Ravi K. Kamepalli MD, CWS Regional Infectious Diseases and ...
1
Complex Surgical Wounds and the Platelet Rich Plasma Option – Case Study of 6 Wounds Background: Platelet rich plasma (PRP*) is a concentrated supply of platelets that release multiple growth factors and has been shown to have multiple clinical applications 4 . Currently the overall evidence regarding PRP and wound healing is inconclusive 3 . Studies are emerging supporting the use of autologous platelet rich plasma in wound care 2 . Given its potential for increasing tissue granulation in soft and hard tissue wounds 1 , more clinical studies needed examining the use of PRP in large surgical wounds. Objective: To present case studies in which platelet rich plasma decreased time to heal in select surgical wounds that had significant tissue deficit and in which delayed closure was likely to fail. Methods: Presentation of six cases with clinical review of wound treatment modalities including detailed pictorial documentation of wound healing process. Patients were selected based on their existing comorbidities and the size and type of wounds. Abdominal wounds (3), lower leg wound (1), cervical wound (1), and lumbar wound (1) were measured, pictured and documented throughout their healing course which visually demonstrated the healing acceleration wound bed was prepared and PRP applied. Results: PRP accelerated the granulation of all six wounds with remarkable clinical improvement and 100% healing at an average of 10.5 weeks without skin grafting despite the substantial starting tissue deficits. Conclusion: Further clinical studies including well planned randomized controlled trials need to be performed to replicate the positive results found with these limited case studies using PRP in healing large wounds. Augmenting healing process in surgical wounds that may not be healing with current strategies may benefit with PRP application after barriers to healing have been removed. *PRP Prepared by SmartPReP®2 APC+•• References 1. Cervelli, V., Lucarini, L., Spallone, D., Palla, L., Colicchia, G., Gentile, P., & De Angelis, ,. (2011). Use of platelet-rich plasma and hyaluronic acid in the loss of substance with bone exposure. Advances in Skin & Wound Care, 24(4), 176-181. doi:10.1097/01.ASW.0000396302.05959.d3 2. Frykberg, R., Driver, V., Carman, D., Lucero, B., Borris-Hale, C., Fylling, C., & ... Clausen, P. (2010). Chronic wounds treated with a physiologically relevant concentration of platelet-rich plasma gel: a prospective case series. Ostomy Wound Management, 56(6), 36. Retrieved from EBSCOhost. 3. Martínez-Zapata, M., Martí-Carvajal, A., Sol, I., Bolibar, I., Angel Expósito, J., Rodriguez, L., & García, J. (2009). Efficacy and safety of the use of autologous plasma rich in platelets for tissue regeneration: a systematic review. Transfusion, 49(1), 44-56. doi:10.1111/j.1537-2995.2008.01945.x 4. Yuan, T., Zhang, C., Tang, M., Guo, S., & Zeng, B. (2009). Autologous platelet-rich plasma enhances healing of chronic wounds. Wounds: A Compendium of Clinical Research & Practice , 21(10), 280-285. Retrieved from EBSCOhost. Platelet Rich Plasma Wound Evaluation Algorithm YES YES NO NO NO YES YES NO NO NO Type of wound eligible for PRP diabetic ulcers decubitus ulcers venous ulcers surgical wounds arterial ulcers traumatic wounds Would wound benefit from increased tissue granulation? Does wound contain tumor or suspicious tissue not recently biopsied? Consider biopsy. PRP contraindicated-Defer to primary wound care physician Is there active, untreated infection in wound? Positive blood cultures within 48hrs Fever >101 within 48hrs Exposed infected bone Increased cellulitis Purulent drainage Continue antibiotics and local antimicrobial wound care per primary wound care physician’s orders Is platelet count < 60 or patient has a known platelet dysfunction syndrome? PRP contraindicated for patients with known platelet dysfunction or critically low platelet count- Continue local care per primary wound care physician Is hemoglobin < 9 or active bleeding in wound? Use of PRP in anemic patients is at discretion of wound care physician Is the base of wound/ulcer >30% slough or nonviable tissue? Recommend debridement prior to application of PRP- If debridement contraindicated, continue local care to wound per primary wound care physician Is there heavy drainage from wound? Evaluate etiology of drainage-If clinically no infection, fistula or other contraindication, PRP can be applied at discretion of wound care physician Currently taking any medication that interfere with clotting or platelet function? NSAIDs Plavix Coumadin Immunosuppressive agents Any meds interfering with normal clotting should be held for 48 hours prior to PRP if possible. PRP application with patients on immunosuppressive agents is up to the discretion of the wound care physician If wound meets criteria and orders for PRP obtained from primary wound care physician, initiate Platelet Rich Plasma Protocol in collaboration with certified wound care physician YES NO NO NO NO NO NO YES YES YES YES Case Study 1 Lumbar wound 40 yr old female with history of chronic back pain and obesity. Underwent lumbar laminectomy and then multiple revisions for surgical site infections. Prior to admission to LTAC had multiple complications with outpatient treatment including PICC infections and repeat ER visits for irretractible pain. Lumbar wound with multiple surgeries to area for infected hardware and finally removal of hardware on Dec 5 2010 with I & D of lumbar area. Lumbar wound left open to heal by secondary intention due to concern for infection and scar tissue. All cultures negative from multiple surgeries except original cultures of area noted to be MSSA. Lumbar fluid negative for beta 2 transferrin. Admitted to LTAC after last surgery for wound care, IV antibiotics and pain management. Negative Pressure Wound Therapy continued to area with serial debridements to remove nonviable tissue. MRSE cultured from wound 12-27 but thought to be possible contaminant. After wound bed preparation, PRP applied to wound bed 12-29-10. Local dressing care with nonadhering adaptic and telfa with gauze utilized post procedure with VAC on hold. Delayed secondary closure in staged manner to lumbar area. Wound continued to drain slightly but patient requested complete closure prior to discharge from hospital. Staged closure done on 1/12/11 to proximal, 1/19/11mid portion and to complete the closure 1/26/11. Did remarkably well post discharged and wound completely healed 2/4/11with suture removal. 12/10/2010 12/15/2010 12/20/2010 12/27/2010 12/29/2010 12/29/2010 12/29/2010 12/30/2010 1/5/2011 1/3/2011 12/30/10 Case Study 2 Abdominal Wound 64 year old patient with history of PVD, afib, chronic kidney disease who initially had emergent sigmoid resection with colostomy for perforated diverticulum and pneumonperitoneum on 9/24/2010. He later dehisced his abdominal surgical wound post-op and required repair of dehiscence on 10/5/2010 with surgical wound left open to heal by secondary intention with Negative Pressure Wound Therapy and IV antibiotics. Readmitted to hospital 2 weeks later with severe confusion and enterococcal bacteremia thought to be from infected line versus endocarditis due to suspicious 2D echo, new murmur, and bacteremia with patient unable to have TEE. Also found to have bilateral murmur, and bacteremia with patient unable to have TEE. Also found to have bilateral pulmonary emboli. Treated for tricuspid valve endocarditis and cognative status returned to baseline. Wound improved significantly with antibiotics and NPWT. Underwent platelet rich plasma application on 11/24/10. Unfortunately noncompliant with follow up visits due to difficulty in traveling great distance for appointment but wife reports wound healed 3/17/11. No further pictures were able to be obtained but home health did confirm healing and discharge from their services mid March. 11/24/2010 11/24/2010 12/2/2010 12/8/2010 Case Study 3 Infected Abdominal Mesh 52 yr old female with history of multiple abdominal surgeries including gastric bypass with reversal and post operative surgical infections with resistent organisms. Retained infected abdominal mesh with nonhealing abdominal wound since 2007. Mesh could not be removed secondary to being adhered to bowel. Had several courses of IV antibiotics and now on long term suppression therapy with doxycycline. Presented again with protruding fluctuant area on previously healed incision line in June 2010. Opted to return to University hospital where surgeon located. Presented back to wound clinic December 2010 with marked improvement in inflammation but mesh remained visible in the wound. Directly admitted to triumph for IV antibiotics, local wound care and serial debridements. Once local inflammation under control and cultures negative, underwent platelet rich plasma on December 29. PRP injected into margins and applied to wound bed. Wound completely healed end of January and continued on oral suppressive meds with doxycyline for MRSA and retained abdominal mesh. Patient returned to University facility under care of her Surgeon. Did not see for nearly 6 months. Presented back to wound clinic with marked improvement in inflammation but mesh remained visible in the wound. Directly admitted to triumph for aggressive wound care and IV antibiotics. 6-24-2010 6-24-2010 6-24-2010 Case Study 4 Nonhealing Abdominal Wound 58 yr old female with history of multiple abdominal surgeries including hysterectomy for endometrial cancer and Whipple procedure in past. Most recent surgery performed for hernia repair secondary to incarcerated bowel on 10-25-2010. Abdominal wound left open after multiple abd surgeries due to infected mesh after hernia repair. Previous whipple and significant scar tissue so surgery deemed her not felt to be a surgical candidate for removal of mesh so deep abdominal wound healed by secondary intention. Transferred to LTAC 11-8-2010. Initial cultures revealed enterococcus and ecoli so short course Tygacil initiated 11-8-2010. Had other medical problems including sinus tachycardia, elevated liver enzymes and rt pleural effusion which required pleural drain insertion. Utilized Negative Pressure Wound Therapy to abdominal wound and serial debridements with tissue cultures during LTAC treatment course. Once tissue quality improved and cultures negative, Plate Rich Plasma therapy performed 11-24- 2010. Wound care post PRP included contact layer and AMD gauze. Cutaneous fistula post PRP at distal edge of wound healed remarkably well and was confirmed by CT scan NOT to communicate with bowel. Discharged home on 12-8-2010 off antibiotics and local care with AMD gauze. Wound completely healed when seen in outpatient Wound Clinic in January 6,2011. 11/8/2010 11/17/2010 11/24/2010 11/24/2010 PRP applied and adaptic to wound bed covered with non-adhering dressing (telfa) and layered gauze with clear occlusive dressing to monitor drainage. Case Study 5 Dehisced cervical surgical wound Unfortunate 75yr old diabetic male on plavix for previous heart stents who slipped on ice on January 13,2011 and developed epidural hematoma with immediate paraplegia secondary to spinal cord compromise. Underwent surgery for evacuation of hematoma and laminectomy of affected posterior neck area. Initially post operative did well but surgical incision dehisced January 31, 2011 leaving large open posterior neck wound with fascia visible. Consulted for wound management after dehiscence in an effort to heal wound quickly so transfer to specialized rehab center could be done. Cultures initially negative but repeat cultures showed growth of gram negative rods. Continued on appropriate IV antibiotics and negative pressure wound therapy utilized to area. After nonviable tissue removed with excisional debridement and wound bed prepared, tissue expander device applied to area in conjunction with negative pressure wound therapy on Feb 23, 2011. Wound more approximated after device removed but significant crevices and depth remained. Plastic surgeon consulted for skin grafting options but depth and tunneling deterred any surgical plans by plastics. Wound re-cultured which was negative and staged wound matrix utilized on March 3, 2011. Platelet Rich Plasma applied to wound with collagen powder March 9, 2011. PRP greatly improved the depth as well as filled crevices. Patient able to be transferred March 16, 2011 for aggressive rehab with simple dressing to remaining superficial wound. Seen in follow up after discharge from University rehab center with hypergranular wound bed treated with silver nitrate. Healed essentially by June 10 . Patient seen initially the day after posterior neck incision dehisced and after all staples had been removed per surgeon 1/31/2011 3/9/2011 Case Study 6 MRSA in Post Surgical Wound 44 yr old female with history of the left hip replacement done in feburary 26th of 2010. Since the surgery she was having some foot drop problem which was diagnosed as being having peroneal vein compression an underwent surgery on 10/8/10. The intraop culture was noted to be positive for mrsa. Patient first seen on 10/12/10 in the office. Attempted to heal the wound with local care and iv antibiotics. Improvement noted but the wound has dehisced open once the sutures were removed. She was started on wound vac after debridment and continue on daptomycin and po cipro. She had PRP application to the left knee lateral wound done 11/24/10 and 12/15/10. she has been using alginate to the ulcer after vac was stopped. Healed completely April 2011. 10/25/2010 11/10/2010 11/5/2010 10/25/2010 11/24/2010 11/19/2010 11/24/2010 11/29/2010 1/12/2011 1/26/2011 1/27/2011 2/4/2011 12/1/2011 11/25/2011 12/7/2011 12/23/2010 1/6/2011 3/16/2011 3/20/11 4/20/2011 4/13/11 12/8/2010 12/15/2010 12/15/2010 12/22/2010 12/29/2010 1/5/2011 3/9/2011 2/9/11 6/2/2011 Ravi K. Kamepalli MD, CWS Regional Infectious Diseases and Infusion Center, Inc. 830 West High St., Suite 255 Lima, Ohio, USA,45801 Office: 419-228-1535 Email: [email protected] Website: www.nobadbugs.com
Transcript of Ravi K. Kamepalli MD, CWS Regional Infectious Diseases and ...
Complex Surgical Wounds and the Platelet Rich Plasma Option– Case Study of 6 WoundsComplex Surgical Wounds and the Platelet Rich Plasma Option
– Case Study of 6 Wounds
Background: Platelet rich plasma (PRP*) is a concentrated supply of platelets that release multiple
growth factors and has been shown to have multiple clinical applications4. Currently the overall evidence
regarding PRP and wound healing is inconclusive3. Studies are emerging supporting the use of
autologous platelet rich plasma in wound care2. Given its potential for increasing tissue granulation in
soft and hard tissue wounds1 , more clinical studies needed examining the use of PRP in large surgicalwounds.Objective: To present case studies in which platelet rich plasma decreased time to heal in select surgicalwounds that had significant tissue deficit and in which delayed closure was likely to fail.Methods: Presentation of six cases with clinical review of wound treatment modalities including detailedpictorial documentation of wound healing process. Patients were selected based on their existingcomorbidities and the size and type of wounds. Abdominal wounds (3), lower leg wound (1), cervicalwound (1), and lumbar wound (1) were measured, pictured and documented throughout their healingcourse which visually demonstrated the healing acceleration wound bed was prepared and PRP applied.Results: PRP accelerated the granulation of all six wounds with remarkable clinical improvement and100% healing at an average of 10.5 weeks without skin grafting despite the substantial starting tissuedeficits.Conclusion: Further clinical studies including well planned randomized controlled trials need to beperformed to replicate the positive results found with these limited case studies using PRP in healing largewounds. Augmenting healing process in surgical wounds that may not be healing with current strategiesmay benefit with PRP application after barriers to healing have been removed.
*PRP Prepared by SmartPReP®2 APC+• •References
1. Cervelli, V., Lucarini, L., Spallone, D., Palla, L., Colicchia, G., Gentile, P., & De Angelis, ,. (2011). Use ofplatelet-rich plasma and hyaluronic acid in the loss of substance with bone exposure. Advances in Skin &Wound Care, 24(4), 176-181. doi:10.1097/01.ASW.0000396302.05959.d32. Frykberg, R., Driver, V., Carman, D., Lucero, B., Borris-Hale, C., Fylling, C., & ... Clausen, P. (2010).Chronic wounds treated with a physiologically relevant concentration of platelet-rich plasma gel: aprospective case series. Ostomy Wound Management, 56(6), 36. Retrieved from EBSCOhost.3. Martínez-Zapata, M., Martí-Carvajal, A., Sol, I., Bolibar, I., Angel Expósito, J., Rodriguez, L., & García,J. (2009). Efficacy and safety of the use of autologous plasma rich in platelets for tissue regeneration: asystematic review. Transfusion, 49(1), 44-56. doi:10.1111/j.1537-2995.2008.01945.x4. Yuan, T., Zhang, C., Tang, M., Guo, S., & Zeng, B. (2009). Autologous platelet-rich plasma enhanceshealing of chronic wounds. Wounds: A Compendium of Clinical Research & Practice, 21(10), 280-285.Retrieved from EBSCOhost.
Platelet Rich Plasma Wound Evaluation Algorithm
YES
YES
YES
YES
YES
YES
NO
NO
NO
NO
YESYES
NO
NO
NO
Type of wound eligible forPRP
diabetic ulcers
decubitus ulcers
venous ulcers
surgical wounds
arterial ulcers
traumatic wounds
Would wound benefitfrom increased tissuegranulation?
Does wound contain tumor orsuspicious tissue not recentlybiopsied?
Consider biopsy. PRPcontraindicated-Defer toprimary wound carephysician
Is there active, untreated infection inwound?
Positive blood cultures within48hrs
Fever >101 within 48hrs
Exposed infected bone
Increased cellulitis
Purulent drainage
Continue antibiotics andlocal antimicrobial woundcare per primary woundcare physician’s orders
Is platelet count < 60 or patienthas a known platelet dysfunctionsyndrome?
PRP contraindicated forpatients with knownplatelet dysfunction orcritically low platelet count-Continue local care perprimary wound carephysician
Is hemoglobin < 9 or activebleeding in wound?
Use of PRP in anemicpatients is at discretion ofwound care physician
Is the base of wound/ulcer >30%slough or nonviable tissue?
Recommend debridementprior to application of PRP-If debridementcontraindicated, continuelocal care to wound perprimary wound carephysician
Is there heavy drainage fromwound?
Evaluate etiology ofdrainage-If clinically noinfection, fistula or othercontraindication, PRP canbe applied at discretion ofwound care physician
Currently taking any medicationthat interfere with clotting orplatelet function?
NSAIDs
Plavix
Coumadin
Immunosuppressiveagents
Any meds interfering withnormal clotting should beheld for 48 hours prior toPRP if possible. PRPapplication with patients onimmunosuppressive agentsis up to the discretion ofthe wound care physician
If wound meets criteria andorders for PRP obtained fromprimary wound carephysician, initiate PlateletRich Plasma Protocol incollaboration with certifiedwound care physician
YES
NO
NO
NO
NO
NO
NO
YES
YES
YES
YES
Case Study 1
Lumbar wound 40 yr old female with history of chronic back pain and obesity. Underwent lumbar laminectomy and then multiple revisions for surgical site infections. Prior to admission to LTAC had multiple complications with outpatient treatment including PICC infections and repeat ER visits for irretractible pain. Lumbar wound with multiple surgeries to area for infected hardware and finally removal of hardware on Dec 5 2010 with I & D of lumbar area. Lumbar wound left open to heal by secondary intention due to concern for infection and scar tissue. All cultures negative from multiple surgeries except original cultures of area noted to be MSSA. Lumbar fluid negative for beta 2 transferrin. Admitted to LTAC after last surgery for wound care, IV antibiotics and pain management. Negative Pressure Wound Therapy continued to area with serial debridements to remove nonviable tissue. MRSE cultured from wound 12-27 but thought to be possible contaminant. After wound bed preparation, PRP applied to wound bed 12-29-10. Local dressing care with nonadhering adaptic and telfa with gauze utilized post procedure with VAC on hold. Delayed secondary closure in staged manner to lumbar area. Wound continued to drain slightly but patient requested complete closure prior to discharge from hospital. Staged closure done on 1/12/11 to proximal, 1/19/11mid portion and to complete the closure 1/26/11. Did remarkably well post discharged and wound completely healed 2/4/11with suture removal.
12/10/2010
12/15/2010
12/20/2010
12/27/2010 12/29/2010
12/29/201012/29/2010
12/30/2010
1/5/2011
1/3/2011
12/30/10
Case Study 2 Abdominal Wound
64 year old patient with history of PVD, afib, chronic kidney disease who initially hademergent sigmoid resection with colostomy for perforated diverticulum andpneumonperitoneum on 9/24/2010. He later dehisced his abdominal surgical woundpost-op and required repair of dehiscence on 10/5/2010 with surgical wound left open toheal by secondary intention with Negative Pressure Wound Therapy and IV antibiotics.Readmitted to hospital 2 weeks later with severe confusion and enterococcal bacteremiathought to be from infected line versus endocarditis due to suspicious 2D echo, newmurmur, and bacteremia with patient unable to have TEE. Also found to have bilateralmurmur, and bacteremia with patient unable to have TEE. Also found to have bilateralpulmonary emboli. Treated for tricuspid valve endocarditis and cognative status returnedto baseline. Wound improved significantly with antibiotics and NPWT.Underwent platelet rich plasma application on 11/24/10. Unfortunately noncompliantwith follow up visits due to difficulty in traveling great distance for appointment but wifereports wound healed 3/17/11. No further pictures were able to be obtained but homehealth did confirm healing and discharge from their services mid March.
11/24/2010 11/24/2010
12/2/201012/8/2010
Case Study 3 Infected Abdominal Mesh
52 yr old female with history of multiple abdominal surgeries including gastric bypass with reversal and post operative surgical infections with resistent organisms. Retained infected abdominal mesh with nonhealing abdominal wound since 2007. Mesh could not be removed secondary to being adhered to bowel. Had several courses of IV antibiotics and now on long term suppression therapy with doxycycline. Presented again with protruding fluctuant area on previously healed incision line in June 2010. Opted to return to University hospital where surgeon located. Presented back to wound clinic December 2010 with marked improvement in inflammation but mesh remained visible in the wound. Directly admitted to triumph for IV antibiotics, local wound care and serial debridements. Once local inflammation under control and cultures negative, underwent platelet rich plasma on December 29. PRP injected into margins and applied to wound bed. Wound completely healed end of January and continued on oral suppressive meds with doxycyline for MRSA and retained abdominal mesh.
Patient returned to University facility under care of her Surgeon. Did not see for nearly 6 months. Presented back to wound clinic with marked improvement in inflammation but mesh remained visible in the wound. Directly admitted to triumph for aggressive wound care and IV antibiotics.
6-24-20106-24-2010
6-24-2010
Case Study 4 Nonhealing Abdominal Wound
58 yr old female with history of multiple abdominal surgeries including hysterectomy for endometrial cancer and Whipple procedure in past. Most recent surgery performed for hernia repair secondary to incarcerated bowel on 10-25-2010. Abdominal wound left open after multiple abd surgeries due to infected mesh after hernia repair. Previous whipple and significant scar tissue so surgery deemed her not felt to be a surgical candidate for removal of mesh so deep abdominal wound healed by secondary intention. Transferred to LTAC 11-8-2010. Initial cultures revealed enterococcus and ecoli so short course Tygacil initiated 11-8-2010. Had other medical problems including sinus tachycardia, elevated liver enzymes and rt pleural effusion which required pleural drain insertion. Utilized Negative Pressure Wound Therapy to abdominal wound and serial debridements with tissue cultures during LTAC treatment course. Once tissue quality improved and cultures negative, Plate Rich Plasma therapy performed 11-24-2010. Wound care post PRP included contact layer and AMD gauze. Cutaneous fistula post PRP at distal edge of wound healed remarkably well and was confirmed by CT scan NOT to communicate with bowel. Discharged home on 12-8-2010 off antibiotics and local care with AMD gauze. Wound completely healed when seen in outpatient Wound Clinic in January 6,2011.
11/8/201011/17/2010
11/24/2010
11/24/2010
PRP applied and adaptic to wound bed covered with non-adhering dressing (telfa) and layered gauze with clear occlusive dressing to monitor drainage.
Case Study 5 Dehisced cervical surgical wound
Unfortunate 75yr old diabetic male on plavix for previous heart stents who slipped on ice on January 13,2011 and developed epidural hematoma with immediate paraplegia secondary to spinal cord compromise. Underwent surgery for evacuation of hematoma and laminectomy of affected posterior neck area. Initially post operative did well but surgical incision dehisced January 31, 2011 leaving large open posterior neck wound with fascia visible. Consulted for wound management after dehiscence in an effort to heal wound quickly so transfer to specialized rehab center could be done. Cultures initially negative but repeat cultures showed growth of gram negative rods. Continued on appropriate IV antibiotics and negative pressure wound therapy utilized to area. After nonviable tissue removed with excisional debridement and wound bed prepared, tissue expander device applied to area in conjunction with negative pressure wound therapy on Feb 23, 2011. Wound more approximated after device removed but significant crevices and depth remained. Plastic surgeon consulted for skin grafting options but depth and tunneling deterred any surgical plans by plastics. Wound re-cultured which was negative and staged wound matrix utilized on March 3, 2011. Platelet Rich Plasma applied to wound with collagen powder March 9, 2011. PRP greatly improved the depth as well as filled crevices. Patient able to be transferred March 16, 2011 for aggressive rehab with simple dressing to remaining superficial wound. Seen in follow up after discharge from University rehab center with hypergranular wound bed treated with silver nitrate. Healed essentially by June 10 .
Patient seen initially the day after posterior neck incision dehisced and after all staples had been removed per
surgeon
1/31/2011
3/9/2011
Case Study 6 MRSA in Post Surgical Wound
44 yr old female with history of the left hip replacement done in feburary 26th of 2010. Since the surgery she was having some foot drop problem which was diagnosed as being having peroneal vein compression an underwent surgery on 10/8/10. The intraopculture was noted to be positive for mrsa. Patient first seen on 10/12/10 in the office. Attempted to heal the wound with local care and iv antibiotics. Improvement noted but the wound has dehisced open once the sutures were removed. She was started on wound vac after debridment and continue on daptomycin and po cipro. She had PRP application to the left knee lateral wound done 11/24/10 and 12/15/10. she has been using alginate to the ulcer after vac was stopped. Healed completely April 2011.
10/25/2010
11/10/201011/5/2010
10/25/2010 11/24/201011/19/2010
11/24/2010 11/29/2010
1/12/2011
1/26/2011 1/27/2011 2/4/2011
12/1/2011
11/25/2011
12/7/2011
12/23/2010
1/6/2011
3/16/20113/20/11
4/20/20114/13/11
12/8/2010 12/15/2010
12/15/2010 12/22/2010
12/29/2010 1/5/2011
3/9/20112/9/11 6/2/2011
Ravi K. Kamepalli MD, CWSRegional Infectious Diseases and Infusion Center, Inc.
830 West High St., Suite 255Lima, Ohio, USA,45801
Office: 419-228-1535Email: [email protected]: www.nobadbugs.com
