Pearls for Practice: Rapid Wound Bed Preparation Using NPWT With Hypochlorous Acid Instillation

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Bonnie Boie, RN, CWCN, COCN, WOC Lowell General Hospital, Lowell, Massachusetts

Wound bed preparation is the management of a wound in order to accelerate endogenous healing or to facilitate the effectiveness of other therapeutic measures.1 To facilitate wound healing, it is important to remove any necrotic tissue and debris from the wound bed, decrease excessive wound exudate, decrease the tissue bacterial level, and remove deleterious chemical mediators. These actions optimize the wound bed, allowing wound(s) the ability to rapidly accelerate endogenous healing or wound closure.2 

Specialized dressings may need to be used because sharp debridement is not tolerated by some patients and excessive debridement may need to be minimized.3 Hypochlorous acid (HOCl; Vashe Wound Solution; SteadMed Medical LLC, Fort Worth, TX) can be used as a soak; it gently debrides when the soaked tissue is wiped away from the wound.4 Negative pressure wound therapy (NPWT) can be combined with fluid instillation to irrigate and remove fluid from the wound surface (VERAFLO Therapy, KCI, an Acelity Company, San Antonio, TX). This system is designed to facilitate controlled instillation along with a soaking/dwell time so thick wound exudate, fibrin, and other infectious materials may be removed.5 NPWT with instillation recently has been combined with a specialized 3-layer dressing that incorporates a contact layer with 1-cm holes that provide mechanical movement at the wound surface (VERAFLO CLEANSE CHOICE DRESSING, KCI, an Acelity Company, San Antonio, TX).6 This dressing, combined with cyclic delivery and instillation fluid dwell time, rapidly removes debris and thick exudate that is trapped in the outer 2 layers of the dressing, thus preventing the vacuum tube from clogging. 

Combining NPWT with HOCl instillation has proven extremely useful in our practice in shortening the time for wound bed preparation. Three (3) illustrative cases demonstrate the effectiveness of this approach.

Case 1. A 28-year-old man who was a long-time IV drug abuser developed compartment syndrome in his left thigh that required a fasciotomy. Standard postoperative dressings left the wound with thick, purulent exudate (see Figure 1). NPWT was used to cleanse the wound, but it did not optimize wound bed preparation (see Figure 2). NPWT with 33 mL of HOCl instillation and a 2-minute soak was followed by 5 continuous hours of NPWT at -125 mm Hg. This provided excellent wound bed preparation (see Figure 3), which was followed by a successful split-thickness skin graft.

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Case 2. An 82-year-old man with long-standing hypertension and peripheral vascular disease presented with a foot ulcer of 1-year duration. Angiography revealed no correctable lesion. The ulcer included devascularized extensor tendon in the wound (see Figure 4). NPWT with 16 mL HOCl was instilled and left to dwell for 8 minutes, followed by 3 hours of NPWT with CLEANSE CHOICE DRESSING (see Figure 5). Wound bed preparation was sufficient for successful split-thickness skin graft application.

owm_0818_pearls_figure4owm_0818_pearls_figure5

Case 3. A 62-year-old man had developed paraplegia following a motor vehicle accident 43 years prior. He had a sacral pressure injury for more than a year and was not a candidate for ulcer reconstruction because of hypertension, cardiomyopathy, and a Clostridium difficile infection (see Figure 6). NPWT with HOCl instillation was started (10 mL, 7-minute soak) before applying NPWT for 2.5 hours. This was repeated 24 hours later with the CLEANSE CHOICE DRESSING to complete wound bed preparation (see Figure 7). 

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These 3 cases demonstrate the effectiveness of using NPWT (VERAFLO Therapy with instillation), Vashe HOCl solution, and CLEANSE CHOICE DRESSING to remove nonviable tissue and debris to facilitate wound bed preparation. The time to achieving wound bed preparation, in our experience, was shorter than when saline was used for instillation. In addition, the time required for NPWT was reduced when products were used in combination and resulted in optimal wound bed preparation. 

References

1. Schultz GS, Sibbald RG, Falanga V, et al.  Wound bed preparation: a systematic approach to wound management.  Wound Repair Regen. 2003;11(1 suppl):S1–S28.

2. Robson MC. Advancing the science of wound bed preparation for chronic wounds.  Ostomy Wound Manage. 2012;58(12):10–12. 

3. Denham D, Jiongco SE, Robson MC. Hydroconductive dressings used to minimize debridement. Ostomy Wound Manage. 2017;62(10):8–9.

4. Couch KS, Miller C, Cnossen LA, Richey KJ, Guinn SJ. Non-cytotoxic wound bed preparation: Vashe hypochlorous acid wound cleansing solution. Wound Source White Paper. Available at: www.woundsource.com/sites/default/files/whitepapers/noncytotoxic_wound_b.... Accessed November 8, 2017.

5. Driver RK. Utilizing the VeraFlo™ Instillation negative pressure wound therapy system with advanced care for a case study. Cureus. 2016;8(11):e903. doi: 10.7759/cureus.903.

6. Téot L, Boissiere F, Fluieraru S. Novel foam dressing using negative pressure wound therapy with instillation to remove thick exudate. Int Wound J. 2017;14(5):842–845.

Pearls for Practice is made possible through the support of SteadMed Medical, LLC, Fort Worth, TX (www.steadmed.com). The opinions and statements of the clinicians providing Pearls for Practice are specific to the respective authors and not necessarily those of SteadMed Medical, LLC; OWM; or HMP. This article was not subject to the Ostomy Wound Management peer-review process.