Use of Negative Pressure Wound Therapy With Instillation and a Novel Reticulated Open-cell Foam Dressing With Through Holes at a Level 2 Trauma Center

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Level 2 trauma centers offer care for a variety of complex wounds, including surgical wounds, traumatic injuries, pressure injuries, ulcers (venous, arterial, diabetic foot), and burn wounds. As the population increases and ages, the number of patients requiring wound care also increases. For example, in 2009, 6.5 million individuals in the United States were affected with chronic, complex wounds.¹ In 2014, 141.4 million visits were made to emergency departments in the United States; of these visits, about 25 million were related to acute wounds due to traumatic injury.² These difficult-to-treat wounds can pose a significant burden on health care systems. 

Current wound treatment options for these complex wounds include traditional dressings, advanced wound dressings (ie, provide moisture balance, have antimicrobial properties), or advanced wound therapies (such as hyperbaric oxygen therapy and negative pressure wound therapy [NPWT]). However, these treatment options may fail if debris, infectious materials, fibrinous material, thick exudate, or devitalized tissue are present. Recently, NPWT has evolved to include the automated instillation of topical wound solutions with a user-specified dwell time (NPWTi-d) to provide an automated option for wound cleansing.³ A novel reticulated open-cell foam dressing with through holes (ROCF-CC) provides an option to assist wound cleansing by removing thick wound exudate and infectious material when surgical debridement may not be possible or appropriate.^4-6 The author’s experience using NPWTi-d with ROCF-CC dressings on complex wounds with thick exudate is presented.

This retrospective study focused on patients admitted to TriStar Skyline Medical Center (a level 2 trauma center in Nashville, TN) between January 2017 and November 2017 who received NPWTi-d with ROCF-CC as part of their wound care plan. Patients that did not receive NPWTi-d with ROCF-CC were excluded from the retrospective review.

All patients (N = 19) underwent a thorough wound evaluation. In some patients, previous treatment of wet-to-dry dressings, excisional debridement, silver hydrofiber dressings, collagen dressings, alginate dressings, and NPWT were utilized. If necessary, patient-reported pain was treated with intravenous or oral analgesics. Patients whose wounds tested positive for infection (ie, wound culture or bacterial swab test) were treated with organism-specific intravenous or oral antibiotics. If appropriate, the wounds underwent sharp debridement to remove devitalized tissue. 

The ROCF-CC contact layer with through holes (V.A.C. VERAFLO CLEANSE CHOICE Dressing; KCI, an Acelity Company, San Antonio, TX) was cut to fit wound dimensions and placed in the wound bed. Based on wound depth and size, a thin (8 mm) or thick (16 mm) ROCF-CC cover layer (without holes) was placed over the contact layer to fill the remainder of the wound bed, including undermined areas. An adherent drape was placed over both foam layers and NPWTi-d (V.A.C. VERAFLO Therapy, V.A.C.ULTA Therapy system; KCI, an Acelity Company) was initiated. Therapy cycle parameters included instilling saline or 0.025% Dakin’s solution with a 1-minute to 10-minute dwell time followed by 2 to 3.5 hours of continuous negative pressure at -125 mm Hg or -150 mm Hg. Dressing changes were performed every 2 to 3 days. All patients were discharged from care with advanced wound dressings or NPWT, or they underwent a wound coverage procedure.

Nineteen patients with a mean age of 57.1 ± 18.1 years were treated (Table 1). Comorbidities included diabetes (N = 8), obesity (N = 7), current tobacco use (N = 6), and hypertension (N = 5). Treated wound types included surgical (N = 8), trauma (N = 4), and ulcers/injuries (pressure and non-pressure, N = 7) (Table 2).

The average duration of NPWTi-d with ROCF-CC use was 9.0 ± 6.9 days. All wounds displayed less malodor, reduced devitalized tissue, and improved granulation tissue formation following NPWTi-d with ROCF-CC dressings. Once the wound bed was clean and free of debris, fibrinous material and slough, and/or thick exudate, NPWTi-d with ROCF-CC was discontinued. Following discontinuation, patients were discharged to a skilled nursing facility, long-term acute care facility, home health, or home with encouragement to follow up at a wound care center. In 2 patients at risk of lower extremity amputations due to their complex wounds, amputation was no longer suggested after the use of NPWTi-d with ROCF-CC dressings. 

Case studies

Case 1. A 36-year-old man with type 2 diabetes was admitted to the trauma center with a diabetic abscess on the dorsum of his right foot after stepping on a nail that punctured both the superior and inferior aspects of the foot (Figure 1A). The wound was surgically debrided and continuous NPWT at -125 mm Hg was applied. On postoperative day 2, NPWT was discontinued and NPWTi-d with ROCF-CC was applied at the bedside with 28 mL of normal saline instilled, followed by a 10-minute dwell time and 3.5 hours of continuous negative pressure at -125 mm Hg (Figure 1B, 1C). A nonadherent contact layer dressing (applied underneath the ROCF-CC dressing) was used to protect an exposed tendon during NPWTi-d. After 3 days, NPWTi-d was discontinued, and the patient was discharged home with advanced wound dressings (including collagen dressings and foam dressings). He returned to the wound care center for weekly follow-up visits (Figure 1D, 1E). The wound was 95% healed 16 weeks after admission (Figure 1F).

Case 2. A 38-year-old man presented to the trauma center following open reduction internal fixation of the right tibial plateau after a crush injury, fasciotomy, and 2 incision and drainage procedures on a right lower anterior leg wound. The wound measured 21.5 cm x 11.5 cm x 2.5 cm and was considered to be at high risk for amputation (Figure 2A). Necrotic muscle, bone, and adipose tissue were exposed. Osteomyelitis was ruled out. A moderate amount of serosanguineous drainage was noted. The patient reported a high level of pain and was given analgesics for pain management. Exposed structures were protected with a nonadherent contact layer, and a hydrocolloid dressing (DuoDERM Extra Thin Dressing; ConvaTec, Bridgewater, NJ) was used to protect the wound edges. The NPWTi-d with ROCF-CC dressing was initiated by instilling 18 mL of normal saline with a 5-minute dwell time followed by 3.5 hours of continuous negative pressure at -125 mm Hg. 

After 2 days, the dressing was changed, and NPWTi-d with ROCF-CC dressing was restarted, instilling 12 mL of normal saline with a 2-minute dwell time followed by 2 hours of negative pressure at -125 mm Hg (Figure 2B). 

After 3 days (5 days post presentation), the ROCF-CC dressing was changed, and NPWTi-d was restarted using 10 mL of normal saline with a 3-minute dwell time followed by 2.5 hours of negative pressure at -125 mm Hg (Figure 2C). 

Two days later (7 days post presentation), the ROCF-CC dressing was changed, and NPWTi-d was initiated, instilling 16 mL of normal saline with a 3-minute dwell time followed by 2.5 hours of negative pressure at -150 mm Hg (Figure 2D). 

Three days later (10 days post presentation), the dressing was changed, and NPWTi-d was restarted using 16 mL of normal saline with a 3-minute dwell time followed by 3.5 hours of continuous negative pressure at -150 mm Hg. 

After 14 days, NPWTi-d was discontinued and a dermal replacement graft (Integra Dermal Regeneration Template; Integra LifeSciences, Plainsboro, NJ) was placed in the operating room by the trauma team before the patient was transferred to an out-of-state hospital (Figure 2E). 

In this case, the adjunctive use of NPWTi-d with ROCF-CC dressing may have contributed to successful limb salvage.

Complex wounds pose a significant burden for patients and health care systems and often require the use of advanced wound therapies. One such therapy, NPWTi-d, includes the automated instillation of topical wound solutions with a user-specified dwell time. For the author’s patients, NPWTi-d was used with a ROCF-CC dressing that can assist with wound cleansing by removing thick wound exudate and devitalized tissue. Furthermore, the adjunctive use of NPWTi-d with ROCF-CC dressings contributed to hospital discharge, wound closure, and successful limb salvage in this patient population. 

Use of NPWTi-d combines the benefits of wound cleansing with topical wound solutions with negative pressure. This combination works to dilute and help solubilize infectious material, debris, and exudate that then are removed from the wound via negative pressure. As a viable adjunctive wound care option for a variety of wounds, including traumatic wounds, venous wounds, and diabetic foot ulcers,^7,8 NPWTi-d has been reported to provide a clinical benefit in patients with similar complex wounds as those presented in this case series. Published NPWTi-d literature has reported a significantly decreased (P < .05) number of operating room visits, mean time to final surgical procedure, and mean time to wound closure in patients receiving NPWTi-d compared with patients receiving NPWT.^9,10 A prospective study (N = 131) from Brinkert et al¹¹ reported successful wound closure in 98% of patients. Also, successful surgical wound closure was seen in a majority of patients after NPWTi-d use, including those who had previously failed standard NPWT.¹² In these studies, use of NPWTi-d contributed to positive clinical benefits. Similar positive clinical outcomes were seen in the present patients, although these patients received NPWTi-d with ROCF-CC dressings. 

In addition to the potential benefits of NPWTi-d, the ROCF-CC dressings assist with wound cleansing through the dilution and solubilization of infectious material and thick exudate such as fibrinous material and slough. This may provide a benefit for patients when surgical debridement is not possible or appropriate. Limited published evidence exists describing the use of NPWTi-d with ROCF-CC dressings in the management of complex wounds. Téot et al⁴ described a retrospective 21-patient study examining the use of NPWTi-d with ROCF-CC dressings in large, complex wounds with substantial areas of devitalized tissue and/or fibrinous slough. Of 21 wounds, 20 (95.2%) showed enhanced granulation tissue formation and wound volume reduction with the use of NPWTi-d with ROCF-CC dressings. Fernandez et al¹³ published a 5-patient case series on the use of NPWTi-d with ROCF-CC dressings in pressure injuries; after a mean of 6 therapy days, all wounds showed improved granulation tissue formation, and patients were transferred to a skilled nursing facility. Similar results and increases in granulation tissue in wounds treated with this therapy have been seen at the author’s trauma center. 

This study has some limitations. For example, this study included a small number of patients and a retrospective, noncomparative design. Future large comparative studies are needed to further examine the efficacy and health economic impact of NPWTi-d with ROCF-CC dressings, with comparison to other wound management regimens, on chronic and complex wounds.

In these 19 complex wounds, thick exudate such as fibrinous material and slough were removed during the use of NPWTi-d with ROCF-CC. This therapy was a safe and efficient adjunctive treatment in these wounds. Patient discharge or wound closure was achieved in all cases after the use of NPWTi-d with ROCF-CC.

Author: Lindsey Blalock, MSN, WHNP-BC

Note: The author thanks Julie M. Robertson (KCI, an Acelity Company, San Antonio, TX) for assistance with manuscript preparation and editing.

Affiliation: Integumetrix, Nashville, TN

Correspondence: Lindsey Blalock, MSN, WHNP-BC, Integumetrix, TriStar Skyline Medical Center, 3441 Dickerson Pike, Nashville, TN 37207; elliot.linsmarie@gmail.com 

Disclosure: Ms. Blalock is a consultant for KCI, an Acelity Company.