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Necrotic Tissue Case Study: Arrowsmith, M

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IntraSite Conformable in the treatment of necrotic tissue.

 

Introduction
The management of skin damage caused by necrotising fasciitis.

 

The Patient
PW is a 29-year-old window cleaner who fell 20 feet from a ladder. Upon impact he sustained a fractured wrist and crushed a large part of his liver. Following a laparotomy and partial lobectomy of the liver for tissue necrosis, he was transferred to the Bristol Royal Infirmary ITU for a further operation on his liver and specialist treatment for liver and kidney failure. Following this operation to stop bleeding internally and remove more necrotic tissue from the liver, he became pyrexial and generally more unwell. It was noticed on his flank a dusky hard area developing rapidly. Following further investigation necrotising fasciitis was diagnosed. He was taken back to theatre and the infection widely excised. Upon discussion with a neighbouring Trust, Betadine TM soaks and Jelonet* were commenced on the clean granulating wound.

 

The Challenge
Manage a wound with necrotising fasciitis, to reduce and control exudation.

 

Aims

  • To use a dressing which would clean and lift areas of slough.
  • To use a wound care product which would stay in contact with the wound.
  • To provide the optimum environment for wound healing.
  • To use a dressing which would be easy to remove.

 

Fig 1a

 

Fig 1b

 

Interventions
The tissue viability project nurse was called in when the exudate levels were too much to cope with and dressing changes were two to three times a day. PW was intubated and unconscious at this time. On inspection of both wounds the fasciotomy wound (Fig 1a) was sloughy and exuding large amounts. A corrugated drain had been inserted into an old jejunostomy site and the drainage was soaking down into the wound itself. It was difficult to determine the tissue type in the wound due to the staining of the Betadine™ and the jaundiced colour of the patient himself.

 

Fig 2

 

Fig 3


The laparotomy wounds branched off in two directions across his abdomen. They looked red around the edges and large abdominal sutures were visible. The wound was closed at time of initial assessment.

 

Due to sloughy tissue and the levels of exudates we decided to start Vacuum Assisted Closure (VAC TM ) as soon as possible to prepare for grafting (Fig 1b). The VAC therapy continued for two days. It was stopped on the second day due to a point of bleeding down in the groin. It was felt that the bleeding would probably continue as he was being anticoagulated at the time.

 

The wound looked cleaner and there was an obvious blood supply (Fig 2). The exudate levels remained high. The dressing used from then on was Intrasite Conformable, a new extension of an already popular dressing used widely throughout the Trust. This is a non-woven sheet impregnated with Intrasite hydrogel. This was chosen as Intrasite Gel would have been difficult to keep in situ in such a large wound.

 

Outcome
Within a week the wound was clean and granulating (Fig 3). Small areas of slough were lifting and softening and the dressing was comfortable and conformable. Dressing changes had reduced to once a day.

 

 

 

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