Use of Negative Pressure Wound Therapy With Instillation in the Management of Complex Wounds in Critically Ill Patients

Negative pressure wound therapy with instillation and dwell time (NPWTi-d) is a negative pressure wound therapy (NPWT) system with an instillation feature and specialized dressings that allow solutions to dwell in the wound for prolonged contact with and cleansing of the wound bed. Use of NPWTi-d has been shown to be an effective approach in difficult-to-treat cases. Several published reviews and recommendations exist for the use of NPWTi-d in both acute and chronic wounds.^1-3 In addition, NPWTi-d has been shown to provide better clinical outcomes overall than conventional NPWT when added to standard wound care.⁴ 

In this report, the authors describe the use of NPWTi-d to manage complex wounds in 2 critically ill patients.

Patient demographics are described in the Table. Both patients received antibiotics and adjunctive nutritional and critical care support. Debridement was performed prior to use of NPWTi-d when possible. In both cases, NPWTi-d (V.A.C. VERAFLO Therapy; KCI, an Acelity Company, San Antonio, TX) was initiated by instilling normal saline with 10- to 20-minute dwell times, followed by 2 hours of -125 mm Hg negative pressure. Dressings were changed every 2 to 3 days. Following NPWTi-d, treatment was changed to conventional NPWT (V.A.C. Therapy; KCI, an Acelity Company) to enable primary closure or coverage with a split-thickness skin graft (STSG).

Patient 1
A 67-year-old woman, with a history of Roux-en-Y gastric bypass surgery 10 years prior, was referred to the Christus Trinity Mother Frances Hospitals (Tyler, TX) for a small bowel obstruction. A celiotomy revealed an ischemic efferent limb requiring detorsion and gastrostomy tube insertion. About 36 hours postoperatively (Figure 1A), she went into septic shock and was sent for emergency surgery. The patient underwent resection of 54 cm of the efferent jejunum, abdominal washout, and damage control surgery (Figure 1B). She was evaluated as having acute kidney injury, acute respiratory distress syndrome, sepsis, acute coronary syndrome, hepatic failure, and coagulopathy. 

Since there was abundant granulation tissue (70%) covering a partially intact abdominal fascia that had been reconstructed with a biological tissue matrix (STRATTICE Reconstructive Tissue Matrix; LifeCell Corporation, an Allergan Affiliate, Madison, NJ), the decision was made to apply NPWTi-d. Her abdomen was closed except for a 2.5-cm enteroatmospheric fistula (Figure 1C), so care was taken to isolate the fistula from exposure to NPWTi-d. A layer of a nonadherent dressing (ADAPTIC TOUCH Non-Adhering Silicone Dressing; KCI, an Acelity Company) and a polyvinyl alcohol foam layer (V.A.C. WHITEFOAM Dressing; KCI, an Acelity Company) were placed onto the wound bed to protect the underlying granulation tissue. A reticulated open-cell foam dressing (ROCF-V; V.A.C. VERAFLO Dressing; KCI, an Acelity company) was placed over the nonadherent and polyvinyl alcohol layers. A foam ring with a nonpermeable drape was placed around the fistula to separate it from the instillation dressing. After application of the dressing, a stoma pouch was placed over the isolated fistula to allow drainage away from the wound dressing (Figure 1D). 

The patient received NPWTi-d for 2 weeks with 3 additional washouts (Figure 1E). Once the wound was granulating, treatment was switched to conventional NPWT (Figure 1F). Definitive surgery was planned for once the patient had recovered from this event and had been physiologically optimized. Per institutional protocol, patients with a “hostile” abdomen are allowed a 12- to 18-month waiting period before attempted repair of the enteroatmospheric fistula. At the time of this publication, the patient had not yet undergone this final surgical procedure.

Patient 2
A critically ill 45-year-old woman presented to the hospital with complex, necrotic wounds resulting from Fournier’s gangrene (Figures 2, 3). The patient was immunocompromised with septic shock, acute kidney injury, and acute renal failure. Her medical history included insulin-dependent diabetes, hypertension, morbid obesity, and a history of smoking. The patient received appropriate initial surgical debridement, antibiotics, vasopressors, and adjunctive nutritional and critical-care support. 

Large wounds (~30% total body surface area) with devitalized tissue covered the patient’s back, right superior buttocks region, thigh, and lower abdomen. On day 2 following presentation, NPWTi-d with a ROCF-V dressing was applied (Figures 2A, 3A); serial debridement was performed at dressing changes when necessary. 

After 68 days post presentation (Figures 2C, 3C), the patient underwent placement of a STSG on the right thigh, inguinal area, perineum, suprapubic area, right superior buttocks region, and lower back. The wounds on the patient’s upper back and lower abdomen closed without further surgical intervention. Conventional NPWT was applied over the grafts as a bolster, and the patient was discharged to a rehabilitation center 27 days later with a 95% graft take (Figures 2D, 3D).

In these 2 cases, the patients presented with serious, life-threatening illnesses involving large, complex wounds with devitalized tissue. Extensive comorbidities and multiorgan failure had compromised their wound healing. In each case, NPWTi-d was used to cleanse the wound surface, provide a protective barrier, and enable the progression of wound healing. 

Historically, patients presenting with these wounds would have been treated with daily wet-to-dry dressing changes with sterile gauze. However, this protocol could increase opportunities for wound contamination, which may prolong wound healing. This risk is especially concerning given the difficult anatomical topography of the wounds — a septic, closed abdominal wound with an enteroatmospheric fistula and large, contaminated wounds extending into the groin area — and the overall vulnerable status of the patients’ health.

In the authors’ clinical practice, NPWTi-d promoted wound healing in these 2 critically ill patients with large, complex wounds. Use of NPWTi-d is appropriate for wounds that require cleansing and removal of infectious materials, and it may provide a healing benefit in high-risk patients with multiple comorbidities. 

Authors: Luis Fernández, MD, KHS, KCOEG, FACS, FASAS, FCCP, FCCM, FICS; Cynthia Ellman, RN, BSN, CWOCN; and Patricia Jackson, BSN, RN, CWOCN

Affiliation: Christus Trinity Mother Frances Hospitals, Tyler, TX

Correspondence: Luis Fernández, MD, KHS, KCOEG, FACS, FASAS, FCCP, FCCM, FICS, Christus Trinity Mother Frances Health System, 910 E Houston Street, Tyler, TX 75702; thebigkahuna115@gmail.com

Disclosure: Dr. Fernández has a consulting agreement with KCI, an Acelity Company (San Antonio, TX). Ms. Ellman and Jackson disclose no financial or other conflicts of interest. No funding was provided to support this study. Mikaela Sifuentes, PhD (KCI, an Acelity Company), provided medical writing support. Data were presented at the 2018 Symposium on Advanced Wound Care Spring.