Wound Instillation — The Next Step in Negative Pressure Wound Therapy. Lessons Learned from Initial Experiences

  • Wed, 9/3/08 - 10:25am
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Author(s): 
Tom Wolvos, MD, FACS

N egative pressure wound therapy (NPWT) using the V.A.C. System® (KCI, San Antonio, Tex.) to aid in wound healing was introduced for general use in the US in 1995 following receipt of FDA clearance for marketing. The system consists of a reticulated sponge that is placed into a wound and sealed with a semi-occlusive dressing. Suction tubing is secured over a hole cut in the dressing, allowing contact with the sponge while the other end of the tubing is attached to a machine that delivers negative pressure as suction in a continuous or intermittent fashion. The negative pressure can be set from negative 50 mm Hg to 200 mm Hg, depending on the clinical situation. Generally, the entire dressing, including the sponge and tubing, is changed every 48 hours.

Negative pressure wound therapy provided by this device is indicated for use with acute, subacute, chronic, traumatic, and dehisced wounds, as well as for diabetic ulcers, pressure ulcers, partial-thickness burns, flaps, and grafts.1 This therapy has been shown to aid wound healing in several ways. Animal studies have demonstrated that NPWT decreases bacterial burden in wounds, changing wounds from infected to colonized after 4 to 5 days of use.2 The therapy decreases wound edema and promotes the formation of granulation tissue as compared to wet-to-moist dressings; intermittent NPWT (5 minutes on, 2 minutes off) is even more effective in granulation tissue formation.2 Some evidence suggests that NPWT may help remove some inhibitory cytokines and activated polymorphonuclear leukocytes.3 Negative pressure wound therapy also has been shown to decrease the depth of deep wounds faster than wet-to-moist dressings.4 In a single-blind, randomized, controlled trial involving 24 patients with 36 wounds, NPWT resulted in a statistically significant (P = 0.00001) decrease in wound depth compared to wet-to-moist dressings.

An evolution of NPWT, the V.A.C.® Instill™ has recently been introduced for the acute care setting (see Figure 1). It combines the “traditional” NPWT system with a method to intermittently instill a solution into the wound and is indicated for patients who would benefit from vacuum-assisted drainage and controlled delivery of topical wound treatment solutions and suspensions over the wound bed. Instead of the traditional single tubing, the NPWT with instillation uses two sets of tubing (see Figure 2).The instillation fluid drips by gravity through the first tubing to saturate the sponge and bathe the wound. Then the irrigation tubing is occluded. The fluid is allowed to sit in the wound for a predetermined period of time (from 1 second to 1 hour), after which the vacuum is applied to the suction tubing; thereby, removing the irrigation fluid and wound exudate and collapsing the sponge. Suction is continuously maintained until the entire cycle is repeated according to the amount of time programmed into the unit (1 minute to 12 hours). Typical instillation solutions include normal saline, antibiotics, antifungals, antiseptics, and local anesthetics. Clinical experience at the author’s institution suggests that the new system may decrease the pain that can be associated with the use of traditional NPWT, decrease the bacterial burden of infected wounds, and be more effective than traditional NPWT in “cleaning up” some infected wounds.

Results of a retrospective analysis of case studies detailing the author’s initial experience using NPWT with instillation are presented and lessons learned after reviewing the cases are described.

References: 

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