Assessment between antiseptic and normal saline for negative pressure wound therapy with instillation and dwell time in diabetic foot infections

Negative pressure wound therapy with instillation and dwell time (NPWTi-d) is increasingly used for a diverse range of wounds. Meanwhile, the topical wound irrigation solution consisting of polyhexamethylene biguanide and betaine (PHMB-B) has shown efficacy in managing wound infections. However, the effectiveness of this solution as a topical instillation solution for NPWTi-d in patients with diabetic foot infections (DFIs) has not been thoroughly studied. The objective of this retrospective study was to evaluate the impact of using PHMB-B as the instillation solution during NPWTi-d on reducing bioburden and improving clinical outcomes in patients with DFIs. Between January 2017 and December 2022, a series of patients with DFIs received treatment with NPWTi-d, using either PHMB-B or normal saline as the instillation solution. Data collected retrospectively included demographic information, baseline wound characteristics, and treatment outcomes. The study included 61 patients in the PHMB-B group and 73 patients in the normal saline group, all diagnosed with DFIs. In comparison to patients treated with normal saline, patients with PHMB-B exhibited no significant differences in terms of wound bed preparation time (P = 0.5034), length of hospital stay (P = 0.6783), NPWTi-d application times (P = 0.1458), duration of systematic antimicrobial administration (P = 0.3567), or overall cost of hospitalization (P = 0.6713). The findings of the study suggest that the use of either PHMB-B or normal saline as an instillation solution in NPWTi-d for DFIs shows promise and effectiveness, yet no clinical distinction was observed between the two solutions.

Negative Pressure Wound Therapy with Instillation and Dwell Time Using Antiseptic Solution in Chronic Limb-threatening Ischemia

Background

Chronic limb-threatening ischemia (CLTI) is a severe peripheral artery disease with rest pain and lower limb ulceration. After revascularization, limb ulceration treatment should be completed quickly before restenosis. We aimed to investigate the effect of negative pressure wound therapy with instillation and dwell (NPWTi-d) using an antiseptic solution (AS) versus a saline solution (SS) in CLTI. There is no research limited to CLTI on this topic.

Methods

All patients underwent revascularization and surgical debridement. NPWTi-d was applied after surgical debridement. We evaluated wound tissue cultivation from pre- and post-NPWTi-d, length of NPWTi-d, and laboratory data pre- and post-NPWTi-d. All data are presented as the median, interquartile range. For univariate analysis, nonnormally distributed data were examined using the Wilcoxon rank sum test between the two groups of NPWTi-d (AS and SS group). A P value of less than 0.05 was considered statistically significant.

Results

Forty-eight CLTI patients participated. The SS group included 24 patients (19 men, five women, average age 68.8 years) and the AS group included 24 patients (16 men, eight women, average age 67.4 years). The comorbidities included 23 and 19 patients with diabetes mellitus and hemodialysis in the SS group, and 22 and 16 patients in the AS group, respectively. There were no adverse events in either group. Both groups reduced the number of bacteria. The AS group required shorter NPWTi-d time (P = 0.02).

Conclusion

The AS group was able to shorten the treatment duration in CLTI.

Bidirectional Irrigation System to Treat a Difficult Wound: A Case Series

AIMS

To date, there is no distinct principle determining whether to use irrigation under negative-pressure wound therapy (NPWT). We developed a new economical device to manage difficult wounds, employing 1 of 2 techniques depending on the wound condition.

METHODS

This case series study was conducted in 12 patients with difficult wound, from 2017 to 2018. Four patients were treated with Type A bidirectional irrigation system (wound irrigation), while 8 patients were treated with Type B bidirectional irrigation system (wound irrigation combined with NPWT).

RESULTS

In the Type A device group, inflammatory profiles in case I, case IV, and case VIII were not monitored due to the stability of their wound. The mean recovery period was 3.75 weeks (2-8 weeks), with decreases in 100% healing rate. In the Type B device group, we noted an average of 71% reduction in inflammatory profiles. All patients' infections were resolved or were healing, and 7 patients recovered satisfactorily. The recovery period ranged from 4 to 17 weeks, with a median value of 7 weeks.

CONCLUSION

Bidirectional irrigation system decreases secondary infections and complications, and increases the healing rate in patients with difficult wound.

Effects of negative pressure wound therapy with instillation and dwell time (NPWTi-d) versus NPWT or standard of care in orthoplastic surgery: A systematic review and meta-analysis

Negative pressure wound therapy (NPWT) is a wound-dressing system that applies sub-atmospheric pressure on the surface of a wound to promote healing. An evolution of this technology, NPWT with solution instillation and dwell time (NPWTi-d), is increasingly being used to maximise wound closure and reduce failure rates. However, there is still a lack of evidence concerning its use in orthoplastic surgery. Therefore, the aim of this study is to compare NPWTi-d with NPWT and standard of care for wound management in orthoplastic surgery. A comprehensive literature search using PubMed, Web of Science, and Cochrane databases up to 15 March 2022 was performed, including studies describing the outcomes of NPWTi-d for traumatic/orthopaedic injuries. A meta-analysis on the number of surgical debridements, as well as the rate of complete wound closure and complications was carried out, although for other outcomes, a descriptive statistic was applied. Risk of bias and quality of evidence were assessed using the Downs& Black's Checklist for Measuring Quality. Thirteen studies with a total number of 871 patients were included, in which NPWTi-d demonstrated significantly higher primary wound closure and lower complication rates (P < .05). No difference in the number of surgical procedures required for final wound healing was observed. Moreover, five out of six studies showed better results for NPWTi-d when the change of the bioburden and bacterial count of the wound were analysed. A singular study investigating the length of the hospital stay of patients treated with NPWTi-d showed a reduction in the latter. The present meta-analysis proves that NPWTi-d is superior to NPTW or conventional dressings in orthoplastic wound care management, in terms of complete wound closure rate and the reduced number of complications. Still, the limited quality of the studies analysed shows that future randomised studies are needed to confirm the benefits and to identify the most appropriate recommendations for using NPWTi-d in orthoplastic surgery, as well as to investigate the cost-effectiveness of this wound-dressing system.

[Surgical wound closure in advanced peritonitis]

To date, mortality in widespread peritonitis is still high (15-20%) and increased up to 70-80% in case of septic shock. Surgeons actively discuss wound closure technique in these patients considering intraoperative findings and severity of illness. The authors present scientific data and opinions of national and foreign surgeons regarding the methods of laparotomy closure. There are still no generally accepted criteria for choosing the method of laparotomy closure in secondary widespread peritonitis. Indications and clinical efficacy of each procedure require additional research.

Effectiveness of negative pressure wound therapy with instillation and dwelling after stoma closure: a retrospective and propensity score matching analysis

The use of temporary diverting stoma has become more common in low colorectal anastomosis to reduce anastomotic complications. Surgical site infection (SSI) at the stoma closure site has been one of the most frequent postoperative complications. The aim of this study was to compare the short-term outcomes between conventional primary suture closure and negative pressure wound therapy with instillation and dwelling (NPWTi-d) therapy following purse-string suturing, using propensity score matching analysis. We retrospectively evaluated the medical records of 107 patients who underwent stoma closure between January 2016 and October 2020. The primary outcome was the proportion of SSI. The secondary outcome was the day of postoperative length of stay. Propensity score matching with one-to-one match was performed for reducing treatment selection bias. Of a total of 107 patients, 67 patients had been treated with conventional primary closure and 40 with NPWTi-d therapy. The propensity score matching derived 37 pairs. The respective SSI proportions were 0% and 16.2% in the groups with NPWTi-d and primary closure (P = 0.025). The respective median days of postoperative hospital stay were 9.0 and 10.0 in the groups with NPWTi-d and primary closure (P = 0.453). NPWTi-d therapy with purse-string suturing was effective in reducing SSI after stoma closure.

Evidence-Based Wound Irrigation: Separating Fact from Fiction

SUMMARY

The relationship between wound irrigation and healing has been recognized for centuries. However, there is little evidence and no official recommendations from any health care organization regarding best wound irrigation practices. This is the first review of wound irrigation that systematically summarizes the literature using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and distills the evidence into a practical format. In this comprehensive review, the authors outline the irrigation fluids and delivery methods used in the identified studies, analyze reported treatment outcomes, summarize irrigation effectiveness, and propose evidence-based guidelines to improve wound healing outcomes and enhance the consistency of wound irrigation. Thirty-one high-quality studies with a combined total of 61,808 patients were included. Based on the current evidence provided by this review, the authors propose the following guidelines: (1) acute soft-tissue wounds should receive continuous gravity flow irrigation with polyhexanide; (2) complex wounds should receive continuous negative-pressure wound therapy with instillation with polyhexanide; (3) infected wounds should receive continuous negative-pressure wound therapy with instillation with silver nitrate, polyhexanide, acetic acid, or povidone-iodine; (4) breast implant wounds should receive gravity lavage with povidone-iodine or antibiotics; and (5) surgical-site infection rates can be reduced with intraoperative povidone-iodine irrigation.

Negative Pressure Wound Therapy: Mechanism of Action and Clinical Applications

Negative pressure wound therapy (NPWT) promotes healing by evenly applying negative pressure on the surface of the wound. The system consists of a sponge, a semiocclusive barrier, and a fluid collection system. Its effectiveness is explained by four main mechanisms of action, including macrodeformation of the tissues, drainage of extracellular inflammatory fluids, stabilization of the environment of the wound, and microdeformation. Rarely will complications linked to NPWT occur, but special care must be taken to prevent events such as toxic shock syndrome, fistulization, bleeding, and pain. New NPWT modalities have been recently developed to make NPWT suitable for a wider variety of wounds. These include NPWT with instillation therapy (NPWTi-d), different cleansing options, and application of NPWT on primarily closed incisions. Finally, vacuum-assisted wound closure therapy has been demonstrated to be efficient for various clinical settings, such as the management of diabetic foot ulcers, pressure ulcerations, chronic wounds, and skin grafts.

Evaluation of effectiveness of a new treatment method for healing infected wounds: an animal model

OBJECTIVE

To evaluate the effectiveness of a new treatment method in healing superficial infected wounds compared with surgical debridement with chlorhexidine solution.

METHOD

In this animal model, two wounds were created on the back of 10 male adult rabbits. Wounds treated by Method 1 were debrided using 0.02% chlorhexidine aqueous solution and an antibiotic topical ointment. Wounds treated by Method 2 wounds were treated using a newly developed device which enabled visual monitoring of the wound as it was treated with various pharmacological solutions (including antiseptic, antiseptic oxidant and an osmotically active agent) specifically formulated for each wound healing stage. Wound area size (using digital planimetry) and time taken to clean the wound were recorded, and biopsies were taken, at the beginning of the study and at various timepoints throughout.

RESULT

It was observed that both wound cleaning and wound healing were accelerated by treatment with method 2 compared with method 1 (by 43.8% and 36.7%, respectively). There were also a significantly smaller number of complications in these wounds [p=0.0044] due to the positive ratios of neutrophils and fibroblasts in the wound cavities (from the third to the fourteenth day after wound modelling).

CONCLUSION

Wounds treated with the new device in method 2 had a shorter wound healing time than wounds treated with a traditional method. The automated influx-outflow of solutions removed any fragments of necrotic tissue from the wound surface. Wounds were able to be monitored without the need to remove dressings. The transparent, airtight film, which allowed for wound monitoring without the need to remove dressings, meant that suturing was not required. This resulted in no complications in the wounds treated by this new method.

Negative-Pressure Wound Therapy With Instillation: A Tool in the Multidisciplinary Approach to Limb Function Preservation

SUMMARY

The multidisciplinary approach to lower extremity function preservation is well established and is globally considered the standard of care. Every member of the team contributes their unique skills and knowledge to patient care. The effective integration of negative-pressure wound therapy with instillation (NPWTi) has fundamentally changed the approach to the infected or contaminated wound. Initially, in conjunction with excisional debridement, NPWTi has demonstrated its utility of expediting wound bed preparation for closure or coverage. With the introduction of a novel foam design, the effectiveness has increased and provided an option in cases where surgical intervention is not available or recommended. The successful implementation and continued monitoring of NPWTi provides an efficient tool to expedite ultimate wound healing and involves all members of the team.

Management of Acute and Traumatic Wounds With Negative-Pressure Wound Therapy With Instillation and Dwell Time

BACKGROUND

A promising and useful development of negative-pressure wound therapy (NPWT) is the addition of instillation and dwell time of topical wound solutions (NPWTi-d). Uses of NPWTi-d include acute and traumatic wounds, whereby wound closure may be facilitated via wound cleansing and promotion of granulation tissue formation. This systematic review summarizes publications on NPWTi-d in the treatment of acute and traumatic wounds.

METHODS

A systematic review was performed analyzing articles from major clinical databases. Only clinical studies ≥10 patients reporting on the application of NPWTi-d in acute and traumatic wounds were included.

RESULTS

One hundred ninety-two articles were retrieved, of which 10 articles met inclusion criteria. Of those, 2 were lesser-quality randomized controlled trials, comparative studies or prospective cohorts, 2 were retrospective studies, and 6 retrospective cohort studies. In total, included publications reported 109 patients with acute and traumatic wounds treated with NPWTi-d. Data from these studies indicated the potential for reduction in bacterial bioburden through wound cleansing and promotion of granulation tissue formation, thereby facilitating wound closure, reduced length of therapy and hospital time. However, for most publications, different wound causes and subsequently no isolated results for acute and traumatic wounds were reported.

CONCLUSION

NPWTi-d has promise to be effective in facilitating wound closure and reducing the time for wound closure. The present systematic review demonstrates a relatively low level of evidence available to objectively support this effect. To underline these positive results, large prospective, randomized controlled trials are necessary to manifest the role of NPWTi-d in the daily clinical routine for this wound category.

Sacral and Ischial Pressure Ulcer Management With Negative-Pressure Wound Therapy With Instillation and Dwell

BACKGROUND

The addition of topical fluid instillation, a programmable "dwell" time and a novel foam-wound interface to the established wound healing benefits of negative-pressure wound therapy (NPWT) works synergistically to benefit patients with complex wounds. This engineering breakthrough for wound care has been termed NPWT with instillation and dwell (NPWTi-d), and the new foam dressings are reticulated open cell foam dressings specifically designed for use with NPWTi-d. This combined technology has shown promise in chronic, complex wounds and has potential for the management of sacral and ischial pressure wounds.

METHODS

A qualitative comprehensive review was performed analyzing articles from PubMed and Medline that reported on the use of NPWTi-d in sacral or ischial pressure ulcers. Case series and case reports were predominant, and results of cases specific to sacral and ischial pressure wounds were extracted from larger studies and summarized for presentation.

RESULTS

Compared with conventional NPWT alone, NPWTi-d has been shown to help irrigate the wound, remove fibrinous debris, and promote granulation tissue formation. This is associated with a decreased number of operative debridements and decreased hospital length of stay.

CONCLUSIONS

This technology is rapidly demonstrating expanded utilization in hospitalized patients with chronic sacral and ischial pressure ulcers. When used correctly, NPWTi-d serves as an effective "bridge to defined endpoint": whether that is a flap reconstruction, skin grafting, or discharge home with a stable chronic wound and simplified wound care.

The technique for less infectious and earlier healing of stoma closure wound: negative pressure wound therapy with instillation and dwelling followed by primary closure

Background

Temporary stomas have been widely used to avoid the risk of complications such as anastomotic leakage after colorectal resection. Stoma closure is relatively easy; however, postoperative surgical site infection (SSI) may be a problem. Various methods have been used to reduce the incidence of SSI. We aimed to evaluate a new technique for stoma wound closure.

Methods

We enrolled patients who underwent stoma closure at our hospital between September 2019 and May 2020. We selected patients who lived far from our hospital and had difficulty visiting the hospital regularly and who agreed to undergo this surgical technique. We used negative pressure wound therapy with instillation and dwelling (NPWTi-d) and delayed primary closure for these patients.

Results

Four patients underwent NPWTi-d and delayed primary closure without the occurrence of SSI. The median postoperative hospital stay was 9 days (range: 7–14 days), and the median number of days to confirmation of epithelialization was 11.5 days (range: 10–16 days).

Conclusion

The combined use of NPWTi-d and delayed primary closure for the stoma wound was very effective. This method may be a valuable new technique for wound management after stoma closure.

Does negative pressure wound therapy with saline instillation improve wound healing compared to conventional negative pressure wound therapy? - A randomized controlled trial in patients with extremity ulcers

BACKGROUND

Wounds are important health problems that cause significant financial burden and loss of time to work, more so in low and lower middle income countries. Negative pressure wound therapy (NPWT) is widely established in managing acute and chronic extremity wounds. We studied the effects of addition of normal saline instillation to NPWT in terms of changes in granulation tissue, bacterial-burden and overall wound healing using readily available means and materials including wall suction for negative pressure, sponge and adhesive transparent sheet for dressing and normal saline for irrigation.

METHODS

All patients with extremity ulcers initially underwent surgical debridement. They were then allotted into two groups, group 1 (NPWT with normal saline instillation- NPWTi) including 25 patients and group 2 (NPWT) including 23 patients. Tissue-bit samples taken on day1 and day 10 were used for bacteriology and for assessing histology. The wound surface-area was measured using the software ImageJ on day 1 and day 10.

RESULTS

Median log difference in colony-count between day1 and day10 was 0.6 (0.2-1.4) in group1 and 0.13 (0.04-0.6) in group 2 (p < 0.05). Mean percentage reduction in wound size was 28.82 and 19.80 in group 1 and group 2 respectively (p < 0.05). Histological parameters of wound healing assessed as surface epithelium, granulation, inflammatory cells, proliferative blood-vessels and fibroblasts were significantly better in group1. A drawback observed with NPWTi was skin maceration around the ulcer which was successfully managed.

CONCLUSION

Our findings suggest that wound healing is significantly better when saline instillation is combined with NPWT. It can aid in complex extremity ulcers management by reducing the size of the wound with healthier looking granulation tissue.

Cost evaluation of temporary abdominal closure methods in abdominal sepsis patients successfully treated with an open abdomen. Should we take temporary abdominal closure methods at face value? Health economic evaluation

BACKGROUND

Many commercial and artisanal devices are utilized for temporary abdominal closure in patients being managed with an open abdomen for abdominal sepsis. The costs of materials required to treat patients with an open abdomen varies drastically. In Costa Rica, due to the lack of accurate information relating to the actual cost to manage a patient entails that the method with the least expensive materials is usually selected.

STUDY DESIGN

A single-center retrospective review of 46 patients diagnosed with abdominal sepsis and successfully treated with an open abdomen and one of the three temporary abdominal closure methods during the year 2018 in a tertiary hospital was evaluated using a gross-cost pricing model developed by the authors. The three temporary abdominal closure methods were a locally manufactured Bogota Bag, and commercial abdominal negative pressure therapy dressing and negative pressure therapy with 0.9% saline solution instillation. The per-unit-costs were hospital day and intensive care day, number of surgical procedures per patient, cost negative pressure therapy kits.

RESULTS

Statistically significant cost reduction was observed in the cohort treated with negative pressure therapy with instillation as compared to the other temporary abdominal closure methods. The reduction of hospital length of stay, as well as fewer number of surgeries were the main contributing factors in diminishing costs. On average, the costs to treat a patient utilizing negative pressure therapy with instillation was nearly 50% lower than using the other two temporary abdominal closure methods.

CONCLUSIONS

The costs relating to managing abdominal sepsis in the septic open abdomen vary greatly according to the temporary abdominal closure utilized. If the hospital length of stay, intensive care unit length of stay and number of surgeries required are the main parameters used in determining costs, the use of negative pressure therapy with 0.9% saline solution instillation reduces costs by nearly 50% in comparison to conventional negative pressure wound therapy and Bogota Bag. In this instance, the more expensive method at first glance, obtained a considerable cost reduction when compared to therapies that utilize less expensive materials.

Negative pressure wound therapy with instillation and dwell time (NPWTi-d) with V. A. C. VeraFlo in traumatic, surgical, and chronic wounds-A helpful tool for decontamination and to prepare successful reconstruction

For nearly two decades, Negative Pressure Wound Therapy (NPWT) has been used for temporary wound coverage as well as wound bed preparation. The addition of instillation and dwell time as an adjunct to NPWT (NPWTi‐d) enables wound bed cleaning and improved wound bed granulation. Thirty patients with different types of colonised wounds (traumatic, surgical, and chronic) were treated with NPWTi‐d using saline for instillation. Patient data, microbiological data and wound characteristics were collected and analysed. Endpoints were bacterial decontamination (count and type), effect on wound bed granulation, and successful reconstruction. Additionally, subgroup analyses for traumatic, surgical, and chronic wounds as well as patients pretreated with conventional NPWT or isolated gram‐positive or negative germs were performed. NPWTi‐d was applied on average for 13 days with a total hospitalisation time of 51 days. After NPWTi‐d, decontaminated wounds were detected in 23% of cases. The number of different bacteria as well as bacterial count could be significantly reduced from 2.38 to 1.16 and 3.9 to 1.3, respectively. This was similar for all subgroups except surgical wounds, in which NPWTi‐d did not lead to a significant reduction of the bacterial count. NPWTi‐d resulted in a significant stimulation of granulation tissue. Successful reconstruction was achieved in 90% of cases. NPWTi‐d enabled wound pre‐conditioning by powerfully reducing or decontaminating the bacterial load and spectrum in most of the wounds. The wound bed integrity was re‐established to prepare successful reconstruction.

Practical Things You Should Know about Wound Healing and Vacuum-Assisted Closure Management

LEARNING OBJECTIVES

After reading this article, the participant should be able to: 1. Understand the basics of negative-pressure wound therapy and practical uses of various vacuum-assisted closure dressings. 2. Understand the mechanisms of action of negative-pressure therapies and other important adjuncts, such as perfusion imaging. 3. Discuss the evidence for hyperbaric oxygen therapy in wound care.

SUMMARY

Wound healing requires creating an environment that supports the healing process while decreasing inflammation and infection. Negative-pressure wound therapy has changed the way physicians manage acute and chronic wounds for more than 20 years. It contracts wound edges, removes exudate, including inflammatory and infectious material, and promotes angiogenesis and granulation tissue formation. These effects have been consistently demonstrated in multiple animal and human randomized controlled trials. Recent innovations that include instillation therapy and closed incision have further increased our arsenal against difficult-to-treat wounds and incisions at high risk of complications. Instillation of topical wound solutions allows physicians to cleanse the wound without return to the operating room, resulting in fewer debridements, shorter hospital stays, and faster time to wound closure. Other concepts have yielded negative-pressure therapy on top of closed surgical incisions, which holds incision edges together, reduces edema, promotes angiogenesis, and creates a barrier to protect incisions during the critical healing period, thereby reducing surgical-site complications, especially infection. Other practical adjuncts to the modern-day treatment of acute and chronic wounds include indocyanine green angiography, which allows real-time assessment of perfusion, and hyperbaric oxygen treatment, which has been suggested to augment healing in acute, chronic, specifically diabetic foot ulcers and radiation-related wounds.

Comparison of Negative Pressure Wound Therapy With and Without Instillation of Saline in the Management of Infected Wounds

Background 

Negative pressure wound therapy (NPWT) with instillation and dwell time (NPWTi-d) includes periodic instillation of topical solution into the wound followed by a negative pressure. Our objective was to evaluate potential differences in wound outcomes in patients receiving NPWT and those receiving NPWTi-d using saline.

Methods

An analysis was performed using two previously published independent studies from a single investigator and hospital to compare patient characteristics and clinical outcomes of infected wounds from 74 NPWT-treated patients with 42 NPWTi-d-treated patients.

Results 

Patient demographics and comorbidities, wound etiologies, and anatomical locations of wounds were similar between groups, although a significantly higher percentage of NPWT-treated patients had end-stage renal disease (P = 0.0119). Compared with patients treated with standard NPWT, NPWTi-d-treated patients had a significantly lower number of operations (P = 0.0048), shorter length of hospital stay (P = 0.0443), shorter time to final surgical procedure (P = 0.0001), higher percentage of closed wounds (P = 0.0004), and a higher percentage of wounds that remained closed at one month (P = 0.0001).

Conclusions

The results of this analysis suggest that management of infected wounds with NPWTi-d using saline leads to favorable wound outcomes when compared to those managed with NPWT.

The impact of negative-pressure wound therapy with instillation on wounds requiring operative debridement: Pilot randomised, controlled trial

Presence of bacteria in wounds can delay healing. Addition of a regularly instilled topical solution over the wound during negative‐pressure wound therapy (NPWT) may reduce bioburden levels compared with standard NPWT alone. We performed a prospective, randomised, multi‐centre, post‐market trial to compare effects of NPWT with instillation and dwell of polyhexamethylene biguanide solution vs NPWT without instillation therapy in wounds requiring operative debridement. Results showed a significantly greater mean decrease in total bacterial counts from time of initial surgical debridement to first dressing change in NPWT plus instillation (n = 69) subjects compared with standard NPWT (n = 63) subjects (−0.18 vs 0.6 log₁₀ CFU/g, respectively). There was no significant difference between the groups in the primary endpoint of required inpatient operating room debridements after initial debridement. Time to readiness for wound closure/coverage, proportion of wounds closed, and incidence of wound complications were similar. NPWT subjects had 3.1 times the risk of re‐hospitalisation compared with NPWT plus instillation subjects. This study provides a basis for exploring research options to understand the impact of NPWT with instillation on wound healing.

Benefits of negative pressure wound therapy with instillation in the treatment of hard-to-heal wounds: a case series

Objective:

Impaired wound healing can lead to hard-to-heal wounds, which impact on patients, clinicians and healthcare systems. Negative pressure wound therapy with instillation and dwell time (NPWTi-d) was developed to manage wounds through early-stage cleansing. This study describes the use of NPWTi-d to help manage hard-to-heal wounds in patients with risk factors for impaired wound healing.

Method:

In this case series, patients were treated between October 2015 and March 2018 at a community hospital in western France. Normal saline solution was instilled into wounds with a dwell time of 10 minutes, followed by the application of negative pressure at −75 mmHg to −125 mmHg for 2–3 hours. If needed, patients were given appropriate oral or intravenous antibiotic treatment in conjunction with NPWTi-d and subsequent wound therapies.

Results:

A total of 15 patients participated in the study. Mean age was 81±13 years, and 12 (80%) patients were malnourished with blood albumin levels of 30.1±5.7g/l, and 12 (80%) patients were given antibiotic therapy. The mean duration of NPWTi-d was 19.4±20.8 days, with a mean number of dressing changes of 6.6±6.8; the duration of NPWTi-d and the number of dressing changes for pressure ulcers was three times that of the other wound types. The mean cost of NPWTi-d in this study was €1643.40±€1709.13. Overall, NPWTi-d provided early-stage wound cleansing and helped achieve adequate granulation tissue formation and progression to the next phase of wound healing.

Conclusion:

In these cases, NPWTi-d was a beneficial and effective method of treating hard-to-heal wounds that were resistant to traditional treatments, yielding favourable clinical outcomes.

Negative pressure wound therapy with instillation: International consensus guidelines update

The use of negative pressure wound therapy with instillation and dwell time (NPWTi‐d) has gained wider adoption and interest due in part to the increasing complexity of wounds and patient conditions. Best practices for the use of NPWTi‐d have shifted in recent years based on a growing body of evidence and expanded worldwide experience with the technology. To better guide the use of NPWTi‐d with all dressing and setting configurations, as well as solutions, there is a need to publish updated international consensus guidelines, which were last produced over 6 years ago. An international, multidisciplinary expert panel of clinicians was convened on 22 to 23 February 2019, to assist in developing current recommendations for best practices of the use of NPWTi‐d. Principal aims of the meeting were to update recommendations based on panel members' experience and published results regarding topics such as appropriate application settings, topical wound solution selection, and wound and patient characteristics for the use of NPWTi‐d with various dressing types. The final consensus recommendations were derived based on greater than 80% agreement among the panellists. The guidelines in this publication represent further refinement of the recommended parameters originally established for the use of NPWTi‐d. The authors thank Karen Beach and Ricardo Martinez for their assistance with manuscript preparation.

Three Cases Describing Outcomes of Negative-Pressure Wound Therapy With Instillation for Complex Wound Healing

BACKGROUND

We describe 3 cases where negative-pressure wound therapy with instillation and dwell time (NPWTi-d) was used as an adjunctive therapy for 3 chronic wounds.

CASES

Three patients (2 males and 1 female), ranging in age from 28 to 53 years, presented with complex, infected wounds: (1) a diabetic foot ulcer with underlying infection, (2) a dehisced abdominal wound with enterocutaneous fistula, and (3) a large wound of the upper torso and axillary region resulting from soft tissue necrosis. Negative-pressure wound therapy with instillation and dwell time was initiated by instilling normal saline or an antiseptic solution; the solution was left in place for 3 to 10 minutes. Continuous negative pressure was then applied at -125 or -150 mm Hg; cycles were repeated every 1 or 3 hours. Treatment was applied for 5 to 44 days, and dressings were changed every 2 to 3 days. Granulation tissue developed in all 3 wounds; all closed after subsequent skin grafting.

CONCLUSIONS

Outcomes of these cases suggest that NPWTi-d may be used as an adjunctive treatment modality for a variety of chronic wounds.

EWMA Document: Negative Pressure Wound Therapy

1. Introduction Since its introduction in clinical practice in the early 1990's negative pressure wounds therapy (NPWT) has become widely used in the management of complex wounds in both inpatient and outpatient care.¹ NPWT has been described as a effective treatment for wounds of many different aetiologies^2,3 and suggested as a gold standard for treatment of wounds such as open abdominal wounds,^4-6 dehisced sternal wounds following cardiac surgery^7,8 and as a valuable agent in complex non-healing wounds.^9,10 Increasingly, NPWT is being applied in the primary and home-care setting, where it is described as having the potential to improve the efficacy of wound management and help reduce the reliance on hospital-based care.¹¹ While the potential of NPWT is promising and the clinical use of the treatment is widespread, highlevel evidence of its effectiveness and economic benefits remain sparse.^12-14 The ongoing controversy regarding high-level evidence in wound care in general is well known. There is a consensus that clinical practice should be evidence-based, which can be difficult to achieve due to confusion about the value of the various approaches to wound management; however, we have to rely on the best available evidence. The need to review wound strategies and treatments in order to reduce the burden of care in an efficient way is urgent. If patients at risk of delayed wound healing are identified earlier and aggressive interventions are taken before the wound deteriorates and complications occur, both patient morbidity and health-care costs can be significantly reduced. There is further a fundamental confusion over the best way to evaluate the effectiveness of interventions in this complex patient population. This is illustrated by reviews of the value of various treatment strategies for non-healing wounds, which have highlighted methodological inconsistencies in primary research. This situation is confounded by differences in the advice given by regulatory and reimbursement bodies in various countries regarding both study design and the ways in which results are interpreted. In response to this confusion, the European Wound Management Association (EWMA) has been publishing a number of interdisciplinary documents^15-19 with the intention of highlighting: The nature and extent of the problem for wound management: from the clinical perspective as well as that of care givers and the patients Evidence-based practice as an integration of clinical expertise with the best available clinical evidence from systematic research The nature and extent of the problem for wound management: from the policy maker and healthcare system perspectives The controversy regarding the value of various approaches to wound management and care is illustrated by the case of NPWT, synonymous with topical negative pressure or vacuum therapy and cited as branded VAC (vacuum-assisted closure) therapy. This is a mode of therapy used to encourage wound healing. It is used as a primary treatment of chronic wounds, in complex acute wounds and as an adjunct for temporary closure and wound bed preparation preceding surgical procedures such as skin grafts and flap surgery. Aim An increasing number of papers on the effect of NPWT are being published. However, due to the low evidence level the treatment remains controversial from the policy maker and health-care system's points of view-particularly with regard to evidence-based medicine. In response EWMA has established an interdisciplinary working group to describe the present knowledge with regard to NPWT and provide overview of its implications for organisation of care, documentation, communication, patient safety, and health economic aspects. These goals will be achieved by the following: Present the rational and scientific support for each delivered statement Uncover controversies and issues related to the use of NPWT in wound management Implications of implementing NPWT as a treatment strategy in the health-care system Provide information and offer perspectives of NPWT from the viewpoints of health-care staff, policy makers, politicians, industry, patients and hospital administrators who are indirectly or directly involved in wound management.

Negative Pressure Wound Therapy with Instillation in the Septic Open Abdomen Utilizing a Modified Negative Pressure Therapy System

BACKGROUND

Various treatment modalities are utilized to treat the open abdomen. The use of negative pressure wound therapy(NPWT)has been a great advancement and has become the preferred modality for temporary abdominal closure technique (TAC). Programmed instillation of the abdominal cavity with saline solution in conjunction with a commercial negative pressure system showed positive results in the management of severe abdominal sepsis in patients that were treated with an open abdomen. Severe abdominal sepsis continues to be an oftendifficult clinical problem for the general surgeon. The use of an open abdomen technique in this setting and the ideal TAC method continue to be debated. The failure to understand the biomechanical features/limitations of negative pressure devices are often contributing factors associated with therapeutic failures reported in the literature.

OBJECTIVES

To describe the underlying principles behind negative pressure wound therapy with instillation in the context of abdominal sepsis, as well as its optimal usage in these conditions.

METHODS

A systematic review and two retrospective cohort studies, both published and unpublished performed by some of the authors were included to provide a basis form comparison between NPWT and NPWT-I outcomes in managing abdominal sepsis.

CONCLUSION

Our findings suggest that this technique appears to reduce morbidity, mortality, and hospital and critical care length of stay. This communication is intended to help inform general surgeons that manage complex abdominal infections on how to optimally apply this technique.

Utilizing Negative Pressure Wound Therapy with Instillation and Dwell Time for Extensive Necrotizing Fasciitis of the Lower Extremity: A Case Report

Necrotizing fasciitis is a rapidly spreading infection of the soft tissue, which carries significant morbidity and mortality. This condition is treated with broad-spectrum antibiotics, irrigation and surgical debridement of the affected area, and hemodynamic support. Negative pressure wound therapy (NPWT) has been utilized after surgical debridement to promote wound healing, especially when significant debridement has occurred. Newer forms of NPWT such as negative pressure wound therapy with instillation and dwell time (NPWTi-d) have shown even greater promise by reducing the time to clear infections and promoting greater debridement with fewer procedures. This case report demonstrates the successful use of NPWTi-d on a 56-year-old man with a severe case of necrotizing fasciitis of the right lower extremity after extensive debridement. Despite the significant loss of soft tissue and the circumferential devitalization of the lower leg, this patient was able to accept a skin graft in approximately four weeks after admission to the hospital. Three months after initial presentation, his wounds were completely epithelialized and healing well. The advantages of using NPWTi-d include decreased dressing changes, increased wound granulation, and faster infection clearance. The disadvantages of such systems include increased cost, additional technical requirements, and required inpatient monitoring of the system. Despite these disadvantages, the authors believe that NPWTi-d is a reasonable choice for patients similar to the one presented in this case report.

Negative pressure wound treatment with computer-controlled irrigation/instillation decreases bacterial load in contaminated wounds and facilitates wound closure

Microbial wound contamination is known to be a hindrance to wound healing. Negative pressure wound therapy (NPWT) with or without irrigation is known to optimise conditions in problem wounds. The aim of this study was to investigate the influence of computer-controlled wound irrigation with NPWT on the bacterial load in contaminated wounds. A total of 267 patients were treated with NPWT with automated instillation because of problematic wounds using an antiseptic instillation solution. In 111 patients, a minimum of 4 operative procedures were necessary, and swabs were taken at least at the first and at the fourth operation in a standardised procedure. The number of different bacteria and the amount of bacteria were analysed during the course. In a subgroup of 51 patients, swabs were taken at all 4 operative procedures and analysed separately. In an overall analysis, the number of different bacteria and the amount of bacteria significantly decreased independent of wound localisation and diagnosis. NPWT with automated instillation demonstrates a positive influence in the reduction of bacterial load in problem wounds. Thus, it may help to optimise wound conditions before definite wound closure.

[Using negative pressure therapy to prevent and treat wounds]

The offer of Negative Pressure Wound Therapy (NPWT) has considerably increased these last years. Nowadays, one can choose between different tools such as motorised systems - or not - like pumps; devices which are particularly portables; automated therapies allowing regular instillations; or finally systems adapted to specific indications like "open abdominal wounds". This diversity of devices implies more than ever that prescriptions from the medical doctor be detailed and a good trackability of the nursing follow-up.

Novel foam dressing using negative pressure wound therapy with instillation to remove thick exudate

We describe our experience with a novel foam dressing architecture in tandem with negative pressure wound therapy and instillation (NPWTi-d) for removing viscous wound exudate and infectious materials. A retrospective review was conducted of the outcomes of 21 patients who received NPWTi-d using a reticulated open cell foam instillation dressing with through holes (ROCF-CC) designed to facilitate the removal of thick wound exudate and infectious materials. NPWTi-d with ROCF-CC was used to treat large complex chronic wounds with viscous wound exudate that contained substantial areas of devitalised tissue. Debridement was performed as appropriate or available. NPWTi-d with ROCF-CC assisted in loosening, solubilising and detaching viscous exudate, dry fibrin, wet slough and other infectious materials. Percent surface area of black non-viable tissue and yellow fibrinous slough was reduced to ≤ 10% in 18/21 (85·7%) and 12/21 (57·1%) wounds, respectively, after an average of 1-3 applications (3-9 days) of NPWTi-d with ROCF-CC. Preliminary evidence suggests that adjunctive use of NPWTi-d with ROCF-CC may help clean large, complex wounds when complete surgical debridement is not possible or appropriate and/or when areas of slough and non-viable tissue remain present on the wound surface.

Components and Quality Measures of DIME (Devitalized Tissue, Infection/Inflammation, Moisture Balance, and Edge Preparation) in Wound Care

OBJECTIVES:

To discuss how patient considerations and the initial wound environment can affect wound treatment and summarize the way in which the initial US Wound Registry measures capture aspects of the DIME (Debridement/devitalized tissue, Infection or inflammation, Moisture balance, and wound Edge preparation/wound depth) principles.

DISCUSSION:

The treatment of chronic wounds often involves extended hospital stays and long-term outpatient follow-up visits with costly advanced therapeutic interventions. As complex care is required for chronic wounds, treatment guidelines such as DIME have evolved to include consideration of patient-centered concerns and etiology, as well as features of wound bed preparation. The US healthcare system is in the midst of transitioning to a quality-based system. However, as wound care is not yet a recognized specialty, it is poorly represented in the current approved quality-based measures.

CONCLUSION:

This article helps to identify the practice guidelines that are not currently represented by quality metrics.

Management of the open abdomen using negative pressure wound therapy with instillation in severe abdominal sepsis: A review of 48 cases in Hospital Mexico, Costa Rica

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Intra-abdominal sepsis remains one the leading causes of mortality in the SICU .

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Multiple surgical approaches have been introduced as part of the management of the open abdomen with varying results.

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Negative pressure wound therapy with instillation in our study population appears as a safe and promising therapeutic option in the context of intraabdominal sepsis.

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NPWT-I is a therapeutic alternative that showed positive results in our patient group.

Introduction

Despite the numerous advances in recent years, severe abdominal sepsis (with associated organ failure associated with infection) remains a serious, life-threatening condition with a high mortality rate. OA is a viable alternative to the previously used scheduled repeat laparotomy or continuous peritoneal lavage. The use of Negative Pressure Wound Therapy (NPWT) has been described as a successful method of management of the open abdomen. Adding instillation of saline solution to NPWT in a programmed and controlled manner, could offer the clinician an additional tool for the management of complex septic abdomen.

Objectives

To explore if the concept of active two-way therapy (Negative pressure wound therapy with instillation or NPWT-I) yields superior control of underlying, life-threatening abdominal infections and its effects on survival and morbidity in patients with severe abdominal sepsis when management with an open abdomen is required.

Methods

A retrospective review of 48 patients with severe abdominal sepsis, who were managed with and open abdomen and NPWT-I was performed. NPWT-I was initiated utilizing the same parameters on all patients, this consisted of cycles of instillation of saline solution, which was removed through negative pressure after a short dwell period. We observed the effects on primary fascia closure rate, mortality, hospital and SICU length of stay and associated complications.

Results

Our patient group consisted of 20 (42%) males and 28 (58%) females. Average age was 48 years. Mortality in these patients was attributed to pulmonary embolism (n = 1), acute renal failure (n = 2) and cardiopulmonary arrest (n = 1). Average total hospital stay was 24 days, and stay in the SICU (n = 26) averaged 7.5 days.

No acute complications related to the NPWT-I. All patients presenting with abdominal compartment syndrome resolved after initiation of the NPWT-I. A total of 46 patients (96%) patients achieved fascia closure after NPWT-I therapy after an average of 6 days. Four patients (8%) died during the course of treatment of causes unrelated to NPWT-I.

Conclusion

This therapy showed added benefits when compared to traditional methods such as ¨Bogota bag̈, Wittmann patch, or NPWT traditional in the management of the open abdomen pertaining to severe abdominal sepsis.

NPWT-I in patients with severe abdominal sepsis had promising results, since we obtained higher fascia closure rates, lower mortality and reduced hospital and ICU length of stay with no complications due to this therapeutic approach.

International consensus conference on open abdomen in trauma

BACKGROUND

A part of damage-control laparotomy is to leave the fascial edges and the skin open to avoid abdominal compartment syndrome and allow further explorations. This condition, known as open abdomen (OA), although effective, is associated with severe complications. Our aim was to develop evidence-based recommendations to define indications for OA, techniques for temporary abdominal closure, management of enteric fistulas, and methods of definitive wall closure.

METHODS

The literature from 1990 to 2014 was systematically screened according to PRISMA [Preferred Reporting Items for Systematic Reviews and Meta-analyses] protocol. Seventy-six articles were reviewed by a panel of experts to assign grade of recommendations (GoR) and level of evidence (LoE) using the GRADE [Grading of Recommendations Assessment, Development, and Evaluation] system, and an international consensus conference was held.

RESULTS

OA in trauma is indicated at the end of damage-control laparotomy, in the presence of visceral swelling, for a second look in vascular injuries or gross contamination, in the case of abdominal wall loss, and if medical treatment of abdominal compartment syndrome has failed (GoR B, LoE II). Negative-pressure wound therapy is the recommended temporary abdominal closure technique to drain peritoneal fluid, improve nursing, and prevent fascial retraction (GoR B, LoE I). Lack of OA closure within 8 days (GoR C, LoE II), bowel injuries, high-volume replacement, and use of polypropylene mesh over the bowel (GoR C, LoE I) are risk factors for frozen abdomen and fistula formation. Negative-pressure wound therapy allows to isolate the fistula and protect the surrounding tissues from spillage until granulation (GoR C, LoE II). Correction of fistula is performed after 6 months to 12 months. Definitive closure of OA has to be obtained early (GoR C, LoE I) with direct suture, traction devices, component separation with or without mesh. Biologic meshes are an option for wall reinforcement if bacterial contamination is present (GoR C, LoE II).

CONCLUSION

OA and negative-pressure techniques improve the care of trauma patients, but closure must be achieved early to avoid complications.

Innovation and wound healing

Innovation in medicine requires unique partnerships between academic research, biotech or pharmaceutical companies, and health-care providers. While innovation in medicine has greatly increased over the past 100 years, innovation in wound care has been slow, despite the fact that chronic wounds are a global health challenge where there is a need for technical, process and social innovation. While novel partnerships between research and the health-care system have been created, we still have much to learn about wound care and the wound-healing processes.

Clinical recommendations and practical guide for negative pressure wound therapy with instillation

Effective wound management involves a comprehensive assessment of the patient and the wound to determine an optimal wound treatment plan. It is critical to identify and address factors that may impair wound healing, prior to selecting the most appropriate therapy for each patient. Negative pressure wound therapy (NPWT) is a well-established advanced therapy that has been successful in adjunctive management of acute and chronic wounds. In recent years, the introduction of topical wound solution delivery in combination with NPWT has provided further benefits to wound healing. A commercially available system now offers automated, volumetric control of instilled topical wound solutions with a dwell time in combination with NPWT (NPWTi-d; V.A.C. VeraFlo Therapy, KCI, an Acelity company, San Antonio, TX). This NPWTi-d system differs from other instillation systems in that a timed, predetermined volume of topical wound solution is intermittently delivered (versus continuously fed) and allowed to dwell in the wound bed (without NPWT), for a user-selected period of time before NPWT is resumed. This added accuracy and process simplification of solution delivery in tandem with NPWT have prompted use of NPWTi-d as first-line therapy in a wider subset of complex wounds. However, considerably more research is required to validate efficacy of NPWTi-d in various wound types. The purpose of this review is to provide a relevant overview of wound healing, describe current literature supporting the adjunctive use of NPWTi-d, propose a clinical approach for appropriate application of NPWTi-d and conclude with case studies demonstrating successful use of NPWTi-d. Based on this review, we conclude that either a large case series examining effects of NPWTi-d on different wound types or possibly a large prospective registry evaluating NPWTi-d with real-world topical wound solutions versus immediate debridement and closure would be valuable to the medical community in evaluating the efficacy of this promising therapy.