Clinical outcomes of negative pressure wound therapy with instillation vs standard negative pressure wound therapy for wounds: A meta-analysis of randomised controlled trials

Negative pressure wound therapy (NPWT) with or without instillation has been extensively applied for patients with multiple wound types. Whether NPWT with instillation is superior to NPWT alone is not known. This study aims to compare the efficacy between negative pressure wound therapy with instillation (NPWTi) and standard negative pressure wound therapy for wounds. The authors searched for randomised controlled trials (RCTs) in PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials investigating clinical outcomes of negative pressure wound therapy with instillation vs standard negative pressure wound therapy for wounds. The registration number (protocol) on PROSPERO is CRD42022287178. Eight RCTs involved 564 patients met the inclusion criteria and were included finally. NPWTi showed a significant fewer surgeries and dressing changes (RR and 95% CI, −9.31 [−17.54, −1.08], P < 0.05), and smaller wound area after treatment (RR and 95% CI, −9.31 [−17.54, −1.08], P < 0.05) compared with NPWT. No significant difference was observed on healing rate, time to heal, length of stay, dehiscence, reinfection, reoperation and readmission between NPWTi and NPWT. The addition of instillation to NPWT could improve clinical outcomes regarding the number of surgeries and dressing changes, and wound area after treatment in patients with multiple wound types. However, because of the heterogeneity these conclusions still need to be further validated by more well-designed RCTs with large sample sizes.     

Research progress on negative pressure wound therapy with instillation in the treatment of orthopaedic wounds

Negative pressure wound therapy with instillation (NPWTi) has the dual function of negative pressure sealing drainage and irrigation, which overcomes the disadvantages of NPWT, such as tube obstruction, inability to apply topical medicine, and poor anti‐infection ability. NPWTi has been researched extensively and widely used in various types of wounds, and certain effects have been achieved. A series of parameters for NPWTi have not been unified at present, including the flushing fluid option, flushing mode, and treatment period. This paper reviews the research progress of these parameters for NPWTi and their application in the treatment of orthopaedic wounds.     

Use of negative pressure wound therapy with instillation and a reticulated open cell foam dressing with through holes in the acute care setting

Negative pressure wound therapy with instillation and dwell time (NPWTi‐d) is an automated system used to deliver, dwell, and remove topical solutions from the wound bed. Recently, a reticulated open cell foam dressing with through holes (ROCF‐CC) was developed, which assists with wound cleansing by removing thick exudate and infectious materials. We present our experience using NPWTi‐d with ROCF‐CC on complex wounds when complete surgical debridement was inappropriate because of medical instability, recurrent non‐viable tissue, or palliative treatment plan. For all wounds, NPWTi‐d with ROCF‐CC was initiated by instilling normal saline, acetic acid, or hypochlorous acid with 2 to 10 minutes of dwell time, followed by 0.5 to 4 hours of negative pressure. Dressings were changed every 2 to 3 days. Fourteen patients with multiple comorbidities were treated for wound types including diabetic foot ulcers, necrotising fasciitis, dehisced wounds, and pressure injuries. Duration of NPWTi‐d with ROCF‐CC ranged from 1 to 15 days, and at dressing changes, wounds showed improved granulation tissue formation, less malodour, less surrounding erythema, and demarcation of healthy skin from devitalised tissue. Based on these patients, adjunctive use of NPWTi‐d with ROCF‐CC provided a practical option for improving tissue quality in wounds for patients in whom surgical debridement was not possible or desired.     

Treatment of anticoagulated patients with negative pressure wound therapy

There is a paucity of evidence surrounding the use of negative pressure wound therapy (NPWT) in patients receiving anticoagulant medication. Guidelines generally recommend caution regarding the use of NPWT in anticoagulated patients in general, but areas of particular risk are frequently not highlighted. The US Food and Drug Authority (FDA) reported six mortalities between 2009 and 2011 in patients receiving NPWT. These mortalities were associated with the use of NPWT over vascular graft sites. The coagulation status of these patients was not reported. It is the authors' recommendation that guidelines regarding the use of NPWT in anticoagulated patients highlight specific clinical situations of risk, although there is insufficient evidence to support the avoidance of NPWT in anticoagulated patients in general.     

Instillation negative pressure wound therapy: An effective approach for hardware salvage

Wound infection involving hardware can be notoriously difficult to treat, often requiring the removal of the infected implant. The goal of this study was to determine the utility of instillation negative pressure wound therapy to help eradicate infection and allow for definitive wound closure in patients without removing the infected hardware. A retrospective review was performed on the outcomes of 28 patients who presented with open wounds with exposed or infected hardware and who were treated with a combination of surgical debridement and negative pressure wound therapy with instillation (NPWTi). Eleven patients were treated for infected spinal hardware, 12 for extremity, and 5 for sternal hardware. Twenty‐five of 28 (89%) patients had successful retention or replacement of hardware, with clearance of infection and healed wounds. Original hardware was maintained in 17 of 28 (61%) patients. In 11 patients, original hardware was removed, with subsequent replacement in eight of those patients after a clean wound was achieved. Average time to definitive closure was 12.6 days. Average follow‐up was 135 days. This series supports NPWTi as an effective adjunct therapy to help expeditiously eradicate hardware infection, allowing for hardware retention.     

Negative pressure wound treatment with computer‐controlled irrigation/instillation decreases bacterial load in contaminated wounds and facilitates wound closure

Microbial wound contamination is known to be a hindrance to wound healing. Negative pressure wound therapy (NPWT) with or without irrigation is known to optimise conditions in problem wounds. The aim of this study was to investigate the influence of computer‐controlled wound irrigation with NPWT on the bacterial load in contaminated wounds. A total of 267 patients were treated with NPWT with automated instillation because of problematic wounds using an antiseptic instillation solution. In 111 patients, a minimum of 4 operative procedures were necessary, and swabs were taken at least at the first and at the fourth operation in a standardised procedure. The number of different bacteria and the amount of bacteria were analysed during the course. In a subgroup of 51 patients, swabs were taken at all 4 operative procedures and analysed separately. In an overall analysis, the number of different bacteria and the amount of bacteria significantly decreased independent of wound localisation and diagnosis. NPWT with automated instillation demonstrates a positive influence in the reduction of bacterial load in problem wounds. Thus, it may help to optimise wound conditions before definite wound closure.     

An inexpensive method of negative pressure wound therapy for extremities

Negative pressure wound therapy (NPWT) is an established method for the faster wound healing of chronic non‐healing wounds. It is also used for laparostomy wounds and healing of split skin grafts. The commercially available machine and the consumables for NPWT are very expensive and economically not feasible in developing and underdeveloped countries. So, we devised a NPWT system for wounds of the extremity using inexpensive, readily available materials in any hospital. The materials used are sterile glove, autoclaved sponge, Foley catheter, and a wall suction unit. The sponge was placed over the wound, and a sterile glove was pulled over it. A Foley catheter was placed over the sponge and taken out through one of the fingers of the glove. Adhesive plaster was used to air‐seal the glove. The Foley catheter was fixed with silk ties and connected to wall suction. Granulation and wound healing was faster in this system. This system was safe and inexpensive for the treatment of wounds of the extremity.     

Management of the open abdomen using negative pressure wound therapy with instillation in severe abdominal sepsis: A review of 48 cases in Hospital Mexico,Costa Rica

IntroductionDespite the numerous advances in recent years, severe abdominal sepsis (with associated organ failure associated with infection) remains a serious, life-threatening condition with a high mortality rate. OA is a viable alternative to the previously used scheduled repeat laparotomy or continuous peritoneal lavage. The use of Negative Pressure Wound Therapy (NPWT) has been described as a successful method of management of the open abdomen. Adding instillation of saline solution to NPWT in a programmed and controlled manner, could offer the clinician an additional tool for the management of complex septic abdomen.ObjectivesTo explore if the concept of active two-way therapy (Negative pressure wound therapy with instillation or NPWT-I) yields superior control of underlying, life-threatening abdominal infections and its effects on survival and morbidity in patients with severe abdominal sepsis when management with an open abdomen is required.MethodsA retrospective review of 48 patients with severe abdominal sepsis, who were managed with and open abdomen and NPWT-I was performed. NPWT-I was initiated utilizing the same parameters on all patients, this consisted of cycles of instillation of saline solution, which was removed through negative pressure after a short dwell period. We observed the effects on primary fascia closure rate, mortality, hospital and SICU length of stay and associated complications.ResultsOur patient group consisted of 20 (42%) males and 28 (58%) females. Average age was 48 years. Mortality in these patients was attributed to pulmonary embolism (n = 1), acute renal failure (n = 2) and cardiopulmonary arrest (n = 1). Average total hospital stay was 24 days, and stay in the SICU (n = 26) averaged 7.5 days.No acute complications related to the NPWT-I. All patients presenting with abdominal compartment syndrome resolved after initiation of the NPWT-I. A total of 46 patients (96%) patients achieved fascia closure after NPWT-I therapy after an average of 6 days. Four patients (8%) died during the course of treatment of causes unrelated to NPWT-I.ConclusionThis therapy showed added benefits when compared to traditional methods such as ̈Bogota bag̈, Wittmann patch, or NPWT traditional in the management of the open abdomen pertaining to severe abdominal sepsis.NPWT-I in patients with severe abdominal sepsis had promising results, since we obtained higher fascia closure rates, lower mortality and reduced hospital and ICU length of stay with no complications due to this therapeutic approach.     

Factors affecting postmusculoskeletal tumour surgery wound problem treatment with negative pressure wound therapy

The aim of the study is to investigate the risk factors identified in literature that have been associated with prolonged Negative Pressure Wound Therapy (NPWT). Our study included patients who developed local wound problems after bone or soft tissue sarcoma surgery with negative margin at our clinic between 2012 and 2018 and treated with NPWT. All patients were followed up of at least 6 months. Sex, albumin level, skin infiltration, type of wound problem, postoperative intensive care unit (ICU) requirement, and intraoperative blood loss were found to be influential factors on NPWT > 10 sessions. We conclude that treatment may be prolonged and the necessary precautions need to be taken in patients with an impaired preoperative nutritional condition, with intraoperative high amount of blood loss, and with long postoperative stays in the ICU as well as if the underlying cause for wound problem is an infection.     

Clinical application and efficacy of negative pressure wound therapy with instillation and dwell time (NPWTi‐d): A systematic review and meta‐analysis

This study evaluates the current clinical evidence of Negative Pressure Wound Therapy with Instillation and dwell time (NPWTi‐d) to establish its clinical application and efficacy. MEDLINE, EMBASE, and CENTRAL databases were searched from 1946 to July 2019 for studies reporting clinical outcomes on wounds treated with NPWTi‐d. The primary outcome was proportion of wounds with complete healing. The secondary outcomes were mean time for healing, NPWTi‐d settings, cost, length of stay, and adverse events. Thirteen articles were included with a total of 624 wounds in 542 patients involving wounds of various aetiology. The pooled proportion of wound that achieved complete healing was 93.65% (95%CI: 84.02‐99.04). Normal saline was the most commonly used instillation solution with the mean dwell time of 14.23 minutes (95%CI: 10.88‐17.59) and instillation cycle every 4.17 ± 2.32 hourly. The mean therapy duration was 10.69 days (95%CI: 10.46‐10.91) with daily cost of $194.80. The mean hospital stay was 18.1 days (95%CI: 17.20‐19.00). There were no severe adverse effects reported. NPWTi‐d is an adjuntive therapy to aid complete healing of the vast majority of wounds. However, the current data are limited by the lack of level 1 evidence.     

自体组织移植联合负压创面治疗技术在创伤性创面治疗中的应用

目的：探讨自体组织移植联合负压创面治疗技术在治疗创伤性创面中的临床分析。方法：选择2010年4月-2012年4月笔者所在医院收治的创伤性创面患者64例,所有患者早期均采取负压创面治疗技术治疗,根据创面情况选择皮瓣移植手术或者皮片移植手术。结果：64例患者创面分泌物进行细菌培养,培养阳性患者37例,阳性率为57.81%;64例患者采取皮瓣移植手术患者30例、采取皮片移植手术患者34例,皮瓣移植手术优良率为96.67%,皮片移植优良率为88.24%,两者比较差异不具有统计学意义（P＞0.05）。结论：自体组织移植联合负压创面治疗技术能够促进创伤性创面的愈合,提高自体组织移植的成活率,值得临床推广运用。     

Ten-year follow-up of a case of necrotizing fasciitis successfully treated with negative-pressure wound therapy,dermal regeneration template application,and split- thickness skin autograft

Introduction: Necrotizing fasciitis is a rapidly progressive and often fatal infection of the fasciae and subcutaneous tissues.

Patient and methods: In this case report, we present the treatment of a 63-year-old patient suffering from diabetes mellitus, who was admitted to the emergency unit for severe right gluteal pain, which had begun 24 hours before admission. Cutaneous symptoms, oliguria, metabolic acidosis, acute renal failure, severe hypotension, and tachycardia occurred, and the patient was admitted to Intensive Care a few hours after initial admission. The patient underwent a debridement of gluteal, abdominal, lower-thoracic, and upper thigh regions. Biopsy of fascia lata confirmed the suspected diagnosis of necrotizing fasciitis. Treatment included prompt surgical debridement, negative-pressure wound therapy, and dermal regeneration template application with fibrin glue, and subsequent split-thickness skin autografting.

Results: After 10 years, elasticity of the skin and limb mobility are comparable to that in non-injured areas, and the patient is pain free.

Conclusion: In our opinion, this combination should be a treatment of choice for large wounds in the patients with NF with multiple comorbidities.     

Use of negative pressure wound therapy on malignant wounds – a case report and review of literature

The presence of malignancy is considered a contraindication to the use of negative pressure wound therapy (NPWT) because of concerns that it may promote tumourigenesis and expedite metastasis. This notion is extrapolated from studies evaluating NPWT in normal tissues. Despite the absence of direct evidence, the use of this technology in malignant wounds is widely considered a contraindication. We present the case of a patient with treatment‐resistant metastatic colon cancer, who developed a chronic abdominal wound with positive margins. A staged reconstruction using NPWT was performed and wound closure allowed the patient to meet eligibility criteria and enrol in a clinical trial for treatment of his oncological disease. Skin closure remained intact until the patient expired 6 months after the wound closure. This case, as well as others in the literature, demonstrated that the use of NPWT should not be considered an absolute contraindication in malignancy. Individualised approaches taking into account the patient's clinical scenario, the available evidence, as well as the risks and benefits of this technology are recommended.     

Use of a novel silicone‐acrylic drape with negative pressure wound therapy in anatomically challenging wounds

Negative pressure wound therapy (NPWT) utilises a polyurethane drape with acrylic adhesive over foam dressings to create a seal. In anatomically challenging areas, ancillary products are frequently used. Additionally, health care providers are unable to reposition the drape once placed. A novel hybrid drape consisting of polyurethane film with acrylic adhesive and silicone perforated layer has been developed to allow for repositioning after initial placement and easy removal. This six‐patient case series evaluates the use of NPWT with hybrid drape over anatomically challenging wounds. Three males and three females were treated. Dressing changes occurred every 2 to 3 days. Drape application, repositioning, and ability to maintain a seal were evaluated. During application, the drape was repositioned 1 to 2 times without periwound skin irritation in 4/6 wounds. Prior to initial application, ancillary products were applied to help create a seal. However, by the second or third application, ancillary products were no longer used in 4/6 wounds. None of the dressing applications resulted in negative pressure seal leaks. In these patients, health care providers could reposition the hybrid drape after initial placement without periwound skin irritation and successfully create a negative pressure seal without ancillary products in anatomically challenging wound locations.     

Topical negative pressure wound therapy: a review of its role and guidelines for its use in the management of acute wounds

Over the past two decades, topical negative pressure (TNP) wound therapy has gained wide acceptance as a genuine strategy in the treatment algorithm for a wide variety of acute and chronic wounds. Although extensive experimental and clinical evidence exists to support its use and despite the recent emergence of randomised control trials, its role and indications have yet to be fully determined. This article provides a qualitative overview of the published literature appertaining to the use of TNP therapy in the management of acute wounds by an international panel of experts using standard methods of appraisal. Particular focus is applied to the use of TNP for the open abdomen, sternal wounds, lower limb trauma, burns and tissue coverage with grafts and dermal substitutes. We provide evidence-based recommendations for indications and techniques in TNP wound therapy and, where studies are insufficient, consensus on best practice.     

Clinical recommendations and practical guide for negative pressure wound therapy with instillation

Effective wound management involves a comprehensive assessment of the patient and the wound to determine an optimal wound treatment plan. It is critical to identify and address factors that may impair wound healing, prior to selecting the most appropriate therapy for each patient. Negative pressure wound therapy (NPWT) is a well‐established advanced therapy that has been successful in adjunctive management of acute and chronic wounds. In recent years, the introduction of topical wound solution delivery in combination with NPWT has provided further benefits to wound healing. A commercially available system now offers automated, volumetric control of instilled topical wound solutions with a dwell time in combination with NPWT (NPWTi‐d; V.A.C. VeraFlo? Therapy, KCI, an Acelity company, San Antonio, TX). This NPWTi‐d system differs from other instillation systems in that a timed, predetermined volume of topical wound solution is intermittently delivered (versus continuously fed) and allowed to dwell in the wound bed (without NPWT), for a user‐selected period of time before NPWT is resumed. This added accuracy and process simplification of solution delivery in tandem with NPWT have prompted use of NPWTi‐d as first‐line therapy in a wider subset of complex wounds. However, considerably more research is required to validate efficacy of NPWTi‐d in various wound types. The purpose of this review is to provide a relevant overview of wound healing, describe current literature supporting the adjunctive use of NPWTi‐d, propose a clinical approach for appropriate application of NPWTi‐d and conclude with case studies demonstrating successful use of NPWTi‐d. Based on this review, we conclude that either a large case series examining effects of NPWTi‐d on different wound types or possibly a large prospective registry evaluating NPWTi‐d with real‐world topical wound solutions versus immediate debridement and closure would be valuable to the medical community in evaluating the efficacy of this promising therapy.     

TIME伤口床准备联合封闭式负压引流用于慢性伤口护理

目的探讨基于TIME原则的伤口床准备联合封闭式负压引流治疗慢性伤口的效果。方法将80例患者随机分为观察组和对照组各40例。观察组采用TIME原则进行伤口床准备,并应用封闭式负压引流,对照组在TIME原则指导下采用传统清创联合无菌敷料换药方法进行伤口护理。比较两组干预前和干预后7d、14d、21d的伤口面积缩小率、深度缩小率、局部症状体征以及观察期内伤口愈合率及所有愈合伤口的愈合时间、伤口换药时数、伤口换药费用。结果观察组伤口面积、深度缩小率和局部症状体征改善显著优于对照组(均P0.01);观察组90d内伤口愈合率显著高于对照组,伤口愈合时间、护理时数和换药费用显著低于对照组(均P0.01)。结论基于TIME原则的伤口床准备联合封闭式负压引流能够显著促进慢性伤口愈合,减少护理工作量及患者经济负担。     

The impact of negative‐pressure wound therapy with instillation on wounds requiring operative debridement: Pilot randomised,controlled trial

Presence of bacteria in wounds can delay healing. Addition of a regularly instilled topical solution over the wound during negative‐pressure wound therapy (NPWT) may reduce bioburden levels compared with standard NPWT alone. We performed a prospective, randomised, multi‐centre, post‐market trial to compare effects of NPWT with instillation and dwell of polyhexamethylene biguanide solution vs NPWT without instillation therapy in wounds requiring operative debridement. Results showed a significantly greater mean decrease in total bacterial counts from time of initial surgical debridement to first dressing change in NPWT plus instillation (n = 69) subjects compared with standard NPWT (n = 63) subjects (?0.18 vs 0.6 log₁₀ CFU/g, respectively). There was no significant difference between the groups in the primary endpoint of required inpatient operating room debridements after initial debridement. Time to readiness for wound closure/coverage, proportion of wounds closed, and incidence of wound complications were similar. NPWT subjects had 3.1 times the risk of re‐hospitalisation compared with NPWT plus instillation subjects. This study provides a basis for exploring research options to understand the impact of NPWT with instillation on wound healing.     

Effects of negative pressure wound therapy on wound infection and healing in patients with open fracture wounds: A meta-analysis

A meta-analysis was conducted to comprehensively evaluate the impact of negative pressure wound therapy (NPWT) on wound infection and healing in patients with open fracture wounds. Computer searches were performed in EMBASE, Google Scholar, Cochrane Library, PubMed, Wanfang and China National Knowledge Infrastructure databases for randomized controlled trials (RCTs) on the application of NPWT in open fracture wounds, with the search period covering the databases inception to September 2023. Two researchers independently screened the literature, extracted data and conducted quality assessments. Stata 17.0 software was employed for data analysis. Overall, 17 RCTs involving 1814 patients with open fracture wounds were included. The analysis revealed that compared with other treatment methods, NPWT significantly shortened the wound healing time (standardized mean difference [SMD] = −2.86, 95% confidence intervals [CI]: −3.51 to −2.20, p < 0.001) and fracture healing time (SMD = −3.14, 95% CI: −4.49 to −1.79, p < 0.001) in patients with open fracture wounds. It also significantly reduced the incidence of wound infection (odds ratio [OR] = 0.36, 95% CI: 0.23–0.56, p < 0.001) and complications (OR = 0.29, 95% CI: 0.20–0.40, p < 0.001). This study indicates that in the treatment of open fracture wounds, NPWT, compared with conventional treatment methods, can accelerate the healing of wounds and fractures, effectively control infections and reduce the occurrence of complications, demonstrating high safety.