At the Southern Arizona Limb Salvage Alliance (SALSA), we are frequently saddled with the most complex patients (and wounds) I have worked with in my career. Our "Toe and Flow" philosophy has been evolving to develop what we call “wound chemotherapy.”
Lately, we have been very active in modifying many of the techniques first described by Wim Fleischmann, MD, PhD, and others to provide active matrix management (negative pressure wound therapy) with other chemotherapeutic tools (i.e. antimicrobials/antiseptics, analgesics, etc.) to manipulate the wound environment.
Imagine a host of potentially promising modalities infused into the wound.
As an example, our SALSA unit frequently uses an old standby in 0.5% Dakin's solution. We provide this solution at approximately 30cc/hr (6 or so drips/min) using standard IV tubing that is inserted separately into a vaccum-assisted closure therapy (VAC therapy, KCI) device at 125mmHg or an ITI SVED unit as part of its standard kit.
As we explore this area, some other modalities (among a literally countless number) immediately spring to mind.
• Doxycycline. Combining this antimicrobial with anti-MMP and anti-TNF alpha effects may prove useful.
• Dilute betadine. In addition to being antimicrobial, iodine stimulates a bit of inflammation. This may be helpful in some "stalled" circumstances.
• Lactoferrin. This is antimicrobial and immunomodulatory.
• Insulin. It is, after all, a growth factor.
• Dilantin. We have long known that it stimulates fibroblast proliferation.
The epidemiology of wounds and diabetic foot complications is, arguably, very similar to cancer. The delivery of care to these patients should be similar as well in terms of how we think about teams and how we think about multiple drug/device classes in facilitating healing along a timeline. The trouble is, none of us do a good job thinking of the problem in this way or communicating and delivering this to our patients. Let us think a bit differently.
We will be chatting more about this in the future but we wanted you to begin (or continue) thinking about both wound “ingress” and “egress” or “input” and “output.” We would love to hear your ideas.
This blog has been adapted with permission from a previously published blog that originally appeared at www.diabeticfootonline.blogspot.com