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PT Classroom - The Effects of Combining Pulsetile Lavage and Vacuum Assistive Closure for the Treatment of a Surgical Wound Infection - A Case Study ׀ by Sarah Wozny, DPT, CSCS |
Sarah Wozny, DPT, CSCS, graduated from Saint Louis University in 2006 with a M.S. in physical therapy and completed her doctorate of physical therapy in 2007. Her clinical experience includes, orthopedics, sports medicine, and manual physical therapy. She also has experience as a personal trainer and utilizes her knowledge of injury prevention and biomechanics to create & continuously maintain various programs for clients of all fitness levels and needs. She is in private practice and the owner of a physical therapy clinic in Racine, WI. |
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Effects of Combining Pulsetile Lavage & Vacuum Assistive Closure for the Treatment of a Surgical Wound Infection - A Case Study |
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The purpose of this case study was to illustrate the effects of combining
pulsetile lavage and vacuum assisted closure dressing for the treatment of a
surgical wound infection. Case Description: The patient was an 81 year
old male who underwent abdominal surgery which became infected. The patient was
sent to physical therapy for wound care for pulse lavage and sharp debridement
prior to application of vacuum assisted closure, three times a week. Outcome:
Measurements were taken during the initial evaluation and once a week during the
treatment period. The wound displayed dramatic results in percent of total wound
area closure and decreased necrotic tissue as a result of the combination of all
three forms of debridement. Discussion: The physical therapy plan of care
assisted wound closure in a shorter period of time when compared to normative
wound healing timeframes. A combination of different forms of debridement
provided a clean, moist, and sterile environment to enhance new granulated
tissue formation, allowing full wound closure.
The art of wound care is a trial and error science. There are over 3000 different wound care products on the market that may be utilized to treat patients. One of the forms of assisting wound closure is the vacuum assistive closure device (VAC). The VAC consisted of a piece of foam placed directly over and in the wound. Transparent tape is placed over the area surrounding the wound to secure the foam and aids with draining the wound to keep the area clean and sterile. Attached to the foam is a tube which removes the drainage from the wound bed. The tube is connected to a vacuum source which pulls the drainage from the wound into a disposable canister. The purpose of the machine is to drain the excess fluid from the wound that may hinder the healing process. Another common treatment option for wound care is pulsetile lavage. This form of mechanical debridement uses intermittent and pulsed jets of saline solution into the wound bed and simultaneously suctions the debris from the wound. The process helps loosen the debris from within the wound bed, reduce bacteria, and has the ability to irrigate tunneling and undermining, common with many wounds. Pulsetile lavage is a more specific form of debridement when compared to whirlpool due to its ability to concentrate on a small area with the suction tube. The common factor with all wound care is a mixture of different forms of debridement, ointments, and dressings. Finding this effective combination can prove to be difficult, but by trial and error, a treatment plan can be created with successful outcomes. This case report describes the combination of different forms of wound care options as treatment for a surgically infected abdominal wound. The following data describes the effectiveness of combining pulsetile lavage, VAC, and sharp debridement as the primary treatment plan. Case Description Patient The patient selected for the study presented to the hospital’s in-patient wound care clinic with a large infected abdominal wound from a surgical procedure two weeks prior. The patient was an 81 year old male who was retired and lived alone at home. He was admitted to the hospital for transitional cell carcinoma. The patient underwent a radical nephrourecterectomy, cystectomy, prostatectomy, and urinary diversion surgery by way of abdominal entrance. Post surgery, the wound became infected with bacteria and opened with necrotic tissue present. The patient’s past medical history consisted of congestive heart failure, myocardial infarct, cardiac artery disease, cardiac artery bypass graft surgery, renal failure, change in mental status, cancer of the bladder, hypertension, diabetes mellitus, hypercholestrecolemit, peripheral vascular disease, and sepsis. The patient was at risk for falling due to pervious falls and his need for an assistive device. The patient presented to the department as alert and had good awareness to safety. He was independent at home with all functional activities of daily living (ADLs) prior to hospital admission. He required the use of a cane when ambulating short distances in and around his home and used a wheelchair for long distances.
Last revised: June 8, 2009 |
The initial evaluation took place in the physical therapy
wound care clinic. The evaluation consisted of a chart
review, wound inspection, measurements, wound description,
determining short and long term goals, developing the plan
of care, and patient education. The site of the wound was
midline of the body in the middle abdominal area. The wound
was considered full by the depth. Wound size measured to be
a width of 2.7cm, length 11.5cm, and depth 2.7cm. While
inspecting the edges within the wound, tunneling was found
at 12:00, most proximal, going 5.2cm superior. Necrotic
tissue within the wound bed was approximately 25% of the
entire wound surface. There was erythema noted around the
wound surface. No odor was present. Drainage was minimal,
consisting of blood. The infection was bactermia. Short and
long term goals were then decided. Short term goals were to
be accomplished by 2-4 weeks. These consisted of decreasing
the size of the wound by 25%, decreasing the amount of
necrotic tissue by 50%, and preparing the patient for
possible surgical intervention for closure of the wound.
Long term goals were to be met within 6-8 weeks. These
consisted of decreasing the size of the wound by greater
than 50% and decreasing amount of necrotic tissue by 100%.
Plan of care was determined, with physical therapy three
times a week; Monday, Wednesday, and Friday and to provide
patient and family education. Interventions included
pulsetile lavage with 2000ml of saline solution, sharp
debridement with scissors and forceps as needed, and
redressing of VAC dressing by the endointestinal nurse.
Measurements
of the wound were taken once a week and the change in total
percent of wound closure and total percent of decreased
necrotic tissue is illustrated on the graph. After week one
of treatment, the wound measured 10.0 cm in length, 2 cm in
width, 2.5 cm in depth, and the tunneling proximal at 12:00
to be 4.3 cm. The amount of necrotic tissue did not show a
significant decrease.
After the third week, the wound was again remeasured. A
bridge of new granulation tissue had formed in the center of
the wound 3.0 cm long, splitting the wound into two separate
areas. The proximal wound measured 3.5 cm in length, 1.2 cm
in width, and 2.0 cm in depth. The distal wound measured 1.5
cm in length, 1.0 cm in width, and 1.5 cm in depth. Necrotic
tissue had decreased to approximally 10% of total wound
area.|
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