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prophylactic

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Physicians and healers have been sucking poisons and toxins (for example, snake bite venom) from wounds for about 2,500 years [1]. Cupping, a procedure thought to stimulate blood flow, has also been used for many centuries. In effect therefore, negative pressure wound therapy (NPWT), also known as topical negative pressure (TNP) and vacuum assisted closure (VAC), is not new. The first mention of a ‘vacuum’ wound treatment appeared in the Russian literature in the 1980’s [1]. Further developments finally led to the Vacuum Assisted Closure (VAC™) [2], the forerunner of most modern systems.

The mode of action in open wounds
A closed drainage system applies controlled suction (negative pressure) to the wound bed. The wound bed is covered firstly with a wound contact layer (WCL), then a wound filler. As the pre-determined negative pressure is applied, the filler compresses into the surface of the wound, reducing microvascular blood flow at the wound bed and contraction at the wound margins (macro-deformation). Negative pressure is often applied at -125mmHg, although pressure may be tailored to the patient’s risk of ischaemia and pain tolerance [3].

Fillers include open-pore polyurethane foam or saline-moistened gauze – the choice depends upon the wound, the system used, and patient preference. Gauze is more conformable (good for large and/or irregular wounds) [4], is thought to minimise scarring [4]. and produces thinner, dense granulation tissue [5]. Foam filler produces thick, hypertrophic granulation tissue (Borgquist et al, 2009), and if used without a WCL, can facilitate in-growth of granulation tissue, causing pain and/or bleeding upon removal, disruption of the wound bed tissue, and potentially acting as a focus for infection [5].

Effectiveness of NPWT
There is a plethora of studies indicating the clinical effectiveness and financial/patient benefits of NPWT in both dehisced wounds (abdomen, sternum) and chronic wounds such as pressure ulcers and leg ulcers. These include meta-analyses [6], systematic reviews [7], literature critiques [8] and evidence based recommendations [9].

Benefits include:

  • Rapid wound healing [10], through exudate management, reduction of oedema [11], and direct stimulation of granulation tissue [12]
  • Fewer dressing changes, therefore less clinician time required [13], leading to reduced wound management costs and length of stay [14]
  • Improvement in patient quality of life (QoL) [15]

Incisional NPWT (iNPWT)
Single-use products for reducing closed incision complications in high risk patients have been developed over the past decade. This has been in response to the increasing incidence and cost of treating incisional complications (SSCs) such as surgical site infection (SSI) and dehiscence, which increase length of stay and costs, may require repeat surgeries, and poor patient outcomes, particularly as infection can present several days post-discharge and can affect long-term survival [16]. Tanner et al’s study [17] identified a higher SSI percentage that that reported in the literature (27% incidence, vs. 19.4%), most of which manifested post-discharge. SCC’s present a large financial burden and may devastate (or even kill) the patient, so along with assessing risk factors, prevention strategies must be considered.

Incisional NPWT is emerging as a possible prophylactic measure against SSCs. Studies both published and currently being undertaken demonstrate decreased SSI, wound dehiscence and better scar quality in:

  • Breast surgery [18]
  • Cardiothoracic surgery [19]
  • Trauma [20,21]
  • Orthopaedic surgery [22]
  • Abdominal surgery [7, 23]
  • Diabetic foot wounds [24]

On-going iNPWT studies have also been presented at a recent expert meeting [25].

The cost-effectiveness of iNPWT has been demonstrated [8]. In an earlier study, Stannard et al [26] estimated that the application of INPWT costs less than $500 for the mean 2.5 days of therapy, making it a cost-effective intervention due to shortened hospital stay and prevention of postoperative surgical site infection.

To date, many of the studies have centred on patients with high risk factors for SSC – those who are obese, use steroids, have had previous radiation exposure (or awaiting radiotherapy), or who smoke. Other risk factors include the actual procedure and use of implants. Further studies are needed to explore any clinical and/or cost benefits in low-risk patients undergoing high-risk procedures.

iNPWT mode of action
How exactly iNPWT works is not entirely clear; Stannard et al [21] suggests that the reduction in haematoma and seroma, accelerated wound healing, increased removal of oedema and splinting of the incisional area, appear contribute to its effectiveness, but further studies are required to ascertain the exact mechanisms of action.

Conclusion

While further studies are required to determine iNPWTs exact mechanism of action, early indications are that it is a useful prophylactic tool for the prevention of surgical site complications.

If you would like to comment on any of the issues raised by this article, particularly from your own experience or insight, Healthcare-Arena would welcome your views.

References

  1. Kubek EW, Badeau A, Materazzi S, et al. Negative-pressure wound therapy and the emerging role of incisional negative pressure wound therapy as prophylaxis against surgical site infections. In: Microbial pathogens and strategies for combating them; science, technology and education. 2013. (Mendez-Villas A, (Ed.). Formatex Research Center. Available at: http://www.formatex.info/microbiology4/vol3/1833-1846.pdf Accessed July 2015
  2. Argenta LC, Morykwas MJ. Vacuum-assisted closure: a new method for wound control and treatment: clinical experience. Annals of Plastic Surgery. 1997. 38:563-576
  3. Malmsjö M, Borgquist O. NPWT Settings and Dressing Choices Made Easy. Wounds International. 2010. 1; 3. Available at: http://www.woundsinternational.com/other-resources/view/npwt-settings-and-dressing-choices-made-easy Accessed July 2015
  4. Jeffrey S. Advanced wound therapies in the management of severe military lower limb trauma: a new perspective. Eplasty. 2009. 9:e28. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2714221/ Accessed July 2015
  5. Borgquist O, Gustafsson L, Ingemansson R, et al. Tissue ingrowth into foam but not into gauze during negative pressure wound therapy. Wounds. 2009. 21; 11:302-9. http://www.woundsresearch.com/images/Borgquist_NEW-Nov09.pdf (to access pdf) Accessed July 2015
  6. Zhang J, Hu ZC, Chen D, et al.) Effectiveness and safety of negative-pressure wound therapy for diabetic foot ulcers: a meta-analysis. Plast Reconstr Surg. 2014. 134; 1:141-51. Available at: http://www.ncbi.nlm.nih.gov/m/pubmed/24622569/ Accessed July 2015
  7. Bruhin A, Ferreira F, Charika M et al. Systematic review and evidence based recommendations for the use of Negative Pressure Wound Therapy in the open abdomen Int J Surg. 2014. 12; 10:1105-14. Available at: http://www.journal-surgery.net/article/S1743-9191%2814%2900881-4/abstract Accessed July 2015
  8. Stannard JP, Gabriel A, Lehner B. Use of negative pressure wound therapy over clean, closed surgical incisions. Int Wound J. 2012b 9(Suppl. 1): 32–39 Available at: http://onlinelibrary.wiley.com/doi/10.1111/j.1742-481X.2012.01017.x/pdf Accessed July 2015
  9. National Institute for Health and Care Excellence (NICE) Negative pressure wound therapy for the open abdomen. NICE Interventional Procedure Guidance [IPG467]. 2014. Available at: www.nice.org.uk/guidance/ipg467 Accessed July 2015
  10. Armstrong DG, Lavery LA. Diabetic foot study consortium. Negative pressure wound therapy after partial diabetic foot amputation: a multicentre, randomised controlled trial. The Lancet. 2005. 366; 9498: 1704–1710. Available at:
  11. Diabetic Foot Study Consortium. Negative pressure wound therapy after partial diabetic foot amputation: a multi-centre randomized controlled trial. http://www.researchgate.net/publication/7477570_Diabetic_Foot_Study_Consortium.Negative_pressure_wound_therapy_after_partial_diabetic_foot_amputation_a_multicntre_randomized_controlled_trial Accessed July 2015
  12. Webb LX New techniques in wound management: vacuum-assisted wound closure. J Am Acad Orthop Surg. 2002. 10:303-311
  13. Mouës CM, van den Bemd GJ, Meerding WJ, et al. An economic evaluation of the use of TNP on full-thickness wounds. J Wound Care. 2005. 14; 5:224–227
  14. Searle R, Milne J Tools to compare the cost of NPWT with advanced wound care: an aid to clinical decision-making. Wounds UK. 2010. 6; 1:106–109
  15. Ousey KJ, Milne J, Cook L, et al A pilot study exploring quality of life experienced by patients undergoing negative-pressure wound therapy as part of their wound care treatment compared to patients receiving standard wound care. Int Wound J. 2014. 11; 4:357-6. Available at: http://eprints.hud.ac.uk/15024/1/IWJ_QoL_NPWT_repository%5B1%5D.pdf Accessed July 2015
  16. Artinyan A, Orcutt ST, Anaya DA, Richardson P, et al. Infectious post-operative complications decrease long-term survival in patients undergoing curative surgery for colorectal cancer. Ann Surg. 2015. 261; 3:497-505
  17. Tanner J, Padley W, Kiernan M, Leaper D, et al., A benchmark too far: findings from a national survey of surgical site infection surveillance. Journal of Hospital Infection 2013. 83; (2): 87-01.
  18. Holt R, Murphy JA. PICO™ incision closure in oncoplastic breast surgery: a case series. Jour Hosp Med. 2015. 76; 4:217-23
  19. Grauhan O, Navasardyan A, Tutkun B, Hennig F, et al. Effect of surgical incision management on wound infections in a poststernotomy patient population. International Wound Journal. 2014. 11: 6–9. To access pdf go to: http://www.researchgate.net/publication/262609088_Effect_of_surgical_incision_management_on_wound_infections_in_a_poststernotomy_patient_population Accessed July 2015
  20. Krug E, Berg L, Lee C, Hudson D, et al..,Evidence-based recommendations for negative pressure wound therapy in traumatic wounds and reconstructive surgery: Steps towards an international consensus. Injury. 2011 42; s1 – s12.
  21. Stannard J, Volgas DA, McGwin G 3rd, Stewart RL et al., Incisional NPWT After High Risk Lower Extremity Fractures; J Orthop Trauma. 2012a. 26: 37-42 13
  22. Karlakki S, Brem M, Giannini S, Khanduja V, et al., (2013). Negative pressure wound therapy for management of the surgical incision in orthopaedic surgery: A review of evidence and mechanisms for an emerging indication. Bone & Joint Research. 2; 12:276–84. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3884878/ Accessed July 2015
  23. Fry DE. The Prevention of Surgical Site Infection in Elective Colon Surgery. Review Article. Scientifica. 2013. Available at: http://dx.doi.org/10.1155/2013/896297. Accessed July 2015
  24. Faroqui L, Mills JL, Rogers LC, et al. Use of an Incision-Line Negative Pressure Wound Therapy Technique to Protect High-Risk Diabetic Foot Wounds, Postoperatively. The Journal of Diabetic Foot Complications. 2013. Issue 5, 2; 3:44-47. Available at: http://jdfc.org/2013/volume-5-issue-2/use-of-an-incision-line-negative-pressure-wound-therapy-technique-to-protect-high-risk-diabetic-foot-wounds-postoperatively/ Accessed July 2015
  25. Smith & Nephew. 6th International NPWT Expert Meeting. Highlights. Berlin, 2015. Available at: http://www.smith-nephew.com/documents/education%20and%20evidence/videos/2015/npwt%20experts%202015/npwt%20expert%20panel%202015%20-%20highlights%20booklet.pdf. Accessed July 2015
  26. Stannard JP, Robinson JT, Anderson ER, et al. Negative pressure wound therapy to treat hematomas and surgical incisions following high-energy trauma. J Trauma. 2006. 60; 6:1301–6

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