Adámková M., Tymonová J., Zámecníková, Kadlcík M., Klosová H.

Burn Center of the FNsP Hospital, Ostrava, Czech Republic

SUMMARY. Morykwas and Argenta developed Vacuum Assisted Closure (VAC®) in the early 90s for the treatment of tissue defects. In 2004 for the first time at our workplace, we used this method in the treatment of six patients between 54 and 91 years of age. Two of the patients were treated for a varicose ulcer on a lower extremity, two patients for loss of skin after an inflammation secondary to infection, one high-risk patient for deep burns, and one patient for a deep defect caused by an inappropriate medical care. We observed blood circulation improvement in all patients, which permitted an early dermo-epidermal graft.

Key words: wound healing, subatmospheric pressure, granulation, infection, economic gain

INTRODUCTION

  Surgical ass well as many non-surgical disciplines are involved in wound care. This problem often concerns senior citizens and patients with multiple diseases, worth preventing extensive surgical intervention with high-risk anaesthesia. Secondary diseases associated with chronic wounds, permanent or repeated pain during wound care, frequent hospitalisations, and exclusion from social life lead to a decreased quality of life and social separation. The financial strain resulting from long-term treatment of chronic defects - for patients as well as the financial provider-is also significant (7, 5). In the early 90s two plastic surgeons, Argenta and Morykwas, developed a method of treatment using subatmospheric pressure: Vacumn Assisted Closure (VAC®). This method speeds up the wound closure procedure, bringing about a significant improvement in the field of wound care (1).

  The method is based on both experimental findings and clinical experience on the part of Argenta, Morykwas and Dersche, indicating that subatmospheric pressure leads to a reduction of edema in the tissue surrounding the wound, improvement of blood circulation, acceleration of tissue granulation and a significant reduction of wound bacterial infection. Vacuum at the level of-125 millimetres of mercury applied intermittently for 5 min utes with a 2-minute break leads after 15 minutes to a quadruple increase of blood flow. Histology confirms that after 8 days the tissue granulation increases by 103 ± 35.3% (8). The positive impact has been verified on blood flow after burn injuries (4, 8), healing of auto-grafts (7), and healing of Integra in inconvenient locations (6).

  The hermetically-closed VAC® system contains a polyurethane or polyvinyl-alcohol sponge of variant pore sizes and a non-contractible tube through which edema and wound exudate is sucked into a closed container, which is inside a vacuum pump. The sponge is attached to the wound by an impermeable film. (Fig. 1, 2, 3.)

MATERIALS AND METHODS

  In 2004 we used this method for the treatment of six patients with subacute and chronic wounds. The patients were previously treated between 11 days and 18 years eartier, in various locations. The age range was from 54 to 91 years. Three patients were over 80 years old. The causes of the wounds on lower extremities were crysipelas, venous and combined insufficiency, and burns. In the upper extremity. it was a paravenous application of cytostatics, and on one patient, a defect after excision of an extensive carbuncle. All patients concerned had concomitant diseases which could have been the primary cause of the prolonged wound healing. The most common secondary disease was coronary disease, hypertension, and anemia. We applied negative pressure to wounds at 2 to 3 day intervals after debridement of necrotic tissues. The maximum period of treatment was 13 days. In all patients we used continual therapy with a gradual increase of vacuum from -75 to -125 millimetres of mercury, according to tolerance, and we used a black polyurethane sponge with larger pores. All wounds showed improvement of blood circulation, increase of granulation tissue at the expense of fibrin deposits. As a result of our first experience with the VAC system, we have assessed the wound changes only clinically. As opposed to other authors (8), we did not notice except in two cases - significant bacterial reduction; this may well be due to the brief application and the lower frequency of foam changes (Table 1).

  Dermo-epidermal grafting followed and was completed between one and 12 days after completion of the negative pressure treatment. During that time we applied Octenisept to the wounds daily. For one patient the antibiotic unit recommended the local use of Colimycin. For three patients Ofloxacin supplemented the treatment due to wound infection. Two patients required vasodilatation infusions due to atherosclerotic obliteration in the lower extremities. All transplants healed well despite transitional epidermolysis in two patients. The average time of hospitalization from starting to employing the VACS system was 32 days. The time of hospitalization could have been even shorter if two-thirds of the patients' social situation had allowed it (Table 2).

CASE STUDY

  A 56-year-old female with hypertension, non-insulin dependent diabetes mellitus and obesity was admitted with a defect on the right side of her back 10 days after excision of an extensive carbuncle. Vacuum at the level of -125 millimetres of mercury was applied 5x2 and 1x3 days. On the second day after the treatment completion we performed skin grafting. Healing wan complicated by epidermolysěs and development of small defects after part of the transplant dissolved. After 33 days the patient was discharged to home care. (Fig. 4, 5.)

  A 70-year old male with a history of universal atherosclerosis, coronary disease. fibrillation and liver disease wan transferred from the infection unit. where he had been hospitalized for necrotizing erysipelas at the tibia and on the dorsum of his right foot. Subatmospheric pressure at the level of 125 millimetres of mercury was applied 2x2 and 1x3 days. Due to the Staphylococcus aureus and Enterobacter faecalis infection in the originally non-contaminated wound, we applied Octenisept two times a day. On the ninth day we perforated dermo-epidermal grafting. The patient was discharged and went home 30 days after initiating VAC treatment. The patient had three remaining defects in the dorsum of the foot with a size about 1.5 cm². (Fig. 6, 7.)

  An 80-year old female repeatedly hospitalized with n varicose ulcer on her left lower extremity, postthrombotic syndrome, and a chronic venous insufficiency of the III rd degree. AL the same time the patient wan being treated for comary disease with angina pectoris and blockage of the right bundle branch, hypertension, anemia, and universal atherosclerosis, She was treated 20 days. Due to signs of increased bleeding, we discontinued the suction for two days and applied it again for another two days. Due to the Pseudomonas aeruginosa, Providencia stuartii and Alcaligenes faecalis infection we applied Colimycin dressing for 12 days with the recommendation from the antibiotic unit. On the following day we performed a dermo-epidermal grafting. The period of therapy from the beginning of suction treatment was 40 days.

  A 54-year-old male with a metastatic carcinoma of the bronchi to hilar glands and left adrenal gland with coronary disease, atrial fibrillation, hypoproteineměa, hypoalbuminemia, and hyperglycemia was admitted due to a wound after a paravenous application of cytostatics. Necronectomy was performed in another surgical unit. Vacuum at the level of-125 millimetres of mercury was applied for 2x3 days. We performed a dermo-epidermal graft two days after completion of the treatment. The patient was discharged after 22 days.

  A 91-year-old male with combined varicose ulcer was treated with a remittent effect for 50 years. For the last 10 years the ulcer had not healed. The patient has a history of coronary disease, obliterating atherosclerosis in lower extremities, hypertension, and glaucoma. The patient was psychologically in good condition. We applied VAC for 2x3 days with subatmospheric pressure at the level of 125 millimetres of mercury. We performed dermo-epidermal grafting on the second day after completion of his treatment. The patient was infused by vasodilators during his entire treatment. Healing slowed down due to partial epidermolysis. After 35 days, the patient's wound healed and the patient was discharged.

  The treatment of a 90-year-old male patient admitted with a skin defect on his left tibia and dorsum of his left foot after a burn injury was more problematic. At the same time. the patient sustained open fracture to his tibia and therefore had a defect on die medial side of the leg. The patient was confused, dehydrated, anemic, and had hypoproteěnemia. The patient also had a left pleuropneumonia and significant universal atherosclerosis involving mainly both lower extremities. The length of treatment before the beginning of vacuum treatment was about 40 days. VAC was applied for 3x2 days. Secondary to severe complications we postponed and performed the dermo-epidermal grafting in six days. The graft was healing well. Vasodilatation infusions were administered throughout the treatment. After 32 days, the patient was transferred to his original place of residence to complete the treatment.

  In order to achieve good results with the subatmospheric pressure treatment it is also necessary to take into consideration the patient's general condition, adjustment of his/her internal balance, stabilization of diabetes, and correction of malnutrition.

DISCUSSION AND CONCLUSION

  Healing of chronic wounds in a problem from the patient's as well as the economic perspective. The VAC® method developed by Argenta and Morykwas (I) and verified by many other authors (7, 4, 6) brings improvement in wound care. This method is less Successful in areas where the use of vacuum is difficult to apply regal-ding anatomical variety, such as in the area of perineum (6, 3). We did not notice any significant impact on the bacterial contamination of the wound treated by VAC, which the other authors report (8).

In conclusion, we have verified other authors' findings that Vacuum Assisted Closure leads to a shortening of the time necessary for wound healing in extensive and a long-term treated defects, which is a great advantage for the patient and at the same time, it is a significant economic improvement.

REFERENCE

1. Argenta, LC.. Morykwas, M.J. Vacuum-assisted closure. a new method for wound control and treatment: clinical experience. Ann. Plast. Surg., 38, 1997, p. 563 - 576.
2. Kamoltz, LP. Andel, H., Haslik, W., Meissl G., Frey M. Use of sub-atmospheric pressure (VAC®) to prevent the progression of partial thickness burns: first experiences. European Surg., Acta Chir Austr., 35, 2003. p. 24 - 26.
3. Lange. W., Kopf. Ch., Haidinger, W., Haidinger, D. V.A.C.® - und Mini-V.A.C.® - Therapie bei ausgedehntem Weichteildefekt im Bereich des Beckenbodens. European Surg., Acta Chir. Austr, 35, 2003. p. 191, 12- 13.
4. Morykwas, M.J. et al. Use of subatmospheric pressure to prevent progression of partial-thickness buns in a Swine model. J. Burn Care Rehab., 20, 1999, p. 15 - 21.
5. Nord, D. Gesundheitsokonomische Aspekte der VAC.® - Therapie. European Surg., Acta Chir Austr., 35, 2003, p. 27 - 28.
6. Schiestl, CM., Reichman, E., Meuli, M. The positive effect of negative pressure: Fixierung von Integra artificial skin® bei Kindern. European Surg., Acta Chir Austr., 35, 2003. p. 16 - 17.
7. Schneider, AM.. Morykwas, MJ., Argenta, LC. A new and reliable method of securing skin grafts to the difficult recipient bed. Plast. Reconstr. Surg., 102, 1998. p. 1195 - 1198.
8. Zoch, G. Das Prinzip der vakuumunterstutzten Wundbehandlung. European Surg., Acta Chir Aust., 35, 2003, p. 3 - 5.

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