Addressing the Pain: Silicone Net Dressing as an Adjunct with Negative Pressure Wound Therapy

  The impervious nature of the integumentary system protects our vital organs from infection, desiccation, minor trauma, and heat loss. Proper metabolic, protein, and electrolyte balances rely on intact skin to maintain local and systemic hemostasis. Traumatic wounds, therefore, can have a negative if not devastating impact on the exposed underlying structures and their system counterparts. Patients who incur these acute injuries must be accurately and systematically evaluated and managed to optimize wound closure. Complex wounds offer problems that are more challenging as they may include fractures, nerve, tendon and vessel injuries and loss of soft tissue coverage.¹

  Negative pressure wound therapy (NPWT) has been found to be an effective modality in the management of complex orthopedic wounds. Indications for NPWT use include removing excessive drainage and fluid, improving wound healing by promoting granulation, and securing split-thickness skin grafts.² The objectives for managing a complex wound due to an open fracture include removal of devitalized tissue, management of edema while maintaining a moist wound environment, and eventual provision of soft tissue coverage of the injury. Use of NPWT before and after definitive surgical soft tissue coverage helps achieve these objectives.

  Traumatic wounds are often very painful and can be a source of significant anxiety, which also may lead to a heightened pain response to dressing changes. Depending on the wound type and the patient’s response to the dressing changes, pain management during NPWT dressing changes may need to be addressed. Among the strategies to assist in the reduction of pain is the use of a nonadherent meshed interface between the wound and the foam dressing. An interface that will assist with the reduction of discomfort and allow for optimization of granulation tissue formation should be considered. The soft silicone coated net and open mesh structure of Mepitel (Mölnlycke Health Care, Newtown, Pa.)³ is an effective interface.

Case Report

  Fifty-year-old Mr. C was driving a motorcycle around a curve when he collided with a brick wall on October 12, 2004. He sustained an open tibia/fibula fracture to the right lower extremity, requiring immediate surgical intervention for repair and stabilization. Mr. C required a total of three surgical procedures. The first surgery on October 12, 2004 included removal of devitalized bone and soft tissue and an open reduction and internal fixation of the fracture. The anterior portion of the wound was left open with exposed muscle and bone. Plastic surgery consultation was requested to determine closure options. The second surgery on October 15, 2004 involved a soleus muscle flap to cover the fracture site and placement of a vacuum-assisted closure (V.A.C.® System, KCI USA, San Antonio, Tex.) device over the muscle flap and a distal area of exposed bone with intact periosteum. The first NPWT dressing change was performed by a Wound Ostomy Continence Nurse and a plastic surgeon at Mr. C’s bedside. Because of the nature of the injury and his response to the dressing change, the decision was made to utilize a porous soft silicone contact layer, against the wound bed under the NPWT dressing at a setting of 75 mm Hg continuous therapy. The dressing changes were scheduled for Monday, Wednesday, and Friday. At subsequent NPWT dressing changes, which included the use of the soft silicone dressing, the patient verbalized a 70% or more reduction in his pain. Mr. C received a total of nine NPWT dressing changes with pain at a level of 3 or below (on a scale of 1 to 10). The third and final surgery November 5, 2004 included reapproximation of the muscle flap, a split-thickness skin graft, and application of NPWT with soft silicone dressing used as an interface between the wound and the foam. The NPWT dressing was removed November 10, 2004. Mr. C was discharged home November 13, 2004.

Conclusion

  In the process of treating complex wounds, NPWT is an invaluable modality for initial wound stabilization and treatment. In the case of trauma wounds, the NPWT dressing is initially placed in the operating room with subsequent dressing changes conducted at the bedside without sedation. If dressing changes elicit a painful response, clinicians have found that the use of a porous nonadherent dressing as an interface between the wound and the NPWT dressing can significantly reduce the pain and anxiety as well as minimize the need for analgesics. The porous quality of the nonadherent soft silicone dressing allows the NPWT device to effectively remove wound drainage while allowing for optimal granulation tissue formation.

Addressing the Pain is made possible through the support of Mölnlycke Health Care, Newtown, PA.

1. Neumeister M. The Management of Traumatic Wounds. 2001;Winter.

2. Laverty D, Webb L, DeFranzo A. Negative pressure wound therapy in the management of orthopedic wounds. Ostomy Wound Manage. 2004;50(11 suppl):18S–19S.

3. Chavez B. Making the case for using a silicone dressing in burn management. Ostomy Wound Manage. 2004;50(6):11–13.