Larval Debridement Therapy: Just for Adults?
“Larval Therapy is only for people not fit to go to theatre”
I couldn’t believe my ears when I heard a Consultant Surgeon say this about a patient for who I was considering using Larvae on to debride his wound! “It’s 2016! Larvae is commonly used for debridement of wounds like this all the time” was my initial thought, but then I reflected on the situation. I’m an Adult Nurse by background and have worked in Tissue Viability for 11 years with adults. Since March 2016, I have worked as a Lead Tissue Viability Nurse in an Acute Paediatric Hospital. How common is the use of Larval Debridement Therapy (LDT) in Paediatrics? I wasn’t sure. Uncommon as it transpires. Could I blame him for having the reaction he did to my recommended method of wound management for this patient? Why isn't LDT commonly used in Paediatrics where other methods of wound debridement are favoured, often with increased associated risks attached ? The documented evidence to support the use of LDT in Paediatrics is limited. A Case Report in 2009 surrounding the use of LDT in a 20 month old girl to manage purpura fulminans did however have good results with outcomes achieved in a short time frame, highlighting that with appropriate selection of patient, LDT should be considered as an option (Rodgers, 2009). Much of the evidence surrounding the benefits of LDT is well documented. Articles such as those demonstrating Larvae to provide effective debridement of deep devitalised tissue where other non surgical treatments have taken longer to achieve the same goals (Sherman 2014) and studies which show that larval excretions contain antimicrobial properties and chemical agents which can restore healing process
Josh is 10 and suffered a traumatic head injury following a fall from height. During his time in Intensive Care he suffered an episode of sepsis leaving his right leg oedematous with blistered areas from medial aspect of his right gaiter to just below his knee. The majority of the blistering was superficial and resolved quickly as his general condition improved and his rehabilitation was commenced. There was however an area of residual ulceration proving difficult to heal which was delaying his rehabilitation and causing him distress.
Josh had obviously been through a lot and had made massive progress. His parents, although eager for his rehabilitation to progress as quickly as possible, were understandably reluctant for him to have any further general anaesthetics so it was initially planned by the plastic surgeon to treat the ulceration conservativley, initially with dry dressings and subsequently with hyrdocolloids to debride the devitialised tissue and allow to heal by secondary intention.
After 2 weeks treatment with hydrocolloids with little debridement evident, I explored the option of LDT with his parents. As an Adult Tissue Viability Nurse by background with experience of using LDT on chronic leg ulcers, I felt LDT could be the answer for Josh to help remove the slough quickly, advance the wound along the healing process and be a step closer towards get his life back on track as quickly as possible. I discussed with his parents how Josh would accept the treatment and they felt that although he would be excited about using a treatment that was not commonly used in children, if he know what was in the dressing, he might get a bit frightened. The decision was therefore made to go ahead with treatment with Josh understanding that he was in a very special position to have such an “unusual” treatment for his leg. He was indeed very excited! Josh did have increased risk of bleeding with LDT as he was anticoagulated for proximal femoral thrombosis bilaterally and mitigation was applied to ensure the treatment could go ahead safely.
Josh was assessed for BioBag LDT and had 2 treatments over 2 consecutive weeks. I felt that BioBag was the preferred method of LDT as it would be quicker to redress, causing as least anxiety and distress as possible. Less chance of escapees too! Once the ulcer was fully debrided of slough, it was clear that the resultant ulceration was deeper than anticipated with fascia exposed. After further deliberation with the plastic surgery team, they decided Josh should have a split skin graft to progress his ulcer to healing. To prepare his leg for grafting, he was treated with topical negative pressure to encourage granulation along with some mild compression therapy to reduce the oedema.
Josh tolerated LDT extremely well with no complication. On day 4 of each treatment he reported that the dressing felt “tickly” but reported no increased pain.
Josh has now returned to school with his leg all but healed. He continues to wear compression hosiery and interestingly his leg does display now, some signs of chronic venous hypertension and I have counselled his parents about what this could mean for him in the future.
So what do I think? Well I think that if I hadn't had the experience with using LDT in Adults, then Josh would not have had this option for his wound management, particularly given the reaction I had from his consultant when I broached the topic! LDT should not be considered only suitable for those who are “not fit for theatre”, but as another tool to rapidly debride a wound, with less associated risk. The patient needs to be selected carefully, and informed consent issues explored.
LDT is not just for adults!
BioMonde (2016) Larval debridement therapy. Application guide and
daily care: BioBag. http://biomonde.com/attachments/article/7/
Cazander G, van der Veerdonk MC, Vandenbrouke-Grauls CM et al (2010) Maggot excretions inhibit biofilm formation on biomaterials. Clin Orthop Relat Res 468(10): 2789-96
Cazander G, Pritchard DI, Nigam Y et al (2013) Multiple actions of
Lucilia sericata larvae in hard-to-heal wounds: larval secretions
contain molecules that accelerate wound healing, reduce chronic
inflammation and inhibit bacterial infection. Bioessays 35(12):
Pritchard DI, Nigam Y (2013) Maximising the secondary beneficial effects of larval debridement therapy. J Wound Care 22(11): 610-6
Rodgers, A. (2009), Maggots for the management of purpura fulminans in a paediatric patient, Wounds UK, vol 5 no 4, 141-145
Sherman RA (2014) Mechanisms of maggot induced wound healing: What do we know, and where do we go from here? Evid Based Complement Alternat Med 592419. Epub