How To Treat Diabetic Ulcers With Dermagraft

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A Six Step Approach To Using Dermagraft

Here is a step-by-step approach of the standard technique we use for applying Dermagraft at the High Risk Diabetic Foot Center at the Southern Arizona Veterans Affairs Medical Center.

Step 1: Unpack. Dermagraft comes shipped on dry ice. Do not open the box until you are ready to apply the graft. Once you remove it from the box, the Dermagraft pouch is now immediately ready for the thaw phase.

Step 2: Thaw. Proceed to thaw the Dermagraft (in pouch) in warm water (approximately 37ºC) for two to three minutes or until you no longer see any ice crystals. You may perform the thaw phase in the basin, which is usually shipped alongside the Dermagraft box. Once this is complete, continue to the rinse phase.

Step 3: Rinse. Remove the pouch containing the Dermagraft from the warm water basin and transfer it into the specialized Dermagraft rinse container. You may open the top of the pouch with scissors. Use normal saline to rinse the Dermagraft of any preservatives that may still be present after the thaw phase. You should repeat this three times.

Step 4: Trace and cut. You may now remove the open pouch from the specialized Dermagraft rinse container, place the pouch against the wound and trace the wound with a felt-tipped marker. You may also want to trace out a small “tab,” which can help you handle the Dermagraft once it is cut out. Now you can cut out the Dermagraft (including the “tab”), removing the two sides of the remaining pouch to expose the active Dermagraft. You are now ready to place the graft.

Step 5: Apply. Handle the graft with sterile gloves or with atraumatic instrumentation and place it over the wound. You can use cotton-tipped applicators to improve contact with the wound bed and remove any air bubbles between the graft and the wound. We are now ready for our secondary dressings.

Step 6: Dress. We typically will apply a non-adherent gauze dressing (mepitel, conformant) and follow up with a pre-moistened silver-containing dressing (Acticoat-7 or Acticoat Absorbant). Then we apply a foam dressing (Allevyn) and/or standard moistened gauze. If you plan on putting the patient into a total contact cast for a plantar wound, you should limit the bulk of the dressing as much as possible and avoid any dressings that require wrapping around the circumference.

We will typically apply a tacky tape (hypafix) to the above-mentioned construct on the plantar foot in lieu of any type of wrap. If you are using another type of offloading modality, such as a removable cast walker, you may use a more bulky bandage. We will typically have patients return in three to five days for their first dressing changes. We rarely re-debride the wound at that time. At that visit, consider another application of Dermagraft or merely reapply the aforementioned dressing over the wound.

Appropriate, aggressive surgical debridement is a critical part of wound bed preparation.
The authors recommend tracing the wound over the Dermagraft pouch (see above). Below, note how the authors apply a silver-containing dressing (Acticoat) to the wound just over the non-adherent dressing.
After performing aggressive debridement, you should be able to achieve a bloodless field with a compressive dressing prior to applying Dermagraft to the wound.
When it comes to preparing the final dressing, the authors tend to use a foam (Allevyn), tacky tape (hypafix tape) and lambswool interdigitally for forefoot wounds.
36
Author(s): 
By Patricia L. Abu-Rumman, DPM, Barbara Aung, DPM, and David G. Armstrong, DPM

On the day of the procedure, you may apply a standard surgical scrub to the area, with the addition of a final rinse with generous amounts sterile normal saline. You should excise all undermining, hyperkeratotic and necrotic tissue. We will often curette the base of the wound to promote an acute wound environment. Bleeding should be controlled by pressure only. Our staff recommends preparing the wound base and following up with the application of a compressive dressing, consisting of gauze and an elastic conforming bandage.
Remember, the graft is shipped at subzero temperatures and must undergo a rapid thaw procedure. It is necessary to have all the required equipment and liquids ready prior to removing the graft from the shipping container. The manufacturer of Dermagraft supplies a reusable starter kit that contains all the necessary thawing equipment.
The thawing process is reasonably straightforward, but you should perform it within two to three minutes of removing the graft from the refrigerated box. Viability of the dermis tends to degrade after the three-minute period. Once the graft has thawed, you may apply it to the patient within a 30-minute window. Be aware that if you apply the graft after the 30-minute window, it may yield less predictable results because of a decreased prevalence of viable fibroblasts.
Take care to handle the plastic bag only by the edges and avoid the central portion containing the graft. After the thawing process is complete, place the bag over the wound and trace the outline of the wound onto the bag. Add a small tab to the outline to allow for handling. Then you cut on the outline of the bag containing the graft. Separate the graft from the plastic bag and implant it directly in the wound base. You may remove the tab with sterile scissors. It is not necessary to mesh the graft, since it is liquid permeable. You may then place a non-adherent dressing layer over the graft and follow up with a wet to dry dressing. Generally, the graft should not be disturbed for a minimum of 72 hours.
Case Study: When You Have To Modify The Procedure
While the technique (described in “A Six Step Approach To Using Dermagraft” on page 34) is ideal, you may need to make minor modifications to the procedure when faced with other eventualities. For example, consider the following case study.
A 58-year-old Hispanic woman with diabetes came in with an ulceration on the anterior distal tibia region of the left leg. She had the ulcer for several months. We chose Dermagraft as the wound healing modality for this patient. We scheduled the patient for surgical debridement and application of the graft. Upon performing surgical debridement of the wound, we noted the patient had exposed deep fascia but this did not change our treatment plan.
Due to untimely shipping, the starter kit did not arrive with the Dermagraft. However, we used a sterile surgical bowl for the thawing tub and submerged the bag by hand. Once we completed the initial thawing in the water bath, we held the plastic bag upright by the edges and cut open on the printed cutting lines. Then we poured the cryopreservative out and poured sterile saline into the bag for the required rinses. Finally, we filled the bag with sterile normal saline to facilitate removal of the post-debridement compressive dressing.
Due to the excessive handling of the bag, we cut the bag open down the sides and removed the graft in toto. We noted four areas where the graft had adhered to the bag. Using saline-moistened sterile swabs, we gently teased the graft from this adhesive site. We transferred the graft to a saline-saturated 4x4 inch gauze, which we flipped over on top of the wound and placed in the wound base. Using swabs, we spread the graft into the wound base and, using sterile surgical scissors, we trimmed the graft to the wound size.
We applied a non-adherent layer, followed it with Acticoat and then Allevyn, which we cut to the size of the graft. We centered the remaining oversized piece of Allevyn over the cutout and secured it with Hypofix tape. Then we applied gauze and an ace wrap. We recommend this dressing protocol but keep in mind that many surgery centers and hospitals do not routinely stock these items. You may have to order these items and the Dermagraft at the same time.

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Anonymoussays: March 1, 2010 at 11:10 pm Are Dermagraft treatments often used for large , deep wounds? and are they successful? Reply to this comment »

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