Cath Lab Digest

R was 83 years old, thin-framed and ambulatory with a history of venous stasis ulcerations for which she had been treated for several months as an outpatient. She was admitted to acute care for infection of a stasis ulcer on her left calf that measured approximately 5 cm in diameter. At the time of her admission, she was wearing a compression wrap. The wound was managed topically with a silver-containing alginate dressing. Within the first week of her hospitalization, her lower extremity edema resolved due to more prolonged supine positioning. During this transition, she became less tolerant of compression and developed an area of pressure necrosis. Compression was stopped and necrotic areas were sharp debrided and treated with collagenase ointment for enzymatic debridement and polysporin powder for antimicrobial protection (see Figure 3a).

     Over approximately the next 3 weeks, Ms. R completed her systemic antibiotics. Topical wound management cleared devitalized tissue from the wound bed and pink granular buds began to develop. However, as her ambulation increased, moisture management became an issue, leading to maceration and circumferential ulceration. Because she was unable to tolerate compression, absorptive cotton pads and elevation were added to her protocol of care.

     As the exudate increased, a thick film layer over the wound bed was noticed. This film persisted after daily pulsed lavage and reformed daily despite application of collagenase. The film could be partially removed by gently rubbing the wound with a sterile gauze pad, revealing an area of red granulation tissue at the distal edge of the ulcer (see Figure 3b). On the following day, a significant amount of sanguinous drainage was noted on the cover dressing and the film had reformed over the wound bed. A silver-containing alginate dressing was applied for two consecutive days and changed daily before performing pulsed lavage. Because the pale green film reformed each day, this strategy was discontinued.

     A silver hydrofiber dressing was used for the next 3 days. This dressing seemed to provide better absorption, leaving a healthier pink/red wound bed with clearly defined contours but further treatment decisions were compromised by this product’s limited availability (this particular product is not available on facility formulary). Hydrofiber and alginate are formally considered by regulators to be interchangeable but in vivo activity appeared distinctly different in this instance. No further study of vessel perfusion pressure was provided.

     During this period of time, exudate management was a problem. The wound bed film reoccurred daily and was physically removed as much as Ms. R was able to tolerate. Wound maceration was leading to increased ulcer size, now nearly circumferential. The most absorptive formulary product, a silver-containing alginate, had demonstrated inadequate absorption for Ms. R’s wounds. Therefore, negative pressure wound therapy was initiated in an attempt to more effectively manage exudate. Ms. R tolerated -50 mm Hg continuous suction with dressing changes on Monday, Wednesday, and Friday. This strategy was effective in promoting wound progression and all ulcers became bright red and granular. Split-thickness graft was performed for final wound closure.

     Case 3. Seventy-eight-year-old Mr. D’s medical history included congestive heart failure, enlarged prostate, hypertension, and chronic lower extremity edema that had been diagnosed as venous stasis disease based on presentation. No formal venous studies had been performed. The referring physician had attempted a procedure to remove or ligate veins but this procedure did not solve Mr. D’s problem.