VAC Therapy in Large Infected Sacral Pressure Ulcer Grade IV—Can Be an Alternative to Flap Reconstruction?

Abstract

Vacuum-assisted closure (VAC) therapy is a new entrant in wound care after growth factors and alginate or hydrocolloid dressing, in the treatment of pressure ulcers. We have been using this technique for diabetic foot ulcers. A young nondiabetic man presented with a large sacral bed sore after high doses of ionotropes in an intensive care unit for treating severe hypotension. His wound was debrided, and instead of flap surgery in such infected wound, he was treated with VAC therapy. The complete wound healing was achieved in 6 weeks and at half the cost of flap surgery. Moreover, the chances of flap failure and its related complications were eliminated.

Introduction

A pressure ulcer is defined as any lesion caused by unrelieved pressure, resulting in damage to underlying tissue, and is acknowledged to be a clinical challenge for both the clinician and the patient [1]. The unpredictable nature of healing response of an individual patient is influenced by many factors (local and systemic): bacterial load and infection; edema; pressure; moisture; chronic medical conditions or comorbidities such as anemia, diabetes mellitus, and renal or hepatic dysfunction; tissue oxygenation; and nutritional status. This causes the failure of any single therapeutic option and thus requires a multimodality approach.

Normal healing is a linear multistep process that progresses from hemostasis through inflammation, granulation tissue formation, and re-epithelialization, to scar formation. Vacuum-assisted closure (VAC®; KCI USA Inc., San Antonio, TX) therapy produces a closed wound healing, reduces edema, promotes perfusion, and removes infectious materials and chronic inflammatory cells from the wound environment by applying topical negative pressure [2, 3]. It also stimulates blood flow to the wound bed [4], resulting in delivery of fresh leukocytes and plasma that counteract the chronic wound environment. The uniform negative pressure creates tissue deformation and cell stretching, leading to metabolic activity, fibroblast migration, and cell proliferation [5].

VAC or negative-pressure wound therapy (NPWT) has gained widespread acceptance over recent years for the treatment of chronic or delayed wound healing. This case study demonstrates the VAC mode of action in relation to clinical results to describe a model of how it enhances the healing of difficult wounds.

Case Report

A 32-year-old man presented with acute febrile illness with shock in emergency. The patient was having severe hypotension and multiorgan failure, for which he was placed on ventilator and received high doses of ionotropes for approximately 7 days. Despite placement on an antipressure sore mattress, posture changes, and body care, he developed a large ischemic sore on the sacral area (Fig. 1). He was then referred to the surgical department for management of his bed or pressure sore.

Fig. 1.

A large sacral sore extending up to 2 cm from the anal verge

He was taken up for wound debridement, followed by daily antiseptic dressings. However, frequent change of dressings was required because of soakage, associated with foul-smelling discharge. Then, we planned it for VAC therapy.

The Problem Was How to Apply Negative Pressure in the Natal Cleft Area, Near the Anus

The wound was approximated with loose holding sutures (Fig. 2) and a foam piece kept in depth of wound. The paste used for colostomy bags (Adapt paste by Hollister) was used to fill the cleavage, and then, VAC foam could be placed without any leak (Fig. 3a–c). There was significant comfort for the patient and enhanced quality of life as the smell and soakage he had due to stagnant discharge disappeared on day 2 of VAC therapy. The foam was changed and VAC reapplied every fifth day until near-complete healing was achieved, and it took six cycles (Fig. 4). After that, simple dressings were performed for the next 2 weeks. Total recovery was seen in about 2 months (Fig. 5).

Fig. 2.

Holding sutures to keep retraction in check as well as to facilitate VAC application

Fig. 3.

a Wound at the second change of VAC. b Application of Adapt paste to prevent air leak from the natal cleft. c VAC negative pressure working

Fig. 4.

Wound at 6 weeks

Fig. 5.

Complete healing

Discussion

Although numerous papers have been published on VAC therapy, which suggest the technique may have an important role to play in the management of many chronic or infected wound types, the cost of the system is such that some clinicians may be reluctant to use it until further prospective studies have been undertaken to demonstrate its cost-effectiveness in routine use.

General indications for VAC therapy include chronic wounds, acute wounds, traumatic wounds, partial-thickness burns, dehisced wounds, diabetic ulcers, pressure ulcers, flaps, and grafts especially where increased amount of fluid discharge is expected. The main contraindications for use of VAC include malignancy in the wound, untreated osteomyelitis, nonenteric or unexplored fistulas, necrotic tissue with eschar present in the wound, and placement over exposed blood vessels or organs.

Pressure ulcer treatment is known to be costly, although the exact costs have not been definitively demonstrated. What role can NPWT have in reducing those costs? A health economics audit of NPWT cited studies in diabetic foot ulcers, which demonstrated lower costs when compared with saline-moistened gauze. Philbeck et al. [5] estimated the average annual cost for treating each of 100 diabetic foot ulcers to be $23,066 with NPWT and $27,899 with saline-moistened gauze. That study assumed that at 20 weeks, wound healing would be higher in the NPWT-treated group (50 %, compared with 31 % of the control group).

Baynham et al. [6] found that three-stage intravenous sacral and ischial wounds, which were refractory to surgical therapy for the past 10 months, got healed in about 2 months with VAC. The device operated at negative pressure of 125 mmHg with 5 min on and 2 min off cycle.

Marcus et al. [7] presented a prospective study of randomizing 22 patients. Two groups of 11 patients each with pressure sores in the pelvic region were included. The time difference to heal was almost the same in the group treated with VAC (27 days) and the traditional group with Ringer’s solution dressings thrice a day (28 days). However, no hospital stay, reduced costs, and improved comfort were noted in the VAC group.

The system may also be of value in the management of heavily exuding wounds, including those with lymphatic involvement. Little modifications and use of VAC or NPWT technique will give you fantastic results.