Negative Pressure Wound Therapy With Instillation and Dwell Time for the Management of Complex Wounds: A Case Series

Negative pressure wound therapy (NPWT) dressings are frequently used for wounds of varying sizes and depths in order to promote formation of granulation tissue and healing. International consensus guidelines have been described for the use of NPWT with instillation and dwell time (NPWTi-d; V.A.C. VERAFLO Therapy; 3M + KCI) in wounds that would benefit from daily cleansing without necessitating daily dressing changes.¹ These guidelines and additional studies also illustrate conditions in which it is beneficial to utilize dressings with reticulated open cell foam (V.A.C. VERAFLO CLEANSE CHOICE Dressing; 3M + KCI) dressings.^1,2 Kim et al³ demonstrated the efficacy of NPWTi-d over standard non-instillation NPWT. Multiple case reports describe situations in which NPWTi-d is used to treat wounds that result from diabetic infections, abdominal trauma ultimately leading to enterocutaneous fistulae, and necrotizing soft tissue infections (NSTIs).^4-6 Padilla et al⁷ described the case of a patient who had sustained 46% total body surface area (TBSA) burn wounds and then received treatment with NPWTi-d after poor results with initial standard grafting.⁷ Negative pressure wound therapy has been well described in the burn populations and is a critical resource utilized by surgeons to assist in the closure in a wide variety of wounds seen in a burn center.^8,9 Standard NPWT improves edema control, constricts the overall size of the boundaries of the open wound, and improves circulation, but NPWTi-d also helps remove turbid devitalized and necrotic tissue containing pro-inflammatory mediators, all of which allow for faster closure.¹⁰ 

The current authors report a case series of 10 patients who presented with complex wounds derived from varying etiologies, which were intermittently managed with NPWTi-d using hypochlorous acid wound solution (HOCl; Vashe Wound Solution; URGO Medical), to a large burn center. The purpose of this study is to highlight the use of NPWTi-d in managing a variety of challenging wounds.

The hospital registry of patients between July 2018 and June 2020 was queried to identify patients who were 18 years or older, whose wounds were managed intermittently with NPWTi-d using HOCl wound solution, regardless of wound etiology. Demographic and surgical data were collected, including age, sex, hospital length of stay (LOS), wound etiology, wound size, number of surgical procedures, number of standard NPWT uses, number of NPWTi-d uses, volume instillation of HOCl wound solution (in mL, if information available), length of dwell time (in minutes, if information available), use of autografting, and use of other adjuncts to promote wound closure. Demographic and surgical data were analyzed and reported using descriptive statistics. 

A total of 10 patients who underwent complex wound management with NPWTi-d were identified (Table). Of the 10 patients, 6 were male and 4 were female. The patients’ ages ranged from 31 to 78 (mean, 57.3 years; median, 54.5 years). Six patients were admitted for NSTIs, 2 patients were admitted for sacral decubitus ulcers, and 2 patients were admitted for burn injuries. The wound size managed with NPWTi-d ranged from 30 cm² to 1000 cm² (mean, 381 cm²; median, 325 cm²). Each patient underwent surgical debridement prior to placement of NPWT or NPWTi-d. The number of surgical debridement procedures ranged from 1 to 15 (mean, 6.2). The number of standard NPWT placements ranged from 3 to 17 (mean, 7.4), and the number of standard NPWTi-d ranged from 1 to 4 (mean, 2). Instillation volume of HOCl wound solution ranged from 25 mL to 50 mL with a dwell time of 15 to 30 minutes, which was to be repeated every 3 hours. All but 2 patients ultimately underwent split-thickness skin grafting (STSG) for wound closure. One patient with a below-the-knee amputation (BTKA) stump ultimately underwent simple closure of the wound. One of the 2 patients with a sacral ulcer did not undergo grafting as the wound was able to heal by secondary intention. 

Necrotizing soft tissue infections

Case 1. A 55-year-old female presented with an NSTI of the abdominal wall secondary to an infection caused by an insulin pump. The patient underwent 2 surgical procedures for aggressive debridement of a region measuring 300 cm². The patient initially underwent wet-to-moist dressing changes; on postoperative day (POD) 3, the decision was made to utilize NPWTi-d in order to minimize frequency of dressing changes while still allowing for effective wound cleansing. The patient underwent NPWT (both standard and instilling) for about 2 months prior to STSG placement. The wound was successfully closed, and there were no complications after grafting was completed. The patient subsequently followed-up in burn clinic with a well-healed abdominal wound and no further sequelae.

Case 2. A 59-year-old female presented with necrotizing fasciitis of the abdominal wall. After serial debridement procedures, the wound ultimately measured 400 cm². An NPWTi-d was placed to help prepare the wound for skin grafting. The patient underwent serial wound NPWTi-d dressing changes every 3 to 4 days for nearly 3 weeks. Part of the wound was able to undergo simple closure, and the remainder was grafted with a meshed STSG and completely closed. The patient followed-up in burn clinic and had healed well without any clinical sequalae or limitations in mobility.

Case 3. A 43-year-old male developed an NSTI of the left foot secondary to a diabetic foot ulcer. After debridement, the wound measured 280 cm². The patient underwent 3 NPWT dressing changes prior to successful grafting and complete wound closure The patient followed-up in burn clinical and was ambulating with physical therapy and subsequently released ambulating without sequelae.

Case 4. Transfer from a referring facility, a 77-year-old male presented with a wound measuring 1000 cm² after serial debridement procedures. The patient had developed necrotizing fasciitis of the right torso, secondary to untreated emphysematous cholecystitis, resulting in fistulization through the right abdominal wall. Once the wound was clean and free of necrosis and infection, the patient underwent NPWTi-d dressing changes and transitioned to standard NPWT dressing changes to prepare the wound for grafting. The patient was subsequently lost to follow-up after several weeks.

Case 5. A 31-year-old female presented with compartment syndrome of the left lower extremity (LLE). The patient underwent emergent fasciotomy, and the muscles of the lower leg initially appeared viable. However, over the course of the patient's hospital stay, the lower leg wounds progressively worsened and subsequently required a left BTKA. The BTKA stump was first managed with an NPWTi-d dressing, then transitioned to a standard NPWT dressing prior to closure of the stump and fasciotomy wounds. The patient was initially followed in burn clinic for their healing wounds, but upon wound closure, the patient was subsequently transitioned to the orthopedic service due to the development of left knee joint contractures. 

Case 6. A 72-year-old female presented with necrotic skin of the LLE found to be secondary to a retained hematoma. After evacuation of the hematoma and debridement of nonviable tissue, the patient had a wound measuring 300 cm² that underwent NPWTi-d dressing placement prior to standard NPWT use, with 4 total dressing changes. The wound was then successfully grafted without complication. The patient was followed up in the wound clinic and was released; further visitation for other medical care did not reveal any wound issues related to her LLE.

Sacral decubitus ulcers

Case 7. A 52-year-old male, who was initially admitted to the burn center for management of 64% TBSA flash burns, underwent serial debridement and grafting procedures and was ultimately discharged to a skilled nursing facility after 3.5 months. Given the prolonged immobility and severe protein calorie malnutrition—even prior to the injuries—the patient developed a sacral decubitus ulcer. The patient was readmitted 3 weeks after discharge for nutritional optimization and management of this ulcer. Measuring about 50 cm², the wound was placed in both standard NPWT and NPWTi-d dressings for 1 month prior to grafting undergoing a total of 12 dressing changes. After the burn wound reconstruction and repair by skin grafting of the sacral decubitus ulcer, the patient was followed up with in the burn clinic; there were no further sequelae to this healed wound.

Case 8. A 52-year-old male who has paraplegia developed a sacral decubitus ulcer after many years of immobility. The patient was admitted, and the wound, measuring 30 cm², was placed in a NPWTi-d dressing, changed every 3 days for 1 week. The patient was deemed stable for discharge with a clean wound and underwent outpatient standard NPWT dressing changes for nearly 6 months. The wound developed adequate granulation tissue, but the patient succumbed to the injuries (a do-not-resuscitate order was in place). 

Burn Injuries

Case 9. A 78-year-old male sustained a contact burn of the right lower extremity (RLE) from a space heater. After serial debridement procedures, the wound measured 350 cm². The wound was dressed in NPWTi-d then transitioned to a standard NPWT dressing, requiring a total of 10 dressing changes. The wound was then suitable for grafting without complication. The patient’s wound was well healed after 1 month of observation in the burn clinic; the patient eventually refused to return for follow-up.

Case 10. The patient was a 54-year-old male who sustained a grease burn to the RLE. The patient underwent tangential excision and debridement of the burn wound, which measured 600 cm². The wound was clean and free of infection, and subsequently managed with both standard NPWT and NPWTi-d for almost 2 weeks, with a total of 6 dressing changes. The wound was grafted successfully without complication (Figures 1–6). The patient followed-up in burn clinical and was ambulating with physical therapy and subsequently released ambulating without sequelae.

Negative pressure wound therapy dressings are a useful and beneficial tool for providers to treat patients with complex wounds. Patients within this case series typically underwent NPWTi-d dressing changes initially with subsequent transition to standard NPWT use. This approach was likely performed to aid in frequent cleansing of the wound early in each patient’s course. Of note, NPWTi-d has recently been shown to result in a shorter LOS, significantly lower the total number of operations performed, have shorter time to final surgical procedures, and have a higher percentage of closed wounds at 1 month compared with patients treated with standard NPWT.¹¹ In addition, NPWTi-d compared with standard NPWT also has shown that when coupled with good clinical practice (eg, appropriate antibiotics, surgical debridements) to improve time to readiness for final wound closure and decreased bacterial bioburden.¹² Occasionally, the dressing may have more frequent leaks as compared with a non-irrigating one. This can be addressed by assessing the adhesive component of the dressing or decreasing the volume of fluid that one may instill in the wound.

There are several limitations to this study. First, the use of NPWTi-d versus non-irrigating dressings is surgeon-dependent. At the authors’ institution, there is no standard protocol with regard to the use of NPWTi-d, and the decision to use it may reflect the personal preference of the surgeon. Therefore, there may be instances during which a patient’s dressing may switch from a NPWTi-d to a standard NPWT dressing, and vice versa, during the time between the injury and grafting. Second, this was a small sample size, and the characteristics of the wounds were very different. With a larger sample size, the data can be stratified according to anatomical location, wound etiology, and wound size. Third, this study did not account for patient comorbidities. Patients who are elderly, with poorly controlled diabetes, with a history of smoking, and/or with a history of poor wound healing may be observed to require a longer duration of NPWT dressing changes compared with patients with fewer risk factors before they are able to undergo grafting. Fourth, it is challenging to draw conclusions regarding the cost of using NPWTi-d with such a heterogeneous group of patients. 

This case series highlights the spectrum of wounds that can be managed with NPWTi-d dressings to promote the debridement of exudative tissue between surgical debridement procedures. Wounds from almost any anatomical location and of nearly any size can potentially be treated with NPWTi-d, as demonstrated by the range of wound size from 30 cm² to 1000 cm² in the present series. In addition, each of the wounds had resulted from different etiologies. Although the sample size was small, it illustrates that NPWTi-d is a useful device in a health care provider’s armamentarium to promote closure of wounds that can be challenging to manage. 

A prospective study that randomizes patients into 2 groups—those with the NPWTi-d dressing and those with the standard/traditional NPWT dressing—would likely provide more information regarding the benefit of the NPWTi-d dressing as well as help guide providers in patient selection. 

Authors: Samantha Delapena, MD¹; Luis G. Fernández, MD, KHS, KCOEG, FACS, FASAS, FCCP, FCCM, FICS²; Kevin N. Foster, MD, MBA, FACS³; and Marc R. Matthews, MD, FACS, FASGS³

Affiliations: ¹Department of Surgery, Valleywise Health Medical Center, Creighton University Arizona Health Education Alliance, Phoenix, AZ; ²Professor of Surgery, Medical Director, Trauma Wound Care, University of Texas Health East, Tyler, TX, and University of Texas Health Science Center, Tyler, TX; and ³Arizona Burn Center, Valleywise Health Medical Center

Correspondence: Marc R. Matthews, MD, FACS, Arizona Burn Center, Valleywise Health Medical Center, 2601 E. Roosevelt Street, Phoenix, AZ 85008; azmrmltc@gmail.com

Disclosures: Drs Fernandez and Matthews are paid speakers for 3M + KCI.