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ROLE OF GAUZE-BASED NEGATIVE PRESSURE WOUND THERAPY ON SPLIT-THICKNESS SKIN GRAFT IN LARGE AND COMPLEX WOUNDS.

Byline: Irfan Ilahi, Muhammad Uzair Ilyas Tahirkheli and Ehtesham ul Haq

ABSTRACT

Background: Negative-pressure wound therapy (NPWT) involve the application of controlled negative pressure on the wound. The objective of the study was to assess the role of gauze-based negative pressure wound therapy on split thickness skin graft in large and complex wounds.

Material and Methods: This descriptive cross-sectional study was conducted at Army Burn Center, CMH, Kharian, Pakistan, from Jan 2016 to June 2017. Sample size was 63, selected through consecutive sampling technique. Very large and complex wounds, infected, wounds with co-morbidity, extensive war wounds were included. Demographic variables were sex and age. Research variables were type of co-morbidities, amount of exudate, duration required for wound preparation, duration of dressing, dressing charges, graft uptake, length of stay, presence of post-operative infection and requirement of re-grafting. Continuous data were summarized using means and SD whereas categorical data were calculated in count and percentages using SPSS version 20.

Results: Out of 63 patients, 42 were males. The mean age of patients was 32+-15 years. Seventeen (26.98%) were having co-morbidities, with 13(20.63%) having DM, 2(3.17%) HTN and 2(3.17%) genitourinary injuries. Fifty-seven percent wounds (90.47%) were having moderate to high amount of exudates. Mean of 8+-5 days were required for wound preparation before the placement of STSG. The mean duration of NPWT dressing was 15 days. Dressing charges in 54(85.7%) were less than PKR-5000, 7(11.1%) 5000-10,000 and only 2(3.17%) >10,000. The graft-uptake percentage was 90% uptake in 7 cases, 95% uptake in 12 cases, 96% uptake in 6 cases, 98% uptake in 12 cases, and 100% uptake in 20 cases. Three cases (4.76%) had surgical site infection post-operatively. Only 2(3.17%) cases required re-grafting for complete coverage of the residual wounds. The mean stay in the hospital was 24+-19 days.

Conclusion: Gauze-based negative-pressure wound therapy on split-thickness skin graft is a cost-effective addition to the care and management of large and complex wounds.

KEY WORDS: Skin grafting; Negative-Pressure Wound Therapy; Degloving injuries;

INTRODUCTION

Negative-pressure wound therapy (NPWT) or vacuum dressings involve the application of a controlled negative pressure on the wound, a method invented in Germany in 1987, when applied for growth of granulation tissue in open fractures, and standardized. It was patented, and published in the United States in 1997 when Morykwas and Argenta studied the use of suction applied to polyurethane foam in wounds.1

In NPWT, also called sub-atmospheric pressure therapy, vacuum assisted closure (VAC), vacuum sealing, vacuum pack therapy, and sealing aspirative therapy, the sub-atmospheric pressure was directed at the surface of the wound through an interface (polyurethane sponge/gauze), allowing distribution of the negative pressure and use of either a constant or intermittent mode of pressure application.

Further utilizing the capabilities of NPWT when it is applied over the split-thickness skin graft (STSG) it proved effective in removal of serous fluid which improved protection against infections that can prevent graft take if allowed to accumulate underneath the graft.2 Also better immobilization of the graft was achieved in anatomically challenging areas (with complicated wound geometries, irregular wound surfaces or wounds subject to movement e.g. joint proximity).3 All the above measures improved the close approximation of graft to the wound bed significantly improving graft take.4

Traditionally, STSGs were fixed with Bolster technique, where sutures are used to fix pressure dressings over the top of recently placed grafts. Taking it a step further in our study we applied an effective and user friendly filler material (surgical roll gauze) on very large defects, which really pose challenge to the cost of wound care of complex wounds for prolonged period.

The objective of the study was to assess the role of gauze-based negative pressure wound therapy on split thickness skin graft in large and complex wounds.

MATERIAL AND METHODS

This descriptive cross-sectional study was conducted at Army Burn Center, Combined Military Hospital Kharian and PNS Shifa Hospital Karachi, Pakistan, from January 2016 to June 2017. Sample size was 63, selected through consecutive sampling technique. Very large and complex wounds which were expected to heal over prolonged time with post healing sequelae, wounds infected with resistant organisms with persistent discharge rendering inability to successful graft uptake, presence of wounds with co-morbidity, extensive war wounds with limited alternate reconstructive options were included in the study. Demographic variables were sex and age in years.

Research variables were type of co-morbidities (DM/HTN/concomitant genito-urinary injuries/none), amount of exudate in the wound bed (low/moderate/high), duration required for wound preparation before placement of NPWT, duration of NPWT dressing post-operatively, dressing charges in PKR (10,000), graft uptake in percentage (90/95/96/98/100), length of stay in days, presence of post-operative infection (yes/no) and requirement of re-grafting (yes/no).

The wound debridement was carried out to prepare the wound bed prior to graft application. The graft was meshed at a 1: 1.5 ratio and stapled to the wound bed (Fig 1). After graft placement, paraffin gauze was placed. The graft was then covered with layers of sterilized gauze and tubing of commercially ilale Redivac drain with second layer of gauze over it. Finally sealed with opsite dressing after applying Tincture Benzoin-co to enhance the adhesiveness of opsite. The tube was then connected to portable suction machine ensuring negative pressure of 80 to 100 mm Hg. The vacuum was set to suction for 10 minutes after every 50 minutes. In more complex wounds with less preparation, the suction protocol was 5 min suction after every 25 min. Same protocol was followed during night where possible. Dressings were changed on every third or fourth day.

Upon removal of the NPWT dressing, the graft site was evaluated to ascertain the "success of graft uptake" (a subjective measurement based on clinical judgment) and a separate assessment of the approximate percentage area of successful and unsuccessful graft take was recorded (an objective measurement of graft success). (Fig 1) Graft sites were subsequently dressed-up with gauze dressing and patients were followed in outpatient clinic weekly after discharge from the hospital.

Data relating to patient demographics, co-morbidities, duration, wound management and subsequent outcome was recorded for all patients. Continuous data with normal distribution were summarized using means and standard deviations (e.g. age, duration of wound preparation before NPWT, duration of NPWT dressing post-operatively and length of stay) and medians and ranges were calculated whereas categorical data such as patient gender, type of comorbidities, amount of exudate in the wound beds, cost of VAC, graft uptake, presence of post-operative infection and requirement of re-grafting were calculated in count and percentages using SPSS version 20.

RESULTS

Out of 63 patients, 42 (66.7%) were males and 21 (33.3%) females, with male to female ratio of 2: 1. The mean age of patients was 32+-15 years. Seventeen patients (26.98%) were having co-morbidities, out of which 13 (20.63%) were suffering from diabetes mellitus, 2 (3.17%) with hypertension, and 2 (3.17%) were having concomitant genitourinary injuries causing fecal contamination of the wounds. Fifty-seven wounds (90.47%) were having moderate (n=34) to high (n=23) amount of exudate in the wound bed. Mean of 8+-5 days (Range=25) were required for wound preparation before the placement of STSG. The mean duration of NPWT dressing post-operatively was 15 days. Dressing charges in 54(85.7%) were less than PKR-5000, 7(11.1%) 5000-10,000 and only 2(3.17%) >10,000. The graft-uptake percentage was encouraging with 90% uptake in 7 cases, 95% uptake in 12 cases, 96% uptake in 6 cases, 98% uptake in 12 cases, and 100% uptake in 20 cases.

Three cases (4.76%) had surgical site infection postoperatively but with no untoward sequelae. Only 2 (3.17%) cases required re-grafting for complete coverage of the residual wounds. The mean stay in the hospital was 24+-19 days.

Large wounds with skin loss is a nightmare for the patients as well as the treating surgeons as it prolongs the duration of treatment and are subject to various complications on the way to healing. Our study included wounds with enormous sizes and complications as evident in Fig. 1 and 2 but with introduction and modification of VAC over graft and effectively reducing the cost by inclusion of commonly available sterilized surgical gauze was our mainstay modality to achieve the successful outcome.

Martinov et al5 followed a case of wound secondary to necrotizing fasciitis for 10 years before declaring a successful outcome as perineal necrotizing fasciitis complicates the situation with contamination by feces and urine. We were able to deal a very complex perineal wound with the same environment in a shorter time and its successful outcome is evident in Fig. 2 (slide 3).

The logical benefits of employing VAC dressings in a wound include arterial vasodilation, stimulation of vascular proliferation, increase in local blood flow, drainage of exudates, removal of edema, and reduction in bacterial colonization as shown by Acosta et al6. Azzopardi et al7 were able to show the evidence of decreased inflammation, and creation of a moist microenvironment beneficial to wound closure and influencing the shape and growth of surface tissues in a way that helps healing. All these factors for the successful graft-take make VAC an important adjunct to be used along STSG with complementary benefits.

Twelve patients in our study had wounds secondary to deep burns and underwent successful STSG with VAC after tedious wound preparation a finding similar to the study carried out by Kantak et al8 as they observed improved rate of revascularization of dermal substitutes and promotion of re-epithelialization of donor sites when wounds were applied with VAC dressings.

The advanced technology associated with the patent VAC dressing module (V.A.C. Granufoam, KCI, San Antonio, Texas)9 makes these devices too complex for routine use due to increased cost of hospitalization and lack of training and motivation of the patient to use them which required further studies testing modifications to reduce cost and easy handling for the patients and attendants but without compromise on results.

When dealing with extensive wounds, sterilized polyurethane foam is not easily available neither cost-effective and hence renders it unusable for frequent change of dressings, on the other hand surgical roll gauze is available in abundance in sterilized form and proves to be cost-effective when wound dressings need to be applied frequently.

Zhao JC10 combined hypertonic glucose along with VAC dressings to reduce the rate of infection at the recipient site with slight benefit but introduction of the fluid in the wound bed needed further processing and preparation and difficult to keep the fluid in the wound bed along application of vacuum. Similarly, other modifications like silver-impregnated dressings as studied by Bukovcan et al11 and antimicrobial-impregnated dressings by Wu et al12 to improve the outcome, although were able to achieve comparable results but when it comes to risk-cost benefits, the simplicity and effectiveness achieved with gauze was unmatchable.

Furthermore, surgical roll gauze is sterilized with less bulk when compared to unsterilized foam causing less pressure to the covering opsite. It is easy to apply and forgiving of complicated wound geometries so it could be an ideal material in this condition. Also if vacuum of the dressing fails surgical gauze can give you time to change the dressing at convenience as there is no threat of surgical site infection by the synthetic un-sterilized material like foam. Also sterilized surgical gause is readily and abundantly available commodity in all the operation theaters everywhere.

There was only one case with poor graft uptake (80%) as multiple factors were involved including continuous fecal discharge nearby causing frequent infections, graft necrosis and frequent leakage of vacuum due to difficult wound geometry in the area of perineum. (Fig. 2) A remarkable study in this regard was carried out by Lee et al13 which involved majority of patients with perineal wounds and all were successfully treated with negative pressure therapy.

Pain as a complication of procedure was not a problem for the patients and in selective cases when observed was secondary to involvement of sensitive superficial nerves and due to pressure by vacuum and bleeding in few cases as a result of involving the large surface area of the wound, often involving the whole chest and whole limb, were the main complications found in our study. Good pain relief with opioids in immediate post-operative period and maintenance of meticulous hydration were the main stay of treatment to that end.

Barendse-Hofmann et al14 published an article in 2009 where they presented the circumferential application of VAC for a degloving injury, we were also able to produce the successful outcome of circumferential VAC application with more ease and lesser cost as evident in Fig. 1.

Although NPWT dressings and devices are more expensive than other wound-care products, cost analysis as done by Koncar et al15 shows lower treatment expenses when used judiciously and with careful patient selection.

CONCLUSION

Gauze-based negative-pressure wound therapy on split-thickness skin graft is a cost-effective addition to the care and management of large and complex wounds.

REFERENCES

1. Argenta LC, Morykwas MJ. Vacuum-assisted closure: a new method for wound control and treatment: clinical experience. Ann Plast Surg 1997;38: 563-76.

2. Fischer S, Wall J, Pomahac B, Riviello R, Halvorson EG. Extra-large negative pressure wound therapy dressings for burns - Initial experience with technique, fluid management, and outcomes. Burns 2016;42: 457-65.

3. Kamolz LP, Lumenta DB, Parvizi D, Wiedner M, Justich I, Keck M, et al. Skin graft fixation in severe burns: use of topical negative pressure. Ann Burns Fire Disasters 2014;27: 141-5.

4. Petkar KS, Dhanraj P, Kingsly PM, Sreekar H, Lakshmanarao A, Lamba S, et al. A prospective randomized controlled trial comparing negative pressure dressing and conventional dressing methods on split-thickness skin grafts in burned patients. Burns 2011;37: 925-9.

5. Martinov S, Ortiz S. Ten-year follow-up of a case of necrotizing fasciitis successfully treated with negative-pressure wound therapy, dermal regeneration template application, and split-thickness skin autograft. Acta Chir Belg 2017: 1-5.

6. Acosta S, Bjorck M, Wanhainen A. Negative-pressure wound therapy for prevention and treatment of surgical-site infections after vascular surgery. Br J Surg 2017;104: e75-e84.

7. Azzopardi EA, Boyce DE, Dickson WA, Azzopardi E, Laing JH, Whitaker IS, et al. Application of topical negative pressure (vacuum-assisted closure) to split-thickness skin grafts: a structured evidence-based review. Ann Plast Surg 2013;70: 23-9.

8. Kantak NA, Mistry R, Halvorson EG. A review of negative-pressure wound therapy in the management of burn wounds. Burns 2016;42: 1623-33.

9. Sachsenmaier S, Peschel A, Ipach I, Kluba T. Antibacterial potency of V.A.C. GranuFoam Silver (R) Dressing. Injury 2013;44: 1363-7.

10. Zhao JC, Xian CJ, Yu JA, Shi K, Hong L. Hypertonic Glucose Combined with Negative Pressure Wound Therapy to Prepare Wounds with Pseudomonas aeruginosa Infection for Skin Grafting: A Report of 3 Cases. Ostomy Wound Manage 2015;61: 28-44.

11. Bukovcan P, Koller J, Hajska M, Zahorec P. Clinical Experience With the Use of Negative Pressure Wound Therapy Combined With a Silver-impregnated Dressing in Mixed Wounds: A Retrospective Study of 50 Cases. Wounds 2016;28: 255-63.

12. Wu CC, Chew KY, Chen CC, Kuo YR. Antimicrobial-impregnated dressing combined with negative-pressure wound therapy increases split-thickness skin graft engraftment: a simple effective technique. Adv Skin Wound Care 2015;28: 21-7.

13. Lee KT, Pyon JK, Lim SY, Mun GH, Oh KS, Bang SI. Negative-pressure wound dressings to secure split-thickness skin grafts in the perineum. Int Wound J 2014;11: 223-7.

14. Barendse-Hofmann MG, van Doorn L, Steenvoorde P. Circumferential application of VAC on a large degloving injury on the lower extremity. J Wound Care 2009;18: 79-82.

15. Koncar I, Cvetkovic S, Dragas M, Pejkic S, Lazovic G, Banzic I, et al. Vacuum-assisted wound closure in vascular surgery-clinical and cost benefits in a developing country. Vojnosanit Pregl 2016;73: 9-15.
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Publication:Gomal Journal of Medical Sciences
Date:Mar 31, 2018
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