Steven Jeffery

Evidence-based recommendations for the use of Negative Pressure Wound Therapy in traumatic wounds and reconstructive surgery: Steps towards an international consensus

Negative pressure wound therapy (NPWT) has become widely adopted over the last 15 years and over 1000 peer reviewed publications are available describing its use. Despite this, there remains uncertainty regarding several aspects of usage. In order to respond to this gap a global expert panel was convened to develop evidence-based recommendations describing the use of NPWT. In this paper the results of the study of evidence in traumatic wounds (including soft tissue defects, open fractures and burns) and reconstructive procedures (including flaps and grafts) are reported. Evidence-based recommendations were obtained by a systematic review of the literature, grading of evidence, drafting of the recommendations by a global expert panel, followed by a formal consultative consensus development program in which 422 independent healthcare professionals were able to agree or disagree with the recommendations. The criteria for agreement were set at 80% approval. Evidence and recommendations were graded according to the SIGN (Scottish Intercollegiate Guidelines Network) classification system. Twelve recommendations were developed in total; 4 for soft tissue trauma and open fracture injuries, 1 for burn injuries, 3 for flaps and 4 for skin grafts. The present evidence base is strongest for the use of NPWT on skin grafts and weakest as a primary treatment for burns. In the consultative process, 11/12 of the proposed recommendations reached the 80% agreement threshold. The development of evidence-based recommendations for NPWT with direct validation from a large group of practicing clinicians offers a broader basis for consensus than work by an expert panel alone.

Evidence-based recommendations for negative pressure wound therapy: Treatment variables (pressure levels, wound filler and contact layer) - Steps towards an international consensus

Negative pressure wound therapy (NPWT) is becoming a commonplace treatment in many clinical settings. New devices and dressings are being introduced. Despite widespread adoption, there remains uncertainty regarding several aspects of NPWT use. To respond to these gaps, a global expert panel was convened to develop evidence-based recommendations describing the use of NPWT. In a previous communication, we have reviewed the evidence base for the use of NPWT within trauma and reconstructive surgery. In this communication, we present results of the assessment of evidence relating to the different NPWT treatment variables: different wound fillers (principally foam and gauze); when to use a wound contact layer; different pressure settings; and the impact of NPWT on bacterial bioburden. Evidence-based recommendations were obtained by a systematic review of the literature, grading of evidence and drafting of the recommendations by a global expert panel. Evidence and recommendations were graded according to the Scottish Intercollegiate Guidelines Network (SIGN) classification system. In general, there is relatively weak evidence on which to base recommendations for any one NPWT treatment variable over another. Overall, 14 recommendations were developed: five for the choice of wound filler and wound contact layer, four for choice of pressure setting and five for use of NPWT in infected wounds. With respect to bioburden, evidence suggests that reduction of bacteria in wounds is not a major mode of action of NPWT.

Shaping the military wound: issues surrounding the reconstruction of injured servicemen at the Royal Centre for Defence Medicine

The conflict in Afghanistan has produced injuries similar to those produced from military conflicts for generations. What distinguishes the modern casualty of the conflict in Afghanistan from those of other conflicts is the effectiveness of modern field medical care that has led to individuals surviving with injuries, which would have been immediately fatal even a few years ago. These patients present several challenges to the reconstructive surgeon. These injured individuals present early challenges of massive soft-tissue trauma, unstable physiology, complex bony and soft-tissue defects, unusual infections, limited reconstructive donor sites, peripheral nerve injuries and traumatic amputations. Late challenges to rehabilitation include the development of heterotopic ossification in amputation stumps. This paper outlines the approach taken by the reconstructive team at the Royal Centre for Defence Medicine in managing these most difficult of reconstructive challenges.

A new, fast LDI for assessment of burns: A multi-centre clinical evaluation

INTRODUCTION Laser Doppler imaging (LDI) provides early accurate determination of wound healing potential. LDI can scan large areas of up to 2500 cm2 within 2 min. This duration may require additional sedation in a mobile, uncooperative child. In five burn centres a faster Laser Doppler Line Scanner (LDLS) was assessed. This new imager scans 300 cm2 in 4s with potential benefit for patients and operators. The aim of this study was to assess the accuracy and convenience of the LDLS and to compare this with an established LDI imager. METHODS Outpatients and admitted patients were included. LDI and LDLS images were obtained between 2 and 5 days post burn (PB). Photographs and records of wound and healing were obtained on day of scan and at 14 and 21 days PB. This provided data on three categories of burn wounds: healing within 14 days, 14-21 days and not healed within 21 days. RESULTS The analysis included 596 burn areas from 204 burns patients. An accuracy of 94.2% was found with use of the LDLS compared with 94.4% for the original LDI imager. CONCLUSIONS The high accuracy of the new line-scan imager was comparable to that of the traditional LDI. Its size and mobility enabled easier ward and outpatient use. The higher scan speed was particularly beneficial for scans in paediatric patients.

Functional splinting of upper limb injuries with gauze-based topical negative pressure wound therapy.

Complex hand injuries can be difficult to dress effectively and achieve adequate splintage of the hand in a functional position. During the past 7 years, we have had a great deal of success with topical negative-pressure dressings in the management of complex blast-related extremity war injuries. We have more recently changed to using a gauze-based system and have found this particularly useful in dressing complex hand injuries. We have been able to use this vacuum dressing system to splint the hand in a position of function. This provides an easily applied dressing that, through topical negative pressure, promotes wound healing and ensures a resting functional position, thus minimizing postoperative stiffness. We have not been able to achieve this as efficiently with standard dressings and plaster-of-Paris casts. This article details the technique of functional splinting of complex hand injuries using a gauze-based, topical negative-pressure dressing system.

Two stage study of wound microorganisms affecting burns and plastic surgery inpatients.

This study was designed to identify wound microorganisms and the reasons for differing prevalence between the wards, burns unit and intensive care unit (ICU) in a regional centre for burns and plastic surgery. Antibiotic sensitivities of the 10 most prevalent microorganisms cultured from inpatient wound swabs were also investigated. Inpatient wound swab data were collected retrospectively using notes and departmental database information between January and June 2007. Data were analyzed using chi-squared tests and P-values. Eight hundred five positive wound swabs from 204 swab positive inpatients were analyzed. Stage 1 of this study demonstrated 917 positive swab episodes and 30 varieties of organism. The five most prevalent organisms cultured were Staphylococcus (23.9%), Acinetobacter (21.2%), Methicillin Resistant Staphylococcus aureus (MRSA) (20.8%), Pseudomonas (9.7%) and Enterococcus (5.2%). Stage 2 revealed that Acinetobacter baumanni (ABAU) was significantly more prevalent in military over civilian inpatients (P < .001) and that military inpatients had a significantly greater proportion of ABAU over civilian inpatients within the first 24 hours after admission (P < .001). ABAU episodes were significantly higher on the ICU over the burns unit and on the wards (P < .001). MRSA was significantly more prevalent in military inpatients (P < .001); however, no significant difference was observed within the first 24 hours after admission (P = .440). MRSA was more prevalent on the ICU over the burns unit (P = .023). Pseudomonas aeruginosa (PAER) was significantly more prevalent in military inpatients over civilian inpatients (P < .001), and on the ICU over the burns unit and wards (P = .018). Stage 1 generated a comprehensive, up to date cross section of bacterial flora, with corresponding percentage antibiotic sensitivities, in a regional burns and plastic surgery centre. This will give clinicians a snapshot of organisms affecting inpatient wounds in advance of culture and sensitivity results. Stage 2 demonstrated that ABAU, MRSA, and PAER were significantly more prevalent in the ICU setting. Furthermore, military inpatient wounds grew more ABAU, MRSA, and PAER than civilians, probably due to the longer inpatient stay, dirty nature of wounds, site and complex mechanism of injury. Finally, this study suggests that ABAU was brought into the unit by military patients.

Integra™ permits early durable coverage of improvised explosive device (IED) amputation stumps

INTRODUCTION Improvised explosive device (IED) blasts cause serious injury. Survivors are left with multiple amputations, considerable soft tissue loss and open fractures with gross contamination. We present our early experience of Integra™ in the acute management of military wounds. METHOD The clinical records of all patients with IED injuries who underwent early reconstruction with Integra™ during the six month period between August and December 2009 in our unit were reviewed and data gathered prospectively. RESULTS There were 7 male soldiers, aged 21-31 years (mean=26). All sustained trunk and limb injuries, including multiple amputations. Number of procedures prior to application of Integra™ was 4-10 (mean=5). Application of Integra™ took place 6-24 days post-injury (mean=13). Size of wounds covered with Integra™ was 1-11.5% TBSA (mean=5%). Anatomical sites reconstructed included amputation stumps, and both upper and lower limbs. There was partial take of Integra in 3 wounds in 2 patients. All wounds were eventually treated with delayed split skin grafting and healed satisfactorily. CONCLUSION IEDs produce a large zone of injury with massive soft tissue damage, multiple discontinuous wounds which are significantly contaminated. The physiological insult is equivalent to a large cutaneous burn and there is a paucity of available donor sites. Multiple amputees also have a greater energy and power requirement(1-4) and cannot spare remaining functional muscles as donors. The literature suggests that microvascular flaps have a high failure rate in military patients.(5) Reconstruction began as soon as wounds were considered sufficiently clean. Integra™ was applied with the aim of providing higher quality coverage than that provided by split skin grafting alone (particularly for amputation stumps) whilst minimising operative time and morbidity. Integra™ allows timely closure of battlefield wounds with minimal operative time and morbidity. The procedure can begin whilst still in the acute phase and certainly before one would consider lengthy complex operations such as free flaps. Our experience suggests that Integra™ can allow early closure with robust tissue, promoting early rehabilitation and return to duties.

A phase II prospective, non-comparative assessment of a new silver sodium carboxymethylcellulose (AQUACEL® Ag BURN) glove in the management of partial thickness hand burns

BACKGROUND Nylon-reinforced silver sodium carboxymethylcellulose (AQUACEL(®) Ag BURN) dressings were developed to be pliable and conforming for the management of partial-thickness burns. This study evaluated the AQUACEL(®) Ag BURN glove for the management of hand burns. METHODS This 21-day, phase II, prospective, non-comparative study included 23 patients with partial-thickness hand burn of at least two fingers. The AQUACEL(®) Ag BURN glove was applied to one hand and could remain in place up to 21 days until clinically indicated to change the glove. Dressings were evaluated 1, 2, 4, 6, 8, 14, and 21 days after initial application. Safety was the primary study endpoint. RESULTS Sixteen (70%) hand burns re-epithelialized fully over a mean of 15.6 days. Initial application was easy/very easy for 20 (87%) patients. Mean time for initial dressing application was 5.4 min. At final evaluation, most patients gave ratings of excellent/good for conformability (91%), overall glove performance (74%), and appropriateness of sizes (83%). Mean pain score from 0 (none) to 10 (worst imaginable) was 3.43 at baseline; during the study, mean scores were 1.15 at rest and 2.29 during movement. Of 61 glove removals, most (72%) were easy/very easy, and 12% had fallen off. Adverse events (wound site or elsewhere) occurred in 15 (65%) patients. Treatment-related adverse events were wound pain (17%), maceration (9%), and stiff fingers (4%). CONCLUSIONS The AQUACEL(®) Ag BURN glove was well tolerated in the management of partial-thickness hand burn. Many patients used only one glove. When glove changes were required, they were usually quick and easy.

Efficacy of an imaging device at identifying the presence of bacteria in wounds at a plastic surgery outpatients clinic

OBJECTIVE Current standard diagnostic practice of bacterial infections by visual inspection under white light is subjective, and microbiological sampling is suboptimal due to high false negative rates and the lengthy time needed for culture results to arrive. The MolecuLight i:X Imaging Device attempts to combat the issues faced in standard practice by providing a non-contact, real-time method of visualising bacteria within wounds. Our aim was to test this imaging device in a series of patients. METHOD A single-centre prospective observational study was conducted in the Queen Elizabeth Hospital, Birmingham. During Plastic Surgery Outpatient dressings clinics, patients had their wounds photographed with the imaging device under white light and violet light illumination. Microbiological swabs were obtained of all the wounds. Any clinical signs and symptoms of infection were noted. White light and violet light photographs were compared with correlate visible clinical signs and symptoms with auto-fluorescence images. Auto-fluorescence images were then compared with the microbiological swab results to discern any differences. RESULTS There were 14 patients with seventeen separate wounds imaged. Of the 17, eight wounds were positive for bacterial growth on microbiological culture. All eight of these were detected positive for bacteria according to auto-fluorescence imaging. There was one wound was detected positive for bacteria by auto-fluorescence imaging with negative microbiological results. CONCLUSION This study demonstrated the potential benefit of the imaging device due to the correlation between microbiological test results and auto-fluorescence imaging. The device greatly reduces the time taken waiting for results and it is simple, quick to use and non-contact. There is potential for the imaging device to guide swab sampling and aid health professionals in the diagnosis and management of wound infections.

The Use of the MolecuLight i: X in Managing Burns

The MolecuLight i:X Imaging Device is a portable, noninvasive, real-time camera used to visualize the bacterial load in a wound. It uses violet light illumination and a dual bandpass optical filter to capture the fluorescence of endogenous structures in the tissue matrix and harmful bacteria. The MolecuLight i:X captures images of wounds and highlights potentially detrimental levels of bacteria. This is an initial evaluation of using the MolecuLight i:X camera in the management of burns to demonstrate the following: the ability of the device to guide clinicians in their management of the burn (ie, detect, identify, and specify swabbing locations). Burn wounds were photographed under standard light and violet light illumination to compare presentations of obvious infection signs and symptoms. Microbiology swab samples were obtained to correlate any bacterial presence to the images. The fluorescence images were used to guide swabs to where the bacteria were congregating. Twenty patients were imaged. Four patients did not have bacterial contamination based on their images and swab results. Sixteen patients showed growth of Staphylococcus aureus, Pseudomonas aeruginosa, or other bacteria. Nine of the patients, by definition, had infections. These findings were correlated with the typical signs and symptoms of infection, the fluorescence images, and the microbiology results. The efficacy of the MolecuLight i:X is evident due to the microbiology results correlating to the images. Further research is being done to test the device in terms of being an early intervention tool. With these early results and guidance of swab samples, the MolecuLight i:X may be able to detect bacterial load before an infection and subsequent graft failure, thereby shortening lengths of hospital stay and improving overall healing.