Use of Reticulated Open Cell Foam Dressings With Through Holes During Negative Pressure Wound Therapy With Instillation and Dwell Time: A Large Case Study

Introduction. Negative pressure wound therapy with instillation and dwell time (NPWTi-d) has been utilized in wounds with positive clinical benefits. A reticulated open cell foam dressing with through holes (ROCF-CC) was developed to assist with wound cleansing by removing thick wound exudate and infectious materials, and it may be used when debridement is not possible or appropriate. Use of NPWTi-d with ROCF-CC dressings has been reported with positive outcomes in complex wounds. Objective. The present study reports the authors’ experience using NPWTi-d with ROCF-CC dressings in 19 patients with complex wounds. Materials and Methods. Of the 19 patients, 8 underwent sharp debridement. Oral and/or intravenous antibiotic treatment was initiated as needed prior to NPWTi-d. All patients received NPWTi-d with ROCF-CC dressings with instillation of quarter-strength Dakin’s solution, hypochlorous acid solution, or saline with a dwell time of 5 to 10 minutes, followed by 2 to 3.5 hours of continuous negative pressure at -125 mm Hg. Dressing changes occurred every 2 to 3 days. Measurements and assessments of wound progression were done as per institutional protocols. Results. The 19 treated patients consisted of 10 males and 9 females, with an average age of 58.2 ± 15.1 years. Common patient comorbidities included hypertension, diabetes, obesity, and paraplegia. Wound types included pressure injuries, traumatic wounds, and surgical wounds. The average length of NPWTi-d use was 9.5 ± 4.1 days. In all of the patients, the wound beds showed development of healthy granulation tissue following NPWTi-d with ROCF-CC. All patients were discharged to one of the following: another hospital facility, skilled nursing facility, long-term acute care facility, or home. Conclusions. In the authors’ clinical practice, NPWTi-d with ROCF-CC provided effective and rapid removal of thick exudate and infectious materials and promoted development of granulation tissue.

Debris, exudate, infectious materials, and devitalized tissue in the wound bed hinder wound healing. Removal of these materials can occur through debridement, wound cleansing, or a combination of both.^1-3 However, surgical debridement under anesthesia may not be appropriate to use in all patients due to increased operative risk associated with the patient’s clinical status and comorbidities. 

Traditionally, negative pressure wound therapy (NPWT) has been utilized to help remove exudate and infectious materials.^4,5 This advanced wound therapy has evolved to include wound cleansing through NPWT with instillation and dwell time (NPWTi-d) of topical wound cleansing solutions within the wound bed.^6-8 For wounds with thick exudate, a reticulated open cell foam dressing with through holes (ROCF-CC) has been developed to assist with wound cleansing.^9-12 The present study reports the authors’ experience using NPWTi-d with ROCF-CC dressings in 19 patients with complex wounds. 

All patients underwent clinical evaluation and wound assessment upon presentation at a tertiary referral, level I trauma center. Oral and/or intravenous (IV) antibiotic treatment was initiated in patients as needed. Of the 19 wounds, 8 underwent sharp debridement prior to initiation of NPWTi-d and ROCF-CC. The remaining patients (n = 11) were not candidates for sharp debridement due to increased operative risk associated with the patient’s clinical statuses and comorbidities. 

All patients received NPWTi-d (V.A.C. VERAFLO Therapy; KCI, now part of 3M Company) using an ROCF-CC dressing (V.A.C. VERAFLO CLEANSE CHOICE Dressing; KCI, now part of 3M Company). The ROCF-CC dressing was cut to fit the wound and then placed in the wound bed. If needed, the cover layer was cut to fit the wound and applied over the ROCF-CC dressing. A drape was placed over the dressings, and the tubing (V.A.C. VERAT.R.A.C. DUO Tube Set; KCI, now part of 3M Company) was attached to the therapy unit. Institutional guidelines were followed in the selection of instillation solution. Wounds that were suspected of infection received either quarter-strength Dakin’s solution or hypochlorous acid solution. Instillation of quarter-strength Dakin’s solution, hypochlorous acid solution, or saline with a dwell time of 5 to 10 minutes, followed by 2 to 3.5 hours of continuous negative pressure at -125 mm Hg were initiated. Dressing changes occurred every 2 to 3 days. 

Of the 19 treated patients, there were 10 males and 9 females, with an average age of 58.2 ± 15.1 years. Common patient comorbidities included hypertension, diabetes, obesity, and paraplegia. The treated wound types included pressure injuries, traumatic wounds, and surgical wounds (Table). The average length of NPWTi-d use with ROCF-CC was 9.5 ± 4.1 days. 

In all patients, the wound beds showed the development of healthy granulation tissue and reduction of slough and thick exudate following NPWTi-d use with ROCF-CC dressings within 72 hours. None of the patients developed treatment-related adverse events. All patients were discharged from care to another hospital facility, a skilled nursing facility, a long-term acute care facility, or home, depending on clinical prognosis and recommendations from the physical therapy and rehabilitative team. 

The following 2 cases are representative of the 19 case studies of complex wounds that were treated using NPWTi-d with ROCF-CC dressings.

Case 1 
A 65-year-old female presented to the hospital with groin pain (pain scale, 7/10). Previous medical history included coronary artery disease, percutaneous coronary angioplasty, breast cancer, diabetes mellitus, hypercholesterolemia, hypertension, a myocardial infarction, diabetic neuropathy, tobacco use, and an iliac artery stent. A computerized tomography scan of the abdominopelvic region revealed muscle stranding. The patient was diagnosed with a left lower extremity ischemia with occluded right superficial femoral and popliteal arteries. The patient underwent a femoral thrombectomy to resolve the occlusions. The patient underwent incision and drainage to remove an abscess (Figure 1A) 4 days after hospital admission. Cellulitis was present, and IV broad-spectrum antibiotics (piperacillin and tazobactam, 4.5 mg IV every 6 hours; linezolid, 500 mg orally twice daily) were given for a period of 14 days. Bacterial cultures were positive for Escherichia coli and demonstrated specific sensitivity to cefazolin; the antibiotic therapy was changed accordingly. Negative pressure wound therapy with instillation and dwell time with ROCF-CC dressings was applied 7 days after admission. A hypochlorous acid wound cleansing solution (30 mL, Vashe Wound Cleansing Solution; Urgo Medical North America) was instilled into the wound bed with a dwell time of 10 minutes, followed by continuous negative pressure for 3 hours at -125 mm Hg. After 3 days, increased granulation tissue development was observed in the wound (Figure 1B). Negative pressure wound therapy with instillation and dwell time was discontinued, and the patient was discharged to a skilled nursing facility with NPWT (V.A.C. Therapy; KCI, now part of 3M Company).

Case 2
A 33-year-old male presented to the hospital with an infection in his above-the-knee amputation stump following a fall (Figure 2A). Previous medical history included tobacco use, anemia, and methicillin-resistant Staphylococcus aureus infection. Conservative sharp debridement was performed at the bedside, and an oral antibiotic (linezolid, 500 mg orally twice daily) was administered for 14 days. Negative pressure wound therapy with instillation and dwell time with ROCF-CC dressings was started, instilling 80 mL to 100 mL of hypochlorous acid solution with a 10-minute dwell time, followed by 2 hours of negative pressure at -125 mm Hg. Dressing changes occurred every 3 days. After the first dressing change at 3 days post-initial application, granulation tissue development was observed in the wound bed (Figure 2B). Further granulation tissue development and reduction of slough was observed after 6 and 9 days of NPWTi-d with ROCF-CC dressing use (Figure 2C, Figure 2D). After 9 days of NPWTi-d with ROCF-CC dressing use, NPWTi-d was discontinued and NPWT initiated with continuous negative pressure at -125 mm Hg. After 1 day of NPWT, the wound bed was 98% covered with healthy granulation tissue (Figure 2E). The patient was discharged to a long-term acute care facility 12 days after admission to the hospital. 

During wound care, removal or reduction of devitalized tissue and debris is necessary to help promote wound healing.^1-3 However, in certain patient populations, sharp or surgical wound debridement is not available or appropriate. In these patients, the use of NPWTi-d with the ROCF-CC dressing may assist in wound cleansing through the removal of thick exudate and infectious materials.

Previously published literature describing the use of NPWTi-d with ROCF-CC dressings is limited. However, the existing studies reported on NPWTi-d with ROCF-CC dressing use in similar patient populations to the present study.^9-12 The patient populations in each of the studies had reported comorbidities of diabetes mellitus, obesity, hypertension, and vascular insufficiency,^9-12 indicating that NPWTi-d use with ROCF-CC dressings may be beneficial for the treatment of complex wounds in these groups of patients. In the aforementioned studies, wound types included the following: pressure injuries, ulcers, necrotizing fasciitis, diabetic foot ulcers, and surgical dehiscence.^9-12 The present patient population wound types differ slightly from the published literature, with the addition of traumatic wounds.

In the present patient population, the effective removal of thick exudate and infectious materials was observed following use of NPWTi-d with ROCF-CC dressings. This result mirrored that of the studies by Téot et al,⁹ Fernández et al,¹⁰ Blalock,¹¹ and McElroy.¹² Téot et al⁹ noted rapid granulation tissue formation and reduction of thick exudate and devitalized tissue following NPWTi-d with ROCF-CC dressing use in 20 out of 21 patients. The studies by Fernández et al (N = 5),¹⁰ Blalock (N = 19),¹¹ and McElroy (N = 14)¹² noted increased granulation tissue formation and reduction in devitalized tissue following NPWTi-d with ROCF-CC dressing use in 100% of the study populations. Blalock¹¹ noted that NPWTi-d with ROCF-CC dressing use helped contribute to limb salvage by aiding in wound cleansing and removal of infectious materials and thick exudate. 

Following successful wound cleansing, all patients in this study were discharged from acute care to other facilities or the home. This rate of discharge is similar to results from 3 of the 4 available studies.^10-12 Téot et al⁹ did not report on patient outcomes after NPWTi-d with ROCF-CC dressing use was discontinued.

The small number of patients and the retrospective, non-comparative design are limitations of this study. However, in line with previously published literature, patient outcomes indicated a reduction of thick exudate and increase in granulation tissue development following NPWTi-d with ROCF-CC dressing use. Future studies with increased patient numbers and a control group are needed to fully assess the impact of NPWTi-d with ROCF-CC dressing use on clinical and health economic outcomes.

In the authors’ clinical practice, NPWTi-d with ROCF-CC provided effective removal of thick exudate and promoted a more rapid development of underlying granulation tissue. 

Note: The authors thank Julie M. Robertson (KCI, now part of 3M Company) for manuscript preparation and editing.

Authors: Luis G. Fernández, MD, FACS, FASAS, FCCP, FCCM, FICS^1,2; Marc R. Matthews, MD, MS, MC, FACS³; Cynthia Ellman, RN, BSN, CWOCN⁴; Patricia Jackson, BSN, RN, CWOCN⁴; David H. Villarreal, MD, FACS^1,2; and Scott Norwood, MD, FACS, FCCM^1,2

Affiliations: ¹University of Texas Health Science Center, Tyler, TX; ²University of Texas, Arlington, TX; ³Arizona Burn Center, Maricopa Medical Center, Phoenix, AZ; and ⁴Christus Trinity Mother Frances Hospitals, Tyler, TX

Correspondence: Luis G. Fernández, MD, KHS, KCOEG, FACS, FASAS, FCCP, FCCM, FICS, Department of Surgery, University of Texas Health East Texas Physicians Tyler-Trauma Surgery, 1020 E. Idel Street, Tyler, TX 75701; thebigkahuna115@gmail.com

Disclosure: Dr. Fernández and Dr. Matthews are consultants for KCI, now part of 3M Company. Manuscript preparation and editing were provided by Julie M. Robertson.