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					 Cutimed® Sorbact®
      physical
   attraction           Hands-on Case Report       10




  Treatment of severe venous leg ulcer
using unique bacteria-binding dressing
                            Kazu Suzuki, DPM CWS
2




    KAZU SUZUKI, DPM CWS
    TOWER WOUND CARE CENTER, CEDARS-SINAI MEDICAL TOWERS, LOS ANGELES, CA, U.S.A.
    DEPARTMENT OF SURGERY, CEDARS-SINAI MEDICAL CENTER, LOS ANGELES, CA, U.S.A.



    Treatment of severe venous leg ulcer using
    unique bacteria-binding dressing with a
    fatty acid contact layer, combined with
    a multi-layer compression dressing




    Introduction
    Venous leg ulcers are one of the most common leg      DVT causes a chronic vein disease, known as
    wounds seen in the United States today, as they       “Post-Thrombotic Syndrome.” This injury to the
    are also the most common symptoms of Deep Vein        venous valves creates chronic venous insufficiency
    Thrombosis (DVT). Currently there are 600,000 cases   that causes painful varicosities, leg edema, as well
    of DVT annually in the United States, or 1 in 1,000   as venous ulcers and associated skin changes. In a
    persons per year.1                                    study of patients two years after developing deep
                                                          venous thrombosis, post-thrombotic syndrome was
                                                          the major factor impairing quality of life.2


     Examples of post-thrombotic syndrome and venous leg ulcers seen in our wound care center




     Example 1                                             Example 2
     Severe varicosities (varicose veins)                  Skin changes (hemosiderin stain) with venous
                                                           leg ulcer




     Example 3
     Severe venous leg ulcer with overlapping
     lymphedema
3




    Clinical evidence and treatment                            Patient history
    In addition to appropriate wound debridement and           71 year old male with a long-standing history of DVT,
    wound dressings, it is widely accepted that com-           post-thrombotic syndrome and varicose veins, pre-
    pression therapy for venous leg ulcers is key to           sented with a large venous leg ulcer that has been
    promoting swift wound closure.                             non-healing for 2 years, despite multiple courses of
                                                               oral antibiotic treatment and Unna Boot application.
    Based on a systemic review of 39 randomized con-
    trolled trials, it was concluded that “Compression         Other co-morbidities include hypertension and
    increases ulcer healing rates compared with no             bilateral leg edema. The patient is currently on
    compression. Multi-component systems are more              Warfarin (Coumadin®) 15 mg daily for the treatment
    effective than single-component systems. Multi-            of chronic DVT and recently diagnosed protein S
    component systems containing an elastic band-              deficiency.
    age appear more effective than those com-
    posed mainly of inelastic constituents.”3                  Physical exam and Doppler exam:
                                                               Well-developed, morbidly obese male. He was not
    This systematic review demonstates that inelastic          showing signs of acute distress, but clearly in pain
    bandages (e.g. “Unna boots”) are less effective than       from the large leg ulceration. Vascular exam showed
    multi-layer compression dressings (e.g., JOBST®            +2-3 pitting edema of bilateral lower extremities,
    Comprifore system) for treating venous leg ulcers.         non-palpable pulses on both legs due to severe
                                                               edema, but biphasic Dopplerable posterior tibial
                                                               and dorsalis pedis arteries, bilaterally.
     2012 CPT code for compression
     dressings
                                                               ABI (Ankle Brachial Index) was 1.12 Resting and
     According to the American Medical Association             1.04 Post-Exercise on left leg, and tibial waveforms
     CPT(r) 2012 book, Category 1 CPT code "29581"             are within normal limits. Skin Perfusion Pressures
     has been assigned as "Application of multi-layer          were 88 mmHg at right foot and 96 mmHg at left
     compression system; leg (below knee), including           foot, with SPP values over 40 mmHg indicating
     ankle and foot."                                          good wound healing potential.

     If one is applying these multi-layer compression          A venous duplex exam showed DVT in the femoral
     bandages on both legs, this "CPT 29581" code              and popliteal veins on both limbs, with chronic and
     should be modified with a -50 modifier to indi-           recanalized thrombus, as well as greater saphenous
     cate bilateral leg applications.                          vein insufficiency in both the thigh and knee on both
                                                               legs. The patient was previously seen by a vascular
                                                               surgeon, who recommended medical therapy with
    Case Presentation                                          warfarin, as opposed to surgical intervention.
    Presented here is a severe venous ulcer case in a
    morbidly obese patient with history of DVT. This
    wound was successfully treated on an outpatient
    basis during weekly local wound care visits, using a
    combination of Cutimed® Sorbact® WCL (Wound
    Contact Layer) and Comprifore multi-layer com-
    pression wraps.

    Cutimed® Sorbact® WCL is a unique bacteria-bind-
    ing dressing coated with DACC (Dialkyl carbamoyl
    chloride), a fatty acid derivative that is highly hydro-
    phobic. When the outer membranes and cell walls
    of pathogenic microbes, which are also hydropho-
    bic, come in contact with DACC, the microbes
    become physically bound to the dressing, unable
    to reproduce, and are removed with each dressing
    change, which helps reduces the risk of wound
    infection. As DACC is a fatty acid derivative, it is
    not an anti-septic, antibiotic, or silver-containing
    product, and has not been linked to any develop-
    ment of resistant bacteria strain or allergic reaction
    to a particular chemical or metal.

    The Comprifore multi-layer compression system is
    a 4-component dressing kit that provides sustained
    graduated compression of 40 mmHg up to 7 days,
    indicated for the treatment of venous leg ulcers.
4




    Treatment history

     1a                                                       1b




     Day 1 (initial visit)
     The patient presented with large venous leg ulcer, with copious sero-sanguinous exudate with slight odor.
     The wound was debrided, and the wound base was also sharply debrided with #10 scalpel, followed by
     saline irrigation using 35 kHz ultrasound device (Quostic system by Arobella Medical) for 5 minutes.

     After debridement, the wound base was covered mostly with moist red granular tissue with some yellow
     fibrotic tissues. This wound was a full skin thickness ulcer. The peri-wound skin was red and inflamed,
     with brawny skin texture, and mild cellulitis. The wound was cultured, and the patient was given empiric
     antibiotics, Oral Doxycycline 100 mg BID for 2 weeks. The wound dressing at this visit consisted of
     Cutimed® Sorbact® WCL, followed by an ABD pad and Comprifore multi-layer compression wraps for
     edema reduction.



     3a                          3b                          Day 3
                                                             The patient returned for the review of wound cul-
                                                             ture results. It was MRSA (Methichillin Resistant
                                                             Staph. Aureus) sensitive to Doxycycline. The patient
                                                             was instructed to continue with Doxycycline until
                                                             the prescription was finished.
                                                             The wound was debrided, irrigated and dressed
                                                             with Cutimed® Sorbact® WCL and Comprifore
                                                             dressing. The patient was instructed to return to
                                                             the clinic 2-3 times per week, as the wound
                                                             drainage was fairly copious.




     8                          10                           Day 8 and 10
                                                             The wound size diminished, and the leg edema
                                                             was much improved. The wound odor was resolved
                                                             by Day 8 and the patient also reported a gradual
                                                             reduction in wound pain and drainage. The wound
                                                             was sharply debrided with a #15 scalpel, followed
                                                             by 35 kHz ultrasound saline irrigation treatments.
                                                             The wound dressing consisted of the same regi-
                                                             men of Cutimed® Sorbact® WCL, an ABD pad,
                                                             and Comprifore multi-layer compression wrap.
5




    Treatment history cont.

    300
     20                       31




                              Day 20, 31 and 39
    39
                              The wound size and leg edema improved steadily
                              at each visit. The wound was again debrided
                              sharply and treated with 35 kHz ultrasound saline
                              irrigation. The same dressing regimen was continued
                              using Cutimed® Sorbact® WCL and Comprifore.




    300
     63                       Day 63
                              Due to the patient’s travel schedule out-of-state,
                              there was a 3-week hiatus of the wound care
                              center visits. The wound treatment was resumed
                              on Day 63, using sharp debridement, followed by
                              35 kHz ultrasound saline irrigation, as well as
                              wound dressing using Cutimed® Sorbact® WCL
                              and Comprifore.




    74                        85




    98                        106




                              Day 74, 85, 98 and 106
                              Gradual reduction of wound size and depth was
                              noted with the same wound treatment regimen.
                              The patient reported much reduced wound
                              drainage.
6




    Treatment history cont.

    300
     114                                                  Day 114
                                                          The wound was completely healed on Day 114,
                                                          just over 9 weeks after the initial visit. At this
                                                          point, the patient was prescribed prescription
                                                          compression stockings of 20-30 mmHg and was
                                                          given education regarding the lifetime use of
                                                          compression stockings.




    300
     128a                                                 Day 128
                                                          The patient was seen 2 weeks later for a follow-
                                                          up visit, and the leg wound had maintained skin
                                                          integrity with minimal scar.




     128b




    Discussion                                            Author
    This case study illustrates that the combination of   Kazu Suzuki, DPM CWS
    Cutimed® Sorbact® WCL and Comprifore multi-layer
    compression wraps can be very effective in success-   Tower Wound Care Center, 8635 West 3rd Street,
    fully treating some severe venous leg wounds, even    Cedars-Sinai Medical Towers, Suite #1085W,
    when Unna Boot therapy had previously failed.         Los Angeles, CA 90048, U.S.A.

    References                                            Department of Surgery, Cedars-Sinai Medical
                                                          Center, Los Angeles, CA 90048, U.S.A.
    1. The Surgeon General’s Call to Action to Prevent
       Deep Vein Thrombosis and Pulmonary                 E-mail: Kazu.Suzuki@cshs.org
       Embolism. 2008.
    2. Kahn SR, Shbaklo H, Lamping DL et al.
       Determinants of health-related quality of life
       during the 2 years following deep vein throm-
       bosis. J Thromb Haemost. 2008;6(7):1105.
                                                                                                               12/2011




    3. O'Meara S, Cullum NA, Nelson EA.
       Compression for venous leg ulcers. Cochrane
       Database of Systematic Reviews. 2009.
                                                                                                               70550-00543-00

				
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