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Discussion, conclusions:
Based on our practical experience and the data from the review of the literature, comes the conclusion of the incomplete use, and possibly the lack of knowledge of the actual possibilities of the expertise, as well as the failure to comply with the requirements of establishing the forensic diagnosis and the certification of the cause of death due to hypothermia.
The literary review did not provide data on the scientific interest of Bulgarian authors with developments and publications on the problems of fatal hypothermia and its forensic medical expertise. Bulgarian-language literature on this topic is presented only by textbooks and practical guides in forensic medicine, in which, for understandable reasons, the exhibition is limited in volume.
In order to optimize the expertise of fatal hypothermia and to standardize the expert practice, it is appropriate to update the specialized Bulgarian-language literature, but especially to elaborate and adopt a standard of forensic medicine and protocols for forensic study of the various nosological units, which would also solve a number of other problems stemming from its financing and related material and personnel provision.
Bibliography:
1. Витер В, Пудовкин В, Юрасов В. и др. Морфологическая диагностика холодовой травмы. Практическо пособие. Москва, „Корина-офсет", 2012.
2. МКБ 10. СЗО.
3. Кузнецова И. Диагностическое значение определения гликогена, глюкозы и гликозилиро-ванного гемоглобина в биологических жидкостях и
тканях трупа. Нормы содержания гликогена, глюкозы и гликозилированного гемоглобина в тканях и жидких средах трупа. Информационное письмо, Кировского областного бюро судебно-медицинской экспертизы, 2004. [08.04.2014.]
http://www.forens-med.ru/book.php?id=538
4. Шигеев В, Шигеев С, Колударова Е. Холо-довая смерть. Москва, „Новости". 2004.
5. Aghayev E, Thali M, Jackowski C, et al. MRI detects hemorrhages in the muscles of the back in hypothermia. Forensic Science International. 2008;176:183-186.
6. DiMaio V, DiMaio D. Hyperthermia and Hypothermia: the Effects of Heat and Cold. Chapter 17 in: Forensic Pathology. 2nd ed. CRC Press LLC, 2001.
7. Hyodoh H, Watanabe S, Katada R, et al. Postmortem computed tomography lung findings in fatal of hypothermia. Forensic Science International. 2013; 231:190-194.
8. Madea B, Tsokos M, Preuft J. Death due to hypothermia. Morphological findings, their pathogenesis and diagnostic value. In: Tsokos M. (ed.), Forensic pathology reviews. Totowa, New Jersey, Humana Press. 2008; 5:3-24. DOI 10.1007/978-1-59745-110-9_1.
9. Palmiere C, Teresinski G, Hejna P. Postmortem diagnosis of hypothermia. Int J Legal Med. 2014; 128:607-614. DOI 10.1007/s00414-014-0977-1
10. Yajima D, Asari M, Okuda K, et al. An objective approach using three indexes for determining fatal hypothermia due to cold exposure; statistical analysis of oxyhemoglobin saturation data. Legal Medicine. Tokyo, 2015;17:451-458.
APPLICATION OF VACUUM ASSISTED CLOSURE THERAPY FOR _TREATMENT OF DIFFICULT TO HEAL WOUNDS_
Elena Krasteva, Elean Zanzov, Stancho Prodanov, Penka Stefanova
Department of Propaedeutics of Surgical Diseases, Medical University-Plovdiv University Hospital "St. George "- Plovdiv
ABSTRACT
Vacuum assisted closure technique (VAT) is a modern form of wound treatment, which uses the creation of a negative pressure within the wound dressing. The introduction of VAT in our clinic has become a method of choice for treating difficult to heal wounds over the last five years. The primary disease leading to the formation of difficult to heal wounds is uncompensated diabetes mellitus with diabetic micro- and macro-angiopathy. This disease is ranked to varying degrees based on either chronic venous or chronic arterial insufficiency . The aim of our team was to apply a vacuum technique to chronic wounds and by doing so we could possibly reduce complications and mortalities .The VAT technique could hence aid specialized treatment.
Material and Methods 11 patients with chronic non healing wounds of the lower leg and foot for a period of two years. In each patient there was a different depth and area of affected structures. In some patients the response orchestrated was epithelialization while others were undergoing surgery involving different types of plastic surgery.
Results In some patients total recovery of the skin defect was observed, others have registered some complications. Rapid and positive treatment contributes to better control of concomitant diseases.
Conclusion Patients with diabetic foot and those with difficult healing wounds result from chronic arterial or venous insufficiency require a multidisciplinary approach to treatment. Our intention was always to use a body sparing method of treatment.
Keywords : vacuum assisted technique, treatment, difficult healing wounds
Introduction
Vacuum assisted closure technique is a modern method of wound treatment which uses the creation of a negative pressure in the region of wound dressing. This method was created in 1995 and introduced into the clinical practice in 1997 within the USA. In our clinic the technique has been used over the last five years, as a method of choice in the treatment of difficult to heal wounds. [1,2]
VAC therapy is a noninvasive method of treatment that involves application of negative pressure to the wound, using a polyurethane sponge or gauze and drainage. The wound exudates are collected in a transparent canister, allowing monitoring of quantity and nature. The device is equipped with rechargeable batteries and can be applied in a domestic environment allowing active movement of patients. [3,4]
Treatment of wounds in the lower leg and foot are challenging in modern surgical practice. The wounds in those areas are a result of vascular insufficiency and patients go through durable hospital treatment with an unsatisfactory outcome. The wounds create discomfort to patients and increase their disability. In diabetic patients with inadequate glycemic control, it is common and the complications are adverse.
Treatment is protracted and difficult requiring surgical debridement of necrotic tissues. This in turn leads to increase in wound Infection, commonly polymicro-bial. Antibiotic resistant of microbial species within the wound also appears to be a problem. In these patients due to reduced tissue perfusion and vascular damage, reconstructive operations are often are beyond consid-eraation. The formation of chronic wounds represents a portal of entry for infectious pathogens further aggravating the primary disease and requiring alternative approach of treatment. [1,2,5] Materials and methods
For a two-year period we have applied VAC therapy in eleven patients (7 males and 4 females) with chronic non-healing wounds of the lower leg and foot. Six patients presented decompensated diabetes mellitus with complications of micro and macroangiopathy, and the other five patients had different degrees of chronic venous or chronic arterial insufficiency. Case study 1
A 66-year-old woman presented with varicose veins at 2nd to 3rd stage with more than a 20-year history. For about a year and a half a chronic varicose ulcer had developed on the lower right leg and ankle. It presented with size 25 cm2, undermined margins, fibrin coat and feeble granulations on the bottom. The wound had been managed conservatively in outpatient conditions without much effect.
On angiography of both lower limbs first degree of arterial insufficiency and second degree of venous insufficiency was established. E. colli was isolated as a causative agent and medical treatment with combination of two antibiotics according to antibiogram and vasodilators was prescribed. Surgical debridement of the wound with excision of the undermined edges and removal of the fibrin coat to healthy tissue was done. Vacuum dressing with silver and polyurethane sponge
was applied. Negative pressure of 125 mmHg on constant aspiration mode was used. The vacuum aspiration continued 15 days and dressing was changed at five-day intervals. At each change of the wound dressing specimens for microbial culturing were collected. Cul-turing showed the presence of no bacterial organisms. When fresh granulations without fibrin coat appeared the treatment continued with topical intra-site gel dressings that were changed every other day. The treatment was completed successfully in three weeks.
Case study 2
A 55-year-old male presented with a 15-year history of diabetes mellitus being on insulin therapy four times daily and biguanide preparation in the recent five years. Despite this treatment the glycemic control remained poor and glycosylated hemoglobin values were above 10mmol /l. The patient was admitted to the clinic for a phlegmon of the left foot and gangrene of the 4th and 5th toes. General symptoms included; chills, fever up to 390C, swelling, redness, pain in the left lower leg and foot. Laboratory findings were as follows; poor blood glucose profile with high blood glucose level, leucocytosis with left shift, high CRP, low levels of hemoglobin and iron. Blood-gas analysis specified metabolic acidosis. Medical treatment was initiated including intense scheme with rapid-acting insulin after preliminary determination of the blood glucose level was initiated; combined antibiotic treatment with two antibiotics according to antibiogram (Acinetobacter bau-mannii was isolated as causative agent), bioproducts. Surgical treatment included broad incisions of the phlegmon with drainage of the abscess cavity. After acute inflammation subsided silver dressing with polyurethane sponge and flat and wide drainage was applied. Negative pressure of 165mm Hg was applied. The dressing was changed at 4-day intervals, because of abundant secretion. After a 14-day treatment and significantly reduced secretion and formation of fresh granulations plastic reconstruction was performed.
Results
Mean duration of treatment and hospital stay was 22 days. All patients were discharged from hospital with improved conditions. After the vacuum dressing and antibiotic treatment, the control wound specimens yielded no bacterial growth on the cultures. The vigorous and successful treatment helped to control the concomitant diseases. Achieving blood glucose levels that improved the glycemic control (glycated hemoglobin values below 7mmol /l) in diabetic patients interrupted the vicious cycle of negative impacts due to the diseases, allowing organ-preserving surgery to be undertaken in diabetic foot. Microcirculation in the lower limb improved, which had strong positive effects on the arterial and venous insufficiency.
Discussion
Vacuum assisted closure technique is a relatively new method in the treatment of difficult-to-heal wounds. As a consequence of the positive results observed; VAT it is becoming more widely applied. It has been shown to reduce bacterial colonization in the wound and prevent development of infection. Additionally the technique reduces interstitial swelling and
increases capillary blood flow. The use of Local negative pressure cleans wound secretion and promotes formation of granulation tissue, which is an essential stage in wound closure. All these advantages were observed in our patients. Furthermore, the suction force reduces the wound area and promotes cellular mitosis in the tissues surrounding the wound. [1,2,6]
Moist-healing environment in the wound achieved by vacuum dressing promotes epithelial migration and development of granulation tissue. Shortened treatment period of diabetic foot ulcers by this method significantly reduced the hospital stay and helped organ-preserving surgery to be performed. Subsequently, this lead to a significant reduction in costs for the management of diabetic foot ulcers. [3,4,5]
Early necrectomy is a very important stage in diabetic foot management. It enables the vacuum dressing to promote formation of granulation tissue. In our patients wide surgical debridement of the wounds was performed initially and thereafter vacuum dressing was applied. [3,4]
We support the opinion that patients with diabetic foot and patients with difficult to heal wounds due to chronic arterial and chronic venous insufficiency require a multidisciplinary approach to treatment. In conclusion, we are in agreement that adequate treatment of underlying disease allows the successful management of its complications and improves the primary dis-iorder. [1,3,4]
Figure 1. Diabetic ulcer before application of vacuum assisted closure therapy.
Figure 2. The same patient with vacuum assisted closure technique applied on the wound.
Figures 3. The same patient at the end of the vacuum assisted closure therapy
Figures 4. The same patient at the end of the vacuum assisted closure therapy
References
1. Brem H., P. Sheehan, H.J. Rosenberg, J.S. Schneider, A.J. Boulton (2006) Evidence-based protocol for diabetic foot ulcers, Plast Reconstr Surg, 117, 193-209S.
2. Argenta L.C., M.J. Morykwas (1997) V.A.C.uum-assisted closure: a new method for wound control and treatment: clinical experience, Ann Plast Surg, 38, 563-76.
3. Morykwas M.J., L.C. Argenta, E.I. Shelton-Brown, W. McGuirt (1997) V.A.C. Vacuum-assisted closure: a new method for wound control and treatment: animal studies and basic foundation. Ann Plast Surg, 38, 553-62.
4. Armstrong D.G., L.A. Lavery. Diabetic Foot Study Consortium (2005) Negative pressure wound therapy after partial diabetic foot amputation: a multi-centre, randomised controlled trial. Lancet, 366, 170410.
5. Blume P.A., J. Walters, W. Payne, J. Ayala, J. Lantis (2008) Comparison of negative pressure wound therapy using V.A.C.uum-assisted closure with ad-
vanced moist wound therapy in the treatment of diabetic foot ulcers: a multicenter randomized controlled trial. Diabetes Care, 31, 631-6.
6. McCallon S.K., C.A. Knight, J.P. Valiulus, M.W. Cunningham, J.M. McCulloch et al (2000) V.A.C.uum-assisted closure versus saline-moistened gauze in the healing of postoperative diabetic foot wounds. Ostomy Wound Manage, 46, 28-32.
7. Ponten B. The fasciocutaneous flap. Its use in soft tissue defects of the lower leg (1981) Br J Plast Surg, 34, 215-20.
8. Harrison D.H., B.D.G. Morgan (1981) The instep island flap to resurface plantar defects. Br J Plast Surg, 34, 315-8.
9. Schwarz R.J., J.F. Negrini (2006) Medial plantar artery island fl ap for heel reconstruction. Ann Plast Surg, 57, 658-61.
10. Attinger C.E., I. Ducic, P. Cooper, C.M. Zelen (2002) The role of intrinsic muscle fl aps of the foot for bone coverage in foot and ankle defects in diabetic and nondiabetic patients. Plast Reconstr Surg, 110, 104754.
