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

Abstract

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.

Keywords: Dwell time; Instillation therapy; NPWTi-d; Negative pressure wound therapy; Wound healing.

Figure 1

Clinical approach to wound healing. Reproduced with permission from KCI Licensing, Inc.

Figure 2

(A) Initial presentation of wound: goal of granulation with benefit of cleansing. (B) Wound after 9 days of NPWTi‐d (saline instillation with a 10‐minute dwell time, followed by 120 minutes of negative pressure wound therapy). (C) Wound 14 days postoperative split‐thickness skin graft (STSG).

Figure 3

(A) Initial presentation of wound; goal of granulation with benefit of cleansing. (B) Application of skin substitute. (C) Graft at 4‐month follow‐up.

Figure 4

(A) Initial presentation of wound; goal of cleansing. (B) Application of split‐thickness skin graft (STSG). (C) Post STSG day 14. (D) Follow up at 6 months. (E) Follow up at 6 months.

Figure 5

(A) Initial presentation of patient. (B) Day of presentation post debridement with traditional negative pressure wound therapy (NPWT) using silver dressing. (C) After 24 hours post presentation and second debridement; primary goal of cleansing. (D) After 6 days of NPWTi‐d (saline instillation with a 10‐minute dwell time, followed by 120 minutes of negative pressure wound therapy), wound was surgically closed and split‐thickness skin graft (STSG) was applied to arm. (E) Torso at 18 weeks follow‐up. (F) Arm at 18 weeks follow‐up.

Figure 6

(A) Initial presentation of plantar wound. (B) Initial presentation of lateral malleolar wound. (C) Initial debridement. (D) After 3 weeks of standard negative pressure wound therapy (NPWT). (E) Application of dermal substitute. (F) Application of split‐thickness skin graft (STSG). (G) Development of infection. (H) Application of NPWTi‐d (saline instillation with a 10‐minute dwell time, followed by 4 hours of negative pressure wound therapy). (I) Wound after 2 weeks of NPWTi‐d. (J) Application of dermal substitute. (K) Wound at follow‐up.