COMPLICATIONS FROM THE USE OF SILVER NITRATEON WOUNDS WITH CELLULOSE DRESSINGS

Authors: Scott Bolhack, MD; Barbara Viggiano, RN; Shirley Grant, LPN; Victoria Hensley, RN

BackgroundComplications from the use of products in the wound center are frequently

underreported in the literature due to many reasons: lack of evidence (multiple

products being utilized at the same time or in rapid sequence), insufficient time

allotted to report, and attributes associated to the wound and not to the product.

Observation The use of silver nitrate is well established in the care of wounds for two main

purposes: hypergranulation and to cauterize bleeding wounds that do not stop

with simple compression. We report two cases that involved the use of silver

nitrate on wounds with the subsequent choice of a cellulose dressing over the

wound. In both cases, the cellulose dressing liquefied the silver nitrate in the

wounds and resulted in periwound leakage in the surrounding healthy skin. In

one of the patients, the leakage resulted in pain where the silver nitrate leaked;

in the other patient, the patient and the spouse were concerned about damage

to the periwound area due to discoloration but no pain occurred.

Actions Due to these two cases, we no longer use cellulose dressings if silver nitrate

has been applied to the wound as part of the treatment plan. The cellulose

dressings are unique in that they purport to have dual properties as it relates

to moisture control in the wound: absorption of fluid and tissue hydration

depending on the wound. This interaction of these two classes of products has

not been reported in the literature.

Case One

This patient had the edges of the wound cauterized with silver nitrate

after debridement. In this case the patient did have burning from

the liquefied silver nitrate; however, no damage occurred to the

underlying tissue.

Case Two

This patient has hypergranulation tissue that was cauterized with

silver nitrate. The spouse took this photograph at home to show us

what had occurred. In this case, no pain occurred from the leakage

and there was no skin damage.

THE USE OF BIOELECTRIC DRESSINGSFOR WOUNDS DUE TO CALCIPHYLAXIS

Authors: Scott Bolhack, MD; Shirley Grant, LPN; Barbara Viggiano, RN; Victoria Hensley, RN

BackgroundThe wounds due to calciphylaxis are challenging to heal. A literature search reveals

descriptions of these wounds but very little guidance related to the treatment.

Case ReportWe cared for a 67 year old female that developed nodular lesions subcutaneously

in her upper thighs. A reluctant surgeon performed surgery to remove these

nodules due to the pain they were causing. Subsequently, the healing process was

stalled and she presented to our wound center eight months after the surgery was

performed with multiple, painful, violaceous wounds. Debridements were limited due

to pain and lack of improvement in the wounds. In addition, multiple dressings were

attempted to close the lesions including antibiotic impregnated dressings, hydrofiber,

and honey-based products. Finally, a bioelectric dressing was used to treat the

wounds with success in both the closure of the wounds and for pain control (apart

from the healing process). The attached pictures demonstrate two of the lesions.

In the second lesion the patient choose to continue her own dressings in the home

setting until closure. Case management confirmed the closure of the wound.

DiscussionWounds due to calciphylaxis are due to the breakdown of skin from the calcification

of microscopic vessels. Treatment regimens for these wounds are not established.

Due to the underlying pathophysiology, debridement of the wounds may not

be helpful except to remove colonized devitalized tissue. Referral back to the

nephrologist to determine if hyperparathyroidism is being addressed or treated

is always warranted. This is the first case in which a bioelectric dressing, a novel

wound product with electrical activity, has been documented to work on wounds due

to calciphylaxis. Six months after closure of her wounds, she remained healed and

free from pain.

This was one of several non-surgical wounds that the patient developed from her calciphylaxis. Note the violaceous color on the skin in the surrounding area. This wound and local skin were very painful for the patient. In the second photograph, we have closure of the wound after four months. We were unable to debride adequately throughout this time period due to pain.

Wound OneThis original wound was a non-healing surgical wound that was open for several months before presenting to the wound center. Again note the violaceous skin. The time to healing was also very extended for this wound. She chose to continue the dressings in the home setting due to multiple health issues including dialysis.

Wound Two