Basics of Negative 73 Pressure Wound Therapy Douglas Helm, MD, Dennis P. Orgill, PhD, MD, and Lauren Bayer, PA-C ‘What is Negative Pressure Wound Therapy (NPWT)? NPWT isa device or wound care apparatus that applies vacuum to a wound surface. It includes a wound interface material, an adhesive film or drape, and cubing connected to a vacuum source. When was NPWT first introduced? Closed suction drainage has been a long recognized principle of surgery that predates NPWT. However, MOEykWas and Argenta frst introduced the concept of NPWT in the ear ‘What are the indications of NPWT? NPWT is indicated in acute, chtonie, traumatic, and dehisced wounds!ipattialhicl@ess buRss diabetic, pressure, and venous ulcers; aps and grafts ‘What are contraindications to NPWT? NPWT is contraindicated in wounds with @X0i@¢ VASEUAHUE, nerves) ARATORMOUE NS an: (mialighaney in the wound, untreat@d GSTGORVEliGs) necrotic LisUe present in che wound, and ponentetic or ‘Semple. BSG UNEXPLORED tus What is the basic principle of NPWT? ‘The exact mechanism of don of NPWT is multifactorial and includes accelerated wound healing by incteasing ‘granulation tissue formation, removal of wound uid, maintenance of moist Wound cavironment, and contracting the wound edges together What factors do NPWT effect to increase blood flow in the wound? Blood flow is dependent on the pressure applied, distance from the edge, and the tissue (ype (Bleed Maw deereases atthe wound edge, but immediately increases with vacuum release su J but iggesting that intermittent NPW increase blood flow. 609610 Plastic & Reconstructive Surgery Board Review © © How docs NPWT effect wet of draining wounds? Jn patients with large open wounds, serous uid may accumulate in the wound bed and betfieiondy removed BY NPWT leading to accelerated wound healing) What effect does NPWT have on skin surrounding the wound? In wounds where the surzounding skin is deformable, such as the abdomen or thigh, i is commonly observed that the wound shrinks considerably when using an NPWT device O How does NPWT maintain wound homeostasis? ‘Covering the wound with a semiocclusive dressing and using foam with insulation qualities Nie eWApOFAUON) desiccation, and heat loss. © What complications can occur from NPWT? (Bleeding ana inion have been reported by the FDA in a small amber of patents In addon, CARTER bare lo been reported hibitors? Can NPWT be used in patients on anticoagulants or platelet aggregati Extteiieeaution/should be used with patients at high risk of bleeding and hemorthage, on anticoagulants ot platelet aggregation inhibitors © ee CLINICAL USES OF NPWT How is NPWT applied to wounds? [An interface materialised to the sie of the wound and placed on or into the wound bed. The adhesive desing is placed over the wound. Tubing is connceced to the wound through a hoe in the adhesive drape and connected 10 2 collection canister anda vacuum source What is used for the wound-interface material? Many materials can be used including open pore foam, gauze, polyvinyl aleohol sponges, and corrugated polymers ‘Open pore sponges are most commonly used O How does the wound-interface material act on the wound? “The interface material distributes the vacuum throughout the wound and alloves for fluid removal. In addition, the ‘wound-incerface material GSS RVEFOA OHRACONS at NE WOURA SUMFIEE and draws che surrounding skin together. O Can the wound-interface material be hemostatic on the wound? “The wound-interfice materials used in NPWT are not hemostatichnd should not be applied to wounds that are bleeding or have a potential to bleed.© © © CHAPTER 73. Basics of Negative Pressure Wound Therapy 611 Does the wound-interface material have antibacterial properties? ‘The commonly used wound-inteface materials re UEjubstance that hav ISAERSTSEREE opeties and should nos be applied to groilyinfesed wounds. Vere ia ver-impregnat foam thac canbe sed with ‘certain NPWT devices and there are also antibacterial gauze produets that ean be used with the device, ‘What happens to the wound if there is no adequate seal to maintain continuous suction on the wound bed? ‘There GE BER RIERA to maint ‘vacuum of ai will leak into the wound causing desiccation, ‘What pressure is commonly used for NPWT? ‘There ate no established guidelines on the amount of pressure applied in NPWT. Applying a pressure of 12518 Hgis most commonly used, bus pressures betwee 60 ad 150 min Hg havealvo becn applied. ‘What waveforms are commonly used? ‘The original work by MOFYRWAS™aR Argenta showed increased granulation tissue formation with Eling waveforms however, varying the level of suction can cause pain and may not be wel colerated by patients. Instead, “continuous suction is most commonly used. When is a wound ready for NPWT? ‘Wounds may be ready foe NPWT after complete debridement ofinfeeted anid necrotic tissue, Does NPWT debride wounds? NP WT daciinst debride or remove devitalized tissue in wounds but rather aids to accelerate wound healing How often does the wound-interface material need to be changed? ‘There are no specific recommendations for changing the wound-interface material. In heavily colonized wounds, the dressing should be ehatiged every’ 12 t6 24 outs, for several days to make sure the wound is clean. Afterwards, the dressings are generally changed ever 21013) days When changing the NPWT dressing, what should be assessed? ‘The wound should be assessed for infection, odor, and need for Further del should be assessed frequently for duskiness, bruising, and bleeding, The surrounding skin integrity should be monitored for skin breakdown ftom the adhesive drape and rash secondary to contact dermatitis or fungal infection, Devitalized tissue should be removed as indicated with each dressing change, Ifche wound is ‘malodorous, the treatment should be stopped for 24 to 48 hours and replaced with saline dressing: until the odor hhas subsided. Then NPWT ereatment can be resumed, How long can NPWT Be used on « wound? Prolonged usd6fiNPMEINBEVORUISIRTORU inay nOtIbe oN benetieluhléss the wound surface area continues to significantly decrease612 Plastic & Reconstructive Surgery Board Review © © When should NPWT be discontinued? NPWT should be discontinued if the patient docs not tolerate dressing changes or ifthe wound needs to be frequently assessed for infection. Ifthe wound bed is dusky, bruised, or bleeding, the wound becomes grossly infected, ot thete is persistent devitalized tissue present, the therapy should be discontinued. The therapy should. also be immediately stopped if blood or purulent exudate is noted in the suction canister. Can NPWT be used in ditty or grosily contaminated wounds? NPWT devices should be used with exreme caution in infected wounds. Some clinicians use NPWT devices on infected wounds, and if used, the device should be changed every 12 to 24 hours to avoid worsening infection ot spss, O Can NPWT be applied to diabetic wounds? PWT hasbeen sed as a wound healing therapy after debridement of diabetic foot ulcers. Mos of the few randomized diabetic Foot wlect tials compare NPWT to hydeogel, alginate, or gsuze—all indicating beter wound baling with NPWL O How docs NPWT prepare a wound for surgical closure? NPWT prepares the wound bed for surgical closure with skin grafis or tissue substicuces byinicreasinig granulation) \eisueYormacion, decreasing whe sutfice sea, and posibly increasing blood flow coche wound bed What effect docs NPWT have on lower extremity wounds? NPWT can be used in patienss with lower extremity stasis ulcers. In studies of patients with lower extremicy ulcers, there was a end Cowasd less seeondaty amputations With NPWT applied to the wounds compared to nontreated controls. Pacis with lower extremity traumatic injuries, specially ibia-fibula fraccutes, created with NPWT were less likely to require fre flap closure of their wounds and were more likely to be closed primarily or wich simple skin grafts, How is NPWT wsed inthe treatment of an open abdomen? When the abdominal fascia is left open after a laparotomy, NPWT can be applied in the wound to control infection, manage exudate, and reduce visceral edema. Any exposed viscera should be covered with a nonadherent dressing prior to placement of the NPWT wound-interfaee material, O How can NPWT be applied to enterocutancous fistulae? “The fistula can be isolated and controlled from the surrounding tissues by placing wound-ineerface material over the fiscula, Theteluene eat be eontolledy while che surrounding tissues are protected, the tissues can granulate and the wound can contract around the fistula. Additional therapy must be directed at the underlining cause and ‘control of the fstula O Can NPWT prevent burn wound progression? Eauly work by Morykwas showed that NPWT RSvERt#GSUEIAjUEYPHOREEION in sine ace PARTRIANIEKESS ‘buins. There have becn several small studies since, but no robust clinical trial has been performed to asses the theoretical edema reduction, improved tissue perfusion, of less sazring with NPWT.© © © CHAPTER 73. Basics of Negative Pressure Wound Therapy 613 O Can NPWT be used in chest wall wounds following median sternotomies? NPWT allows for wound drainage, chest wall stabilization, and isolation of the chest cavity to prevent contamination, maintenance of a moist environment, granulation stimulation, and increased blood flow to the tissues, After NPWT is used for several days deep sternal Wound, definitive closure is usually performed wit soft tissue flaps, How is NPWT used as a bolster for skin grafts The use of NPWT as a bolster for skin gralts has been shown (/iSREGE GFA AKEcompared with foam bolsters ‘without vacuum. INPWIT is generally used for-48 K0'72,hours and then femoved: A nonadherent material should be applied hetween the skin graft and wound-interface material How is NPWT used to treat lower extremity compartment syndrome? NPT canbe applied flopen fscotomy wounds which decreases the ema and promos granulation ise Formation allowing these wounds to ether completely close in an accelerated manner or contract enough to accept askin graf. What role docs NPWT have in controlling lymphatic injuries? PWT is tfctive in contollinglymphocde or Iymphai fistula with comple resolution ofthe drainage ina “mean of 1 (0 2 weeks. © © @ REFERENCES © © Blume PA, Walters J, Payne W, Ayala J, Lands J. Comparison of negative pressure wound therapy wing vacuum assisted closure with advanced moise wound therapy in the westment of diabetic foot ulcers: a mulkienter randomized controlled til. Diabetes Care 2008; 31(4)631-636. Cothten CC, Moore RF, Jobnion JL, Moote JB, Burch JM. One hundred percent closure af the open abdomen. Am j Sur. 2006; 192:238-242. Hamed ©, Mack PE, Smith IM, Krllman K, G ‘complications after vaeulat procedure: new approach for lymphoceles. J Vae Surg 2008; 48:1520-1523, sal approximation with sequential abdominal fh NM. Use of vacuum-asssted closure (VAC) therapy in treating lymphatic “Morykwas MJ, Argenta LC, Shelton-Brown BI, MeGuirt W. Vacuum-assted closure: a new method for wound contzol and seatment ‘snimal studies and basic foundation. An Plan Surg 1997; 38(6)'553.582 Saxena V, Hwang CW, Huang S, Fichbaum Q. Ingber D, Oxgll DP Vacwum-asssted closure: microdelormations of wounds and cell prolfeation. Plast Reconstr Surg. 2004; 114(5):1086-1096