Pulse Lavage for Full Thickness Wounds

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

Negative Pressure Wound Therapy (NPWT) Contraindications and Risk Factors

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

Venous Wounds and VAC Therapy

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.

Skin Tissue after Compression for Venous Etiology WoundsFinally, 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 http://www.veintreatment.com).

Wound VAC Placement Tips

This is a list of wound VAC tricks that I have learned over the years. These tips will make your dressing change go faster with longer lasting results.

1. Cutting Foam – I typically use a number ten blade to cut the foam and drape. The drape can be a little tough to cut with a  blade so you may want to work with scissors.

2. Sizing the Foam – I size the wound with my gloved finger then bring it over to the foam. Cutting a mark in the foam for the horizontal line, then repeating the process for the vertical line. Always make the foam a little smaller (than the wound opening) to allow for contraction.

3. Corners or Bridging – Cutting the foam in half makes the foam more workable around corners or when bridging. This is best done with a 10 blade (as always watch your fingers).

4. Leaks – Check the connections (sometimes they crack). Listen for leaks with your stethoscope. Rub skin prep along the edges to paste down any open drape. Drape over any suspect areas.

5. Small Wounds - For smaller wounds surround the wound edges with a hydrocolloid (duoderm thin) or VAC drape to reduce the risk of foam suction trauma on normal tissue.

6. Difficult Contours – Stoma paste is useful for the filling in difficult contours or skin folds so the VAC drape can sit over a flatter surface, and maintain a seal. Make sure the stoma paste is dry before turning on the VAC or else it will suck the paste inward.

7. Protecting – Cover and protect weakened, irradiated or sutured blood vessels or organs with Silicone or other type of non-contact layer (Mepitel – Molnlycke or Conformant 2 Wound Veil – Smith & Nephew).

8. Pain Reduction- Mepitel and Wound Veil,  is also very useful for patients who have pain with VAC foam removal. If this is the case, place a narrow strip of the non contact sheet along the top line of wound tissue ( closest to the skin). This prevents the foam from getting caught in the most innervated tissue.

Instill 1% lidocaine into the tubing and foam 30 minutes prior to removal of the foam from the wound bed. Use adhesive remover to lift the drape to reduce tape burn. Give pain medication prior to removal of the foam dressing.

9. Large Wounds – Contract larger wounds by cutting the VAC foam smaller than the wound. Then, after securing the drape to one side of the wound edge, pull the drape over the VAC foam. At the same time push (with care) the undraped wound edge towards the wound bed and sponge. Finally, lay the drape down on the undraped side a few cm at a time while slowly moving the tension providing hand out from under the drape.

10. Rash - If the skin is reactive (rash) to the VAC drape use duoderm thin as the first layer. Make as small of a VAC drape foot print as possible (so that none of the drape adheres to the skin, only over the duoderm).

11. Small opening Large undermining -  This trick is called the “cinnamon bun”. First, cut a spiral in the foam. Then feed the spiraled foam into the wound opening, leaving a few inches on top to secure the dressing.

12. Legal - With a black sharpee write on the VAC drape how many pieces were used.

Revised 8/20/2010

VAC Therapy Flap Closure Technique

Consider using these steps (listed in the KCI VAC Therapy Clinical Guidelines) when attempting to close flaps with the assistance of VAC therapy.

1. Suture the flap in place using about a third fewer sutures than usual. The greater spacing will allow V.A.C.® Therapy to remove fluid through the suture line.

2. Place a single layer of V.A.C.® Drape or other semi-occlusive barrier, such as a hydrocolloid dressing or vapor-permeable adhesive film dressing, over the intact epidermis on top of the flap and on the opposite side of the suture line. Place a single layer of wide-meshed, non-adherent dressing over the exposed suture line.

3. If the recipient bed is exuding heavily, cut a thin strip of V.A.C.®WhiteFoam Dressing and place it under the flap, between the sutures, to wick fluid from the interior of the flap. Make sure the V.A.C.®WhiteFoam Dressing and V.A.C.® GranuFoam® Dressing communicate directly.

4. Select an appropriate size of V.A.C.® GranuFoam® Dressing to cover the entire flap, including the suture line and 2-3cm beyond the flap. Ensure the area covered by the foam is protected intact skin (Step 2).

5. Prepare and apply the V.A.C.® Drape over the foam, according to Step 4 of Dressing application technique (p. 19). Apply a SensaT.R.A.C.®/T.R.A.C.® Pad and connect to canister tubing.

6. Initiate therapy on continuous setting.

7. Removal of the V.A.C.® Drape requires lateral stretch (pull) on the drape to prevent lifting of the flap.

KCI, 2009. V.A.C. Therapy Clinical Guidelines retrieved from http://www.kci1.com/Clinical_Guidelines_VAC.pdf

VAC Therapy for the Treatment of Sinus Tunnels

During the initial wound VAC dressing placement into a sinus tunnel. First,  determine the measurement of the sinus tract. Second,  cut the V.A.C.®White Foam Dressing to fit the sinus tract dimensions and an additional one to two centimeters into the wound bed. Third, gently guide the foam into the  sinus tract up to the attended measurement. Insure that the  foam of the sinus tunnel contacts the foam of the wound bed.

For following wound VAC dressing changes when granulation tissue is observed and drainage is reduced consider the following variation with subsequent dressing changes: After confirming the sinus tract measurement cut the V.A.C.® White Foam Dressing narrow (on what will be the distal end) and wider (on what will be the outer end). “This specific placement leaves the distal portion of the tunnel or sinus tract clear of foam and enables the distribution of higher pressures to collapse the edges together, allowing the wound to granulate together from the distal portion forward” (KCI, 2009). Follow the guidelines of the initial VAC dressing placement, continue continuous therapy at previous settings, and repeat this technique until the sinus tunnel has closed.

KCI, 2009. V.A.C. Therapy Clinical Guidelines retrieved from http://www.kci1.com/Clinical_Guidelines_VAC.pdf

How to Protect Denuded or Reactive Skin under Wound VAC Dressings.

I recently received a note from a reader who is having considerable problems with breakdown of skin underlying the KCI wound VAC drape.  Typically, this is caused by four problems.  First, improper removal of the VAC drape can strip fragile skin. Second,  some individuals are  reactive to wound VAC drape itself.  Third,  individuals with considerable edema (fluid build up) in the surrounding tissues are more susceptible to the striping of fragile skin.  Finally, a fungal component may lead to areas of red, itching, weeping, combined microlesions. The following are my recommendations for adapting your approach to VAC Therapy dressing changes  with each of these situations.

1. Denuded Fragile Skin -

A. Drape Removal – First, use adhesive remover wipes to work under the drape. As you move the wipe under the drape pull the drape away from (not up from) the center of the dressing. Apply light pressure ahead of the elevated aspect of the dressing so you don’t pull to much drape to soon. Applying light pressure in this manner also helps to defer the sensation of discomfort in this area. Continue this technique slowly and take breaks as needed. Note: use these removal techniques for the other three skin conditions.

B. Placement – Placing VAC drape directly over  denuded fragile skin can lead to more skin stripping when attempting to remove the drape (regardless of skin prep). First, make the size of the VAC drape dressing as small as possible. Second, under the drape place a Duoderm thin or other hydrocolloid. Finally only place the VAC drape over the hydrocolloid and foam. According to the KCI VAC Therapy Clinical Guidelines it is appropriate to leave the duoderm intact to the skin for up to seven days (KCI, 2007). Only removing the foam in the interim. When finally removing the Duoderm (hydrocolloid) consider using an adhesive remover.

2. Reactive Skin – For individuals who are reactive  to wound VAC drape (reactive skin is located only under the drape, red, and perhaps a little swollen and itchy). I have found benefit in reducing the size of the footprint of the VAC drape. Placing Duoderm thin or other hydrocolloid as a non-reactive protectant over the reddened areas. Then adhering the VAC drape over the top of the duoderm.  When replacing the VAC foam, during the next dressing change, it will be OK to remove only the foam. Leaving the duoderm intact to the skin for up to seven days (KCI, 2007). When finally removing the Duoderm (hydrocolloid) consider using an adhesive remover. It will take about a week  for the redness to fade. If in this time the red areas have not reduced in intensity, consider the chance that there may be an autoimmune component to the wound. If able to reduce the size of the dressing consider using Topicort ointment  as an anti-inflammatory agent for the  inflamed areas over the undressed skin.

3. Denuded Weeping  Edematous Skin – Placing VAC drape over denuded weeping  edematous skin is one of the most difficult challenges  for a wound care nurse. I have had good luck with placing Stoma Powder (Convatec) over the weeping area. Typically, with up to  moderate weeping, the stoma powder will dry over the open areas allowing  for VAC drape placement. Please note that the stoma powder can sting. For excessive weeping skin conditions (common in individuals with gross pitting edema ) and when it is imperative that VAC therapy be continued; place a layer of wound veil over the weeping denuded area.   Then place the VAC drape over the foam, wound veil, and then attach the VAC drape to the skin that has not eroded. This should allow the skin to be protected while removing any fluid. To prevent continued skin erosion of the healthier tissue consider placing a duoderm (hydrocolloid) down over the healthier skin. Then lay the VAC drape over the top of of the hydrocolloid, Wound Veil, and VAC foam. If the skin continues to degrade consider holding off on the VAC Therapy until the skin condition improves.

4. Fungal Skin Rash -For light to moderate fungal infections consider using the smaller foot print trick listed above. Consider using a process called “crusting” which is a progressive build up of layers of alternating anti-fungal powder with Skin Prep (applied by dabbing lightly so that it moistens the powder but doesn’t remove the lower layer of powder). After about eight or so alternating applications a crust of anti-fungal powder should form with enough stick to allow the wound VAC drape to adhere to its service. For a raging fungal infection consider holding VAC Therapy (until resolved) and providing a systemic anti-fungal (Diflucan).Note an example of anti-fungal powder is Micro Guard Powder AF from Coloplast with Miconazole Nitrate 2%.

KCI, 2007. V.A.C. Therapy Clinical Guidelines retrieved from http://www.kci1.com/Clinical_Guidelines_VAC.pdf

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