Management of Complex Wounds with Vacuum Assisted Closure Wendy McInnes Vascular / Wound Nurse Practitioner The Queen Elizabeth Hospital, Adelaide, South Australia Treasurer ANZSVN wendy.mcinnes@health.sa.gov.au 1
Wound Complexity & Healing Patient related factors Wound related factors Health Care Professional Resource/ Treatment related factors Age Duration/senescence Pathology Co-morbidity Allergy Size (area/depth) Wound bed condition Ischaemia Skill Knowledge Healthcare system Availability Suitability Medication Psychosocial Supports Inflammation/Infection Anatomical site Extent of tissue loss Diagnostic Therapeutic Interventional Effectiveness Cost Reimbursement Pain Treatment response Concordance Nutrition Lifestyle Risk factors Hard to heal wounds a holistic approach http://woundsinternational.com/pdf/content_45.pdf 2
Managing a complex wound Not healing in normal time frame? Wound exudate is difficult to manage? Wound not able to be managed with traditional dressings? Reduce wound for surgical closure? Reduce oedema for surgical closure? Requires sealed environment? History Examination Investigations Diagnosis Intervention Evaluation Hard to heal wounds a holistic approach http://woundsinternational.com/pdf/content_45.pdf VAC therapy interactions in the healing process http://www.woundsinternational.com/pdf/content_74.pdf Negative Pressure Wound Therapy in everyday practice http://www.woundsinternational.com/pdf/content_9720.pdf Adapted from: Harding K, Gray D, Timmons J, Hurd T (2007)Evolution or revolution? Adapting to complexity in wound management International Wound Journal;4 (Suppl. 2):1 12. 3
Vacuum Assisted Closure Controlled levels of negative pressure Promote formation granulation tissue Moist wound healing Reduce complexity/ size of wound Optimise wound bed prior to and following surgery Reduce complexity of surgical wound closure procedures Topical negative pressure in wound management http://woundsinternational.com/pdf/content_46.pdf 4
Vacuum Assisted Closure 6) In vitro studies show that cell stretch under negative pressure stimulates cellular activity that results in granulation tissue formation 1) Draws wound edges together 2) Removes infectious material 5) In vitro/in vivo studies show that foam contact with tissue under negative pressure creates tissue micro-deformation that leads to cell stretch 3) Reduces edema 4) Promotes perfusion 5
Vacuum Assisted Closure Intuitive software Simplified touch screen Seal check Therapy history reports Settings guide/ alarms Cost effective Info V.A.C upload photo s Patient information for D/C 6
Foam Granufoam polyurethane- hydrophobic, enhances granulation Versafoam hydrophilic, Silver foam micro bonded metallic silver V.A.C Consumables Therapeutic Regulated Accurate Care (T.R.A.C) Pad Monitors and maintains target pressure at the wound site Canister Sealed single use Disposable 7
Types of wounds Chronic Acute Traumatic Partial thickness burns Diabetic foot ulcers Amputation sites Pressure Ulcers Grafts/ Flaps Fasciotomy sites Lymph leaks Pilonidal sinus Explored fistula 8
Contraindications Malignancy in the wound Untreated osteomyelitis Non enteric & unexplored fistula Necrotic tissue with eschar 9
Precautions Active bleeding Difficult wound haemostasis Anticoagulants Bone fragments Organs Exposed tendon Palliation 10
Complex Diabetic Foot Multiple co-morbidities heart failure does not stick to fluid restriction Refuses amputation Refuses to admit to diabetes Treated osteomyletis D/C home IV antibiotics Weekly review in multi-d high risk foot clinic Offload pressure - footwear 11
V.A.C Application 12
Complex Diabetic Foot Potential damage from tubing Areas of granulation over bone 13
Tips Take time when sealing Use a barrier wipe or spray to protect peri wound skin Cut the drape into smaller, manageable strips Take care when dressing the foot encapsulating all the toes can result in further problems Use the drape as the underface to bridging protects the skin Use an interface reduces dressing changes reduces sticking Prontosan will help float the foam if stuck 14
Toe Amputations difficult to seal Cut the drape into smaller more manageable strips when dressing the toes criss cross to allow for movement on mobilisation 15
Oedema Management - Fasciotomy Pre-operatively Oedema management Sealed system infection control Earlier closure Post operatively Oedema management Better take if grafting Will not float off with fluid Reduces risk of potential infection 16
Over split skin grafts in theatre 17
Staged Skin Grafting on the Ward 18
V.A.C & Flaps 4 weeks post flap Not healing V.A.C post debridement Wound healed 4 weeks later with V.A.C 19
Wound Dehiscence with Lymph Leak Exudate management Able to mobilise Sealed area Reduces infection risk At risk suture line Earlier discharge Discharge home with V.A.C Lymphocele 20
Complex Abdominal Wounds Dehischence Compartment Syndrome Trauma Staged abdominal repair Minimises fascia sutures Quantifies fluid loss Environmental barrier Removes Protects Contains 21
V.A.C with Venous Ulcers Day 1 Day 7 Day 11 Day 16 22
Improves Pressure Injury Healing Elderly man had been on the bathroom floor for 3 days following a stroke 13 pressure injury sites Incontinent Unable to eat swallowing difficulties Unable to reposition himself deconditioned Surgical intervention V.A.C post operatively 2 weeks later halved in size 23
Multiple Pressure Areas Y- connect multiple lines Now we have Bridge Dressings to relieve pressure 24
Metal on View Hip Replacement 25
Prophylaxis on Bariatric Patients Cost saving At risk patients 250ml canister Easy to apply 26
Discharge Home Portable/lightweight Waterproof (take care with unit itself) Dressing changes in outpatients Hospital at home Cost savings to the hospital early discharge Manage complex wounds at home that may have otherwise required admission Assess ability to cope at home family support Patient information for trouble shooting at home
Summary Caring for people with complex wounds requires good assessment skills Patient related factors Wound related factors Health care professional skill & knowledge Resource related factors V.A.C is a tool in your kit to help manage complex wounds providing better outcomes for your patients History Examination Investigations Diagnosis Intervention Evaluation 28
Websites of Interest Hard to heal wounds a holistic approach http://woundsinternational.com/pdf/content_45.pdf Hard to heal wounds a holistic approach http://woundsinternational.com/pdf/content_45.pdf VAC therapy interactions in the healing process http://www.woundsinternational.com/pdf/content_74.pdf Negative Pressure Wound Therapy in everyday practice http://www.woundsinternational.com/pdf/content_9720.pdf Topical negative pressure in wound management http://woundsinternational.com/pdf/content_46.pdf 29