Treating a non‐healing postoperative sternal wound in a woman with type 2 diabetes mellitus: A case report

Abstract

One of the leading causes of impaired chronic wound healing is diabetes mellitus because it involves many factors that influence the physiopathology of tissue healing. Therefore, it is strategic to analyse clinical cases of this population. We presented a clinical case report of a 51‐year‐old female with type 2 diabetes mellitus, presenting a non‐healing sternal wound after open heart surgery. Appropriate dressing and assessment contributed to the healing of the sternal wound in 5 weeks.

1. INTRODUCTION

Wounds that have failed to heal through a proper and timely reparative process that produces anatomic and functional integrity over a period of 3 months are defined as chronic wounds.1 Causative factors underlying non‐healing wounds can be identified in arterial insufficiency, venous stasis, chronic disease (eg, diabetes), and pressure injury.1 One of the leading causes of impaired wound healing is diabetes mellitus.2 There are many factors that can contribute to the altered tissue‐repairing process of diabetes mellitus (eg, predisposition to diseases such as atherosclerosis or renal failure, predisposition to the development of neuropathy, microvascular disease).3, 4, 5 The presentation of chronic wounds in this patient group can be challenging to manage as microcirculatory deficiencies occur early in diabetes.6 For this reason, the description of case reports of patients with diabetes and chronic wound is strategic to provide insights for clinical practice.

1.1. Case Report

A 51‐year‐old female with type 2 diabetes mellitus treated with oral hypoglycaemic agents was referred to the wound care specialists for a non‐healing sternum wound after open heart surgery in a university hospital in the north of Italy. The patient was referred wound care specialists by the infectious disease specialist. The patient underwent coronary artery bypass surgery on December 2017 with a normal immediate postoperative course. The patient's sternal wound was initially managed using standard protective surgical dressings. During postoperative hospitalisation in the Cardiac Rehabilitation Unit, the patient developed a septic sternal wound dehiscence that led to methicillin‐susceptible Staphylococcus aureus (MSSA) (Figure 1). In particular, the patient had a non‐healing wound that did not improve after 7 months of treatment, which were based on antibiotic therapies (ie, narrow‐spectrum beta‐lactam antibiotic) and negative pressure wound therapy (NPWT).

Figure 1.

Surgical wound 1 month after surgery (January 2018)

She was discharged with NPWT in situ on January 2018. After periodic dressings, the cardiac surgeon interrupted the NPWT on March 2018. As presented by the patient, she had pyrexia onset a few days later, and her wound started draining serum, presenting a dehiscence. For these reasons, she was re‐hospitalised. Again, wound swabs showed an MSSA infection, which was treated by antibiotic therapies (ie, narrow‐spectrum beta‐lactam antibiotic). Sternal wound infection required revision surgery and soft tissue curettage at this point, and NPWT was restarted. After MSSA infection resolution, the patient developed another infection because of Neisseria Elongata, which required treatment with third‐generation cephalosporin. Once the infection resolved, the patient underwent surgery for the closure of the sternal wound, again starting the NPWT on May 2018.

Despite all the treatments, the wound did not present any improvement over 2 months of NPWT. For this reason, the infectious disease specialist consulted the wound care specialist in June 2018 (Figure 2). After clinical status assessment, the wound care specialist thought it appropriate to stop the NWTP to use a bacteria‐ and fungi‐binding dressing (Sorbact). Sorbact was applied as a wound contact layer to remove wound pathogens and avoid chemical agents, protecting the tissue from further wound colonisation. In addition, Sorbact was covered using a standard dressing.7 After 48 hours of using Sorbact, the wound edge and the surrounding wound tissue became softer and lighter in colour. The granulation tissue was more homogeneously distributed and less flaky (Figure 3). By week 2, the wound edges were lower, less indurated, and less inflamed. The wound bed was observed to have a pink colour, associated with positive wound healing and autolytic debridement of fibrin and cellular debris. By week 4, the wound appeared to be almost completely healed (Figure 4).

Figure 2.

Wound assessment at the first visit to the wound care specialist

Figure 3.

Wound assessment after 48 hours of Sorbact dressing

Figure 4.

Wound assessment after 4 weeks of dressings by Sorbact

2. DISCUSSION

This case report shows a complex case of non‐healing sternal wound management in a patient with type 2 diabetes mellitus. Several factors could have affected the healing process over the course of the treatments, such as lifestyle and patient compliance, so it can be difficult to define which clinical change could be associated with the wound healing.8, 9, 10 However, the timing of consultation with the wound care specialist appears to reflect the traditional modus operandi in managing sternal wounds after cardiac surgeries. In fact, the wound care specialist, unlike other wounds (eg, pressure ulcers), did not initially assess the sternal wound because its treatment was initially managed without wound specialist consultation. In this case report, the application of a form of bacteria‐ and fungi‐binding dressing acted as the healing trigger because this form of dressings is able to interrupt the cycle of chronic or prolonged inflammation.11 In fact, after the introduction of a proper dressing scheme, there was an improvement of the sternal wound. The improvements observed with the Sorbact were not detected during the previous 7 months of NPWT.

In conclusion, this case report shows the use of an inert dressing that binds bacteria and fungi, which could be useful to treat chronic surgical wounds in diabetic patients, where the creation of an optimal wound‐healing environment is pivotal to treat the wounds.

CONFLICT OF INTEREST

The authors declare no conflict of interest.

Author contributions

GC, GG, FD, FT, and RC made substantial contributions to the conception and design of the case report. GC and FT also contributed to the acquisition of data. All the authors were involved in drafting the manuscript and revising it critically for important intellectual content, and they also gave final approval of the version to be published.

Castiello G, Ghizzardi G, Dellafiore F, Turrini F, Caruso R. Treating a non‐healing postoperative sternal wound in a woman with type 2 diabetes mellitus: A case report. Int Wound J. 2019;16:713–715. 10.1111/iwj.13085