We are thrilled the patient in this case study had a positive outcome (“Calciphylaxis: An Unusual Case with an Unusual Outcome,” October 2014). As certified wound and ostomy nurses, however, we are concerned about the methodologies used to treat her throughout her stay on the surgical–medical progressive care unit. Wound care for the patient with calciphylaxis is controversial.1,2 Unfortunately, selecting whirlpool for debridement of a “foul smelling, deep, and necrotic” wound was a poor choice. The ABIM Foundation's “Choosing Wisely” campaign includes recommendations by members of the American Physical Therapy Association. These include encouraging care providers to cease using whirlpools for wound care (for more information, see http://bit.ly/1C0bPug). Although the dressings selected were antimicrobial, the dressing changes “were stressful, causing anxiety and extreme pain. Each session could last up to an hour.” There are antimicrobial dressings available that do not require wound care this frequently and can also provide some palliation to the wound bed. Compatibility with hyperbaric therapy would, of course, need to be considered, but three dressings a day could have been avoided. It's quite obvious how much the nursing staff cared about this patient. However, the wound care rendered doesn't represent the standard of care for patients with calciphylaxis. Mary Arnold Long, MSN, RN, CWOCN-AP Mary Kate Skinner, BSN, RN, CWON Jacqui Streeter, BSN, RN, CWON Charleston, SC Author Tina Wangen, RN, CNS, responds: The “Choosing Wisely” recommendations were released in 2014—after the care of the patient described in this scenario. Hydrotherapy continues to be an option for select patients who have large surface wounds with extensive necrotic tissue.1 According to Tao et al,2 hydrotherapy is a component of wound care used to remove substantial amounts of necrotic debris on large surfaces, decrease wound pain, and, ultimately, accelerate healing. The presence of bacteria or biofilm can be obstacles to healing; however, all wounds have a degree of contamination that does not equate to infection. The use of potassium permanganate effectively controlled the bacteria on this patient's wounds and lowered the risk of cross contamination. Although pulsatile lavage and ultrasonic mist therapy are newer and effective treatments, given the extensiveness of this patient's wounds, hydrotherapy was the best initial treatment. The dressing changes were anxiety producing for her because of the length of time and the significant amount of pain they caused. Different dressings were considered, but the options were limited owing to the degree of her wounds and bioburden. She was also on an air-fluidized bed, necessitating dressings that would keep the wound bed moist, as this type of bed can potentiate hydration issues.3 As more of the necrotic tissue was removed, antimicrobial dressings were implemented and the patient's pain, and therefore anxiety level, decreased.
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