TIME management by medicinal larvae.

Wound bed preparation (WBP) is an integral part of the care programme for chronic wounds. The acronym TIME is used in the context of WBP and describes four barriers to healing in chronic wounds; namely, dead Tissue, Infection and inflammation, Moisture imbalance and a non-migrating Edge. Larval debridement therapy (LDT) stems from observations that larvae of the blowfly Lucilia sericata clean wounds of debris. Subsequent clinical studies have proven debriding efficacy, which is likely to occur as a result of enzymatically active alimentary products released by the insect. The antimicrobial, anti-inflammatory and wound healing activities of LDT have also been investigated, predominantly in a pre-clinical context. This review summarises the findings of investigations into the molecular mechanisms of LDT and places these in context with the clinical concept of WBP and TIME. It is clear from these findings that biotherapy with L. sericata conforms with TIME, through the enzymatic removal of dead tissue and its associated biofilm, coupled with the secretion of defined antimicrobial peptides. This biotherapeutic impact on the wound serves to reduce inflammation, with an associated capacity for an indirect effect on moisture imbalance. Furthermore, larval serine proteinases have the capacity to alter fibroblast behaviour in a manner conducive to the formation of granulation tissue.

Biodebridement in the Surgical Intensive Care Unit: Unique Therapy for Unique Patients.

Acute care surgery has evolved to encompass the advanced management of complex nonhealing wounds. Biodebridement has the potential to improve the care of chronic wounds for acute care surgery patients, particularly for patients in the surgical intensive care unit (SICU) with hospital-acquired pressure injuries. A case report of biodebridement using larval maggot therapy in the SICU is presented to illustrate real-world application and progression in wound healing. A review of current research involving biodebridement was conducted. A septuagenarian gentleman sustained a fall resulting in cervical spine fractures with neurological deficits. The patient had a prolonged hospital course in the SICU, complicated by myocardial infarction, respiratory failure requiring tracheostomy, and development of a Stage IV sacral pressure ulcer. The wound base was sharply debrided several times and became refractory to conventional mechanical/chemical debridement techniques. The patient had a prohibitively high risk for the operating room but remained too sensate for further effective bedside debridement. Biodebridement was utilized to create a viable wound base, with improved appearance noted within 2 weeks. A review of the current literature shows biodebridement has numerous benefits in the management of chronic wounds. Biodebridement is a unique therapy that possesses great value for select patients in the SICU. In particular, patients who are too high risk for further operative intervention, but too sensate for ongoing bedside debridement and dressing changes, benefit significantly from this underutilized approach. Further research is needed to solidify the place of biodebridement in the surgical management of chronic nonhealing wounds.

Wound Myiasis in Severe Venous Stasis Ulcer.

Although myiasis infestation of wounds presents with significant psychological discomfort to patients, studies have shown that it can be beneficial in the management of recalcitrant ulcers resistant to standard management. Here we report a patient with persistent ulcers unresponsive to standard management who was lost to follow-up for five months and presented with ''maggots in his wound''. This however proved beneficial to the patient as the ulcer showed healthy granulation tissue on presentation and improved healing on follow-up. Our case presents the beneficial effect of myiasis infestation in the 21st century and helps to highlight a time-tested therapy with further encouragement of the use of biotherapy (sterile maggots) for the management of recalcitrant ulcers.