LOUISE WEBBER AMPUTEE & REHAB CNC SSWAHS AMPUTEE WOUND CARE LOUISE WEBBER AMPUTEE & REHAB CNC SSWAHS I’m not sure about the spelling of your name. I’ve done this on plain background and font is comic sans – this is the font I always use – Times Roman is boring!!!

AIMS OF POST-OP WOUND CARE WOUND HEALING WITHOUT COMPLICATION POTENTIAL COMPLICATIONS: WOUND BREAKDOWN DEHISCENCE INFECTION

WOUND MANAGEMENT NEED TO CLEAN THE WOUND BED – DEBRIDE NECROTIC TISSUE DECREASE THE BACTERIAL BURDEN OF THE WOUND

METHODS OF WOUND DEBRIDEMENT SURGICAL DEBRIDEMENT AUTOLYTIC DEBRIDEMENT Advanced wound care products BIOLOGICAL DEBRIDEMENT Maggot Debridement Therapy

Maggots used are from the fly Lucilia sericata Which fly? Maggots used are from the fly Lucilia sericata

Life Cycle of the Fly Fly Pupa Egg Maggot Fly This slide starts with the fly laying the egg and progresses round clockwise. Eggs are laid directly onto the food source – road kill, pork chops in the bin, sloughy leg ulcers because if the baby maggot had to go and look for food after hatching most would die. The eggs hatch after approx 12 hours – sooner if it is warm. The baby maggot needs darkness (photophobic), warmth (flies hibernate in winter), moist environment (very easily dehydrated when small),good food source – devitalised tissue. If they get these ideal conditions they will increase their size to resemble the ones everyone knows – sometimes I say they triple their size but this actually relates to their body weight and can cause confusion as everyone imagines a monster maggot. This takes approx 6 days depending on the amount of food available. When the maggot has had sufficient food to reach optimum size the need to move on through their cycle to become a pupa (like caterpillar, chrysalis to butterfly). For this they need different conditions – they still need the warmth and the dark but they no longer need a food source as they stop eating when they reach optimum size and their mouth seals over. The most important thing from the patient’s point of view is that they now need a dry environment for the outer case to harden – this can’t happen in a moist wound, so if the maggot is left in the wound too long all that will happen is that they will desperately try and get out of the wound, and if they can’t they will die in the wound – they will then be broken down and come away with the wound exudate (biodegradable). In nature the maggots leave the food source (dead body) and pupate in the earth – in the lab we pupate them in saudust. They are pupae for a further 7 days and then hatch out as the adult fly. The cycle takes approx 2 weeks. Pupa

How do they work? Contrary to popular belief maggots do not have teeth, so they cannot bite or chew away dead tissue ( this is also why they cannot be felt in a wound)

How do they eat? They feed by extra-corporeal digestion, secreting collagenases, trypsin-like, & chymotrypsin-like enzymes that break down necrotic tissue into a semi-liquid form that the maggots can ingest. These enzymes are only effective on devitalised tissue

Problems with maggot therapy Potential “yuk” factor Run-away dressing Short shelf life

Perceived advantages of maggot therapy Rapid wound debridement Reduction in odour Control of infection Maggots take their oxygen from the air Stimulation of granulation tissue Highly cost effective

79 year old Lady admitted to Hospital from Nursing Home “off her legs”, semi conscious, no relatives. I.V Saline commenced- 1 litre in 24 hours.

Same wound 2 weeks later – only had 1 application of maggots then wound dressed with Allyven Cavity dressing. That is not slough in the Photo it’d fibrous covering. This Lady still on 1 litre saline in 24 hours – no food – but wound is continuing onto healing, unfortunately she passed away from malnutrition !!!

79 year old diabetic man, admitted for above knee amputation, Arrested on the table, was resuscitated operation completed and sent to ITU. Because of his altered centre of gravity due to his amputation and the fact that he has dynomap and central line in situ and chronic arthritis in both hands the only way he can reposition himself in bed is to use his elbow. He developed a small wound with an underlying sinus – M.R.S.A. positive. 1 pot free range maggots applied on Friday.

Same wound on Monday, Maggots removed using forceps and sputum pot Same wound on Monday, Maggots removed using forceps and sputum pot. Wound swab introduced into sinus. Subsequently come back negative to M.R.S.A.

67 year old diabetic gentleman, partial amputation of foot – wound not progressing, further surgery ruled out. 2 pots free range maggots applied ( should have been 3 but this was in early days when I was still learning!

Same wound 3 days later – needed 1 more application to remove all slough but you can see see how clean and undamaged the tendons are

82 year old lady with venous leg ulcer 82 year old lady with venous leg ulcer. Ulcer present for 3 years but static like this for 18 months. 1 pot free range maggots applied on Tuesday

Same wound on Thursday

79 year old lady pressure ulcer on heel acquired after admission to hospital for fracture neck of femur. Been home 18 months wound M.R.S.A. positive. Lives in Nursing Home, been isolated for all this time to contain M.R.S.A. 18 months of autolytic dressings – no effect. 1 pot free range maggots applied

Same wound 2 days later – bone visible in base of wound Same wound 2 days later – bone visible in base of wound. Swab taken – result M.R.S.A. negative

78 year old man with Myesthelioma (not sure about spelling) bilateral leg ulcers present over 20 years. Admitted to Dermatology for pain control and TLC. Been in hospital for 3 weeks before referral, wound Is being treated with hydrogel – 12 pots per leg per day. Patient on syringe driver and needs Entinox for dressing Changes which are not having any effect on slough. Amputation is arranged for 6 days time. This is inner aspect of leg.

This is the outer aspect

This is the back of the wound

Unable to apply hydrocolloid as wound border – too painful, used zinc paste instead. Applied collar hydrocolloid just above knee ( you can see it on other leg) 3 pots free range maggots applied to each leg, large bag placed over them and secured to hydrocolloid collar.

Same wound 2 days later – no further maggots applied Same wound 2 days later – no further maggots applied. Returned to previous dressings (Gel) and as we got his pain under control we switched dressings to alginates.

Same legs2 months later. Patient discharged home with large hydrocolloid dressings and paracetamol for pain. Legs went on to heal in 6 more weeks

78 year old man – high through thigh amputation – wound not closed because Surgeon not sure if surrounding tissue viable. By time they decide tissue is viable, unable to close wound due to slough and M.R.S.A. 3 pots free range maggots applied under ½ boot

Same wound 3 days later

6 weeks post –op 22/01/10

12/02/10 Pre MDT

15/02/10 Post 1st Application

19/02/10 Post 2nd application

26/02/10 After 3 days VAC 23/02/10 VAC Applied

17/03/10 03/03/10

QUESTIONS?????