practice
Treatment of necrotising fasciitis using glycerol-preserved skin allografts for temporary wound coverage Allografts of human skin have been used for both temporary and permanent wound coverage. They are useful as temporary bridges for the critically ill patient who is not allowed to receive definite wound coverage, or for wound bed preparation before permanent grafting. Glycerol-preserved skin allografts have several benefits including good adherence to the wound bed, water vapour transport, antimicrobial characteristics, low toxicity and antigenicity, ease of application and removal, a long shelf-life, and minimal storage requirements. We achieved lower limb salvage using a glycerol-preserved skin allograft for temporary wound coverage in the treatment of necrotising fasciitis. necrotising fasciitis; glycerol-preserved skin allograft; skin grafting; wound coverage
F
S.W. Kim, MD, Fellow; I.K. Choi,1 MD, Resident J.H. Lee,1 Clinical Assistant Professor; S.T. Ahn,1 PhD, Professor; J.W. Rhie,1 PhD, Professor; 1 Department of Plastic and Reconstructive Surgery, The Catholic University of Korea, Seoul, Korea. Email: [email protected] 1
S20
Fig 1. A 63-year-old man spontaneously developed painful hemorrhagic bullae on both lower legs, which resulted in extensive skin and soft tissue necrosis.
A 63-year-old man presented to the emergency department with painful haemorrhagic bullae that had developed spontaneously on both lower legs (Fig 1). He was a heavy alcoholic, drinking ten bottles of whisky weekly for the past 20 years. Due to high suspicion for necrotising fasciitis, fasciotomy
ltd
Case report
© 2014 MA Healthcare
Declaration of interest: There were no external sources of funding for this study. The authors have no conflicts of interest to declare with respect to the article or its contents.
undamental treatment of necrotising fasciitis includes surgical intervention, intravenous antibiotics, and supportive care.1 Early radical debridement plays an essential role, however, it leads to the development of wide raw surfaces, resulting in extensive loss of fluid, protein and electrolytes, and increased susceptibility to infection. Moreover, immediate skin graft is not advisable until the wound bed is well vascularised, free of infection, is adequately prepared, and the patient’s general health status allows.2–4 Glycerol-preserved skin allografts have been widely used for various purposes in the treatment of large burn wounds.2,5 We successfully used the glycerol-preserved skin allograft as a bridge therapy, serving to temporarily cover the wound between radical debridement and split-thickness skin grafting in the treatment of necrotising fasciitis.
J O U R N A L O F WO U N D C A R E C A S E S S U P P L E M E N T V O L 2 3 , N O 2 , 2 0 1 4
© MA Healthcare Ltd. Downloaded from magonlinelibrary.com by 137.189.171.235 on October 5, 2016. Use for licensed purposes only. No other uses without permission. All rights reserved.
practice was immediately performed. Eight days later, debridement of the involved skin, muscle, and tendon was performed, resulting in extensive defects which were covered by vacuum-assisted closure devices. The patient received daily replacement of 200ml of 20% albumin and two pints of fresh plasma in the intensive care unit and received serial debridement and application of vacuum-assisted closure devices in the operating room. Because the wound bed was not sufficiently prepared due to persistent infection and poor vascularisation, immediate autologous graft was not possible. Therefore, 8 days after initial debridement, a glycerol-preserved cadaveric skin allograft (Tissue Bank, Organ Transplantation Center, Seoul St. Mary Hospital, Seoul, Korea) was applied to reduce the burden of the defect and to relieve the pain (Fig 2). Subsequently, his albumin requirement was reduced, his platelet count recovered, erythrocyte sedimentation rate and C-reactive protein levels improved, and pain during wound dressing was relieved (Fig 3 and 4). Twelve days after the application of the glycerol-preseved allograft, it was replaced with autograft since a well-vascularised wound bed was finally achieved at that point. Unfortunately, around this time, his left lower limb with severe osteomyelitis needed to be amputated below the knee level. After a 2-year follow-up, successful salvage of his lower limb was noted, and the patient was able to walk with the aid of a prosthesis (Fig 5).
Fig 2. After glycerol preserved cadaveric skin allograft was applied, healthy granulation wound bed was achieved.
Fig 3. Follow-up serum albumin level (red line) and albumin requirement (blue line). Albumin requirement was decreased after application of allograft, and the serum albumin level was maintained above 2.5g/dl. 3.5
3
3
2.5
2.5
2.
2.
1.5
1.5
1
1
0.5
0.5
0 Admission
Debridement
GPA applied
20% Albumin (100ml/bottle)
3.5
Serum albumin (g/dl)
Necrotising fasciitis is a rare but life-threatening soft tissue infection characterised by rapidly spreading inflammation and subsequent necrosis of surrounding fascial planes and tissues. Timely diagnosis, broad-spectrum antibiotics, and aggressive surgical debridement of affected tissue are fundamentals of treatment.1 Surgical debridement is essential in eliminating the necrotic tissue, a source of infection. However, wide tissue defects inevitably develop as a result of debridement, which leads to bleeding, extensive leakage of fluid, protein, and electrolytes, and increased susceptibility to infection. Often, immediate autologous graft is not possible due to on-going infection, insufficient preparation of the wound bed, and hemodynamic instability of the patient.4 In our case, infection was not fully controlled at the point of initial debridement, so serial debridement was required. Moreover, the patient’s general status did not permit definite autologous graft. Developing another raw surface as the donor site for the autologous graft can be a burden to the critically ill patient and can lead to devastating results. The glycerol-preserved skin allograft is preserved in 85% glycerol and can be stored at 4ºC. Glycerolisation destroys the vital structure, so the allograft is
0 Autograft
Clinical course
s
© 2014 MA Healthcare
ltd
Discussion
J O U R N A L O F WO U N D C A R E C A S E S S U P P L E M E N T V O L 2 3 , N O 2 , 2 0 1 4
S21
© MA Healthcare Ltd. Downloaded from magonlinelibrary.com by 137.189.171.235 on October 5, 2016. Use for licensed purposes only. No other uses without permission. All rights reserved.
practice Fig 4. Change in the erythrocyte sedimentation rate (red), C-reactive protein (purple) and platelet count (blue line) after application of the allograft. 140
400
120
350
100
300 250
80
200
60
150
40
100
20
50 0 Admission
Debridement
GPA apply
ESR (mm/h), CRP (mh/dl)
Platelet count (x1000)
450
0 Autograft
Clinical course
considered non-viable. Moreover, glycerol preservation is simple, cost-effective, and possesses antibacterial and antiviral properties, and suppressed immunogenicity compared to cryopreserved allograft. Therefore, the use of the glycerol-preserved skin allograft as a biological coverage or skin substitute is popular and commonly used in clinical practice in many major burn centers. In burn management, the allograft is used as a temporary cover for freshly excised wounds, applied with a sandwichgrafting technique for widely meshed autografts, and used for wound bed preparation prior to autografting. The mechanism of wound preparation is attributed to the increase in vascularity. The glycerol-preserved skin allograft promotes angiogenesis with enhanced capillary in-growth on the wound bed. A viable skin allograft can revascularise by inosculation, like autologous skin grafts. In addition, skin allografts can provide growth factors and essential cytokines, while promoting chemotaxis and proliferation at the wound bed. Once the allograft adheres to and vascularises on the wound bed, with bleeding on removal, the wound bed is considered ready for autografting.2,5 In this case, we applied the glycerol-preserved skin allograft to temporarily cover the wound until the patient’s general status stabilised and sufficient preparation of a wound bed was achieved. After application of the allograft, daily albumin requirements decreased, and platelet count recovered to the normal range. In terms of infection control, erythrocyte sedimentation rate and C-reactive protein levels also improved after application of the glycerol-preserved skin allograft. A well-vascularized wound bed was achieved 12 days after application of the allograft, and subsequent replacement with an autograft was successful.
Conclusion
S22
allografts in the treatment of burn injuries. Burns 2002; 28: S26–S30. 3 Atiyeh, B.S., Hayek, S.N., Gunn, S.W. New technologies for burn wound closure and healing – review of the literature. Burns 2005 ;31: 8, 944–956.
4 Pomahac, B., Garcia, J.A., Lazar, A.J. et al. The skin allograft revisited: a potentially permanent wound coverage option in the critically ill patient. Plast Reconstr Surg 2009; 123: 6, 1755–1758. 5 Khoo, T.L., Halim, A.S., Saad,
A.Z., Dorai, A.A. The application of glycerol-preserved skin allograft in the treatment of burn injuries: an analysis based on indications. Burns 2010; 36: 6, 897–904.
ltd
References 1 Bellapianta, J.M, Ljungguist, K., Tobin, E., Uhl, R. Necrotizing fasciitis. J Am Acad Orthop Surg 2009; 17: 3, 174–182. 2 Druecke, D., Steinstraesser, L., Homann, H.H. et al. Current indications for glycerol-preserved
© 2014 MA Healthcare
Fig 5. After a 2-year follow-up, successful salvage of the lower limb was achieved
Necrotising fasciitis is a rare but life-threatening soft tissue infection characterised by rapidly spreading inflammation and subsequent necrosis of surrounding tissues. In this article, we report an excellent outcome in our experience of limb salvage using the glycerol-preserved skin allograft for temporary wound coverage in the treatment of necrotising fasciitis. They are useful during the transitional time period between surgical debridement and skin grafting, for temporary wound coverage and pain relief. n
J O U R N A L O F WO U N D C A R E C A S E S S U P P L E M E N T V O L 2 3 , N O 2 , 2 0 1 4
© MA Healthcare Ltd. Downloaded from magonlinelibrary.com by 137.189.171.235 on October 5, 2016. Use for licensed purposes only. No other uses without permission. All rights reserved.
Treatment of necrotising fasciitis using glycerol-preserved skin allografts for temporary wound coverage Allografts of human skin have been used for both temporary and permanent wound coverage. They are useful as temporary bridges for the critically ill patient who is not allowed to receive definite wound coverage, or for wound bed preparation before permanent grafting. Glycerol-preserved skin allografts have several benefits including good adherence to the wound bed, water vapour transport, antimicrobial characteristics, low toxicity and antigenicity, ease of application and removal, a long shelf-life, and minimal storage requirements. We achieved lower limb salvage using a glycerol-preserved skin allograft for temporary wound coverage in the treatment of necrotising fasciitis. necrotising fasciitis; glycerol-preserved skin allograft; skin grafting; wound coverage
F
S.W. Kim, MD, Fellow; I.K. Choi,1 MD, Resident J.H. Lee,1 Clinical Assistant Professor; S.T. Ahn,1 PhD, Professor; J.W. Rhie,1 PhD, Professor; 1 Department of Plastic and Reconstructive Surgery, The Catholic University of Korea, Seoul, Korea. Email: [email protected] 1
S20
Fig 1. A 63-year-old man spontaneously developed painful hemorrhagic bullae on both lower legs, which resulted in extensive skin and soft tissue necrosis.
A 63-year-old man presented to the emergency department with painful haemorrhagic bullae that had developed spontaneously on both lower legs (Fig 1). He was a heavy alcoholic, drinking ten bottles of whisky weekly for the past 20 years. Due to high suspicion for necrotising fasciitis, fasciotomy
ltd
Case report
© 2014 MA Healthcare
Declaration of interest: There were no external sources of funding for this study. The authors have no conflicts of interest to declare with respect to the article or its contents.
undamental treatment of necrotising fasciitis includes surgical intervention, intravenous antibiotics, and supportive care.1 Early radical debridement plays an essential role, however, it leads to the development of wide raw surfaces, resulting in extensive loss of fluid, protein and electrolytes, and increased susceptibility to infection. Moreover, immediate skin graft is not advisable until the wound bed is well vascularised, free of infection, is adequately prepared, and the patient’s general health status allows.2–4 Glycerol-preserved skin allografts have been widely used for various purposes in the treatment of large burn wounds.2,5 We successfully used the glycerol-preserved skin allograft as a bridge therapy, serving to temporarily cover the wound between radical debridement and split-thickness skin grafting in the treatment of necrotising fasciitis.
J O U R N A L O F WO U N D C A R E C A S E S S U P P L E M E N T V O L 2 3 , N O 2 , 2 0 1 4
© MA Healthcare Ltd. Downloaded from magonlinelibrary.com by 137.189.171.235 on October 5, 2016. Use for licensed purposes only. No other uses without permission. All rights reserved.
practice was immediately performed. Eight days later, debridement of the involved skin, muscle, and tendon was performed, resulting in extensive defects which were covered by vacuum-assisted closure devices. The patient received daily replacement of 200ml of 20% albumin and two pints of fresh plasma in the intensive care unit and received serial debridement and application of vacuum-assisted closure devices in the operating room. Because the wound bed was not sufficiently prepared due to persistent infection and poor vascularisation, immediate autologous graft was not possible. Therefore, 8 days after initial debridement, a glycerol-preserved cadaveric skin allograft (Tissue Bank, Organ Transplantation Center, Seoul St. Mary Hospital, Seoul, Korea) was applied to reduce the burden of the defect and to relieve the pain (Fig 2). Subsequently, his albumin requirement was reduced, his platelet count recovered, erythrocyte sedimentation rate and C-reactive protein levels improved, and pain during wound dressing was relieved (Fig 3 and 4). Twelve days after the application of the glycerol-preseved allograft, it was replaced with autograft since a well-vascularised wound bed was finally achieved at that point. Unfortunately, around this time, his left lower limb with severe osteomyelitis needed to be amputated below the knee level. After a 2-year follow-up, successful salvage of his lower limb was noted, and the patient was able to walk with the aid of a prosthesis (Fig 5).
Fig 2. After glycerol preserved cadaveric skin allograft was applied, healthy granulation wound bed was achieved.
Fig 3. Follow-up serum albumin level (red line) and albumin requirement (blue line). Albumin requirement was decreased after application of allograft, and the serum albumin level was maintained above 2.5g/dl. 3.5
3
3
2.5
2.5
2.
2.
1.5
1.5
1
1
0.5
0.5
0 Admission
Debridement
GPA applied
20% Albumin (100ml/bottle)
3.5
Serum albumin (g/dl)
Necrotising fasciitis is a rare but life-threatening soft tissue infection characterised by rapidly spreading inflammation and subsequent necrosis of surrounding fascial planes and tissues. Timely diagnosis, broad-spectrum antibiotics, and aggressive surgical debridement of affected tissue are fundamentals of treatment.1 Surgical debridement is essential in eliminating the necrotic tissue, a source of infection. However, wide tissue defects inevitably develop as a result of debridement, which leads to bleeding, extensive leakage of fluid, protein, and electrolytes, and increased susceptibility to infection. Often, immediate autologous graft is not possible due to on-going infection, insufficient preparation of the wound bed, and hemodynamic instability of the patient.4 In our case, infection was not fully controlled at the point of initial debridement, so serial debridement was required. Moreover, the patient’s general status did not permit definite autologous graft. Developing another raw surface as the donor site for the autologous graft can be a burden to the critically ill patient and can lead to devastating results. The glycerol-preserved skin allograft is preserved in 85% glycerol and can be stored at 4ºC. Glycerolisation destroys the vital structure, so the allograft is
0 Autograft
Clinical course
s
© 2014 MA Healthcare
ltd
Discussion
J O U R N A L O F WO U N D C A R E C A S E S S U P P L E M E N T V O L 2 3 , N O 2 , 2 0 1 4
S21
© MA Healthcare Ltd. Downloaded from magonlinelibrary.com by 137.189.171.235 on October 5, 2016. Use for licensed purposes only. No other uses without permission. All rights reserved.
practice Fig 4. Change in the erythrocyte sedimentation rate (red), C-reactive protein (purple) and platelet count (blue line) after application of the allograft. 140
400
120
350
100
300 250
80
200
60
150
40
100
20
50 0 Admission
Debridement
GPA apply
ESR (mm/h), CRP (mh/dl)
Platelet count (x1000)
450
0 Autograft
Clinical course
considered non-viable. Moreover, glycerol preservation is simple, cost-effective, and possesses antibacterial and antiviral properties, and suppressed immunogenicity compared to cryopreserved allograft. Therefore, the use of the glycerol-preserved skin allograft as a biological coverage or skin substitute is popular and commonly used in clinical practice in many major burn centers. In burn management, the allograft is used as a temporary cover for freshly excised wounds, applied with a sandwichgrafting technique for widely meshed autografts, and used for wound bed preparation prior to autografting. The mechanism of wound preparation is attributed to the increase in vascularity. The glycerol-preserved skin allograft promotes angiogenesis with enhanced capillary in-growth on the wound bed. A viable skin allograft can revascularise by inosculation, like autologous skin grafts. In addition, skin allografts can provide growth factors and essential cytokines, while promoting chemotaxis and proliferation at the wound bed. Once the allograft adheres to and vascularises on the wound bed, with bleeding on removal, the wound bed is considered ready for autografting.2,5 In this case, we applied the glycerol-preserved skin allograft to temporarily cover the wound until the patient’s general status stabilised and sufficient preparation of a wound bed was achieved. After application of the allograft, daily albumin requirements decreased, and platelet count recovered to the normal range. In terms of infection control, erythrocyte sedimentation rate and C-reactive protein levels also improved after application of the glycerol-preserved skin allograft. A well-vascularized wound bed was achieved 12 days after application of the allograft, and subsequent replacement with an autograft was successful.
Conclusion
S22
allografts in the treatment of burn injuries. Burns 2002; 28: S26–S30. 3 Atiyeh, B.S., Hayek, S.N., Gunn, S.W. New technologies for burn wound closure and healing – review of the literature. Burns 2005 ;31: 8, 944–956.
4 Pomahac, B., Garcia, J.A., Lazar, A.J. et al. The skin allograft revisited: a potentially permanent wound coverage option in the critically ill patient. Plast Reconstr Surg 2009; 123: 6, 1755–1758. 5 Khoo, T.L., Halim, A.S., Saad,
A.Z., Dorai, A.A. The application of glycerol-preserved skin allograft in the treatment of burn injuries: an analysis based on indications. Burns 2010; 36: 6, 897–904.
ltd
References 1 Bellapianta, J.M, Ljungguist, K., Tobin, E., Uhl, R. Necrotizing fasciitis. J Am Acad Orthop Surg 2009; 17: 3, 174–182. 2 Druecke, D., Steinstraesser, L., Homann, H.H. et al. Current indications for glycerol-preserved
© 2014 MA Healthcare
Fig 5. After a 2-year follow-up, successful salvage of the lower limb was achieved
Necrotising fasciitis is a rare but life-threatening soft tissue infection characterised by rapidly spreading inflammation and subsequent necrosis of surrounding tissues. In this article, we report an excellent outcome in our experience of limb salvage using the glycerol-preserved skin allograft for temporary wound coverage in the treatment of necrotising fasciitis. They are useful during the transitional time period between surgical debridement and skin grafting, for temporary wound coverage and pain relief. n
J O U R N A L O F WO U N D C A R E C A S E S S U P P L E M E N T V O L 2 3 , N O 2 , 2 0 1 4
© MA Healthcare Ltd. Downloaded from magonlinelibrary.com by 137.189.171.235 on October 5, 2016. Use for licensed purposes only. No other uses without permission. All rights reserved.
