Ethical consideration. The study was carried out according to the principles of the Declaration of Helsinki and ensuring compliance with Spanish Decree 29/2009, which regulates the use of and access to electronic medical records. Informed consent of the parents was obtained for the use of photographs of their son.
History. The patient was a 3-day-old premature baby boy, delivered vaginally at Coruña’s Hospital, Coruña, Spain at gestational week 35 of a twin pregnancy. The baby’s birthweight was 1785 g. The mother had received prenatal care; the pregnancy was unremarkable and all prenatal ultrasounds were normal.
Thirty-six (36) hours after birth, the baby presented with rectal bleeding and abdominal distension. Initially, he was managed medically, using gastric decompression, bowel rest, and intravenous antibiotics. Simple abdominal radiography showed pneumatosis intestinalis; laboratory tests revealed decreased platelet counts (35 000 x 10^9/L) and leucopenia (2500 x 10^9/L). After 48 hours of medical management, the baby showed signs of clinical deterioration, including temperature instability, apnea, and an increase of abdominal distension with abdominal erythema.
On day 3 of life, an exploratory midline laparotomy was performed during which 10 cm of necrosis in the distal ileum were noted and resected. An ileostomy also was performed to control the associated peritonitis, and a Penrose drain was left in the surgical site.
On postoperative day 3, the laparotomy dehisced, including fascial dehiscence and skin necrosis (see Figure 1). The decision was made to apply NPWT. White gauze was manually trimmed to the size of the dehiscence (approximately 12 cm). White gauze was used instead of black foam because in the authors’ experience it fits better in the small abdominal wall of the premature infant.
Nonadherent (silicone) dressing was applied over the wound bed before the gauze to protect underlying structures (bowel wall), and an adhesive drape (see Figure 2) and vacuum pad (see Figure 3) were placed.
Initially, negative pressure was applied continuously at 50 mm Hg (lowest setting available); after 2 hours, the pressure was increased to 80 mm Hg and changed to intermittent therapy (5 minutes on, 30 seconds off). Limited reports of NPWT use in preterm infants do not include protocols to guide the practitioner; the authors relied on anecdotal experience in preterm and neonatal patients. In their center, NPWT is initiated at the lowest setting and increased depending on patient tolerance. Tolerance was evaluated using subjective (signs of pain, irritability, or requirement of analgesics) and objective (hemodynamic changes, monitoring cardiac frequency, arterial pressure, and cardiac output) parameters. Electrolyte balance was monitored every 12 hours. These parameters remained stable and the baby’s health was satisfactory after the device placement. The ileostomy was isolated from the NPWT system without difficulty despite the small space between the 2 sites and protected with a pertrolatum gauze. The surrounding skin tolerated the NPWT system without any complications.
The NWPT system was applied 4 times in 11 days. The dressing was changed every 48 to 72 hours. The amount of fluid exudate removed by the system was measured daily by a trained nurse and replenished — the same amount of fluid excreted was replaced plus basic fluid requirements. After 11 days, the abdominal wall was completely granulated and chlorhexidine applied as a antiseptic. No additional surgical procedures such as suturing of the skin or flap/graft were required for the complete closure of the abdominal wall (see Figure 4). No complications occurred; the baby was discharged on postop day 15 with the stoma and the abdominal wall completely healed, anticipating reconstructive intestinal surgery.