Ann Thorac Surg 2001;72:1409-1410
© 2001 The Society of Thoracic Surgeons
How to do it
Vacuum-assisted closure in the treatment of a 9-year-old child with severe and multiple dog bite injuries of the thorax
Karen M. Brown, FRCSa,
Fiona V. Harper, FRCSb,
William J. Aston, MB, ChBa,
Peter A. O’Keefe, MS, FRCS(C/Th)a,
Charles Robert Cameron, FRCSa
a Department of Cardiothoracic Surgery, Guy’s Hospital, London, England, United Kingdom
b Department of Plastic Surgery, Guy’s Hospital, London, England, United Kingdom
Accepted for publication May 1, 2001.
Address reprint requests to Miss Brown, c/o Mr Cameron, Department of Cardiothoracic Surgery, Guy’s & St. Thomas’ NHS Trust, Guy’s Hospital, St. Thomas’ St, London, SE1 9RT, England
e-mail: kbrown{at}doctors.org.uk
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Abstract
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The vacuum-assisted closure (VAC; KCI International, San Antonio, TX) device is a negative pressure dressing, which we have used in the treatment of wounds with devitalized or infected tissues. Although introduced in plastic and reconstructive surgery, its use has extended to orthopedic and cardiothoracic surgical practice in the treatment of infected joint replacement and sternal wound infections, respectively. Although the VAC is becoming more widely used in surgical practice, only a small number of case reports exist in addition to the original case series by Argenta and Morykwas in 1997. Previously, the device was described in treating single wounds in adult patients. We report a case where it was successfully used to treat multiple dog bite injuries in a 9-year-old child.
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Introduction
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A 9-year-old girl was attacked by a bullmastiff, which was the family pet. The dog’s jaws gripped the entire right hemithorax, shaking her violently to create a combination of degloving, crushing, and shearing injuries with extensive tissue loss. Her injuries included fracture of ribs 2, 3, 4, and 5 with a flail segment, hemopneumothorax, and fractured scapula. The hemopneumothorax was managed with intercostal chest tube drainage. Soft tissue loss was considerable with multiple bite marks over the right thorax and buttock. Two bites were particularly severe; one, a subaxillary chest wall wound, 12 x 6 cm, extended beneath the pectoral muscles to the chest wall and underlying lung, and the second, a posterior wound, 4 x 3 cm, extended deep to the scapula. There were three additional more superficial, yet significant chest wall wounds. These were assessed and debrided at her referring hospital under general anesthetic (GA). She was transferred to this unit having been electively intubated and ventilated. All wounds were further assessed and further debridement under GA was undertaken as appropriate. She was extubated immediately postoperatively. During the following 10 days, the wounds required further debridement under GA on four occasions. Despite systemic antibiotics, the wounds failed to improve and became colonized with Pseudomonas aeroginosa. There was significant oozing from the wounds, with dressing soilage and malodor increasingly distressing her.
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Technique
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We had extensive experience with vacuum-assisted closure (VAC; KCI International, San Antonio, TX) dressings in complex sternal wound problems after cardiac surgery. The device had been used as a component in the treatment of serious superficial and deep sternal wound infections, including mediastinitis, in over 40 patients. It had addressed the combination of problems experienced in this particular case to good effect. At this stage, therefore, it was decided to apply the VAC dressing to the larger subaxillary wound. Dressing change after 2 days showed remarkable progress, and hence, two separate VAC dressings were applied both to this wound and to the posterior wound. Both sponges were connected to a single VAC suction unit (set at -125 mm Hg) by means of a Y connector (Fig 1). The lack of wound odor and strike-through of dressings met with patient satisfaction. In addition, she was disconnected intermittently from the pump to allow mobilization and participation in planned ward activities. Within 5 days, the deep posterior wound had become superficial, filled with healthy granulation tissue, and was closed by direct suture (Fig 2, immediately before closure). The larger subaxillary wound was redressed using the VAC pump and had a further 2 days (9 days in total) of treatment. Remarkable granulation tissue formation was achieved. At this stage, wound microbiological cultures were negative and the VAC was discontinued. Although the wound had become fairly superficial, a large tissue defect remained, preventing direct closure. This was left to heal by secondary intention with a view to elective scar revision in due course.
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Fig 1. Vacuum-assisted closure (VAC) pump with collection chamber, tubing to Y connector, and two dressings.
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Fig 2. View of patient’s back in left lateral position showing posterior wound over right scapula granulating after 5 days.
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Comment
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The VAC device was first described in 1997 in a large patient series by Argenta and Morykwas [1]. Two hundred and ninety-six of 300 chronic, subacute, and acute wounds responded to the subatmospheric treatment with increased granulation tissue formation allowing skin graft or flap coverage. Although originally used in plastic surgery, the VAC dressing has been used to treat poststernotomy mediastinitis after cardiac surgery [2]. In these three cases described, the VAC was applied after initial surgical debridement, but fibrous union was achieved without further surgical intervention by tissue transposition (flaps) or direct secondary suture. In a larger series of 15 patients, complete healing was achieved in 13 survivors, some of whom had VAC dressing as a primary treatment [3]. The device consists of a sterile foam dressing with 400-µm to 600-µm pore size that maximizes tissue ingrowth. A length of tubing is embedded in the foam dressing with multiple side ports. This empties into a detachable collection canister, which is then connected to an adjustable vacuum pump. A clear plastic adhesive drape is sealed over the dressing with generous overlap and formation of a mesentry around the tube to ensure complete isolation of the wound. A Y connector easily allows the tube from a second wound to be connected to the vacuum pump, as in our case. Once switched on, the vacuum pump applies negative pressure in a controlled manner and the foam dressing shrinks down into the wound cavity. The acceleration of wound healing is thought to be multifactorial but includes removal of third-space fluid and debris from the wound, improved microvascular tissue perfusion, decreased bacterial colonization, removal of inhibitory wound-healing factors, and the mechanical response of surrounding tissues to controlled force.
As far as we are aware, this is the first reported case in the literature where the VAC dressing has been used in children, and for multiple injuries such as dog bites with a Y connector. In complicated wounds with extensive contamination, it is a useful and versatile device that accelerates granulation tissue formation and healing. It reduces the need for dressing changes under general anesthetic and is acceptable to both adult and pediatric patients.
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References
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Argenta L.C., Morykwas M.J. Vacuum assisted closure: a new method for wound control and treatment: clinical experience. Ann Plast Surg 1997;38:563-577.[Medline]
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Obdeijn M.C., De Lange M.Y., Lichtendahl D.H.E., et al. Vacuum assisted closure in the treatment of poststernotomy mediastinitis. Ann Thorac Surg 1999;68:2358-2360.[Abstract/Free Full Text]
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Tang A.T.M., Ohri S.K., Haw M.P. Novel application of vacuum assisted closure technique to the treatment of sternotomy wound infection. Eur J Cardiothorac Surg 2000;17:482-484.[Abstract/Free Full Text]
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