▶ Previous Artlcle : #16-1. Understanding and Clinical Application of basic Fibroblast Growth Factors (bFGF)
The silicone tube is usually placed in the center of the skin defect but should avoid high-pressure protruding bone areas such as ischium or sacrum to prevent formation of new sores due to pressure from the tube. Connect the silicone tube to the continuous suction unit and maintain the suction pressure at 125mmHg. When pain, bleeding or adhesion of granulation tissues inside the silicone tube are observed, the suction pressure lowers. The patient can close the suction tube when he is on the move. It is important to check for obstruction or contamination of the silicone tube and suction tube to manage the wound site.
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Devices of debridement, irrigation or vacuum-assisted closure should be changed 1-3 times a week depending on the condition of the wound site. Formation of good granulation tissues is usually observed in 1-3 months. In general, bFGF is combined around this time. When a single debridement successfully removes all necrotic tissues, bFGF is combined with vacuum-assisted closure from the start. After sufficient removal of exudate, bFGF is sprayed five times, 5cm away from the bottom of the bed sore. When the total wound area exceeds 6cm, make sure the entire area is sprayed equally 5 times.
Thirty seconds after application of bFGF, fix the vacuum-assisted closure device. When spraying, switch the body position from left to right supine position or vice versa to prevent lopsided application. If the exudate is effectively irrigated, perform twice a week to prevent obstruction or contamination of the suction tube.
In a chronic wound, especially, intractable ulcer such as bed sores, repeated tissue damage in the early phase of wound healing delays the healing mechanism. Wound bed preparation prevents this vicious cycle and normalizes the healing mechanism. Wound bed preparation is a concept applicable to the whole process of wound healing and means ‘creation of an environment conducive for accelerated wound healing.’ More precisely, it consists of five steps; removal of necrotic tissues, establishment of bacterial balance, maintenance of optimal moisture, recovery of cellular functions, and recovery of biochemical balance. Removal of necrotic tissues, prevention of infection and exudate control are necessary in treatment of chronic wound such as bed sore. Among them, the amount of exudate is particularly important for repair of bed sore. Therefore, the exudate control of acute bed sore helps early recovery and maintains the inflammatory cytokine levels high. To create an ideal environment for wound healing in bed sores, exudate control is crucial.
The negative pressure therapy was first introduced by Argenta and Morykwas in 1997. Effective exudate control is considered to reduce local edema and bacterial burden as well as promote proliferation of granulation tissues and angiogenesis. Following reports of efficacy, VAC system was first commercialized in Europe and the US. Film dressing and new vacuum-assisted closure technology using stoma pouch have also been developed. bFGF was developed for the purpose of treating intractable skin ulcer. It binds with fibroblasts and FGF receptors to promote cell proliferation, migration and wound recovery. However, a case study reported lack of clinical response to bFGF when used alone. The reason may be that the imbalance of cellular growth factors or cytokines in the wound site weakens the differentiation activity of fibroblasts in the base of the ulcer compared to fibroblasts in the normal skin. Moreover, fibroblasts in the base of intractable ulcer may have weaker proliferation activity and response to bFGF (reduced number of bFGF receptors) due to repeated proliferation and necrosis.
Therefore, combination of vacuum-assisted closure and bFGF brings faster repair through wound bed preparation. Combination of vacuum-assisted closure and bFGF not only shortens the treatment time but provides a more effective modality for cases not responding to a single method.
References
Robson MC1, Phillips LG, Lawrence WT, Bishop JB, Youngerman JS, Hayward PG, Broemeling LD, Heggers JP, The safety and effect of topically applied recombinant basic fibroblast growth factor on the healing of chronic pressure sores. Ann Surg. 1992 Oct;216(4):401-6; discussion 406-8.
Akita S, Akino K, Imaizumi T, Hirano A, A basic fibroblast growth factor improved the quality of skin grafting in burn patients. Burns. 2005 Nov;31(7):855-8.
-To be continued-
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