Received 09/21/2018 Review began 10/15/2018 Review ended 11/14/2018 Published 11/26/2018

© Copyright 2018Matthews et al. This is an openaccess article distributed under theterms of the Creative CommonsAttribution License CC-BY 3.0., whichpermits unrestricted use, distribution,and reproduction in any medium,provided the original author andsource are credited.

The Use of V.A.C. VERAFLO CLEANSECHOICE in the Burn PopulationMarc R. Matthews , Aaron Hechtman , Asia N. Quan , Kevin N. Foster , Luis G. Fernandez

1. Surgery, The Arizona Burn Center, Scottsdale, USA 2. Surgery, Arizona Burn Center at MaricopaIntegrated Health System, Phoenix, USA 3. Pharmacy, Maricopa Integrated Health System, Phoenix, USA4. Surgery, Arizona Burn Center, Phoenix, USA 5. Department of Medical Education, Adjunct ClinicalAssistant Professor, University of North Texas Health Science Center, Fort Worth, Texas, USA

Corresponding author: Marc R. Matthews, marc_matthews@dmgaz.org Disclosures can be found in Additional Information at the end of the article

AbstractNegative pressure wound therapy (NPWT) is routinely used in the treatment of acute andchronic wounds. The technology continues to evolve with improved results NPWT is routinely

used at the Arizona Burn Center and the addition of the V.A.C. VERAFLO CLEANSE CHOICETM

with its reticulated open foam device has been used with promising results in a variety ofcomplicated wounds. We present a case series involving the use of this negative pressure woundtherapy device and irrigation in burn and necrotizing soft tissue patients treated at the ArizonaBurn Center.

Categories: General SurgeryKeywords: burn, cleanse choice, hypochlorous acid

IntroductionContact burns are very prevalent during the Arizona summer [1]. Negative pressure woundtherapy (NPWT) has been effective in the treatment of acute and chronic wounds. NPWT isroutinely used to assist in the formation of granulation tissue, increase in wound blood flow,removal of bacteria and its fibrinous exudate, wound edema, and subsequent wound closure [2].Advances in this technology have allowed for improved results utilizing new devices, such asV.A.C. VERAFLO CLEANSE CHOICE™ (VVCC, KCI, Acelity, San Antonio, TX, US). VVCC is areticulated open cell foam dressing (ROCF) that allows for the instillation of an irrigant in orderto lavage the wound bed with the removal of the thickened wound exudate and prokaryoticmaterials. The VVCC also helps large and complex acute and chronic wounds not only removefibrinous and bacterial exudate but also increases granulation tissue [3-4]. The use ofinstillation therapy with various irrigants (normal saline, prontosan, and hypochlorous (HOCl)acid) have also been described in combination with NPWT and ROCF dressings [3-5]. Such newadjuncts have helped with a more rapid tissue defect contraction, bacterial exudate clearance,and subsequent skin closure with skin grafting techniques. The addition of Vashe® (Stead Med,Inc, Fort Worth, TX, US) (HOCl) instillation therapy provides an effective medium to assist in aneutrophil respiratory burst in the killing of bacteria thereby eliminating any prokaryoticorganisms within 15 seconds of contact. At the Arizona Burn Center, we routinely use VVCC forlarge soft tissue defects following deep skin tangential excisions or soft tissue debridementswhether from burns or necrotizing soft tissue infections. Typically, requiring multiple NPWTchanges over weeks to allow for defect closure prior to skin grafting, VVCC has been trialed atour burn center with encouraging results. The purpose of this case series is to review the useand promising results of VVCC and HOCl irrigation in the treatment of a variety of complicated

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Open Access CaseReport DOI: 10.7759/cureus.3632

How to cite this articleMatthews M R, Hechtman A, Quan A N, et al. (November 26, 2018) The Use of V.A.C. VERAFLOCLEANSE CHOICE in the Burn Population. Cureus 10(11): e3632. DOI 10.7759/cureus.3632

https://www.cureus.com/users/107384-marc-r-matthewshttps://www.cureus.com/users/107409-aaron-hechtmanhttps://www.cureus.com/users/107413-asia-n-quanhttps://www.cureus.com/users/107414-kevin-n-fosterhttps://www.cureus.com/users/103007-luis-g-fernandez

wounds at our burn center.

Case PresentationCase 1: contact burn to left hipA 77-year-old male was admitted for contact burns to the bilateral lower extremities and overthe left hip, involving not only the skin but a burn injury down to the fascia and muscle. Thepatient had multiple medical comorbidities, including diabetes mellitus and hyperlipidemia.After debridement and dressing changes (Figure 1), attempts at grafting the site with split-thickness skin grafts (meshed 2:1, 150 sq cm) resulted in graft loss within days, secondary to aninadequate depth of debridement and the lack of appropriate granulation tissue presence.Therefore, the patient was transitioned into VVCC NPWT to assist in irrigation debridement,granulation tissue formation, and wound contraction with the addition of Vashe® instillationat 30 ml for 20 minutes duration every three hours before returning to suction for over twoweeks. NPWT suction was maintained at 125 mmHg while on suction. Rapid improvement inwound granulation tissue formation was noted (“comedones” or discrete and increasedgranulation tissue within the ROCF hole boundaries, Figure 2). The patient continues to followup in our clinic with planned skin grafting at the time of this manuscript’s submission.

FIGURE 1: Initial debridement of burn eschar revealing deepnecrotic tissue still in place

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FIGURE 2: Rapid improvement in wound granulation tissueshowing classic VVCC “comedone” development withincreased granulation tissue within the ROCF hole boundariesVVCC: V.A.C. VERAFLO CLEANSE CHOICE™; ROCF: reticulated open cell foam dressing

Case 2: contact burn to left buttockAn 87-year-old male was admitted for contact burns following a syncopal episode. The woundswere full thickness burns requiring excision down to the subcutaneous tissue (Figure 3). Asignificant soft tissue defect over the left buttock was noted and VVCC NPWT was placed overthe wound. Vashe instillation was started at 30 ml for 20 minutes every three hours beforereturning to NPWT suction at 125 mmHg, which was applied to assist in the debridement andgranulation of the wound. Short-term therapy with the VVCC resulted in a healthy granulationbed demonstrating near-skin-level comedone granulation tissue formation (Figure 4). Thepatient received an autologous skin graft (meshed 1:1, 200 sq cm) after the completion of VVCCtherapy with 100% skin graft take (Figure 5).

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FIGURE 3: Initial third-degree burn wounds to the patient’s leftbuttocks and hip

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FIGURE 4: Rapid improvement in wound granulation tissueafter several days post-excision showing classic VVCC“comedone” development with increased granulation tissuewithin the ROCF hole boundariesVVCC: V.A.C. VERAFLO CLEANSE CHOICE™; ROCF: reticulated open cell foam dressing

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FIGURE 5: Closure of left buttock and hip wounds afterstandard split-thickness skin grafting techniques

Case 3: contact burns to bilateral buttocksA 61-year-old female was admitted with full thickness contact burns to the bilateral buttocks(Figure 6). Initially, this was debrided down to the soft tissues. After a week of dressingchanges, an autologous skin graft was applied (meshed 1:1, 100 sq cm) but the skin graft failedand necessitated a return to the operating room for further debridement. A VVCC NPWT wasplaced with improved granulation tissue formation (Figure 7). Vashe solution was used toirrigate the wound with 30 ml for a 20 minute dwell time every three hours with a NPWTsuction of 125 mmHg. Eventual split-thickness skin grafting to the bilateral buttocks had a100% graft take (Figure 8).

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FIGURE 6: Initial bilateral buttock contact burn wounds

FIGURE 7: Afterburn wound eschar debridement and severaldays of VVCC, appearance of the classic VVCC “comedone”development with increased granulation tissue within theROCF hole boundariesVVCC: V.A.C. VERAFLO CLEANSE CHOICE™; ROCF: reticulated open cell foam dressing

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FIGURE 8: Closure of the bilateral buttock wounds afterstandard split-thickness skin grafting techniques

Case 4: contact burns to the anterior torso and bilateral lowerextremitiesA 76-year-old male admitted with 21% total body surface area (TBSA) full thickness contactburns to his anterior torso and bilateral lower extremities following a ground level fall. Thepatient was debrided multiple times, which included a right, above-knee amputation, andautologous skin grafting to the anterior upper torso and right thigh. Deeper tissue defects ofthe lower abdomen (Figure 9) and left lower extremity (Figure 10) required the placement of theVVCC NPWT system with HOCl instillation of approximately 30 ml to the lower abdomen and30 ml to the left lower extremity for 30 minutes every three hours with an NPWT suction of 125mmHg. After two weeks of therapy (Figures 11-12), the patient had an autologous skin graftapplied to the anterior torso and left lower extremity (meshed 2:1, 1400 sq cm). There was a100% skin graft take to the lower abdominal torso and 90% skin graft take of the left lowerextremity (Figures 13-14).

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FIGURE 9: Initial debridement of an abdominal burn eschar

FIGURE 10: Initial left leg burn eschar

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FIGURE 11: Followed by the appearance of the classic VVCCcomedones granulation tissueVVCC: V.A.C. VERAFLO CLEANSE CHOICE™

FIGURE 12: Followed by the appearance of the classic VVCCcomedones granulation tissue after the multiple debridementsand applications of the VVCC deviceVVCC: V.A.C. VERAFLO CLEANSE CHOICE™

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FIGURE 13: Finally, closure of the abdominal wound with split-thickness skin grafts

FIGURE 14: Subsequent closure of the left leg wound withsplit-thickness skin grafts

Case 5: necrotizing fasciitis of the lower abdominal wallA 55-year-old female was admitted with a past medical history of multiple medicalcomorbidities, including diabetes mellitus (type 1), rheumatoid arthritis requiringimmunosuppressant therapy, and baseline liver dysfunction. She had an abdominal wall

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necrotizing fasciitis due to an infected subcutaneous insulin pump. The patient underwentextensive debridement down to the rectus fascia and was left with a large soft tissue defect(Figure 15). The patient had placement of the VVCC NPET once the wound was debrided toviable tissue and the initial infection was controlled. The wound has been granulating andcontracting with V.A.C. VERAFLO CLEANSE CHOICE™ also utilizing HOCl instillation of 30ml with a dwell time of 20 minutes every three hours and then returning to a negative pressureof 125 mmHg. Because of the patient’s multiple medical issues and compromised immunesystem that would normally impair wound healing, the patient is weeks away from woundclosure (Figure 16). The patient's therapy was completed with the closure of the woundfollowing split-thickness skin grafting (Figure 17).

FIGURE 15: Large anterior abdominal wound after serialdebridements

FIGURE 16: Contraction of the large anterior abdominal wound

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and development of comedone granulation tissue around asmall area of remaining fibrinous exudate

FIGURE 17: Lower abdomen following completion of therapyand skin grafting

DiscussionThe use of the V.A.C. VERAFLO CLEANSE CHOICE™ (VVCC) has advanced our wound therapyregimen in the burn population and those with large wounds such as necrotizing fasciitis. Someburn center patients have large soft tissue defects following debridement that only requireporcine xenografting or cadaveric allografting before they undergo split-thickness skingrafting while other patients have much deeper defects that require a healthy granulation bedbefore ultimately undergoing closure. The VVCC has provided an opportunity to effectivelyimprove complex wound healing by the better elimination of the necrotic material and fastergeneration of granulation tissue in conjunction with the use of HOCl solution as reported byFernandez and others [5-6]. Heibert and Robson described the reduction in bacterial growthwith the use of HOCl acid compared to normal saline in the treatment of infected wounds [7]. Inaddition, it has been shown that the use of HOCl has led to a decrease in bacterial growth, andthat even at low concentrations of HOCl, bacterial growth and cell division are decreased [8].Studies in vitro have even shown that the presence of a prokaryotic biofilm is disrupted by atleast 90% with just a brief exposure to HOCl [9]. When HOCl is used with an NPWT device, ithas led to the more rapid development of granulation tissue and healthier wound beds [10].Irrigation with HOCL should now be considered instrumental when the ROCF NPWT is usedand irrigation is required to further treat the heavily exudative wounds or wounds that haveheavy prokaryotic contamination before any attempt at closure. Other studies have also shownthe benefit of HOCl solution using Vashe® wound therapy as the principal wound solution fordressings in non-healing and malodorous wounds [11-12].

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ConclusionsWhile this is not the first description of the use of NPWT in the burn population, in ourexperience, the use of VVCC as an ROCF device with the use of HOCl irrigation results in ashorter time to wound closure using skin grafting techniques in the burn or necrotizing softtissue infection patient populations.

Additional InformationDisclosuresHuman subjects: Consent was obtained by all participants in this study. Conflicts of interest:In compliance with the ICMJE uniform disclosure form, all authors declare the following:Payment/services info: All authors have declared that no financial support was received fromany organization for the submitted work. Financial relationships: All authors have declaredthat they have no financial relationships at present or within the previous three years with anyorganizations that might have an interest in the submitted work. Other relationships: Dr.Marc Matthews is a consultant for KCI Dr. Luis Fernandez is a speaker for KCI .

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The Use of V.A.C. VERAFLO CLEANSE CHOICE in the Burn PopulationAbstractIntroductionCase PresentationCase 1: contact burn to left hipFIGURE 1: Initial debridement of burn eschar revealing deep necrotic tissue still in placeFIGURE 2: Rapid improvement in wound granulation tissue showing classic VVCC “comedone” development with increased granulation tissue within the ROCF hole boundaries

Case 2: contact burn to left buttockFIGURE 3: Initial third-degree burn wounds to the patient’s left buttocks and hipFIGURE 4: Rapid improvement in wound granulation tissue after several days post-excision showing classic VVCC “comedone” development with increased granulation tissue within the ROCF hole boundariesFIGURE 5: Closure of left buttock and hip wounds after standard split-thickness skin grafting techniques

Case 3: contact burns to bilateral buttocksFIGURE 6: Initial bilateral buttock contact burn woundsFIGURE 7: Afterburn wound eschar debridement and several days of VVCC, appearance of the classic VVCC “comedone” development with increased granulation tissue within the ROCF hole boundariesFIGURE 8: Closure of the bilateral buttock wounds after standard split-thickness skin grafting techniques

Case 4: contact burns to the anterior torso and bilateral lower extremitiesFIGURE 9: Initial debridement of an abdominal burn escharFIGURE 10: Initial left leg burn escharFIGURE 11: Followed by the appearance of the classic VVCC comedones granulation tissueFIGURE 12: Followed by the appearance of the classic VVCC comedones granulation tissue after the multiple debridements and applications of the VVCC deviceFIGURE 13: Finally, closure of the abdominal wound with split-thickness skin graftsFIGURE 14: Subsequent closure of the left leg wound with split-thickness skin grafts

Case 5: necrotizing fasciitis of the lower abdominal wallFIGURE 15: Large anterior abdominal wound after serial debridementsFIGURE 16: Contraction of the large anterior abdominal wound and development of comedone granulation tissue around a small area of remaining fibrinous exudateFIGURE 17: Lower abdomen following completion of therapy and skin grafting

DiscussionConclusionsAdditional InformationDisclosures

References