Tag Archives: negative-pressure wound therapy

Instill instead: Negative pressure wound therapy with instillation for complex wounds

Negative pressure wound therapy (NPWT) uses negative pressure to draw wound edges together, remove edema and infectious material, and promote perfusion and granulation tissue development. The tissue stretch and compression created by negative pressure during NPWT promotes tissue perfusion and granulation tissue development through angiogenesis, cellular proliferation, fibroblast migration, increased production of wound healing proteins, and reduction of wound area. NPWT has been used to improve healing in a variety of wounds, including traumatic injuries, surgical wounds, pressure ulcers, diabetic foot ulcers, and venous stasis ulcers.

NPWT has now evolved to include automated instillation with dwell time (NPWTi-d, V.A.C. VERAFLO™ Therapy,KCI, an ACELITY Company, San Antonio, TX) that provides wounds with the benefits of both NPWT and wound irrigation. Wound irrigation is an effective, commonly used method to remove debris and infectious material as a means to promote wound healing. This article provides an overview of NPWTi-d.

Support for NPWTi-d

NPWTi-d has been used to treat many different wound types, including traumatic injuries, dehisced surgical wounds, pressure ulcers, diabetic foot ulcers, venous stasis ulcers, and burns. Studies report that NPWTi-d, compared to NPWT alone, decreases the number of surgical debridements, length of hospital stay, and length of treatment. These studies also report improved granulation tissue production and filling of undermined cavities. One study detailed the use of NPWTi-d as adjunctive treatment for bioburden management.

When to use (and not use)

NPWTi-d is primarily indicated for wound cleansing or to promote granulation tissue formation. (See Wound characteristics and NPWTi-d therapy goals.) NPWTi-d is contraindicated for patients with:

• a wound malignancy

• untreated osteomyelitis

• nonenteric and unexplored fistula

• necrotic tissue with eschar.

The treatment also shouldn’t be used with Octenisept® (Schülke and Mayr GmBH, Norderstedt, Germany), hydrogen peroxide, or alcohol-based solutions, or to deliver fluid into the thoracic or abdominal cavity because of the risk to alter core body temperature and cause fluid retention within the cavity. In addition, each wound should be thoroughly explored for intactness before starting NPWTi-d to avoid instilling topical solutions into adjacent body cavities.

Clinical considerations

Several wound irrigation solutions have been recommended for use with NPWTid. (See Instillation therapy settings). Common wound cleansers include normal saline, quarter strength (0.125%) or 0.0125% (one-tenth the concentration of quarter strength due to cytotoxicity) Dakin’s solution, super-oxidized water with neutral pH (Microcyn®, Oculus Innovative Sciences, Petaluma, CA), 0.5% sliver nitrate, and 0.01% polyhexanide (Prontosan® Wound Irrigation Solution, B. Braun Medical, Bethlehem, PA).

Concerns have been raised in Europe regarding polyhexamethylene biguanide (PHMB), a component of 0.01% polyhexanide. It was classified as a cancer-causing agent in concentrations of 1.0% or higher. However, 0.01% polyhexanide contains PHMB in extremely low concentrations (0.1%) diluted with betaine and purified water, so the carcinogenic classification does not apply.

Here are tips to ensure patients receive the optimal benefit from NPWTi-d:

• Become familiar with how to operate the pump. Getting used to the format may require a learning curve.

• Understand that NPWTi-d foam has higher tensile strength than traditional black NPWT foam to facilitate its easier removal from the wound bed and undermined cavities. It’s also less hydro – phobic, which helps to evenly distribute the wound irrigation solutions.

• For very large wounds, traditional black foam may be used in addition to the NPWTi-d foam to fill large wound cavities.  If an additional drape is needed, a traditional drape may be used; however, the NPWTi-d drape is specifically designed to provide enhanced moisture-resistant adhesion along the wound edges to minimize irrigation solution leakage.

• In large wounds, it’s important to keep a running tally of the number of foams used. This will ensure their complete removal during dressing changes and when treatment has been completed.

• Periwound skin is fragile, so take care to protect it before treatment is started. Foam dressings should not come into contact with intact skin. Application of skin preparation products, an additional drape, hydrocolloid dressings, or transparent film over the periwound skin is recommended.

• Know that NPWTi-d can be used with bridging techniques if needed. Use careful attention to ensure the wound cavity is not overfilled, as additional irrigation solution will be required.

• Ensure a good seal because leaks could alter the amount of instillation volume and the negative pressure delivered to the wound and lead to a leak alarm. Apply gentle traction to skin creases and folds to obtain a flat surface for optimal drape adhesion. Apply the drape carefully, avoiding creases or puckering of the drape even in areas where they may overlap. Drape wrinkles may create small, unidentifiable passages for air to enter along the skin or in sections where the drape is overlapped into the foam as the negative pressure is initiated, which could cause a leak alarm. Applying a thin strip of additional drape along the existing edges or a silicone-based skin prep on the overlapped sections of drape may help achieve a good seal.

• Confirm that both the NPWTi-d cassette and canister are fully engaged and latched. Inappropriate placement or latching of the cassette and canister will cause errors in treatment application.

• Check that the NPWTi-d cassette tubing is not kinked, crimped, or blocked and that all clamps are open. This will allow the instillation fluid to be delivered easily into the wound bed.

• Remember that NPWTi-d canisters usually fill more quickly when combining wound drainage with the instilled solutions, so have extra canisters on hand to alleviate this problem. The unit will alarm when the canister is full.

• As the wound improves and the wound dimensions decrease, reduce the amount of solution instilled accordingly. Overfilling the wound may lead to a compromised seal and solution leakage.

• If possible, have an extra bag of prescribed irrigation solution on hand. Solutions other than normal saline will come from the pharmacy. Use quarter strength (0.125%) Dakin’s solution to minimize cytotoxicity. The pump will alarm when the solution bag is empty.

• Remember that you do not need to prime the line when spiking a new solution bag.

• Become familiar with the settings. The home screen on the unit will display the current NPWTi-d phase (Instill, Soak, or NPWT) with a timer indicating time remaining in that particular phase.

• Be aware of any discrepancy between the amount of prescribed solution instilled into the wound and the amount of solution returning into the drainage canister. Decreased or no return of solution may indicate transmission into an internal cavity. If this is the case, immediately stop instillation and notify the prescribing clinician.

• Understand that there is a learning curve with using NPWTi-d. Estimating the amount of solution to be instilled will vary. I have noticed a slight predisposition to overfilling. As such, I have taken 20% off the suggested instillation volume and continue to have success.

See Case study of NPWTi-d for an example of how this treatment can benefit patients.

An optimal patient experience

NPWTi-d helps remove infectious materials and promotes a wound-healing environment by combining the wound management benefits of NPWT and wound irrigation. Obtaining a complete drape seal, achieving appropriate attachment of canisters and cassettes, maintaining an open instillation solution line, and monitoring levels of fluid instilled and returned can contribute to a more comfortable patient treatment experience.

Ron Rock is the nurse manager and clinical nurse specialist for the WOC nursing team in the Digestive Disease Surgical Institute of the Cleveland Clinic in Cleveland, Ohio. R. Rock is a consultant for KCI, an ACELITY Company. The author thanks Julie M. Robertson, PhD (ACELITY) for assistance in the preparation and editing of this manuscript.

Selected references

Back DA, Scheuermann-Poley C, Willy C. Recommendations on negative pressure wound therapy with instillation and antimicrobial solutions – when, where and how to use: what does the evidence show? Int Wound J. 2013;10(1):32-42.

Gabriel A, Kahn KM. New advances in instillation therapy in wounds at risk for compromised healing. Surg Technol Int. 2014;24:75-81.

Gupta S, Gabriel A, Lantis J, et al. Clinical recommendations and practical guide for negative pressure wound therapy with instillation. Int Wound J. 2016;13(2):159-74.

Huang C, Leavitt T, Bayer LR, et al. Effect of negative pressure wound therapy on wound healing. Curr Probl Surg. 2014;51(7):301-31.

Kim PJ, Attinger CE, Steinberg JS, et al. Negativepressure wound therapy with instillation: international consensus guidelines. Plast Reconstr Surg. 2013;132(6):1569-79.

Guidelines for safe negative-pressure wound therapy

By Ron Rock MSN, RN, ACNS-BC

Since its introduction almost 20 years ago, negative-pressure wound therapy (NPWT) has become a leading technology in the care and management of acute, chronic, dehisced, traumatic wounds; pressure ulcers; diabetic ulcers; orthopedic trauma; skin flaps; and grafts. NPWT applies controlled suction to a wound using a suction pump that delivers intermittent, continuous, or variable negative pressure evenly through a wound filler (foam or gauze). Drainage tubing adheres to an occlusive transparent dressing; drainage is removed through the tubing into a collection canister. NWPT increases local vascularity and oxygenation of the wound bed and reduces edema by removing wound fluid, exudate, and bacteria.

Every day, countless healthcare providers apply NPWT devices during patient care. More than 25 FDA Class II approved NPWT devices are available commercially. If used safely in conjunction with a comprehensive wound treatment program, NPWT supports wound healing. But improper use may cause harm to patients. (See Risk factors and contraindications for NPWT.)

Lawsuits involving NPWT are increasing. The chance of error rises when inexperienced caregivers use NPWT. Simply applying an NPWT dressing without critically thinking your way through the process or understanding contraindications for and potential complications of NPWT may put your patients at risk and increase your exposure to litigation.

Proper patient selection, appropriate dressing material, correct device settings, frequent patient monitoring, and closely managed care help minimize risks. So before you flip the switch to initiate NPWT, read on to learn how you can use NPWT safely.

Understand the equipment and its use

Consult your facility’s NPWT protocols, policies, and procedures. If your facility lacks these, consult the device manufacturer’s guidelines and review NPWT indications, contraindications, and how to recognize and manage potential complications. Ideally, facilities should establish training programs to evaluate clinicians’ skills. Enhanced training should include comprehension of training materials, troubleshooting, and correct operation of the device, as shown by return demonstration of the specific NPWT device used in the facility.

Assess the patient thoroughly

The prescribing provider is responsible for ensuring patients are assessed thoroughly to confirm they’re appropriate NPWT candidates. Aspects to consider include comorbidities, contraindicated wound types, high-risk conditions, bleeding disorders, nutritional status, medications that prolong bleeding, and relevant laboratory values. The pain management plan also should be evaluated and addressed.

Assess the order

Before NPWT begins, make sure you have a proper written order. The order should specify:

  • wound filling material (foam or gauze dressing and any wound adjunct, such as a protective nonadherent, petrolatum, or silver dressing)
  • negative pressure setting (from -20 to-200 mm Hg)
  • therapy setting (continuous, intermittent, or variable)
  • frequency of dressing changes.

Follow all parts of the order as prescribed. Otherwise, you may be held responsible if a complication arises—for example, if you apply a nonadherent dressing when none is ordered and this dressing becomes retained, requiring surgery for removal; or if you set a default pressure when none is ordered and the patient suffers severe bleeding or fistula formation as a result.

Assess the wound

If you know what your patient’s wound needs, you can take proactive measures. What is the wound “telling” you? With adept assessment, you can become a “wound whisperer”—a clinician who understands wound-healing dynamics and can interpret what the wound is “saying.” This allows you to see the wound as a whole rather than just maintaining it as a “hole.”

  • If the wound tells you it’s too wet, take steps to absorb fluid or consider increasing negative pressure, as ordered.
  • If it’s telling you it’s dry, consider decreasing negative pressure, as ordered. If the wound bed remains dry, you might want to take a NPWT “time out”. Apply a moisture dressing for several days and assess the patient’s hydration status before restarting NPWT.
  • If the wound says it’s moist, maintain the negative pressure.
  • If it tells you it’s infected, treat the infection.
  • If it tells you it’s dirty, debride it.
  • If it says it’s malnourished, feed it.

The DIM approach

To establish a baseline evaluation, develop a systematic approach for assessing
the wound before NPWT. This will help optimize wound-bed preparation, enhance NPWT efficacy, and prevent delayed wound healing. (See Assessing with DIM.)

Take a time-out
Before you apply the NPWT dressing, be a STARStop, Think, Act, and Review your action. This time-out allows you to critically think your way through the application process and consider potential consequences of your actions.

Ongoing patient assessment and monitoring

Follow these guidelines to help ensure safe and effective NPWT:

  • Follow the device manufacturer’s instructions and your facility’s NPWT protocol, policy, and procedures.
  • Identify and eliminate factors that can impede wound healing (poor nutritional status, limited oxygen supply, poor circulation, diabetes, smoking, obesity, foreign bodies, infection, and low blood counts).
  • Evaluate the patient’s nutritional status to ensure protein stores are adequate for healing.
  • Assess and manage the patient’s pain accordingly.
  • Protect the periwound from direct contact with foam or gauze.
  • Prevent stretching or pulling of the transparent drape to secure the seal and avoid shear trauma to surrounding tissue.
  • Prevent stripping of fragile skin by minimizing shear forces from repetitive or forceful removal of transparent drapes.
  • Use protective barriers, such as multiple layers of nonadherent or petrolatum gauze, to protect sutured blood vessels or organs near areas being treated with NPWT.
  • Don’t overpack the wound too tightly with foam. Compressing the foam prevents negative pressure from reaching the wound bed, causing exudate to accumulate.
  • Position drainage tubing to avoid bony prominences, skinfolds, creases, and weight-bearing surfaces. Otherwise, a drainage tubing related pressure wound may develop.
  • Bridge posterior wounds to the lateral or anterior surface to minimize drainage tubing related pressure wounds to the surrounding tissue.
  • Count and document all pieces of foam, gauze, or adjunctive materials on the outer dressing and in the medical record, to help prevent retention of materials in the wound.
  • Ensure the foam is collapsed and the NPWT device is maintaining the prescribed therapy and pressure at the time of initial patient assessment and when rounding.
  • Address and resolve alarm issues. If you can’t resolve these issues and the device needs to be turned off, don’t let it stay off more than 2 hours. While the device is off, apply a moist-to-dry dressing.
  • With a heavily colonized or infected wound, consider changing the dressing every 12 to 24 hours.
  • Monitor the patient frequently for signs and symptoms of complications.

Evaluate patient comprehension of teaching

A proactive approach to education can ease the patient’s anxiety about NPWT. Unfamiliar sounds and alarms may heighten anxiety and cause unwarranted concerns, so inform patients in advance that the device may make noise and cause some discomfort. An educated and empowered patient can participate actively in treatment. Improved communication may enhance outcomes and help identify errors in technique before they cause complications.

Be prepared to answer patients’ questions, which may include:

  • Am I using the device correctly?
  • How long will I have to use it?
  • What serious complications could occur?
  • What should I do if a complication occurs? Whom should I contact?
  • How do I recognize bleeding?
  • How do I recognize a serious infection?
  • How do I tell if the wound’s condition is worsening?
  • Do I need to stop taking aspirin or other medicines that affect my bleeding system or platelet function? What are the possible risks of stopping or avoiding these medicines?
  • Can you give me written patient instructions or tell me where I can find them?

View: Patient Education

Be a STAR

To avoid patient harm and potential litigation, be a STAR and a wound whisperer. If you’re in doubt about potential complications of NPWT or how to assess and monitor patients, stop the therapy and seek expert guidance. “Listen” to the wound and assess your patient. This may take a little time, but remember—monitoring NPWT, the wound, and the patient is an ongoing process. You can’t rush it. Sometimes, to go fast, you need to go slowly.

Access more information about NPWT.

Selected references
Agency for Healthcare Research and Quality. Technology Assessment: Negative Pressure Wound Therapy Devices. Original: May 26, 2009; corrected November 12, 2009. Available online at: www.ahrq.gov/research/findings/ta/negative-pressure-wound-
therapy/negative-pressure-wound-therapy.pd
f. Accessed January 30, 2014.

Daeschlein G. Antimicrobial and antiseptic strategies in wound management. Int Wound J. 2013; 10(Suppl 1):9-14.

Food and Drug Administration. Guidance for Industry and FDA Staff—Class II Special Controls Guidance Document: Non-powered Suction Apparatus Device Intended for Negative Pressure Wound Therapy. November 10, 2010. Available at: www.fda.gov/MedicalDevices/DeviceRegulationand
Guidance/GuidanceDocuments/ucm233275.htm
. Accessed January 30, 2014.

Food and Drug Administration. FDA Preliminary Public Health Notification: Serious Complications Associated with Negative Pressure Wound Therapy Systems. November 13, 2009. Available at: www
.fda.gov/MedicalDevices/Safety/AlertsandNotices/
PublicHealthNotifications/ucm190658.htm
. Accessed January 30, 2014.

FDA Safety Communication: UPDATE on Serious Complications Associated with Negative Pressure Wound Therapy Systems. February 24, 2011. Available at: /www.fda.gov/MedicalDevices/Safety/
AlertsandNotices/ucm244211.htm
. Accessed January 30, 2014.

Fife CE, Yankowsky KW, Ayello EA, et al. Legal issues in the care of pressure ulcer patients: key concepts for healthcare providers—a consensus
paper from the International Expert Wound Care Advisory Panel©. Adv Skin Wound Care. 2010;23(11):493-507.

Improving the Safety of Negative-Pressure Wound Therapy. Pa Patient Saf Advis. 2011;8(1):18-25. Available at: http://patientsafetyauthority.org/
ADVISORIES/AdvisoryLibrary/2011/mar8(1)/Pages/18.aspx
. Accessed January 29, 2014.

Krasner D. Why is litigation related to negative pressure wound therapy (NPWT) on the rise? Wound Source. Posted November 11, 2010. Available at: www.woundsource.com/article/why-litigation-related-negative-pressure-wound-therapy-npwt-rise. Accessed January 30, 2014.

Lansdown AB. A pharmacological and toxicological profile of silver as an antimicrobial agent in medical devices. Adv Pharmacol Sci. 2010; Article ID 910686. Available at: www.hindawi.com/journals/aps/2010/910686/

Lipsky BA, Hoey C. Topical antimicrobial therapy for treating chronic wounds. Clin Infect Dis. 2009;49(10):1541-9.

RG, Goodman L, Woo KY, et al. Special considerations in wound bed preparation 2011: An update©. Adv Skin Wound Care. 2011;24(9):415–36.

Sibbald RG, Woo KY, Ayello EA. Clinical Practice Report Card: A Survey of Wound Care Practices in the U.S.A. Ostomy Wound Manage. April 2009 Suppl:12-22.

Ron Rock is the nurse manager and clinical nurse specialist for the WOC nursing team in the Digestive Disease Institute of the Cleveland Clinic in Cleveland, Ohio.

DISCLAIMER: All clinical recommendations are intended to assist with determining the appropriate wound therapy for the patient. Responsibility for final decisions and actions related to care of specific patients shall remain the obligation of the institution, its staff, and the patients’ attending physicians. Nothing in this information shall be deemed to constitute the providing of medical care or the diagnosis of any medical condition. Individuals should contact their healthcare providers for medical-related information.