Email - Feb 17, 2005

Wound Care Information Network

February 17, 2005

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Previous email questions & their replies are listed below. Remember, replies have not been validated for accuracy or truthfulness.

I recently began working in a long-term acute care facility that specializes in ventilator dependent patients and patients requiring wound care. Many of our patients come from the short term facility where they were on a wound VAC. I understand the purpose of the VAC and have seen some amazing results and some disappointments. Since we are long term care, it can be quite expensive because these patients stay with us for at least a month. I have been charged with developing a policy not only for how to use the VAC (that was easy enough to do) but also what therapies to try before instituting VAC. My COO (an RPT) suggested a trial of pulsed lavage before using VAC (makes no sense if the wound is already debrided). What about E-stim or ultrasound? Are these any less expensive and are they effective treatments? Are there any other treatments to be considered in place of VAC? Thanks for your help. Nancy B. RN, CWCN	Both pulsed lavage and e-stim can be very helpful modalities, with different indications. To help grow granulation tissue, ES can be very helpful. Renee Cordrey, MSPT, MPH, CWS --- Hi, I am not a medical professional in any way but I do have a suggestion. Please consider MDT (Maggot Therapy) for your patients. It just became FDA approved last year and is becoming more and more popular, as the great success stories are getting out. Like mine. My name is Pam Mitchell and I had Stage lV diabetic ulcers with osteomyelitis. The maggots not only healed up my ulcer, they also worked on the exposed bone and healed up the osteo. It was totally amazing. The maggots eat only the dead infected tissue and also excrete enzymes to promote healing. Most of for your situation they are extremely cost effective. Please do some research and consider. Thank You, Pam Mitchell Board of Directors BTER Foundation --- YOU MIGHT WANT TO LOOK INTO THE "VERSATILE ONE NEGATIVE PRESSURE THERAPY".(www.blueskymedical.com) IT IS USED MORE IN LTC BECAUSE OF THE LOWER COST. WE USE THIS VS. THE KCI WOUND VAC BECAUSE OF THE PRICE PER DAY FOR PPS PATIENTS. SKILLED AS YOU KNOW, YOU HAVE TO WATCH YOUR DOLLARS. I ALSO WORK AT THE WOUND CENTER AND WE HAVE USED IT THERE ON OUR LTC PATIENTS. IT HAS SHOWN GREAT RESULTS AS THE KCI WOUND VAC DOES. GOOD LUCK. WOUND NURSE - OHIO --- Nancy, The VAC is a good modality. However, there are many considerations to its use. One as you say is the financial aspect. I have had vacs removed from the wounds and we use alginates and other modalities like HVPC. The vac supplies/rental fee are not only expensive but the modality itself does require monitoring. When used appropriately and monitored well, the vac works well. However, if there are staffing issues it can be a problem. For instance, we've seen patients who have active bleeding from the vac and no one follows up sooner to check into potential causes of bleeding, then the vac can be harmful more than helpful. Before you know it, the patient is anemic. The one problem too is when you have staff who might not monitor the patient enough to keep pressure off the area with the vac. We've seen wounds subjected to trauma from the vac tubing end when they lay on this. Then there could be insufficient monitoring of patient responses. I wouldn't use the vac on a protein depleted person who does not get the nutritional support. The vac foams can also be a source for bacterial growth and the wound needs to be monitored for high bacterial load tantamount to infection. If there is adequate 24 hour care and all the staff are trained and comfortable/able to manage the vac, I would advocate for its use. If again there are staffing issues, then dressings which are less expensive and easier to apply for the general staff, not require as much monitoring (such as alginates or alginates with silver plus secondary dressing, etc.), and e-stim might be better. I've compared results and healing rates to me are comparable. It's an educational issue. People think you hook an individual to a vac then the vac can do everything, forgetting that wounds need nutritional support, prevention of infection, good hydration, moisture, minimal to no trauma, etc. But then again, some individuals think the same way with dressings- the typical bandage approach that you cover a wound, then the dressing will do everything. I applaud your efforts to research this. Good luck, Maria Carunungan, DPT, CWS ---- I've been told that a product called hydrofera Blue supplies negative pressure in the range of 60mm Hg. Call the manufacturer 1-860-456-0677 and they will send you information on the negative pressure studies.I have had multiple experiences with the negative pressure, hydrofera wicks out the endotoxins and excess drainage. The correct website is hydrofera.com Sharon
Has anyone used Anodyne therapy and what do you think? (either for wounds or neuropathy)? unsigned	We have used the Anodyne therapy with mixed results. It seems that it works better on acute wounds (not chronic) and diabetic neuropathy. It works differently with everbody but has been successful with burning, tingling, and pain in the feet and legs. Hopefully this will help! Cindy RN WCC --- Anodyne works in that patients do have improved sensation/circulation. However, once its use is discontinued, the neuropathic feet reverts back to its original condition. This suggests to preserve the benefits of Anodyne, you must continue to use Anodyne. This is great if it is not cost-prohibitive and insurances cover it for individual use for maintenance. Maria Carunungan, DPT, CWS --- WE USED THE ANODYNE THERAPY ON AN HYPERBARIC OXYGEN PATIENT AND SHE DID VERY WELL. HER DX WAS PYRODERMA GANGRENOSUM OF THE R GAITER AREA. SHE ACTUALLY BOUGHT THE SYSTEM FOR $2500.00. IT IS USED FOR ALL KINDS OF DX THEY CLAIM. C.ADAMS LPN WCC HBOT
Hello, I have a question that hopefully you may answer for me. I recently started working in a nursing home and I have observed the "wound nurse",who is an lvn, cleaning a stage 4 pressure ulcer with bleach and water. It looks very painful and seems like it would really burn. Is this appropriate cleanser for such a deep and open wound?? I would really appreciate your reply. Sincerely, Crystal (Concerned employee) (responding to a follow up question) I am not sure what else is done to the wound after cleansing. I know an ointment was applied, the wound was packed with gauze, and a bandage was taped over it. It seems that the "wound care nurse" makes the decisions about the care of the wounds.	Crystal, There is what you call "cytotoxic" agents which means these substances actually destroy vital tissue (good, living tissue). Once you do so, you delay healing. Cleaning by irrigating with saline water or sterile water then using some anti-microbial like silver dressings is better because it protects good healthy tissue. Bleach water is as harmful as iodine, etc. The rule of thumb is "you do not pour anything on a wound that you wouldn't use on a mouth sore or your eyes..." Glad you voiced your concern. Maria Carunungan, DPT, CWS --- Diluted bleach is not appropriate for most wounds. Once in a while it is appropriate, but that is the exception not the rule, and only for a few days. Full strength bleach is never appropriate as it is too strong. The physician needs to provide orders for any treatment done, even if the treatment nurse made the suggestion for the plan. Regarding what treatment would be appropriate, it's impossible to say based on what you've written. Treatment is very individualized. What was done may or may not be appropriate for that patient. Renee Cordrey, MSPT, MPH, CWS --- Bleach and water is known as "Dakiins Solution" and it is often used to clean infected wounds. Caution should be used with the strength of the solution and length of time used. It is cytotoxic to granulation tissue. unsigned ---- Crystal- The "bleach and water" solution may be Chlorpactin, whcih has a smell of bleach about it. It is sometimes used for short periods of time (usually not more than 2 weeks) for malodorous, heavily exuding wounds. Most commonly a gauze dressing is saturated with this solution and the wound is lightly packed and covered. A moisture barrier should be used on periwound tissue to prevent maceration/damage. However, to cleanse a wound of any type, there are various wound cleansers on the market as well as NSS. Since you are new to this facility, have you inquired if a wound formulary or algorithm is currently in use? Does your facility have interdisciplinary weekly wound rounds? If so, you may want to look at formulary and participate in the weekly rounds. If these things are not in place, perhaps a committee can be started to develop protocols. Kim, LPN --- Crystal, All I can say is look up Dakin's solution, a lot of surgeons will write orders for Dakin's wet to dry on wounds that have been infected. Some will just order the cleaning with it. Tina (LVN, wound care nurse) --- Cleaning a Stage 4 w/ Bleach? Sounds like Dr. Mengele opened a nursing school. Very inappropriate I would say. I work in wound care and if someone said bleach as wound care, ther would be a problem.---John-LPN-CWCS --- Cleaning a wound with bleach and water is really old school. While the bleach is eating away the dead tissue, it is actually also damaging the good tissue surrounding the wound. I would suggest accuzyme spray to the black necrotic areas and panafil spray to any red granulating tissue. An appropriate cleanser would be normal saline or commercial cleanser such as Sea-Cleanse. S.Mason LPN/Wound care nurse --- WELL, THE ONLY THING I CAN THINK OF IS THAT THIS NURSE IS USING DAKINS SOLUTION OR IS PLAIN NUTS! OH MY, GOOD LUCK WITH THIS ONE. I WOULD BE REPORTING THIS TO THE DON ASAP. C. ADAMS LPN WCC HBOT --- Bleach and water, known as Dakin's solution, has been used for many years in wound care. It is effectively reduces the bacterial load in wounds and supports debridement. It is used in a wide range of dilutions. The stonger concentrations (full stength Dakins--.5% solution) can negatively effect the cells that make new tissue. It is generally used only in highly contaminated wounds for short duration, or if palliative care, not healing, is the goal. A more dilute concentration (0.0125%) is broadly antimicrobial and yet is dilute enough not to impair the activity of the proliferative cells. It is inexpensive and easy to use. I have used this solution with great success in many kinds of wounds for 10 years, both as a cleanser and as a treatment regimen. Trish B. RN, MSN, ANP, CWOCN
I have been diagnosed with cellulitis of the right leg. My condition began approximately 4 months ago. A month and a half ago I was referred to a wound care center where I was placed on IV therapy (Cubacin 750 mg) for two weeks. This was preceded by 2 weeks of oral antibiotics. The first three days the affected area looked 25% better and no other change thereafter. My doctor then discontinued the IV therapy and referred me to a dermatologist. The dermatologist performed a biopsy of the lesion and injected steriods into the lesion (to reduce inflammation) Approximately 3 days later the area on my leg became open, bled and discharged. A new lesion appeared a couple of inches above the first. I returned to the wound care center and the doctor took cultures of the old and new lesions, in addition the nares. The culture of the nose did not grow anything. The culture of the old lesion had heavy growth of lactobacillus. I was placed back on IV therapy, this time (Rocephin 2g) and (Biaxcin 500 mg x 4) orally each day. The biopsy did not indicate any infection. It could have been a cyst that ruptured. The open wound on my leg is still very red and looks as if it is tunneling. The dermatologist injected Kanalog into the old and new lesion to reduce inflammation. The wound care center wants to refer me to another dermatologist. I am hesitant. What should the next course of action be? Could this be a vascular problem? Diabetes late onset? I am at the end of my rope. Thanks. DJ	DJ- you seem to be answering your own questions. When did you last have a complete physical? Is your primary care physician aware of your current issues and concerns? It would not be out of line to see a vascular physician/surgeon. Are the health care proffesionals in the wound care center you have been to certified in wound care? You seem to have a gut feeling that everythign that should be done is not being done. Youu raise some valid points about other possibilities. I would pursue those avenues. Kim, LPN --- I would ask one of the several doctors on the case to refer you to a vascular surgeon. Tina (LVN, wound care nurse) --- why don't you try maggot therapy? unsigned
11 days ago I dropped a very sharp knife from a counter onto the top of my foot. The cut was deep, tedon was visible. I closed the wound with butterfly closures, tight bandage. It held for 2 days until I stretched it in my sleep, reopening it...it healed again even stopped weeping... just last night I put a triple antibiotic petroleum based ointment on it...i thought it would help with healing...I removed the butterflies and the cut while not bleeding, is not attached at the edges it is quite open and opens and closes with the movement of my foot...ugh! Please advise me... should I see a DR for stitches after 11 days?? Because there's no blood, is it healed deeper inside the cut? Did the ointment interfere with the edges of the wound adhearing to eachother?? Will it eventually heal? Thank you very much. unsigned (knife)	You do need to see a doctor, not necessarily for stitches but you didn't say if the knife was clean or dirty. You may have an infection in the wound that is preventing it from staying closed. Tina (LVN, wound care nurse) --- I would show this to a physician to make sure it is not infected. If it is infected, it is better it does not close until the infection (if present) is controlled. It may already be infected as it does not heal well. Also, you need to protect the tendon that it does not dry out and usually you might even have a non-adherent dressing layer around the tendon. You most likely need to protect the ankle by using a splint to reduce motion. Even check into using silver-based dressing to protect against infection. But do need to see a physician. Maria Carunungan, DPT, CWS --- You should see a doctor. It is not possible to give you a good answer without seeing your foot. In the future, anytime you have a deep wound, especially where you can see tendon, you should go to the ER. There is a real risk of serious infection, and tissue damage. Renee Cordrey, MSPT, MPH, CWS
Mom mother developed a pressure wound months ago. It seemingly healed and then she broke her hip. In the hospital, after surgery, the wound reared its ugly head again. She is currently in nursing care while waiting to be full weight bearing. She has dementia and is only walking during her therapy sessions because she cannot remember not to put weight on the leg of the hip she broke. When she entered the nursing facility on January 4, i saw the wound at the end of her spine. It was at worst, a stage 2. The nursing facility says they have been treating her pressure wound but I was shocked when I saw it yesterday, January 19th. It was a stage 4. The wound nurse said that when she checked it Friday, January 15, it was not at all like this. My question is, can a wound go from a stage 2 to stage 4 in five days? All they are doing is keeping in in bed instead of sitting and putting saline on the wound. Is this good enough? I am very worried and hope you can educate me. Thank you, Eileen L. Baker pollywallydoodle@sbcglobal.net	The answer is "yes"... there are three basic things that a wound must have the begin the healing process... 1) it must be clean (free of infection), 2) pressure must be relieved (that doesn't mean that she can never sit up, but that the time that she does needs to be limited), and finally 3) nutrition (if your mom isn't drinking or eating enough protein and high cal. foods to facilitate healing the other two won't matter). Sometimes no matter what the facility does to try to prevent a wound, they can't be prevented. And if we can't for some reason or another meet the three requirements of healing we can't always prevent them from getting worse once they happen. As a wound care nurse, if all three requirements can't be met, the one thing I can try to do is reduce the amount of pain caused by the treatment (even if that means bringing on high power pain meds with the treatment). Tina (LVN, wound care nurse) --- Sorry about your mom. To answer your question, yes a wound can one day be a stage 2 and just as short as a day(even a shift) be staged @ 4. Crazy/impossible as this may sound, it is true, I have seen this with my own eyes. I don't want to be stepping where i shouldn't but I would like to offer you some advice. Now that you are aware of your mothers problem, try to become involved in all facets of her care. Check on her nutritional status, toileting/incontinence sched's etc... Try to do this as upbeat as possible, and you may find greater rewards than you expected. Oh, be consistant with your friendly pestering:) unsigned --- Eileen, Wounds can easily progress from one stage to another depending on what factors are there that can delay healing. With your mother, you have two conditions (the healing fracture and the wound) which require increased nutritional support. The two processes (fracture healing and wound healing are actually competing against each other). Sometimes too there are other conditions a patient has which might delay healing. If it is at the end of the spine (is it by the tail bone?), it is harder to heal because of the proximity to the perineal area so you can easily get infection from fecal or urinary contamination. It might be necessary to culture the wound to see if there is infection. Then also it is in bad spot and you can't sit on it without causing more trauma to the wound. Some even get a check on circulation if the change in the wound might be significant within a short period of time. Ask if they have done labs as it may be your mother is anemic which is common after a surgical procedure or a traumatic event. Is she eating well and drinking enough? There are increased nutritional needs for fracture healing, moreso with a patient who also has another wound. Ask about any support of vitamins? When you've asked these questions, then you can get a clearer picture of her health, not just the wound, which might explain the slow healing, worsening or improvement. The answers will pretty much tell the staff attending to your mother what next step to take once these questions have been answered. Good luck, Maria Carunungan, DPT, CWS --- Yes it is possible for a wound to exacerbate that quickly, but if they are doing good cares it really should not. She should still be gotten out of bed into a chair for short periods of time as part of a repositioning program. Hopefully she is on nutritional interventions, had an albumin check, pressure relief device to chair and bed. Nutritional interventions could include: zinc, protein drinks, multivitamin with iron. I would get a wound and ostomy care nurse involved also. I would think they could be a little more agressive than saline to the wound. Good luck. LPN --- Eileen, Pressure ulcer can degrade and to become worse within a few hours! As about treatment: It is right to avoid sitting (unless it is on 30 degrees tilting position), because, when a person is sitting there is pressure of 300 mm Hg on the spine area, when only 17-24 mm Hg are permitted, so it is OK, that she does not sit, but, they should walk with her and when she is lying in a bed, it should be very good and special mattress ( like viscoelastic) so it is preventing new pressure ulcers or worsening of existing. Wound treatment - try lavender essential oil on gauze - few times a day. Good luck and let me know what happens with the wound. Catty
Hi Everybody, I am a Wound Care Nurse taking care of a 34 year old male paraplegic patient with a bedsore at the left ischial tuberosity with an opening measuring 3 x 2 cm and a very, very deep cavity inside measuring 8 cm with the part of the ischial bone exposed. I am using three pieces of Actisorb Plus 25 as a packing to the cavity cover it with Allevyn Dressing and secure it with Mepore Dressing. I am doing the dressing daily at home. My problem is the wound does not heal for six months already since August 2004 and how will the cavity be filled with tissue and have healing. Could you advise for other treatment I could try? Thank you very much. Frank Jamandre	Frank, Ask about culturing the wound (both aerobic and anaerobic). A deep seated infection can cause slow or lack of healing and even undermining or tunneling. Also, ask the doctor for the possibility of labwork. This can tell you about the nutritional status of the patient and other things about the patient, including hydration. When you have a wound, you have increased nutritional needs. For instance, if you might take 250 mg of vitamin C, a patient with a large wound might need a megadose of vitamin C. Check with the doctor about this. There might also be some other conditions that might prevent a person from "using up" what he eats for wound healing, so tests like prealbumin might be useful. You might ask about an alginate rope dressing with silver. Silver is an antimicrobial and the alginate is good packing material for a deep wound with moderate to heavy drainage. Then you can use the Allevyn as a dressing over the alginate. Also, check on how the patient is positioned in bed? He should not be laying on the side of the wound, maybe alternating laying on his back then laying a quarter turn onto the unaffected side. Best thing to do is look up a wound care specialist in your area. I'd check the aawm.org website. Good luck, Maria Carunungan, DPT, CWS --- You might consider a wound vac in this instance. I am not real fond of them but it could help here. LPN --- WOUND VAC !!!!!!! Tim --- Hello, How is your Pts. nutrition status, very important. I have had a modicum of success with large openings using curasol soaked nu-gauze as packing and covering with Alldress. Respectfully, Chuck R.N. --- Has your patient seen by a wound care physician or been seen in a wound care clinic? You do not mention the characteristics of the wound bed, draingage, odor, etc. Is patient compliant with positioning, nutrition, etc. Also with bone exposure, there is probably an osteomylitis. Has there been any ABT use? Also if you keep the wound lightly packed as you mentioned, this will indeed help with proper cell migration for proper resolution. Has this patient had a previous ulcer in this spot? The dressing you are using will inhibit growth of MRSA , VRE and other bacteria. You may want to pursue, if you have not already, a more indepth assessment of causal factors, patient compliance with plan of care, and is plan of care covering multidisciplinary areas? Kim, LPN ----- I recommend the patient sees a wound specialist who has extra tools available. 6 months is a long time. Try looking at www.aawm.org and www.wocn.org for a specialist near you. Renee Cordrey, MSPT, MPH, CWS --- Frank, I don't think that Actisorb is the best choice, I think it is better to use any hydrogel (NuGel, Curafil, Dermager e t.c.) and to fill ( but not to overfill) the wound with any Calcium Alginate ( Kaltostat, Curasorb, e t.c.) you can also try Polymem ( Polywic) with or without silver. It is very important that you will rinse the wound with plenty of water - to remove necrotic tissue. Remember, it could be biofilm on the wound that disturbs healing and till you remove it - there will be no cure. Also it is important to use right mattress or support on the wheelchair. You can also try some complementary treatement - soft lazer, infrared lamp or Terra Quant ( you can seek for it on Internet) Good luck Catty, RN
I am a dietitian at a small rural hospital. We have a new MD and are now doing more extensive wound care. I would like to do a public presentation, for my diabetic patients on prevention. I have no budget for this type of program. I do have info on foot care etc. from drug reps. Any suggestions? Judith Winter CDN	Judith- this sounds great. Are there any Podiatrists and/or Orthopods on staff who would be interested in giving you information or in participating? Great marketing for potential patients, and potential patients can get a feel for these physicians. Also do you have a WOCN nurse on staff, or is there a wound care clinic in your vicinity that would be willing to also participate? How about your Therapy department, and they could probably recommend an orthotic company who would be willing to also be willing to attend and educate. Cna you video tape this effort? Would your Drug reps be willing to donate anything??? If you do have a WOCN could she get her distributers to donate suplies, etc.? Good luck. Kim, LPN
I have an area of exposed bone on the top of my ankle where the tibia finishes. i had an operation to fit an Illisirov frame due to a broken leg, an insicion was made shin to ankle and most of it healed up except for a small area in the middle. It just got worse until eventually bone was visible. About the size of a shirt button. Now after 4 months and out of hospital its still the same size. District nurses have tried VAC and promogran( which is supposed to promote granulation) and Aquqcell AG (which prevents infection due to the silver in the dressing) but nothing seems to work. Am i expecting too much too soon or is there anything else i can try? Someone at this forum suggested Comfrey root powder, is that a good idea? Thanks for your help, Daniel, London, UK	There is a possibility that you have a bone infection. You should see a wound physician, orthopedic surgeon, or infectious disease physician for it. I know nothing about comfrey root powder for wounds. Renee Cordrey, MSPT, MPH, CWS ----- Dan, It looks like you have tried numerous avenues, that would, in many cases, resolve your wound. In similar cases that I have seen, the wound fails to close due to what is called "epibole" or rolled wound edges. Having not seen your wound, of course, I do not know if this is the case. If your practitioners find this to be the case, they would want to debride the edge which returns the wound to an acute state and forces the wound to resume healing. At that point, you could resume a product like your Aquacell Ag. I would also hope that your physicians have ruled out osteomyelitis, or infection of the bone. Douglas Ross, RN, ACHRN, CWCN Center for Hyperbaric Medicine at Virginia Mason Seattle, Washington
Scientifically, how does the enzyme trypsin work in cleaning wounds and also dissolving blood clots? unsigned 2	Trpsin can activate fibrinolytic mechanism (exposing cleavage site on antithrombin-iii) that dissolves clot forming fibrin split product and fibrin degradation product. Promotion of wound healing by trypsin may be more of proteolytic mechanism on dead/necrotic tissue thus assisting in debridement. Bromelain I think share similar mechanism(extract from pineapple) Ahmed M. Sabo, Jos.
I am really worried that I may be starting to develop a medial molecules venous ulcer.....If it is caught early, can I keep it from going through all of the ugly stages ?? Right now it looks like a possible bruise...no red, but sort of yellowish. I noticed itching a couple of days ago and have seen edema and skin changes for the past 2 to 3 years....my probs started out as varicose veins...had a ligation in ' 91...and spot vein removal in '95. Please write me back and let me know if there is anything at all I can do before it breaks through the skin. Thank you !! Margaret Harris margh522@aol.com	Ask your physician for compression stockings, class III if you can handle it. Until then, keep your legs elevated above your heart, and wiggle your ankles, like you're pressing on a gas pedal, several times each hour. That will help. Renee Cordrey, MSPT, MPH, CWS

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