SoundEvidence - August 2008 - (Page 51) electrical stimulation (ES) can be effective for treatment of pressure ulcers refractory to conventional therapy3 and specifically in patients with spinal cord injury. However, ES use may be limited by clinical contraindications, such as osteomyelitis or infection. Acoustic pressure wound therapy (APWT), a low-frequency, noncontact, nonthermal ultrasound therapy indicated to promote healing through cleansing and maintenance debridement of yellow slough, fibrin, tissue exudates, and bacteria,4 has no known contraindications related to wound status.4,5 Randomized and nonrandomized studies5 primarily involving lowerextremity ulcers have reported increases in the proportion of wounds healed and decreases in healing time when APWT is added to conventional therapy. Case reports6-10 describe the use of APWT to remove necrosis and promote development of granulation tissue in nonhealing wounds. This paper reports the course and outcomes of using APWT in mobility-compromised patients to increase granulation tissue and render sacral pressure ulcers suitable for ES and other additional therapy. This particular rehabilitation nursing facility specializes in patients with spinal cord injuries, ventilator dependency, and neuromuscular degenerative diseases. The wound care team (rehabilitation director, certified registered nurse practitioner specializing in wound care, certified wound treatment nurse, and physical therapist specializing in wound care) determines when APWT would be of benefit and identifies when wound characteristics are compatible with indications for less-costly therapies such as ES. A physical therapist administers advanced wound care modalities including ES and APWT. Wounds considered appropriate for physical therapy intervention include Stage III and Stage IV ulcers and ulcers post surgical debridement. Case Series Patient data were collected retrospectively from the medical records of five nonconsecutive inpatients who had received APWT for chronic sacral pressure ulcers containing substantial necrotic tissue (ie, >50% slough or any eschar). These patients were provided consistent 2-hour turning schedules, similar pressurerelieving mattress surfaces, and consistent nutritional support. Acoustic pressure wound therapy (MIST Therapy® System, Celleration, Inc., Eden Prairie, Minn) was administered per the manufacturer’s recommended use11 three times per week for 4 to 6 minutes per session in conjunction with appropriate moist dressings. Treatment continued until necrotic tissue was removed, granulation was complete, drainage resolved to moderate levels, and wound parameters compatible with indications for ES (EGS 4000 highvoltage pulsed galvanic stimulator, ElectroMed Health Industries, Miami, Fla) or dressings such as NPWT and silver foam. Weekly wound assessments included length, width, depth, odor, percentage of granulation and necrosis, tissue color, and drainage. Treatment characteristics and outcomes for all five patients are shown in Table 1. Patient 1. A 23-year-old man with quadriplegia and a history of chronic sacral wounds resulting in thin, weak scar tissue over the sacrum was readmitted following hospitalization with a Stage IV sacral ulcer with 50% yellow, adherent slough. Acoustic pressure wound therapy was administered to cleanse the wound of slough. After 5 weeks of simultaneous treatment with APWT, nonadhesive silver foam dressing (Contreet, Coloplast US, Minneapolis, Minn), and mandatory bedrest initially (side-lying only) followed by seating in a wheelchair up to 4 hours per day with gapped area around the sacrum, the wound contracted and the wound bed showed 100% red granulation tissue. Acoustic pressure wound therapy was discontinued due to very small wound size (see Table 1); foam with silver dressing was continued until closure 2 weeks later. Patient 2. An 81-year-old woman in a persistent vegetative state developed a Stage II sacral pressure ulcer that rapidly declined to an unstageable ulcer, despite a 2-hour turning schedule, side-to-side only. Acoustic pressure wound therapy was administered to debride the wound of large amounts of black necrosis and copious, purulent drainage. Wound size increased as the necrosis was debrided (see Table 1). After 10 weeks of APWT and use of a sodium hypochlorite solution dressing, collagenase, and hydrofiber with alginate, the wound bed was 100% red granulation tissue. At this time, it was determined that equal benefit could be achieved with ES, which was administered August 2008 Vol. 54 Issue 8 51
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