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Managing Pressure Ulcers with Vacuum Assisted Closure (VAC) therapy in a 16-year old patient with Terminal Ependymoma: A Case Study

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Managing Pressure Ulcers with Vacuum Assisted Closure (VAC) therapy in a 16-year old patient with Terminal Ependymoma: A Case Study

 

Introduction

Negative pressure wound therapy is now a commonly used method of managing both acute and chronic wounds; however its use in patients undergoing chemotherapy for a terminal condition is not well documented. Master A (pseudonym for confidentiality reasons) was diagnosed with ependymoma 6 years ago. Over the years his physical condition has deteriorated and is now unable to weight bare, and unable to self-position in bed. He is a wheelchair user and is pushed by mum; at home he is transferred from one point to the other by mum carrying him, and repositioned regularly in bed. He is under the oncology department in an acute hospital in London, where he undergoes weekly chemotherapy. He is also under the Ellenor Hospice for palliative care.

His inability to reposition himself, poor nutrition, and chemotherapy put him at a very high risk of pressure damage. He is also at a very high risk of infection due to a compromised immunity. Master A developed 2 large pressure ulcers to his left buttock and 3 other smaller ulcers to his knee, left groin and right hip. This abstract focuses on the management of the 2 large ulcers using VAC therapy. 

Methods

The management of Master A’s pressure ulcers has been through a multidisciplinary approach; with the involvement of Children’s Hospice at Home Service, Tissue Viability Service, Community Children’s Nursing Team, his mum and the occupational Therapist.

Initial presentation of the wounds on referral to the Tissue Viability Service was 100% necrosis with erythematous surrounding skin. Due to the age of the patient full written consent was sought from him and as well as his parent. The primary goal on initial assessment was to prepare the wound for conservative sharp debridement. All other factors such as pressure relief, nutrition, skin, incontinence, and mobility were considered and appropriate measures put in place to minimise risk and promote healing.

One main challenge with managing these wounds was the rapid formation of non-viable tissues following debridement. Regular sharp debridement was carried out with consent from the patient and parent. His consultant was fully informed of progress of his wounds. Following a few weeks of wound hydration and debridement VAC therapy was commenced with training support to the Children’s Hospice Team from Industry and the Tissue Viability Nurse Specialist. No further input was requested from Industry.

Following debridement the wounds presented undermined areas. Therapy therefore involved the combination of black and white foams to enable safe and appropriate management; set at -150mmHg and continuous therapy. Dressings were initially changed three times weekly and eventually reduced to twice weekly as per clinical judgement.

Master A’s mum was provided with training on the identification of possible problems associated with the pump and how to troubleshoot as need be.

Master A was on prophylactic antibiotics (cotrimoxazole) to reduce the risk of infection

Master A was also provided with psychosocial support, including complementary therapy (at Ellenor Hospice); he also had access to the Demelza Children’s Hospice when needed.

Results

The use of VAC therapy has helped prevent the reformation of sloughy and necrotic tissues, reduce the risk of infection, promote healing, promote quality of life, and patient satisfaction. Prior to commencement of VAC therapy the wounds had to be regularly debrided as sloughy and necrotic tissues reformed very quickly following debridement. The wounds have remained fully granulated, infection free, and reduced in size and depth. It also helped and empowered his parent to manage the situation. Other benefits include reduced number of visits to manage the wound from seven to 2 in a week. Master A’s mum reports that this is the best to happen to her.

Discussion

Chemotherapy compromises immunity and affects wound healing (Drake and Oishi 1995). The clinical presentation of Master A put him at a very high risk of wound infection, delayed healing, and sepsis. The use of VAC therapy in this situation was for conservative management; promotion of comfort, reduce the risk of infection and associated complications; however the wounds have reduced in size and depth in addition.

Conclusion

The use of VAC therapy has made a huge difference to Master A and his family. Not only has it promoted a viable wound bed, but has also promoted some healing, reduced number of visits, promoted better quality of life for Master A and his family. According to Master A’s mum “the use of VAC enables them to go away, and to various appointments without worrying about the wound leaking or smelling”. 

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