Negative Pressure Therapy in Acute Wounds
Negative Pressure Therapy in Acute Wounds
Background. Negative pressure wound therapy (NPWT) is empirically expanding across the globe. Yet published data with NPWT in acute, contaminated wounds is limited, and several concerns arise regarding contemporary acute wound care NPWT practice. Specifically, there are no evidence-based time intervals specifying when NPWT should be changed after initial placement in such cases; therefore, NPWT was studied in acute, contaminated wounds.
Methods. The authors retrospectively reviewed 86 consecutive patients, and a total of 97 contaminated wounds. All wounds were class IV, based on Centers for Disease Control and Prevention (CDC) criteria. All patients were managed with NPWT. Patient and wound-specific variables were analyzed. Outcome endpoints included durability of wound closure and death.
Results. Mean time of subsequent NPWT after initial placement was 2.9 days, median time 3 days, mode 2 days, and standard deviation (SD) 1.24 days. Durability of wound closure was 73/79 (92%). Deaths were noted in 6/86 (7%) of patients. No deaths appeared related to NPWT.
Conclusions. Based on the findings in this study, analyzing NPWT in the largest known patient cohort of this type, a time interval of 1.7 days to 4.1 days (mean time 2.9 days, SD 1.24), between initial and subsequent placement of NPWT in acute, contaminated wounds is safe and effective.
Negative pressure wound therapy (NPWT) came into widespread clinical use in 1997 after the publication of a subatmospheric wound care technique. Foam or gauze is placed into the wound, which is then covered by a plastic drape and the system set to suction via tubing. The subatmospheric wound care technique has US Food and Drug Administration (FDA) indications in "chronic, acute, traumatic, subacute and dehisced wounds, partial-thickness burns, ulcers (such as diabetic or pressure), flaps, and grafts." The vacuum-assisted closure device (V.A.C., Kinetic Concepts, Inc, San Antonio, TX) is the most widely available commercial product, though at least 9 proprietary products exist worldwide.
Negative pressure wound therapy is in widespread use with more than 338 million vacuum-assisted therapy days reported worldwide during a 2-year period from 2009–2011, (oral communication, Steven Jackson, director of regulatory compliance, KCI, 7/1/2011), with availability in 25 countries as of 2012. These figures demonstrate an expanded clinical use of NPWT in acute wound care across the globe. This includes empiric applications of NPWT in contaminated wounds, of which there is currently limited published data. Such contemporary empiric NPWT practice has involved treatment of wounds sustained in military conflicts, terrorist attacks, natural disasters, and developing countries. In addition, the value of NPWT in helping to stabilize patients with acute, complex, and contaminated wounds for transport is undergoing formal evaluation by the United States military.
Though there is limited published data on the use of NPWT in acute, contaminated wounds, contemporary writings specifically denote "monitoring closely," stating such wounds "may require more frequent dressing changes." These concerns appear to arise from a theoretic potential for sepsis with the use of NPWT in necrotic and/or infected wounds. Albeit rare, there are case reports detailing such occurrences, yet published recommendations are scant and without reference relating to a defined time interval for subsequent NPWT changes after initial placement in acute, contaminated wounds. Therefore, the authors studied this paradigm to guide evidence-based practice.
In an effort to most accurately address the proposed question, the authors restricted the study to patients with acute, contaminated wounds. All wounds met class IV Centers for Disease Control and Prevention (CDC) criteria for contamination (ie, tissue necrosis and/or infection). Also, as the vast majority of patients in this cohort met sepsis criteria, this further defined the acuity of these wounds and corroborated the characteristics of the patient cohort being evaluated. The results of this study provide evidence-based guidance for a safe and efficacious time interval of subsequent NPWT change after initial placement in acute, contaminated wounds.
Abstract and Introduction
Abstract
Background. Negative pressure wound therapy (NPWT) is empirically expanding across the globe. Yet published data with NPWT in acute, contaminated wounds is limited, and several concerns arise regarding contemporary acute wound care NPWT practice. Specifically, there are no evidence-based time intervals specifying when NPWT should be changed after initial placement in such cases; therefore, NPWT was studied in acute, contaminated wounds.
Methods. The authors retrospectively reviewed 86 consecutive patients, and a total of 97 contaminated wounds. All wounds were class IV, based on Centers for Disease Control and Prevention (CDC) criteria. All patients were managed with NPWT. Patient and wound-specific variables were analyzed. Outcome endpoints included durability of wound closure and death.
Results. Mean time of subsequent NPWT after initial placement was 2.9 days, median time 3 days, mode 2 days, and standard deviation (SD) 1.24 days. Durability of wound closure was 73/79 (92%). Deaths were noted in 6/86 (7%) of patients. No deaths appeared related to NPWT.
Conclusions. Based on the findings in this study, analyzing NPWT in the largest known patient cohort of this type, a time interval of 1.7 days to 4.1 days (mean time 2.9 days, SD 1.24), between initial and subsequent placement of NPWT in acute, contaminated wounds is safe and effective.
Introduction
Negative pressure wound therapy (NPWT) came into widespread clinical use in 1997 after the publication of a subatmospheric wound care technique. Foam or gauze is placed into the wound, which is then covered by a plastic drape and the system set to suction via tubing. The subatmospheric wound care technique has US Food and Drug Administration (FDA) indications in "chronic, acute, traumatic, subacute and dehisced wounds, partial-thickness burns, ulcers (such as diabetic or pressure), flaps, and grafts." The vacuum-assisted closure device (V.A.C., Kinetic Concepts, Inc, San Antonio, TX) is the most widely available commercial product, though at least 9 proprietary products exist worldwide.
Negative pressure wound therapy is in widespread use with more than 338 million vacuum-assisted therapy days reported worldwide during a 2-year period from 2009–2011, (oral communication, Steven Jackson, director of regulatory compliance, KCI, 7/1/2011), with availability in 25 countries as of 2012. These figures demonstrate an expanded clinical use of NPWT in acute wound care across the globe. This includes empiric applications of NPWT in contaminated wounds, of which there is currently limited published data. Such contemporary empiric NPWT practice has involved treatment of wounds sustained in military conflicts, terrorist attacks, natural disasters, and developing countries. In addition, the value of NPWT in helping to stabilize patients with acute, complex, and contaminated wounds for transport is undergoing formal evaluation by the United States military.
Though there is limited published data on the use of NPWT in acute, contaminated wounds, contemporary writings specifically denote "monitoring closely," stating such wounds "may require more frequent dressing changes." These concerns appear to arise from a theoretic potential for sepsis with the use of NPWT in necrotic and/or infected wounds. Albeit rare, there are case reports detailing such occurrences, yet published recommendations are scant and without reference relating to a defined time interval for subsequent NPWT changes after initial placement in acute, contaminated wounds. Therefore, the authors studied this paradigm to guide evidence-based practice.
In an effort to most accurately address the proposed question, the authors restricted the study to patients with acute, contaminated wounds. All wounds met class IV Centers for Disease Control and Prevention (CDC) criteria for contamination (ie, tissue necrosis and/or infection). Also, as the vast majority of patients in this cohort met sepsis criteria, this further defined the acuity of these wounds and corroborated the characteristics of the patient cohort being evaluated. The results of this study provide evidence-based guidance for a safe and efficacious time interval of subsequent NPWT change after initial placement in acute, contaminated wounds.
