Successful Treatment of Life-threatening Posttraumatic Wounds With Negative Pressure Wound Therapy: A Case Report

Introduction. Debridement and control of wound drainage are critical for managing patients with extensive traumatic wounds because wound infection can result in sepsis and further complications. Case Report. The authors report the case of a 19-year-old woman with an extensive crush/degloving injury to her right lower limb that was treated with negative pressure wound therapy (NPWT) with a reticulated open-cell foam dressing. The patient received 2 treatments of sharp debridement and vacuum drainage using wall suction and polyvinyl alcohol dressings. Her respiratory failure, sepsis, and septic shock continued to worsen, and she could not tolerate anesthesia. On post admission day 9, after simple debridement where only superficial necrosis tissue was debrided without anesthesia, NPWT was applied for 5 days and removed about 8500 mL of exudate the first day and 6000 mL on the second. After 5 days, her wound began to improve, granulation tissue formed, no necrotic tissues were visible, and vital signs were stable. On day 14, she underwent anesthesia, surgical debridement, and application of NPWT for an additional 5 days. Following autologous skin grafting on day 19, she was removed from the ventilator (which was started on day 3). The extensive wound was effectively closed; she recovered satisfactorily. There was no patient follow-up. Conclusions. In this case, NPWT, in continuous mode at -125 mm Hg, effectively removed exudate after simple debridement in a patient who could not tolerate anesthesia.

Treatment of contaminated acute wounds with negative pressure has expanded globally,¹ and various types of vacuum therapy have been developed and used in China. In October 2010, negative pressure wound therapy (NPWT; V.A.C. Therapy; KCI, an Acelity company, San Antonio, TX) was approved for commercialization in China. 

In this case study, the authors used NPWT with a polyurethane, hydrophobic, reticulated open-cell foam dressing (V.A.C. GranuFoam Dressing; KCI, an Acelity company) to help manage the extensive lower limb wound of a patient with respiratory failure, sepsis, and septic shock who had not responded to vacuum drainage (a local Chinese product using wall suction with a polyvinyl alcohol [PVA] dressing). The guidelines of the First Affiliated Hospital of Anhui Medical University (Hefei, Anhui Province, China) were followed in the development of this report. 

A 19-year-old woman was admitted to the First Affiliated Hospital of Anhui Medical University with complaints of pain and bleeding lasting 4 hours after an injury to the right lower limb caused by a car accident. The patient did not have a headache, dizziness, or fall into a coma as a result of the accident. A previous x-ray suggested fractures of the right pubic bone and ramus of the ischium. Physical examination performed 30 minutes after admission to the hospital showed a temperature of 36°C, pulse of 145 beats per minute (bpm), respiratory rate of 20 breaths per minute, blood pressure of 118/62 mm Hg, presence of consciousness, and clear breath sounds of the lungs.

Additional examination indicated an extensive crush and degloving injury to the right lower limb. The wound surface was badly contaminated, and, on the right lower limb, only 20% of the skin and subcutaneous tissue normally connected to the deep fascia remained. The wound was deep to the fibula and the surface of the calcaneocuboid joint had sustained a contusion. After examination, the admitting diagnosis was a crush injury to the right lower limb, fracture of the pelvis, and Stage 1 traumatic shock (ie, compensated). Important hospital procedures/treatments and the patient’s vital signs are summarized in the Table. Emergency debridement of the right lower limb and application of vacuum drainage were conducted on day 2, and the operation went smoothly. 

Postoperatively, the patient developed a fever of 39.9°C, an increased respiratory rate of approximately 40 breaths per minute, a heart rate of 140 bpm, a blood pressure of 103/71 mm Hg, and an oxygen level of as low as 70% in a state of oxygen uptake, which was complicated by oliguria and edema. Laboratory tests reported a white blood cell (WBC) count of 4.10 x 10⁹/L, neutrophil 83.91%, and hemoglobin 84 g/L. Arterial blood gas analysis showed a blood acidity (pH) of 7.358, partial pressure of oxygen (PO₂) 60.90 mm Hg, partial pressure of carbon dioxide (PCO₂) 26.0 mm Hg, base excess (BE) of extracellular fluid -11.0 mmol/L, and BE of blood 9.1 mmol/L. Type I respiratory failure and respiratory alkalosis were diagnosed, and the patient was transferred to the intensive care unit on day 3. Noninvasive mechanical ventilation was administered to improve hypoxia, and continuous hemodynamic monitoring (PiCCO; PULSION Medical Systems AG, Feldkirchen, Germany) was initiated to measure the patient’s cardiac preload, afterload, and output.

Debridement and vacuum drainage were repeated by the orthopedist on day 4; however, the patient’s state of shock was not effectively alleviated. High body temperature, low blood pressure, and respiratory distress persisted. Arterial blood gas analysis was pH 7.271, PO₂ 51 mm Hg, PCO₂ 30.5 mm Hg, and BE -13.0 mmol/L. 

Mechanical ventilation was administered via endotracheal intubation on day 4 (a tracheotomy was performed on day 12). The ventilator primarily used synchronized intermittent-mandatory ventilation with pressure support ventilation mode (fraction of inspired oxygen [FiO₂] 50%, ventricular tachycardia [VT] 450 mL, R 16 breaths per minute, positive end-expiratory pressure [PEEP] 8 cm H₂O). The patient was agitated during the treatment, and propofol was administered continuously for sedation (maximum dose, 2000 mg/day; maintenance dose, 1000 mg/day). Continuous hemodynamic monitoring showed global end-diastolic and intrathoracic blood volumes were slightly lower than normal, and the patient’s blood pressure was maintained around 60/47 mm Hg by application of noradrenaline (maximum dose, 30 mg/day; maintenance dose, 6 mg/day) and dobutamine. Laboratory tests on day 5 reported WBC count 6.63 x 10⁹/L, neutrophil 79.64%, hemoglobin 74 g/L, lactate dehydrogenase (LDH) 1781 U/L, total bilirubin (TBIL) 30.2 µmol/L, aspartate aminotransferase (AST) 2015 U/L, alanine aminotransferase (ALT) 1225 U/L, TL-6 990.3 pg/mL, and procalcitonin (PCT) 4.230 ng/mL. 

Extensive necrotic tissue adhering to the wound surface of the patient’s right lower limb remained. In addition, piperacillin/tazobactam with vancomycin were administered to strengthen the antibiotic regimen. The patient sustained a persistently high fever with a heart rate of 120 bpm. She did not have an obvious increase in peripheral WBC count but maintained a persistently low oxygenation index < 300 and a volume-dependent blood pressure. Bacterial swab culture of the wound surface suggested Pseudomonas putida, Aeromonas hydrophila/A caviae, and P aeruginosa; blood culture and catheter culture showed no bacterial growth. Inflammatory indicators, such as C-reactive protein, interleukin 6, and PCT, increased significantly, suggesting septic shock.²

After a multidisciplinary meeting on day 9, it was concluded that despite 2 cycles of debridement and vacuum drainage, necrotic skin and subcutaneous tissue had not been sufficiently eliminated, as indicated by the large amount of necrotic tissue with serious infection (Figure 1), extensive wound exudate, and toxin absorption, and could still cause unstable hemodynamics. Therefore, it was determined that positive wound surface drainage should still be administered to reduce toxin absorption, improve hemodynamics, and promote granulation tissue growth that would create conditions for skin grafting. At the same time, the antibiotic regimen was strengthened by the combined use of imipenem/cilastatin and vancomycin as well as by application of ornidazole and voriconazole to attempt to prevent and potentially address anaerobic and fungal infections. 

Because of the patient’s respiratory failure, septic shock, and unstable blood pressure, she could not tolerate general anesthesia, which eliminated the option of thorough surgical debridement. On day 9, the lead author was invited to join the medical team and handlethis patient’s wound management. After comprehensive consideration, a simple debridement without anesthesia was performed, and wound surface cleansing using NPWT was initiated to remove exudate and infectious material from the right lower limb (Figure 2). About 8500 mL of exudate was removed on the first day, 6000 mL on the second day, and 3000 mL on the third day. On day 14, the dressing was changed and NPWT removed 2200 mL of exudate. The dressing was changed every 5 days. 

Two days after NPWT initiation, both the patient’s sepsis and her mental state noticeably improved. She regained consciousness gradually, and sedation was gradually withdrawn. The patient’s body temperature dropped from around 40°C to approximately 38°C, her heart rate decreased to 100 bpm, and her blood pressure stabilized at 90/50 mm Hg after withdrawal of the pressure-increasing agents.  Also, ventilation parameters improved (FiO₂ 40%; VT 450 mL; respiration 14 breaths per minute; PEEP 5 cm H₂O), and her vital signs stabilized gradually following the procedure. Laboratory tests on day 12 of admission showed WBC count 7.06 x 109/L, neutrophil 82.24%, LDH 224 U/L, TBIL 16.73 µmol/L, AST 24 U/L, and ALT 41 U/L. 

On day 14, her right lower limb was surgically debrided under anesthesia and NPWT was reapplied for 5 days. After the second cycle of NPWT, the patient’s respiratory failure, sepsis, and septic shock were effectively controlled; by day 19, there was well-developed granulation tissue on the wound surface (Figure 3). 

Autologous skin grafting with a large piece (about 70% of the right lower extremity) of skin was performed on day 19, and the ventilator was withdrawn after the procedure. Vital signs were stable, and blood gas analysis and laboratory tests were normal. Grades of antibiotics used were reduced gradually, and the patient was transferred to a general ward in the burn department. With the use of wound dressings, the skin grafted to the wound surface of the right lower limb on day 32, closing the wound (Figure 4). One additional skin graft was applied to residual wound granulation on day 35. Post procedure, the patient recovered well and was discharged from the hospital on day 57. 

For the initial treatment, debridement was not complete, and there was still adhered necrotic tissue onto the surface of the wound. In addition, the signs and symptoms of infection presented a couple of days later, which were treated with adjunctive antibiotics. Also, the local vacuum drainage system initially used with the PVA dressing did not effectively remove the exudate, which led to the buildup of absorbed toxins, leading to sepsis and septic shock. However, after further debridements, antibiotics, and the use of NPWT with the polyurethane reticulated open-cell foam dressing, immediate improvements were observed in the patient. Thus, the early use of NPWT instead of the local vacuum drainage may have minimized some of these difficulties.

In the population < 30 years of age, trauma is the leading cause of death, and it ranks third among the causes of death in the Chinese population between 2004 and 2010.³ Although the incidence of life-threatening complications in patients with severe trauma and the fatality rate within 24 hours after injury have been dramatically reduced through continuous developments of emergency medicine, the rate of death caused by sepsis and multi-organ failure within several days or weeks after injury still remains as high as ≥ 45%.⁴ Treatment of severe sepsis and septic shock after trauma typically relies on adequate fluid resuscitation, effective mechanical ventilation, application of antibiotics, infection control, and administration of a vasoactive agent.⁵ In this case, the patient’s symptoms were not effectively controlled after adequate fluid supplementation, assisted ventilation, continuous vacuum drainage after debridement, an antibiotic regimen with high-grade antibiotics, and persistent use of noradrenaline. Also, the patient’s septic shock was attributed to persistent and extensive wound exudate, absorption of toxins, and unstable hemodynamics caused by various controllable and uncontrollable factors. Accurately judging the patient’s condition and determining the next treatment procedures were challenging in this case, as an error in judgment could cause serious results; therefore, decisions had to be made quickly. While NPWT was developed as adjunctive therapy for use before or after surgery, it was also considered to be an alternative treatment for patients who could not undergo surgery.⁶ 

In this case, a local product was applied twice in the first stage. The heavy exudation was not sufficiently removed and toxin absorption resulted in severe infection and septic shock. Negative pressure wound therapy was applied as an alternative, and, after 2 days of adequate drainage removing infectious materials, the patient’s septic shock noticeably improved and her vital signs gradually stabilized. In this case, NPWT ensured adequate and effective drainage under uniform negative pressure by removing wound fluid in a timely manner, reducing chances of cross infection,⁷ improving local blood supply,⁸ and promoting growth of granulation tissue.⁹

At present, treatment of the posttraumatic complications of sepsis and septic shock remains a difficult medical challenge. Based on the present case, the following treatments were critical for wound closure: debriding necrotic tissue completely, choosing an appropriate vacuum therapy for wound drainage, and changing dressings as frequently as the patient’s condition allows. Manufacturer’s guidelines recommend NPWT dressing changes every 48 to 72 hours or at least 3 times per week; however, based on patient tolerance, in some cases daily dressing changes might be helpful to ensure the wound is not deteriorating. Therefore, the combination of several treatment methods, including NPWT, may be a way to remove exudate and thus offer better treatment to patients. 

Affiliations: Burns Department, First Affiliated Hospital of Anhui Medical University, Shushan, Hefei, Anhui, China; Orthopaedics Department, First Affiliated Hospital of Anhui Medical University; and Intensive Care Department, First Affiliated Hospital of Anhui Medical University 

Correspondence:
Qinglian Xu, MD
Burns Department 
First Affiliated Hospital of Anhui Medical University
218 Jixi Road
Shushan, Hefei
Anhui, China 230022
xuqinglian@sina.com

Disclosure: Dr. Xu is a speaker for KCI, an Acelity company. All other authors have no conflict of interest. Alice Goodwin (Acelity) provided editorial assistance.