.65cm2(5–332)to68cm2afterVACapplication(2–294;
p<0.05;Table 1). Thedegree ofthe injury, initiallygrade4 inallcases,reducedtograde2in15patients(75%).Inthis group,onlysevenpatientsrequiredanadditionalprocedure forwoundclosure(skingraft).Inthe entiregroup,complex procedures(muscleflapsorskinadvancegraft)were neces-saryinonlythreecases.
Nocomplicationsthatcouldbedirectlyattributedtothe useofNPWT,suchasdeepbleedingorworseninglocal infec-tion,wereobserved.Threepatientshadamildlocalitching complaint,whichwassuccessfullytreatedwithoral medica-tion, allowingforthe maintenanceoftreatment. Apatient who underwent skingrafting on the legshowed scar con-tracture ofthe graftedarea,which improved aftersurgical release.
Discussion
woundsoffersadvantagessuch aswounddrainage, angio-genesisstimulation,proteinaseexcretion,anddecreasedlocal andsystemicbacterialload.6Inthepresentstudy,themean timeofVAC®usewas22.5daysandthemeandurationof intra-venousantibiotictherapywas20days,incontrastwithdatain theliteratureindicatingtheuseofintravenousantibioticsfor sixweeksforpatientswithinfectedwounds.17,18Inthis treat-mentperiod,theVACwaschangedevery3.4days,providing comforttothepatientandthenursingstaff,while maintain-ingacleandressingwithouttheneedfordailychanges.
In the present study, healthy infection-free granulation tissue was obtained in 19 patients, as well as a signifi-cantdecreaseinlesionsize.Thesedataaresimilartothose obtained by Gregor et al.,19 who, in a systematic review toassess the effectivenessand safety ofVACcompared to conventionaltherapiesforcomplexwounds,observeda sig-nificantreductionofthelesionareaforthosetreatedwithVAC, withoutsignificantadverseeffects.Inthepresentstudy,there werenomajorcomplications,suchashemorrhage,whichisa well-knowncomplicationthatmayreactivateimportant ini-tialbleeding. Therefore,the authorsrecommendtreatment discontinuationinthepresenceoflocalbleeding,particularly inchildren.
Damiani et al.,20 in asystematicreview, comparedVAC andconventionaldressingsinthetreatmentofpatientswith infectedwoundsaftercardiacsurgery.Inthesixstudiesthat evaluatedthehospitalstayofpatientswithsternalinfection, therewasameanreductionof7.2days(95%CI:3.54–10.82), withnoimpact,however, inmortalityreduction.Themain limitationofthepresentstudy,apartfromthesmallsample size,wasthelackofcontrolgroup,whichdidnotallowfora directcomparisonofpatientstreatedinthesamecenterwho underwentconventionalmethodorNPWT.
TheauthorsbelievethatNPWTmaybeperformedthrough conventionalandlow-costmethods(throughthevacuum sys-tem),asdescribedinthestudybyOllatetal.21Theirresultsare similartothoseobservedinthepresentstudy;nonetheless, thoseauthorsreporteddrawbackssuchastheimpossibility ofanaccuratecontrolofthepressureappliedtothewound, impossibilityofalternatingtheapplicationofpressure,and theneedtochangethedressingevery2–3daystoavoid prob-lemssuchasspongeobstructionbywoundsecretions.
Conclusion
Thepresentfindingsaddtothegrowingevidenceofthe bene-fitsofNPWTasanadjuncttherapyinthetreatmentofinfected andcomplexwounds,especiallyforfacilitatingtheformation ofalocalinfection-freehealingtissueinashortperiodoftime, whichreducestheneedforcomplexsurgicalproceduresfor thefinalcoverageofimportantstructures.Hence,itisafast andcomfortablealternativetoconventionalmethodsinthe treatmentofinfectedwounds.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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