Photobiomodulation of Surgical Wound Dehiscence in a Diabetic Individual by Low-Level Laser Therapy Following Median Sternotomy
A 48-year-old male presented with the history of coronary artery (triple vessel) disease, type 2 diabetes, hypertension, ischemic heart disease, moderate pulmonary hypertension, and moderate left ventricular systolic dysfunction. CABG was done using three grafts from the saphenous vein, the right and left internal mammary artery with a cardiopulmonary bypass of 127 min. The individual was discharged from the hospital after the 20th postoperative day with an ejection fraction of 39%. On 58th postoperative day, there was a yellowish pus discharge from the surgical wound and pain in both the shoulders. Visual analogue scale (VAS) for pain in the surgical wound and shoulders was 4 and 6, respectively. The wound was surgically explored revealing a length of 21 cm and width of 2 cm for the dehiscence. The wound was classified as stage III wound with sloughing, pressure ulcer scale of healing (PUSH) score of 13 before the commencement of laser therapy. The individual had a New York Heart Association functional classification of III during the treatment sessions.\nInvestigations before the commencement of the therapy were as follows: Hemoglobin – 8.2 g/dL, platelet count – 461 × 103/μL (microliter), erythrocyte sedimentation rate – 140 mm/h; total white blood cells – 11400/μL (microliter), C-reactive protein 36 mg/L, blood urea – 65 mg%, serum creatinine – 1.1 mg/dL, serum potassium 4.5 mEq/L. The individual had a fasting glucose of 115 mg/dL. Moderate growth of gram negative pseudomonas aeruginosa was isolated from a wound swab that was found to be resistant to penicillinase, aminopenicillins, and extended-spectrum penicillin.\nThe individual was on linezolid (600 mg), antiplatelet therapy (aspirin and clopidogrel, 75 mg), atorvastatin, antiarrhythmic agents, furosemide (loop diuretics), isosorbide mononitrate (vasodilators), and beta blockers. For the management of diabetes, a combination of short acting (15 units) and intermediate acting insulin (5 units) was administered daily, during the treatment session. When no significant healing of the wound was noticed in spite of daily dressing, frequent debridement and standard medical care, on the 70th postoperative day (about 2 weeks after the wound dehiscence was noticed), the individual was counselled regarding the nature of treatment with LLLT. LLLT irradiations commenced on 71st postoperative day after the sutures were removed. The individual was evaluated for any possible absolute and relative contraindications with laser therapy at baseline. Before undergoing the irradiation with laser, a written informed consent was obtained.\nThe accuracy for output dosage of the laser machine was tested prior to irradiation using specialized photodiode equipment (dosimeter). After deciding the parameters, the individual was asked to wear wavelength-specific goggles throughout the treatment sessions to obviate any risk of accidental application into the eye. The subject was comfortably placed in a semireclining position with his back and spine well-supported. Before beginning with the irradiation, the surrounding skin surface along the surgical incision was cleaned to enhance the absorption of laser in the wound area. The frequency of the irradiation was kept to once a day for 5 days till 2 weeks.\nA handheld class 4 light-emitting diodes (LEDs) (gallium aluminum arsenide) was used at a distance of 1 cm from the surgical incision. The probe was a collection of 69 such LEDs, of which 34 LEDs of 660 nm had a spectral width of 50 nm at a 50% intensity, an average power of 10 mW, a spot size of 0.2 cm2 and a power density (irradiance) of 50 mW/cm2. The remaining 35 LEDs were of 950 nm wavelength with a spectral width of 50 nm at 50% intensity, generating a total power of 865 mW and a frequency of 156 Hz. For the sternal wound, an energy density of 14 J/cm2 was used for 700 s/session per day and for each shoulder single point was irradiated, anterolaterally with an analgesic dosage of 4 J/cm2 for 240 s/session per day.\nThe PUSH score became 12 and then 9 on the 8th and the 11th days of the irradiation, respectively. The length of the wound remained 21 cm but the breadth decreased to 0.5 cm [Figures and ], and proliferation of healthy granulation tissue filling up the wound deficit was observed on 11th day of irradiation. The VAS score became 2 for the shoulder joints but remained 4 for the surgical incision on the 11th day of the irradiation [Figures and ], approximately 82nd day postoperatively].