Background
As a consequence of hospitalisation, ICU, in connection with initial spinal injury, an approximately 60-year-old man developed a sacrum pressure ulcer which very quickly expanded to a category 4. It became heavily infected, and over the following 15 months in hospital followed by 19 months in community care, the wound has needed daily treatment by usually specialty nurses mostly from tissue viability. Essentially, all available approaches to wound care have been tried including NPWT with and without instillation of saline, but it has proven impossible to close the wound. Judging from the history; the state of the wound; and the fact that chronicity in wounds is due to infection (Leaper et al. 2015) it is most likely that the patient by now has developed a very deep-seated infection that – given all the methods tried – has developed resistance to practically all available approaches.
In hospital the following products had been used:
Inadine, Kaltostat, Durafiber,Durafiber Ag,Allevyn Life, Allevyn Adhesive, Allevyn Gentle, Tegaderm foam, Sorbaderm, Debrisoft, Aquacel Foam, Promogran, Iodoflex.
In community, among others, the following products had been used:
Prontosan, Aquacel Ag, VAC pump, Inadine, Kaltostat, Durafiber, Durafiber Ag, Allevyn Gentle Border, Tegaderm Foam, Sorbaderm, Debrisoft, Aquacel Foam, Promogran, Iodoflex, PICO, Suprasorb, Medihoney gel, Packing ribbon, Manuka honey, Flamazine, Cutimed Sorbact, Flaminal Forte, Biatain Silicone, Kliniderm, Allevyn.
Goal of Acapsil trial:
The wound was being scheduled for surgery. The aim of the Acapsil treatment was to contain the spreading infection and reduce it as far as possible. This would allow for a reduction of the area to be excised as well as significantly increase the chances of success of surgery. Acapsil could then be used again immediately following surgery, in order to remove any remnants of infection and to keep the healing process progressing uneventfully.
This goal has been reached Day 21. While awaiting surgery, the further progress will be monitored.
While awaiting surgery, the wound is flushed with tap water daily and dabbed dry with a gauze. It is left to air only covered with a simple gauze and no antimicrobials are being used. So far, it has only needed a light, superficial dusting with Acapsil once, due to possible detection of odour.
The monitoring will continue until surgery.
Example of analysing wound status and progression
3.5-year-old category 4 sacrum pressure ulcer. 17×17 cm covered with bright red shiny skin and scar tissue with a relatively small opening in the centre. As most of the wound area is closed over by skin on top, the wound can only be evaluated from the colour, texture and temperature of the skin as well from the level, colour, texture and smell of the exudate. The 4 pictures below are identical, from Day 0, i.e. before start of Acapsil, and indicate the 4 main areas of the wound.
Area 1:
Day 0: The opening and the surrounding skin in the inner blue circle is deep purple and the texture is stiff and hard like cardboard in the entire area within the broad blue circle – the signs of cellulitis in old non-healing wounds. The inside of the wound is brown-yellow and necrotic. The cranial and right sides are undermined by 1 cm (blue line). The wound edges are curved downwards facing into the open cavity. The exudate level is very high. The wound is malodourous.
Day 21: Area1: All purple areas have changed to pink and the cardboard-like texture is gone – i.e. the cellulitis is cleared, fending off the acute risk of septicaemia. The skin is now skin-like and even the old scar tissue is well pliable. The inside of the wound is pink and granulating. It has granulated up from the bottom, the opening has reduced by one third from the distal end and the undermining along the right side has disappeared. The exudate level is reduced to being controlled by a cotton gauze. No smell is associated with the wound.
Area 2:
Day 0: The distal area of the wound show clear signs of widespread tissue infiltration.
Day 21: The area is now cleared of infiltration and the skin is normal in both texture and colour practically up to the wound opening.
Area 3:
Day 0: 2 sinuses of 4 and 5 cm, respectively, open underneath the undermining and run cranially under the skin as indicated by the blue lines. The entire area circled in blue is warm to touch, red, inflamed and swollen with cracked and fissured skin resembling miniature wounds – the signs of infectious infiltration.
Day 21: The acute skin infection is cleared and the skin is returning to its normal colour. The 2 sinuses run underneath the deeply infiltrated area making sure the body has a means to drain out the necrotic tissue and the debris created by the infection. The area has clearly reduced in redness and the swelling on left side is starting to reduce. The sinus tunnels have been deblocked and cleared of infection; this is witnessed by fresh tissue being brought out during probing. The sinuses need to remain open temporarily to allow for the regular drainage of infective debris until the entire area has been cleared from tissue infiltration. As practically the entire wound area is covered by skin, only the sinuses represent an opening for Acapsil to reach the distant tissue to support the immune system. The infection is 3.5 years old and judging from the colour of the exudate pushed out on different days, pockets of infection with different infective agents have broken of different days. The process of infection containment and removal is ongoing and, as the wound is 3.5 years old, this will take the immune system some time to penetrate all the pockets and get to the bottom of the infection in all directions.
