AN ENZYME ALGINOGEL® IN THE MANAGEMENT OF HAND ULCERATION DUE TO STEAL SYNDROME
Ischaemic steal syndrome is a complication of arteriovenous (AV) access creation for haemodialysis. It can often result in significant neurologic injury, motor deficit or tissue loss.1 Constructing vascular access for haemodialysis causes changes in blood flow to the extremity which can lead to distal ischaemia. Patients with diabetes are more prone to ischaemia.2 Dialysis access-steal syndrome (DASS) is a well-recognized access-related complication and occurs in up to 5% to 8% of dialysis patients.3 Clinically symptomatic steal is a serious complication of haemodialysis access creation due to the associated morbidity including ischaemic symptoms.4
This case study describes the management of 61 year old Paul, a married man who is no longer able to work due to poor health. He requires haemodialysis three times a week due to diabetic nephropathy (end stage). He also has connective tissue disease with inflammatory myocarditis and had his right foot amputated five years ago, significantly impacting on his mobility.
Paul had ischaemic lesions to his left hand and ring finger, with his ring finger necessitating amputation. He suffered with recurrent episodes of cellulitis requiring antibiotics; Paul lost function in his hand with an accompanying increase in pain. He was referred to a plastic surgeon who amputated the ring finger on his left hand, with a fillet flap to cover the defect and debrided his right fourth finger.
On initial assessment by the TVN Paul had a 100% sloughy wound to his palm and a wound to the dorsum of his hand with 60% granulation tissue and 40% slough; both wounds had moderate levels of purulent exudate, were malodorous with peri wound erythema.
The aims of treatment were to reduce the wound bioburden, autolytically debride the sloughy tissue (thus reducing odour), control the exudate and reduce Paul’s pain. The wounds were dressed with Flaminal® Forte (Flen Health), an Enzyme Alginogel®, containing two antimicrobial enzymes (glucose oxidase and lactoperoxidase), with a higher proportion of alginate than Flaminal® Hydro to cope with the high exudate levels. This was covered with a non-adherent polyester mesh wound contact layer and a silicone non-adhesive foam dressing held in place with wool and a light bandage. It was important that the wound bioburden was reduced and the exudate controlled; his dressings were changed every 5 days.
Paul tolerated the dressing regimen well and within two weeks there was marked progress with slough and malodour reducing. Importantly Paul did not experience any further episodes of infection and his pain reduced. Both wounds were fully healed within 14 weeks meaning that a referral could be made to the hand therapy department for a specialised garment which would reduce the thickness of the graft and improve circulation to his hand as well as cosmesis.
In steal syndrome the blood supply is compromised causing ischaemia when the blood in the vertebral basilar artery shunts into the distal end of the ipsilateral subclavian artery. Because of low resistance in the venous outflow the AV access takes not only the antegrade flow into the feeding artery but also ‘steals’ retrograde flow from the hand via the palmar arch and jeopardises it adequate perfusion.2
There is the ever present risk in diabetes of a more serious deep tissue infection. Devitalised tissue is a barrier to healing with necrotic tissue and slough acting as a reservoir for microorganisms and biofilm formation5 which impedes healing.6 Devitalised tissue also increases odour and exudate and can mask the true extent of a wound.7
Flaminal® Forte with its alginate polymers and enzymes has a proven broad-spectrum antibacterial activity8 with the ability to inhibit biofilm formation9, thereby helping to control bioburden whilst absorbing exudate.
Flaminal® Forte enabled the team to address several key issues, namely devitalised tissue, bioburden and exudate in one primary dressing thus negating the need for multiple products. The team were able to utilise Flaminal® throughout the healing trajectory thus minimising potential waste of products, since Flaminal® can be utilised for up to 2 years from opening.