Negative pressure wound therapy
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National Orthopaedic Hospital Dala Kano Friday Hospital Presentation by Plastic Team
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Negative pressure wound therapy
- 1. Negative Pressure Wound Therapy at NOH Kano By Plastic Team NOHD Kano Dr Shehu M, Dr Salisu K & Dr Aroju SA 12th May 2017
- 2. Outline • Case presentation • Introduction • Mechanism of action VAC • Component of VAC • Application • Advantages • Indications • Contraindication • Monitoring • Complication • NOH Dala experience • Conclusion • References
- 3. CASE PRESENTATION BY DR M SHEHU
- 4. CASE 1 BIODATA • A.B • 25 YEAR • FEMALE • SINGLE • AGBO, DELTA STATE • YOUTH CORPER • DOA 27/07/2017
- 5. PC • DISCHARGING WOUND LEFT LEG X 9/7
- 6. • Patient had removal of implant at KTOSH 9/7 prior to presentation. • Noticed blisters and dark discoloration of skin around the surgical site as well as purulent discharge • For which patient was referred to this center
- 7. • She had initial ORIF 9yrs following closed injury to the leg. • The surgery later got infected with persistent discharge for about 4years prior to removal of implant • No other co-morbidity
- 8. O/E • Not pale, afebrile, not dehydrated • MSS –
- 10. Diagnosis;- Flap necrosis post implant removal (L) leg
- 11. • Pt was admitted into A/E • Prepared for and had debridement and bone drilling on the same day
- 13. She had Vacuum Assisted Closure(VAC) which was commenced 5days later
- 14. After 2nd VAC
- 15. At presentation Post debridement 12 days on admission (2cycles of VAC)
- 16. CASE 2 BIODATA • G. H • 20 YRS • MALE • HAUSA • FARMER • TARABA STATE • DOA 19/06/2017
- 17. PC • OPEN INJURY TO RIGHT ANKLE X I/12
- 18. • He sustain open injury to the right ankle with pain, deformity and inability to bear weight following a fall from tree • He had TBS splintage immediately which was removed 3/7 later due to excessive swelling
- 19. • He was taken to a peripheral hospital were he was commenced on wound dressing before finally referred to this center • No other co-morbidity
- 20. O/E • Not pale, afebrile, anicteric • MSS – An ulcer measuring about 15 x 10cm at the anterior aspect of the ankle extending to the malleoli, exposing desiccated distal tibia and purulent discharge – Distal neurovascular status
- 21. Diagnosis Open infected right ankle fracture dislocation
- 22. Rx – Admitted into A/E – Had debridment with excision of desicated bone on the day of admision – Billed for ilizarov frame for bone transport and arthrodesis – Plastic team were invited and also reviewed • Commenced on VAC
- 23. Post debridement After 1st cycle After 2nd cycle
- 24. NPWT Introduction Mechanism of action VAC Component of VAC Application Advantages Dr Salisu K
- 25. Introduction • Negative pressure wound therapy (NPWT) Is a therapeutic technique using a vacuum dressing to promote healing in acute or chronic wounds • First described by Fleischmann et al in 1993
- 26. • NPWT promotes wound healing by applying a vacuum drainage through a special sealed dressing • Negative pressure wound therapy is also called Vacuum Assisted Closure (VAC),
- 28. Component of VAC Polyurathane foam Vacuum pump Tube Transparent adhesive membrane (op site)
- 30. Improvised VAC
- 33. • Neonates : - 50 mmHg. • Children < 2 years : -50 to -75 mmHg • Children > 2 years : -75 to -125 mmHg • Adults : -125mmHg
- 34. Advantages of VAC • Maintenance of moist • Removal of excess interstitial fluid • Increased local vascularity • Decreased bacterial colonization • Quantification of wound drainage • Increased rate of granulation tissue formation • Increased rate of contraction • Increased rate of epithelization • Protect wound • Prevent cross infection
- 35. • Indications • Contraindication • Monitoring • Complication • NOH Dala experience • Conclusion • References Dr Arojuraye SA
- 36. NPWT - Indications To completely heal a wound: • Expensive • Time-consuming • Not always effective A more practical use is to: • Expeditiously prepare a wound bed for surgical closure
- 37. Indications NPWT is indicated for almost any open wound where surgical closure is not feasible or desirable • Full thickness pressure ulcers • Dehisced surgical wounds • Diabetic/neuropathic ulcers • Venous leg ulcers
- 38. Indications… NPWT is indicated for almost any open wound where surgical closure is not feasible or desirable • Post-surgical wounds • Traumatic wounds • Pre & post op flaps & grafts • Burns wounds
- 43. Contraindications US FDA • Necrotic tissue & eschar • Unexplored fistulas • Malignant wounds • Exposed vasculature • Exposed anastomosis • Exposed nerves • Exposed organs.
- 46. Monitoring • Pressure (75 – 125mmHg) • Effluent / Electrolytes • Infections • Pain control
- 47. Termination of NPWT Adequate granulation base allowing for: • Changing to conventional dressing • Split-thickness skin graft • Flap closure
- 48. NOHD Experience – 1year INDICATIONS FREQUENCY PERCENT 1 Traumatic wounds a) Acute b) Chronic 5 9 21.8 39.1 2 Pressure injuries 6 26.1 3 Surgical wound 3 13.0 23 100
- 49. NOHD Experience – 1year… 69.6 30.4 0 0 DEFINITIVE WOUND COVER AFTER NPWT STSG (16) FLAP COVER (7)
- 50. Conclusion • NPWT has revolutionized wound management. It is easy, safe and can be achieved using cheap and conventional material in resource constraint settings.
- 51. Thank you
Editor's Notes
- She was well until 9years ago when she was involved in RTA She sustain open injury to the left leg with pain deformity and inability to bear weight She was managed initially by TBS for about 2years with no significant improvement She later went to peripheral hospital were she had ORIF The surgery later got infected with persistent discharge for about 4years
- Vacuum assisted closure (also called vacuum therapy, vacuum sealing or topical negative pressure therapy) is a sophisticated development of a standard surgical procedure, the use of vacuum assisted drainage to remove blood or serous fluid from a wound or operation site. In essence the technique is very simple. A piece of foam with an open-cell structure is introduced into the wound and a wound drain with lateral perforations is laid on top of it. The entire area is then covered with a transparent adhesive membrane, which is firmly secured to the healthy skin around the wound margin. When the exposed end of the drain tube is connected to a vacuum source, fluid is drawn from the wound through the foam into a reservoir for subsequent disposal
- vacuum therapy, vacuum sealing or topical negative pressure therapy
- Reduces oedema Reduces bacterial load Stimulates cell proliferation Enhances dermal perfusion Promotes micro angiogenesis Protects wound from re-infection, cross infection or spreading further infection Promotes Skin Graft/Flap uptake (The flexible foam dressing gently presses the skin graft or flap ensuring full contact with the wound bed
- Pore size: 400-600 microns
- Romovac
- The observation that intermittent or cycled treatment appears more effective than continuous therapy is interesting although the reasons for this are not fully understood. Two possible explanations were advanced by Philbeck et al [9]. They suggested that intermittent cycling results in rhythmic perfusion of the tissue which is maintained because the process of capillary autoregulation is not activated. They also suggested that as cells which are undergoing mitosis must go through a cycle of rest, cellular component production and division, constant stimulation may cause the cells to 'ignore' the stimulus and thus become ineffective. Intermittent stimulation allows the cells time to rest and prepare for the next cycle. For this reason it is suggested that cyclical negative pressure should be used clinically, although some authors [10] [11] suggest that this may follow a 48-hour period of continuous vacuum, which can be applied to exert a rapid initial cleansing effect.
- The strongest contraindication is of tumour in the wound; theoretically the increase in blood flow may encourage tumour growth and possibly facilitate movement of malignant cells across tissue planes • Excessive necrotic tissue or untreated osteomyelitis • Fistulae may cause large fluid losses though in selected cases vacuum therapy has been used to close fistulae. Other relative contraindications include: arterial disease, heavily infected wounds and patients with bleeding or those on anticoagulants. Vacuum wound closure can be applied to a wide variety of wounds; there are numerous case reports/studies in the literature. It has been used in venous and diabetic ulcers, pressure sores, and surgical wounds such as sternotomy wounds. In addition, its use in flaps, flap donor sites and split skin graft fixation, particularly on borderline recipient sites, has been described. Its effectiveness seems well established but there is a lack of randomized data comparing it to standard methods. One common concern is that the cost makes clinicians reluctant to use it, although some studies compare it favourably to other treatments in terms of overall cost. Introduction of a wider role for this treatment depends on increased awareness as well as establishing its efficacy in robust randomized controlled trials and demonstrating its cost-effectiveness.
- Suction can be painful, particularly with venous ulcers. It may require analgesia; topical local anaesthetic can be applied on the wound or injected through the tubing. One can start at a lower pressure and titrate upward; if the pain is uncontrollable, the treatment may need to be stopped. • Excessive fluid loss may cause electrolyte or fluid disturbance in large exuding wounds. • Over-granulation into the sponge may lead to bleeding when the dressing is removed.