The use of Activon Tulle dressing on extensive cellulitis of the right leg

A seventy six year old lady was admitted on 3rd September 2008 with extensive cellulitis of the right leg. On examination her limb was found to be hot and erthematous. Her foot was sloughy, blistered and oedematous. There was concern that it could be necrotising fasciitis. In view of this she was seen by the surgical team who confirmed it to be a soft tissue infection.

The lady had a past medical history of rheumatoid arthritis. She had suffered a recent fractured neck of femur. She had been visiting her daughter a few days prior to admission when she fell over injuring her ankle.

On admission to hospital the right lateral border and dorsum of the foot appeared grey. The skin was very thin and fragile. When the patient was seen by the consultant he advised that we observe for twenty four hours. The wound was painful and had an odour.

Treatment aims:

• To aid autolytic debridement
• Reduce the bacterial burden
• To deodorise the wound
• To reduce inflammation
• To provide moist wound healing
• To reduce level of pain

Action Plan

• Activon honey tulle was applied to aid autolytic debridement.
• An Alpha Relief mattress was in place.
• Prafo boots were ordered.
• She was referred to the dietitian and commenced on a high energy diet as well as two Fortisip drinks per day.
• She was commenced on IV antibiotics.
• Her analgesia was increased.
• Blood cultures were obtained.
• The wound was swabbed and a complete MRSA screen was obtained.

8th September 2008

Her leg was very painful still when mobilising.

She was catheterised and reviewed by the physiotherapist. She was advised to use a zimmer frame.

The wound was now covered in yellow slough. It was less swollen and the odour was diminished. Larvae therapy was applied.

Larvae therapy will speed up debridement and we can then start to promote wound healing. The maggots produce an enzyme that breaks down the slough quicker than could be achieved using other dressings. At the same time the maggots ingest and kill any bacteria.

The patient felt uneasy about having the maggot therapy but was keen to try so that she could get on her feet again.

The initial application of larvae was removed and showed a good response but a second application was necessary. At this point the wound was photographed. This was shown to the patient.

After seeing the improvement the patient was keen for a second application.

22nd September 2008

The second application of maggots has deeply debrided the wound exposing the tendons.

The wound was reviewed by the Plastic Surgeons who felt that the wound was not yet ready for a graft.

Activon honey was applied to the wound to promote granulation and to help to keep the bacterial burden down, thus maintaining the healing process.

The Activon honey tulle when applied to the wound caused slight pain.

It was explained to the patient that this pain was due to the acidity of the honey.There is evidence that honey stimulates nocioceptors - nerve endings that create pain sensation in response to heat, acidity and some organic chemicals.

This stinging pain did not last long.

6th October 2008

Activon honey osmotic effects have desloughed and helped to debride this wound.

There is a marked reduction in odour. Activon honey tulle has protected the wound bed and provided a moist healing environment and as you can see has promoted granulation and faster wound healing.

The wound bed had granulation which was healthy and the granulation tissue was near the top of the wound. The wound was now ready to receive a fine skin graft. The patient was transferred to the care of the Plastic Surgeons.

In conclusion it is felt that the use of Activon honey tulle helped to debride, reducing the slough biofilm and overall bioburden .

The patients morale improved greatly and she was keen to start mobilising again as she had been frightened to walk due to the condition of her foot. She was transferred to the care of the Plastic Surgeons for a small graft and is now back to normal.

References:

Maran, P.C. (1999) The Role of Honey in the Management ofWounds,Joumey ofWound Care, 8 pp.415- 8. Lusky, P.E., Coombes,A. and Wilkinson, S.M., Haney a potent agent for wound healing.