Egyptian_Pediatric yahoo group           Egyptian_Pediatric yahoo group http://health.groups.yahoo.com/group/    http://he...
Don’t Put Off Your EducationCatherine L. WittT        he question of educational preparation for           practitioners w...
106           Witteven on-site work programs in collaboration with                              2. Aiken LH, Clarke SP, Ch...
LAURA A. STOKOWSKI, RN, MS • Section EditorHospital Stay for Healthy                                                      ...
108          Stokowski                                                                         oration or critical illness...
Noteworthy Professional News                 109aureus accounted for most EOS episodes within this       The high proporti...
REGINA GRAZEL, MSN, RN, BC, APN-C • Section Editor                                                       Board Member of N...
Grazel     111transport were used to create a new guideline,            only a physician can direct respiratory care servi...
NANN Position Statement 3049112                  Advances in Neonatal Care • Vol. 10, No. 3 • pp. 112-118
NANN Position Statement 3049   113Advances in Neonatal Care • Vol. 10, No. 3
114   NANN Position Statement 3049                                     www.advancesinneonatalcare.org
NANN Position Statement 3049   115Advances in Neonatal Care • Vol. 10, No. 3
116   NANN Position Statement 3049                                     www.advancesinneonatalcare.org
NANN Position Statement 3049   117Advances in Neonatal Care • Vol. 10, No. 3
118   NANN Position Statement 3049                                     www.advancesinneonatalcare.org
LINDA IKUTA, RN, MN, CCNS, PHN • Section EditorUse of a Vacuum-Assisted Device in aNeonate With a Giant Omphalocele       ...
120       Wilcinskiusing a Surgisis graft (Cook Medical Products,Bloomington, Indiana) that was placed over the defect    ...
Use of a V.A.C.® Device in a Neonate With an Omphalocele   121abnormalities, neural tube defects, and the genetic         ...
122        Wilcinskicells later migrate, differentiate, and resurface the         used for the treatment of acute and chro...
Use of a V.A.C.® Device in a Neonate With an Omphalocele   123GranuFoam Silver™ dressing, is also available. It is a      ...
124       Wilcinski    A report in 2006 described V.A.C.® therapy of 3         bowel perforation secondary to necrotizing ...
Use of a V.A.C.® Device in a Neonate With an Omphalocele         125granulation tissue to the Black Foam. Intermittent    ...
126       Wilcinski                                                          systems such as the V.A.C.® therapy system ma...
CE TestUse of a Vacuum-Assisted Device in a Neonate With aGiant OmphaloceleInstructions:                                  ...
13. When using wound VAC therapy, the negative pressure                                   16. A priority of wound VAC ther...
03 advances in neonatal care june2010
03 advances in neonatal care june2010
03 advances in neonatal care june2010
03 advances in neonatal care june2010
03 advances in neonatal care june2010
03 advances in neonatal care june2010
03 advances in neonatal care june2010
03 advances in neonatal care june2010
03 advances in neonatal care june2010
03 advances in neonatal care june2010
03 advances in neonatal care june2010
03 advances in neonatal care june2010
03 advances in neonatal care june2010
03 advances in neonatal care june2010
03 advances in neonatal care june2010
03 advances in neonatal care june2010
03 advances in neonatal care june2010
03 advances in neonatal care june2010
03 advances in neonatal care june2010
03 advances in neonatal care june2010
03 advances in neonatal care june2010
03 advances in neonatal care june2010
03 advances in neonatal care june2010
03 advances in neonatal care june2010
03 advances in neonatal care june2010
03 advances in neonatal care june2010
03 advances in neonatal care june2010
03 advances in neonatal care june2010
03 advances in neonatal care june2010
03 advances in neonatal care june2010
03 advances in neonatal care june2010
03 advances in neonatal care june2010
03 advances in neonatal care june2010
03 advances in neonatal care june2010
03 advances in neonatal care june2010
03 advances in neonatal care june2010
03 advances in neonatal care june2010
03 advances in neonatal care june2010
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Transcript of "03 advances in neonatal care june2010"

  1. 1. Egyptian_Pediatric yahoo group Egyptian_Pediatric yahoo group http://health.groups.yahoo.com/group/ http://health.groups.yahoo.com/group/ egyptian_pediatric/ egyptian_pediatric/
  2. 2. Don’t Put Off Your EducationCatherine L. WittT he question of educational preparation for practitioners who must consider returning to school nursing practice is not new. Forty-five years to obtain a doctorate of nursing practice and nurses ago in 1965, the American Nurses Association who must consider earning a baccalaureate degree.published a position paper calling for the baccalau- There are certainly many practicing nurses who doreate degree as the minimum requirement for entry not have a baccalaureate degree and provide safe,into professional nursing practice.1 It is interesting effective care to their patients. They have a wealth ofthat nearly a half century later, we are no closer to experience that is invaluable. They may reasonablyachieving this standard. Many components of the question the value of returning to school in the mid-debate have not changed. Healthcare continues to dle of a satisfying career. One author looked at bar-become increasingly complex. The amount of knowl- riers that prevented nurses from pursuing a BSNedge required to provide safe patient care has degree.6 Incentives included increased options inincreased substantially. Nurses are also required to their career, including improved mobility and oppor-have an in-depth knowledge of healthcare systems, tunities. The possibility of pursuing an advancedinformation technology, and research methodology. degree that would allow for advanced practice nurs-An increasing number of studies have shown that ing, management opportunities, or teaching careersthere is a connection between baccalaureate nursing was another incentive. Barriers included not enougheducation and lower mortality rates.2-4 time, lack of confidence, and lack of recognition by Despite this evidence, in 2004, only 47.2% of RNs employers. Previous negative experiences in schoolcurrently working have a baccalaureate or graduate were also noted as a barrier.degree.5 Fifty-one percent of RNs currently working Employers can do more to encourage their staff tohave an associate degree or a diploma in nursing.5 This return to school. Tuition reimbursement and studentis in contrast to other healthcare professionals with loan forgiveness programs can help. Pay differentialswhom patients interact. Physical therapists, occupa- that reward education and requiring a BSN degree fortional therapists, pharmacists, social workers, audiolo- leadership positions can also provide incentives.gists, and speech therapists have not only a baccalau- Changing state or certification requirements havereate degree but also graduate degrees. This argument proved to be a big incentive for advanced practicehas been used to justify requiring nurse practitioners to nurses. Schools of nursing can help by recognizing andhave a doctoral degree but should illustrate the need giving credit for educational and work experiences.for a baccalaureate degree (BSN) as a minimum entry- Easy transfer of credits from associate degree pro-level educational criterion for nurses. grams to 4-year schools should be made standard. There are many other arguments for increasing the Increased federal funding of nursing education at therequirement for entry into practice. Unfortunately, baccalaureate and graduate levels should be a priority.despite 45 years of debate, we have not made much However, waiting for someone to make you pur-progress as a system. Human nature being what it is, sue a degree is not very proactive. The desire tomany will put off pursuing this degree until it is increase one’s professional credibility and careerrequired. I would ask you to consider this waiting options should be a driving force. In fact, states, hos-until someone makes you do something, meaning pitals, and certification boards can change rules andthat you might put it off until it is too late. Some nurse requirements for various positions with little warning,practitioners have learned this to their detriment. meaning that by the time someone makes you get aWhile most states have “grandfathered” those practi- degree, you will not have adequate time to make ittioners who do not have a master’s degree, changing happen. Also, if you are waiting until you have time,rules requiring certification, prescriptive authority, or consider that you will likely never have unlimitedother factors have limited the ability of a few to prac- free time in which to pursue a degree unhindered.tice. It is possible that future changes in nurse prac- You have to make available the time. There are nowtice acts will limit the practice of those who do not more options than ever: online programs, acceler-have the necessary education. This applies to nurse ated programs, traditional classroom programs, andAdvances in Neonatal Care • Vol. 10, No. 3 • pp. 105-106 105
  3. 3. 106 Witteven on-site work programs in collaboration with 2. Aiken LH, Clarke SP, Cheung RB, Sloane DM, Silber JH. Educational levels of hospital nurses and surgical patient mortality. JAMA. 2003;290:1617-1623.hospitals and universities. Don’t wait until it is too 3. Aiken LH, Clarke SP, Sloane DM, Lake ET, Cheney T. Effects of hospital carelate. There is no time like the present. environment on patient mortality and nurse outcomes. J Nurs Adm. 2008;38:223-229. 4. Estabrooks CA, Midodzi WK, Cummings CG, Ricker KL, Giovanetti P. The impact of hospital nursing characteristics on 30-day mortality. Nurs Res.References 2005;54,72-84.1. Nelson MA. Education for professional nursing practice: looking backward 5. American Association of Colleges of Nursing. Fact Sheet: creating a more into the future. Online J Issues Nurs. 2002;7:3. Manuscript No. 3. highly qualified nursing work force. http://www.aacn.nche.edu/Media/ https://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ pdf/nursingworkforce.pdf. Accessed March 14, 2010. ANAPeriodicals/OJIN/TableofContents/Volume72002/No2May2002/ 6. Megginson LA. RN—BSN education: 21st century barriers and incentives. EducationforProfessionalNursingPractice.aspx. Accessed March 14, 2010. J Nurs Manag. 2008;16:47-55. www.advancesinneonatalcare.org
  4. 4. LAURA A. STOKOWSKI, RN, MS • Section EditorHospital Stay for Healthy Parents’ MedicationTerm Newborns Administration ErrorsT B he American Academy of Pediatrics has pub- efore discharge, nurses often teach parents how lished a revised policy statement, “Hospital to draw up and administer oral medications that Stay for Healthy Term Newborns.” It is the the parents need to administer to their infants atfirst revision in 15 years and contains many evidence- home. Although we may send home an oral syringe orbased updates. Here are a few of the updates; for all two for this purpose, who really knows how parentsdischarge-readiness criteria and the complete set of are measuring these medications after they go home?changes, please see the policy statement.1 A simple, yet practical, study1 recently assessed the ability of 302 parents to measure liquid medications • Along with stable vital signs, newborns should in 6 different commonly available measuring instru- have no signs of respiratory distress. ments (2 types of dosing cups, a dosing spoon, a cal- • Infants should complete 2 successful consecutive ibrated dropper, and 2 types of oral syringes). The feedings. volume of these instruments ranged from 5 to 30 mL. • Clinical risk of development of subsequent Participants were asked to measure a test medica- hyperbilirubinemia has been assessed, and tion in each of the 6 methods presented. An error was appropriate management or follow-up plans or generously defined as 20% or more than 20% over or both have been instituted. under the intended dose. The actual dose measured • Evaluation and monitoring for sepsis on the by participants was determined by weighing the basis of maternal risk factors. measured sample and subtracting the weight of the • Screening tests in accordance with state regula- measuring instrument. In addition, the investigators tions includes a test for human immunodefi- examined the potential role of health literacy in the ciency virus. parents’ ability to accurately measure medications. • Newborn hearing screenings have been Health literacy was assessed with the Newest Vital completed. Sign Test, which classifies health literacy as limited, • Mothers’ infant-feeding techniques are assessed possibly limited, or adequate. by trained staff. Errors were alarmingly frequent with some meas- • Along with safety in the home, a smoke-free uring instruments, and almost all errors were over- environment and room sharing are emphasized. doses. Errors were most frequent and most significant • The presence of communicable illness in the with the 2 dosing cups, and least frequent with oral home is assessed. syringes. Only 30% of parents measured the test dose • Continuing care after discharge includes identi- accurately with a dosing cup that had printed cali- fication of a medical home for the infant. bration marks, and 50% measured accurately with a • Barriers to adequate follow-up are identified dosing cup that had etched calibration marks. The and assistance is given as appropriate (trans- most accurate instrument was the standard oral portation, translators) syringe, with which 91% of parents measured the test dose within 20% of the intended dose. The updated policy statement also describes the Both instrument type and health literacy had inde-purpose and requirements of the first newborn fol- pendent effects on the rate of error. Dosing cups werelow-up visit. associated with large overdosing errors, and parentsReference who had low health literacy were most at risk of mak-1. American Academy of Pediatrics, Committee on Fetus and Newborn. Policy ing an error. Part of the discharge teaching with respect statement: hospital stay for healthy term newborns. Pediatrics. 2010;125: to oral medications should include the importance of 405-409. continuing to use an oral syringe to measure liquid medications, and cautioning parents about using dos-Address correspondence to Laura A. Stowkowski, RN, MS; ing cups to measure their infant’s medication doses.Stowkowski@cox.net.Author Affiliation: Inova Fairfax Hospital for Children, FallsChurch, Virginia. Reference 1. Yin HS, Mendelsohn AL, Wolf MS, et al. Parents’ medication errors: role ofCopyright © 2010 by the National Association of dosing instruments and health literacy. Arch Pediatr Adolesc Med. 2010;Neonatal Nurses. 164:181-186.Advances in Neonatal Care • Vol. 10, No. 3 • pp. 107-109 107
  5. 5. 108 Stokowski oration or critical illness at a later age, premedicationSevere Combined Immunodeficiency should be used for all endotracheal intubations inAdded to Uniform Newborn newborns. Medications with rapid onset and short duration of action are preferable. RecommendationsScreening Panel for premedication include the following:A historic unanimous vote early this year by • analgesic agents or anesthetic dose of a hypnotic the Secretary’s Advisory Committee for drug should be given (fentanyl, remifentanil, Heritable Disorders in Newborns and and morphine);Children paves the way for severe combined immun- • vagolytic agents and rapid-onset muscleodeficiency (SCID) to be the latest addition to the relaxants should be considered (atropine,uniform newborn screening panel performed by state glycopyrrolate);public health programs. • use of sedatives alone, such as benzodiazepines The SCID is a rare group of generic disorders with (midazolam) without analgesic agents, shouldan estimated incidence of 1 in 40,000—100,000 new- be avoided;borns, and perhaps higher as a result of undiagnosed • a muscle relaxant should not be used without ancases.1 The SCID is a lethal disorder of adaptive analgesic (pancuronium, vecuronium, etc);immunity, characterized by the absence of T-lym- andphocytes. With essentially nonfunctional immune • each NICU should develop protocols andsystems, infants with SCID are at the mercy of their lists of preferred medications to improve com-surroundings and must live in protected environ- pliance and minimize medication errors andments (eg, “boy in the plastic bubble”) where expo- adverse effects.sure to infectious agents can be minimized. Without treatment, recurrent opportunistic infections A full table of medications, doses, and routes ofare eventually fatal. However, because SCID has no administration can be found in the article.1overt signs or symptoms, the only way to save affectednewborns is to identify them with universal newborn Referencescreening and perform early stem cell transplantation. 1. Kumar P, Denson SE, Mancuso TJ; Committee on Fetus and Newborn, Section on Anesthesiology and Pain Medicine. Premedication for non- In 2005, the Advisory Committee for Heritable emergency endotracheal intubation in the neonate. Pediatrics. 2010;Disorders in Newborns and Children adopted a list 125:608-615.of 29 conditions recommended for newborn screen-ing. Since that time, only 6 conditions (Fabry disease,Krabbe disease, Niemann-Pick disease, Pompe dis- Sepsis in Late Preterm Infantsease, spinal muscular atrophy, and SCID) have been Ibrought to the committee for consideration of inclu- t is now well known that late preterm infantssion in the uniform newborn screening panel. The (born with estimated gestational ages of 34-36 wk)SCID is the first condition to be added to the manda- are at high risk for numerous problems, such astory newborn screening panel since 2005. hyperbilirubinemia, hypoglycemia, and respiratory distress. Early- and late-onset sepsis and sepsis-Reference related mortality are also believed to occur more fre-1. National Human Genome Research Institute. Severe combined immunod- quently in this gestational age group. eficiency. http://www.genome.gov/13014325. Accessed March 19, 2010. In the largest observational study conducted to date, Cohen-Wolkowiez and colleagues1 prospec- tively collected data from 119,130 late pretermPremedication for Nonemergency infants admitted to 248 NICUs to determine specificIntubation in the Neonate infection rates, pathogen distribution, and mortality associated with early- and late-onset sepsis. A bloodA recent evidence-based review of premedica- culture was obtained from most (69%) of these new- tion for nonemergent intubation in the borns within the first 3 postnatal days. Whether these neonate was published by the American blood cultures were prompted by clinical signs ofAcademy of Pediatrics Committee on Fetus and sepsis or premature birth is unclear.Newborn.1 An ideal strategy for premedication for A total of 531 episodes of early-onset sepsis (EOS)intubation eliminates the pain, discomfort, and phys- were documented for a cumulative incidence of 4.42iologic abnormalities of the procedure; helps to carry per 1,000 admissions. The highest rate of EOSout intubation expeditiously; minimizes the chances occurred in Hispanic infants, who had a frequency offor traumatic injury to the newborn; and has no 20%. Gram-positive organisms caused most episodesadverse effects. of EOS (66.4%, 353/531), gram-negative organisms Except for emergent intubation during resuscita- accounted for 27.3% of EOS, and yeast for 0.8%.tion either in the delivery room or after acute deteri- Group B strep, Escherichia coli, and Staphylococcus www.advancesinneonatalcare.org
  6. 6. Noteworthy Professional News 109aureus accounted for most EOS episodes within this The high proportion of infants evaluated with agroup of infants. blood culture and the small number of infection Late-onset sepsis (LOS) episodes numbered 803 episodes suggest that the yield from sepsis evalua-for a cumulative incidence of 6.30 per 1,000 admis- tions in most late preterm infants is low.sions. Like EOS, most LOS episodes were caused bygram-positive organisms (59.4%), followed by gram- Referencenegative organisms (30.7%), and yeast (7.7%). The 1. Cohen-Wolkowiez M, Moran C, Benjamin DK, et al. Early and latehighest mortality was associated with LOS and onset sepsis in late preterm infants. Pediatr Infect Dis J. 2009;28:1052-gram-negative rods. 1056.Advances in Neonatal Care • Vol. 10, No. 3
  7. 7. REGINA GRAZEL, MSN, RN, BC, APN-C • Section Editor Board Member of National Association of Neonatal NursesUPDATES ON NANN’S CONFERENCE,PRODUCTS, AND ADVOCACY INITIATIVESLAS VEGAS, BABY!NANN’s annual educational conference “Embracingthe Power of Change: Advancing, Leading, andLearning” will be held on September 19 to 22 in excit-ing Las Vegas. This nationally renowned conferencewill feature • an opening keynote address by John Nance, pi- lot, safety expert, and author of Why Hospitals Should Fly; • an in-depth symposium on the “Golden Hour” by Robin Bissinger, PhD, RN, NNP-BC, high- lighting important nursing interventions for the critical first hour of life; • sessions on core content for certification; • a stimulating lineup of sessions in RN, manage- ment, advanced practice, and review tracks; • preconference workshops on NICU certification review, the S.T.A.B.L.E. Cardiac Module, pallia- tive care, pharmacology, and the late preterm infant; • a procedural skills laboratory (back by popular demand)—a hands-on learning experience for ad- vanced practice nurses, to include umbilical arte- rial catheter insertion, chest tube placement, and lumbar puncture; • the Faces of Neonatal Nursing Photo Contest; and • a closing keynote address by Rick Kirschner— G REAT N EW P RODUCTS F ROM NANN “Bringing Out the Best in People (Even at Their Worst).” Transport Guideline Also, Vegas offers something for every taste. Get Rapid advances in neonatal care, technologies, andready for fun! For more information, visit www.nann. regionalization of neonatal services have improvedorg. care and outcomes for at-risk newborns. Access to ter- tiary care is available, made possible through the efforts of neonatal transport teams that facilitate inter- hospital transfer of critically ill newborns. NeonatalAddress correspondence to Barbara Hofmaier, MAT, National transport medicine has evolved in recent decades, andAssociation of Neonatal Nurses, 4700 W Lake Ave, Glenview, neonatal transport teams need up-to-date informationIL 60025. on evidence-based clinical care practices and ways toNo grant funding was involved in the production of this article. ensure patient safety throughout the transport process.Copyright © 2010 by The National Association of Research from related areas and best practicesNeonatal Nurses established by experts in the field of neonatal110 Advances in Neonatal Care • Vol. 10, No. 3 • pp. 110-111
  8. 8. Grazel 111transport were used to create a new guideline, only a physician can direct respiratory care services.Neonatal Nursing Transport Standards: Guideline for Although this rule allows advanced practice regis-Practice, being released by NANN in 2010. This is a tered nurses (APRNs) in all specialties to write respi-must-have resource for all nurses involved in neona- ratory care orders, it also mandates that the “respon-tal transport. For information on how to get your sible doctor of medicine or osteopathy must cosigncopy of this vital new publication from NANN, visit the order.” For APRNs in the 15 states that still re-our Web site at www.nann.org. quire a physician—APRN relationship of “supervi- sion or collaboration,” this requirement presents aOther Valuable Resources Coming significant impediment to providing prompt and ap-From NANN in 2010 propriate care. For the NNPs practicing in those • RNC (registered nurse, certified) review course— states, this ruling causes significant duplication of An Internet-based, modular, comprehensive work, complicated workflows, and unnecessary re- review course. dundancy. The NNPs caring for critically ill infants • Understanding Clinical Research: A Guide for the in the NICU can write hundreds of respiratory or- New Researcher—An introductory guide to review- ders a day, depending on the size of the unit and the ing, evaluating, and conducting research that in- acuity level of the patients. Following The Joint cludes material on literature evaluation and a Commission’s support of this requirement, the com- continuing education component. mittee made this issue a priority. A sample letter of • Competencies and Orientation Tool Kit for Neonatal concern was sent to NANN’s advocacy e-mail dis- Nurse Practitioners—A valuable tool kit that will cussion group, along with information about where help neonatal nurse practitioners (NNPs) to assess to send letters of concern. their practice and identify their own learning The committee has also initiated grassroots cam- needs and will help preceptors and staff educators paigns in response to several US House and Senate both to determine the learning needs of NNP stu- bills introduced this session, including bills about dents and new NNPs and to evaluate the contin- fighting antimicrobial resistance, researching ued competence of experienced NNPs. endocrine disrupters, and establishing an Office of • Resource Guide for Cardiac Care in the NICU and the National Nurse. For more information about accompanying quick reference guide—A handy these “calls to action,” please visit the NANN Web resource that includes common medications, site and click on the Advocacy button on the right dosages, and tips on bedside care. side. Visit www.nann.org for product-ordering information. State LiaisonsH EALTH POLICY AND ADVOCACY We are in the process of identifying a NANN or NANNP member from each state to serve as a liaisonThe Health Policy and Advocacy Committee of to our committee. The state liaison (SL) is a volunteerNANN and NANNP has been extremely busy during who has a strong interest in advocacy, health policy,the 111th US Congress. Although it sometimes seems and legislative issues. The SL will monitor and sharethat global healthcare reform is the only item on the information about current or pending legislation of in-congressional agenda, other issues that affect neonatal terest at the state level and act as liaison to the Healthnursing practice and neonates have arisen at both state Policy and Advocacy Committee. The SL need notand federal levels. have previous experience in health policy and advoca- cy. For more information about this role or to expressIssues of Interest your interest, please contact committee membersThe committee is responding to the Centers for Joyce Stein (jazstein@mac.com) or Katie MalinMedicare & Medicaid Services requirement that (kmmalin@gmail.com).Advances in Neonatal Care • Vol. 10, No. 3
  9. 9. NANN Position Statement 3049112 Advances in Neonatal Care • Vol. 10, No. 3 • pp. 112-118
  10. 10. NANN Position Statement 3049 113Advances in Neonatal Care • Vol. 10, No. 3
  11. 11. 114 NANN Position Statement 3049 www.advancesinneonatalcare.org
  12. 12. NANN Position Statement 3049 115Advances in Neonatal Care • Vol. 10, No. 3
  13. 13. 116 NANN Position Statement 3049 www.advancesinneonatalcare.org
  14. 14. NANN Position Statement 3049 117Advances in Neonatal Care • Vol. 10, No. 3
  15. 15. 118 NANN Position Statement 3049 www.advancesinneonatalcare.org
  16. 16. LINDA IKUTA, RN, MN, CCNS, PHN • Section EditorUse of a Vacuum-Assisted Device in aNeonate With a Giant Omphalocele Susan L. Wilcinski, MS, RN, NNP-BC ABSTRACT Wound healing is a complex process that can be even more challenging in neonatal and pediatric patients. Infants and children have special characteristics such as skin immaturity, a high body surface to weight ratio, sensitivity to pain, increased potential for percutaneous absorption of medication, and an immature immune system that adds to the com- plexity of treating their wounds. The use of controlled topical negative pressure across a wound surface has been used in adults and children since 1995. Recently, the use of this device has been reported in neonates. This article discusses the normal process of wound healing and describes the use of this device in an infant with a giant omphalocele. KEY WORDS: giant omphalocele, Vacuum-Assisted Closure, wound healing and her pregnancy was complicated by an abnor-T he care and treatment of large chronic wounds in neonatal and pediatric Z can be very chal- mal 2-hour glucose tolerance test and pregnancy- lenging. Since 1995, Vacuum-Assisted Closure® induced hypertension.Therapy (V.A.C.®; Kinetic Concepts, Inc [KCI] San The infant was delivered vaginally underAntonio, Texas) has been a useful therapy in the epidural anesthesia and her Apgar scores were 7 atmanagement of complex wounds in adults and chil- 1 minute and 8 at 5 minutes. She weighed 3320 g.dren. Little has been published regarding its use in Resuscitation included oral and gastric suctioning,full-term and premature infants. The V.A.C.® device stimulation, and blow by oxygen. A giant omphalo-uses the application of controlled topical negative cele, measuring 10 12 cm, was noted at the timepressure across a wound surface in a manner that of delivery, which was not diagnosed antenatally.produces rapid wound healing. This case presenta- The defect was wrapped with sterile normal saline–tion describes the use of this device in a full-term soaked gauze and Kerlix (Kendall Brands, now partbaby with a giant omphalocele who had difficult of Coviden, Mansfield, Massachusetts). A Reploglewound healing and reviews normal wound healing. tube was also passed to decompress her stomach and bowel.CASE PRESENTATION Shortly after delivery, IZ developed increased work of breathing with mild to moderate subcostalBaby girl IZ was born at 38-week gestation to a retractions and tachypnea because of the large size of24-year-old, gravida 3, para 1 mother at a local the defect that limited her lung expansion, and shereferring hospital. Her mother was negative for was placed into a 40% oxygen hood with good oxy-hepatitis B and HIV, her rapid plasma reagin test gen saturation levels achieved. A blood culture waswas negative for syphilis, and her blood type was A obtained and a peripheral intravenous catheter wasnegative. Her mother received early prenatal care placed for antibiotics (ampicillin and gentamicin) and hydration. She was transported to a regional referral center for surgical repair and ongoing care.Address correspondence to Susan L. Wilcinski, MS, RN, Initially, the pediatric surgeon thought she wouldNNP-BC, Presbyterian St Luke’s Medical Center, 1719 E, require a staged closure that involves placing a silo19th Ave, Denver, CO 80218; swilcinski@comcast.net. but a primary repair was achieved on day 1. DuringAuthor Affiliation: Presbyterian St Luke’s Medical Center, surgery, the omphalocele was excised and the liver,Denver, Colorado. spleen, and the majority of bowel were extruded,Copyright © 2010 by the National Association of the sac was completely excised, and the umbilicalNeonatal Nurses. cord structures were ligated. The defect was closedAdvances in Neonatal Care • Vol. 10, No. 3 • pp. 119-126 119
  17. 17. 120 Wilcinskiusing a Surgisis graft (Cook Medical Products,Bloomington, Indiana) that was placed over the defect FIGURE 1.attaching circumferentially to the fascia. The skin wasthen closed over the Surgisis graft. The repair wascompleted without evidence of significant abdominalcompartment syndrome. A Broviac central venouscatheter was also placed at the time of surgery. Shereceived perioperative antibiotics, which werecontinued for 5 days. Six days postoperatively, a patch of wound openedexposing the Surgisis mesh graft. The antibioticsamikacin and vancomycin were started as well asnormal saline wet-to-dry dressing changes 3 times aday. Five days later, on day 11, the wound was mal-odorous and acetic acid wet-to-dry dressing changeswere begun twice a day. On day 14, healing of the Postoperative wound prior to application of thewound was improved, the wet-to-dry dressing V.A.C.® therapy. Photograph courtesy of Presbyterian/changes were stopped, and a nonocclusive dressing St. Luke’s Medical Center, Denver, Colorado.was placed over the wound that has little granulation Reprinted with permission.tissue over the mesh graft. Silvadene (silver sulfadi-azine) was used topically daily beginning on day 17for increased wound breakdown. During this time, IZreceived 2 more courses of antibiotics. Over the next embryonic disk. Migration and fusion of the cranial,3 days, progressive wound breakdown developed caudal, and lateral folds normally result in an intactand the decision was made to consult the wound care umbilical ring by 5-week gestation.1 Partial or com-team located at the hospital. A wound punch biopsy plete arrest of this process results in an omphalocele,was done and showed a full-thickness wound with with insertion of the umbilical cord onto the centralchronic infection of the SurgiSIS graft mesh. omphalocele sac with a surrounding facial defect.Silvadene was stopped and Silvasorb was placed over The size of the defect may vary with large defects ofthe wound twice a day. the entire midgut as well as the stomach, liver, and On day 47, IZ was taken to the operating room spleen. In 50% of cases, the liver, spleen, and ovarieswhere the wound was debrided and 90% of the or testes accompany the midgut.1 The abdominalSurgisis graft mesh was excised. It was necessary to cavity remains small with the absence of the viscera.leave a portion of the graft mesh in place because the One in 5000 babies has an omphalocele that involvesmajority of the graft was adherent to the liver that the bowel only.1 Only 1 in 10 000 infants have a giantmade cautery dissection difficult. The fascial edges omphalocele that involves the liver.1were joined by bolster sutures and the defect was Fetal omphalocele may occur in conjunction withclosed. Postoperatively, the incision was cleaned with other conditions, such as cardiac or genitourinaryhalf-strength hydrogen peroxide and triple antibioticointment and she received 1-week dose of amikacinand vancomycin. Wound culture specimens that FIGURE 2.were taken intraoperatively were growing methi-cillin-sensitive Staphylococcus aureus and Escherichiacoli. One week postoperatively, the skin broke downaround the retention sutures. Once again, Silvasorbwas used to treat the open wound. Progressive dehis-cence developed, and 9 days postdebridement, theopen wound measured 5 2 cm and contained fas-cia and Surgisis (Figure 1). At this time, the decisionwas made to apply a V.A.C.® Therapy device (KCI)(Figure 2).GIANT OMPHALOCELEAbdominal wall defects in infants have 3 subtypes: Device used for wound vacuum assisted closureomphalocele, gastroschisis, and hernia of the cord. therapy, V.A.C.®, Kinetic Concepts, Inc (San Antonio,Closure of the fetal abdominal wall depends upon Texas). Reprinted with permission.appropriate craniocaudal and lateral infolding of the www.advancesinneonatalcare.org
  18. 18. Use of a V.A.C.® Device in a Neonate With an Omphalocele 121abnormalities, neural tube defects, and the genetic which collagen fibers are deposited, mature, anddefects trisomy 13 or 18. In addition, omphalocele strengthen. This gel-like substance keeps the woundmay be associated with Beckwith–Wiedemann moist, which facilitates healing.6 Vitamin C, zinc,Syndrome or pentalogy of Cantrell. oxygen, and iron are required for this process. Granulation occurs when collagen, capillaries, andNORMAL WOUND HEALING cells begin to fill the wound space with new connec- tive tissue. Granulation tissue is red and bumpy withWound healing is an ever-changing and delicate a meaty appearance. The wound contracts as myofi-process that at times is taken for granted. The process broblasts align along the lines of contraction. This isis an overlapping series of events, beginning with a unified process requiring cell-to-cell and cell-to-injury to eventual repair. Normally, rapid wound matrix communication. The effect of contraction is tohealing occurs in infants and pediatric patients but decrease the area to be filled in with granulation tis-healing can be delayed by a number of reasons sue. Reepithelialization begins as epithelial cellsincluding impaired perfusion, infection, prolonged migrate from surrounding skin. Epithelial cells needpressure, poor nutrition, edema, and the wound envi- a viable wound edge and a moist wound surface toronment. Neonatal and pediatric wound care requires migrate across a wound bed.7 These cells eventuallyspecial expertise and precise management. Infants begin to differentiate into various layers of the der-and children have special characteristics such as skin mis. The initial scar is bright red, thick, and blanchesimmaturity, a high body surface to weight ratio, sen- with pressure.sitivity to pain, increased potential for percutaneous In the fourth stage, remodeling of the scar contin-absorption of medication, and an immature immune ues for about 1 year. Scar tissue regains about two-system that adds to the complexity of treating their thirds of its original strength and is never as strong aswounds.2,3 Effective wound management is depend- the normal tissue and never fully retains tensileent upon an understanding both of the normal repair strength.4 Wounds slow down or stop their healingprocess and of factors affecting this process and inter- process because of numerous factors. Tissue hypoxiaventions that can impact the ultimate outcome. There is an important cause. Tissue hypoxia decreasesare 4 phases of wound healing. resistance of the wound to infection by interfering The first stage includes a vascular response, so with phagocytosis. Hypoxia impairs collagen synthe-within seconds of an injury, blood vessels constrict to sis and increases collagen lysis as well as decreasesstop any bleeding and to limit exposure to bacteria. epithelial proliferation and migration.8,9 A balancedPlatelets cluster together to form a clot, which is the nutrition is also very important for wound healing. Aresult of conversion of thrombin to fibrinogen and neonate should optimally be in a good anabolic stateultimately to fibrin.4 The second stage involves an with good protein intake. Some centers measureinflammatory response, which is the body’s first albumin and prealbumin levels and consider themdefense system against bacterial invasion. Neutrophils markers of optimal protein intake during their man-along with macrophages arrive and ingest bacteria. agement of chronic wounds.2 Full formula or breastMonocytes, which play a critical role in the healing milk feedings should provide enough protein to opti-process, arrive later. They phagocytose bacteria along mize wound healing. If oral feedings are not toler-with damaged tissue, engulfing and destroying microbes ated, total parenteral nutrition with adequate protein,present there. Macrophages secrete angiogenesis glucose, and fat along with vitamins and trace miner-factor, which stimulates the formation of new blood als should be provided.vessels.4,5 Ischemic cells release the vasoactive sub- Wounds that are chronically infected are very slowstances bradykinin, histamine, and prostaglandin. to heal. Infection prolongs the inflammatory phase ofVessels start to dilate, permeability increases, and healing, resulting in diminished levels of oxygen influid begins to leak into the wound. Inflammation is a the tissue, with decreased fibroblast production andsign of healing but prolonged inflammation due to diminished collagen formation. Many chronicnecrotic, infected tissue or foreign bodies slows the wounds require surgical debridement before they canhealing process and can lead to chronic wounds. begin the healing process. The proliferative phase is the third stage of healing The use of corticosteroids can inhibit the inflam-and involves intense multiplication of cells. matory response and phagocytosis, interfering withAngiogenesis, collagen synthesis, contraction, and healing. In addition, these medications decrease col-epithelialization are part of this phase.2 Angiogenesis lagen strength and can inhibit epithelial prolifera-is the growth of new capillaries by which local blood tion.4 A dry wound bed should be avoided becauseflow for healing is increased. Macrophages secrete this leads to slow healing.4 When a wound is dry,lactate and growth factors into the wound, which keratinocytes, which are the major cell type of thestimulate fibroblast proliferation. Fibroblasts secrete epidermis, to heal the wound, will need to burrowcollagen, which reconstructs connective tissue. down to a moist environment in the wound in orderCollagen is initially secreted as a gel matrix onto to secrete collagenase, which lifts the scab. TheseAdvances in Neonatal Care • Vol. 10, No. 3
  19. 19. 122 Wilcinskicells later migrate, differentiate, and resurface the used for the treatment of acute and chronicwound. A dry wound bed will also interfere with wounds.10,11 Since its introduction more than aepithelial proliferation and migration. A very impor- decade ago, it was initially used in adult wound heal-tant goal of wound healing is to provide a moist ing and has been applied to the pediatric population.wound bed that stimulates the wound into its healing However, its use in neonates has been limited.cascade.4,7 V.A.C.® therapy uses the application of controlled Infants have multiple developmental considera- topical negative pressure across a wound surface in ations that place them at higher risk for skin injury and manner that produces rapid wound healing.10,12-14slower wound healing. During the last trimester of This negative pressure system creates an environ-pregnancy, collagen is deposited into the dermis. The ment within the wound bed that resists bacterialdermis of a full-term baby is 60% as thick as that of an growth, encourages capillary growth, and establishesadult.2 This lack of collagen places a neonate at microcirculation. Blood is drawn into the woundgreater risk of becoming edematous, making their bed and brings growth factor, neutrophils, andskin more susceptible to injury. Differences in skin macrophages to the area. Again, neutrophils are thepH place a neonate at greater risk of skin breakdown. first responders; they phagocytize bacteria andA full-term infant has an alkaline skin surface at birth. breakdown fibrin. These cells activate fibroblasts andWithin 4 days, the pH drops to less than 5, creating keratinocytes and attract macrophages to the area.an “acid mantle.” An acidic skin surface protects These macrophages engulf large particles such asagainst bacterial invasion.8 Premature infants have an bacteria, yeast, and drying cells. They clean theimmature stratum corneum, which is the outer layer wound and secrete cytokines and growth factors.of the dermis, and overall underdeveloped skin struc- Cytokines and growth factors attract fibroblaststures, and they are at risk for skin disruption and tox- and endothelial cells, which convert oxygen toicity from topically applied substances. A number of superoxide. Superoxide serves as a natural antimicro-studies involving wound cleansers indicated that sev- bial agent, inhibiting infection in the wound.eral cleansers and disinfectants can destroy or dam- Keratinocytes migrate into the wound bed and beginage fibroblasts and granulation tissue in healing epithelialization, which, in turn, stimulates secretionwounds.8,9 These include Ivory Liqui-Gel, Dial of growth factors, cytokine activity, and angiogenesis.4,14Antibacterial Soap, and Hibiclens. These products Negative pressure increases local blood flow andwere at a 1/100,000 dilution to be considered non- decreases edema, which improves oxygen delivery totoxic.9 The skin and wound cleansers, povidone– the wound bed.12,14 Slough and loose necroticiodine surgical scrub (Betadine Surgical Scrub) and material are removed from the wound, cleaninghydrogen peroxide, were found to be nontoxic to the wound and improving the blood supply.fibroblasts at a 1/1000 dilution.9 Shur-Clens was Removing the necrotic tissue decreases bacterialnoted to be the least toxic to fibroblasts, requiring no colonization.12,14dilution to maintain viable cells, with SAF-Clens and A good blood supply and a clean wound promotesaline not far behind. Acetic acid, Biolex, Cara- the formation of granulation tissue, which encouragesKlenz, and Puri-Clens had a toxicity index of 10, cor- wound closure and ensures that white blood cells areresponding to a 1/10 dilution.9 This was an in vitro supplied with necessary oxygen while ensuring thatstudy and it is difficult to establish a direct correlation aerobic bacteria in the wound bed die. V.A.C.®of in vitro findings with in vivo results. There may not therapy provides a moist wound environment, whichbe issues with the efficacy of cleansing actions but is essential for healing, preventing further necrosisbenefits to tissue repair should be cautiously exam- and tissue loss.ined.9 It is possible that the use of hydrogen perox- V.A.C.® therapy is applied in a manner that waside and acetic acid on IZ’s wound added to its slow originally described in 1997, with clean wound tech-healing, but there were other significant factors nique predominantly used.13 The choice of foam isincluding chronic infection that added to nonhealing important. The black reticulated foam (GranuFoam™of her wound. Silvadene, in addition, is not recom- Dressing; KCI), is the most common dressing used. Itmended for use in babies younger than 3 months is hydrophobic and does not absorb fluid, but it willbecause of concern for absorption of silver.8 stay moist under the occlusive drape. This foam is the most effective at stimulating granulation tissue andPRINCIPLES OF MOIST WOUND HEALING wound contraction. This foam is cut to the exact size of the wound. The White Foam™ Dressing (KCI) isThe goal of wound healing is to accomplish all of the an alternative, but it is a denser sponge. It is premoist-principles listed with every wound. These include ened and nonadherent. It is more hydrophilic thanoxygenation and circulation, removal of necrotic tis- the Black Foam. It is used more commonly insue, control of exudates and infection, and provision wounds with exposed tendon, bone, organs, fistulas,of a clean, moist, and protective environment. or tunnels. It is used to pack tunnels because of itsVacuum-assisted closure V.A.C.® therapy has been higher tensile strength. A third type of foam, www.advancesinneonatalcare.org
  20. 20. Use of a V.A.C.® Device in a Neonate With an Omphalocele 123GranuFoam Silver™ dressing, is also available. It is a (Johnson & Johnson, New Brunswick, New Jersey) orBlack Foam microbonded with silver that acts as an Mepitel (Molynlycke Health Care, Eddyston,effective barrier to bacterial penetration and may Pennsylvania) or applying a thin layer of a hydrogelhelp to reduce infection. Because the foam is kept to the wound base can be used to line the woundconstantly moist with the suction force of the pump, before the Black Foam is placed.13-15 With woundscare is needed not to overlap the intact skin because with extensive drainage, there is a collection canistermaceration of the wound edges can occur. In large that can accurately quantify the drainage.15,16wounds, multiple pieces of Black Foam can be used. The foam is placed into the wound without over- LITERATURE REVIEWlapping the edges and an occlusive drape dressing isplaced over the wound extending on to the intact Negative pressure therapy has been accepted as askin to create an airtight seal. A 2-cm hole is cut into valuable adjunct for wound closure in adults sincethe drape by pinching it over the foam. The 1993.13 Its use was originally reported for the treat-SensaT.R.A.C.™ (Therapeutic Regulated Accurate ment of deep chronic wounds with moderate to highCare; KCI) pad is placed directly over the hole in the exudate levels such as pressure ulcers, abscesses, anddrape and gentle pressure is applied. Then, the deep wounds secondary to trauma. A retrospectiveSensaT.R.A.C.™ pad tubing is connected to the canis- study reported experience in 42 patients from 1999ter tubing. The seal from the transparent drape needs to 2002 for conditions such as nonhealing sternal,to stay intact and occlusive for the therapy to be effec- spinal, and lower extremity wounds. The use of thetive since air leaks are common problems (Figure 3). V.A.C.® therapy provided faster wound healing,The V.A.C.® therapy unit is then programmed for a there were shorter hospital stays, and a reduction inspecific amount of suction-negative atmospheric overall cost.16pressure. For infants and children, there are no pub- Another study by Mooney et al17 reviewed 27lished recommendations. Typically, the lowest nega- pediatric patients with complex wounds, whichtive pressure of 50 mm Hg is chosen. The negative included open fractures, failed flap closure, abdomi-pressure settings vary from 50 to 200 mm Hg, admin- nal and sterna dehisced wounds, and spinal woundistered continuously or intermittently. Continuous infection. V.A.C.® therapy proved to be advanta-suction is typically used for the first 48 hours, later geous in this group, aiding in closure without need foradjusted to intermittent suction. Dressing changes are complex surgical interventions.17commonly performed at 48-hour intervals or 3 times A retrospective medical record review of childrena week.22 To prevent granulation tissue from growing and infants was conducted to evaluate the effective-into the foam, more frequent dressing changes should ness of V.A.C.® therapy at a large pediatric hospitalbe performed.22 To help minimize patient discomfort between January 2003 and 2005.18 Data were col-during dressing changes, the White nonadherent lected on wound type, treatment method and dura-foam or a nonadherent dressing layer of Adaptic tion, and complications. Sixty-eight patients with 82 wounds were identified. The mean age was 8.5 years and ranged from 7 days to 18 years. Twenty patients (29%), including 8 neonates, were 2 years or FIGURE 3. younger. Wound types identified were pressure ulcers, extremity wounds, dehisced surgical wounds, open sterna wounds, wounds with fistula, and com- plex abdominal wall defects. Following the use of negative pressure therapy, 93% of wounds decreased in volume. It was concluded that negative pressure therapy by using the V.A.C.® therapy system can be effectively used to manage a multitude of wounds in children and neonates. No major complications were identified.18 Another retrospective medical record review was conducted on 24 neonatal and pediatric patients who had received negative pressure wound therapy for their wounds from 1999 to 2004.19 Their ages ranged from 14 days to 18 years. The most common wound Example of patient with the V.A.C.® therapy device in type was traumatic, with exposed hardware and place. Photograph courtesy of Presbyterian/St. Luke’s bone. In a median time of 10 days, 11 wounds were Medical Center, Denver, Colorado. Reprinted with closed by flap, 3 by split-thickness skin graft, 4 sec- permission. ondarily, and 4 primarily. Results were promising. Complete closure was achieved in 22 of 24 patients.19Advances in Neonatal Care • Vol. 10, No. 3
  21. 21. 124 Wilcinski A report in 2006 described V.A.C.® therapy of 3 bowel perforation secondary to necrotizing entero-infants with giant omphalocele from 2002 to 2004.20 colitis.21 She received total parenteral nutritionAll patients had undergone unsuccessful attempts at through a percutaneously placed central venousclosure by using other methods. The first patient was catheter through a saphenous vein that infiltrated,initially treated by staged silo reduction, which dis- and she developed on day 31 a 7 3.5-cm blister onrupted after 21 days. The large mass of the bowel and her lower back. There was extensive full-thicknessliver made primary or skin flap closure impossible. necrosis from the T8/9 region to L5/S1 over the pos-V.A.C.® therapy was applied for 45 days. The viscera terior torso and dehiscence of tissues between thewere subsequently covered with acellular dermal paraspinous muscles, involving the spinal laminaematrix (AlloDerm). The dermal matrix that failed to and epidural tissue. The dura was exposed but viable.integrate into the fascial rim was removed. The small Following intravenous antibiotic administration andremaining defect was covered with split-thickness debridement, a 7 10-cm defect remained on herskin graft at 3 months of age. In the second case, back. The V.A.C.® therapy system was applied ini-mesh placement was performed 5 months after birth, tially by using the White Foam at a negative pressurewith subsequent necrosis of the infant’s abdominal of 50 mm Hg. Within a week, this was changed to theskin within the immediate postoperative period. The Black Foam and the negative pressure was increasedmesh was removed and V.A.C.® therapy was applied to 75 mm Hg. The V.A.C.® therapy dressing wasfor 22 days. The infant subsequently underwent acel- changed every 3 to 4 days for 21 days. Mepitellular dermal matrix replacement of the fascial defect (Molylycke Health Care) was applied to the woundand full-thickness skin flap closure by tissue expan- and changed daily until the wound was completelysion. The third case was of a full-term infant with a 6- epithelialized 10 days following V.A.C.® therapycm omphalocele that was initially treated by staged removal.21silo reduction. After multiple suture line disruptions,the silo was removed and gross-type skin flaps were NURSING IMPLICATIONSused to cover the large defect. This procedure wascomplicated by an enterocutaneous fistula. The mesh When a V.A.C.® therapy device is applied, it is thewas removed and V.A.C.® therapy was applied for 36 responsibility of the nurse to maintain its functiondays. A healthy granulation bed developed and the and settings that are outlined by the wound careV.A.C.® therapy device was allowed for the treatment team. A team-centered approach should be used andof the fistula and coverage of the defect. This case a care plan for the V.A.C.® therapy changes shouldseries illustrated the challenges faced by pediatric sur- be instituted at the bedside.geons in the management of giant omphalocele and Maintenance of the V.A.C.® therapy system isdemonstrates the usefulness of V.A.C® therapy.20 important and careful assessment is vital to ensure In 2005, the V.A.C.® system was used in the care proper negative pressure. Air leaks from under theof 2 premature infants, weighing less than 1500 g, with occlusive dressing are common problems. An air leakextensive soft tissue defects.21 The first case involved can be identified when a hissing sound is heard;a former 23-week gestation infant who at 6 weeks of smaller leaks may be auscultated with the use of aage and 850 g was found to have an omphalomesen- stethoscope. An air leak would also be suspected whenteric duct fistula that became infected and ruptured the foam is observed to not being collapsed becauseinto the abdominal wall. At laparotomy, a 3-cm seg- the negative pressure has been lost. The pump will alsoment of ileum adjacent to the ruptured omphalome- alarm if negative pressure is lost. If an air leak devel-sentric duct was resected. An ileostomy and mucus ops, it can be patched with an additional drape.15fistula were placed but the patient had necrosis of the Pain assessment and treatment should be a prior-midline musculature and the closure was not accom- ity. Initially, continuous suction is typically used. Aplished. A bovine pericardial patch was used for tem- pain assessment scale should be put into practice andporary closure of the muscle defect, and the overly- a pain management plan instituted. Some patientsing necrotic skin was debrided. One week following experience pain during the dressing change when thesurgery, V.A.C.® therapy was applied. The White pump is initially turned on and the foam is com-Foam was placed over the defect and a negative pres- pressed. Pain medication should be given in 10 tosure of 75 mm Hg was applied. The dressings were 30 minutes, depending on the route of medicationchanged every 2 to 3 days for 43 days. V.A.C.® ther- before the dressing change. Most infants and childrenapy was discontinued when the wound was at the with moderate wounds tolerate device changes withlevel of the skin and the suction device was bigger oral pain medications. Typically, acetaminophen isthan the open wound. Later, wet-to-dry dressings used for pain control but with larger wounds, par-were used and the wound was completely epithelial- enteral pain medication or conscious intravenousized 14 days after V.A.C.® therapy removal.21 In the sedation may be needed.10 If pain or bleeding seemssecond case, the neonate was a former 27-week ges- excessive with V.A.C.® therapy dressing changes,tation infant, born weighing 800 g, who developed a one should assess for invasion or adherence of www.advancesinneonatalcare.org
  22. 22. Use of a V.A.C.® Device in a Neonate With an Omphalocele 125granulation tissue to the Black Foam. Intermittent crib while the wound is healing. Range-of-motionsuction has been proven to accelerate the growth of exercises should also be considered as indicated.granulation tissue faster than continuous suction.23 Optimally, a developmental specialist should be aTherefore, switching to continuous suction may part of the care team.diminish rapid growth of granulation tissue and Wound healing can test family members to thedressing changes may be more comfortable. Lining limit of their endurance. A family may have tothe wound bed with a nonadherent, oil emulsion– endure multiple surgeries and a prolonged hospital-type dressing (eg, Adaptic; Johnson & Johnson) or a ization when healing is nonexistent or slow.contact lining (Mepitel; Molynlcke Health Care) Frustration with the lack of progress in healing ismay disrupt adherence of the V.A.C. sponge.23 common. Doubts and fears should be treated withDecreasing the amount of suction used may also help respect. Depression can be avoided or improved withwith pain. More frequent dressing changes may also good psychological support. Information aboutdecrease the growth of granulation tissue into the wound healing and how a wound V.A.C. systemfoam. The manufacturer of the wound V.A.C. device works should be provided.recommends dressing changes every 48 hours formost wounds.15 Denuded wound margins are noted IZ’S OUTCOMEby older patients and researchers to be a commonsource of wound pain.23 To protect intact wound mar- Three days following the initial V.A.C.® therapy, IZ’sgins under the occlusive V.A.C.® therapy drape, the wound was showing some granulation tissue and wasV.A.C.® therapy sponge should be cut to the exact epithelializing along the wound edges. One week fol-size of the wound, avoiding overlapping of the lowing placement, there was marked improvement;sponge on to good skin or to apply a water-soluble the wound showed healthy granulation tissue.skin sealant (3M No Sting Barrier swab; 3M Fibrous tissue was noted to be present as well and thisHealthCare, St Paul, Minnesota) as primary preven- was treated with Accuzyme (DPT Laboratories, Ltd,tion. If periwound skin margins break down, one San Antonio, Texas) during dressing changes tosource recommends applying 1-in strips of thin debride this tissue (Figure 4). The wound washydrocolloid (Duoderm Thin; Convatec, Princeton, assessed and the V.A.C.® therapy device was reap-New Jersey) or thin adhesive form (Allevyn; Smith & plied every other day. Following 7 weeks of negativeNephew, Largo, Florida) to protect the areas that are pressure wound therapy, the wound was healedopen before applying the V.A.C.® therapy drape.23 enough to stop the V.A.C.® therapy.Include parents in comfort measures during and after IZ was discharged from the hospital at approxi-dressing changes. Offering an oral sucrose solution mately 5 months of age. In addition to the difficultmay also help with pain. wound-healing course, IZ had feeding difficulties Close monitoring of fluid loss from the wound into because of significant gastroesophageal reflux thatthe canister is extremely important, especially in was related to her large abdominal wall defect. Inhighly exuding wounds or large wounds in relation topatient size. Neonates in particular can lose a signifi-cant amount of extracellular fluid from the woundbed and are at risk for dehydration. Accurate meas- FIGURE 4.urement is required since fluid replacement mayneed to be instituted. Rapid contraction of the wound bed can occurshortly after placing the V.A.C® therapy on an infantwith a large abdominal wound at risk for respiratoryembarrassment. Care should be taken to follow theneonate’s work of breathing and oxygen requirementand to stabilize as needed. Developmental care issues need to be addressed.Depending upon the site of the wound, neonatesmay need to lie in a position that is not developmen-tally supportive. For instance, IZ could lie only onher back because of the limitation of her largewound and the V.A.C.® therapy device. However,positional supports and boundaries were provided tooptimize and facilitate appropriate postural align- Wound after 3 days of V.A.C® therapy. Photographment. Her mother could not provide kangaroo care. courtesy of Presbyterian/St. Luke’s Medical Center,Providing age-appropriate stimulation is important Denver, Colorado. Reprinted with permission.since infants can be spending significant time in theirAdvances in Neonatal Care • Vol. 10, No. 3
  23. 23. 126 Wilcinski systems such as the V.A.C.® therapy system may be FIGURE 5. helpful in some infants. References 1. Magnuson DK, Parry RL, Chwals WJ. Abdominal wall defects. In: Martin RJ, Fanaroff AA, Walsh MC, eds. Fanaroff and Martin’s Neonatal-Perinatal Medicine, Diseases of the Fetus and Newborn. 8th ed. Philadelphia, PA: Mosby-Elsevier; 2006:1380-1386. 2. Lund, CH, Tucker JA. Adhesion and newborn skin. In: Hoath SB, Mailbach HI, eds. Neonatal Skin Structure and Function. 2nd ed.; pp. 299-324. New York, NY: Marcel Decker Inc; 2003. 3. Barharestani M, Pope E. Chronic wounds in neonates and children. In: Krasner D, Rodheaver GT, Sibbald RG, eds. Chronic Wound Care: A Clinical Source Book for Healthcare Professionals. 4th ed. Malvern, PA: HMP Communications; 2007:673- 693. 4. Strodtbeck F. Physiology of wound healing. Newborn Infant Nurs Rev. 2001;1:43-52. 5. Clark RAF. Wound repair: overview and general considerations. In: Clark RAF, ed. The Molecular and Cellular Biology of Wound Repair. 2nd ed. New York, NY: Plenum Press; 1995:3-50. 6. Flanigan KH. Nutritional aspects of wound healing. Adv Wound Care. 1997;10: 48-52. Wound after 2 months V.A.C® therapy. Photograph 7. Waldrop J, Doughty D. Wound healing physiology. In: Bryant RA, ed. Acute and courtesy of Presbyterian/St. Luke’s Medical Center, Chronic Wounds. Nursing Management. 2nd ed. St Louis, MO: Mosby; 1997:413-429. 8. Association of Women’s Health, Obstetric and Neonatal Nurses. Neonatal Skin Denver, Colorado. Reprinted with permission. Care, Evidenced Based Clinical Practice Guidelines. 2nd ed. Washington DC: AWONN; 2007. 9. Wilson J, Mills J, Prather I, Dimitrijevich SD. A toxicity index of skins and wound cleansers used on in vitro fibroblasts and keratinocytes. Adv Skin Wound Care. 2005;18:373-378. 10. Caniano DA, Teich S, Ruth B. Wound management with vacuum-assisted closure: experience in 51 pediatric patients. J Pediatr Surg. 2005;40:128-132.addition, coordination and stamina were issues for 11. Jerome D. Advances in negative pressure wound therapy. J Wound Ostomyher, which made nippling a challenge. She was dis- Continence Nurs. 2007;34:191-194. 12. Smith N. The benefits of VAC therapy in the management of pressure ulcers.charged from the hospital with an indwelling nasal Br J Nurs. 2004;13:1359-1365.gastric tube in place. She was not a candidate for sur- 13. Argenta L, Morykwas M. Vacuum-assisted closure: a new method for wound control and treatment. Annu Plast Surg. 38:563-576.gical treatment of her gastroesophageal reflux 14. Miller M, Glover D. Wound Management: Theory and Practice. London, England:because of previous multiple abdominal wall surger- The Friary Press; 1999. 15. KCI The Clinical Advantage. V.A.C. Therapy Clinical Guidelines: A Referenceies. She was nippling small volume of formula dur- Source for Clinicians; 2007. Accessed October 2008 from http://www.KCI1.ing the day and was fed the remainder by her mother com/KCI1/vacapplicationsvideoswith gavage feedings. To improve growth, she was 16. Antony S, Terrazas S. A Retrospective study: clinical experience using vacuum assisted closure of the treatment of wounds. J Natl Med Assoc. 2004;96:1073-1077.discharged home on 27 cal/oz of formula and 17. Mooney JF, Argenta LC, Marks MW, et al. Treatment of soft tissue defects in pedi-received continuous-drip nighttime feedings. atric patients using the VAC system. Clin Orthop Relat Res. 2000;376:26-31. 18. McCord SS, Murphy K, Olutoyeo L, Naik-Mathuria B, Hollier L. Negative pressure Following discharge, she was followed by the wound therapy is effective to manage a variety of wounds in infants and chil-Wound Healing Center and pediatric surgeons. One dren. J Wound Ostomy Continence Nurs. 2007;34:573-574. 19. Baharestani M. Use of negative pressure wound therapy in the treatment ofweek following discharge, her wound began to break neonatal and pediatric wounds: a retrospective examination of clinical out-down once again (Figure 5). V.A.C.® therapy was reap- comes. Ostomy Wound Manage. 2007;53(6):75-85.plied and her mother was instructed on how to change 20. Kilbride K, Cooney D, Custer M. Vacuum-assisted closure: a new method for treating patients with giant omphalocele. J Pediatr Surg. 2006;41:212-215.the V.A.C.® therapy dressings. Three weeks later, the 21. Arca M, Somers K, Derks TE, et al. Use of vacuum assisted closure system in thewound was completely healed and V.A.C.® therapy management of complex wounds in the neonate. Pediatr Surg Int. 2005;21:532- 535.was discontinued. Her wound has remained closed. 22. Bookout K, McCord S, McLane K. Case studies of and infant, a toddler, and an Wound healing can be difficult in neonates, partic- adolescent with a negative pressure wound treatment system. J Wound Ostomy Continence Nurs. 2004;31:184-192.ularly those with large wounds or surgical sites. The 23. Krasner D. Managing wound pain in patients with vacuum assisted closureuse of controlled topical negative pressure with devices. Ostomy Wound Manage. 2002;48(5):38-43. www.advancesinneonatalcare.org
  24. 24. CE TestUse of a Vacuum-Assisted Device in a Neonate With aGiant OmphaloceleInstructions: • Questions? Contact Lippincott Williams & Wilkins: The ANCC’s accreditation status of Lippincott Williams &• Read the article on page 119. 800-787-8985 Wilkins Department of Continuing Education refers only to• Take the test, recording your answers in the test its continuing nursing educational activities and does not answers section (Section B) of the CE enrollment form. Registration Deadline: June 30, 2012 imply Commission on Accreditation approval or Each question has only one correct answer. Provider Accreditation: endorsement of any commercial product.• Complete registration information (Section A) and course LWW, publisher of Advances in Neonatal Care, will award Disclosure Statement: The authors have disclosed that evaluation (Section C). 3.0 contact hours for this continuing nursing education they have no financial relationships related to this article.• Mail completed test with registration fee to: Lippincott activity. Williams & Wilkins, CE Group, 333 7th Avenue, This article has been approved by the National 19th Floor, New York, NY 10001. LWW is accredited as a provider of continuing nursing Association for Neonatal Nurses Certification Board for• Within 4-6 weeks after your CE enrollment form is education by the American Nurses Credentialing Center’s Category B credit toward recertification as an NNP. received, you will be notified of your test results. Commission on Accreditation.• If you pass, you will receive a certificate of earned This activity is also provider approved by the California Payment and Discounts: contact hours and answer key. If you fail, you have the Board of Registered Nursing, Provider Number CEP 11749 • The registration fee for this test is $17.95 for NANN option of taking the test again at no additional cost. for 3.0 contact hours. Lippincott Williams & Wilkins is also members and $24.95 for nonmembers.• A passing score for this test is 13 correct answers. • If you take two or more tests in any nursing journal pub- an approved provider of continuing nursing education by• Need CE STAT? Visit www.nursingcenter.com for imme- lished by LWW and send in your CE enrollment forms to- the District of Columbia and Florida #FBN2454. diate results, other CE activities, and your personalized gether, you may deduct $0.95 from the price of each test. CE planner tool. Your certificate is valid in all states. • We offer special discounts for as few as six tests and• No Internet access? Call 800-787-8985 for other rush institutional bulk discounts for multiple tests. Call 800- service options. 787-8985 for more information.CE TEST QUESTIONSGENERAL PURPOSE STATEMENT: To provide the registered 6. A wound’s resistance to infection is decreased byprofessional nurse with the use of vacuum assisted closure (VAC) device to a. tissue osmolality.assist wound healing in the neonate with a giant omphalocele. b. tissue hypoxia.LEARNING OBJECTIVES: After reading this article and taking this test, c. release of angiogenesis factor.the nurse will be able to: d. inhibition of bradykinin.1. Identify normal wound healing in neonates. 7. Which of the following leads to slow healing? a. a dry wound bed2. Describe wound VAC therapy in neonates with giant omphalocele. b. a wet wound bed 1. Following development of progressive dehiscence, a c. full formula feedings wound VAC device was applied on Baby Girl IZ at how d. breastmilk feedings many days post debridement? 8. A neonate is at greater risk of skin breakdown due to a. 3 days a. excessive collagen. b. 5 days b. a thick dermis. c. 7 days c. differences in skin pH. d. 9 days d. increased cardiac output. 2. Abdominal wall defects in infants include all of the 9. For Baby Girl IZ, use of which of the following wound following except : cleansers may have added to slow wound healing? a. hiatal hernia. a. hydrogen peroxide and acetic acid b. gastroschisis. b. antibacterial soap c. omphalocele. c. Shur-clens d. hernia of the cord. d. Hibiclens 3. Fetal omphalocele may occur in conjunction with 10. To produce rapid wound healing, VAC therapy uses the a. cystic fibrosis. application of controlled: b. neutral tube defects. a. topical negative pressure. c. Down syndrome. b. systemic negative pressure. d. fetal alcohol syndrome. c. topical positive pressure. 4. Which is a special characteristic that adds to the complex- d. systemic positive pressure. ity of treating neonatal wounds? 11. VAC therapy encourages rapid wound healing by a. a high body surface to weight ratio a. constricting blood flow into the area. b. a low body surface to weight ratio b. drawing blood into the area. c. decreased sensitivity to pain c. preventing angiogenesis. d. decreased potential for percutaneous absorption of medication d. limiting granulation. 5. Which stage of wound healing involves intense multiplica- 12. Which is the most common dressing used with wound tion of cells? VAC? a. first stage b. second stage a. black foam b. white foam c. third stage d. fourth stage c. silver foam d. gold foamAdvances in Neonatal Care • Vol. 10, No. 3 127
  25. 25. 13. When using wound VAC therapy, the negative pressure 16. A priority of wound VAC therapy care is typically chosen for infants is a. pain management. a. 50 mmHg b. oxygen administration. b. 100 mmHg c. fluid administration. c. 150 mmHg d. antibiotic therapy. d. 200 mmHg 17. To protect intact wound margins under the occlusive VAC14. As described in this article, a retrospective chart review of drape, the VAC sponge should be 24 patients who received negative pressure wound therapy a. smaller than the wound. found that complete closure was obtained in b. larger than the wound. a. 12 of 24 patients. c. the exact size of the wound. b. 18 of 24 patients. d. overlap the wound. c. 22 of 24 patients. 18. Optimally, the team caring for the infant receiving wound d. all patients. VAC therapy should include15. Which is a common problem with wound VAC therapy? a. an infection control specialist. a. fluid leaks from under the occlusive dressing b. a developmental specialist. b. air leaks from under the occlusive dressing c. a neurologist. c. wound infection d. a cardiologist. d. wound fistula ANC0510CE Enrollment FormAdvances in Neonatal Care June 2010Use of a Vacuum-Assisted Device in a Neonate With a Giant Omphalocele A Registration Information: ❑ LPN ❑ RN ❑ CNS ❑ NP ❑ CRNA ❑ CNM ❑ other______________Last name______________________ First name____________________MI____ Job Title______________________Specialty_____________________________Address__________________________________________________________ Type of facility_____________________________________________________City_______________________________State_________________Zip_______ Are you certified? ❑ Yes ❑ NoTelephone___________________Fax______________email________________ Certified by_______________________________________________________Registration Deadline: June 30, 2012 State of License (1)__________License #________________________________Contact Hours: 3.0 State of License (2) __________License#________________________________Fee: NANN member: $17.95 ❑ Please check here if you do not wish us to send promotions to your email NANN Membership No. _______________________ address. ❑ Please check here if you do not wish us to release your name, address, email Nonmembers: $24.95 address to a third party vendor. B Test Answers: Darken one for your answer to each question. A B C D A B C D A B C D A B C D A B C D 1. ❍ ❍ ❍ ❍ 5. ❍ ❍ ❍ ❍ 9. ❍ ❍ ❍ ❍ 13. ❍ ❍ ❍ ❍ 17. ❍ ❍ ❍ ❍ 2. ❍ ❍ ❍ ❍ 6. ❍ ❍ ❍ ❍ 10. ❍ ❍ ❍ ❍ 14. ❍ ❍ ❍ ❍ 18. ❍ ❍ ❍ ❍ 3. ❍ ❍ ❍ ❍ 7. ❍ ❍ ❍ ❍ 11. ❍ ❍ ❍ ❍ 15. ❍ ❍ ❍ ❍ 4. ❍ ❍ ❍ ❍ 8. ❍ ❍ ❍ ❍ 12. ❍ ❍ ❍ ❍ 16. ❍ ❍ ❍ ❍ C Course Evaluation D Two Easy Ways to Pay: A B1. Did this CE activity’s learning objectives relate to its ❑ Yes ❑ No ❑ Check or money order enclosed general purpose? (Payable to Lippincott Williams & Wilkins)2. Was the journal home study format an effective way ❑ Yes ❑ No ❑ Charge my ❑ Mastercard ❑ Visa ❑ American Express to present the material?3. Was the content relevant to your nursing practice? ❑ Yes ❑ No Card #_____________________________________Exp. Date_________4. How long in minutes did it take you to read the article____study the Signature___________________________________________________ material____and take the test____?5. Suggestion for future topics_____________________________________ Need CE STAT? Visit www.NursingCenter.com for immediate results, other CE activities, and your personalized CE planner tool!128 www.advancesinneonatalcare.org

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