Early-stage Management of Complex Wounds Using Negative Pressure Wound Therapy With Instillation and a Dressing With Through Holes

Introduction. An early-stage decision clinicians often make in the management of complex wounds is which method of wound preparation will be appropriate for the patient. This decision can be affected by numerous wound and patient risk factors that present challenges and may make surgical debridement difficult in patients with complex wounds. Recently, negative pressure wound therapy with instillation and dwell time (NPWTi-d) using a novel reticulated open-cell foam dressing with through holes (ROCF-CC) was shown to aid in the loosening and removal of thick exudate and nonviable tissue from wounds. Objective. The authors present their experiences of using NPWTi-d with ROCF-CC, along with rationales for wound care decisions. Materials and Methods. Patients received antibiotics and surgical debridement when appropriate. Therapy selection and parameters were based on a decision-tree model for wound care management that takes into consideration patient and wound information. Most patients received NPWTi-d with ROCF-CC for a duration of 5 to 8 days; however, 1 patient received NPWTi-d with ROCF-CC for more than 30 days due to the wound extent and severity. Therapy consisted of instilling saline or quarter-strength sodium hypochlorite solution with dwell times of 3 to 10 minutes, followed by 2 hours or 3.5 hours of NPWT either at -100 mm Hg or -125 mm Hg. Results. There were 6 patients (3 men, 3 women; average age, 58.5 years) treated. Wound types included 3 pressure ulcers, 1 necrotizing soft tissue infection, 1 perianal abscess, and 1 large abdominal wound. Patient comorbidities included obesity, type 2 diabetes, and radiation therapy. In all cases, progression of wound healing was observed with no complications. This method produced viable granulation tissue and wound bed preparation; however, patients were not followed to closure or grafting. Conclusions. These cases help support the use of NPWTi-d with ROCF-CC as a viable option for wound care providers in the early-stage management of complex wounds.

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Numerous wound healing risk factors (eg, wound size and duration, etiology, anatomical location, and wound infection) and patient-related risk factors (eg, advanced age, nutritional status, vascular disease, and diabetes) are known to complicate and delay wound healing.^1,2 It is recognized that wounds respond better when debrided early; however, comorbidities and/or wound size may make surgical debridement impossible for some patients. 

Recently, negative pressure wound therapy with instillation and dwell time (NPWTi-d) using a reticulated open-cell foam dressing with through holes (ROCF-CC) was shown to aid in wound cleansing by loosening and removing thick exudate and nonviable tissue from wounds.³ Therefore, NPWTi-d using ROCF-CC may provide clinicians an option for wound management in patients who are unwilling or not good candidates for surgical debridement.

The objectives of this study were to present the authors’ rationales for early-stage wound care decisions and present their initial experience applying NPWTi-d using a ROCF-CC to help manage complex wounds.

In this pilot study, 6 patients were treated with NPWTi-d (V.A.C. VERAFLOTherapy; KCI, an Acelity Company, San Antonio, TX) using the ROCF-CC dressing (V.A.C. VERAFLO CLEANSE CHOICE Dressing; KCI, an Acelity Company) at a Level 1 trauma center in Minnesota. None of the patients underwent surgical debridement immediately before the application of NPWTi-d with ROCF-CC at the authors’ facility; however, they had undergone previous debridements when possible at the treating facility or other facilities prior to hospital transfer. The ROCF-CC dressings were changed every 2 to 3 days for all cases, and all patients received antibiotics and sharp debridement when appropriate. The therapy selection and parameters were based on the facility’s decision-tree model for wound care management that takes into consideration patient and wound information (Figure 1).

The NPWTi-d consisted of instilling normal saline or quarter-strength sodium hypochlorite solution (NaClO) with dwell times ranging from 3 to 10 minutes, followed by 2 hours or 3.5 hours of NPWT either at -100 mm Hg or -125 mm Hg. Four of the 6 patients received NPWTi-d with ROCF-CC for a duration of 5 to 8 days, and 2 patients received therapy for more than 8 days. One patient (case 1) received NPWTi-d using ROCF-CC dressings for more than 30 days due to the wound extent and severity (Figure 2, Figure 3, Figure 4, Figure 5, Table). Another patient (case 3) received NPWTi-d using ROCF-CC for 10 days, which was followed by 14 days of continuous NPWT without instillation (V.A.C. Therapy; KCI, an Acelity Company) (Table).

There were 6 patients assessed and treated in this study (3 men, 3 women; mean age, 58.5 ± 13.7 years) (Table). The wound types included 1 large abdominal wound, 1 necrotizing soft tissue infection, 3 pressure ulcers, and 1 perianal abscess (Table). Medical histories and patient comorbidities were extensive and included numerous risk factors impacting wound healing and surgical intervention outcomes (Table). In all cases, progression of wound healing was observed with no complications. The ROCF-CC dressings were removed and NPWTi-d was discontinued when each wound had achieved robust granulation and could undergo primary closure, be covered with a flap or graft, or be transitioned to conventional NPWT or other advanced wound dressings. 

In this pilot study, the authors described 6 cases in which NPWTi-d using a ROCF-CC dressing for early-stage wound management yielded favorable clinical outcomes. Although the sample size of this study was small, the data further support previous reports describing the use of NPWTi-d with the ROCF-CC dressing to help disrupt, solubilize, and remove thick wound exudate and nonviable tissue.^1,3,4 The data also support several previous studies showing NPWTi-d can be used to help effectively treat both acute and chronic wounds.^5-11

These cases help support the use of NPWTi-d using a ROCF-CC dressing as a viable option for wound care providers in the early-stage management of complex wounds. These cases also support future prospective studies to assess the effectiveness of this treatment modality in assisting with wound cleansing by removing thick wound exudate and devitalized tissue.

Authors: Mary Anne Obst, RN, BSN, CWON, CCRN¹; Jane Harrigan, RN, BSN, CWON²; Aaron Wodash, BS, RN, CWON, CFCN³; and Stina Bjurstrom, RN, BSN, CWON²

Affiliations: ¹Complex Abdominal Reconstruction Service, Regions Hospital, Saint Paul, MN; ²Wound and Ostomy Service, Regions Hospital; and ³Orthopedics, Regions Hospital

Correspondence: Mary Anne Obst, RN, BSN, CWON, CCRN, Complex Abdominal Reconstruction Service, Regions Hospital, 640 Jackson Street, St. Paul, MN 55101; maryanneobst@gmail.com 

Disclosure: Ms. Obst is a paid consultant for KCI, an Acelity Company (San Antonio, TX). Data were presented at the 2018 Symposium on Advanced Wound Care Spring in Charlotte, NC, and at the 2018 Wound, Ostomy and Continence Nurses Society’s Annual Conference (now WOCNext) in Philadelphia, PA.