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In September 2010, a male child (A.Z.) was born by Caesarean section at 37 weeks of gestational age. An antenatal diagnosis of congenital left diaphragmatic hernia had been made at 25 weeks of gestational age. At birth the baby weighed 2,860 g (50th percentile), was 49 cm long (50th percentile) and had a head circumference of 34 cm (50th percentile). The 1- and 5-minute Apgar scores were both 4. He was immediately intubated and transferred to the neonatal intensive care unit.
On day 2 he underwent surgical repair of the congenital left diaphragmatic hernia with positioning of a Vicryl mesh. Severe lung hypoplasia and pulmonary hypertension required 15 days of conventional mechanical ventilation, 8 days of high frequency oscillatory ventilation requiring forced supine decubitus, 5 days of nasal continuous positive airways pressure (CPAP), 23 days of oxygen therapy and 15 days of inhaled nitric oxide; also several vasoactive drugs (dopamine, dobutamine, adrenaline, milrinone) were used.
On day 25, three occipital decubitus ulcers developed; two were clean and relatively small (diameter <1 cm). The third, central lesion was 3×3 cm covered by an eschar, and rapidly evolved to stage IV of the US National Pressure Ulcer Advisory Panel classification (Figure 1A)1. Local treatment with enzymatic debridement and paraffin dressings was started. None of the lesions showed signs of infection and the wound swab cultures were negative. No improvement was seen over a 10-day period.
Considering the high risk of superinfection, on day 37 the central lesion was surgically debrided. On the same day, in order to accelerate the healing process and tissue repair, treatment with platelet leucocyte gel (PLG) was also started. Platelets for PLG were obtained from a regular blood donor (screened according to the Italian law) matched for the major blood group phenotype (B+/B+); and stored at −80 °C in sterile Petri dishes.
In detail, a sample of 25 mL of anticoagulated (ACD-A) whole blood was withdrawn and centrifuged at low speed (1,000 rpm) to manually obtain platelet-rich plasma containing a final platelet concentration about 2.5 times higher than the initial peripheral sample. The platelet-rich plasma (11 mL) was produced under sterile conditions; care was taken to collect the white blood cells (WBC). The final product (containing 560×109/L platelets and 12.2×109/L WBC) was then activated by adding a solution of batroxobin and calcium gluconate (2 mL), divided into seven aliquots and finally gelified in Petri dishes2.
PLG was applied topically to all three ulcers on alternate days for 14 days (7 applications): the areas were carefully cleaned with sterile saline solution, the PLG was positioned on the ulcers under sterile conditions, gently pulling from the centre towards the borders of the ulcers (thanks to the plastic nature of the gel itself), and irrigated with the residual PRP in the Petri dish, and finally the lesions were covered with occlusive dressing. A dramatic improvement was evident from the second application of PLG, with rapid appearance of granulation tissue. Definitive healing was obtained after seven applications, without any infectious complications (Figure 1B).
On day 64, the baby was discharged in a good clinical condition; his pressure ulcers had healed, leaving only a small scar in the occipital area.
Decubit ulcers are severe complications and a cause of multiple morbidity and immobility in the field of paediatrics3. The prevalence of pressure ulcers has been reported to be around 27% in paediatric intensive care units and 23% in neonatal intensive care. The incidence of occipital decubitus ulcers in severe ill neonates is probably underestimated. Most pressure ulcers occur within 2 days of admission and are not always preventable or curable. Among other factors, impaired perfusion increases the risk of decubitus ulcers in severely ill neonates4,5.
Although treatment is not standardised, the appropriate care of decubitus ulcers requires adequate preventive and therapeutic measures; however, few data are available on these issues, particularly in the paediatric setting. The most frequent sites of decubitus ulcers in paediatric patients are the occipital region (primary in infants), sacral region (primary in children), ear lobes, and heels6,7.
Recently, Fischer et al. published an interesting report about nasal trauma secondary to nasal CPAP, describing an incidence ranging from 20 to 60%. The risk was significantly higher in patients less than 32 weeks of gestational age, those weighing less than 1,500 g and in those staying in the neonatal intensive care unit for more than 14 days. The local pressure of CPAP devices to the nasal area tends to cause decubitus lesions in the neonate because of the newborn's cutaneous vulnerability8.
To our knowledge, this is the first report of successful treatment of decubitus ulcers with PLG in a newborn patient.
PLG is a relatively new option for ulcer treatment, initially developed for patients with non-healing diabetic foot ulcers. In fact, there is strong evidence of its capacity to stimulate and accelerate wound healing and tissue repair processes9. PLG is a mixture of concentrated platelets and leucocytes which, after activation, becomes a highly tensile, gelatinous mass which can easily be adapted to the damaged area.
The rationale for using PLG in decubitus ulcers is based on the delivery of a large variety of growth factors contained in platelet alpha granules. Platelet-derived growth factors are peptides able to stimulate chemotaxis, differentiation and proliferation of cells involved in wound healing. Furthermore, the leucocytes present in PLG (monocytes, lymphocytes and neutrophils rich in myeloperoxidase) act as efficient anti-microbial agents. Moreover, recent data show that platelets, in addition to white blood cells, can release microbicidal proteins, strengthening the leucocyte activity10–12.
In our patient the healing process was evident as early as the fifth day of treatment; this entails a lower risk of infections and may even shorten the time spent in hospital.
In our experience, the small volume of whole blood required to produce PLG, the simple laboratory procedures need to make the gel, the fact that it can be stored for a long time and its low cost, make PLG a simple and practical therapeutic option.
In high-risk patients (such as neonates with severe life-threatening decubitus ulcers), PLG in association with traditional treatment represents an appealing strategy; however, standardisation in the preparation methodology and definitive confirmation of its efficacy in controlled clinical trials are still needed.
The Authors declare no conflicts of interest.