Adapting a Vacuum Assisted Closure dressing to challenging wounds: negative pressure treatment for perineal necrotizing fasciit

ARTICLE

Auteur(s) : Luca NEGOSANTI¹, Arianna ACETI², Tommaso BIANCHI³, Luigi CORVAGLIA², Francesca NEGOSANTI⁴, Rossella SGARZANI¹, Paolo Giovanni MORSELLI¹, Riccardo CIPRIANI¹, Massimino NEGOSANTI⁴, Annalisa PATRIZI⁴, Giacomo FALDELLA²

¹Unit of Plastic Surgery, S.Orsola-Malpighi Hospital, Via Massarenti 9, 40138 Bologna, Italy
²Unit of Neonatology and Neonatal Intensive Care, S.Orsola-Malpighi Hospital, Via Massarenti 9, 40138 Bologna, Italy
³Unit of Dermatology, Bellaria-Maggiore Hospital, Bologna, Italy
⁴Unit of Dermatology, S.Orsola-Malpighi Hospital, Via Massarenti 9, 40138 Bologna, Italy

accepté le 15 F�vrier 2010

Necrotizing fasciitis (NF) is rare in paediatric patients. NF is usually monomicrobial [1]: Staphylococcus Aureus is the most common bacterial cause, however other bacteria, especially Gram-negative, can also be responsible [2]. Predisposing factors include minor injuries, surgical procedures and debilitating conditions, such as immunosuppression. NF is a life-threatening condition, with an overall neonatal mortality of approximately 59% [3], therefore prompt diagnosis and treatment are mandatory to avoid fatal complications. Medical care involves the administration of appropriate antibiotics and intravenous immunoglobulins. Surgical debridement of the entire necrotic area is mandatory [1]. The repair of the resultant wound is difficult in newborns: surgical reconstruction should be avoided, in our patient the use of topical negative pressure achieved a good result.

Topical negative pressure therapy supports wound healing by stimulating blood flow, the formation of granulation tissue and angiogenesis. In addition, the negative pressure within the pores of the polyurethane foam dressing contracts the wound and draws the wound edges closer together [4]. Topical negative pressure has proved to be effective in children and also in newborns [2, 5]; the indications for using it in pediatric patients have been reported by Baharestani [11].

Materials and methods

After the histological analysis of skin lesions and bone marrow, acute monoblastic myeloid leukaemia was diagnosed. The patient underwent a one-week treatment with Doxorubicin, Etoposid and Cytarabine, according to the guidelines of the Italian Association of Haematology and Pediatric Oncology.

When the patient was 20 days old, physical examination of the perineal area showed erythema and haemorrhagic pustules which rapidly progressed into necrotizing fasciitis. At 23 days, physical examination of perineal area showed a lesion of approximately 18 cm² involving the superficial and deep fascial planes around labia majora, a greenish secretion, a black eschar with an erythematous halo and rectal prolapse. The histology of the perianal lesion reported fascial necrosis, vascular thrombosis and myonecrosis. Swap culture revealed the presence of Pseudomonas aeruginosa, however, blood cultures were negative.

The infant was initially treated with systemic administration of: broad-spectrum antibiotics, immunoglobulins, inotropic drugs and nutritional support. Antibiotic therapy was subsequently modified according to the result of the swab culture (Meropenem, Vancomycin, Tobramycin). The initial treatment of the wound consisted of surgical debridement followed by the application of advanced dressings, such as silver polyurethane foam and hydrofiber (figure 1).

Due to the reduced healing rate and the persistence of Pseudomonas colonies in the wound, a topical negative pressure device (V.A.C.^®, KCI, San Antonio, TX) with V.A.C. GranuFoam Silver^® dressing was applied directly on the wound [6]. The entire V.A.C.^® dressing was changed every 48 hours. During hospitalization at the Neonatal Intensive Care Unit, the newborn was continuously monitored: pain was assessed and opioid analgesia was used.

The positioning of the V.A.C.^® dressing on the perineal area was challenging, the main problems were: preventing direct suction on the anal sphinter while maintaining normal sphinteric functions and avoiding pressure sores due to the suction tube. A double polyurethane film covering the foam on both sides was applied, extending from left hypocondrium to the perineum, to allow the negative pressure to be transferred from the suction pad to the wound. To prevent direct suction on the anal sphinteric, a custom made polyurethane foam ring tailored from an advanced dressing (Biatain^®, Coloplast DK) was placed between the polyurethane sheets; this was necessary to keep sub atmospheric pressure in the wound area while maintaining normal sphinteric functions. The suction tube on the foam was not applied directly on the wound, in order to avoid the occurrence of pressure sores: it was placed in the left hypocondrium (where the skin was protected by a polyurethane layer). Figure 2 shows a template of V.A.C. dressing multilayer positioning. Topical negative pressure was set at – 50 mmHg according to McCord [5] for 6 days and then raised to – 75 mmHg for seven days. The rise in negative pressure was concurrant with an increase of the C-reactive protein (CRP) value (from 1.09 to 5.07 mg/dL), however, local signs of inflammation were reduced.

After 13 days of negative pressure treatment, the wound was almost healed. The V.A.C. therapy was then stopped (figure 3); at that time, the CRP had decreased to 1.13 mg/dL. All the microbiological cultures performed in the perineal area were negative. Definitive closure was achieved in 5 days of application of collagen dressing (Condress, Abiogen, Pisa). After these treatments there were no signs of NF and the swab culture was negative for Pseudomonas aeruginosa. When the infant was 76 days old, she was transferred from the Neonatal Intensive Care Unit to the Onco-haematological Unit for the leukaemia follow up. She underwent anorectoplasty to reconstruct her anal sphincter.

Discussion

Lo described another case of a newborn affected by AML who developed an extensive NF caused by Pseudomonas aeruginosa located in the left cheek. The infant was treated by surgical debridement, fasciotomy, meticulous wound care and systemic administration of antibiotics and GM-CSF [7]. Zuloaga-Salcedo reported a case of NF due to Enterobacter cloacae and coagulase-negative Staphylococcus in a full-term female newborn treated with negative pressure therapy [8]. Other authors [9, 10] reported two cases of NF due to Pseudomonas aeruginosa in paediatric patients affected by acute leukaemia.

Topical negative pressure has been used since 1997 in adult wound care practice and from 2000 in paediatric patients. The indications for negative pressure therapy in paediatric and neonatal wounds have been discussed by Baharestani, who described his experience with pressure settings selection, ranging from – 50 to – 100 mmHg [11].

In our experience, the use of topical negative pressure therapy for neonatal NF allowed us to achieve rapid wound healing after debridement. Other advanced dressings were not useful in our patient. Interestingly, after the increase of suctioning pressure from – 50 to – 75 mmHg, a higher CRP value was observed, although local signs of inflammation had reduced. This can be explained, as previously reported [12], by the fact that topical negative pressure determines the local release of IL-6, IL-8 and VEGF and IL-6 induces an increase in plasma CRP concentration [13].

In conclusion, we strongly suggest that negative pressure therapy should be considered in the treatment of NF in newborns when conventional wound care fails to achieve complete wound closure.

Acknowledgements

References

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