A Retrospective Study: DISCUSSION
The first case, in which negative pressure was used in the treatment of pressure ulcers and chronic wounds, was described in 1993 by Argenta et al. Since then, it has been used in a variety of wounds, including diabetic ulcers, abdominal wounds, sternal wounds, and spinal wounds. The principle of negative pressure includes promotion of granulation tissue by arterial dilatation. The device also has been shown to reduce edema, bacterial colonization, and reduce excess fluid. These effects seem to shorten the duration of wound healing as noted in a previous report and suggested by this study. It has been suggested that successful healing correlates with less than 105 organisms per gram of tissue. The number achieved with wound VAC therapy is usually less than 10.
Complications with the wound VAC are infrequent if the patient population is properly selected. These include bleeding from the wound at the time of sponge change due to excessive growth of granulation tissue into the sponge if it has been left in place longer than 48-72 hours. Pain has been associated with sponge changes but usually is short lived and can be controlled with oral narcotics. Occasionally, odor may be a problem, and one needs to ascertain that there is no active infection present. Allergic reactions to the drape have been reported as well, and these have been managed with topical steroids or antihistamines.
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Sternal wound infections have been quite a problem in terms of healing until the advent of the VAC. In one paper, 16 patients with sternal wound infections were treated with the combination of antimicrobials, debridement, and VAC therapy with good results. None of these patients had any complications and had shorter hospitalization stays, earlier extubation, and better outcomes when compared to patients treated with normal saline dressing changes.
In lower-extremity wounds, such as graft site infections, there appears to be a reduction in exudates and bacteria with rapid formation of granulation tissue especially when compared to traditional methods of treatment. Complications with this method are negligible and compares with our experience as well.
In spinal wounds, the occurrence of serious complications is around 4% but can be as high as 20% in some series. These wounds may be associated with exposure of vertebral canal, spinal sac, and hardware. Significant morbidity and mortality exists with these wounds, and the average cost for treating these patients is approximately $100,000 per patient. Some investigators have found successful closure of spinal wounds can be achieved much more rapidly than traditional methods in patients being able to tolerate the device. Animal studies using pigs with wounds were studied to validate the efficacy of the wound VAC. These animal models were studied to document the rate of wound healing using subatmos-phere pressure and by laser doppler probes to measure blood perfusion. Bacterial clearance studies were conducted by infecting wounds with s. aureus and s. epidermis, the results of which showed reduction in the bacterial load, longer flap survival, and increased rate of granulation.
Nonhealing wounds can be associated with diabetes; venous stasis ulcers; prolonged nonmobiliza-tion; and postoperative wounds, such as deep, persistently infected spinal wounds, etc. The treatment of these wounds is costly, demanding lengthy hospital stays and incurring both psychological and emotional stress to patients. The advent of the VAC appears to have helped such wounds achieve faster healing, shorter hospital stays, and reduction in the overall cost. Our study presents a series of patients with a variety of infections in which the wound VAC was successfully used. In our experience, it appears that most of these wounds occurred in the elderly with a history, coronary artery disease, and peripheral vascular disease with the predominant pathogen isolated being Staphylococcus. Patients who did not receive antimicrobials but were treated with the VAC and debridement alone also healed without any adverse outcomes. The optimum duration of application of the VAC has not been well-established but seems to vary depending on the site where the wound occurred, vascularity, and infection. The wound VAC in combination with antimicrobial therapy and surgical debridement should be standard-of-care soon in the treatment of difficult to heal wounds such as sternal, spinal, and lower-extremity or graft sites. Further studies need to be done to evaluate the efficacy of the wound VAC with these types of wounds, and to access the safety and clinical efficacy of this modality of treatment.
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