Negative pressure wound therapy‐assisted dermatotraction for the closure of large open wounds in a patient with non‐clostridial gas gangrene

Abstract

Case

A 53‐year‐old woman developed septic shock associated with non‐clostridial gas gangrene. She presented to the emergency department with two large open wounds on both thighs and in her sacral region. Non‐enhanced computed tomography showed air density in contact with the right iliopsoas, which extended to the posterior compartment of the thigh. We made repeated efforts at surgical debridement of the wound with resection of necrotic tissues.

Outcome

Using negative pressure wound therapy‐assisted dermatotraction, the pus pockets and the wound dehiscence decreased in size. Using this method we were successful in achieving delayed closure without skin grafts.

Conclusion

Negative pressure wound therapy can be an effective treatment for large and infected open contoured wounds. Negative pressure wound therapy‐assisted dermatotraction might be beneficial for poorly healing, large, open wounds in patients in poor condition and with insufficient reserve to tolerate reconstructive surgery.

Introduction

Negative‐pressure wound therapy (NPWT) is a therapeutic technique to promote healing in both acute and chronic wounds.1 Although the use of NPWT should be avoided for infected wounds, the use of NPWT in the treatment of soft tissue infection has been reported.2, 3 Dermatotraction was evaluated as an alternative method for the gradual closure of wounds. Negative‐pressure wound therapy‐assisted dermatotraction is reported to be an effective method for large, open wounds.3, 4 This paper presents a case of NPWT‐assisted dermatotraction for the delayed closure of large, open contoured wounds in a patient with non‐clostridial gas gangrene.

Case

A 53‐year‐old schizophrenic woman developed non‐clostridial gas gangrene. She was found at home between a toilet and a wall where she had been trapped for 4 months. On admission, septic wounds were noted in both the right and left posterior thighs (Fig. 1), and in the sacral region. Two of these wounds spanned areas of 18 × 8 cm and 15 × 4 cm extending from the posterior aspect of the thigh to the buttock. The wound at the sacral region was 10 × 5 cm in area. Her vital signs were as follows: blood pressure, 97/27 mmHg; heart rate, 145 b.p.m.; and respiratory rate, 18 breaths/min. A complete blood cell count showed white blood cells at 22,300/mm³. Serum electrolytes revealed: sodium, 134 mEq/L; chloride, 97 mEq/L; bicarbonate, 12.6 mmol/L; creatinine, 1.34 mg/dL; blood urea nitrogen, 108 mg/dL; and glucose, 217 mg/dL. The hemoglobin A1c result was 6.3%. Non‐enhanced computed tomography showed air density in contact with the right iliopsoas, which extended to the posterior compartment of the thigh. Air density was also noted in the left posterior compartment of the thigh (Fig. 1A–C).

Figure 1.

A 53‐year‐old woman developed septic shock associated with non‐clostridial gas gangrene. On admission, non‐enhanced computed tomography showed air density in contact with the right iliopsoas muscle (A) (arrows), and air density extending from the wounds to the bone (B). Air density and fluid collection (arrows) were also noted in the posterior compartments of the thighs (C). The patient presented with a partially necrotized gluteus maximus (D). The extents of the pocket are illustrated (E).

Thorough mechanical irrigation of the wounds was carried out using normal saline. The patient also presented with a partially necrotized gluteus maximus infested with maggots. There was a small amount of granulation tissue in the wounds. We performed surgical debridement with resection of necrotic tissue and drainage of the infected areas (Fig. 2). The wounds were dressed with gauze. We administered 0.5 g meropenem i.v. to the patient every 8 h.

Figure 2.

Use of negative‐pressure wound therapy (NPWT) and NPWT‐assisted dermatotraction in a 53‐year‐old woman who was admitted with two large open wounds on both of her thighs and in her sacral region. After daily debridement (hospital day 2) (A, D), NPWT was applied to the large, open wounds (hospital day 4) (G). Dermatotraction (hospital day 10) (B, E); NPWT‐assisted dermatotraction (hospital day 10) (H) was used where the wound dehiscence had decreased in size. We successfully carried out delayed closure without skin grafts (hospital day 30) (C), (hospital day 35) (F), (hospital day 81) (I).

After daily debridement and resection of residual necrotic tissues in the intensive care unit (Fig. 2A, D), NPWT was applied to the patient's open wounds (Fig. 2G). We set the NPWT device to provide a continuous negative pressure at 125 mmHg. The dressings were changed every 2–3 days to prevent infection. At this point, foam‐based NPWT (V.A.C. ATS Therapy System; Kinetic Concepts Inc., Tokyo, Japan) was applied to the sacral region; for both of the thighs we used gauze‐based NPWT (RENASYS GO; Smith & Nephew Inc., USA). Non‐enhanced computed tomography showed no residual dead space in the soft tissue (Fig. 3A, B). Air density in the right retroperitoneal cavity was also spontaneously resolved.

Figure 3.

Gauze‐based negative‐pressure wound therapy. A, B, Non‐enhanced computed tomography demonstrated saline‐soaked gauze (arrows) placed into the contoured wounds and pus pockets with no dead space (hospital day 7).

Although we identified granulation tissue 2 weeks after initiating NPWT, dehiscence of the wounds remained. Subsequently, we started the use of NPWT‐assisted dermatotraction (Fig. 2B, E, H); as a result, on postoperative day 11 we were able to successfully carry out direct closure of the wounds without skin graft (Fig. 2F). We stopped antibiotics after 7 days of use with no evidence of local infection. On day 18 of admission, the serum C‐reactive protein level was gradually increased and wound cultures grew Proteus mirabilis and Enterococcus faecalis, which were sensitive to ampicillin. Therefore, antibiotic treatment was resumed with ampicillin for fear of local infection (Fig. S1). Our patient required 5 days of mechanical ventilation for septic shock. She received enteral feeding through a nasogastric tube. Diarrhea was not caused during hospital stay. We managed to control fecal contamination from wounds by use of the NPWT system covered with adhesive film dressing. The wounds were restored and the patient was transferred to a rehabilitation hospital (Fig. 2C, F, I).

Discussion

Negative‐pressure wound therapy has some advantages in promoting the wound healing process by aiding tissue perfusion and removal of wound edema.1 Once the wound is clean and the tissues are healthy while keeping infection under control, NPWT can be appropriate. Alternative negative pressure systems, which use saline‐soaked gauze, are also becoming available.5 Although foam resulted in more pronounced granulation tissue formation than gauze under negative pressure,6 the degree of wound contraction is similar after NPWT regardless if foam or gauze is used as a wound filter.7 Gauze‐based NPWT is thought to be effective for contoured wounds.8 The wound beds in this case were contoured with crevices and pockets, whereas the foam pad used in this system is flat. In the initial system used for this patient, the foam‐based NPWT might have come into contact with only part of the wound bed. Due to this concern, we decided to convert to gauze‐based NPWT and placed the saline‐soaked gauze into the pus pockets (Fig. 3A, B). With consideration of the type of wound bed and exchange frequency of dressing material, two NPWT devices were applied to the sacral region and both thighs in our patient. Although the use of NPWT for infected wounds should be avoided, the use of NPWT in the treatment of soft‐tissue infections has been reported.2, 3 Our experience suggests that NPWT can be an effective treatment for large, open, contoured wounds while also keeping infection under control.

Previous reports have described either NPWT or dermatotraction as potential methods for wound management.9, 10 Negative‐pressure wound therapy combined with dermatotraction has also been reported.3, 4 Dermatotraction entails approximation of the wound edges using several elastic vessel loops, which are then anchored by skin staples. The tension in the elastic vessel loops is then gradually increased across the wound margins in a shoelace manner. Sterile polyurethane foam or gauze is then placed in the wounds; these open wounds with applied dermatotraction are then covered with NPWT devices. Negative‐pressure wound therapy‐assisted dermatotraction is an effective treatment aimed at promoting wound closure for large dehisced wounds. We initially speculated that skin grafts would be required for wound dehiscence in the patient reported here. However, reconstructive surgery was considered inappropriate because of her poor general condition and contoured wound bed. Instead we found that, with increased tissue pressure and wound contraction using NPWT‐assisted dermatotraction, the pus pockets and the wound dehiscence receded gradually. Finally, we successfully performed delayed closure of her wounds without skin grafts. Negative‐pressure wound therapy‐assisted dermatotraction might be considered for poorly healing, large, open wounds in patients in poor condition and with insufficient reserve to tolerate reconstructive surgery.

Conclusion

In summary, we report herein our experience in the use of NPWT‐assisted dermatotraction for the delayed closure of large, open, contoured wounds in a patient with non‐clostridial gas gangrene. Moreover, we found that NPWT can be an effective treatment for large, open, contoured wounds while also keeping infection under control. Negative‐pressure wound therapy‐assisted dermatotraction might be beneficial for large open, contoured wounds in patients who are in poor general condition and are inappropriate candidates for reconstructive surgery.

Conflict of Interest

None.

Supporting information

Fig. S1. Therapeutic course in a 53‐year‐old woman who developed septic shock associated with non‐clostridial gas gangrene. We stopped antibiotics after 7 days of use with no evidence of local infection. On day 18 of admission, the serum C‐reactive protein level was gradually increased and wound cultures grew Proteus mirabilis and Enterococcus faecalis, which were sensitive to ampicillin. Therefore, antibiotic treatment was resumed with ampicillin for fear of local infection.