Wound cleansing is an essential part of wound therapy that allows transition to subsequent therapies in order to promote granulation tissue formation and epithelialization and provide wound coverage or primary closure. Negative pressure wound therapy with instillation and dwell time (NPWTi-d; V.A.C. VERAFLO Therapy, KCI) utilizes the instillation of topical wound solutions and negative pressure for wound cleansing and removal of infectious materials.1-5 This approach has gained increasing utilization and interest due, in part, to the increasing complexity of wounds and patient conditions. Best practices for the use of NPWTi-d have shifted in recent years based on a growing body of evidence and expanded worldwide experience with the technology. Although initially largely used as a last-resort therapy, clinicians are using NPWTi-d to influence the wound healing process by combining the mechanisms of action of standard NPWT (ie, to draw wound edges together, promote perfusion and granulation tissue formation, remove exudate, and reduce edema) with the benefits of cyclic cleansing that dilutes and renders wound debris soluble.
Early experiences with NPWTi-d indicated the therapy assists with wound bed preparation. In the acute care setting where the length of hospital stay is so important, Kim et al3 and Gabriel et al4 showed the clinical efficacy of NPWTi-d in comparison to traditional negative pressure wound therapy (NPWT) without instillation reduced the length of hospital stay and the number of operative debridements, along with fewer days to definitive surgical closure.
The 2019 international consensus guidelines update1 notes NPWTi-d may be used as an adjunct therapy in traumatic wounds; surgical, including dehisced, wounds; diabetic wounds; venous leg ulcers; pressure injuries/ulcers; wounds with exposed intact bone; wounds with treated, underlying osteomyelitis; infected or contaminated wounds in the presence of orthopedic fixation hardware; full-thickness burns after excision; wounds resulting from evacuation of a hematoma and when hemostasis is achieved; and wounds that are a bridge between staged/delayed amputation. Compatible solutions that may be used with NPWTi-d with reticulated open cell foam-V (VERAFLO) or reticulated open cell foam; Cleanse Choice dressings include normal saline, hypochlorous acid (HOCl) solution, sodium hypochlorite solution (dilute Dakin’s solution 0.125%), acetic acid solution (0.25% to 1.0%), and polyhexamethylene biguanide (0.1%) + betaine (0.1%).
Although the consensus panel concluded that normal saline was their instillation solution of choice, other solutions may be of greater assistance in wound bed preparation, specifically when surgical closure is anticipated. However, bioburden must be addressed to achieve surgical success. Whether related to its mechanics or fluid dynamics, NPWTi-d can help reduce the bacterial load and subsequently the incidence of postoperative infection.