Download negative pressure wound therapy

CASE STUDY #1
DEHISCED STERNAL MUSCLE
FLAP, DEHISCED LEG,
ABDOMINAL WOUND
The Patient
•55 years old
•Female
•Married
•5 children
•22 grandchildren
•Non-smoker
CO-MORBIDITIES
• Diabetic
• Hypertension
• Coronary Artery Disease
• Hyperlipidemia
• Probable Sleep Apnea
• Obesity
Treatment Course
Bypass Surgery
10/01
Dismissed from hospital
10/04
Sternal Wound and Donor Site Infection- Readmitted
10/28
Incision and debridement of leg and sternum - sternum removal
11/06
Closure of chest with muscle flap
Debridement of leg wound
11/14
Transferred to NHS Clarkson Hospital
12/05
Hyperbaric Oxygen Treatments Initiated
12/06
Debridement of Sternal/chest/leg wounds - VAC Therapy Initiated
12/12
Treatment Course
Debridement of sternal and leg wounds - abdominal wound
01/13
STSG to sternal and leg wounds with VAC therapy
1/20
Transferred from acute care to sub-acute rehab unit
02/05
sternum
leg
rectus
TRANSFERRED TO NHS
12/05
Sternal muscle flap and donor site are open
Lower leg is dehisced and infected
sternum
leg
rectus
STERNAL, RECTUS AND LEG WOUNDS
IMPROVE QUICKLY
12/12
Use of HBO and VAC therapy along with Multi-disciplinary
approach
leg
rectus
sternum
abdomen
STERNUM AND LEG GRANULATE
ABDOMINAL WOUND DEBRIDED
01/13
Abdominal wound measures 15x10x4cm
sternum
leg
abdomen
SKIN GRAFT TO STERNUM AND LEG
1/20
VAC therapy replaced post skin graft for 5 days
sternum
leg
COMPLETE TAKE ON SKIN GRAFTS TO
LEG AND STERNUM
1/26
At first dressing change grafts have 100% take
abdomen
ABDOMEN CONTINUES TO HEAL
2/5
Patient is transferred to Sub-acute rehab floor
INTERDISCIPLINARY
PLAN OF CARE
• Plastic Surgery
• General Surgery
• Infectious Disease
• Cardiology
• Pulmonary Medicine
• Endocrinology
• Nutrition
• Nursing
• Physical and Occupational Therapy
STERNUM
PHOTOGRAPHIC REVIEW
2
1
4
3
5
RECTUS
PHOTOGRAPHIC REVIEW
1
2
3
4
LEG
PHOTOGRAPHIC REVIEW
2
1
3
4
5
ABDOMEN
PHOTOGRAPHIC REVIEW
2
1
3
CASE STUDY #2
SHOULDER WOUND
OSTEOMYLITIS
REMOVAL OF HARDWARE
THE PATINET
• 39 Years Old
• Male
• 2 Children
• Non-Smoker
• In Nebraska visiting family
CO-MORBIDITIES
• Healthy Young Man
• No co-morbidities
• Wound occurred when dirt biking
Treatment Course
Accident occurred
Closed, grossly displaced clavicle fracture
11/10
Presented at ER
11/15
Surgical reduction/fixation with plate and 6 screws
11/24
Released from hospital without any problems
11/25
Presented with signs and symptoms of infection
11/29
Staph cultured – plate and screws noted to be dislodged
IV antibiotics initiated
12/01
Plate and screws surgically removed
Systemic reaction to Nafcillin and oral dicloxacillin
12/12
Released to home
12/20
Treatment Course
Readmitted for further evaluation of non-healing wound
1/23
Surgical resection of mid third of clavicle with debridement of soft tissue
infection
Infectious disease consulted
1/30
Plastics called in – V.A.C. placed
2/2
Released with home care and V.A.C.
2/7
Clinic follow-up – V.A.C. discontinued-alginate initiated
2/14
IV antibiotics discontinued
2/21
Released from care-healed
2/28
Resection of Clavicle with debridement
VAC placed
2/02
ABDOMEN
First VAC dressing change
2/05
ABDOMEN
Released to home with Home Care
2/07
V.A.C. therapy
IV antibiotics
ABDOMEN
First Clinic Follow Up
2/14
V.A.C. discontinued
Alginate dressing applied
Clinic Follow up
2/21
IV antibiotics discontinued
ABDOMEN
Wound is closed 
2/28
Hypergranulation area in center
Removed with silver nitrate stick
INTERDISCIPLINARY
PLAN OF CARE
• Plastic Surgery
• Orthopedic Surgery
• Infectious Disease
• Nutrition
• Nursing
• Home healthcare
CLAVICLE
PHOTOGRAPHIC REVIEW
1
4
3
2
5
6
CASE STUDY #3
Perineal cyst
Necrotizing Component
Radical Surgical Debridement
THE PATINET
• 51 years old
• Female
• Single
• Smoker
CO-MORBIDITIES
• Diabetic
• Hypertension
• Hyperlipidemia
• Probable Sleep Apnea
• Obesity
Treatment Course
Presented to Emergency Room with Perineal Cyst Infection
Adult Onset Diabetes Mellitus Diagnosis
Massive Infection with necrotizing features
Emergency Surgery for debridement
1/16
Infectious Disease Consult
1/18
Plastic Surgery Consult
V.A.C. Placement
1/24
Sub Acute Care Transfer
1/28
Released to Home
2/28
Healed
4/21
1/24
Vac placed
18cm – length
7cm – width
5cm tunnel @ 4:00
5cm tunnel @ 9:00
1/26
18cm length
5cm width
1cm undermining
0 tunnels
2/14
12cm length
5cm width
2/19
10cm length
4cm width
Released to Home
2/28
9cm length
4cm width
Clinic Follow-up
3/07
6cm length
4cm width
Clinic Follow-up
3/14
6cm length
3cm width
V.A.C. discontinued
Normal Saline Moist dressings
Clinic Follow-Up
03/21
6cm length
3cm width
Clinic Follow-Up
03/28
5cm length
3cm width
Clinic Follow-Up
4/05
2.5cm length
2cm width
Clinic Follow-Up
4/13
2cm length
2cm width
4/21
Healed 
Released from care
INTERDISCIPLINARY
PLAN OF CARE
• Plastic Surgery
• General Surgery
• Infectious Disease
• Endocrinology
• Nutrition
• Nursing
• Home health care
Photographic Review
Groin/peri-rectal
2
1
5
9
6
10
4
3
8
7
11
12
CASE STUDY #4
Perirectal Abscess
Necrotizing Component
Radical Debridement
The Patient
•62 year old
•Female
•Widow
•2 Children
CO-MORBIDITIES
Adult Onset Diabetes Mellitus
• Hypertension
• Hyperlipidemia
• Status Post hysterectomy related to
cervical cancer with abdominal radiation
therapy
• Obesity
• Nutritional Deficit
Treatment Course
Surgical debridement of necrotizing rectal-perineal abscess
Performed at rural hospital
3/24
Further surgical debridement and diverting colostomy performed at rural
hospital
3/25
Transferred to NHS Clarkson for Interdisciplinary care
Infectious Disease Consult
3/26
Hyperbaric Oxygen Treatments Started
Hyperalimentation for Nutrition
3/26
Plastics Consulted
Many organisms
¼ strength Betadine packs q8hours
3/30
Treatment Course
Acute Renal Failure
Atelectasis
Bronchoscopy with Removal of Large Mucous Plug
4/5
Transferred from Intensive Care Unit to Floor
Tube feeding initiated
4/10
V.A.C. Placed
4/13
Respiratory Arrest
Ventilator Placement
4/21
Removed from Ventilator
4/23
Retention Sutures Placed in Wound
4/25
Patient Requested “No Code Status
Last Dressing Change
4/27
Respiratory and Cardiac Arrest
5/1
4/13
Status Post Radical Debridement
V.A.C. Placed
4/16
First V.A.C. dressing Change
4/18
NG tube feeding
Hyperbaric Oxygen Treatments
4/23
V.A.C. continues
I.V. Antibiotics – Hyperbaric Oxygen Treatments
4/25
Retention Sutures placed to encourage
adhesion of skin flaps
V.A.C. continues
4/27
Multiple setbacks
Renal Failure
INTERDISCIPLINARY
PLAN OF CARE
• Plastic Surgery
• General Surgery
• Infectious Disease
• Pulmonology
• Endocrinology
• Oncology
• Nutrition
• Nursing
• Social Services
• Physical Therapy
• Occupational Therapy
Peri-rectal
Photographic Review
1
4
3
2
5
6
7
CASE STUDY #5
Diabetic Foot Wound
Radical Debridement
Partial Bone Removal
The Patient
77 Year Old Woman
Married
3 Children
9 Grandchildren
3 Great Grandchildren
CO-MORBIDITIES
Breast Cancer
Ongoing Chemotherapy
Peripheral Neuropathy
CAD
CABG
Treatment Course
Admission related to acute infection left foot
9/20
Infectious Disease Consultation
Orthopedic Consultation
9/21
Surgical Debridement of left foot
9/24
Surgical Debridement of left foot
9/28
Plastic Surgery Consultation
10/1
V.A.C. Placed 10/3
Prior to first V.A.C.
dressing change
First Metatarsal
debridement for
osteo – bone exposed
Measures
5cm Length
2.5cm Width
4cm Depth
First V.A.C. Dressing
Change
I.V. antibiotic continue
Hyperbaric Oxygen
continues
Measures
3.5cm Length
1.2cm Width
2cm Depth
Last V.A.C. Dressing
Change
Patient dismissed to
home with alginate
dressing changes qod
Measures
2cm Length
0.9cm Width
<0.2cm Depth
INTERDISCIPLINARY
PLAN OF CARE
Plastic Surgery
• Orthopedic Surgery
• Infectious Disease
• Pulmonary Medicine
• Endocrinology
• Nutrition
• Nursing
• Pedorthics
• Physical and Occupational Therapy
Photographic Review
Foot
1
2
3