Biosurgery (Maggot Debridement Therapy) an … Poster 11 Turner...Free Range MDT. Introduction....

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Free Range MDT Introduction References The first step in chronic wound management is removal of devitalized necrotic tissue. There are numerous methods to accomplish debridement including surgical, sharps, enzymatic, ultrasonic, mechanical and biologic. Currently, no research exists definitively showing one method as better than the other however, there are advantages and disadvantages to each. Maggot debridement therapy(MDT) is an underutilized biologic method of debridement. It has proven to be a highly selective and effective. The digestive enzymes of the larvae liquefies the necrotic tissue only, leaving healthy tissue intact. The debridement benefits of maggots in wound care have been documented as far back as 1557 during the Italian War. William Baer, M.D. published the first clinical study using MDT in 1931 In the mid 1940’s MDT fell out of favor due to the rise in antibiotic use. Antibiotic over prescribing in the 1980's resulted in antibiotic resistant bacterial infections and an increase in necrotic wounds. A resurgence in MDT has been noted. Despite the approval of the U.S. Food & Drug Administration of MDT as a medical device in 2004, it is not widely used. It is a cost effective, painless and easy to apply. Since it is considered a medical device, MDT can be applied by the wound care specialist. Currently, two methods for application are available - “free range” and “containment” (Turner, 2017; Werdin, Tennenhaus, & Rennekampff, 2009; Baer, 2011). Free range maggots are applied to the wound individually utilizing 5-8 larvae per sq. cm. It is possible for the free range larvae to leave the wound looking for a dark dry spot to pupate. Free range MDT must be individually removed from the wound. By Alexsey Nosenko / Maggot Medicine - Лечение ран личинками. Диабетическая стопа / Maggot debritment therapy. Diabetic foot, CC BY 3.0, https://commons.wikimedia.org/w/index.php?curid=46390555 Containment MDT is easier to apply and remove. The correct number of larvae for the size wound are contained in a porous polyester bag which is heat sealed. This method takes the “yuck” factor out of using maggot therapy. Baer, W. S. (2011, April). The classic: The treatment of chronic osteomyelitis with the maggot (larva of the blow fly). 1931. Clinical Orthopeadic And Related Research, 469(4), 920-940. http://dx.doi.org/10.1007/s11999-010-1416-3 Turner, J. (2017, July). Debriding chronic wounds with larval therapy: The new answer for biosurgery in the outpatient wound clinic? Today's Wound Clinic, 20-24. Werdin, F., Tennenhaus, M., & Rennekampff, H. (2009, June 4). Evidence-based management strategies for treatment of chronic wounds. Eplasty, 9(9), 169-179. Retrieved from Https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2691645/pdf/eplasty09e19.pdf Armstrong, D.G., Salas P., Short, B. et al. (2005, March) Maggot therapy in “lower- extremity hospice” wound care: Fewer amputations and more antibiotic-free days. Journal of American Podiatry Medical Association, 95 (3) 254-7. Mudge, E., Price, P., Walkely, N., Harding, K.G. (2014). A randomized controlled trial of larval therapy for the debridement of leg ulcers: Results of a multicenter, randomized, controlled, open observer blind, parallel group study. Wound Repair and Regeneration, 22(1), 43-51. Wolf, H. Hansson, C. (2003). Larval therapy – An effective method of ulcer debridement. Clinical and Experimental Dermatology. 28(2), 134-137. The Green Blow Fly Containment MDT Case 1 96 year-old female who is otherwise healthy was living with a necrotic non healing wound post-radiation for a squamous cell carcinoma of the left anterior lower leg. The wound was being treated at another facility and had been present for 11 months. Previously treated with hyperbaric oxygen therapy, Dakin’s solution and Manuka honey. Presented to the outpatient clinic with a malodorous highly exudating wound with 100% slough. Three applications of MDT were used prior to NPWT to increase granulation tissue. A split thickness skin graft was applied. Lucilia (Paenicia) sericata, the green blow fly larvae are the most common strain of fly used for maggot debridement therapy. Grown in an aseptic laboratory, only the larvae are harvested for use in wound therapy. The toothless larvae uses its hook shaped mandible to help propel across the wound bed as it looks for food. The microscopic spines covering its body brush against the wound bed loosening the debris. Proteolytic, digestive enzymes secreted by the larvae turn the necrotic tissue into a liquid and is then ingested and used as food. Suitable Wound Types Conclusion Healthcare in the United States is constantly changing with new technology emerging daily. Budget restrictions force the wound care specialist to think outside of the box when managing chronic wounds. Debridement of non-viable tissue is the first step in wound bed preparation. Surgical or sharp debridement is the fastest way to debride a wound however, healthy tissue is at risk for damage. Despite using anesthetics, surgical or sharp debridement can be painful and other methods are not as effective and are very slow. Elderly and immunocompromised are at a higher risk of developing chronic non- healing wounds, which often progress to limb amputation. As in the patients presented, Maggot Debridement Therapy is an effective, painless, and cost effective alternative to surgical debridement in all patients. Additionally, MDT is selective debridement with no viable healthy tissue disturbed. Insurance providers and hospitals can see cost savings by reducing surgical costs, readmission rates and faster healing time. Maggot debridement therapy does not require a physician to apply (Turner, 2017). https://digitalinsectcollection.wikispaces.com/Commo n+Green+Bottle+Fly Case 2 75-year-old male with history of renal transplant presented to ED with altered mental status and pain in his right leg two days after pulling weeds from around the edge of his lake. Diagnosed with Aeromonas hydrophila by direct water inoculation, the wound was surgically debrided while in the hospital. Post discharge he presented to the outpatient clinic for continued wound care, with the goal of preserving enough tissue to do a below the knee amputation. The wound measured 33.5cm x 22cm x 0.5cm. The patient was in an extreme amount of pain and was not a good candidate for repeated surgical debridement. Using a collagenase would have been cost prohibitive and sharp debridement at bedside proved too painful. The initial goal was to develop enough granulation tissue to do a below the knee amputation. After 2 applications of MDT the tissue was clean and 8 weeks later a split thickness skin graft was done. Use of MDT was essential in preventing an amputation in this elderly patient. . Biosurgery (Maggot Debridement Therapy) an Underutilized Alternative to Surgical Debridement in Chronic Wounds Judith H. Turner, DNP, RN, APRN, CWCN, COCN-AP Wound and Hyperbaric Medicine; Piedmont Atlanta Hospital – Atlanta, Georgia The enzymes can not dissolve healthy tissue which makes them ideal for debriding necrotic tissue. The larvae will feed for 4-5 days are ready to leave the wound to begin the next phase of the life cycle. Blow fly life cycle (http://www.medicaledu.com/maggots.htm) 4/3/17 2 days prior to skin graft 11/22/16 2 nd clinic visit (wound present > 1 year ) 12/8/16 1 st application of MDT 12/12/14 Day 4 Removal of MDT. 2 nd application applied 5/3/2017 Week 4 post STSG; 90% closed 1/19/17 3 rd Application of MDT 5/23/17 99 % closure 1 year post initial injury 7/21/16 Prior to 1 st MDT 8/4/16 2 nd application of MDT 9/26/2017 Ready for STSG (applied 10/5/2016) 12/12/16 5 months after initial MDT 8/8/16Removal of # 2 MDT Pyoderma ganrenosum Arterial ulcers Burns Malignant wounds Gangrene Hematoma Diabetic foot ulcers Pressure ulcers Calciphylaxis Dehisced surgical wounds Venous stasis ulcers Traumatic wounds Necrotizing fasciitis http://mickhartley.typepad.com/.a/ 6a00d83451ebab69e201a73e02 6945970d-550wi Colored Electron Micrograph of the larvae head. http://biomonde.com/images/US_Linked_Docs/BM026_US_02_0316.pdf Acknowledgements To my wonderful husband – Hugh Turner thank you for your support! Thank you Piedmont Wound and Hyperbaric Medicine!

Transcript of Biosurgery (Maggot Debridement Therapy) an … Poster 11 Turner...Free Range MDT. Introduction....

Page 1: Biosurgery (Maggot Debridement Therapy) an … Poster 11 Turner...Free Range MDT. Introduction. References. The first step in chronic wound management is removal of devitalized necrotic

Free Range MDT

Introduction

References

The first step in chronic wound management is removal of devitalized necrotic tissue. There are numerous methods to accomplish debridement including surgical, sharps, enzymatic, ultrasonic, mechanical and biologic. Currently, no research exists definitively showing one method as better than the other however, there are advantages and disadvantages to each. Maggot debridement therapy(MDT) is an underutilized biologic method of debridement. It has proven to be a highly selective and effective. The digestive enzymes of the larvae liquefies the necrotic tissue only, leaving healthy tissue intact. The debridement benefits of maggots in wound care have been documented as far back as 1557 during the Italian War. William Baer, M.D. published the first clinical study using MDT in 1931 In the mid 1940’s MDT fell out of favor due to the rise in antibiotic use. Antibiotic over prescribing in the 1980's resulted in antibiotic resistant bacterial infections and an increase in necrotic wounds. A resurgence in MDT has been noted. Despite the approval of the U.S. Food & Drug Administration of MDT as a medical device in 2004, it is not widely used. It is a cost effective, painless and easy to apply. Since it is considered a medical device, MDT can be applied by the wound care specialist. Currently, two methods for application are available - “free range” and “containment” (Turner, 2017; Werdin, Tennenhaus, & Rennekampff, 2009; Baer, 2011).

Free range maggots are applied to the wound individually utilizing 5-8 larvae per sq. cm. It is possible for the free range larvae to leave the wound looking for a dark dry spot to pupate. Free range MDT must be individually removed from the wound.

By Alexsey Nosenko / Maggot Medicine - Лечение ран личинками. Диабетическая стопа / Maggot debritmenttherapy. Diabetic foot, CC BY 3.0, https://commons.wikimedia.org/w/index.php?curid=46390555

Containment MDT is easier to apply and remove. The correct number of larvae for the size wound are contained in a porous polyester bag which is heat sealed. This method takes the “yuck” factor out of using maggot therapy.

Baer, W. S. (2011, April). The classic: The treatment of chronic osteomyelitis with the maggot (larva of the blow fly). 1931. Clinical Orthopeadic And Related Research, 469(4), 920-940. http://dx.doi.org/10.1007/s11999-010-1416-3

Turner, J. (2017, July). Debriding chronic wounds with larval therapy: The new answer for biosurgery in the outpatient wound clinic? Today's Wound Clinic, 20-24.

Werdin, F., Tennenhaus, M., & Rennekampff, H. (2009, June 4). Evidence-based management strategies for treatment of chronic wounds. Eplasty, 9(9), 169-179. Retrieved from Https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2691645/pdf/eplasty09e19.pdf

Armstrong, D.G., Salas P., Short, B. et al. (2005, March) Maggot therapy in “lower-extremity hospice” wound care: Fewer amputations and more antibiotic-free days. Journal of American Podiatry Medical Association, 95 (3) 254-7.

Mudge, E., Price, P., Walkely, N., Harding, K.G. (2014). A randomized controlled trial of larval therapy for the debridement of leg ulcers: Results of a multicenter, randomized, controlled, open observer blind, parallel group study. Wound Repair and Regeneration, 22(1), 43-51.

Wolf, H. Hansson, C. (2003). Larval therapy – An effective method of ulcer debridement. Clinical and Experimental Dermatology. 28(2), 134-137.

The Green Blow Fly

Containment MDT

Case 196 year-old female who is otherwise healthy was living with a necrotic non healing wound post-radiation for a squamous cell carcinoma of the left anterior lower leg. The wound was being treated at another facility and had been present for 11 months. Previously treated with hyperbaric oxygen therapy, Dakin’s solution and Manuka honey. Presented to the outpatient clinic with a malodorous highly exudating wound with 100% slough. Three applications of MDT were used prior to NPWT to increase granulation tissue. A split thickness skin graft was applied.

Lucilia (Paenicia) sericata, the green blow fly larvae are the most common strain of fly used for maggot debridement therapy. Grown in an aseptic laboratory, only the larvae are harvested for use in wound therapy. The toothless larvae uses its hook shaped mandible to help propel across the wound bed as it looks for food. The microscopic spines covering its body brush against the wound bed loosening the debris. Proteolytic, digestive enzymes secreted by the larvae turn the necrotic tissue into a liquid and is then ingested and used as food.

Suitable Wound Types

ConclusionHealthcare in the United States is constantly changing with new technology emerging daily. Budget restrictions force the wound care specialist to think outside of the box when managing chronic wounds. Debridement of non-viable tissue is the first step in wound bed preparation. Surgical or sharp debridement is the fastest way to debride a wound however, healthy tissue is at risk for damage. Despite using anesthetics, surgical or sharp debridement can be painful and other methods are not as effective and are very slow. Elderly and immunocompromised are at a higher risk of developing chronic non-healing wounds, which often progress to limb amputation. As in the patients presented, Maggot Debridement Therapy is an effective, painless, and cost effective alternative to surgical debridement in all patients. Additionally, MDT is selective debridement with no viable healthy tissue disturbed. Insurance providers and hospitals can see cost savings by reducing surgical costs, readmission rates and faster healing time. Maggot debridement therapy does not require a physician to apply (Turner, 2017).

https://digitalinsectcollection.wikispaces.com/Common+Green+Bottle+Fly

Case 275-year-old male with history of renal transplant presented to ED with altered mental status and pain in his right leg two days after pulling weeds from around the edge of his lake. Diagnosed with Aeromonas hydrophilaby direct water inoculation, the wound was surgically debrided while in the hospital. Post discharge he presented to the outpatient clinic for continued wound care, with the goal of preserving enough tissue to do a below the knee amputation. The wound measured 33.5cm x 22cm x 0.5cm. The patient was in an extreme amount of pain and was not a good candidate for repeated surgical debridement. Using a collagenase would have been cost prohibitive and sharp debridement at bedside proved too painful. The initial goal was to develop enough granulation tissue to do a below the knee amputation. After 2 applications of MDT the tissue was clean and 8 weeks later a split thickness skin graft was done. Use of MDT was essential in preventing an amputation in this elderly patient. .

Biosurgery (Maggot Debridement Therapy) an Underutilized Alternative to Surgical Debridement in Chronic Wounds

Judith H. Turner, DNP, RN, APRN, CWCN, COCN-APWound and Hyperbaric Medicine; Piedmont Atlanta Hospital – Atlanta, Georgia

The enzymes can not dissolve healthy tissue which makes them ideal for debriding necrotic tissue. The larvae will feed for 4-5 days are ready to leave the wound to begin the next phase of the life cycle.

Blow fly life cycle (http://www.medicaledu.com/maggots.htm)

4/3/17 2 days prior to skin graft

11/22/16 2nd clinic visit (wound present > 1 year )

12/8/16 1st application of MDT

12/12/14 Day 4 Removal of MDT. 2nd application applied

5/3/2017 Week 4 post STSG; 90% closed

1/19/17 3rd Application of MDT

5/23/17 99 % closure 1 year post initial injury

7/21/16 Prior to 1st

MDT 8/4/16 2nd application of MDT

9/26/2017 Ready for STSG (applied 10/5/2016)

12/12/16 5 months after initial MDT

8/8/16Removal of # 2 MDT

Pyoderma ganrenosum Arterial ulcers Burns

Malignant wounds Gangrene Hematoma

Diabetic foot ulcers Pressure ulcers Calciphylaxis

Dehisced surgical wounds Venous stasis ulcers

Traumatic wounds Necrotizing fasciitis

http://mickhartley.typepad.com/.a/6a00d83451ebab69e201a73e026945970d-550wi

Colored Electron Micrograph of the larvae head.

http://biomonde.com/images/US_Linked_Docs/BM026_US_02_0316.pdf

AcknowledgementsTo my wonderful husband – Hugh Turner thank you for your support!Thank you Piedmont Wound and Hyperbaric Medicine!