Sound Evidence - December 2008 - (Page 56) TABLE 1 UNSTAGEABLE PRESSURE ULCERS PRESENT ON HOSPITAL ADMISSION DEBRIDED WITH APWT Patient/Wound Patient 1: 89-year-old man Bedridden, history of pressure ulcers, diabetes, myocardial infarction, dementia Location: sacrum Patient 2: 52-year-old man Diabetes, hypertension, chronic pain syndrome, chronic morphine use, smoker Location: left lateral ankle Duration of APWT 2 days 7 min/day Tissue Characteristics Post-APWT Pre-APWT 30% slough 100% adherent 70% granulation grey slough Pressure Ulcer Stage Pre-APWT Post-APWT Stage IV Unstageable exposed bone Note: Sharp debridement performed pre and post APWT; substantially more slough was removed after APWT 2 daysa 3 min/day 50% eschar 40% slough 10% unhealthy pink 50% slough 50% granulation Unstageable Stage III 2 days Patient 3: 61-year-old woman Breast cancer with metastasis to 4 min/day lung, not tolerating chemotherapy, radiation, hypertension Location: left heel a 100% tan/brown thick slough 80% yellow slough 20% granulation Unstageable Stage IV Necrotic tissue continued to obscure the wound bed after application of papain urea.b After APWT, red tissue down to muscle was visible b Although the wound was stageable after 2 days, APWT was continued for 3 more days to promote healing before discharge. The US Food and Drug Administration has since issued a statement that topical papain urea products have not been proven safe or effective and are therefore considered unapproved products. unstageable pressure ulcers in an effort to expeditiously expose the wound base and stage pressure ulcers accurately on admission to an acute care facility. Case Series The authors began using APWT (MIST Therapy® System, Celleration Inc., Eden Prairie, Minn.) at their acute care hospital on a trial basis in September 2008. The patients reported here are the first three patients for which the authors were consulted to evaluate unstageable pressure ulcers and the only three such cases during the 1-month trial period. Pressure ulcer was the primary reason for hospitalization of Patient 1 and a secondary diagnosis for Patients 2 and 3. APWT was utilized to assist with debridement of slough and eschar in the wound beds of pressure ulcers unstageable on admission. Before utilizing APWT for debridement of unstageable pressure ulcers at this facility, such wounds were treated with sharp or enzymatic debridement and moist wound healing. APWT was administered as an adjunct to moist and enzymatic wound dressings, including collagenase and gauze (Patient 1), petrolatum gauze with bismuth tribromophenate followed by hydrocolloids (Patient 2), and papain urea (Patient 3; see footnote to Table 1). As shown in Table 1, all three wound beds were covered completely with slough and eschar, eliminating the possibility of accurately staging the wounds based on depth of tissue damage. Sufficient debridement to enable accurate staging of all wounds as Stage III or Stage IV was achieved in 2 days. Wound area remained unchanged in Patient 1 (16 cm2) and Patient 3 (8.75 cm2) after 2 days of APWT, but decreased by more than 50% in Patient 2 (1.95 cm2 to 0.88 cm2) after 5 days of APWT (see Figure 1). Patients were discharged home within 1 day of the last APWT treatment (Patients 1 and 2 same day, Patient 3 next day) with either hospice staff or family members performing dressing changes. 56 OstomyWound Management
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