2 Modern wound care for the poor: a randomized clinical trial comparing the vacuum system with conventional saline-soaked gauze dressings
3 BackgroundA clinical randomized trial was performed to determine whether a simple homemade wound vacuum-dressing system (HM-VAC) is a feasible alternative to the use of conventional saline-soaked gauze dressings (WET) for the treatment of complex wounds in a resource-poor hospital.
4 Methods49 patients were analyzed to compare the HM-VAC and the WET dressings. The HM-VAC was assembled with tools available in most operating room worldwide. The primary outcome measure was the time of complete wound healing. Additionally, the costs of both methods were calculated. Each patient had a single wound at the time at which he/she was included in the study. Patients entered the study when the decision to perform surgical debridement was made. Patients were randomized by a sealed envelope to receive treatment with either WET dressings or the HM-VAC technique. Patients with associated bony injuries or vascular ulcers were excluded from the study.
5 ResultsThe time required to achieve complete healing was 16 days in the HM-VAC group compared with 25 days in the WET group (P = .013). The HM-VAC costs US $360 per case, and the WET technique costs US $271 per case (P = .008
6 The VAC has been shown to enhance granulation formation and wound closure in comparison with other dressing techniques for acute and chronic wounds .and The positive impact on wound healing and the improved patient comfort afforded by the VAC have resulted in a wide increase in the popularity of this new technique in the Western world.
7 The VAC treatment would also be ideal for the management of severe wounds often encountered by doctors in countries that, because of their low socioeconomic status, have been defined by the United Nations as less- and least-developed countries (LDCs). However, commercial devices are either not available or prohibitively expensive for most patients in resource-poor regions. In these countries, most surgeons apply the conventional daily dressings of saline .9%-soaked gauzes (WET) and perform frequent surgical debridements to enhance wound healing
8 Even though the VAC is claimed to be a cost-effective treatment and the commercially available devices are too expensive for most hospitals in LDCs. In contrast, a “homemade” VAC (HM-VAC) can be assembled with materials that are cheap and easily available. The HM-VAC would be of great value for treating severe wounds in underdeveloped parts of the world
9 Dressing TechniquesHM-VAC dressingAfter radical surgical debridement, the sterile sponge of a single—use povidone-iodine hand scrub brush (E-Z Scrub 205; Becton Dickinson, Franklin Lakes, NJ) (Fig. 1) was trimmed and shaped to make a close contact with all surfaces of the wound (Fig. 2). The number of sponges used for each dressing was recorded and controlled at the next dressing change to avoid the retention of sponge pieces. Multiple small holes were cut into a sterile suction drainage tube (5 mm × 3.1 m, Argyle; Kendall, Chicopee, MA), which was placed on top of the sponge (Fig. 3). All holes of the suction drainage tube were in close contact with the sponge. The wound was covered with an adhesive drape (OpSite; Smith & Nephew, Inc, Largo, FL), which extended at least 2 cm beyond the wound margins onto intact and dry skin.
10 The drape was carefully wrapped around the suction tube to avoid pressure leakage and attached to the skin with a stitch (silk 1.0) (Fig. 4). The tube was then connected to the fluid bottle of a conventional chest tube suction device with a continuous negative pressure of 100 mm Hg. The amount of fluid or blood drained by the HM-VAC was monitored every 30 minutes for the first 6 hours after the application of a new dressing or a dressing change. In case of hemorrhage (200 mL per 30 minutes), the surgeon on call was informed. From 6 hours onward, the checkups were performed every 2 hours. Dressings were changed every 4 days under regional or general anesthesia
15 WET dressingThe WET technique consisted of daily bedside changes of gauze dressings soaked with sterile .9% saline. In the event of persistent infection or necrotic wound areas, a surgical debridement was performed under regional or general anesthesia in the operating room.
16 Comments:The results of the present randomized clinical study suggest that wound management with the HM-VAC is feasible in a LDC inpatient facility with excellent short-term results. The greatest benefit of the HM-VAC is the 41% reduction in the median wound-healing time in contrast to the WET dressing technique (Table 3). The materials required to assemble the HM-VAC are readily available, and the technique can be rapidly adopted by local surgeons
17 Previous experimental studies have shown that shear forces exerted by vacuum on the wound bed lead to tissue proliferation with an increased rate of mitosis and overexpression of tissue growth factors.5 The phenomenon of cellular proliferation under shear forces has been made use of in tissue expansion in plastic surgery.19 In our opinion, the larger number of primary wound closures in the vacuum group might be related to enhanced tissue proliferation and wound contracture.
18 Despite a significantly reduced duration of hospital stay in the HM-VAC group, the total average cost per patient was clearly higher with this treatment. Significantly higher operative costs and higher costs for dressing material were observed with the HM-VAC treatment compared with the WET management. Nevertheless, costs remained within a range that is probably affordable for most patients or charitable organizations in underdeveloped parts of the world
19 The VAC has revolutionized the wound-management approach for difficult-to-treat wounds in the Western world. The commercial VAC system is one of many examples that show how patients in LDCs remain underprivileged not only economically but also concerning the quality of medical care. The application of the HM-VAC in the developing world warrants excellent wound care and acceptable costs. However, long-term clinical results with this new device are necessary, even though this may not always be easy in countries in which patients depart for their villages once they are cured.