Benefits of Negative Pressure Therapy Application in Newborns

  The literature and support for use of negative pressure wound therapy (NPWT) in neonates and infants living with dehisced abdominal wounds is sparse. NPWT has been used on infants for open wounds related to surgical complications, but the actual process for application and the amount of negative pressure suction to use is limited to a few anecdotal/case review articles in the literature. As the inpatient wound resource nurse in a large community teaching hospital, this author has been exposed to a number of full-term neonate’s and pre-term patients who may have benefited from the use of NPWT. This article discusses the different forms of abdominal wall defects seen in neonates and the role of NPWT in one severe omphalocele in a patient cared for within the last 4 years.

Variations in Neonatal Birth Defects

  Abdominal wall defects in neonates occur in three forms: omphalocele, gastroschisis, and hernia of the umbilical cord. Omphalocele is a defect in the anterior abdominal wall when the intestines, and sometimes the liver, are contained in the omphalocele sac with the umbilical cord attached at the omphalocele sac. Isolated omphalocele occur in approximately 1 in 5,000 live births. A “giant” omphalocele contains at least 75% of the liver, intestines, and may include other intra-abdominal organs such as the spleen and stomach.¹   Generally, the defect is closed by conducting a primary closure or a multi-step staged closure. Dehisced abdominal wounds in neonates are often treated by the surgical team with twice-per-day moistened saline gauze.

Giant Omphalocele Preemie Case

  In 2010, I was asked to evaluate an infant who had been born at 37 weeks with a giant omphalocele that had begun to separate at the suture line 21 days after surgical repair due to tension on the surgical incision. Initially placed in an advanced wound dressing that was needed over a relatively small area of separation (1.7cm x 1cm x 0.1cm), the wound measured 4.5cm x 4cm x 0.2cm 24 hours later. The pediatric surgeon was consulted at that time to discuss the possible use of NPWT. In this particular case, the surgeon had ordered NPWT as a means of closure, which increases the rate of healing, decreases bacterial burden, and decreases dressing changes from twice daily with the traditional moistened gauze dressing to three times per week with the NPWT dressing.   After an advanced wound care product with silver gel was used for two days, NPWT was administered with the wound continuing to dehisce due to the continued tension on the suture line. Application of the NPWT dressing was completed in the usual manner, with use of drape to protect the periwound skin and the skin under the bridge for the trac pad. Due to the lack of fascial covering the abdominal cavity, it was decided to bridge the trac pad away from the top of the wound. This was possible in large part because of the infant’s size and weight. Additionally, there was enough surface area on the abdomen provided to place the trac pad away from the wound bed. After prepping with the drape, coarse petrolatum gauze was used to cover the wound, with white foam placed over the wound and a black foam for the bridge — all of which was covered with NPWT drape. The white foam was used to decrease adherence to the wound base and to provide hydrophilic foam with decreased suction to the wound bed. The NPWT suction was initially set at 25 mm Hg continuous.   After five days of NPWT as described above, the dressing was changed to coarse petrolatum gauze in order to provide protection to the wound while the black foam dressing maintained a bridged area for the trac pad. Also, at this time the suction was increased to 50 mm Hg continuous. This dressing was maintained for two weeks with continued, slow-and-steady decrease in the size of the wound and increase in granulation tissue. After one month of NPWT, the wound had decreased from 4 x 4.5 cm to 1.5 x 1.2cm. A collagen product was then added to the wound bed and the wound was considered closed in another five days. The infant would have the NPWT in place for 36 days and his abdominal wound closed without any complications. He was kept in the nursery for another four days before being discharged home with a simple, adhesive foam dressing for protection. A home health nurse was employed for approximately two weeks before the parents could assume total care. He returned to the hospital approximately four weeks later for a ventral and right inguinal hernia repair. After four days he was again discharged without further complications or problems. During the period of NPWT treatment, the infant continued breastfeeding without experiencing difficulties with stooling or gastrointestinal symptoms. Although used at a very low level of suction, the NPWT provided enough therapeutic effect to begin the healing process, and completed the granulation of this wound in an additional five days when increased to only 50 mm Hg with the black foam.

Assessing Advantages of NPWT

  The advantages of this therapy for the infant in question were a decrease in the number of dressing changes needed from a minimum of daily to three weekly as well as reduction in pain with each dressing change. By the fourth week of NPWT, if a dressing were changed after a feeding, the infant would sleep through the procedure. The biggest challenge with the use of this dressing modality was related to the size of the equipment and dressing supplies. Wound care clinicians who care for this patient population should consider that over the three-plus years since this patient was cared for with NPWT there have been newer products with smaller trac pads and newer dressings that may result in easier use and application of NPWT in neonates and infants. Carol Price is on staff at the Children’s Hospital of Denver.

References

1. Magnuson DK, Parry RL, Chwals WJ. Abdominal wall defects. Perinatal Medicine Diseases of the Fetus and Newborn. 8th ed. Philadelphia, PA: Mosby-Elsevier; 2006: 1306-1308.