We at SALSA, by virtue of the people that we serve locally and beyond, 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 and others to both provide active matrix management (negative pressure wound therapy) with other chemotherapeutic tools to manipulate the wound environment (i.e antimicrobials/antiseptics, analgesics, etc).
Imagine a host of potentially promising modalities infused into the wound.
As an example, our SALSA unit frequently uses an old standby, 0.5% Dakin’s solution run at approximately 30cc/hr (6 or so drips/min using standard IV tubing inserted separately into a VAC device at 125mmHg or an ITI SVED unit as part of its standard kit. Some other modalities (among literally countless) that immediately spring to mind as we explore this area:
- Doxycycline: Its antimicrobial coupled with anti-MMP and anti TNF 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: antimicrobial and immunomodulatory
- Insulin: It is, after all, a growth factor
- Dilantin: we’ve long known that it stimulates fibroblast proliferation.
- Biguanide antiseptics: antimicrobial and wound optimization
In summary: 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 (see “toe and flow”) and how we think about multiple drug/device classes in healing along a timeline. The trouble is, none of us do a good job thinking of this problem in this way or communicating/delivering this to our patients. Let’s think a bit differently.
We’ll be chatting more about this in the future, but we wanted you to begin (or to continue) thinking about both wound “ingress” and “egress” or “input” and “output”. We’d love to hear your ideas.