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Adjuvant Dressing for Negative Pressure Wound Therapy in Burns
Wound healing is a complex process involving cell migration, debris removal, infection and inflammation control, angiogenesis, granulation tissue deposition, contraction, connective tissue matrix remodeling, and maturation.1 The advent of negative pressure wound therapy (NPWT) as delivered by the V.A.C.® Therapy System has substantially increased wound closure rates, reduced morbidity, and reduced healthcare costs for many patients.2,3
Negative pressure wound therapy has been utilized for many wounds with varied etiologies, including burns.4 The goals of burn care are to maintain homeostasis and mobility, prevent infection, perform debridement, and provide appropriate dressing changes, splinting, and compression. Negative pressure wound therapy can follow traditional burn care.
Because burns can be painful, placing a non-adherent dressing on the bum/wound bed before applying the NPWT dressing has been suggested. Mepitel® (Mölnlycke Health Care, Norcross, Ga), a soft silicone-coated primary contact layer, can be used in some cases to line the wound bed. This product was used with good results in the following case.
Case Report
Mr. O, 62 years old, sustained first-degree burns to his face, deep second-degree burns to both ears and scalp, partial second-degree burns to both hands, and partial second-degree burns to his bilateral buttocks as the result of a gas explosion in his home. His previous medical history was unremarkable.
Mr. O’s treatment was provided through the physical therapy department of an acute care hospital. His scalp and hands were sharp debrided at the bedside and dressed with silver sulphadiazine, Adaptic* (Johnson & Johnson Wound Management, a division of Ethicon, Inc, Somerville, NJ) 4 x 4 gauze , and Kerlix® bandages (Tyco Health Care/Kendall, Mansfield, Mass). He was provided oral and intravenous medication for his pain.
Mr. O’s buttocks also were (easily) sharp debrided. Once eschar was completely removed, NPWT was applied to Mr. O’s buttocks.
To prepare for NPWT, a film of lidocaine 2% gel for pain was applied to the area, followed by a dime-thickness layer of silver sulfamylon (SSD) for continued debridement and as an antimicrobial agent, and then the soft-silicone dressing. The area then was covered with the V.A.C.® foam and the V.A.C.® drape. Negative pressure was applied at 125 mm Hg. The procedure was repeated every 48 hours (see Figures 1 through 4).
Mr. O’s ears, scalp, and buttocks went on to heal uneventfully; he achieved complete epithelialization in 3 weeks. His hands, however, required surgery due to tissue contractures because he was not compliant with his hand range-of-motion exercises. His patient education consisted of mobility and hand range-of-motion recommendations.
Discussion
Negative pressure wound therapy was utilized in this case for several reasons. First, dressing the area and obtaining proper perineal hygiene with conventional dressings was difficult. The NPWT sealed the area and allowed for easier mobility without the worry of dislodging of dressings during ambulation or restroom use. Second, because NPWT enabled Mr. O to shower and defecate with the device in place, the opportunity for cross-contamination was reduced. Third, the literature supports the use of NPWT in burn treatment in that it has the ability to expedite healing and help maintain a moist wound environment.
The actual dressing approach addressed several factors. The application of lidocaine gel provided some local pain control. The use of silver sulphadiazine provided an antimicrobial and debridement effect. The soft-silicone dressing allowed for pain-free removal of the dressing by preventing the NPWT sponge from being “sucked” into the epithelial tissue.
Conclusion
Negative pressure wound therapy can be an effective adjunct to burn treatment. Because removal of the NPWT sponge can be painful, application of a soft-silicone dressing before NPWT is recommended.
Addressing the Pain is made possible through the support of Mölnlycke Health Care, Norcross, Ga.
1. Antony S, Terrazas S. A retrospective study: clinical experience using vacuum-assisted closure in the treatment of wounds. J National Medical Assoc. 2004;96(8):1073–1077.
2. Joseph E, Hamori C, Bergman S, et al. A retrospective randomized trial of vacuum-assisted closure versus standard therapy of chronic non-healing wounds. WOUNDS. 2000;12:60–67.
3. Demaria R, Giovannini U. Teot L, et al. Using VAC to treat vascular bypass site infection. J Wound Care. 2001;10:12–13.
4. De Santi L. Pathophysiology and current management of burn injury. Skin and Wound Care. 2005;18(6):323–332.
