Watch closely for pain once the NPWT device is placed. Ask patients if they have any pain and observe for signs of pain, such as grimacing or agitation, in patients who are unable to speak. Make adjustments in the application of the device as needed until the patient is comfortable.
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If the patient is unable to tolerate NPWT, discontinue and revisit in the future as needed.
Bleeding, though rare, is a serious life-threatening complication of NPWT. When it occurs, it is usually associated with certain types of wounds (vascular grafts) or locations (sternum, groin). It can also be associated with medications (anti-coagulants), hematologic disorders, and the removal of adherent or embedded foam.
It is hypothetically possible for patients to develop dehydration or fluid shifts due to the loss of extracellular fluid in high-output wounds. If patients show signs of fluid imbalance, all possible causes should be investigated and corrected.
Follow infection control and antibiotic stewardship principles when using NPWT as you would with any other dressing. If signs and symptoms of infection are observed, consider using instillation NPWT or discontinuing the device until the infection is treated.
Foam can become adherent to the wound bed. If the foam is forcefully removed, small pieces may break off and remain attached to the wound bed. Removal of embedded foam can cause bleeding; one must be prepared to manage any potential issues that arise.
a. It is helpful to soak foam with saline for at least 15 minutes before attempting its removal.
b. Gentle sharp technique should be used to avoid force that could damage tissue.
c. Once all of the foam has been removed, monitor the wound bed for signs of trauma or bleeding.
Another situation in which foam retention may arise is in wound tunnels or undermined areas. White foam, rather than the typical black, should be used in any tunneled areas. If black foam is placed in a tunnel, it often tears and leaves pieces of foam in an area that cannot be easily visualized.
This is the most common problem seen with NPWT. Given the patient&#;s risk of having a device in place without suction, it is imperative that suction be re-established promptly.
There are multiple potential causes, including loss of the dressing seal, incorrect placement of the suction drain tube, power source disconnection, nonfunctional batteries, suction tube blockage, and a full canister.
Patients may also turn off the device themselves; patient education is important to prevent this.
The adhesive film used to attach the device can be irritating to the skin. Discontinue if you observe peri-wound sensitivity or inflammation. It is often possible to resume the use of the device after allowing the skin to recover for a week or two.
Damage to the surrounding skin leads to erosion or necrosis. Assure that foam does not extend beyond the wound bed in order to avoid maceration and damage to surrounding skin.
Watch for duskiness or discoloration of the wound bed and edges. If this is observed, consider reducing the device pressure or discontinuing the treatment.
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Authors: Christian Kaare Paaskesen Stud. Med, Magnus Balslev Avnstorp, MD, & Hasan Gökcer Tekin MD.
Multiple systems have been developed to preformed NPWT, in this chapter V.A.C and PICO V.A.C will be described.
V.A.C is a negative pressure wound therapy system used in inpatient and outpatient settings (the outpatient setting requires a portable bag). V.A.C can be used multiple times and is commonly used in combination with different types of foams. Black foam has a pore size of 400-600mm, whereas white foam has a pore size of 250mm. White foam has a higher tensile strength and is preferable for undermining wounds compared with black foam, to avoid small pieces of cut foam in the wound. Black foam does not clot as easy as white foam and can transport larger amounts of exudate and generate more granulation tissue. Although, caution is advised in low exuding wounds if the wound dries out and leads to ischemia and necrosis.
The function of foam dressings in NPWT is to distribute an even negative pressure over the whole wound bed. A silver foam is also available for wounds that needs an antibacterial component to ensure healing.
To prevent the foam from sticking to the wound, a silicone dressing (Cuticerin®) can be used as a primary dressing.
When the foam dressing is applied, a fenestrated evacuation tube is applied, and the site is covered with an adhesive drape. To ensure a water- and airtight site, secure the drape in a 3-5 cm peri wound distance on healthy tissue. The V.A.C. system provides the therapist with a selection of modes to choose from, either a continuous or intermittent (2 &#; 5 minutes) negative pressure ranging from 50 mmHg to 125 mmHg. Large and heavily exudating wounds may require a higher pressure(>150mmHg) (1, 2). Intermittent mode is recommended as it generates more blood flow in periods where the vacuum is off. Studies suggest that wound contraction and the formation rate of granulation tissue is improved using intermittent pressure settings on NPWT systems (3).
V.A.C treatment reduces the need of dressing changes and promote patient comfort. It also reduces bacterial load and edema while still maintaining an optimal closed moist environment. Ultimately resulting in faster healing and as a result reduces hospital stay. V.A.C has proven to create granulation tissue, and is widely used to fill out wound cavities. (2)
Some V.A.C. systems also have the ability to perform NPWTi-d and should be used according to manufacture and international guidelines. (4)
Air leak in the dressing can result in an air flow over the wound, desiccating the wound and forming eschar. Eschar seals the wound with retained exudate and leads to worsening of the wound. Once started, NPWT should not be terminated abruptly after one session, as it may result in what is called &#;rebound phenomenon&#; which leads to worsening of the wound. 2-3 sessions should always be planned. V.A.C. requires health-care professionals to ensure right and optimal treatment without technical failures. After 2-3 weeks, the formation of granulation tissue will stop, this is an indication to pause the treatment.
PICO is a onetime use negative pressure wound therapy system. It consists of a pocket-sized pump attached to special developed dressing. PICO is used in an outpatient setting and operates at an 80mmHg negative pressure.
PICO makes it possible to discharge patient earlier while still maintaining active treatment of a wound. This makes it easier for patients to maintain normal day to day activities. Dressing changes are easy and can be performed by patients at home. The PICO is usually to last 14 days before running out of battery, dressing changes are usually indicated after 5-7 days. PICO also removes wound odor through a unique combination of absorption and vaporization.
If necessary, materials like white and black foam can still be used in combination with the PICO. (5)
The PICO device is pocketsize, and easy for patients to carry around.
Compliance is very important when discharging patients. Information about hygiene and dressing changes must be understood properly, to ensure that the wound bed and peri wound skin do not take damage. The PICO has no cannister for wound exudate, this makes the PICO dependent on the dressing for the maximum exudate absorbance (multiple dressing sizes are available).
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