Management of a Complex Open Chest Wound with NPWT

Clinical Problem: Management of a large, complex chest wound in a 64 year old morbidly obese malnourished diabetic female after a coronary bypass graft with exposed bone and fascia over pericardia poses a unique management problem for the WOC nurse. This presented a clinical challenge because (1) location of the wound with exposed vital tissue (2) Pseudomonas aeruginosa infection in the breast (3) a clean adjoining chest wound.

Past Management: Conservatively treated with an enzymatic debridement agent.

Management: During the operation to debride the wound, the WOC nursing team was contacted to initiate negative pressure wound therapy (NPWT). NPWT was chosen because of evidence showing effectiveness in managing wound exudate and formation of granulation tissue. The delicate pericardial tissue and exposed bone were protected with polyvinyl alcohol foam and covered with hydrophobic polyurethane foam. The remaining wound bed was covered with hydrophobic polyurethane foam. The procedure included separating the infected breast wound from the clean chest wound during irrigation and dressing application to prevent cross contamination. NPWT was applied at 100mmhg continuous. The patient was placed on a high protein diet with dietary supplements. The weight of the right breast caused tension on the healing wound necessitating the creation of a breast sling.

Outcomes: NPWT was an effective strategy in managing this complex wound until it could be closed surgically, 20 days after her initial debridement. A multidisciplinary collaborative approach to this case contributed to positive outcomes for the patient. She was discharged home 11 days after closure with her incision showing no signs of complications. A surgical support bra was provided to prevent wound dehiscence.

Conclusion: This is one case example which demonstrates NPWT can manage two types of wounds within a large complex wound and manage the infection in one wound without cross contamination, further research is needed.