The Aplication Of Vacuum Sealing Drainage In Anticoagulated Patients With Chronic Wounds

Background and Objectives:chronic wounds were defined as wounds which could not recover normal morphological structure and functional integrity in a timely fashion(>1 months).In recent years,the incidence of chronic wounds is still high.Among these patients with chronic wounds,some of them always require anticoagulation due to restricted mobility or cardiac valve replacement.It is well known that anticoagulant drugs have a good effect in preventing venous thromboembolism,but anticoagulants may equally increase the risk of wound bleeding.Therefore,how to safely and effectively treat these chronic wounds is still an urgent clinical problem to be solved.Although there are kinds of new methods to treat chronic wound,no one can cure all patients.Nowadays,vacuum sealing drainage(VSD)is used as a standardized treatment for patients with chronic wounds,which has shown the advantages of promoting wound healing.However,whether VSD could be safe in anticoagulated patients is controversial.Therefore,we wonder if VSD could be safely used in anticoagulated patients,and need to know how VSD cooperate with other treatment method to maximize accelerating wound healing through wound bed preparation.Referring to related literature,we found both “TIME” principle and “TIME-H” principle were only one part of systematic evaluating and comprehensive understanding of wound conditions.It is necessary to establish corresponding treatment strategy and relevant clinical pathways with further study of chronic refractory wounds.Meanwhile,most clinicians still insist that VSD should be unavailable for anticoagulated patients through wound bed preparation which increases the risk of wound bleeding or skin necrosis,so that anticoagulation should be suspended or other anticoagulant of lower bleeding risk should replace the old one during the use of VSD.The Smith&Nephew negative pressure wound therapy clinical guidelines also proposal caution on the use of VSD in anticoagulated patients.When patient exists active bleeding or difficult hemostasis,VSD should be banned.However,there is a paucity of evidence anecdotally that reported the safety and efficacy of VSD in anticoagulated patients without discontinuing or replacing the anticoagulant.In general,the evidence about the safety and efficacy of using VSD in patients concurrent receiving anticoagulant medication is insufficient and disputed,and the precautions of VSD is still unclear to reduce the risk.Therefore,evidence-based research is needed to judge the safety and efficacy of VSD in anticoagulated patients.We treated 140 anticoagulated patients after cardiovascular surgery or trauma from 2008 to 2017,and discovered that VSD could be safely used in anticoagulated patients during wound bed preparation when the anticoagulant was not discontinued or replaced.Although warfarin had higher risk of bleeding than other anticoagulants,the bleeding risk of patients anticoagulated by warfarin also didn't increase when warfarin was not discontinued or replaced.Given that,we conducted this retrospective study with aims of analyzing the clinical practice of VSD in patients concurrent using anticoagulant,including treatment strategies,precautions,safety and clinical efficacy,and determining whether the use of VSD for wounds in anticoagulated patients increases related complications.Methods:Part I Formulation of wound bed preparing strategy and clinical pathways for chronic refractory wounds during the use of VSD On the basis of patients' electronic medical records,we collected the data of 373 patients with chronic refractory wounds in our department from January 2008 to December 2017,which benefited to formulate the procedural wound bed preparing strategy and related clinical pathway considering actual situation of the patients,and evulated the therapeutic and prognostic effects of procedural wound bed preparation strategy by wound area,healing time,cure rate,recurrence rate.Part II The safety and therapeutic effects of VSD in anticoagulated Patients.Of these patients,we retrospectively analyzed the data of 140 anticoagulated patients with chronic wounds from January 2008 to December 2017.According to the type of anticoagulant,the patients are assigned to the warfarin group and the other anticoagulant group.Then,on the basis of the treatment modality,the patients are further divided into two additional groups: the NPWT group versus the conventional treatment group.The demographic parameters of the patients(gender,age,BMI,and concomitant diseases)are used to analyse the patients' baseline level bias.Wound area and healing time are used to analyse the efficacy of VSD in anticoagulated patients.The complications(dressing-ralated dermatis,infection,bleeding)can be used to evaluated the safety of VSD.Biochemical indexes(coagulation function and exudate culture)assess the risk of bleeding and infection.Through describing the mode and pressure of VSD for different anticoagulated patients,we summarized the precautions of VSD for patients using anticoagulants.All data were analyzed by SPSS23.0.Statistical significance was set at p<0.05.Results:1.The chronic wounds in our department were mainly traumatic ulcers,postoperative ulcers,diabetic ulcers,pressure ulcers,and vascular ulcers(95.4%).Through the procedural wound bed preparation,the mean wound healing time was 43 days,95.2% patients were cured.After 6 months follow-up,only 6.7% patients appeared recurrent chronic wounds.2.The anticoagulated patients mostly accompanied with cardiovascular disease or traumatism.The patients using warfarin therapy were tended to be older and female,with comorbidities.The wounds were mainly distributed in the thorax and were caused by incision dehiscence after cardiac or vascular operation;the second most common wound site was the lower extremity.In addition,the majority of patients who used other anticoagulants therapy were middle-aged males with nonhealing traumatic wounds on the lower extremity.3.Versus warfarin group,patients in other anticoagulant group had a larger mean area(P=0.00),resulting in a longer healing time(39±22 vs 62±35,P=0.00).4.Within the warfarin group,the subgroup analysis showed there were no significant difference in wound area and healing time between VSD group and conventional treatment group(P>0.05).5.Within the other anticoagulant group,subgroup analysis showed that there was no significant difference in wound area between VSD group and conventional treatment group(P>0.05),but VSD obviously accelerated wound healing versus the conventional treatment group(54±29 vs 72±39,P=0.04).6.Both univariate analysis and binary logistic regression analysis revealed that the risk of complication or wound bleeding did not increase compared warfarin group with other anticoagulant group(P>0.05),and the use of VSD in anticoagulated patients also did not increase the risk of related complications or bleeding versus conventional treatment(P>0.05).Conclusions:1.The procedural wound bed preparation strategy for chronic refractory wounds means that,on the condition of improving patients' comorbidities and systemic nutrition,we adopt thoroughly debridement and “noninvasive treatment” concept to control infection,systemic antibiotics therapy when necessary,keep wound moisture balance,promote the growth of granulation and accelerate epithelialization by adjuvant therapy,such as VSD,PRP.Meanwhile,we endeavor to achieve the early stage of germy wound healing by combination with skin grafts,which greatly shortens the wound healing time.2.This study demonstrated that VSD with an appropriate pressure and mode could improve and accelerate chronic wound healing in patients concurrent receiving anticoagulant therapy even in the presence of infection,fistula and sinus and did not increase related adverse effects.3.We chose the mode and pressure of VSD according to the infection situation of the wound and species of anticoagulant.When severe infection and abundant pus secretion were present,the continuous mode and higher pressure(-80?-100mmHg)of VSD was adopted;when wound infection was light,the intermittent mode and lower pressure(-60?-80 mmHg)was used.In patients receiving warfarin therapy,we adopted the continuous mode and lower pressure(-60?-80 mmHg)of VSD.4.If sudden bleeding or difficult hemostasis was observed,we need immediately discontinue VSD therapy and take appropriate measures for hemostasis.Patients receiving anticoagulant therapy,especially warfarin,must be monitored closely for bleeding in order to adjust the dose of anticoagulant in time and control the INR between 1.8 and 3.0.Infectious wounds occasionally required frequent dressing to prevent aggravation of wound infections.