Management of challenging acute and chronic wounds poses a substantial challenge to the patient and also the caregiver. The application of negative pressure wound therapy (NPWT) has proven to ease some of this burden by promoting a favorable wound-healing environment, decreasing the need for frequent dressing changes, improving patient comfort, and reducing associated costs.
In NPWT, a pliable foam dressing is cut to shape, placed into a wound, and covered with an occlusive dressing. Controlled sub-atmospheric pressure is then applied to the wound by evacuating air and liquids from the foam dressing. Probably the most commonly utilized device for applying NPWT is the wound VAC.
Initial research on pigs demonstrated the superiority of NPWT when compared with moist saline dressings. Even though few randomized controlled trials exist in humans, one review suggests that NPWT improves granulation, augments wound contraction, and reduces the need for systemic antibiotics. Several mechanisms may be responsible for these observations.
NPWT has been shown to enhance local tissue perfusion and reduce the bacterial load on wounds. NPWT may also enhance granulation tissue formation by reducing proteolytic enzymes found in wound exudates, by promoting a moist wound, and by applying shear forces that induce cellular hyperplasia.
Indications
Since NPWT has become commercially obtainable, the list of indications has continued to grow. NPWT is indicated for almost any open wound where surgical closure isn't feasible or desirable. While it may be utilized as a sole treatment toward achieving wound closure, NPWT is frequently utilized as a bridge toward definitive surgical management. Much of its utility is in creating favorable conditions for subsequent wound reconstruction.
With the success seen in treating a selection of wounds, numerous authors have tried to extend the application to improve graft take and flap survival. When flaps are utilized to cover wounds, some studies suggest that extra use of the NPWT may promote improved flap survival and overall wound healing.
In a number of case series, skin graft take was shown to be 90% or higher when the VAC was employed in lieu of a conventional bolster dressing. Recipient sites with irregular contours, susceptibility to shear forces, and excess drainage had been thought to be particularly amenable to VAC dressings. Nevertheless, these outcomes have yet to be confirmed in randomized control trials.
Application of NPWT can be performed by anyone with the suitable training, provided that the wound is hospitable. Prior to application, the wound should be debrided of any necrotic or fibrinous debris and adequate hemostasis achieved. The surrounding skin is then cleansed and dried. The sponge is cut to be slightly smaller than the volume of the wound. The adhesive dressing is then applied over the sponge such that there's at least a 6 cm overlap on adjacent skin; it is imperative that a hermetic seal be achieved.
Once the adhesive dressing has been applied, it is pierced and also the adhesive suction tube is applied over this opening. The device is then turned on and continuous suction is applied. When placed properly, the dressing will produce a closed suction environment. Depending on the nature of the wound, the NPWT dressing can be changed every 48 to 72 hours. The dressing should be taken down sooner ought to the patient show signs of infection or if the seal on the dressing becomes compromised.
The VAC device comes with two kinds of foam available for use. The original foam is black, and it is made of polyurethane. It's hydrophobic which enhances exudate removal. It has reticulated pores and is regarded as to be the most efficient at stimulating granulation tissue while aiding in wound contraction. The second, newer available foam is white. It's a denser foam having a higher tensile strength.
It is hydrophilic and possesses overall nonadherent properties. The white foam doesn't require the use of a nonadherent layer. It is usually recommended for situations in which slower growth of granulation tissue into the foam is desired or when the patient can't tolerate the black foam because of pain. Because of the reality that it has a higher density than the black foam, higher pressures must be utilized in order to offer adequate negative pressure distribution throughout the wound. Newer foams are constantly emerging, like silver-impregnated foams.
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