A rather large wound

Re: A rather large wound

Kate Richardson — Thu, 08 Dec 2011 09:41:30 GMT

I had a very similar case which also healed with conservative treatment. And I really rate manuka honey, its great stuff. Coverts really manky wounds into fresh clean ones within 1-2 days usually.

Re: A rather large wound

Jillian Hall — Wed, 07 Dec 2011 22:07:06 GMT

No surgery beyond the initial tail amputation/stitch up.

I kept saying to the owner we would do reconstructive surgery as soon as we stopped seeing progress with 2nd intention healing - but it just kept slowing plodding along with improvements. Lots of honey, later changing to dry non-adherent dressings and lots and lots of flushing - although its not had any dressing for a good few months now.

I'm very surprised how little scarring there is. The wound contraction has been pulling her anus further and further dorsally/cranially but it doesn't seem to affect her in the slightest.

And yes, it's very refreshing to have a positive outcome

Re: A rather large wound

Niall Taylor — Tue, 06 Dec 2011 18:10:13 GMT

Brilliant - that's a fantastic achievement!

Niall

Re: A rather large wound

Simon Neuhoff — Tue, 06 Dec 2011 15:55:36 GMT

Good stuff! Was this all secondary intention healing or did you do any grafts/flaps?

Re: A rather large wound

Bob Russell — Tue, 06 Dec 2011 11:25:57 GMT

Very impressive - thanks for the update!

Re: A rather large wound

Hannah Wynne Richards — Tue, 06 Dec 2011 10:09:10 GMT

Lovely to see good news

Wynne

Re: A rather large wound

Mark Hedberg — Mon, 05 Dec 2011 22:31:41 GMT

Awesome. Bet the owners are thrilled to bits! Congratulations! :)

Re: A rather large wound

Jillian Hall — Mon, 05 Dec 2011 22:29:46 GMT

Here is what 6 months and a dedicated owner can achieve:

Same cat today.

Re: A rather large wound

Georgie Hollis — Thu, 18 Aug 2011 07:47:44 GMT

[quote user="Emily Herskind Nightingale"]

At a recent CPD course held by Alison Moores from the Willows, she said manuka honey being unpasteurised maintained presence of enzymes that were capable of converting glucose to glucosidic acid which is bacteriocidal (- as far as I can remember).

[/quote]

Yup, that is correct. Pasteurisation (or any high heat) denatures glucose oxidase which is just one of the beneficial enzymes thought to benefit wound healing. furthermore, pasteurisation does not kill the spores of clostridium botulinum (the reason not to give children under 1 year honey to eat) so potentially you are risking the patient's wound by using shop bought honey!?? Manuka in a jar is not necessarily 100% manuka. There was a big issue with a very large and well known chain blending allegedly high UMF manuka honey with australian and other honey to make it go further...just because it says it 'contains' manuka honey doesn't mean its 100%. also look out for 'Kanuka' or the words bioactive... they mean nothing. Food standards are NOT medical standards. its scary when you dig deeper!!

To be honest, the medical honey is not expensive, its cold, gamma sterilised to preserve enzymes, filtered to prevent wax getting in your wounds and at least you can fall back on a company that is promoting it for the purpose.

Just my opinion.

Georgie.

Re: A rather large wound

stuart mcmorrow — Wed, 17 Aug 2011 22:22:44 GMT

Wet to dry then sharp debridement and flaps to close - skin fold and possibly caudal superficial axial pattern.

Re: A rather large wound

Emily Nightingale — Wed, 17 Aug 2011 21:48:29 GMT

Re: A rather large wound

Georgie Hollis — Wed, 17 Aug 2011 19:01:14 GMT

[quote user="Mark Hedberg"]You mean like how all the liquids for sale after airport security are officially safe? ;)

[/quote]

bit of a late reply but love it, and certainly thought that myself, when you are determined there are ways round anything!

Have to disagree that all honey is honey though i'm afraid. Manuka is special, research has proven it (see Peter Molan, Waikato University), yes regular honey works, BUT Manuka works harder for longer... down to the plant phytochemicals that are passed into the honey from the nectar.

If you need proof that this is true try the honey from the Eastern Black Sea region, (Turkey, Georgia and Russia) where they harvest honey derived from nearly pure rhododendron nectar. Its mean stuff! Can stop your heart if you eat too much!

Honey takes on some attributes from its source and Manuka IS special, but you have to decide weither it is worth paying a premium for the medical stuff. I'd say so just so you know you've got the real deal .... (that's another story!!!)

regards the case, would love to see how it looks now.

Re: A rather large wound

Mark Hedberg — Sat, 30 Jul 2011 11:45:23 GMT

You mean like how all the liquids for sale after airport security are officially safe? ;)

Re: A rather large wound

Bob Russell — Sat, 30 Jul 2011 11:26:23 GMT

[quote user="Mark Hedberg"][quote user="Stephen Courtney"]

I've always felt honey is honey...does it really matter if it's Manuka?

[/quote]

Well, co op honey is cheap as chips and a basic yellow honey, so i would agree that yes, honey is honey. The wound moisturizing is what does the trick, not magic manuka-ness.

[/quote]

Fresh honey contains spores so has the potential to be a real problem. The stuff from the wholesaler does not come with this risk.

Re: A rather large wound

Jillian Hall — Sat, 30 Jul 2011 09:26:53 GMT

[quote user="Mark Hedberg"]

I've always felt honey is honey...does it really matter if it's Manuka?

[/quote]

I gather it's not so important if it's Manuka or not, but it should be unpasteurised. Pasteurised honey will still moisturise and inhibit bacteria, but will have lost it's enzymes (altho I'm not sure exactly what the purpose of the enzymes are).

Re: A rather large wound

Mark Hedberg — Sat, 30 Jul 2011 09:11:05 GMT

[quote user="Stephen Courtney"]

I've always felt honey is honey...does it really matter if it's Manuka?

[/quote]

Well, co op honey is cheap as chips and a basic yellow honey, so i would agree that yes, honey is honey. The wound moisturizing is what does the trick, not magic manuka-ness.

Re: A rather large wound

Noweia — Fri, 29 Jul 2011 22:45:35 GMT

[quote user="robloxley"]

The point that granulation tissue will only contract for about 6 weeks, after that you can dress it all you like but the chances of it healing are slim.[/quote]

I thought new epithelial tissue grew under the granulation tissue, so it doesn't matter how much it contracts, it will heal given time?

Re: A rather large wound

Rob Loxley — Fri, 29 Jul 2011 22:31:56 GMT

It's hard to tell from the photos how much is necrotic tissue or maybe honey, but another advocate of wet-to-dry dressings after thorough lavage to really help clean these up, then intrasite/allevyn over a healthy granulation bed. The point that granulation tissue will only contract for about 6 weeks, after that you can dress it all you like but the chances of it healing are slim.

I wonder whether there's such a proliferation of different and ever-new dressings because they all have their place, none of them really work better than the other, or there's just a lot of money to be made from wound dressings??

Re: A rather large wound

Stephen Courtney — Fri, 29 Jul 2011 22:00:39 GMT

I've always felt honey is honey...does it really matter if it's Manuka?

Re: A rather large wound

Mark Hedberg — Fri, 29 Jul 2011 21:28:12 GMT

Just by the by, if you're working someplace where manuka honey can't be had, Co-op squeezy honey works just fine too. :)

Re: A rather large wound

Utlendigur — Fri, 29 Jul 2011 20:40:53 GMT

Was that possibly a burn from contact with the car exhaust? For really necrotic or contaminated wounds I tend to debride surgically initially, then flush and redress daily with the old favourite of wet-to-dry dressings under sedation. After a few days they usually start to granulate and then I switch to allevyn every 2-5days depending on the amount of exudate, sometimes with intrasite gel if still some necrotic tissue (but I stop that once the necrotic tissue has disappeared). Once they start granulating I can't see a reason to culture an open wound. (As aside on resistant infected wounds, I had one dog with a nasty wound with a Pseudomonas infection resistant to most things (except I think gentamicin) and a referral centre suggested flushing with saline, then EDTA, then using flamazine Q 24-48hrs which worked wonders). Another Heath-Robinson response I used to manage two big wounds on a JRT (flank, and over dorsum - shoulder to shoulder) last year was some velcro pads and elastic strips - superglue the velcro to the skin a few cm from the wound edge, attach the other bit to the elastic and stretch it across the wound - takes some of the tension off and holds dressings in place.

After 1 week..

Re: A rather large wound

Alan Tevendale — Fri, 29 Jul 2011 20:31:50 GMT

This will take a fair bit of time I would imagine. Keep flushing - lots, until you have a good healthy bed of granulation tissue present. I try to use hartmans, a 20ml syringe and a 21g needle to get the correct pressure (just as Nowenia says). culture and sens can be of help in cases where the wound isn't healing and might be of benifit in a case such as this. If healing is not progressing checking biochem and haematology is worthwhile as well as checking for underying viral infections. Pain relief is essential in the early stages of this type of wound as this open tissue will be very painful. Once you have a complete bed of granulation tissue you sould notice a good improvement in comfort. Wound contracture will, presuming that infection is under control and the animal is otherwise healthy, take place fairly rapidly and continue for up to somewhere in the region of 6 weeks.

Looking at your photos I think there is certainly evidence of good granulation tissue in places although there certainly still looks to be infection present. The wound margins also look to have some contracture present so obviously things are progressing.

If you are considering surgical closure of this wound I would certainly wait until everything is under control first. Debriding dressings can be useful in the areas of necrotic tissue but otherwise flushing seems to make the most difference. Keep flushing the tissue until it all looks fairly oedematous every time you flush. I remember going on a wound course once where we were advised to keep flushing until everyone in the room is soaked. If funds allow I'd try to flush as often as you can.

Definately agree with everyone about manuka honey - works very well at controlling infection and promoting granulation tissue formation. Once it is there just make sure that the honey doesn't cause overgrowth of the granulation. Could consider changing onto silver although again this is expensive.

I love the surgery for closing these sorts of wounds (although often time consuming) but as previously mentioned in most cases these will close themselves and heal perfectly well given sufficient time.

Re: A rather large wound

Noweia — Fri, 29 Jul 2011 19:16:38 GMT

We had a multi-resistant cat almost residing permanently at our main branch until last year, had a large wound on its flank. It would get so small by itself and then another vet would decide to try and close it over, then we'd get a massive breakdown, and a massive hole again. Went through this cycle several times - so frustrating. Cat was on Surolan as every other antibiotic was ineffective. I eventually instigated thrice daily flushing of the wound with saline (slightly more cencentrated than IV bag stuff) and within weeks we had the hole small enough to go home. So I second all the above suggestions of saline flushing - a 20ml and green needle does the trick.

Re: A rather large wound

Evelyn Barbour-Hill — Fri, 29 Jul 2011 18:53:32 GMT

Keep doing what you are doing till all unhealthy tissue is gone and you have just clean granulation tissue. Unless there is some special evil bacterium there, this time will come. Only then consider all the clever grafting or closure options; which might possbly even prove unnecessary.

In my opinion.

Re: A rather large wound

Jillian Hall — Fri, 29 Jul 2011 18:02:07 GMT

I have recently reduced the frequency of flushing only because of engineering a more complicated dressing which is more difficult for the owner to remove several times per day. We're currently using the Activon honey dressings.

Primary closure is a possiblity but I was planning to wait until all the necrotic skin had gone before assessing this - which is the stage we're almost at now. I had just debreided a large flap of dead skin immed prior to this photo being taken. I think I could make the skin stretch to close at least part of the wound but I would be worried that the degree of tension will lead to further breakdown. That option is still being considered.