To return to the pre-COVID theme (interesting congenital neonatal conditions and their management), this month’s column focuses on a treatment approach commonly used in various neonatal and pediatric cases: the application of negative pressure wound therapy (NPWT).
What we consider modern NPWT was first provided in 1980 by Russian army surgeons; it made its way to the United States by 1989, initially as a method to drain enterocutaneous fistulas. Its use became more accepted in adult medicine in 1990 to facilitate epithelialization and wound closure. Currently, NPWT is used to manage acute and chronic wounds, prevent surgical site infection, and facilitate grafts and incision integrity. NPWT devices have evolved from bulky and cumbersome to small and portable and from traditional canister models to single-use, battery-operated, portable models. NPWT foam dressings have evolved from black, hydrophobic, open-cell polyurethane to white hydrophilic to perforated, less-adhering varieties. Drapes have gone through a similar evolution, leading to strong adhesion with less traumatic removal. Closed incision NPWT is now considered a supportive, preventative modality, and NPWT with installation has added an extra infusion of infection prevention.2
In step with industry, practitioners have made great strides in maximizing opportunities for NPWT utilization. We have evolved from complete fear of pediatric/neonatal NPWT to efficient, safe, and efficacious inpatient and outpatient use of NPWT. This month, I am delighted to share the proverbial lectern with Ferne Elsass, MSN, RN, CPN, CWON, a board-certified wound ostomy and pediatric nurse specializing in pediatric and neonatal wound care at Children’s Hospital of The King’s Daughters, Norfolk, Virginia, for the past 20 years. Drawing on her experience, she describes the use of single-use NPWT to facilitate at-home management of challenging wounds.
Elsass: NPWT is a mainstay treatment for wound care; it improves the granulation within a wound and manages fluid while still maintaining a moist wound environment.1,3 Although still not a popular go-to modality for some pediatric clinicians, NPWT can be and is used with the same frequency and with similar steps and precautions as in adult counterparts.2-4 As with adult patients, a sponge and prescribed negative pressure are applied to the wound bed; use in pediatric patients requires adjustments based on age and weight, along with careful observation.3-5 NPWT has been shown to be safe and effective in neonatal and pediatric patients, providing wound and exudate management and advanced wound healing.7
Although a safe option for the pediatric population, traditional NPWT requires large and cumbersome equipment. The pediatric population and its care providers may find the equipment intimidating and that it further limits patient activity. In addition, neonatal and pediatric patients require closer monitoring related to many of the same concerns that apply to adult patients, such as bleeding and discomfort.3 As such, young patients require an increased amount of restraint related to the equipment, placing additional confines on activity. Dressing changes are suggested several times a week; pediatric patients and their families may feel anxious about dressing changes that often require pain medication and sedation.3-5,7 Dressing removal, if painful, makes future dressing changes overwhelming for patients and their families.2 Because the United States Food and Drug Administration does not recognize NPWT for neonatal or pediatric patients, insurance coverage for outpatient NPWT may be restricted or denied for patients under the age of 12 years, requiring patients to remain in the hospital until the completion of treatment1 or to seek other, nonevidence-based means of wound care.
Single-use/disposable NPWT is an alternative to traditional NPWT. The single-use version consists of a silicone border dressing connected by a tube to a small pump that provides 80 mm Hg continuous suction. The pump on the single-use system stays on for 7 days, and then a new pump and dressing are applied. The drainage is held within the dressing either until the dressing is full or at the end of the 7 days. Single-use NPWT is applied in a similar fashion to a silicone foam border and secured with transparent securing strips on all 4 sides to ensure a tight seal and to prevent the dressing from being easily removed. The primary dressing has a silicone layer and silicone border to allow for ease in placement and removal. No canister or large equipment is necessary, and the suction pump is small enough to clip on a waistband or fit into a pocket. A second dressing is included in the application kit and may be used within the 7 days as needed. The suction pump provides a preset negative pressure.6 Patients in this article were provided the PICO system (Smith & Nephew).
The following case reports demonstrate how single-use NPWT was provided to patients under the care of a surgeon and a pediatric wound and ostomy-certified (WOC) nurse to increase patient mobility, decrease the number of dressing changes, and provide an earlier discharge home.