Hypochlorous Acid as a Wound Cleanser
M. Mark Melin, MD, FACS, RPVI, FACCWS, and Abigail E. Chaffin, MD, FACS, CWSP, FAPWCA, discuss several respective cases in which hypochlorous acid was used as a wound cleanser in both the operative and postoperative settings to successfully treat chronic or complex wounds and achieve wound closure.
Transcript:
Dr. Melin: Hi, I'm Mark Melin. I'm a wound care surgeon in Minneapolis, Minnesota. I wanted to introduce Dr. Abigail Chaffin from Tulane University, one of the excellent plastic surgeons down in Louisiana. We're here today to talk about some complex cases and how we incorporate hypochlorous acid Vashe into our practices.
I'm going to start off with my poster quickly, if that's okay with you?
Dr. Chaffin: Yeah.
Dr. Melin: It should be ladies first always, but this is where we're going to go. We've got a complex wound care system up in Minneapolis, part of M Health Fairview, where we've really focused on lymphatic dysfunction performance first. We're very focused on adjunctive micronutrients. We use a lot of micronized purified flavonoid fractions. We look at edema reduction with two layer wraps, and these are very important components to getting accelerated wound care. But the other thing that we know, and we've seen a lot of data on this, is that wound pH typically runs 7.15 to 9 in these chronic wounds. Now, the skin microbiome and the skin acid mantle is about a pH of 5.5. If we decrease wound pH, we get improved granulation tissue because we're decreasing things like MMPs and inflammation and we see accelerated then closure and epithelialization.
And this particular poster was with complex patients where we were asked to manage their wounds and we did a moist to moist dressing change of hypochlorous acid Vashe, twice a day. The first patient that you see, it's an abdominal wound. She had had a GYN surgical procedure. Now, she was originally on negative pressure wound therapy but had a significant bioburden, significant odor when we first met her in the office, she didn't want to wear the negative pressure wound therapy any longer. We changed out to hypochlorous acid Vashe dressing changes on gauze twice a day. And you can see we went from December of 2022 to February of 2023 with wound resolution.
Good outcome. Now again, this is not standard of care because typically most of these wounds, especially gaping like that, you'd be negative pressure wound therapy to the end. Good outcome, complex patient. The next case which is listed as case one, is a 54-year-old male with HIV, presented for a left lower quadrant abscess incision and drainage. Again, put on negative pressure wound therapy initially, developed significant odor. He did not want to be on negative pressure wound therapy and we transitioned him to twice daily, moist to moist hypochlorous acid dressing changes. Again, good outcome over the course of about eight weeks.
Now, case five at the top, in that third panel, 27-year-old who's on a cardiac transplant list, he's got a left ventricular assist device in his chest. This is the pneumatic driver cord that's going into his left upper quadrant. And he went through an incision and drainage, and to take this out would be complicated, remove it. And the transplant cardiac waiting lists right now are pretty long. We contacted the manufacturer, I talked to the transplant team, talked to the cardiologist, and we started hypochlorous acid Vashe, moist to moist stressing changes twice a day with Vashe. And you can see again between July and then going into October, and the October one was a telehealth visit simply because he lived about two hours away, complete epithelialization.
No impact on the cord. He continued to work this whole time and really ultimately did very well. Now the case six listed in the middle panel, this is a 42-year-old female metastatic pulmonary malignancy into her cervical vertebrae. And she went through a complex neurosurgical resection with an excision of the metastases component and then broke open her wound. Now this is in a field that had previous extensive radiation, which you see all the time.
Complex wounds when you got radiation exposure. We would have her lay on her stomach, her mom was doing her dressing changes, fill that cavity with Vashe, let it sit for about 10 to 15 minutes, and then twice a day moist dressing changes. And then this is where we got to over the course of several months, again, telehealth visits, she lived a fair amount away. Now I think the 60% has to do with our inter-rater variability with our measuring system. There's no depth in this, whereas she had significant undermining at the initial picture. You can see the hardware in the neck picture. She has since gone on to completely healed in the updated photos. Case seven, 42-year-old female young mom fell in her backyard, trimalar fracture. They had to repair the tib and the fib and she ended up with significant postoperative edema, no deep vein thrombosis and she had exposed hardware.
Now as I understand it's always not good when you can read serial numbers on a piece of hardware out of your bone, correct? That's a bad thing.
Dr. Chaffin: That's not good.
Dr. Melin: And of course principal care would be, you got to get rid of the hardware. Contacted the orthopedic surgeon and they took out the hardware off of the fibula and then she did not want negative pressure wound therapy on this. We just started moist to moist Vashe dressing changes. And again, over the course of three months, primary closure compression is critical in these patients because she's got postoperative edema. You can't just do the Vashe, you have to do also, we were doing fuzzy whale a product called EdemaWear underneath Velcro inelastic compression for management because that allows us to take down the dressing twice a day, do the Vashe dressing change, put it back together.
Case eight, woman on chronic anticoagulation for atrial fibrillation, fell on her right knee, large hematoma. And this is probably something else you see in your practice too, where you've got these large hematomas that just said, "It'll get better." And we need to debride them. It's one of the things you and I as surgeons we like to operate. And when you see a wound like this, significant retained hematoma, took her to the operating room, used ultrasonic debridement, and then Abby and I both use also something called Antimicrobial Endoform and the surgical component is called myriad. And that's how we help eliminate some of this undermining but Vashe in the operating room is on my OR, critical component. And then we wash the whole thing out with Vashe after doing the ultrasonic debridement, did negative pressure therapy with in still therapy using hypochlorous acid as well, and then ultimately got rid of all the undermining and then outpatient management with twice a day.
And then the last case, and then we're going to move on to, you've got some phenomenal patients to talk about. Colostomy sitting right here. Tough closure to get negative pressure wound clinic or seal consistently. Typically, I would want to do VAC instill on this initially and then transitioned outpatient, but just not enough purchase skin. We ended up doing hypochlorous acid twice a day. And again over four months, complete closure right next to a colostomy. You just imagine the bacteria load living in a wound right next to your colostomy. Lot of anaerobes, probably some fungus, again, nice outcomes. In conclusion, taking some of these complex patients with totality of care, adjunctive micronutrients, other aspects, edema reduction to maximize microvascular perfusion and good control of the wound bed with debridement and then management of the wound pH, driving it down to decrease inflammation and enhancing epithelialization and angiogenesis. Now we're going to move on to your really excellent case series here. You've got two slides we're going to talk about. Tell us about some of these complex cases.
Dr. Chaffin: Thanks Mark. As a plastic surgeon focusing on reconstructive surgery and complex wound reconstruction, this first case series is all of my cases over a 60-day period in which there were 20 cases, which encompassed general plastic surgery reconstruction, breast reconstruction, necrotizing soft tissue infection, melanoma reconstruction, pilonidal cyst reconstruction, and hydro adenitis. Many of these all with a chronic bioburden and microbial colonization in which I'm called to do excision of the wounds and flap or graft reconstruction. Using the Vashe irrigation, I have found increased surgical success of prepping these wounds with a thorough wound bed prep prior to my very valuable flap or graft reconstruction with a goal of decreasing surgical complications such as infection or dehiscence or recurrence of the wounds. I'll go over the first case here, seen at the bottom as case 15. This was a gentleman with diabetes and some venous leg ulcers who had a melanoma there at the heel and plantar foot. After initial excision, the oncologic surgeon preferred to wait on permanent margins.
I again applied the Vashe intraoperative irrigation protocol, negative pressure. Once we had negative margins, came back for a split thickness skin graft reconstruction, as you can see here with full take of the graft and success. The second case is a 58-year-old diabetic patient who came in with a severe neck necrotizing soft tissue infection involving the lower abdominal wall, hemi perineum, pubis thigh and buttocks. And this lady also had a paralyzed left leg after all of these resections. My goal as a plastic surgeon is to accomplish robust flap reconstruction to control vaginal secretions, urine secretions. But my challenges here were very thin coverage over the femoral artery and vein. And as you can see on the top photo, a necrotic area of osteomyelitis at the pubis and very difficult reconstruction. Using the hypochlorous acid Vashe irrigation in the OR to help eradicate this microbial colonization, a debridement of the osteomyelitis also used the myriad graph to help fill in that area to accomplish better coverage and robust granulation tissue, which got me to the second photo.
Which is where I was able to take her to the OR and perform one of the only options available here, which was a large oblique rectus abdominis mucocutaneous flap reconstruction to accomplish the hemi perineal reconstruction and cover over the ischial region to help prevent stage four ulceration there and then skin graft over the remaining of the thigh wound.
This helped me achieve a two-stage, very complex reconstruction on a sick patient with poor diabetic control and in necrotizing infection.
Dr. Melin: And this is really high price real estate.
Dr. Chaffin: High price real estate.
Dr. Melin: The femoral anterior that we've all seen blow up, bleeds in this area. I want to go back to the middle slide because you talked about the importance of having Vashe in the operating room. And I think if we can do anything to help educate our surgical colleagues talk to the importance of Vashe in the operating room.
Dr. Chaffin: Absolutely. From what we know and what you've gone over with the pH similar to nominal pH with this effectiveness, I have vaginal secretions free in this wound. I'm right next to the rectum, she was diverted. I have osteomyelitis and using this in the operating room along with an adequate surgical debridement of necrotic tissue helps assure that I have hopefully a clean slate that's going to accomplish granulation and get me to where I'm going to have a successful flap and graft reconstruction without infected dehiscence. This is another one where I would've used negative pressure wound therapy but really, it would be impossible to achieve a seal to the remaining perineum and the urethra is there and the vaginas there. And this helps accomplish really cleaning up and prepping that wound bed for a surgical reconstruction so that I have surgical success.
Dr. Melin: And really great quality of life outcome. Think about the really wonderful outcome. Thinking ahead of time, planning, great case. And then you've got this very interesting hidradenitis case.
Dr. Chaffin: Hidradenitis can be very challenging. This is a gentleman who had lost 200 pounds but still had a BMI of 42 with severe multifocal Hurley stage three hidradenitis suppurativa. And here we see the right axillary region with multiple chronic purulent fibrotic sinuses and required a large resection of this entire area of the axilla seen there on the second photo of the entire subcutaneous space down to the pectoralis muscle tendon. What I do here is excising the disease, but obviously there's quite a bioburden. Using appropriate irrigation with Vashe with a good dwell time of five to eight minutes to help eradicate the colonization.
And then an advancement flap reconstruction of fascia cutaneous tissue from the arm and the chest, closed over multiple layer suture closure with drain wicks and then standard treatment in our postoperative wound clinic. And as you can see the photo there at four months shows no further hidradenitis, an excellent retained range of motion of the shoulder and successful healing of what had been a process that he had been undergoing for 10 years. For quality of life, he no longer has painful chronic infection draining from his axilla. He has gone on now to have the abdominal region addressed with a similar protocol and also the thighs and the perineum also was success.
Dr. Melin: I think a lot of people don't appreciate this and the tunneling effect, like Swiss cheese component.
Dr. Chaffin: Even worse is the significant bioburden oftentimes with anaerobes, multiple gram-positives or gram-negatives is really hidden in this disease under fibrotic tunnels to where it's not able to be treated adequately and eradicated pre-op. Then in the operating room, you're sizing all of the involved disease, but you have a very hostile surgical field. I tend to prefer fascia cutaneous advancement when possible versus skin graft when there's excess skin. But these are at high risk for infected dehiscence and the patients have already been dealing with chronic infection and pain for years. And if we can accomplish one surgery to heal them up and get them back to their quality of life, and this is one essential tool in the shed to have intraoperative irrigation and get it to a clean surgical field.
Dr. Melin: And again, you said he had this for 10 years?
Dr. Chaffin: Yeah, over 10 years.
Dr. Melin: That's impressive. We're going to transition to your next slide and talk about some of these same principles again.
Dr. Chaffin: Right. I took what was the general plastic surgery case series and I did a deep dive on my stage four pressure injury reconstructive surgeries over a one-year period. And this was 18 patients, 20 cases. And these patients, the published recurrence rates of stage four pressure injuries are 40 to 80% and there's a high postoperative surgical dehiscence and infection rate. These are wounds and challenging pelvic locations with chronic microbial colonizations. As you can see here on the first case, this is a 52-year-old gentleman who had multiple prior stage four pelvic pressure injuries and multiple prior flap surgeries who presented there in the first photo. Unfortunately, after a hurricane in our region, he lost power to his powered offloading bed and powered wheelchair, sustained recurrent stage four pressure injury at the left is ischium region and left trochanteric region and had been in and out of the hospital for six months with this and lost his independence.
And took him to the operating room for a complete excision of all these ulcers leading to a very large defect and then standard rotational flap. This was a gluteal myocutaneous rotation flap with intraoperative irrigation, again with the hypochlorous acid Vashe solution to help eradicate the multiple organisms that grew in the wound, including proteus, E.coli, and enterobacter on the postoperative closures. Really, I had one shot here. There was very few spare parts left after his multiple prior flap reconstructions to try to get him healed and get him home. And he went on to heal successfully.
Dr. Melin: And one of the critical things is with such a big area, there is no cytotoxicity with hypochlorous acid to impair the cells that are actually trying to heal. Correct?
Dr. Chaffin: Absolutely. Unlike some of the other solutions out there that may have cytotoxicity just due to the chemical or just a pH imbalance with healthy skin, this is something that helps make wound prep more adequately without damaging the remaining limited viable tissue.
Dr. Melin: And Greg Schultz gave this great talk yesterday. It just makes me think of biomimicry because when he talks about neutrophil production for internal defense barriers, you're producing small micro of hypochlorous acid, you're not producing some of the other substances we see put on wounds chronically.
Dr. Chaffin: Absolutely.
Dr. Melin: Again, biomimicry, we're trying to replicate what the body's natural defenses are.
Dr. Chaffin: The body's innate immune responses to produce hypochlorous acid, as you mentioned, as part of the neutrophil oxidative burst. And we're mimicking that on a larger scale to accomplish a more successful difficult reconstruction.
Dr. Melin: Tell us about case two.
Dr. Chaffin: Case two, this is a 58-year-old gentleman with acute quadriplegia after a motor vehicle accident who unfortunately left the hospital with a large stage four fibrotic extensive pressure injury seen there on the preoperative photo. As you can see, the wound's much larger than anticipated due to the significant fibrosis of the surrounding tissue. The resection picture is picture two, approximately a 10 by eight by six centimeter wounds. On him again, adequate ulcer excision, irrigation with the Vashe hypochlorous acid solution in the OR and then gluteal muscle advancement flap and fascia cutaneous rotation flap reconstruction. He went through our standard postoperative team-based pressure injury protocol, which really takes everybody involved in managing these patients and went on to heal. There's his post-op at four months, he's now home with a motorized offloading reclining wheelchair with the aid of his wife and living an independent life after a C4 quadriplegic injury.
Dr. Melin: That's an amazing outcome. And you highlighted team involvement in this interdisciplinary.
Dr. Chaffin: Interdisciplinary preoperative prep of these patients, nutritional management, osteomyelitis management, infectious disease, inpatient and outpatient wound care teams, and then appropriate care. He went to the ulcer facility. Appropriate postoperative care of these very fragile flaps. All of this I think is essential to make a dent in those high recurrence rates because the patients only have so many spare parts and once they've had all their spare parts used, they may not be fixable.
Dr. Melin: Now I've only left you about 60 seconds for case three.
Dr. Chaffin: All right. Case three, 56-year-old gentleman with uncontrolled diabetes and nicotine use who was a roofer, who had his buttocks burned on a roofing job. He had undergone excision and grafting in an outside burn center and then a right buttock stage four ischial pressure ulcer and a fascia cutaneous flap at an outside hospital which had failed. He presented to me, I excised the ulcer, used the intraoperative hypochlorous acid irrigation protocol and flap reconstruction. And as this was a revision flap, used forward-looking infrared camera imaging in the OR to ensure that I had full vascularity of my flap. He also went on to follow the same protocol and heel. He is now successfully retired from his roofing job and is back to a high quality life.
Dr. Melin: Fabulous. I think in the closing moments here, we want to thank Vashe, and their team, for helping to educate us and for helping us to get the word out to our colleagues about the importance of hypochlorous acid management of chronic wounds, how it compliments our surgical skills, and you've got fabulous surgical skills.
Dr. Chaffin: Thank you.
Dr. Melin: It's terrific.
Dr. Chaffin: As are you.
Dr. Melin: I look at your outcomes, it's tremendous. And how really it improves quality of life and outcomes for the patients we serve.
Dr. Chaffin: Absolutely. It's an essential tool in management of these very complex patients to get them healed and get them home to a high quality life.
Dr. Melin: Thank you for presenting with us today.
Dr. Chaffin: Thank you for being my co-presenter.
Dr. Melin: And we want to thank the audience for spending time with us on this educational endeavor to learn more about hypochlorous acid and Vashe and how it plays into our surgical armamentarium and into our outpatient clinical management of wounds. Thank you.
