Special reports Case reports
included his surgeon and tissue viability nurse specialist (as recommended by NICE, 2011[5] On examination, Mr M had an extensive re-
).
ulceration overlying his previous ray amputation (whereby the phalanx is removed along the metatarsal head and a portion of the metatarsal bone). There was slough present and exudate levels were high, leading to periwound maceration and excoriation[Fig 1]. Pain was not an issue in his ulcer presentation. Wound swabs revealed heavy bacterial colonisation and he was commenced on parenteral antibiotics.
Treatment Following discussion within the care team it was decided to treat the wound with NPWT using the SNaP device.
The objectives of therapy were to: n Manage wound exudate n Prevent further infection n Assist in autolysis of necrotic matter n Maintain independence and mobility n Facilitate wound granulation n Obtain wound closure and healing.
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NPWT settings and dressing choices Made Easy
The SNaP device was selected as it offers proven ability to deliver the benefits of NPWT, notably the promotion of wound granulation and wound healing. It is also portable, has a low weight and is easy to operate. The wound bed and periwound skin was
thoroughly cleansed and the ulcer was covered with moistened AMD gauze-interface material. The hydrocolloid dressing was cut to size to enable placement over the area. It was decided to place the drainage port directly over the wound area to minimise the risk of displacement. This could be reviewed when Mr M recommenced mobilisation. Therapy was commenced at -125mmHg and the dressing was covered with a wound pad and retention bandage to provide additional security [Fig 2]. The cartridge was attached to the patient’s calf with the adjustable carry clip provided. Mr M was instructed on how the SNaP therapy system is managed and how to re-prime the dressing cartridge if required. Mr M remained an in-patient for a further
week during which time arrangements were made to continue oral antibiotic therapy in the community. His dressing was changed twice weekly. Improvement was seen in the periwound skin health and new granulation was apparent. One area (in the centre of the wound) was found to contain exposed tendon. However, this tendon was considered viable and it was hoped that the NPWT could facilitate its coverage with
44 Wounds International Vol 3 | Issue 3 | ©Wounds International 2012
granulation tissue [Fig 3]. On discharge, Mr M was advised to limit his
mobilisation[Fig 4]. The foot was protected with padding and bandages and he was fitted with an orthotic shoe. Although being advised to remain non-weight bearing, Mr M insisted on returning to work to undertake ‘light duties’ following discharge. This did raise some issues, namely, the inability to elevate his foot resulted in increased exudate levels, and increased foot movement did produce an occasional break in the air-tight dressing seal. However, Mr M was able to manage these
himself and his therapy continued as planned. Granulation was seen to increase in the wound bed and covered the exposed tendon. Wound contraction occurred despite the presence of foot oedema and the wound margin showed signs of epidermal regeneration and migration.
Results Mr M was able to maintain self-care, including continuation of work during the latter stages of his wound management [Figs 5 and 6]. There were no secondary infection issues and peri-wound skin health improved. Wound healing was initiated during therapy resulting in a significant reduction in wound size. This continued following cessation of NPWT and the wound closed[Figs 7 and 8]. Mr M is one of the few individuals to have been
treated with three different types of portable NPWT device. Compared with battery-powered units, he found the SNaP system light, portable and easy to use. The silent system did not disturb his sleep and prevented his work colleagues becoming aware that he was undergoing active treatment.
CONCLUSION Achieving good wound healing outcomes is essential in managing diabetic foot ulceration if amputation is to be avoided. However, patients often need to deal with work pressures that can compromise their ability to rest. NPWT enhances healing of intransigent wounds, including diabetic foot ulcers. The SNaP system offers a method of delivering NPWT that enables patients to maintain independence and meet many of the social and economic demands they face, while providing a wound environment that promotes healing.
AUTHOR DETAILS Teresa Awad, Tissue Viability Clinical Nurse Specialist, BUPA Cromwell Hospital, London, UK
Martyn Butcher, Independent Tissue Viability and Wound Care Consultant
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