Vacuum-Assisted Closure (VAC Therapy) and the Risk of Fluid Loss in Acute Trauma

Abstract

T he Vacuum-Assisted Closure (VAC) therapy system has become a common useful adjunct in the treatment of a spectrum of both acute and chronic wounds. 1 The dressing maintains a negative pressure, removing exudate and encouraging granulation. What is often overlooked is the total volume of fluid extracted from these wounds and the effect large volume loss might have on a patient's overall fluid balance. The consequences of VAC therapy on a right-arm fasciotomy wound following axillary artery repair illustrates this point. CASE REPORTA 17-year-old motorcyclist was admitted with polytrauma following a road traffic accident. He had sustained disruption of the right axillary vessels, a fractured right clavicle, a closed fracture of the right femur, and a closed fracture of the left tibia. The right axillary artery required immediate repair with a Dacron graft, while the axillary vein was ligated. Full-arm fasciotomies were performed prophylactically to reduce the risks of a reperfusion injury following inevitable temporary ischemia. Simultaneously, the left tibia was stabilized with an intramedullary nail, and fasciotomies were also performed on the left lower leg. The right femur was stabilized with an external fixator.Once stabilized in theater, the patient was admitted to the intensive therapy unit (ITU). At 48 hours, he returned to theater for wound review and change of dressing. The rightarm wound dressings were very saturated with exudate and the vessels were not exposed. It was therefore decided to apply a VAC dressing at 150 mm Hg continuous negative pressure for ease of ongoing wound care. The left-leg fasciotomies required limited muscle debridement, and difficulty achieving hemostasis contraindicated the use of VAC dressings to the area.The VAC dressing significantly simplified the wound care for the right arm in this ITU patient in that nursing care for the wound was reduced as the dressings were no longer changed daily. However, very large volumes of exudate were noted to be being drawn off, with the consequent need for multiple VAC pump cartridges. The volume of fluid drained peaked at over 3 L in 24 hours on day 5. The right upper limb showed signs of gross edema attributed largely to the disruption of both lymphatic and venous drainage. This was further compounded by the patient's acute inflammatory response to injury, his consequent hypoalbuminemic state, and the use of crystalloid in resuscitation. Following discharge from ITU on day 6, he became steadily hemodynamically compromised due to his large insensible losses and required readmission to ITU the same day for further resuscitation. His renal function and electrolytes remained within normal limits throughout. The fasciotomy wounds continued to receive VAC therapy, with progressively less drainage, until they were successfully grafted at day 12. DISCUSSIONThe use of VAC therapy has become a routine adjunct in wound care across almost all surgical specialties. The spectrum of application in the management of acute and chronic wounds ever widens, a...