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EAKIN - VAC Case Study

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EAKIN - VAC Case Study

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									EAKIN - V.A.C. Case Study

Epworth Eastern Hospital Box Hill

Andrea Farrugia Clinical Nurse Consultant Stomal Therapy

Written March 2008

EAKIN - V.A.C. Case Study – August to November 2007
Epworth Eastern Hospital – Box Hill Andrea Farrugia – Clinical Nurse Consultant – Stomal Therapy Patient Details: Male, 65 years old Height: 168cms Weight: 85kgs BMI: 30 Private Health Insurance: Medibank Private Medical History • 2007 Ca Bladder • 2005 AMI – 2 Arrests: at different hospitals, requiring Angiogram and stents • intermittent angina on exertion • Asthma – nil hospital admissions Clinical History: 3/8/2007 - Ca Bladder – Cystectomy and formation of Ileal Conduit Leaking ileal Anastomosis, wound dehiscence and faecal fistula 9/8/2007 - Transferred to Epworth Eastern Hospital – Box Hill. Taken back to theatre for attempted defunctioning ileostomy – unsuccessful due to short mesentry, therefore fistula remained insitu in abdominal wound. Initially dressed with betadine packs post theatre, but experiencing copious ooze while in ICU. 10/8/2007 - ICU contacted KCI and commenced on VAC therapy 11/8/2007 - Vac dressing intact, minimal drainage. 125mmhg continuous therapy. 12/8/2007 - Dressing change overnight by night staff due to leakage. Output of 280ml. Area cellulitis R)lateral abdo – commenced IV Antibiotics 13/8/2007 - Vac intact 14/8/2007 - Vac dressing changed, wound clean Patient being maintained with Total Parenteral Nutrition (TPN) Commenced on diet and fluids 15/8/2007 - Temp. elevated – 38.2.C – Blood Cultures taken Vac dressing changed, but refilled again – excessive drainage. Bile noted to be draining from wound site. VAC dressing stopped. 16/8/2007 - ‘Low volume fistula’ found on CT scan. TPN, IV Antibiotics continue, now nil orally. Abdominal wound dressed with ‘exidry’ and combine dressings PRN 17/8/2007 - Referred to stomaltherapy for wound management

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17/8/2007 Referral to Stomal Therapy for management of faecal fistula and abdominal wound. Request by surgeon for pouchin ‘drip and suck’(continuous irrigation and continuous low grade suction). Had been managed by ward staff with frequent combine pad changes, which was uncomfortable for the patient, and not effective in managing faecal fluid output.
Assessment: Large abdominal wound, with areas of slough, and faecal fistula expelling bile stained fluid over surface of the wound Wound tissue is red. Surrounding skin is generally in good condition Wound measured 200mm x 150mm, approx. 30 mm deep Action: Commenced on Eakin Vertical Incision (bung closure)Fistula Drainage Pouch (839226 – cutting edge 290 x 130mm with continuous N/Saline irrigation (1000ml 12-24/24 rate) and clements low grade suction (30 – 50 mmhg). We were able to maintain on average a three day wear time using this method. To accommodate the wound, The pouch was cut to the maximum cutting margin, and then manipulated round the wound edges. Another layer of Eakin Cohesive Seal was applied to the fistula pouch adhesive edges to help prolong wear time. In order for the fistula pouch to mold to shape and adhere quickly to the skin surface, the prepared Eakin Fistula Pouch was wrapped in a hand towel, and warmed in the microwave on high for 13 seconds. Once the fistula pouch was applied round the wound, it was again warmed by the heat of the patient’s body and my hands over the adhesive edge. This was to ensure Eakin had molded into uneven skin surfaces and created a good seal. To help support the pouch, Mefix tape was applied round adhesive edges. To gain access for Normal saline irrigation, a small opening was created at the uppermost part of the pouch. The end of an IV line was inserted so that the saline would drip onto top of wound, and the saline irrigation was set at a 12 to 24 hourly rate. To drain the discharge, a Nelaton catheter was inserted at the drainage outlet of the pouch, and positioned just below base of wound. This was secured in place at the outlet port with tegaderm film. Clements suction was attached to the Nelaton catheter. As the suction commenced, the catheter was positioned with the aim of not sitting in wound to avoid trauma. An air filter was not used, the idea being that space for effluent to pool and collect was reduced. Using this method allowed for approximately 3 day wear time, providing skin protection, irrigation of wound and removal of output. This method assisted in cleaning the wound of slough and faecal debris. Compared with having dressing pads changed frequently/PRN to manage the fistula output, using the Eakin Fistula Pouch was far more comfortable for the patient. Having the output better managed gave the patient confidence in our care, and lifted his spirits. The patient became interested in the management of his wound and encouraged our attempts to document his wound’s progress by photographing and tracing the wound.

Figure 1: 17/8/2008

Figure 2: 20/8/2007

Figure 3: 23/8/2007 3

Attempt to have access to abdominal wound with Eakin Fistula Pouch in place by applying an access window. As clements suction being utilized, the access window ‘sucked’ down onto the wound causing discomfort. VAC foam was inserted under access window to assist with cushioning. This method of management was not successful and discontinued. Although using ‘drip and suck’, the wound was not dramatically improving, but being maintained. 30/8/2007 -The decision was made to recommence VAC therapy

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Figure 4: 31/8/2007 – VAC therapy

Eakin cohesive seals were adhered round edges of wound to provide a durable protection of surrounding skin from faecal fluid. Adaptic interface dressing between wound base and foam. Foam cut to fit wound.

Film was positioned and adhered over wound. After seeking advice from KCI, the suction/track pad was placed in close proximity to fistula opening. This was an attempt to force fistula closure by maintaining high pressure over the fistula. With hindsight, the fistula had established itself (21 days) and would not have closed using this method, but we did not have the experience to know this.

The pressure was commenced at 125 mmhg. We were advised to increase the pressure in 50mmhg increments if the effluent continued at high volumes at half hourly intervals. The aim was to repeat the process until effluent significantly decreased, reaching a maximum pressure of 200mmhg. Unfortunately, a forced closure was unsuccessful. 1/9/2007 Vac dressing leaking faecal fluid ++ from base of wound where it has been pooling, despite suction being maintained. Dressing taken down, with large amount of faecal sediment collecting in wound bed. Surgeon contacted by staff and ‘drip and suck’ using Eakin Fistula Pouch recommenced, providing a three day wear time. 6/9/2007 Patient taking in high protein drinks orally and TPN to discontinue. Discussion with dietician re concern that Sustagen and milky drinks were precipitating in ileal fistula output. Sustagen changed to Resource fruit beverage. The wound was traced, and now measured 15.5 x 9.5 cm, and approximately 2 cm deep Fistula pouch discontinued, and VAC dressing recommenced.

8/9/2007 -

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12/9/2007 -

Wound traced – measured 13 x 8 cm

Figure 5: 12/9/2007

Vac dressing attended second daily. 20/9/2007 Wound traced – 11.5 x 7 cm

Output volume appears to be gradually decreasing in amounts of bile stained fluid according to fluid balance chart. 3/10 980ml (oral input) 950ml (Faecal fistula output) 4/10 1250ml 1000ml 5/10 1020ml 500ml

Figure 6: 20/9/2007

6/10/2007 - Vac dressings changed second daily. VAC pressure maintained at 150mmhg currently. The skin edges have been protected well from the effluent by using an Eakin Cohesive Seal border round the wound 10/10/2007 - Wound reviewed by KCI educator – Chris Mann. After discussion re management, Chris suggested we try to ‘wall off’ the fistula from the wound and apply a pouch to collect fistula output. As the fistula was concealed under the skin surface and not clearly visible, it would be difficult to isolate. Creating a wall with the aim of diverting the output into a pouch, away from the wound bed in this instance, was innovative. Traditionally, the fistula would have to be clearly visible in order to isolate effectively. Figure 7: 10/10/2007

13/10/2007 - wound decreasing in size – measures9.5 x 6cm 6

Demonstration of walling off faecal fistula from wound Figure8: 13/10/2007

Eakin Cohesive Seals were adhered to edges of the wound to protect surrounding skin. A rectangle of foam was wrapped in film, with the surface to be in contact with the wound lined with Eakin Cohesive Seal to help create a seal/barrier. The aim was to wall off the wound from exposure of faecal fluid exuding from the fistula, to enable healing of wound. Adaptic interface dressing was placed at wound base, while fistula suctioned as output bubbled up.

Foam was placed into wound cavity. Gauze was placed where the opening of the fistula was situated. The area was covered with film. An opening in the film was created above the gauze, and the gauze was extracted, leaving an opening to allow the fistula fluid to escape.

A convex adhesive drainable pouch was placed over this opening to collect the output. 18/10/2007 - wound measures 8.5 x 5.5 cm 24/10/2007 - wound measures 7.5 x 4.2 cm 31/10/2007 - wound measures 6 x 3.5 cm This regime continued until patient went back to theatre for surgical closure of faecal fistula with formation of end ileostomy 9/11/2007.

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The wound improved from this (20/8/2007 – 20 x 15cm),

then …(20/9/2007 – 11.5 x 7cm)

(24/10/2007 – 7.5 x 4.2cm) to this……

Closure 9/11/2007 (24/11/2007)…………To THIS!!!

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Throughout the management of the abdominal wound and faecal fistula, the ileal conduit also required care, and the patient needed education re stoma care. A crease had developed where the ileal conduit had been positioned, as the stoma retracted and the opening stenosed, which made it difficult for the patient to see. Eventually the mucosa was not really visible, however the urine was flowing and the appliance was maintaining a good seal. The urine colour varied from yellow to caramel in colour. The patient would intermittently develop temperatures which would resolve with antibiotics. Eventually, the patient developed an area of tender inflammation to the right lateral side of abdomin, adjacent to his ileal conduit. When he returned to theatre during early November 2007 for closure of abdo wound and formation of end ileostomy, he had his ileal conduit reviewed. It was found that the ileal conduit had necrosed. A new ileal conduit was created above the old site, where he was able to see and manage it well. Conclusion The patient was able to be transferred to rehab on the 29/11/2007, where I continued to visit, to offer support and education re stoma care for his ileal conduit and ileostomy. He was discharged from rehab to home on the 11/12/2007 with RDNS (Royal District Nursing Service) support. We continue to correspond by email – he has been to Hamilton Island with his lovely wife in February, and has sent me photos of him in the snow during June. He is making the most of his second chance and trying to live life to the fullest. He has been offered closure of the ileostomy, but understandably, is nervous and is in no rush! Managing this patient’s abdominal wound and fistula was quite a challenge for the patient and for those caring for him. We witnessed his courage in dealing with the pain and discomfort of his wound and the dreadful fear that he may not survive his ordeal. His determination had a huge impact on his recovery, Throughout the process, he was very much part of the ‘team’ caring for his wound. He called himself the ‘foreman’ as he had overseen all the dressings, monitored his wound’s progress (even taking his own photos using his phone and sending them to his surgeon to keep him updated), and was involved in warming the Eakin Cohesive seals at each change, encouraging the staff attending to his care, and cracking jokes. A huge collaborative effort from all the staff on 5 North at Epworth Eastern – Box Hill was the key to this successful outcome . Claire McLellon (ANUM, Breast Care nurse and VAC Queen!) and I made a commitment for one of us to be available for the patient’s second daily VAC dressing changes. This was to ensure that the dressings were attended to consistently, and to help allay the fears of the patient who at times was at breaking point emotionally. The use of Eakin Fistula Pouches and Eakin Cohesive Seals was instrumental in protecting the patient’s parafistula skin from the corrosive effects of his fistula output. The prolonged wear time of the Eakin Fistula Pouches provided comparative comfort and control of the fistula, ensuring the wound did not deteriorate further. When the VAC dressings were commenced, the Eakin Cohesive Seals protected the skin from the potential trauma of the VAC dressing coming in contact with the skin surrounding the wound. The seals also provided a buffer between the fistula output and the wound edges, protecting the surrounding skin and providing ongoing comfort. In this case, the Eakin Cohesive Seals were used successfully to line the ‘wall’, to attempt to separate the fistula from the wound bed, which improved wound healing time significantly. The use of VAC dressing helped to rapidly shrink the large abdominal wound in a relatively short period of time, where other methods (frequent pad changes and then containing fistula and wound in fistula pouch using ‘drip and suck’) were unable to significantly improve the wound size. Although my personal experience with VAC was limited prior to this patient, the support offered by KCI ensured that the use of VAC was effective and efficient. KCI’s input in helping us develop a ‘wall’ to segregate the fistula from the wound was the turning point in this patient’s recovery and contributed to a very successful outcome.

Andrea Farrugia Clinical Nurse Consultant – Stomal Therapy Epworth Eastern Hospital – Box Hill 2008

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