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In detail, a sample of 25 mL of anticoagulated (ACD-A) whole blood was withdrawn and centrifuged at low speed (1,000 rpm) to manually obtain platelet-rich plasma containing a final platelet concentration about 2.5 times higher than the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.