Experience With Wound Care in a Case With ECMO Cannulation Using a Self-Made Vacuum-Sealing Drainage Device With Constant-Temperature Flushing

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Extracorporeal membrane oxygenation (ECMO) is an important treatment approach for refractory, severe respiratory failure and/or circulatory failure.^1-2 Dilated cardiomyopathy (DCM) is a type of chronic myocardial disease characterized by enlargement of the left ventricle or bilateral ventricles and decline of myocardial contractile function. It can be complicated by secondary heart failure and sudden cardiac death, which are the main causes of death in this group of patients.³ ECMO cannulation is one of the most direct and effective therapeutic approaches currently clinically available for patients with heart failure. It works by means of establishing ex-vivo peripheral arteries, through which oxygenated blood can be pumped to reduce burden to the heart and lungs.⁴ The complexity of such a technique commonly leads to various complications, such as hemorrhage, embolization, infection, acute kidney injury, and brain injury. Infections are more likely to present as local infection to the wound, lung, urinary system, and site of ECMO cannulation.⁵ In recent years, negative pressure wound therapy (NPWT) and moist healing techniques have been extensively applied in the clinical treatment of wounds caused by trauma, infection, and soft-tissue defects, including difficult-to-heal wounds,^6-8 with satisfactory clinical outcomes. In the present study, the authors report the case of a patient with DCM who underwent ECMO cannulation in a tertiary hospital of Hangzhou, Zhejiang Province, China. After ostomy and wound clinic specialty consultation, the wound at the site of cannulation after weaning from ECMO was processed for anti-infective treatment using a self-made NPWT device with constant-temperature flushing. The device was used to decrease the economic burden and increase comfort for this patient, and the wound eventually healed.

A 64-year-old male had a 15-year history of DCM and 8-day loss of consciousness. Treatment in a local hospital was ineffective, and the patient was referred to the intensive care unit of the authors’ hospital. The admission diagnosis was DCM, cardiogenic shock after cardiopulmonary resuscitation (CPR) for cardiac arrest and respiratory arrest, multiple organ dysfunction syndrome, ventricular fibrillation after electrical defibrillation, and hypoalbuminemia. After being referred to the authors’ department, the patient was in a state of significant shock. Large-dose vasoactive drugs (norepinephrine and epinephrine) were administered, but the patient’s hemodynamics remained unstable and the shock was not corrected. These were the indications for ECMO. The patient’s guardian signed informed consent and this work passed the review of the Zhejiang Xiaoshan Hospital Ethics Committee (2024 No. 011).

With consent from the patient’s family, the cardiac surgeon performed a conventional puncture technique. The right groin was exposed and an oblique incision was created 1 cm below the ligament. The femoral artery and femoral vein were cannulated (venoarterial  modality), and continuous renal replacement therapy with continuous venovenous hemodiafiltration was performed. On day 14 after admission, the patient was weaned from ECMO. A wound measuring 1.5 cm × 1.5 cm × 3.2 cm was observed, with a small amount of necrotic tissue and a large amount of exudate visible inside. After cleaning, granulation tissue with edema was visible inside the incision. The wound secretion was taken for bacteriological culture, resulting in 100% Candida tropicalis. Blood culture was negative. The patient’s pain was evaluated using the Numeric Rating Scale (NRS). In the resting state, the patient reported mild pain in the wound, and the NRS pain score was 0 to 1 points. Upon turn-over activities and dressing changes, the patient reported increasing pain, with an NRS pain score of 7 to 8 points. Sufentanil was administrated, and the pain was effectively controlled (NRS pain score, 0-1 points). Because of the complexity of the wound, a consultation with a wound specialist nurse and the Department of Rehabilitation Medicine was required 2 days after weaning, and a care program was formulated. After 48 days of integrated care, the incisional infection was well controlled and the wound healed. The patient was stable and was transferred to a general ward.

Wound care

Wound assessment. The incision site, size and depth, sneak path, exudate (color, property, and volume), base tissue, and peripheral tissue were assessed. On day 14 after admission, the patient was weaned from ECMO. A wound measuring 1.5 cm × 1.5 cm × 3.2 cm was identified at the site of cannulation in the right groin. No sinus tract or sneak path was observed. Inside the wound there was a small amount of necrotic tissue and a large amount of exudate, which was clear, yellow, and had a low viscosity but no malodorous smell. After cleaning, dark red granulation tissue with edema was visible inside the incision, and the base yellow vessels and peripheral punctate cutaneous defects were exposed.

Local incision care. Inflammatory period. This period is the first stage of wound healing, and its main function is to remove the source of infection and necrotic tissue and guide the repair process. There was a small amount of yellow necrotic tissue attached to the lateral wall and base of the initial wound, and a large amount of yellow exudate was observed. Wound debridement was first performed in a surgical fashion, then mechanical and autolytic debridement were carried out. Dressing change was performed once daily.

(1) Surgical debridement: In this patient, the wound and peripheral skin were disinfected using povidone-iodine (0.5% efficient iodine), cleaned with normal saline, and patted dry with gauze. The infected granulation tissue was removed via conventional surgical debridement technique.

(2) Mechanical debridement: Due to the depth of the wound, necrotic tissue was cleared via flushing with normal saline through a No. 12 needle, which prevented attachment of the necrotic tissue to the base.

(3) Autolytic debridement: As moist healing theory continues to be promoted and applied, a variety of new wound dressings have emerged. In this patient, the wound was infected and small. Therefore, the wound surface was treated with mesalt to generate a hypertonic environment, which effectively absorbed wound exudate to create a moist microenvironment and promoted the dissolution of the infected necrotic tissue in the sodium chloride solution to help drainage. The treatment reduced edema and promoted growth of granulation tissue, accelerating local wound healing.

Value-added period. This period is the second stage of wound healing, and its main function is to reconstruct the tissue structure and repair the damaged matrix. Two days after wound debridement, necrotic tissue was reduced, but the amount of exudate remained large and the granulation tissue still suffered from edema. The wound-care program was adjusted, and a self-made NPWT device with constant-temperature flushing was applied. Dressing changes were performed twice per week. The fluid from drains (60 mL/d)—which was clear, odorless, and pale red in color—was collected. After 5 days, a 1.3 cm × 1.3 cm × 3.0 cm wound without blood leakage or exudate was observed. The wound became smaller with a ruddy bed, and the basal aspect demonstrated growth of granulation tissue. After consultation with the wound specialist nurse, NPWT was stopped. The wound was packed with petrolatum impregnated gauze to avoid adhesion and keep the inner environment moist. The wound was covered with gauze, which was immobilized with tape. Dressing change was performed once every 2 days based on wound exudate.

Remodeling period. This period is the final stage of wound healing, which is characterized by complete or near-complete tissue repair and functional recovery. On day 18 after weaning, the base red granulation tissue grew well, and there was no blood leakage or exudate. Phase II suture was performed to shorten the wound healing time. Phase II suture is commonly used in cases of wound infection, tissue necrosis, poor wound edges, and inflammation in order to facilitate healing and reduce the occurrence of complications.The wound was kept clean and dry, and attention was paid to the presence of blood leakage or exudate. On day 24 after weaning, the stitches were removed and the wound had healed well.

Fabrication and connection of a self-made NPWT device with constant-temperature flushing. Sterile gloving was required during the entire process (Figure).⁹ A sterile sputum-suction catheter with an appropriate diameter for the wound size was selected as the suction tube, while a disposable nutrient-supply line (Baitong) free from the head was used as the flushing tube. Multiple lateral holes of 1 mm to 2 mm were cut in the heads of the 2 tubes, based on the wound depth. The heads were then coated with mesalt, and the wound base was covered with Urgo silver dressing to avoid adhesion. The tube head was inserted to the wound, with the redundant mesalt trimmed off using sterile scissors. The outer layer of the wound was covered with gauze and sealed using transparent sterile dressings. The tail end of the suction tube was connected to a disposable flushing tube, and a wall-mounted NPWT device was connected to keep the sealed incision in a state of negative pressure. The negative pressure was set at -80 mmHg, because appropriate negative pressure is necessary for wound healing.¹⁰ The wound was flushed continuously with normal saline through the flushing tube, with the matched pump working at 37℃⁹ with a pump speed of 120 mL/h. The amount of negative pressure on the wound, the state of the suction tube, and air leaks were closely monitored during the entire process. In the absence of negative pressure, the tightness of the applications was immediately checked and, if necessary, an additional transparent sterile application was used. When occlusion of the suction tube occurred due to secretions or necrotic tissue, the tube was squeezed manually. If manual manipulation was unsuccessful, a new tube was used. Negative pressure was immediately discontinued and the incision checked when a large amount of bloody fluid was suctioned. Attention was also paid to the flushing tube’s patency and the amount of fluid, and whether it was compressed, twisted, or folded.

Nutrition management. Good nutritional status is critical to wound healing.  A general assessment to help inform early supplementation is conducive to improving not only the nutritional state of patients, but also their prognosis.¹¹ According to the European guidelines,¹² early enteral nutrition is recommended in patients receiving ECMO. For those whose shock has not yet been controlled and whose hemodynamics and tissue perfusion are not yet stabilized, delayed enteral nutrition is recommended. However, if shock is controlled by fluid infusion and use of vasopressors/positive inotropic drugs, low-dose enteral nutrition should be started early. For patients in critical condition, target feeding volume corresponding to a target protein yield of 1.2 g·kg^-1·d^-1 to 2.0 g·kg^-1·d^-1 is set to 25 kcal·kg^-1·d^-1 to 30 kcal·kg^-1·d^-1.¹³ In the present study, the patient was diagnosed with hypoalbuminemia on admission. On day 3 after admission, the patient’s circulation improved. The dose of vasoactive drugs was reduced, and Enteral Nutritional Suspension (TPF) nasogastric fluid was delivered at 20 mL/h. During nasogastric feeding, the rate of delivery was gradually increased to 55 mL/h based on the patient tolerance to enteral nutrition, whereas the level of serum albumin was persistently low. In order to increase protein intake and improve patient nutrition, on day 22 after admission, Enteral Nutritional Suspension was replaced with Enteral Nutritional Emulsion (TP-HE) nasogastric fluid (55 mL/h).

During nasogastric feeding, the nasogastric tube should be well fixed to prevent pressure injury and tube slippage. A warming device is recommended to keep the nutrient fluid at an appropriate temperature, usually 37℃ to 40℃. The nasogastric tube should be evacuated every 4 hours to prevent retention; it should also be flushed with warm water before and after infusion to prevent occlusion. The rate of delivery of nasogastric feeding should be controlled, and an initiation rate of 10 mL/h to 20 mL/h is suggested for patients in critical condition. Nasogastric fluid should be selected based on patient medical condition. Laboratory indices—such as electrolytes, blood lipid levels, liver and kidney function, and albumin—should be checked regularly. Attention should be paid to the patient’s outcomes at 24 hours. Complications of enteral nutrition should be prevented, and timely management is required upon their occurrence.

Pain care. Pain as the “fifth vital sign” has become increasingly appreciated by health care workers. The patient in this case study had pain during movement, such as turning in bed facilitated by a nurse. He refused further movement and complained of intolerable pain in the wound during movement. As previously noted, his NRS pain score was 7 to 8 points. Modest analgesia was obtained with sufentanil (6-10 μg^-1 ml^-1 h), and the NRS pain score was then < 3 points. The dose of sufentanil was gradually reduced as the wound healed. Thereafter, the patient reported no pain during movement, including turning in bed.

Psychological care. Psychological factors such as anxiety, depression, and tension can lead to impaired immunity due to their effect on the neuroendocrine system, indirectly influencing wound healing. Therefore, care measures should be individualized in the context of the patient’s family, education level, and disease characteristics. Bedside assessment noted that the patient discussed here felt depressed and had substantial concerns about his illness. The treating physician talked with the patient about the current disease severity and treatment plans, and shared successful cases of similar cases. This built trust and enhanced treatment adherence. Patience and enthusiasm on the part of the health care workers was also reinforced, which helped avoid disputes with the patient and relieved his psychological burden. Because of the COVID-19 epidemic, visitation was not allowed in the intensive care unit; as such, the patient communicated with his family by videos. This improved the patient’s mood and helped him more actively cooperate with treatment.

While the self-made NPWT device showed promising results in promoting wound healing and reducing infection, it is important to note that this article only focuses on the experience of 1 patient and may not be generalized to other patients.

Individualized care programs are required in patients with a refractory wound. During care, appropriate dressings should be selected based on wound condition. The self-made NPWT device with constant-temperature flushing used in this case study provided an environment with appropriate temperature and humidity, which was beneficial for wound healing, increased comfort, and decreased pain in this patient. Early nutritional support facilitated patient well-being and provided the nutrient basis for wound healing. Appropriate care of patient pain and emotional health helped build trust between the patient and medical workers, make the patient feel more confident about himself, and promoted patient recovery.

Authors: Qiaoyun Sun, BSN¹; Suyan Li, BSN¹; Hongyan Xu, BSN²; Xiaoxaio Guan, BSN³; and Feifei Ye, BSN³

Affiliations: ¹Department of Emergency Intensive Care Unit, Zhejiang Xiaoshan Hospital, Zhejiang, China; ²Nursing Department, Zhejiang Xiaoshan Hospital, Zhejiang, China; ³Department of Critical Care Medicine, Zhejiang Hospital, Zhejiang, China

Correspondence: Feifei Ye, Department of Critical Care Medicine, Zhejiang Hospital, Lingyin Road No.12, Hangzhou, Zhejiang 310013, China; 821900464@qq.com.

Availability of data and materials: Data sharing is not applicable to this article, as this study is a case report.

Disclosure: The authors declare that they have no competing interests.

Author Contributions: (1) Concept or design: S.Q.Y. (2) Case collection: Y.F.F. (3) Case study or explanation: L.S.Y. (4) Manuscript drafting: Y.F.F and X.H.Y. (5) Critical revision of important knowledge content: G.X.X. and Y.F.F. All authors had full access to the data, contributed to the study, approved the final version for publication, and were responsible for its accuracy and completeness.

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