VSD (vaccum sealing drainage) negative pressure closed drainage technology, refers to the use of polyethylene alcohol hydrated seaweed salt foam dressing (VSD excipient) containing drainage tube to cover or fill the skin, soft tissue defect trauma, and then closed with a biological semi-permeable membrane, so that it becomes a closed space, and finally connect the drainage tube to the negative pressure suction, through a controlled This is a new treatment method to promote wound healing by controlled negative pressure. This method has been widely used in patients with severe orthopedic trauma, and can effectively promote wound healing. Based on the principle of VSD technology, our department tries to combine it with Chinese traditional medicine external washing for the treatment of peripheral vascular diseases, and the application experience of treating severe diabetic wet gangrene infection is reported as follows. Liu Ping, Department of Peripheral Vascular Disease, The First Affiliated Hospital of Henan College of Traditional Chinese Medicine
1. Materials and methods
1.1 General data: The enrolled patients were all patients with diabetic wet gangrene. The infected lesions mostly accumulated at the plantar, dorsal and internal and external ankles, with abnormal redness and swelling of the foot, dripping pus and unpleasant odor. The patients were accompanied by malignant chills and high fever, with leukocytes >2.0×109 and neutrophil percentage >85%.
1.2.1 General treatment: Immediately after admission, the foot was cleared, dead bone and infected tendons were removed, each pus cavity was opened as much as possible, adequate drainage was achieved, and the wound was flushed with hydrogen peroxide, etc. At the same time, pus bacterial culture was performed, and antibacterial drugs were used reasonably according to the bacterial culture results. Most of these patients have poor blood glucose control and use insulin intensive treatment to control blood glucose.
1.2.2 Application of VSD treatment: Generally, 3 to 5 days after admission, the foot infection is somewhat controlled, the redness and swelling are relieved, the blood picture decreases, and the local malodor is reduced when the application of VSD technique is started to promote ulcer healing.
1.2.2.1 Firstly, under anesthesia, further open the ulcer wound thoroughly, remove the putrefied flesh and pus fetus, open all the infected cavities, and ensure the blood supply to the soft and bone tissues.
1.2.2.2 Then VSD dressings with multiple lateral holes are designed and trimmed according to the size and shape of the ulcer, the size of the VSD dressing is appropriate to cover the ulcer surface exactly, and the end holes of the drainage tubes and all lateral holes are completely wrapped by the auxiliary material when trimming. The VSD dressing around each 1 drain should not exceed 50px, i.e. there must be one drain in a block of VSD dressing about 4 to 125px wide [1]. The direction of the drainage tube exit tube is based on the principle of facilitating the sealing of the drainage tube and avoiding pressure to facilitate drainage.
1.2.2.3 Covering the filling dressing. Cover the surface of the ulcer with the designed VSD dressing so that it is in full contact. The trimmed VSD remnants can be filled at the suture or deeper parts of the trauma, leaving no dead space. Secure the VSD dressing with a #4 or #7 silk suture to the skin to prevent it from falling off.
1.2.2.4 Dry the skin around the wound and close the entire wound covered by the VSD dressing with a bio-permeable adhesive film. The dressing can be applied by the “stacking method”, and the trauma edge of the drainage tube can be closed by the “lacing method” and “dumpling method”. That is, the drainage tube is wrapped with a film, and the excess film is taped into a tethered film, which can effectively prevent the loosening of the drainage tube at the film and air leakage, and the coverage of the semi-permeable film should include 50px of healthy skin around the wound [1].
1.2.2.5 Combine all drains into one outlet with a tee tube as needed, connect the drainage tube to a negative pressure device, open the negative pressure, and check for good airtightness.
1.2.2.6 After returning to the ward, connect the drainage tube to the central negative pressure suction device. Adjust the negative pressure to -125 mmHg~-450 mmHg. Observe that the VSD dressing is obviously deflated, there is no fluid accumulation under the film, and there is no air leakage from the side hearing of the drainage tube joint, which indicates good containment and effective negative pressure.
1.2.2.7 It is necessary to regularly observe whether the negative pressure containment drainage is normal every day. Circulate the wound by clamping the drainage tube on one side and opening the other side by aspirating compound cypress fluid. change the VSD dressing once in 7-10 days. Observe whether the granulation tissue on the ulcer surface is fresh and full. After the wound surface is completely covered by fresh granulation tissue and it is determined that there is no residual pus cavity, apply the dotted implant method to repair the wound surface and promote its healing.
1.3 Results None of the enrolled patients used antibacterial drugs during the application of VSD, and the body temperature was gradually controlled from high fever (>39℃) on admission to between 37℃-38℃, and in some cases the body temperature returned to normal. The pus bacterial culture was partially negative. The blood routine indicated that the white blood cells were all decreased to different degrees. There was granulation tissue growth on the ulcer surface in all cases. However, one patient had severe infection of the osteoarticular cavity of the foot and Achilles tendon, and the limb was finally amputated.
2 Discussion
2.1 Advantages of VSD technique applied to diabetic wet gangrene
2.1.1 Adjustable negative pressure drainage facilitates ulcer healing. Diabetic foot wet gangrene has more local exudate and pus dripping, which is not conducive to ulcer healing, so adequate drainage is the key to promote its healing. Long, Bing et al [2] concluded that central negative pressure suction is ideal. One study showed [3] that within the rated negative pressure range, the greater the negative pressure, the more obvious the drainage effect. In addition, most diabetic feet are also combined with blood flow disorders, and another study showed that when 16.67 kPa negative pressure is continuously applied, the peak of trauma blood flow can reach four times the baseline blood flow [4], and the microcirculatory flow rate and microvascular caliber also increase significantly [5], which is conducive to the improvement of blood flow in the foot and accelerates granulation tissue growth.
2.1.2 Effective infection control and reduction of antibacterial drug use The closure of the biological semi-permeable membrane isolates the ulcer wound from the surrounding environment and reduces the chance of cross-infection. Diabetic foot combined with septic osteomyelitis, a multi-bacterial infection with more drug-resistant strains [6], the VSD technique with continuous negative pressure suction can drain the secretions from the wound in time, which can effectively control the infection and reduce or avoid the use of antibacterial drugs.
2.1.3 The application of VSD technology can reduce the number of drug changes, alleviate the pain caused by drug changes to patients, and effectively reduce the workload of medical staff.
2.1.4 It is advantageous to use the advantages of Chinese medicine. VSD technology can realize circulating flushing of the wound surface under airtight conditions through two drainage tubes. The ingredients of the compound Huangbai solution are forsythia, Huangbai, jinyinhua, dandelion and centipede. The daily flushing of ulcer wound through the three-way tube can achieve the effect of clearing heat and detoxification, eliminating swelling and eliminating decay, which is suitable for positive sores and wound infection.
2.2 Problems and difficulties encountered in VSD technique in diabetic wet gangrene
2.2.1 Treatment of common VSD problems [7]
2.2.1.1 Blockage of the drainage tube. Diabetic foot wet gangrene with more and thicker local pus, or due to fat particles, blood clots and necrotic tissue shedding and granulation growth, can lead to drainage tube obstruction. Treatment can be injected with saline flushing, and in case of clot obstruction, heparin can be added.
2.2.1.2 The VSD dressing bulges and the tube shape is not visible. Common reasons, in addition to drainage tube blockage, should also consider the negative pressure source abnormal, suction machine failure, central negative pressure gauge head damage, air leakage at the interface, power failure, central negative pressure stop, drainage tube is compressed, folded, etc., should promptly find the cause to give corresponding treatment.
2.2.1.3 VSD material dries and hardens [8]. If it becomes hard in the first 48 hours, saline can be slowly injected from the drainage tube to soak it, and the VSD dressing becomes soft and then connected to negative pressure again. If it becomes hard after 48 hours, there is no longer a continuous flow of drainage in the drainage tube and it can be left untreated.
2.2.1.4 Discoloration of VSD material. a little necrotic tissue and exudate remains in the VSD material, sometimes emitting odor through the semi-permeable membrane, and even yellow-green, gray and other dirty colors appear on the material, which is not caused by necrotic tissue of the trauma and will not affect the therapeutic effect of VSD, and generally no special treatment is done.
2.2.1.5 Fresh blood aspiration. When a large amount of fresh blood is found to be aspirated, the trauma should be carefully inspected for active bleeding and treated accordingly.
2.2.1.6 Pay attention to enhancing nutritional support. Most patients with diabetic wet gangrene have combined hypoproteinemia, and the exudate aspirated by continuous closed negative pressure drainage of VSD contains a large amount of protein. Therefore, attention should be paid to improving the patient’s general condition and correcting hypoproteinemia to improve the patient’s resistance and promote wound healing.
2.2.2 Difficulties of VSD technique applied to diabetic wet gangrene
2.2.2.1 Diabetic wet gangrene is different from other septic infections of the bone and joint site. Although the VSD technique has changed from traditional point or local drainage to surface drainage, it is still unable to drain the complex joint cavities of the foot, such as the pus cavity of the ankle joint, in all directions. Moreover, it is impossible to create sufficient drainage in the ankle joint area, otherwise the joint will be destroyed, the foot will lose its function and the meaning of limb preservation will be lost. In the face of such complex foot joint cavity infections, amputation is still the effective treatment method.
2.2.2.2 Diabetic wet gangrene is often combined with complex bacterial infections, and the key to the VSD technique is to use a bio-permeable membrane to seal the wound and create negative pressure drainage. In the author’s opinion, the use of VSD technology is not recommended in the early stage of diabetic wet gangrene, but should still be based on thorough open debridement to destroy the anaerobic environment of bacteria, and then used when the local infection is under some control and the odor of exudate is not obvious, otherwise it may lead to the proliferation of anaerobic colonies in the case of poor drainage.
3 Prospects
The VSD negative pressure drainage technique is characterized by all-round continuous negative pressure drainage, which is conducive to the improvement of local circulation of ulcers and the continuous discharge of secretions. It has been shown [3] that negative pressure closed suction plays an important role in the repair and healing of wounds. Chinese herbal irrigation of the wound can clear heat and detoxify, and remove decay and create new ones. Therefore, the combination of Chinese and Western medicine treatment method of VSD technology with Chinese herbal medicine external irrigation has incomparable superiority to traditional treatment in peripheral vascular diseases such as diabetic wet gangrene and ulcerative diseases such as polyposis [9], and it is easy to implement, reliable and has little side effects, so it is worth promoting in clinical work and has a wider prospect.
[Reference]
[1] Liu S.F., Liu C.H., Dai Z.B. Clinical study of negative pressure closed drainage (VSD) technique for repair of various complex wounds [J]. Contemporary Medicine, Feb. 2009, 15(6):66-67.
[2]Long Bing, Li Qifen. Application of continuous negative pressure closed drainage in trauma surgery [J]. Chinese Journal of Modern Surgery, 2005, 2(8);712-713
[3] Qiu Huahua, Song Jiuhong. Negative pressure closed drainage technique [M]. Beijing: People’s Health Publishing House, 2008: 1-8.
[4]Xu Longshun, Chen Shaozong, Qiao Ren. The effect of negative pressure on trauma blood flow [J]. Journal of the Fourth Military Medical University, 2000, 21(8): 976-978
[5] Li Jing, Chen Shaozong, Li Xuezong. Experimental study on the effect of closed negative pressure drainage on the microcirculatory flow rate and vascular caliber of trauma [J]. Modern Rehabilitation, 2000, 4(12): 1848-1849
[6]Xie Kegong, Tang Renguang, Tang Yujin, Lu Minan, Culture and drug resistance analysis of pathogenic bacteria of septic osteomyelitis, Laboratory Medicine and Clinical, 2009,6(5):325-326.
[7] Shen Cuihua, Ye Chunping. Nursing experience of patients with closed negative pressure drainage [J]. Zhejiang Trauma Surgery, 2009, 14(2):204.
[8]Tao Shengxiang, Yu Aixi．The application of VSD in severed palm reimplantation with severe soft tissue injury[J]Anatomy and Clinical, 2007, 2(11):415, 671.
[9] Lu Peihong. Clinical observation and care of negative pressure closed drainage (VSD) in the treatment of pollicization [J]. Chinese Community Physician,2010,12(25):203