Heavily draining rectal wound

[paddler]

Hello,

I work in home health which, of course, involves a lot of varying wound types. Struggling with this one and I would like to approach the surgeon for another solution.

My patient had a colorectal resection secondary to rectal cancer. He had a colostomy placed and there are no problems with this. However, he has had continuous low grade fevers since the surgery. The surgeon has left the rectal opening (no longer has an orifice or lower intestinal tract) open to drain and close via secondary intention. At first he ordered TID moist gauze dressings but this did not contain the drainage. Then he ordered a KCI wound vac. Usually I am a HUGE fan of these and love them. However, due to the proximity of the wound, and many various attempts at bridging, not bridging, trying different foams, different therapy intensities, increasing the suction etc, nothing is working to contain the drainage and the wound tract is getting deeper and deeper, (now 16cm). The exudate used to be serosanguinous but is now thick foul purulent matter with some clotting which I believe may be too thick to be fully drawn through the KCI foam packing. I thought wound vacs were contraindicated with infection?

For some reason the surgeon (who is aware of, has assessed and seen the wound and drainage) is not willing to prescribe antibiotics. That issue aside, I am wondering about an alternative dressing situation. The KCI track pad is in a very uncomfortable location for the patient and the dressing removal and application is difficult and has not seemed to improve the wound over a 4 week period. The measurements keep getting deeper, probably due to opening up new pockets of drainage within the tract.

I am thinking of suggesting anal closure to the surgeon and maybe employing a drain/sump system to his anterior pelvis. I have not seen this done, but I think it would benefit the patient's comfort and quality of life as well as possibly reduce the tissue (and emotional) trauma associated with the present dressing situation. He would no longer have foul purulent drainage coming from his former rectum and would also have more comfort and mobility. Heck, he could probably carry the pump around in his pocket!

I found a drain system I think may work, but have never seen or used one, Reliavac (http://www.bardmedical.com/400ccRELIAVACKits). Before I think too far outside the box and come off to the doctor like I am an idiot, I want to seek your advise. THANK YOU!!!!

[mommy.19, MSN, RN, APRN]

I agree with your notion of surgical debridement/closure. In the meantime an antimicrobial dressing would serve him well. Something like Aquacell AG rope that can be packed into the wound and possibly help further bacterial burden. Also, something absorbent like an abd pad over the packing or Sorbion Sachet (relatively pricey) could provide comfort for the patient and decrease the dressing changes to daily. And, I too am fond of wound vacs but they're only advantageous to a point, and infection is definitely a contraindication. I would agree that the wound should be cultured and sensitivities be done to see what abx can be given, but I'm not the doc! :)

[TVN2011]

Hi,

I would agree with the previous post that an antimicrobial dressing would be appropriate in this patients case, also protection of the periwound skin with Cavilon spray would prevent maceration. Dry Max Extra as a secondary dressing would help to manage the exudate also.

As the operation was done for cancer, local invasion of wound margins would be a concern also with the use of Vac.

Hope this helps

[paddler]

Thanks! Still no antibiotics, still foul purulent drainage and low grade fevers. But, the vac seems to have finally kicked into gear and is managing the drainage and is finally staying in place. Poor patient has a long road ahead, but after 5 weeks of tinkering, I think we're on track. Now, just to get the doc to address the infection... Really good point about cancer and the wound vac!!! THanks!