Upload
others
View
0
Download
0
Embed Size (px)
Citation preview
Four Layer VLU Compression Dressing Appears Safe for Profound Arterial Ischemia:
Moving Water from Subcutaneous Fat is Salutary for Skin Perfusion
Martin J. Winkler Sr. MD FACSCreighton UniversityUniversity of Nebraska College of MedicineOmaha, Nebraska
Alan S. Neil BSc.ASN Associates Indian Shores, Florida
Sara Monica WinklerStanford University, Palo Alto, California
Problem:• Completeinfrarenalaorticocclusion • Partialposttraumaticparaplegia,thuspatientisnota candidate for extra anatomic bypass• Exquisitelypainful,onmultiplenarcotics• NPWTfailedduetomaceration
Problem: • Nonhealingexquisitelypainfulvenouslegulcers• NonagenarianAirCorpveteranservedinoccupiedJapan• Painfulstasisdermatitis• ComorbidCOPDonprednisone,CHFondigoxinand diuretics• Arterialocclusivedisease,ABI 0.25/0.35
Problem:• PostMIICU“TEDsore”• RHeelandcalfnecrosisfollowingMIwithlowcardiacoutput&stupor• Rsuperficialfemoralarteryocclusive disease, ABI 0.31
Problem: Institutionalizedprofoundlyretarded58y.o.male• Llateralmalleolusulcer• ArterialocclusivediseaseABI0.35• Nondiagnosedvasospasm,coldacrocyanoticpedalskinmottling
Thispatienthasapainful,profoundlyischemicRfootwithnoaudiblepedaldopplersignalsin,checkedbyauthoronthreeoccasions.ThisvasculopathhasanoccludedaortawithanABIof0.0.TwoboardcertifiedvascularsurgeonsrecommendedRBKA.Observethemacerationduetovinylcoveringfromunsuccessfulnegativepressurewoundtherapy.Observethreeischemiculcers,exposedlateralmalleoluscapsule,edemaofdependencyandfibrinexudate..Theanklecontracturedeformityistheresultofspinalchordinjuryandpartialparaplegia.
Treatment:• Fuzzywaleelasticcompressiontocontrolswelling,layereddressing to control exudate*• Hypochlorousacid**andultrasonicdebridement***• Bioengineeredskinsubstitute****
Ultrasonicpowereddebridementofforefootwound,***allowsforhumanecontrolofextensivebiofilm.Observeintenseinflammationfromischemicdermatitis,pedaledema,anddeepcornrowfurrowsfromfuzzywaleelasticcompression.*
Observethedeepcornrowfurrowsintheexuberantgranulatingwoundsurface.Weconsistentlyseeimprovedgranulationwhenthefuzzywalessitdirectlyonthegranulatingwoundsurface.Theanecdotalobservationthatfuzzywalecompressionstimulatesgranulationtissue,suggeststhatcontrollingedemaonthewoundsurfacewithfuzzywalecompressionis,likethecontrolofwoundsurfaceedemawithnegativepressurewoundtherapy,NPWT,salutaryforhealing.
Observehealingfiveweekafterbioengineeredskin.****Observethatischemicinflammationandedemahasdecreasedwith5weeksoffuzzywaleelasticcompression.*
Cornrowfurrowsfromfuzzywaleelasticcompressionareseenonthegranulatingwound.Patientlaundershercompressiontextileathomebetweenweeklyvisitstothewoundcenter.Fuzzywalecompressiononthehealingsurfaceseemstospeedhealingbyreepithelization.Reepithelization,wenowbelieve,isduetodaughtercelldivisionfrombonemarrowderivedcirculatingepithelialprecursorcellsthatarerecruitedtothewound.
Outcome: Completehealingwithoutscarring
Notecornrowfurrowsinskinandcompletehealingwithoutascar.Healingwithoutscarissaidtobeevidencethat
circulatingepithelialcellprecursorsareatwork.Itisnowunderstoodthat
chemical signals from the living allograft cellsstimulatethebonemarrowtorecruit
circulatingepithelialcellprecursors.Thesecirculatingepithelialprecursors
colonizethewound.Multiplegenerationsofdaughtercellsspreadoverthesurface
andclosethewoundwithminimalscarring.
Observethedeepcornrowfurrowsthatresultfromedemafluidmovingoutof
thesubcutaneousfat.Fuzzywaleelasticcompressionstockinet*haseffectivelytreatedthepreviouslyinflamedswollendermatitis.Webelievethatfuzzywale
elasticcompressionimprovedthesurvivalofcirculatingepithelialprecursordaughter
cellsinthispatient.
Edematousredskinistheresultofvenousstasisdermatitis.Painpreventedadequatedebridementatauniversitywoundcarecenter.Theseulcersweretreatedonandoffforfourmonthswithcollagenaseointment.Anklebrachialindexwas0.25/0.35,R/L,performedinthewoundcenter.Comorbiditiesincluded:Atheroscleroticperipheralvasculardisease,VLUpresent>6months,oralprednisoneandnasaloxygenforCOPD,CHFwithedemaofthelimbsrequiringdiuretics.
Photoofpatientafterseveralmonthsoffuzzywaleelasticcompressiontherapy.Photoshowscornrowfurrowsintheskinthatisnolongeredematous,inflamedandred,andpainful.Whereoncetherewaspainful,swollen,at-riskskin,brightredwithdermatitis,nowthereishealing. Unfortunately the venous leg ulcersarestillpresent.FourweeksofwoundcentertherapypassedwithanoimprovementinthesizeoftheVLUs,suggestingthat“advancedwoundtherapy“wasrequired.
Treatment:• Fuzzywaleelasticcompression*startsatweek#4• Twoapplicationofbioengineeredhumanskinsubstitute****• Ultrasonicpowereddebridement,***Hypochlorousacidirrigation(HOCl)**
ThispatientillustratesseverallessonsontreatingVLUs,venouslegulcers,withfuzzywaleelasticcompression.Sharpdebridementatthefirstvisit,asshowninphotoabove,waslimitedbypain.Adequateelasticcompressionwaslimitedbypainfuldermatitis.Atthefirstvisit,todelivercompressiontothepainfulskin,aRobertJonesdressing,withfuzzycottonbattingagainstthedermatitis,ACEwrapandCobamdressingwasapplied.AfterfourweeksofRobertJonesdressing,swellingandpaindecreasedtothepointthatstandardfuzzywaleelasticcompression*couldbestarted.Asaresultofthispatient,andotherpatientspresentingwithpainfulVLUsthatstandardelasticcompressionwasnotpossible.InresponsetoourexperiencewiththisWWIIveteranofthePacifictheatre,wedevelopedafuzzywale“LITE”elasticstockinet*thatdeliverslesscompressionandiscomfortableforinflamedpainfulskinsuchasseeninthephotoabove.
Photoshowsthevenouslegulcers(VLUs)being“grafted”withbioengineeredskinsubstitute,ahomograftofbi-layeredepithelialcellsderivedfrominfantforeskin.Aonemillimeterskinbiopsypunchwasusedtofenestratethelivingcellallograftgraft,notethecrescentshapedincisionsintheculturedskin.Thesebioengineeredtissueculturedepithelialcellswillsurvive~2weeksonthiswound.Whiletheyarealivetheseallograftcellssendstrongmessagestothebonemarrowtorecruitcirculatingepithelialprecursorcellstothewoundbed.CurrentresearchsuggeststhatisthedaughtercellsofcirculatingepithelialprecursorsacttoclosethewideflatVLUwounds.Thetransientresidenceofallograftcellsishighlyeffectiveforrecruitingepithelialcirculatingprecursorcellstothegranulatingwound.Anecdotalcasestudiessuggestthatfuzzywalelongitudinalcompressiontextilecreatesahighlyeffectivewoundmilieuintérieurthatissalutaryfortheincubationofmultiplegenerationsofdaughtercellsrequiredforepithelialcellcoverageofthewoundbed.
CompleteVLUhealingrequiredasecondapplicationofbioengineeredhumanskin,10weeksafterthefirstbioengineeredskingraft.****Culturedepithelialcellsfromhumaninfantforeskinsendpowerfulsignalstothebonemarrow—mobilizeepithelialprecursorcellstoclosethewound.Theselivingbioengineeredepithelialcellsdonotsurvivemuchbeyondtwoweeksonthewoundsurface.
Outcome:• Inflammationfromstasisdermatitisdisappearsafter~4monthswithfuzzywaleelasticcompression*• CompletehealingoftheVLUsat~11months• Twoapplicationsofbioengineeredskinsubstitute****
CompleteresolutionofthestasisdermatitisandcompleteVLUhealing.Healingwascomplicatedinthispatientwitharterialocclusivedisease,anklebrachialindexABI0.25.
Observenecroticheel,inflammationandmassiveedemafiveweeksafterdischargefromtheICU.Heelpressuresores are rare in the absence of arterial occlusive disease. This94y.o.nonsmoking,nondiabetichadABIof0.30. Thesenecroticlesionsresultedfromlowperfusionand“pressure”ontheheelwhilecoveredbyTEDhoseinauniversityICUinthefivedaysfollowingaMIwithstupor.TEDhosearenoteffectivetopreventpulmonaryembolus.TEDhosecan,asinthispatient,beharmful,byobscuringtheclinicalfindingsthatestablishthestatusoftheskinperfusion.
Treatment:• Fullthicknesseschardebridementin clinic• AngiogramwithpercutaneousRfemoralatheroectomy*****inresponsetodelayedhealing
Woundisstalledafter7weeksoftreatment.Vascularsurgeryandcardiologyconsultscamebackwith“lowcardiacejectionfraction,<18%,makesthispatientunfitforvascularintervention(normalEF>65%).”Consultationwithcardiologyleadtoalowimpactalternativeplan:cardiologyservicewouldperformalowimpactRlimbangiogramandperformapercutaneouspoweredcatheteratherectomytotheRfemoralandpoplitealartery..
Woundsarehealing~10weeksafteratherectomybycardiologyservice.****
Limbstillappearsedematousaftermonthsoflayereddressing.Woundsappearreadyforasplitthicknessskingraft.Importantly,in2007wewereNOTyetusingFuzzywaleelasticcompressionstockinetonprofoundlyischemiclimbs.ThedecisionforSTSGrequiredacardiologyconsulttoclearpatientforlocalanesthesia.
Outcome:• Fuzzywalecompressionspeedsmaturationofskingraft,STSG• FuzzywalecompressiontoughensupSTSGandpreventsheelgraftfromrecurrentbreakdown
Firstsplitthicknessskingraftdressingchange02/06/2007showscompletetakeoftheSTSG.Observeextensivelimbedema.
During the treatment ofthesewound,edemafromCHFremained a constant comorbidproblemforthispatient.Afterthe skin graft second dressing change, wetriedfuzzywaleelasticcompressionfor calf edema control.Inspiteofour initial fears fear thatpoorperfusionmight result from fuzzywaleelasticstockinet, results on thecalfandhellweredramatic, as seen above.Inoneweekoffuzzywaleelasticcompression,thecalfSTSG(asseenabove)dramatically“toughenedup”.
PhotoshowsbreakdownofSTSGonheelandextensiveedema~10weeksafterskinsurgeryinspiteofpaddeddressingandRookeboot.Becausefuzzywalecompressionhelpedtoughenthe calf skin graft, the decision tousefuzzywaleelasticcompression*directlyontheheelwasmade.Afterthispatientexperience,webeganusingfuzzywalecompressionto control edema in all ischemiclimbswithulcerationandischemicdermatitiswithconsistently good results.
Purpose: Moffatt,atCharringCrossLondon,introducedfourlayer dressings for venous leg ulcers that have been widelyembracedaroundtheworld.(1,2,3)Afterextensive use, initial concerns about arterial necrosis duetoexcessiveconcentriccompressionlayershavenotbeenrealized.InitialDopplerpressure,ABI,guidelines,setuptoprotectfromischemiccomplication,stated‘…compressionisnotusuallyrecommendedwithanAPBIoflowerthan0.8,’arenotwellsupportedbyclinicaldata.(4,5)Kozenyintroducedfocusedfuzzywaleelasticcompression(FWC)stockinetin2007thatlimitscompressionto20%oftheskinsurfaceandrapidlymoveswateroutofsubcutaneousfat.(6)NoDopplerbloodpressureguidelineswereadvocated.Thiscase series and extensive clinical use suggests that FWCisnotonlysafe,butmaybetherapeuticforat-risk ischemic skin.
Methods: FWCwasusedastheelasticengineofa four layer dressing to treat four chronic VLUswithcomorbidprofoundarterialischemia.
Results: Photos document technical details of therapyandthehealingofallwounds.
Conclusion: Fuzzywaleelasticcompression,FWC,appearssafefortheelasticcompressionofVLUswithco-morbidarterialocclusivedisease.TheobservationofhealinginspiteoflowABIvaluesraisesthepossibilitythatfocusingfuzzywalecompressionon20%oftheskinsurfaceimprovesarterialperfusionof at risk skin..
References:1.Moffatt,Christine;Four-layerbandaging:fromconcepttopracticePart1:Applicationofthefour-layersystem,http://www.worldwidewounds.com/2004/december/Moffatt/Developing-Four-Layer-Bandaging.html#summary2.Moffatt,Christine;Four-layerbandaging:fromconcepttopracticePart2:Applicationofthefour-layersystem,http://www.worldwidewounds.com/2003/september/Thomas/New-Compression-Bandage.html3.FranksPJ,MoffattCJ,ConnollyM,BosanquetN,OldroydMI,GreenhalghRM,etal.Factorsassociatedwithhealinglegulcerationwithhighcompression.AgeAgeing1995;24(5):407-10.4.RCNInstitute,CentreforEvidence-BasedNursing,UniversityofYork,SchoolofNursing,MidwiferyandHealthVisiting,UniversityofManchester.Clinicalpracticeguidelines:themanagementofpatientswithvenouslegulcers.London:RCNInstitute,1998.5.MarstonW,VowdenK.Compressiontherapy:aguidetosafepractice.In:Understandingcompressiontherapy:EWMAPositiondocument.London:MEPLtd,2003;11-17.6.KozenyD,StottK,Longitudinalyarncompressiontextile:Aninnovativetreatmentforlegswelling.JournalofVascularNursingVolume25,Issue3,Page62,September2007.
Product Suppliers:*EdemaWear®,EdemaWearLITE™,CompressionDynamicsLLC,Omaha,NE;Staytex™,AnacapaTechnologiesInc.,SanDimas,CA
**Vashe®,PuriCore,Malvern,PA
***SonicOne®,MisonixInc.,Farmingdale,NY
****Apligraf®,OrganogenesisInc.,Canton,MA
*****SilverHawk™PlaqueExcisionSystemwithProprietaryMECTechnology,Coviden,Plymouth,MN
InitialtherapyatinstitutionwasafauxsheepskinRookeBoot,stomaadhesivetoprotecttheLlateralmalleolousfromtraumaandfuzzywaleselasticcompressiontocontroldependentedema.
Observeskinmottlingandchronictoenailchangesconsistentwitharterialocclusivedisease.Anklebrachialindex,Llegis0.3.Highdoseantipsychoticmedicationsareknowntocausealphaadrenergicvasocompressionoftheskin.Antipsychoticmedicationmayhavecontributedtothemottledcoldskinchangesweseeinthispatient.Afteroneweekoffuzzywaleelasticcompression,notecornrowfurrowsintheskin,themottling is less.
Treatment :• Negativepressurewoundtherapy(NPWT)• Fuzzywaleelasticcompressionstockinet*
Observedramaticimprovement,after~8weeksofelasticcompression,andbilateralfauxshearlingsheepskininappearanceoftheskin.Skinmottlingandedemahavedecreased.NPWTdeviceisheldinplacebyfuzzywaleelasticcompressiontextile.Theoutcomeofthis2007caseopenedoureyestothepossibilitythatfuzzywaleelasticcompressionwasnotonlysafe,buthelpful,salutatoryforprofoundlyischemicskin.
Outcome:• Lateralmalleolusulcer healsin~11wks• NPWTx4weeks• Fuzzywaleelasticcompression&Rookeboot
Notegastrostomyfeedingtubeatlefthip,musclewasting,trunkalobesity,andbrightredlips,consistentwithchronicpoornutritionalstate.Patientwasonhighdoseantipsychoticmedicationswhichareknowntocausealphaadrenergicvasocompressionoftheskin.Antipsychoticdrugsmayhavecontributedtothemottledcoldskinchangesweseeinthispatient..
InthisphotoNPWThasbeendiscontinued.Observetheskin,afterweeksoffuzzywalecompression,isnolongermottledcornrowfurrowsaredirectlyonthehealingwoundsurface.Severalweekslatertheescharfelloffthehealedwound.Importantlyintermsofcost,noangiogramwasorderedandnoinpatientcarewasrequired.Thispatient’sgoodoutcomewithfuzzywaleelasticcompression,earlyon,encouragedustousefuzzywalecompressiononotherpatientswithischemiclimbs.Wenowbelievethatfuzzywaleelasticcompressionstockinetistherapeuticforischemicskin.