The Use of V.A.C. Instill in the Wounded Pediatric Population
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Abstract: V.A.C. Instill® Therapy Unit (Kinetic Concepts, Inc. [KCI], San Antonio, TX) incorporates negative pressure wound therapy (NPWT) with intermittent automated wound irrigation. The following case describes a 2-year-old male with right thigh compartment syndrome from an acutely developing hematoma. Devascularization of the overlying skin led to full-thickness skin necrosis of the anterolateral and posterior right thigh. Following emergent evacuation and a lateral fasciotomy, necrotic skin was excised and nonviable subcutaneous fat was debrided. Wound care included NPWT with the V.A.C. Instill Therapy Unit. Definitive coverage was achieved with a split-thickness skin graft, which took completely without surgical complications at the patient’s 4-month follow up.
Address correspondence to:
Kevin Broder, MD
Rady Children’s Hospital
8899 University Center Ln., #350
San Diego, CA 92122
V.A.C.® Therapy was designed to provide an occlusive, moist, negative pressure wound environment.1,2 Over the years, the benefits of this negative pressure wound therapy (NPWT) have been elucidated by various studies. These benefits include the removal of accumulating interstitial fluid,3 increasing oxygen tension in the wound,4 matrix proliferation through the mechanical stress that negative pressure puts on cytoskeleton elements,5,6 increased blood flow,7–9 and increased granulation tissue proliferation.10–17 The fact that the therapy system has been shown to reduce wound size more rapidly compared to standard moist wound care18–21 is of great importance. First introduced in 2004,22,23 the V.A.C. Instill® Therapy Unit incorporates NPWT with intermittent automated instillation of wound irrigation. Irrigation fluids range from Dakin’s solution to ones containing antibiotic agents. A review of the literature demonstrated that the use of the Instill unit only has been reported in the adult patient population. We report a case whereby the Instill unit was successfully utilized as part of the comprehensive surgical management of a complex lower extremity wound in a pediatric patient.
A 23-month-old male presented with right thigh compartment syndrome secondary to an acutely developing hematoma in the context of a longstanding history of a consumptive coagulopathy of unclear etiology. The patient underwent emergent evacuation of the right thigh hematoma along and fasciotomy by orthopedic surgery for increased anterior compartment pressures of 36 mmHg. The lateral fasciotomy indicated an increased anterior compartment pressure of 36 mmHg. Prior to presentation to the hospital the hematoma had been present for over 48 hours. Devascularization of the overlying skin ensued and the patient demonstrated full-thickness skin necrosis of the anterolateral and posterior regions of the right thigh, totaling 300 cm2 (Figure 1A).
Plastic surgery was consulted for complex wound management. The patient required full-thickness excision of the necrotic skin as well as partial-thickness debridement of nonviable subcutaneous fat (Figures 1B and 1C). Multiple operative debridements followed to ensure complete removal of devitalized and infected tissue. Culture directed antimicrobial therapy was started for Stenotrophomonas maltophilia, Escherichia coli, and Enterococcus faecalis, which were cultured from wound tissue. Our comprehensive approach to wound care also included optimization of nutrition with supplemental enteral feeding, hyperbaric oxygen therapy (HBOT), and NPWT initially with the V.A.C.
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