A Consensus Report on the Use of Vacuum-Assisted Closure in Chronic, Difficult-to-Heal Wounds

  • Wed, 9/3/08 - 10:25am
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Author(s): 
R. Gary Sibbald, MD, FRCPC; James Mahoney, MD, FRCSC; and The V.A.C.(R) Therapy Canadian Consensus Group

T he shift toward the practice of evidence-based medicine requires careful review of the literature, coupled with and expert opinion (eminence base) and patient preference. A review of the evidence base for vacuum-assisted (VAC) therapy (KCI, San Antonio, Tex.) and chronic wounds, performed by interdisciplinary wound care opinion leaders, acknowledged although initial clinical results are promising, a need exists for more random controlled studies to guide clinicians in the integration of VAC therapy for patients with chronic wounds. The gap between the best available scientific evidence (eg, case series and case reports) and every day clinical practice (knowledge translation or research utilization) does not give a balanced view of the appropriate application and duration of therapy clinicians, healthcare systems, and patients need. Often, patients' conditions are complex and do not fit into the evidence base of random controlled trials and controlled studies. To enhance the knowledge base, a consensus group may be formed to obtain expert opinion. However, if a consensus group consists of only individuals who are frequent users of VAC technology, conclusions maybe biased.

In order to compensate for the gap in available literature, as well as in consideration of the bias of dedicated users of VAC therapy, the authors synthesized the evidence base with balanced expert opinion (frequent and occasional VAC therapy users) to develop recommendations for VAC therapy in the treatment of patients with chronic wounds. This consensus should be reviewed in 3 years (2006) or when significant new evidence is published.

General Approach to Chronic Wounds

The first approach to patients with chronic wounds is to identify and treat the cause (see Figure 1). The wound-specific cause must be addressed as well as the patient's health in general. The healthcare provider must ascertain whether physiological and/or pharmacological reasons exist that might interfere with healing.2 An overall assessment of general health and wound-specific factors need to be addressed to determine healability before considering adjunctive therapies.

Adjunctive therapies include electrical stimulation, therapeutic ultrasound, and surgery, as well as using the VAC. A number of published random controlled trials have demonstrated that these therapies are effective.3-6 However, translating some of these treatments into everyday clinical practice (efficiency) may be difficult because of lack of standardized guidelines for use (eg, type of electrode for TENS, voltage frequency, local wound application or application to the periwound skin, frequency and duration of treatments, and type of machinery and modality used), as well as a lack of provider expertise and no access to equipment or reimbursement. Surgical procedures such as grafts and flaps can be combined with adjunctive therapies.

Vacuum-assisted closure is an adjunctive therapy consisting of a non-invasive wound closure system that uses controlled local negative pressure to promote the healing of difficult-to-heal wounds.7 The VAC removes exudate from chronic wounds to help establish fluid balance. Increased exudate in chronic wounds can be caused by low albumin,8 congestive heart failure (right-sided), venous insufficiency, outflow obstruction of a vessel, and infection9 - the cause of which must be corrected just as local fluid must be managed (see Figure 2).

References: 

1. Sibbald RG, Williamson D, Orsted HL, et al. Preparing the wound bed - debridement, bacterial balance, and moisture balance. Ostomy/Wound Management. 2000;46(11):14-35.
2. Reddy M, Sibbald RG. Treatment strategies for pressure ulcers. Journal of Geriatrics and Aging. 2002; 5(5):23-25.
3. Kloth LC. Physical modalities in wound management UVC, therapeutic heating and electrical stimulation. Ostomy/Wound Management. 1995;41:19-27.
4. Houghton PE. Effects of therapeutic modalities on wound healing: a conservative approach to the management of chronic wounds. Physical Therapy Reviews. 1999;4(3):167-182.
5. Dyson M. Ultrasound for wound management. In: Gogia PP (ed). Clinical Wound Management. Thorofare,NJ: Slack Inc.;1995.
6. Nussbaum EL, Biemann I, Mustard B. Comparison of ultrasound/ultraviolet-C and laser for treatment of pressure ulcers in patients with spinal cord injury. Physical Therapy. 1994;74:812-825.
7. Morykwas M, Argenta L. Non-surgical modalities to enhance healing and care of soft tissue wounds. Journal of the Southern Orthopedic Association. 1997;6(4):279-288.
8. Zarogen, A. Nutritional assessment and intervention in the person with a chronic wound. In: Krasner DL, Rodeheaver GT, Sibbald RG. Chronic Wound Care: A Clinical Source Book for Healthcare Professionals, Third Edition. Wayne, Pa.: Health Management Publications, Inc.;2001:117-126.
9. Bowler PG, Duerden BI, Armstrong DG. Wound microbiology and associated approaches to wound management. Wound Microbiology. 2001;14(2):244-269.
10. Margolis D, Gross E, Wood CR, et al. Planimetric rate of healing in venous ulcers of the leg treated with pressure bandage and hydrocolloid dressing. Journal of the American Academy of Dermatology. 1993;28:418-421.
11. Tallman P, Muscare E, Carson P, Eaglestein WH, Falanga V. Initial rate of healing predicts complete healing of venous ulcers. Arch Dermatol. 1997;133(1):1231-1234.
12. Friedman SJ, Su WP. Management of leg ulcer with hydrocolloid occlusive dressings. Arch Dermatol. 1988:120;1329-1336.
13. Fabian TS, Kaufman HJ, Lett ED, et al. The evaluation of subatmospheric pressure and hyperbaric oxygen in ischemic full-thickness wound healing. The American Surgeon. 2000;66(12):1136-1143.
14. Morykwas MJ, Argenta LC, Shelton-Brown EI, et al. Vacuum-assisted closure: a new method for wound control and treatment: animal studies and basic foundation. Annals of Plastic Surgery. 1997;38(6):553-562.
15. Joseph E, Hamori C, Bergman S, et al. A prospective randomized trial of vacuum assisted closure versus standard therapy of therapy of chronic non-healing wounds. Wounds: A Compendium of Clinical Research and Practice. 2000;12(3):60-67.
16. Baynham S, Kohlman P, Katner HP, et al. Treating stage IV pressure ulcers with negative pressure therapy: a case report. Ostomy /Wound Management. 1999;45(4):28-35.
17. Deva AK, Siu C. Vacuum assisted closure of a sacral pressure sore. Journal of Wound Care. 1997;6(7):311-312.
18. Armstrong DG, Lavery LA, Abu-Rummnan P, et al. Outcomes of subatmospheric pressure dressing therapy on wounds of the diabetic foot. Ostomy/Wound Management. 2002;48(4):64-68.
19. Falanga V, Sabolinski M. A bilayered living construct (APLIGRAF) accelerates complete closure of hard to heal ulcers. Wound Repair and Regeneration. 1999; 7(4):201-207.
20. Chesher E. Use of vacuum assisted closure in the community. Primary Intention. 1998; 6 (1) 12-15.
21. Greer S, Duthie E, Cartolana B, et al. Techniques for applying subatmospheric pressure dressing to wounds in difficult regions of anatomy. JWOCN. 1999;26:250-253.
22. Kalailieff D. Vacuum assisted closure: wound care technology for the new millennium. Perspectives. 1998; 22(3):28-29.
23. Murphy, Gallagher S. Care of an obese patient with a pressure ulcer. JWOCN. 2001;28(3):171-176.
24. Hartnett J. Use of vacuum assisted wound closure in three chronic wounds. JWOCN. 1998;25:281-290.
25. Philbeck TE, Whittington KT, Millsap MH, et al. The clinical and cost effectiveness of externally applied negative pressure wound therapy in the treatment of wounds in home healthcare Medicare patients. Ostomy /Wound Management. 1999;45(11):41-50.
26. Ford C, Reinhard E,Yeh D, et al. Interim analysis of a prospective randomized trial of vacuum assisted closure versus the Healthpoint System in the Management of Pressure Ulcers. Annals of Plastic Surgery. 2002:9(1):55-61.
27. Philbeck T, Schroeder W, Whittington KT. Vacuum assisted closure therapy for diabetic foot ulcers: clinical and cost analyses. Home Health Care Consultant. 2001;8(3):1-7.
28. McCallon S, Knight C, Valiulus JP, et al. Vacuum-assisted closure versus saline moistened gauze in the healing of post operative diabetic wounds. Ostomy/Wound Management. 2000;46(8):28-34.
29. Steed DL, Donohue D, Webster MW, et al. Effect of extensive debridement and treatment on the healing of diabetic foot ulcers. Journal of the American College of Surgeons. 1996;183:61-64.
30. Krasner D. Caring for the person experiencing chronic wound pain. In: Krasner DL, Rodeheaver GT, Sibbald RG. Chronic Wound Care: A Clinical Source Book for Healthcare Professionals, Third Edition. Wayne, Pa.: Health Management Publications, Inc.;2001:79-89

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