Ischial Wound Study

Progress photos and case study of an ischial wound being treated with Enluxtra Self-Adaptive Wound Dressing

Renetta Winkler, CWON CHPN RN
VNA, Western Pennsylvania

My patient has been diagnosed with multiple sclerosis 16 years ago at the age of 20. She is married and lives with her husband and a 9-year-old son.

Prior to becoming my patient, while holding a job as a computer data reviewer for the past 2 years, she has suffered from complications of her progressive disease and slowly started losing mobility and feeling in her lower extremities. Due to decreased appetite and difficulty swallowing, she has become malnourished.

She developed pressure ulcers on her ankles, feet and knees, for which she was successfully treated with NPWT and foam dressings at a wound care clinic. During this time she also developed bilateral deep tissue injuries of ischial and sacral areas. By January 2010, these injuries progressed to become Stage III and IV pressure ulcers. After a short period in home care, she was admitted to a hospital with wound infection and spent 3 weeks there, and then spent additional 4 ½ months in a nursing home. In July 2011, she was back at home under palliative care and that’s when she became my patient.
The local wound care clinic provided tube feeding, protein supplement, gel foam mattress as well as wound treatment which included irrigation with NSS, packing of the wound with alginate and covering it with hydrocolloid, with 3 times per week change schedule.

Monthly blood tests were showing persistently low levels of albumin and prealbumin despite the use of Prosource and 5 cans of Jevity 1.2 daily. The patient started to take some food orally during the summer, and even though her protein stores were poor, she had to start buying clothing two sizes larger due to gained weight.

The wound care managed by a local clinic was limited due to frequent cancellations by the patient, and in the period between July 2011 and December 2012 consisted of the following:

2011

July week 1 – Santyl applied to wound bed, dead space filled with alginate and covered with thin hydrocolloid.
July week 4 – Fibercol added to pink tissue, Santyl applied to slough, dead space filled with alginate and covered with hydrocolloid.

2012

January week 2 – Santyl discontinued, wound bed covered with Fibercol, dead space filled with Aquacel and covered with thin hydrocolloid.
March week 3 – Fibercol discontinued due to increased slough. Dead space continued to be filled with Aquacel, and then covered with foam and secured with hydrocolloid due to increased exudation.
August week 3 – Wound filled with Mesalt and covered with Drawtex in an attempt to manage the increased drainage.
September week 3 – The patient made a decision to stop her wound clinic visits due to poor results and difficulty getting to the clinic. During the home visit, wound care physician stopped Mesalt and ordered Aquacel covered with Drawtex and hydrocolloid. The bilateral hip X-ray ordered by the physician showed damage of the head of femur and acetabulum bilaterally.
October week 4 – Aquacel was changed to Aquacel AG, covered with Drawtex and secured with hydrocolloid. A CT scan was ordered.
November week 1 – The patient developed a S/S infection and was prescribed a 5-day treatment that included irrigation with Dakin’s solution and daily application of gauze soaked in Dakin’s solution. Then she was returned to Aquacel AG, Drawtex and hydrocolloid.
In December of 2012, my desperate patient started looking for a more effective new treatment on the internet and found Enluxtra. We requested a sample and started using Enluxtra. We irrigated the wound with NSS, applied Enluxtra, filled the dead space over Enluxtra with Aquacel and covered with thin hydrocolloid. We used hydrocolloid because the patient was sensitive to tape and transparent dressing.

Previously, excessive drainage would loosen the dressing in the vaginal area, but with Enluxtra this never occurred, even when the slits were cut in it in an attempt to have Aquacel absorb the exudate vertically. We quickly stopped Aquacel because it remained dry. In this particular case Enluxtra Ultra would be of benefit, but we were not aware of its existence at the time. With continued Enluxtra applications, the wound autolytically debrided and the drainage slowed to a containable rate.

After the CT scan was performed, the radiologist, certain he was seeing osteomyelitis, sent my patient to the local rural ER, from where she was transferred to a teaching hospital in the city. There she was seen by an infectious disease and plastic surgeon who changed her treatment to NSS-moistened gauze changed twice a day, in accordance with the hospital treatment protocol. Osteomyelitis was ruled out after aspiration of both hips was performed.

Even though the patient had the wounds for 2 years, the plastic surgeon, possibly influenced by the patient’s choice, didn’t feel that debridement and closure with flap and graft were appropriate, stating that the wounds were very clean and very chronic. After 4 days in the hospital, the patient returned home and also returned to Enluxtra.

We had a few setbacks related to the dressing becoming saturated with menstrual blood and the fact that the gelfoam mattress was not an appropriate offloading device for a person who is bedbound. The patient, trying to maintain a normal course of life and sharing a bed with her husband, resisted using a replacement pressure-relief mattress that requires a hospital bed. She refused alternating air as well due to a previous bad experience with this product. During the time she was in my care, she has gone through 2 gelfoam mattresses and by January 2013 her current mattress had a deep sinkhole in it.

Despite my suggestions to go to an inpatient wound clinic or have a plastic surgery, my patient preferred to stay at home, trying to spend as much time with her family as she could instead of leaving for treatment. In the 2 years that I have been caring for her, her progressive disease started affecting her speech, her vision in the left eye, caused weakness in the left arm and poor fine motor movement of the right arm. In addition, she continued having painful BLE spasms, bilateral ankle and pedal edema, foot drop and bilateral contractures of the ankles, knees and hips.

My patient has been trying hard to offset the emotional impact caused by the progression of her disease. Needing to have some kind of purpose, she stays actively involved in child rearing, maintains family finances, manages her private caregivers, and is developing a charity organization that helps people who are isolated due to a home-bound status to get out in the world.
In an attempt to maintain a certain level of control in her life, she has been somewhat non-compliant to doctor’s orders by remaining for good part of each day in Fowler’s position which puts a lot of pressure on her wounds.

In light of the dramatic improvement that occurred from using Enluxtra my patient’s emotional state and her quality of life in general have greatly improved as well. She now has a new incentive to be more compliant with offloading. Before she would only let me or her husband help change her position. As a result, she sometimes stayed in the same position for 12 hours or longer. She is now willing to allow her caregivers to help with changing her position. She is also considering switching to an APP mattress which should decrease the setbacks caused by pressure to the wound.

THE WOUND CONDITION PRIOR TO ENLUXTRA APPLICATION.
WEEK 0.