Recommendations on negative pressure wound therapy with instillation and antimicrobial solutions - when, where and how to use: what does the evidence show?

Abstract

Infections of contaminated or colonised acute or chronic wounds remain a grave risk for patients even today. Despite modern surgical debridement concepts and antibiotics, a great need exists for new therapies in wound management. Since the late 1990s, advantageous effects of negative pressure wound therapy (NPWT) have been combined with local antiseptic wound cleansing in the development of NPWT with instillation (NPWTi). This article summarises the current scientific knowledge on this topic. MEDLINE literature searches were performed on the subject of negative pressure wound and instillation therapy covering publications from the years 1990 to 2013 (36 peer-reviewed citations) and regarding randomised controlled trials (RCTs) covering wound care with bone involvement (27 publications) or soft-tissue wounds without bone participation (11 publications) from 2005 to 2012. The use of NPWTi in the therapy of infected wounds appears to be not yet widespread, and literature is poor and inhomogeneous. However, some reports indicate an outstanding benefit of NPWTi for patients, using antiseptics such as polyhexanide (concentration 0·005-0·04%) and acetic acid (concentration 0·25-1%) in acute and chronic infected wounds and povidone-iodine (10% solution) as prophylaxis in contaminated wounds with potential viral infection. Soaking times are recommended to be 20 minutes each, using cycle frequencies of four to eight cycles per day. Additionally, the prophylactic use of NPWTi with these substances can be recommended in contaminated wounds that cannot be closed primarily with surgical means. Although first recommendations may be given currently, there is a great need for RCTs and multicentre studies to define evidence-based guidelines for an easier approach to reach the decision on how to use NPWTi.

Keywords: Antiseptics; Contamination; Instillation; Negative pressure wound therapy; Vacuum-assisted closure.

© 2013 The Authors. International Wound Journal © 2013 John Wiley & Sons Ltd and Medicalhelplines.com Inc.

Figures

Figure 1

Development of the spectrum of indications for negative pressure wound therapy (NPWT) from 1993 to 2013. The assigned time is based on the date of publication. NPWT with instillation (NPWTi) is described for the first time in 1998. WD, wound dehiscence; THA, total hip arthroplasty; TKA, total knee arthroplasty; SI, stump insufficiency. (Reprinted with permission from Dr Christian Willy.)

Figure 2

Functional principles of the negative pressure wound therapy (NPWT). (A, B) The wound (A) and a foam that has been fitted to the wound geometry, cut to size and placed inside the wound (B). (C, D) The wound is sealed airtight with a thin adhesive drape (C); similarly, with the attached suction pad (trac‐pad connector) including the drainage tube (D). (E) The wound is hermetically sealed with a thin adhesive drape and connected to the vacuum source by means of the attached suction pad (suction strength 0 mmHg). (F) Suction strength 125 mmHg. The foam has collapsed and the exudate collection reservoir is already partly filled. (Reprinted with permission from Dr Christian Willy.)

Figure 3

Example of a clinical application of negative pressure wound therapy with instillation (NPWTi) in a patient with necrotising fasciitis (instillation with polyhexanide 0·02%). (A) Reticulated open‐cell foam (V.A.C. VeraFlo™ Dressing; KCI USA, Inc., San Antonio, TX) fitted to the wounds; (B) well‐perfused clean soft tissue after second look and two intervals with vacuum instillation therapy; (C) reticulated open‐cell foam fitted to the upper arm wound, sealed in the first step with two drape strips, with skin protected by hydrocolloid dressing; (D) double lumen SensaTRAC‐pad (V.A.C. VeraT.R.A.C.™ Pad; KCI USA, Inc.) with closed wound.