Pulse Lavage for Full Thickness Wounds

February 10, 2012 — Matthew Livingston R.N. C.W.S.

Matt, a question for you: Have you had any experiences with pulse lavage therapy as a treatment for wounds? In particular, stage III and IV wounds. If so, what are your thoughts on the therapy?

K, I have a lot of experience with pulse lavage in deep full thickness wounds (mostly in the early 2000s). I believe that pulse lavage has lost favor related to the high risk for spreading microorganisms via water droplets that inevitably spray back out of the wound. Two other developments have lead to the reduction in pulse lavage use including VAC instill (NPWT) and Celleration Mist therapies.  That being said pulse lavage does have a place in the care of patient’s if the wound is grossly contaminated (say status post traumatic injury to flush debris).

I would review the goals that you expect to achieve when treating the patient with pulse lavage. Typically, pulse lavage helps to reduce slough and clean a contaminated wound bed.  Depending on your goals I think there are better solutions. To reduce or loosen slough in high draining wounds I recommend DrawTex (SteadMed). If you fear contamination (and in a hospital setting) I would recommend VAC instill with Microcyn as the irrigant. If the patient is at an ECF, Home Care, or being seen at a wound clinic I would consider going with our classic antimicrobial silver (We use a ton of Silvadene) , but opt for an silver alginate if the patient can’t get the dressing changed daily.

Thanks again for the question,

Matthew

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Negative Pressure Wound Therapy (NPWT) Contraindications and Risk Factors

February 8, 2012 — Matthew Livingston R.N. C.W.S.
Table 1: NPWT is contraindicated for these wound types/conditions:
  • necrotic tissue with eschar present
  • untreated osteomyelitis
  • non-enteric and unexplored fistulas
  • malignancy in the wound
  • exposed vasculature
  • exposed nerves
  • exposed anastomotic site
  • exposed organs
Table 2: Patient risk factors/characteristics to consider before NPWT use:
  • patients at high risk for bleeding and hemorrhage
  • patients on anticoagulants or platelet aggregation inhibitors
  • patients with:
    • friable vessels and infected blood vessels
    • vascular anastomosis
    • infected wounds
    • osteomyelitis
    • exposed organs, vessels, nerves, tendons, and ligaments
    • sharp edges in the wound (i.e. bone fragments)
    • spinal cord injury (stimulation of sympathetic nervous system)
    • enteric fistulas
  • patients requiring:
    • MRI
    • Hyperbaric chamber
    • Defibrillation
  • patient size and weight
  • use near vagus nerve (bradycardia)
  • circumferential dressing application
  • mode of therapy- intermittent versus continuous negative pressure

FDA Safety Communication: UPDATE on Serious Complications Associated with Negative Pressure Wound Therapy Systems

Date Issued: February 24, 2011

Retrieved: http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm244211.htm

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Pressure Ulcer Evidence Based Treatment Pathway

February 7, 2012 — Matthew Livingston R.N. C.W.S.

This Pressure Ulcer Evidence Based Treatment Pathway is based from documents such as the NPUAP/EPUAP and WOCN guidelines. I have revised them in a time related format that is based on predictive modeling evidence.

Week 1 Pressure Ulcer Evidence Based Treatment Pathway

  1. Relieve Pressure                              Support Surfaces / Other Offloading Devices
  2. Manage Infection                            Culture / Antimicrobials
  3. Remove Avascular tissue              Debride (Leave heel wounds intact unless infected)
  4. Optimize Nutrition                          Pre-albumen / Dietary consultation
  5. Control Moisture                             Absorbent dressing
  6. Reduce Healing Delays                  Treat Co-morbid Conditions
  7. Fill Dead Space                                  Fill to volume of wound (Don’t over pack)
  8. Resolve aggravating conditions  Treat friction, shear, moisture, and incontinence
  9. Sponsor Granulation                      Consider NPWT

Week 4 Pressure Ulcer Evidence Based Treatment Pathway – If the pressure ulcer heals less than 75% over the first 4 weeks* then consider the following adjunctive therapies or treatments:

  1. Sponsor Granulation                      NPWT (Revisit use if not previously ordered)
  2. Fill volume                                          Apply Dermal substitutes
  3. Revise tissue                                      Surgical Intervention
  4. Treat Chronic Conditions              Debride and Treat with Collagen

10 Week Benchmark: The median days to healing is 73 days for large (>4cm2) ulcers¹.

* Note: Wounds that did not decrease in area by 77% after 4 weeks were significantly less likely to  heal² (a 75% closure rate at 4 weeks was selected due to wound measurement conventions)

Sources

  1. Bergstrom et al., 2008.  NPUAP & EPUAP. Prevention and treatment of pressure ulcers: clinical practice guideline. Washington DC: National Pressure Ulcer Advisory Panel; 2009. Pg 54.
  2. Van Rijswijk L. Full-thickness pressure ulcers: patient and wound healing characteristics. Decubitus. 1993;6:16–2
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Venous Wound Evidence Based Treatment Pathway

February 6, 2012 — Matthew Livingston R.N. C.W.S.

This Venous Wound Evidence Based Treatment Pathway is based from documents such as the RNAO and WOCN guidelines. I have revised them in a time related format that is based on predictive modeling evidence.

Week 1: Venous Wound Evidence Based Treatment Pathway

  1. Confirm Venous Etiology              Venous Duplex Ultrasound
  2. Rule Out Arterial Etiology             ABI
  3. Apply Compression                         Multilayer compression
  4. Remove avascular tissue                Debride Non-Viable Tissue
  5. Optimize Nutrition                          Dietary Consultation
  6. Protect Surrounding Tissue           Barrier Paste
  7. Control Moisture                             Absorbent Dressing

Week 4 Venous Wound Evidence Based Treatment Pathway: If the venous leg ulcer heals less than 30% over the first 4 weeks* then consider the following adjunctive therapies or treatments:

  1. Sponsor Granulation                       NPWT
  2. Introduce  Growth Factors            Skin Substitute
  3. Revisit diagnosis                              Rule Out Associated Etiologies

24 Week Benchmark:  A benchmark 49% of the venous ulcers treated with compression therapy alone in the control arm of a randomized clinical trial healed at 24 weeks¹.

*Note: “Data suggests that a venous leg ulcer that fails to decrease in size by 30% (percentage area reduction) of its initial size over the first 4 weeks of treatment has a 68% probability of failing to heal within 24 weeks”².

1. Falanga V, Margolis D, Alvarez O, et al. Rapid healing of venous ulcers and lack of clinical rejection with allogeneic cultured human skin equivalent. Arcj Dermatol 1998;134:293-300.

2. Kanter J, Margolis D, A multicenterstudy of percentage change in venous leg ulcer area as a prognostic index of healing at 24 weeks. Br. J Dermatol. 2000;142(5):960-964.)

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Diabetic Wound Evidence Based Treatment Pathway

February 6, 2012 — Matthew Livingston R.N. C.W.S.

This Diabetic Wound Evidence Based Treatment Pathway Is based from documents such as the RNAO and WOCN guidelines. I have revised them in a time related format that is based on predictive modeling evidence.

Week 1 of Diabetic Wound Evidence Based Treatment

  1. Relieve Pressure                              Offloading Devices
  2. Manage Infection                            Antimicrobials
  3. Remove Callus                                  Debride Callus
  4. Remove Avascular Tissue             Debride Non-Viable Tissue
  5. Optimize Nutrition                          Glucose Control
  6. Protect Surrounding Tissue         Barrier Paste
  7. Control Moisture                             Absorbent dressing

Week 4 of Diabetic Wound Evidence Based Treatment: If the diabetic foot ulcer heals less than 50% over the first 4 weeks* then consider the following adjunctive therapies or treatments:

  1. Assess Circulation                            T-com study
  2. Sponsor Granulation                      NPWT
  3. Introduce  Growth Factors           Skin Substitute / Regranex
  4. Improve Microcirculation             Hyperbaric Oxygen Therapy (Wagner 3 or Greater Diabetic Wounds)

20 Week Diabetic Wound Benchmark: 67% of diabetic foot ulcers remain unhealed after 20 weeks of care¹.

*Note: “50% percentage area reduction at four weeks was significantly associated with healing at 12 weeks”².

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

2. Snyder R, Kirsner R, Warriner R, Lavery L, Hanft J, & Sheehan P, 2010. Consensus Recommendations on Advancing the Standard of Care for Treating Neuropathic Foot Ulcers in Patients with Diabetes. Ostomy Wound Management. 2010;56 (suppl 4):S1-S24.

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