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Wound Cleansing — A Therapy Revisited
Journal of Tissue Viability 1997 Vol 7 No 4
119
WOUND CLEANSING -A THERAPY REVISITED MARY JONES 1 and STEPHEN THOMAS 2 ISenior Clinical Research Nurse, 2Director, Surgical Material Testing Laboratory
Summary The use of blowfly maggots for wound debridement has been apparent in the past, disappeared with the advent of antibiotics but is now making a comeback. An 82 year-old diabetic developed a deep pressure sore on his elbow following amputation of lower left leg complicated by a cardiac arrest. The wound was sloughy and infected with MRSA; cellulitis, wound tenderness and a pyrexia were also present. A 48 hour, single application of sterile maggots completely debrided the wound revealing a previously unsuspected narrow sinus, the likely seat of the infection. Swabs taken after application of maggots were negative for MRSA and both local and systemic signs of infection had now disappeared. The patient reported no unpleasant reactions to the maggots. The wound was subsequently dressed with hydrocolloid and healed uneventfully.
Introduction The basis of modern wound care is founded on the principle of moist wound healing! and for this to be effective, the wound must be free of necrotic or sloughy tissue2. There are a number of ways that wound cleansing can be achieved. The fastest way is by sharp debridement but this is not without risk, as healthy tissue may be damaged in the process and blood vessels may be disrupted. Not all patients are suitable for this type of intervention as it may involve the administration of anaesthesia. Debridement may also be achieved by use of wound dressings such as hydrogels, alginates, hydrocolloids, which rehydrate the desiccated tissue and thereby promote autolysis or by enzymatic preparations which break down the devitalised tissue. However these take time to achieve their objective, rely on a reasonable blood supply to promote autolysis and can be costly if used for extended periods. There is another, much older method of wound debridement that has been revived with a great deal of success and that is the use of fly larvae in wounds. Larvae in wounds are not a new phenomenon but they usually find their way there unintentionally. The active introduction of larvae into wounds has only been recorded in the past 150 years3. Evidence of the effectiveness of the fly larvae in the removal of devitalised tissue from wounds and of their role in helping to control wound sepsis may be found in the literature but most of these articles are dated. The up to date literature available is quite recent, dating back only about 7 years
because the use of fly larvae in wound care was replaced after the advent of antibiotics and it is only now re-emerging. The fly larva used today in wound care is Lucilia serricata which is produced under sterile conditions, packed and dispatched under strict quality control procedures from the Biosurgical Research Unit at the Surgical Materials Testing Laboratory, Bridgend. Because the larvae are guaranteed sterile, there is no need to protect patients with antibiotic therapy other than that which they would normally receive as part of their wound care. The larvae are sent from the Biosurgical Unit to designated centres in the UK and to some centres abroad and are applied to a variety of wounds in differing settings, with a great deal of success. It is not necessary for patients to be hospitalised for the treatment: they can be managed successfully in the community. This article will describe a case history where larvae were used to debride a difficult wound and the priority in patient care was to shorten the length of time the patient spent in isolation.
Case Study Mr T is an 82 year old insulin dependant diabetic with severe necrosis of his lower right leg who was admitted to hospital for an above knee amputation. He also suffered from chronic rheumatoid arthritis affecting both hands and elbows, which restricted the movement in his arms. Following a straightforward operation for removal of his lower right leg, Mr T suffered a cardiac arrest from which he was successfully resuscitated. He was admitted to the Intensive Therapy Unit for close observation of his condition. He was judged to be at high risk of pressure sore development according to the Waterlow assessment score, so he was nursed on an alternating pressure mattress. His stump wound began to heal uneventfully but unfortunately he developed a small pressure sore on his left elbow (figure 1). This was because he had to use his elbow to manoeuvre himself in bed. The wound became sloughy and caused him a great deal of pain and discomfort. A wound swab was taken which showed the presence of MRS A. Mr T was isolated and transferred to a cubicle on a general medical ward. The wound was treated with mupirocin ointment applied daily, this being the local protocol for the treatment of MRSA infected wounds. He still had a central intravenous line in situ and required close observation because of his cardiac condition. Because his wound infection required him to be isolated, he became very anxious and frightened. Everyone who entered his cubicle
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Journal of Tissue Viability 1997 Vol 7 No 4
Figure 1. Pressure sore before larval therapy,
Figure 2. Appearance of larvae during removal from the wound.
Figure 3. Pressure sore after one application of larval therapy.
Journal of Tissue Viability 1997 Vol 7 No 4 had to wear disposable gloves and aprons and he began to think of himself as "highly contagious". He worried about the effect this was having on his wife and whether she would become infected. His wife for her part was also very worried about the "killer bug" in her husband's arm- she had seen a recent programme about the spread of MRSA on the television and was concerned that this could affect him more than his amputation. The wound to his left elbow although apparently only 7mm x 3mm was extremely painful. Cellulitis and tenderness extended 7em down his arm, and he had a temperature of 38T. Because of his isolation and physical problems, his amputation and arthritis and the infusion into his subclavian vein, Mr T was very immobile and this was further complicated by the pain in his left arm when any pressure was put on his elbow. In view of all these factors and with the agreement of both Mr T and the medical team responsible for his care, larval therapy was initiated to try to achieve rapid debridement and combat the infection present, in order to return him to the ward environment.
Larval Therapy A wound swab was taken prior to the commencement of treatment, which subsequently confirmed that MRSA was still present in the wound. The larvae were applied in the recommended manner4. The wound was surrounded by a hydrocolloid wafer in which a hole had been made the same size as the wound opening to protect the surrounding skin. The larvae were applied to the wound and covered with a sterile net which was secured to the hydrocolloid wafer with a strong adhesive tape (Sleek, Smith & Nephew Medical). The wound was then covered by an absorbent pad and a light retention bandage. Mr T stated that the dressing felt very comfortable and that he was not able to detect the larvae on his wound. Mr T was warned that there might be some discharge through the bandage and that this might be red in colour, but this was not a cause for concern. He was also told that if at any time he felt uncomfortable or changed his mind about the therapy he was to inform a member of staff and the larvae would be removed immediately. The wound was then left undisturbed for 48 hours. After 2 days, during which time Mr T did not complain of
121
any pain or discomfort, the outer dressing was removed and there was evidence of larval activity, characterised by red staining on the absorbent pad. When the dressing was completely removed the larvae were found to have increased greatly in size (figure 2) and the wound proved to be completely debrided (figure 3). The larvae were able to enter the narrow sinus running from the wound down the forearm and remove the devitalised tissue. These were easily removed by irrigation of the sinus with sterile saline. A wound swab taken at this time proved to be negative for MRSA and there were no longer any signs of clinical infection. Mr T said that he felt much better, the pain in his elbow had receded, indeed it only hurt when he put his weight on it to alter his position in bed. As the wound was completely debrided and showed evidence of granulation the dressing was changed to a hydrogel (Granugel, Convatec Ltd) to complete the healing process.
Conclusion The use of larvae brought about rapid debridement and exposed an unexpected sinus - probably the site of the infection. Although initially MRSA positive, following the application of larvae MRSA was eliminated and Mr T could be moved out of the cubicle onto the general ward much to the relief of himself and his wife. Although further MRSA positive swabs were obtained sometime after, the wound continued to make good progress and healed uneventfully.
Address for Correspondence M Jones, Senior Clinical Research Nurse, Surgical Material Testing Laboratory, Quarella Road, Bridgend, Mid Glamorgan CF31 1JP.
References 1.
2. 3.
4.
Winter GD. Formation of the scab and the rate of epithelialisation of superficial wounds in the skin of the young domestic pig. Nature 1962; 193: 293. Cutting K. Factors influencing wound healing. Nursing Standard 1994; 8(50): 33-34. Baer WS. The treatment of chronic osteomyelitis with the maggot (larva of the blowfly). Journal of Bone & Joint Surgery 1931; 13: 438-475. Thomas S, Jones M, Shutler S, Jones S. Using larvae in modem wound management. Journal of Wound Care 1996; 5(2): 60-70.
119
WOUND CLEANSING -A THERAPY REVISITED MARY JONES 1 and STEPHEN THOMAS 2 ISenior Clinical Research Nurse, 2Director, Surgical Material Testing Laboratory
Summary The use of blowfly maggots for wound debridement has been apparent in the past, disappeared with the advent of antibiotics but is now making a comeback. An 82 year-old diabetic developed a deep pressure sore on his elbow following amputation of lower left leg complicated by a cardiac arrest. The wound was sloughy and infected with MRSA; cellulitis, wound tenderness and a pyrexia were also present. A 48 hour, single application of sterile maggots completely debrided the wound revealing a previously unsuspected narrow sinus, the likely seat of the infection. Swabs taken after application of maggots were negative for MRSA and both local and systemic signs of infection had now disappeared. The patient reported no unpleasant reactions to the maggots. The wound was subsequently dressed with hydrocolloid and healed uneventfully.
Introduction The basis of modern wound care is founded on the principle of moist wound healing! and for this to be effective, the wound must be free of necrotic or sloughy tissue2. There are a number of ways that wound cleansing can be achieved. The fastest way is by sharp debridement but this is not without risk, as healthy tissue may be damaged in the process and blood vessels may be disrupted. Not all patients are suitable for this type of intervention as it may involve the administration of anaesthesia. Debridement may also be achieved by use of wound dressings such as hydrogels, alginates, hydrocolloids, which rehydrate the desiccated tissue and thereby promote autolysis or by enzymatic preparations which break down the devitalised tissue. However these take time to achieve their objective, rely on a reasonable blood supply to promote autolysis and can be costly if used for extended periods. There is another, much older method of wound debridement that has been revived with a great deal of success and that is the use of fly larvae in wounds. Larvae in wounds are not a new phenomenon but they usually find their way there unintentionally. The active introduction of larvae into wounds has only been recorded in the past 150 years3. Evidence of the effectiveness of the fly larvae in the removal of devitalised tissue from wounds and of their role in helping to control wound sepsis may be found in the literature but most of these articles are dated. The up to date literature available is quite recent, dating back only about 7 years
because the use of fly larvae in wound care was replaced after the advent of antibiotics and it is only now re-emerging. The fly larva used today in wound care is Lucilia serricata which is produced under sterile conditions, packed and dispatched under strict quality control procedures from the Biosurgical Research Unit at the Surgical Materials Testing Laboratory, Bridgend. Because the larvae are guaranteed sterile, there is no need to protect patients with antibiotic therapy other than that which they would normally receive as part of their wound care. The larvae are sent from the Biosurgical Unit to designated centres in the UK and to some centres abroad and are applied to a variety of wounds in differing settings, with a great deal of success. It is not necessary for patients to be hospitalised for the treatment: they can be managed successfully in the community. This article will describe a case history where larvae were used to debride a difficult wound and the priority in patient care was to shorten the length of time the patient spent in isolation.
Case Study Mr T is an 82 year old insulin dependant diabetic with severe necrosis of his lower right leg who was admitted to hospital for an above knee amputation. He also suffered from chronic rheumatoid arthritis affecting both hands and elbows, which restricted the movement in his arms. Following a straightforward operation for removal of his lower right leg, Mr T suffered a cardiac arrest from which he was successfully resuscitated. He was admitted to the Intensive Therapy Unit for close observation of his condition. He was judged to be at high risk of pressure sore development according to the Waterlow assessment score, so he was nursed on an alternating pressure mattress. His stump wound began to heal uneventfully but unfortunately he developed a small pressure sore on his left elbow (figure 1). This was because he had to use his elbow to manoeuvre himself in bed. The wound became sloughy and caused him a great deal of pain and discomfort. A wound swab was taken which showed the presence of MRS A. Mr T was isolated and transferred to a cubicle on a general medical ward. The wound was treated with mupirocin ointment applied daily, this being the local protocol for the treatment of MRSA infected wounds. He still had a central intravenous line in situ and required close observation because of his cardiac condition. Because his wound infection required him to be isolated, he became very anxious and frightened. Everyone who entered his cubicle
120
Journal of Tissue Viability 1997 Vol 7 No 4
Figure 1. Pressure sore before larval therapy,
Figure 2. Appearance of larvae during removal from the wound.
Figure 3. Pressure sore after one application of larval therapy.
Journal of Tissue Viability 1997 Vol 7 No 4 had to wear disposable gloves and aprons and he began to think of himself as "highly contagious". He worried about the effect this was having on his wife and whether she would become infected. His wife for her part was also very worried about the "killer bug" in her husband's arm- she had seen a recent programme about the spread of MRSA on the television and was concerned that this could affect him more than his amputation. The wound to his left elbow although apparently only 7mm x 3mm was extremely painful. Cellulitis and tenderness extended 7em down his arm, and he had a temperature of 38T. Because of his isolation and physical problems, his amputation and arthritis and the infusion into his subclavian vein, Mr T was very immobile and this was further complicated by the pain in his left arm when any pressure was put on his elbow. In view of all these factors and with the agreement of both Mr T and the medical team responsible for his care, larval therapy was initiated to try to achieve rapid debridement and combat the infection present, in order to return him to the ward environment.
Larval Therapy A wound swab was taken prior to the commencement of treatment, which subsequently confirmed that MRSA was still present in the wound. The larvae were applied in the recommended manner4. The wound was surrounded by a hydrocolloid wafer in which a hole had been made the same size as the wound opening to protect the surrounding skin. The larvae were applied to the wound and covered with a sterile net which was secured to the hydrocolloid wafer with a strong adhesive tape (Sleek, Smith & Nephew Medical). The wound was then covered by an absorbent pad and a light retention bandage. Mr T stated that the dressing felt very comfortable and that he was not able to detect the larvae on his wound. Mr T was warned that there might be some discharge through the bandage and that this might be red in colour, but this was not a cause for concern. He was also told that if at any time he felt uncomfortable or changed his mind about the therapy he was to inform a member of staff and the larvae would be removed immediately. The wound was then left undisturbed for 48 hours. After 2 days, during which time Mr T did not complain of
121
any pain or discomfort, the outer dressing was removed and there was evidence of larval activity, characterised by red staining on the absorbent pad. When the dressing was completely removed the larvae were found to have increased greatly in size (figure 2) and the wound proved to be completely debrided (figure 3). The larvae were able to enter the narrow sinus running from the wound down the forearm and remove the devitalised tissue. These were easily removed by irrigation of the sinus with sterile saline. A wound swab taken at this time proved to be negative for MRSA and there were no longer any signs of clinical infection. Mr T said that he felt much better, the pain in his elbow had receded, indeed it only hurt when he put his weight on it to alter his position in bed. As the wound was completely debrided and showed evidence of granulation the dressing was changed to a hydrogel (Granugel, Convatec Ltd) to complete the healing process.
Conclusion The use of larvae brought about rapid debridement and exposed an unexpected sinus - probably the site of the infection. Although initially MRSA positive, following the application of larvae MRSA was eliminated and Mr T could be moved out of the cubicle onto the general ward much to the relief of himself and his wife. Although further MRSA positive swabs were obtained sometime after, the wound continued to make good progress and healed uneventfully.
Address for Correspondence M Jones, Senior Clinical Research Nurse, Surgical Material Testing Laboratory, Quarella Road, Bridgend, Mid Glamorgan CF31 1JP.
References 1.
2. 3.
4.
Winter GD. Formation of the scab and the rate of epithelialisation of superficial wounds in the skin of the young domestic pig. Nature 1962; 193: 293. Cutting K. Factors influencing wound healing. Nursing Standard 1994; 8(50): 33-34. Baer WS. The treatment of chronic osteomyelitis with the maggot (larva of the blowfly). Journal of Bone & Joint Surgery 1931; 13: 438-475. Thomas S, Jones M, Shutler S, Jones S. Using larvae in modem wound management. Journal of Wound Care 1996; 5(2): 60-70.