Question About a Wound Vac (long)

[Sapphy, BSN, RN]

We have a pt right now who has a wound vac. She has an abdominal incision that would not close from back in August of last year. She came to us about a month ago with TPN running, and with the wound vac over this incision. There is a fistula underneath the wound vac. Our WCC Nurse has been concerned about this from the start. Wound vacs are contraindicated with a fistula and this patient is not exactly compliant. So the mess started last Sunday. I was assessing my patient, changed the dressing on the wound wac all was well. Her skin is a little irritated from months of opsite being peels from around the incision but nothing that we were terribly concerned about. A few hours later the patient calls for me because she is concerned about her drainage. It has now gone from tan/brown to a deep olive green. Nothing I have ever seen before. I promptly went to get one our experienced nurses who says that green drainage usually means pseudomonas. So I call the doc and he puts the pt NPO untill the surgeon can be consulted in the morning. The pt pitches an absolute FIT about being NPO. We took all the snacks and crap out of her room but when I went back to take her water pitcher it was empty. She has emptied it all into her own personal water bottle that I cannot take from her.

Anyway, She gets to the surgeon on Monday who looks at it, says oh it is just Bile coming from her fistula nothing to worry about! While she is at this surgeon, she asks him to put her on a regular diet and he says OK.

This woman has been on a limited diet in addition to her TPN for months to control the amount of gastric juices she is making. So she gets her way and gets her regular diet. So yesterday, I have this patient again. She is making so much gastric juices we changed the cannister on the vac 4 times from 5 AM to 2 PM. And her skin under the opsite is purple and raw from the acid sitting on her skin where it is leaking around the tubing. There is NOTHING we can do to stop the leaking and it is just eating her skin away. She sobs anytime we have to change the dressing because it hurts so badly and she sobs anytime she eats because the gastric juices flow like a river and leak out onto her skin.

The docs refuse to address this situation. They keep playing pass the buck. I feel we are doing the patient a huge disservice with our inaction. Finally yesterday afternoon I got the doc to at least consult the ostomy nurses for some ideas. But I am willing to listen to anyideas that might be out there. I cannot just take the vac off.... she just leaks out onto her skin more, my hands feel really tied here.

[meownsmile, BSN, RN]

Wow,, big problem. Obviously the vac isnt working the way they wanted it to now that she is eating. She is probly headed for a revision of her wound at some point because of the bile problem. But then again maybe the dr knew this was going to be an issue and is waiting it out on a non compliant patient.