Negative Pressure Wound Therapy
Recommendations
| Identify and Treat the Cause | ||
|---|---|---|
| 1 | Obtain a careful history and assess the patient's ability to heal before application of NPWT. | Level of Evidence 5 |
| 2 | Optimize the wound environment to support healing - ensure adequate blood supply, control infection, maximize nutrition. | Level of Evidence 2 |
| Address Patient Centered Concerns | ||
|---|---|---|
| 3 | Consider patient preferences and establish realistic expectations with patients and their family. | Level of Evidence 5 |
| 4 | Assess and control pain: persistent (chronic) and acute with dressing changes or procedures. | Level of Evidence 3 |
| Provide Local Wound Care | ||
|---|---|---|
| 5 | Assess the wound for appropriateness of NPWT, Document baseline wound size and characteristics along with changes on reassessment. | Level of Evidence 5 |
| 6 | Provide an optimum wound environment: Debridement, infection control, moisture balance. | Level of Evidence Not Assessed |
| 7 | Protect underlying structures in the application of NPWT. Determine initial pressure and mode (continuous versus intermittent) and select proper foam dressing. Maintain the seal over the foam dressing to enhance effectiveness. | Level of Evidence 5 |
| 8 | Consider the use of other adjunctive therapies, skin grafts, and surgical closure if wound healing fails to progress at the expected rate and after appropriate re-assessment of the cause and patient centered concerns. | Level of Evidence Not Assessed |
| Provide Organizational Support | ||
|---|---|---|
| 9 | Develop an interprofessional approach with appropriate consultation to improve patient outcomes. | Level of Evidence Not Assessed |
Background
Large soft tissue deficits are a challenge in wound care and decreasing complex wound closure time is very important to return patients to normal life. Vacuum Assisted Closure (VAC) system is one type of Negative Pressure Wound Therapy (NPWT) that has been extensively studied in the healing of complex acute and chronic wounds other negative pressure wound therapy systems have been developed with very little scientific evidence published to date.The VAC system was developed by Argenta and Morykwas to assist the healing of complex or stalled open wounds often associated with excess exudates. The unit is programmed to deliver controlled negative pressure on wound surface ranging from 50 to 200 mmHg applied with either a continuous or intermittent pressure setting.
NPWT provides a moist wound environment. The negative (sub-atmospheric) pressure applied to the wound site enhances cell proliferation and migration. Negative pressure wound therapy promotes wound healing by preparing the wound bed for closure, removal of wound exudates, reducing edema, altering the wound fluid composition, promoting blood perfusion, and assisting granulation tissue formation. The recent introduction of NPWT has provided new possibilities for the management of complex wounds including pressure ulcers, diabetic neuropathic foot ulcers, and leg ulcers, abdominal and sternal wounds. There are very few established absolute contraindications; however, the VAC is not recommended over necrotic tissue, non healable wounds such as tumors and individuals with coagulopathies. The use of NPWT for the treatment of deep wound infection is currently under debate.
There is a need to determine realistic clinical outcomes such as a decrease in wound depth or size (chronic wounds that are 30% smaller by week 4 are likely to heal by week 12), The VAC or other NPWT should be discontinued as soon as the outcomes have been achieved. As well all other modalities, there is a need for continued research and expanding evidence for optimal use of NPWT.
Guidelines and consensus statements provided by KCI have been reviewed and appraised using the AGREE Instrument.
The following figure indicates the AGREE domain scores for these negative pressure wound therapy guidelines, specifically vacuum-assisted closure (V.A.C.) and one consensus statement.
The following recommendations are intended to help busy clinicians provide excellent care. They are based on the guidelines, consensus statements and technical reports that are referenced.
References
| Essential Publications |
|---|
| 1 | Pressure Ulcers |
Quality Indicator
|
Type: CPG (Clinical Practice Guideline) |
| Gupta S, Baharestani M, Baranoski S, deLeon J, Engel SJ, Mendez-Eastman S, Niezgoda JA, Pompeo MQ. Guidelines for Managing Pressure Uulcers with Negative Pressure Wound Therapy. Adv Skin Wound Care 2004;17(Suppl 2):1-18 | |||
| This clinical practice guideline provides an algorithm as well as questions and answers for treating pressure ulcers using NPWT. Although this document was sponsored by KCI, the guideline developers were clinicians serving on an independent panel. | |||
| 2 | Diabetic Foot Ulcers |
Quality Indicator
|
Type: CPG (Clinical Practice Guideline) |
| Andros G, Armstrong DG, Attinger CE, Boulton AJM, Frykberg RG, Joseph WS, Lavery LA, Morbach S, Niezgoda JA, Toursarkissian B. Consensus Statement on Negative Pressure Wound Therapy (V.A.C.® Therapy) for the Management of Diabetic Foot Wounds. Wounds 2006; Suppl:1-32. | |||
| This clinical practice guideline provides an algorithm for treating diabetic foot wounds using NPWT. | |||
| 3 | Open Abdomen Ulcers |
Quality Indicator
|
Type: CPG (Clinical Practice Guideline) |
| Kaplan M, Banwell P, Orgill DP, Ivatury RR, Demetriades D, Moore FA, Miller P, Nicholas J, Henry S. Guidelines for the Management of the Open Abdomen. Wounds 2005; Oct Suppl:1-24 | |||
| This clinical practice guideline provides an algorithm and other helpful information about treating open abdomen wounds using NPWT | |||
| 4 | Complex Chest Wounds |
Quality Indicator
|
Type: CPG (Clinical Practice Guideline) |
| Orgill DP, Austen Jr WG, Butler CE, Fine NA, Horvath KA, Mihaljevic T, Song DH, Wolfe WG. Guidelines for Treatment of Complex Chest Wounds with Negative Pressure Wound Therapy. Wounds 2004; Dec Suppl:1-23. | |||
| This clinical practice guideline provides an algorithm and other helpful information about treating complex chest wounds using NPWT | |||
| 5 | Pressure Ulcers |
Quality Indicator
|
Type: Concensus Statement |
| Baharestani M, de Leon J, Mendez-Eastman S, Powell G, Weir D, Niezgoda J, Payne W, Nanney LB, Pelham F, Gupta S. Consensus Statement: A Practical Guide for Managing Pressure Ulcers with Negative Pressure Wound Therapy Utilizing Vacuum-Assisted Closure – Understanding the Treatment Algorithm. Advances in Skin & Wound Care 2008;21(Suppl 1):1-20 | |||
| This is a very recent consensus statement that involved numerous stakeholder groups in its development. It is clearly presented and provides algorithms for treating pressure ulcers. Information about patient optimization, methods of debridement, and a reconstructive surgical ladder | |||
| 6 | Deep Sternal Wound Infections |
Quality Indicator
|
Type: CPG (Clinical Practice Guideline) |
| Fleck T, Gustafsson R, Harding K, Ingemansson R, Lirtzman MD, Meites HL, Moidl R, Price P, Ritchie A, Salazar J, Sjo¨ gren J, Song DH, Sumpio BE, Toursarkissian B, Waldenberger F, Wetzel-Roth W. The management of deep sternal wound infections using vacuum assisted closureTM (V.A.C. ®) therapy. Int Wound J 2006;3:273–280. | |||
| This clinical practice guideline provides an algorithm for treating deep sternal wound infections using NPWT | |||
| 1 | Negative Pressure Wound Therapy after Partial Diabetic Foot Amputation |
Quality Indicator
|
Type: RCT |
| Armstrong DG, Lavery LA; Diabetic Foot Study Consortium. Negative Pressure Wound Therapy after Partial Diabetic Foot Amputation: a multicenter randomized controlled trial. Lancet 2005; 366(9498):1704-1710. | |||
| This well-designed multicenter RCT was conducted to determine the efficacy of V.A.C. in wound healing compared with moist wound dressings in complex diabetic foot amputation site wounds. All patients received off loading therapy using a pressure relief walker or sandals. 56% of patients in V.A.C therapy group healed with or without surgical intervention versus 39% in the control group (P=0.04). The median total healing time (complete wound closure) was significantly shorter in the V.A.C. group, 56 days versus 77 days in the control group (P=0.005). There was a significant increased rate of mature granulation tissue formation in VAC therapy patients. The most common type of adverse event was infection but there were no significant differences in treatment related infections. This study indicates that there are advantages to using V.A.C. therapy to reduce patient healing time. | |||
| 2 | Vacuum-assisted closure – chronic leg ulcers |
Quality Indicator
|
Type: RCT |
| Vuerstaek JDD, Vainas T, Wuite J, Nelemans P, Neumann MHA and Veraart JCJM. State-of-the-art treatment of chronic leg ulcers: a randomized controlled trial comparing vacuum-assisted closure (V.A.C.) with modern wound dressings. J Vasc Surg 2006; 44:1029-38. | |||
| This well-designed RCT was conducted to determine the efficacy of V.A.C. in wound healing compared with standard wound dressings in hospitalized patients with chronic venous, combined venous and arterial, or micro angiopathic leg ulcers with durations greater than six months. Median total healing time was significantly shorter in the V.A.C. group, 29 days (95% CI 25.5-32.5) compared with 45 days (95% CI 36.2-56.8) in the control group (P=0.0001). There were non-significant differences in recurrence rates, relapse rates, and complications. The V.A.C. reduced healing times in these patients. | |||
| 3 | Negative Pressure Wound Therapy Utilizing Vacuum-Assisted Closure - Diabetic Foot Ulcers |
Quality Indicator
|
Type: RCT |
| Blume PA, Walters J, Payne W, Ayala J, Lantis J. Comparison of negative pressure wound therapy utilizing vacuum-assisted closure to advanced moist wound therapy in the treatment of diabetic foot ulcers - a multicenter randomized controlled trial. Diabetes Care. E-published 2007 Dec 12. | |||
| This large multicenter RCT was conducted to evaluate safety and clinical efficacy of Negative Pressure Wound Therapy (NPWT) compared to Advanced Moist Wound Therapy (AMWT) in the treatment of diabetic neurotrophic foot ulcers. All patients received off loading therapy using a pressure relief walker or sandals. 43.2% of patients in V.A.C therapy group healed versus 28.9% in the control group (P=0.007). The median healing time (complete wound closure) was significantly shorter in the V.A.C. group (96 days) compared to the control group (P=0.001). NPWT patients experienced fewer secondary amputations (p=0.035). There were no significant differences in treatment related complications including infection, cellulitis, and osteomyelitis at 6 months. NPWT is a safe treatment with V.A.C. therapy reducing patient healing time. | |||
| 4 | Negative Pressure Wound Therapy |
Quality Indicator
|
Type: Technical Report |
| The Ontario Health Technology Advisory Committee (OHTAC) recommendation; Negative Pressure Wound Therapy, July 2006. | |||
| This technical report was conducted using systematic review methodology. The analysis of the existing data (at that time) did not support the benefit of NPWT over standard care for the rate of complete wound closure. There are studies that have surrogate endpoints demonstrating the benefit of NPWT including decreased wound size and a decreased time to closure. The authors were concerned that there may be an increased rate of wound infection associated with NPWT. | |||