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

Posted in NPWT - VAC Education, Products, Wound Infection. Tags: , , , . 1 Comment »

Wound Offloading Orthotic Products

September 10, 2010 — Matthew Livingston R.N. C.W.S.

Total Contact Cast ( MedE-Kast, Instant Total Contact Cast, Custom TCC):

This product is indicated for offloading planter digit, planter metatarsal, medial metatarsal, lateral metatarsal, charcot midfoot  and heel wounds.

Removable Cast Walker/ Walking Boots
1. Charcot Restraint Orthotic Walker  (CROW) boot:
This product is indicated for offloading planter digit, planter metatarsal, medial metatarsal, lateral metatarsal, charcot midfoot,  and heel wounds.
2. DH Walker (also known as Active Offloading Walker):
This product is indicated for offloading planter digit, planter metatarsal, medial metatarsal, lateral metatarsal, charcot midfoot,  and heel wounds.
3. Prefabricated Walker (any premade walking boot):
This product is indicated for offloading planter digit, planter metatarsal, medial metatarsal, lateral metatarsal, ankle, and heel wounds.
4. Patella Tendon Bearing (PTB) brace:
This product is indicated for heel wounds.

Wedge Shoes
1. Darco Wedge Shoe:
This product is indicated for offloading planter digit, planter metatarsal, medial metatarsal, and lateral metatarsal wounds.
2. Ortho Wedge Shoe:
This product is indicated for offloading planter digit, planter metatarsal, medial metatarsal, and lateral metatarsal wounds.
3. Darco Reverse Wedge Shoe:
This product is indicated for offloading heel wounds.

Multipodus Splint / Boot (Prafo, L’nard, Bend-a-boot, Multiboot):
This product is indicated for offloading heel and ankle wounds.

Surgical Shoes or Shoes with Pressure relief Insoles
1. Post op shoe (e.g. the Darco med-surg shoe with “peg assist”):
This product is indicated for offloading dorsal digit wounds.
2. DH Pressure Relief shoe (also the DH offloading post-op shoe):
This product is indicated for offloading planter digit, planter metatarsal, medial metatarsal,  lateral metatarsal wounds, and ankle wounds.
3. Plastizote Healing Shoe:
This product is indicated for offloading the dorsal digit, planter digit, planter metatarsal, medial metatarsal, lateral metatarsal, and heel wounds.

Posted in Diabetic Wounds, Products. Tags: , , . 1 Comment »

Wound Debridement when Accuzyme and Panafil are gone (Part 1) Mesalt and Hypergel

October 30, 2008 — Matthew Livingston R.N. C.W.S.

Healthpoint will stop shipping Accuzyme and Panafil in January of 2009. So it is important to look at other products that can assist in debridement. (The author will discuss Santyl and biologicals in part 2 and 3). These are some details of products that I have used to debride wounds. Again these will not be as fast as Accuzyme and Panafil, but they are quicker than autolytic debridement. This product uses osmotic debridement  (  Which has increased sodium and creates a chemical pull leading to necrotic  tissue being lifted up). These products include mesalt and hypergel. Below is a detail from the company web site with a link for more information.

Authors Note:

1.  These products can cause pain related to the sodium.

2. The products work very well in patients with peripheral neuropathy

Mesalt® – Molnlycke

Sodium Chloride Impregnated Gauze helps stimulate the cleansing of moist necrosis (slough), draining, and infected wounds.

It absorbs exudate, bacteria and necrotic material from the wound and into the dressing, thereby facilitating the natural wound healing process. Mesalt is intended for the management of heavily discharging and discharging infected wounds in the inflammatory phase and deep cavity wounds such as pressure ulcers and surgical wounds.

http://www.molnlycke.com/item.asp?id=15159&catid=15076&lang=2&si=181

Hypergel®Molnlycke

Hypertonic Saline Gel for the black, necrotic phase of wound healing.

This water based hypertonic saline gel softens eschar and draws drainage and debris from the wound. Hypergel debrides dry necrotic tissue (eschar), which is essential for wound healing to progress. Use directly from sterile, single dose tubes without mixing, mess or waste.

http://www.molnlycke.com/item.asp?id=15051&pid=15009&lang=2&si=181

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Wound debridement when Accuzyme and Panafil are gone (Part 2)- Santyl Collagenase

October 29, 2008 — Matthew Livingston R.N. C.W.S.

Santyl Collagenase (Enzymatic Ointment) - Healthpoint

Description: Santyl Collagenase digests collagen in necrotic tissue

Indications: debridement for chronic dermal ulcers including pressure ulcers, venous ulcers, arterial ulcers, diabetic foot ulcers, and severely burned areas. (Healthpoint, 2006)

Authors notes:

1. Slowest debridement ointment verses Accuzyme or Panafil

2. Less risk for pain or inflammation than with Accuzyme or Panafil

3. Can be used in a wound bed that has a combination of non-viable tissue along with granulation tissue and epithelization

4. Because Santyl doesn’t lead to inflammation, evidence suggests that (While slower to debride at first)the closure times of the wound are the same as papian based products (Brett, 2004).

5.Panafil and Accuzyme are not going to be made after January of 2009 (So Santyl may be the only ointment for debriding wounds)

6. For dry wounds that need to be debrided, use a moist primary dressing (hydrogel impregnated) to keep the Santyl from drying out.

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Wound Debridement when Panafil and Accuzyme are gone (part 3) – Maggot Therapy

October 28, 2008 — Matthew Livingston R.N. C.W.S.

The U.S. Food and Drug Administration (FDA) has ordered companies to stop marketing unapproved drug products that contain papain in a topical dosage form. This includes Accuzyme, Allanfil, Allanzyme, Ethezyme, Gladase, Kovia, Panafil, Pap Urea, and Ziox. A few options have already been discussed in the prior two prior blogs. One good option is biologicals (A nice way to say maggot therapy). Our clinics use Monarch Labs for our medical maggots or medical debridement therapy (MDT). To learn more go to the Monarch Lab web site at http://www.monarchlabs.com/

Mechanisms of Action – Debridement results from the necrotic tissue through proteolytic digestive enzymes and the physical action of the maggots mouth hooks on the tissue (this tears the tissue), allowing the digestive enzymes penetrate deeper into the necrotic tissue.

Clinical Indications – Maggot debridement therapy is indicated for infected, sloughy, or necrotic wounds, irrespective of etiology and including non-healing necrotic skin, pressure ulcers, neuropathic (diabetic) foot ulcers, chronic leg ulcers, malignant wounds or non-healing traumatic or post-operative wounds.

Contraindications for maggot therapy include: dry necrotic wounds, fistulae, wounds that connect with the abdominal cavity, wounds that bleed easily, wounds close to major blood vessels or nerves and any situations where the blood supply is insufficient to permit healing to take place.

Authors notes:

Read the package insert it is very informative

Don’t use harsh chemicals around the maggots (Kills them fast)

Stoma paste allowed to dry before introducing the maggots is a good adhesive

Advise the patient to call you ASAP should the dressing open.

If the maggots make it the full two days they will be much bigger. Open the dressing and they will escape pretty fast. Use an alcohol soaked 4×4 to swoop them up an smother them (place in double red bag). Irrigate the wound to flush out any strays.

Remember a straight face helps the patient cope with the thought of active maggots on their body.

Posted in Products, Uncategorized. Tags: , , . Leave a Comment »
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