Negative Pressure Wound Therapy (NPWT)
A wound treatment method using controlled negative pressure that ensures fast and effective healing and transitions the patient to outpatient treatment.
-
Method advantages
Fast and effective wound closure, reduced need for frequent dressing changes, and the possibility of outpatient treatment. -
Principle of action
Creation of controlled negative pressure in the wound bed to stimulate healing and transition the patient to home care.
Advantages of Vacuum Therapy
Vacuum wound therapy is a wound treatment method which has significant advantages over the traditional methods of treatment. The method includes the establishment of controlled negative pressure in the wound bed and pressure maintenance at a preset level, which permits to close a wound defect quickly and effectively, and transfer the patient into outpatient treatment, when they continue to receive qualified medical care without the necessity to make frequent visits to the doctor.
The principle of vacuum wound therapy (NPWT) is to generate a negative pressure at a specific, preset level over the entire area of wound chamber or wound surface using an open porous polyurethane foam sponge inserted into the wound chamber. To prevent air absorption from the external environment, the wound and the filler, located inside or on the wound, are hermetically sealed with an adhesive film which is permeable for water vapor, transparent and bacteria protected. Then drainage is applied to a small hole made in the film surface and connected to a vacuum source using a tube (Fig. 1, Fig. 2).
NPWT's mode of action
The following effects on the wound chamber, resulting from the use of negative pressure applied uniformly to the entire wound surface, are considered as the main clinically significant advantages of NPWT. (2–10) 23, 25, 29–35
Wound effect
• Reduction of wound area due to the use of negative pressure applied to the polyurethane foam sponge, strapping of wound edges (wound retraction);
• Stimulation of granulation tissue formation in an optimally humid wound environment; in some situations, NPWT may stimulate granulation tissue formation even over bradytrophic tissue, such as tendons and bones.
• Continuation of effective mechanical wound cleaning (removal of small tissue residues by suction).
• Effective biochemical decrease in the concentration of liquid proteases that impede wound healing (such as elastase) in the first days.
• Reliable, continuous removal of wound exudate (and, therefore, a reduced number of dressing changes) in a closed system.
• Pressure-related reduction of interstitial edema with consistent improvement of microcirculation, blood stimulation and oxygenation.
Patient management
• Hygienic wound suturing — bacteria-protected dressing for wound sealing, protecting the wound from the penetration of any external bacteria and preventing the spread of the patient's inherent wound bacteria.
This is especially important in case of infection with problem bacteria, as in patients with wounds infected with methicillin-resistant Staphylococcus aureus (MRSA). Thus, it also reduces the risk of cross infections and resistance development in the hospital.
• A transparent dressing allows continuous clinical monitoring of the surrounding skin through the film used for wound suturing.
• Odorless hygienic dressing technique; constant leakage through the dressing onto the patient's clothes and bedding may be avoided, reducing the requirements to medical personnel.
• Reduction in the number of required dressing changes (dressing is changed every three days only), reducing any care needs, especially in patients with exudative wounds.
Patient comfort
• Simple and early patient mobilization.
• Visually attractive dressing method due to clean, exudate-free dressing conditions, even during mobilization.
Materials used in the article:
1. Apelqvist, J., Willy, C., Fagerdahl, A.M. et al. Negative Pressure Wound Therapy — overview, challenges and perspectives. J Wound Care 2017; 26: 3, Suppl 3, S1–S113.
2. Fleischmann, W., Becker, U., Bischoff, M., Hoekstra, H. Vacuum sealing: indications, technique and results. Eur J Orthop Surg Traumatol 1995; 5: 37–40. Medline doi:10.1007/BF02716212
3. Argenta, L.C., Morykwas, M.J. Vacuum-assisted closure: a new method for wound control and treatment: clinical experience. Ann Plast Surg 1997; 38: 6, 563–577.
4. Banwell, P.E., Téot, L. Topical negative pressure (TNP): the evolution of a novel wound therapy. J Wound Care 2003; 12: 1, 22–28.
5. Armstrong, D.G., Lavery, L.A., Abu-Rumman, P. et al. Outcomes of subatmospheric pressure dressing therapy on wounds of the diabetic foot. Ostomy Wound Manage 2002; 48: 4, 64–68.
6. Deva, A.K., Buckland, G.H., Fisher, E. et al. Topical negative pressure in wound management. Med J Aust 2000; 173: 3, 128–131.
7. Avery, C., Pereira, J., Moody, A., Whitworth, I. Clinical experience with the negative pressure wound dressing. Br J Oral Maxillofac Surg 2000; 38: 4, 343–345. Medline doi:10.1054/bjom.1999.0453
8. Banwell, P.E. Topical negative pressure therapy in wound care. J Wound Care 1999; 8: 2, 79–84.
9. Banwell, P., Holten, I., Martin, D.L. Negative pressure therapy: clinical applications and experience with 200 cases. Wound Repair Regen 1998; 6: 460.
10. Fleischmann, W., Lang, E., Russ, M. [Treatment of infection by vacuum sealing]. [Article in German] Unfallchirurg 1997; 100: 4, 301–304.
The principle of vacuum wound therapy (NPWT) is to generate a negative pressure at a specific, preset level over the entire area of wound chamber or wound surface using an open porous polyurethane foam sponge inserted into the wound chamber. To prevent air absorption from the external environment, the wound and the filler, located inside or on the wound, are hermetically sealed with an adhesive film which is permeable for water vapor, transparent and bacteria protected. Then drainage is applied to a small hole made in the film surface and connected to a vacuum source using a tube (Fig. 1, Fig. 2).
NPWT's mode of action
The following effects on the wound chamber, resulting from the use of negative pressure applied uniformly to the entire wound surface, are considered as the main clinically significant advantages of NPWT. (2–10) 23, 25, 29–35
Wound effect
• Reduction of wound area due to the use of negative pressure applied to the polyurethane foam sponge, strapping of wound edges (wound retraction);
• Stimulation of granulation tissue formation in an optimally humid wound environment; in some situations, NPWT may stimulate granulation tissue formation even over bradytrophic tissue, such as tendons and bones.
• Continuation of effective mechanical wound cleaning (removal of small tissue residues by suction).
• Effective biochemical decrease in the concentration of liquid proteases that impede wound healing (such as elastase) in the first days.
• Reliable, continuous removal of wound exudate (and, therefore, a reduced number of dressing changes) in a closed system.
• Pressure-related reduction of interstitial edema with consistent improvement of microcirculation, blood stimulation and oxygenation.
Patient management
• Hygienic wound suturing — bacteria-protected dressing for wound sealing, protecting the wound from the penetration of any external bacteria and preventing the spread of the patient's inherent wound bacteria.
This is especially important in case of infection with problem bacteria, as in patients with wounds infected with methicillin-resistant Staphylococcus aureus (MRSA). Thus, it also reduces the risk of cross infections and resistance development in the hospital.
• A transparent dressing allows continuous clinical monitoring of the surrounding skin through the film used for wound suturing.
• Odorless hygienic dressing technique; constant leakage through the dressing onto the patient's clothes and bedding may be avoided, reducing the requirements to medical personnel.
• Reduction in the number of required dressing changes (dressing is changed every three days only), reducing any care needs, especially in patients with exudative wounds.
Patient comfort
• Simple and early patient mobilization.
• Visually attractive dressing method due to clean, exudate-free dressing conditions, even during mobilization.
Materials used in the article:
1. Apelqvist, J., Willy, C., Fagerdahl, A.M. et al. Negative Pressure Wound Therapy — overview, challenges and perspectives. J Wound Care 2017; 26: 3, Suppl 3, S1–S113.
2. Fleischmann, W., Becker, U., Bischoff, M., Hoekstra, H. Vacuum sealing: indications, technique and results. Eur J Orthop Surg Traumatol 1995; 5: 37–40. Medline doi:10.1007/BF02716212
3. Argenta, L.C., Morykwas, M.J. Vacuum-assisted closure: a new method for wound control and treatment: clinical experience. Ann Plast Surg 1997; 38: 6, 563–577.
4. Banwell, P.E., Téot, L. Topical negative pressure (TNP): the evolution of a novel wound therapy. J Wound Care 2003; 12: 1, 22–28.
5. Armstrong, D.G., Lavery, L.A., Abu-Rumman, P. et al. Outcomes of subatmospheric pressure dressing therapy on wounds of the diabetic foot. Ostomy Wound Manage 2002; 48: 4, 64–68.
6. Deva, A.K., Buckland, G.H., Fisher, E. et al. Topical negative pressure in wound management. Med J Aust 2000; 173: 3, 128–131.
7. Avery, C., Pereira, J., Moody, A., Whitworth, I. Clinical experience with the negative pressure wound dressing. Br J Oral Maxillofac Surg 2000; 38: 4, 343–345. Medline doi:10.1054/bjom.1999.0453
8. Banwell, P.E. Topical negative pressure therapy in wound care. J Wound Care 1999; 8: 2, 79–84.
9. Banwell, P., Holten, I., Martin, D.L. Negative pressure therapy: clinical applications and experience with 200 cases. Wound Repair Regen 1998; 6: 460.
10. Fleischmann, W., Lang, E., Russ, M. [Treatment of infection by vacuum sealing]. [Article in German] Unfallchirurg 1997; 100: 4, 301–304.
Vacuum-Instillation Therapy (VIT)
VIT Medical presents advanced technologies for effective wound treatment.
-
Vacuum-Instillation Therapy (VIT)
A modernization of vacuum wound therapy that automatically delivers medicinal solution into the wound bed. -
Method advantages
Even solution distribution and the possibility of home treatment, reducing the need for frequent dressing changes.
Vacuum-instillation therapy (VIT)
Vacuum-instillation therapy (VIT) is a modernization of vacuum wound therapy technology which provides the possibility of automatic medical solution supply into the wound bed without removing a dressing. Therapeutic effect is achieved when the system operates in three distinct phases: Vacuum phase, Solution supply phase and Solution exposure phase. Due to this, the solution is evenly distributed and does not leave the wound chamber before a preset time.
Treatment — In instillation mode, the medicinal solution selected by the physician is delivered to the entire wound area.
Cleaning — As a result of the instillation mode, the wound is cleaned and irrigated automatically according to the set algorithm.
Removal — Infected material and breakdown products are evacuated after instillation.
Functional principles of vacuum-instillation therapy
This is a modification of traditional vacuum therapy, which provides the possibility to instill physiological saline solution, antiseptic or antibiotic into the wound chamber (2). Use of automatic operation algorithms permits to control the level and time of negative pressure maintenance, solution supply volume, solution exposure time, and also permits to use the therapy in a cyclic mode. VIT is successfully used in world practice for the treatment of acute wound infections (3, 4–10); however, some international studies suggest the application of vacuum-instillation therapy (VIT) to non-infected wounds, where VIT with physiological saline solution has some advantages in comparison with traditional vacuum wound therapy or other traditional treatment methods. (11, 12, 13)
Method of action
Instillation therapy is conducted against the background of traditional vacuum wound therapy: the required amount of medicinal solution is supplied into the polyurethane foam sponge through the additional port, then the solution is evenly distributed over the wound cavity and exposure of the solution is carried out for a preset period of time (during solution exposure the vacuum motor is turned off); after the exposure phase is completed, the vacuum phase is activated and the solution is evacuated. The cycling and the time of each phase are set individually by the specialist. To achieve a sufficient therapeutic effect, the instillation phase should be carried out several times a day. Solution supply time (depending on the solution volume, may vary from 10 to 280 seconds), solution exposure time (depending on the solution and wound type, for example, 20 minutes), and vacuum phase period (for example, 2–3 hours).
The first phase (instillation) lasts for 10–280 seconds; at this time the vacuum line is closed, and the instillation line is open and supplies the solution first to the sponge through the additional port, then the solution is evenly distributed over the entire wound surface. During instillation, due to the difference between atmospheric pressure and the pressure in the wound, the solution is evenly distributed. The wound surface fully contacts the medicinal solution. After the preset solution volume is achieved, the second phase begins.
The second phase (solution exposure)
After the preset solution volume in the wound chamber is achieved, the medicinal solution exerts its therapeutic effect. Both the vacuum and instillation lines are closed, preventing solution leakage from the system and allowing it to reach the entire wound area. The duration of this phase is based on the pharmacodynamics of the solution used and the specific characteristics of the wound. The phase duration usually constitutes 5–30 minutes.
The third phase (vacuum)
At the beginning of the third phase, the initial negative pressure is restored, and at the same time the solution is evacuated together with the wound exudate. The duration of the vacuum phase depends on the clinical picture, exudate viscosity and the specialist's opinion. It may take from 30 minutes to several hours.
Due to VIT hardware algorithms and the possibility of medicinal solution supply, the number of required dressings is significantly reduced, even in comparison with traditional vacuum wound therapy, because the instillation phase provides constant, systematic wound cleaning, which opens new possibilities in wound treatment.
For both the doctor and the patient, the number of long, durable and often painful dressing changes is significantly reduced. Thus, vacuum-instillation therapy (VIT) improves patient comfort, convenience and quality of life. In addition, the use of VIT significantly saves costs for the treatment of acute and chronic wounds. First of all, it is the automation of the treatment process, ensuring safety (prevention of re-infection), efficiency and comfort. The container for exudate collection also serves for the collection of the "used" medicinal solution.
Comparison of vacuum-instillation therapy and passive drainage
Vacuum-instillation therapy (VIT) should not be confused with irrigation-suction drainage (14), which creates a continuous directed liquid flow that naturally follows the shortest path along the pressure gradient between the inflow through the infusion line and the outflow through the drainage tube. The use of irrigation-suction drainage implies the creation of dead zones in the vicinity of these "irrigation routes". These areas are no longer washed even after several cycles and may thus be preserved as septic pockets. With VIT, the wound is completely filled with a polyurethane foam sponge, the system is closed and the method is non-flowing, so that the creation of "dead zones" is improbable.
Indications for vacuum-instillation therapy
Current experience of VIT application includes the following indications:
— Septic wounds: soft tissues after the initial surgical treatment (acute infections, especially postoperative infections, are considered the most favorable indications for VIT), osteitis, osteomyelitis (chronic soft tissue and bone infections after surgical removal of the septic focus)
— General surgery: abdominal sepsis, resistant bacterial wound infection after liver transplantation (15, 16)
— Thoracic surgery: para- and post-pneumonic pleural empyema, bronchopleural fistula with thoracic empyema, mediastinitis after cardiac surgery (however, this is off-label) (17–20)
— Severe periprosthetic infection in the result of breast reconstruction (21)
— Injury and orthopedics: complex fractures, acute complex wounds of the lower extremities, endoprosthesis infections, infection in the area of the implant bed (in many cases, asepsis was achieved even without removing the osteosynthesis material). (22–27) However, treatment of such wounds may be limited due to the risk of fluid retention.
— Necrotizing fasciitis and gas gangrene. (28–30)
— Chronic wounds, such as diabetic ulcers of the lower extremities. (31–37)
— Uncomplicated wounds, where instillation therapy may additionally improve the patency of the polyurethane foam sponge, which maintains tightness and increases the intervals between dressing changes. For aseptic wounds, Ringer's solution may be used for instillation to increase the formation of granulation tissue. (38–40)
— Painful wounds (postoperative wounds or infection-related pain may benefit from time to time from instillation of local anesthetics; it may also be an option when a painful dressing change is expected). (41)
Solutions for vacuum-instillation therapy
Usually, the course of vacuum-instillation therapy (VIT) constituted 7–14 days; however, one group of authors used VIT for up to 3 weeks. (42) The application of VIT continues with various instillation fluids:
• 0.9% physiological saline solution: the average duration of VIT is 12 days, 4 cycles per day, exposure 5 or 60 minutes. (12, 43–45)
• Polyhexanide: 0.02% or 0.04%, exposure time 20 minutes, for 4–8 days, 4–8 cycles per day. (22, 46–51)
• Octenidine-based irrigation solution: exposure time 3 minutes, 4–8 days, 2 cycles per day. (2, 52)
• Acetic acid solution: 1% solution, exposure time 20 minutes, for 4–8 days, 4–8 cycles per day. (48, 53)
• Super-oxidized water: repeated every 2–4 hours with an exposure time of 5–10 minutes. (31, 54)
• Dakin's solution: 10 minutes every hour, diluted to 12.5%, for 10 days. (54, 55)
• Potassium permanganate solution: 1:5000. (56)
• Antibiotic solution: such as doxycycline, colistin and rifampicin. (16, 57, 58, 59)
• Insulin. (60, 61)
VIT is increasingly used as adjunctive therapy for a wide range of acute and chronic wounds.
In particular, over the past ten years, VIT has played a role in the treatment of postoperative infected wounds. The use of instillation has permitted to enhance the possibilities of traditional vacuum wound therapy in difficult situations using antiseptic and antibiotic solutions. Nevertheless, the literature shows that the role of vacuum-instillation therapy continues to expand and may be used today also for the treatment of both acute and chronic infected wounds to support the wound healing process, mainly due to the supply of physiological saline solution into the wound chamber.
Despite the growing popularity, there are few publications on this technique. However, available studies show that VIT is an effective treatment protocol. It has been shown to help reduce healing time, ensure long-term functional and positive cosmetic results in patients with severe difficult clinical situations, and potentially help accelerate wound closure.
Review and analysis of the literature show that vacuum-instillation therapy in certain clinical situations is more useful than the traditional vacuum wound treatment method for the additional treatment of acute and chronically infected wounds requiring hospitalization. (39) In addition, there are clinical observations proving that VIT with physiological saline solutions is more effective for healing than simple vacuum wound therapy. As a future trend, it should be clarified from a scientific point of view and evaluated from the point of view of economic efficiency, whether all uninfected wounds should be treated using vacuum-instillation therapy with physiological saline solution. (62–64)
Materials used in the article:
1. Apelqvist, J., Willy, C., Fagerdahl, A.M. et al. Negative Pressure Wound Therapy — overview, challenges and perspectives. J Wound Care 2017; 26: 3, Suppl 3, S1–S113.
2. Matiasek, J., Djedovic, G., Mattesich, M. et al. The combined use of NPWT and instillation using an octenidine based wound rinsing solution: a case study. J Wound Care 2014; 23: 11, 590–596.
3. Fleischmann, W., Lang, E., Russ, M. [Treatment of infection by vacuum sealing]. [Article in German] Unfallchirurg 1997; 100: 4, 301–304.
4. Fleischmann, W., Suger, G., Kinzl, L. Treatment of bone and soft tissue defects in infected nonunion. Acta Orthop Belg 1992; 58 Suppl 1, 227–235.
5. Dunford, C.E. Treatment of a wound infection in a patient with mantle cell lymphoma. Br J Nurs 2001; 10: 16, 1058–1065.
6. Gerber-Haughton, R. et al. VAC-Therapie bei gasbildenden Anaerobiern. [The use of V.A.C. in gas producing anaerobic infections]. ZfW 2000; 5: 60–61.
7. Müller, G. [Vacuum dressing in septic wound treatment]. [Article in German] Langenbecks Arch Chir Suppl Kongressbd 1997; 114: 537–541.
8. Wongworawat, M.D., Schnall, S.B., Holtom, P.D. et al. Negative pressure dressings as an alternative technique for the treatment of infected wounds. Clin Orthop Relat Res 2003; 414: 414, 45–48. Medline doi:10.1097/01.blo.0000084400.53464.02.
9. Stang, H.P. [Fast and effective VAC-therapy in abdominal wall infections and Fournier gangrene] [In Dutch]. Eur Surg 2003; 35: supplement 191.
10. Zeininger, D. VAC-therapy of patients after streptococcus infections. J Wound Healing 2000; 13: 2, 48.
11. Gupta, S., Gabriel, A., Lantis, J., Teot, L. Clinical recommendations and practical guide for negative pressure wound therapy with instillation. Int Wound J 2016; 13: 2, 159–174. Medline doi:10.1111/iwj.12452.
12. Fluieraru, S., Bekara, F., Naud, M. et al. Sterile-water negative pressure instillation therapy for complex wounds and NPWT failures. J Wound Care 2013; 22: 6, 293–299.
13. Brinkert, D., Ali, M., Naud, M. et al. Negative pressure wound therapy with saline instillation: 131 patient case series. Int Wound J 2013; 10: s1 Suppl 1, 56–60.
14. Willenegger, H. Local treatment of infections in traumatology. The irrigation-suction drainage system. Indication, principle of function and the technique of irrigation-suction drainage. Aktuelle Probl Chir Orthop 1979; 12: 68–70.
15. Tao, Q., Ren, J., Ji, Z. et al. VAWCM-Instillation Improves Delayed Primary Fascial Closure of Open Septic Abdomen. Gastroenterol Res Pract 2014; 2014: 245182.
16. Dondossola, D., Cavenago, M., Piconi, S. et al. Negative Pressure Wound Treatment of Infections Caused By Extensively Drug-Resistant Gram-Negative Bacteria After Liver Transplantation: Two Case Reports. Transplant Proc 2015; 47: 7, 2145–2149.
17. Morodomi, Y., Takenoyama, M., Yamaguchi, M. et al. Application of continuous negative pressure irrigation and negative pressure fixation to treat a bronchopleural fistula with thoracic empyema. J Am Coll Surg 2014; 218: 5, e87–e90.
18. Karaca, S., Kalangos A. Vacuum-assisted closure (VAC)-Instill® with continuous irrigation for the treatment of Mycoplasma hominis mediastinitis. Int Wound J 2015; 12: 5, 595–597.
19. Sziklavari, Z., Ried, M., Neu, R. et al. Mini-open vacuum-assisted closure therapy with instillation for debilitated and septic patients with pleural empyema. Eur J Cardiothorac Surg 2015; 48: 2, e9–e16.
20. Sziklavari, Z., Ried, M., Hofmann, H.S. [Intrathoracic Vacuum-Assisted Closure in the Treatment of Pleural Empyema and Lung Abscess]. [Article in German] Zentralbl Chir 2015; 140: 3, 321–327.
21. Meybodi, F., Sedaghat, N., French, J. et al. Implant salvage in breast reconstruction with severe peri-prosthetic infection. ANZ J Surg 2015 doi:10.1111/ans.13379. [Epub ahead of print].
22. Lehner, B., Fleischmann, W., Becker, R., Jukema, G.N. First experiences with negative pressure wound therapy and instillation in the treatment of infected orthopaedic implants: a clinical observational study. Int Orthop 2011; 35: 9, 1415–1420.
23. Borrero Esteban, M.P., Begines Begines, R., Rodríguez Llamas, S., Díaz Campos, T. [Managing complications in severe traumatic injury with VAC therapy with instillation]. [Article in Spanish] Rev Enferm 2013; 36: 11, 42–47.
24. Norris, R., Chapman, A.W., Krikler, S., Krkovic, M. A novel technique for the treatment of infected metalwork in orthopaedic patients using skin closure over irrigated negative pressure wound therapy dressings. Ann R Coll Surg Engl 2013; 95: 2, 118–124.
25. Bollero, D., Degano, K., Gangemi, E.N. et al. Long-term follow-up of negative pressure wound therapy with instillation: a limb salvage procedure? Int Wound J 2016; 13: 5, 768–773.
26. Sharr, P.J., Buckley, R.E. Current concepts review: open tibial fractures. Acta Chir Orthop Traumatol Cech 2014; 81: 2, 95–107.
27. Temiz, G., Sirinoglu, H., Güvercin, E., Yesiloglu, N. et al. A useful option to obtain maximal foreign body removal and better prognosis in high pressure injection injuries: Negative pressure wound therapy with instillation. J Plast Reconstr Aesthet Surg 2016; 69: 4, 570–572.
28. Crew, J.R., Varilla, R., Allandale Rocas Iii, T. et al. Treatment of acute necrotizing fasciitis using negative pressure wound therapy and adjunctive neutrophase irrigation under the foam. Wounds 2013; 25: 10, 272–277.
29. Frankel, J.K., Rezaee, R.P., Harvey, D.J. et al. Use of negative pressure wound therapy with instillation in the management of cervical necrotizing fasciitis. Head Neck 2015; 37: 11, E157–E160.
30. Hu, S.X., Gold, D.M. Maximising vacuum drainage prior to wound closure. Ann R Coll Surg Engl 2015; 97: 1, 82.
31. Dalla Paola, L. Diabetic foot wounds: the value of negative pressure wound therapy with instillation. Int Wound J 2013; 10: s1 Suppl 1, 25–31.
32. Matiasek, J., Djedovic, G., Unger, L. et al. Outcomes for split-thickness skin transplantation in high-risk patients using octenidine. J Wound Care 2015; 24: 6 Suppl, S8, S10–S12.
33. Dale, A.P., Saeed, K. Novel negative pressure wound therapy with instillation and the management of diabetic foot infections. Curr Opin Infect Dis 2015; 2: 2, 151–157.
34. Hasan, M.Y., Teo, R., Nather, A. Negative-pressure wound therapy for management of diabetic foot wounds: a review of the mechanism of action, clinical applications, and recent developments. Diabet Foot Ankle 2015; 6: 27618.
35. Tian, G., Guo, Y., Zhang, L. Non-invasive treatment for severe complex pressure ulcers complicated by necrotizing fasciitis: a case report. J Med Case Reports 2015; 9: 1, 220.
36. Wen, H., Li, Z., Zhang, M. et al. [Effects of vacuum sealing drainage combined with irrigation of oxygen loaded fluid on wounds of patients with chronic venous leg ulcers]. [Article in Chinese] Zhonghua Shao Shang Za Zhi 2015; 31: 2, 86–92.
37. Yang, C.K., Alcantara, S., Goss, S., Lantis, J.C. 2nd. Cost analysis of negative-pressure wound therapy with instillation for wound bed preparation preceding split-thickness skin grafts for massive (>100 cm²) chronic venous leg ulcers. J Vasc Surg 2015; 61: 4, 995–999.
38. Zhang, M., Li, Z., Wang, J. et al. [Effects of vacuum sealing drainage combined with irrigation of oxygen loaded fluid on chronic wounds in diabetic patients]. [Article in Chinese] Zhonghua Shao Shang Za Zhi 2014; 30: 2, 116–123.
39. Wen, H., Li, Z., Zhang, M. et al. [Effects of vacuum sealing drainage combined with irrigation of oxygen loaded fluid on wounds of patients with chronic venous leg ulcers]. [Article in Chinese] Zhonghua Shao Shang Za Zhi 2015; 31: 2, 86–92.
40. Kim, Y.H., Hwang, K.T., Kim, J.T., Kim, S.W. What is the ideal interval between dressing changes during negative pressure wound therapy for open traumatic fractures? J Wound Care 2015; 24: 11, 536–542.
41. Wolvos, T. Wound instillation — the next step in negative pressure wound therapy. Lessons learned from initial experiences. Ostomy Wound Manage 2004; 50: 11, 56–66.
42. Morinaga, K., Kiyokawa, K., Rikimaru, H. et al. Results of intra-wound continuous negative pressure irrigation treatment for mediastinitis. J Plast Surg Hand Surg 2013; 47: 4, 297–302.
43. Derrick, K.L., Lessing, M.C. Genomic and proteomic evaluation of tissue quality of porcine wounds treated with negative pressure wound therapy in continuous, noncontinuous, and instillation modes. Eplasty 2014; 14: e43.
44. Allen, D., LaBarbera, L.A., Bondre, I.L. et al. Comparison of tissue damage, cleansing and cross-contamination potential during wound cleansing via two methods: lavage and negative pressure wound therapy with instillation. Int Wound J 2014; 11: 2, 198–209.
45. Kim, P.J., Attinger, C.E., Oliver, N. et al. Comparison of Outcomes for Normal Saline and an Antiseptic Solution for Negative-Pressure Wound Therapy with Instillation. Plast Reconstr Surg 2015; 136: 5, 657e–664e.
46. Timmers, M.S., Graafland, N., Bernards, A.T. et al. Negative pressure wound treatment with polyvinyl alcohol foam and polyhexanide antiseptic solution instillation in posttraumatic osteomyelitis. Wound Repair Regen 2009; 17: 2, 278–286.
47. Back, D.A., Scheuermann-Poley, C., Willy, C. Recommendations on negative pressure wound therapy with instillation and antimicrobial solutions — when, where and how to use: what does the evidence show? Int Wound J 2013; 10: s1 Suppl 1, 32–42.
48. Davis, K., Bills, J., Barker, J. et al. Simultaneous irrigation and negative pressure wound therapy enhances wound healing and reduces wound bioburden in a porcine model. Wound Repair Regen 2013; 21: 6, 869–875.
49. Nolff, M.C., Layer, A., Meyer-Lindenberg, A. Negative pressure wound therapy with instillation for body wall reconstruction using an artificial mesh in a Dachshund. Aust Vet J 2015; 93: 10, 367–372.
50. Gabriel, A., Kahn, K.M. New advances in instillation therapy in wounds at risk for compromised healing. Surg Technol Int 2014; 24: 75–81.
51. Kim, P.J., Attinger, C.E., Oliver, N. et al. Comparison of Outcomes for Normal Saline and an Antiseptic Solution for Negative-Pressure Wound Therapy with Instillation. Plast Reconstr Surg 2015; 136: 5, 657e–664e.
52. Vowden, K., Pilcher, M. Early experience with instillation negative pressure wound therapy. The EWMA 2015 conference May 13, 2015; London: EWMA; 2015.
53. Jeong, H.S., Lee, B.H., Lee, H,K. et al. Negative pressure wound therapy of chronically infected wounds using 1% acetic Acid irrigation. Arch Plast Surg 2015; 42: 1, 59–67.
54. Wolvos, T. The use of negative pressure wound therapy with an automated, volumetric fluid administration: an advancement in wound care. Wounds 2013; 25: 3, 75–83.
55. Raad, W., Lantis, J.C. 2nd., Tyrie, L. et al. Vacuum-assisted closure instill as a method of sterilizing massive venous stasis wounds prior to split thickness skin graft placement. Int Wound J 2010; 7: 2, 81–85.
56. Hu, N., Wu, X.H., Liu, R. et al. Novel application of vacuum sealing drainage with continuous irrigation of potassium permanganate for managing infective wounds of gas gangrene. J Huazhong Univ Sci Technolog Med Sci 2015; 35: 4, 563–568.
57. Scimeca, C.L., Bharara, M., Fisher, T.K. et al. Novel use of doxycycline in continuous-instillation negative pressure wound therapy as wound chemotherapy. Foot Ankle Spec 2010; 3: 4, 190–193.
58. Wolvos, T. The evolution of negative pressure wound therapy: negative pressure wound therapy with instillation. J Wound Care 2015; 24: Sup4b Suppl, 15–20.
59. Fleischmann, W., Russ, M., Westhauser, A., Stampehl, M. [Vacuum sealing as carrier system for controlled local drug administration in wound infection]. [Article in German] Unfallchirurg 1998; 101: 8, 649–654.
60. Scimeca, C.L., Bharara, M., Fisher, T.K. et al. Novel use of insulin in continuous-instillation negative pressure wound therapy as wound chemotherapy. J Diabetes Sci Tech 2010; 4: 4, 820–824.
61. Sun, Y., Fan, W., Yang, W. et al. [Effects of intermittent irrigation of insulin solution combined with continuous drainage of vacuum sealing drainage in chronic diabetic lower limb ulcers]. [Article in Chinese] Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi 2015; 29: 7, 812–817.
62. Rycerz, A.M., Allen, D, Lessing, M.C. Science supporting negative pressure wound therapy with instillation. Int Wound J 2013; 10: s1 Suppl 1, 20–24.
63. Kim, P.J., Attinger, C.E., Olawoye, O. et al. Negative pressure wound therapy with instillation: review of evidence and recommendations. Wounds 2015; 27: 12, S2–S19.
64. Lessing, M.C., James, R.B., Ingram, S.C. Comparison of the effects of different negative pressure wound therapy modes — continuous, noncontinuous, and with instillation — on porcine excisional wounds. Eplasty 2013; 13: e51.
Treatment — In instillation mode, the medicinal solution selected by the physician is delivered to the entire wound area.
Cleaning — As a result of the instillation mode, the wound is cleaned and irrigated automatically according to the set algorithm.
Removal — Infected material and breakdown products are evacuated after instillation.
Functional principles of vacuum-instillation therapy
This is a modification of traditional vacuum therapy, which provides the possibility to instill physiological saline solution, antiseptic or antibiotic into the wound chamber (2). Use of automatic operation algorithms permits to control the level and time of negative pressure maintenance, solution supply volume, solution exposure time, and also permits to use the therapy in a cyclic mode. VIT is successfully used in world practice for the treatment of acute wound infections (3, 4–10); however, some international studies suggest the application of vacuum-instillation therapy (VIT) to non-infected wounds, where VIT with physiological saline solution has some advantages in comparison with traditional vacuum wound therapy or other traditional treatment methods. (11, 12, 13)
Method of action
Instillation therapy is conducted against the background of traditional vacuum wound therapy: the required amount of medicinal solution is supplied into the polyurethane foam sponge through the additional port, then the solution is evenly distributed over the wound cavity and exposure of the solution is carried out for a preset period of time (during solution exposure the vacuum motor is turned off); after the exposure phase is completed, the vacuum phase is activated and the solution is evacuated. The cycling and the time of each phase are set individually by the specialist. To achieve a sufficient therapeutic effect, the instillation phase should be carried out several times a day. Solution supply time (depending on the solution volume, may vary from 10 to 280 seconds), solution exposure time (depending on the solution and wound type, for example, 20 minutes), and vacuum phase period (for example, 2–3 hours).
The first phase (instillation) lasts for 10–280 seconds; at this time the vacuum line is closed, and the instillation line is open and supplies the solution first to the sponge through the additional port, then the solution is evenly distributed over the entire wound surface. During instillation, due to the difference between atmospheric pressure and the pressure in the wound, the solution is evenly distributed. The wound surface fully contacts the medicinal solution. After the preset solution volume is achieved, the second phase begins.
The second phase (solution exposure)
After the preset solution volume in the wound chamber is achieved, the medicinal solution exerts its therapeutic effect. Both the vacuum and instillation lines are closed, preventing solution leakage from the system and allowing it to reach the entire wound area. The duration of this phase is based on the pharmacodynamics of the solution used and the specific characteristics of the wound. The phase duration usually constitutes 5–30 minutes.
The third phase (vacuum)
At the beginning of the third phase, the initial negative pressure is restored, and at the same time the solution is evacuated together with the wound exudate. The duration of the vacuum phase depends on the clinical picture, exudate viscosity and the specialist's opinion. It may take from 30 minutes to several hours.
Due to VIT hardware algorithms and the possibility of medicinal solution supply, the number of required dressings is significantly reduced, even in comparison with traditional vacuum wound therapy, because the instillation phase provides constant, systematic wound cleaning, which opens new possibilities in wound treatment.
For both the doctor and the patient, the number of long, durable and often painful dressing changes is significantly reduced. Thus, vacuum-instillation therapy (VIT) improves patient comfort, convenience and quality of life. In addition, the use of VIT significantly saves costs for the treatment of acute and chronic wounds. First of all, it is the automation of the treatment process, ensuring safety (prevention of re-infection), efficiency and comfort. The container for exudate collection also serves for the collection of the "used" medicinal solution.
Comparison of vacuum-instillation therapy and passive drainage
Vacuum-instillation therapy (VIT) should not be confused with irrigation-suction drainage (14), which creates a continuous directed liquid flow that naturally follows the shortest path along the pressure gradient between the inflow through the infusion line and the outflow through the drainage tube. The use of irrigation-suction drainage implies the creation of dead zones in the vicinity of these "irrigation routes". These areas are no longer washed even after several cycles and may thus be preserved as septic pockets. With VIT, the wound is completely filled with a polyurethane foam sponge, the system is closed and the method is non-flowing, so that the creation of "dead zones" is improbable.
Indications for vacuum-instillation therapy
Current experience of VIT application includes the following indications:
— Septic wounds: soft tissues after the initial surgical treatment (acute infections, especially postoperative infections, are considered the most favorable indications for VIT), osteitis, osteomyelitis (chronic soft tissue and bone infections after surgical removal of the septic focus)
— General surgery: abdominal sepsis, resistant bacterial wound infection after liver transplantation (15, 16)
— Thoracic surgery: para- and post-pneumonic pleural empyema, bronchopleural fistula with thoracic empyema, mediastinitis after cardiac surgery (however, this is off-label) (17–20)
— Severe periprosthetic infection in the result of breast reconstruction (21)
— Injury and orthopedics: complex fractures, acute complex wounds of the lower extremities, endoprosthesis infections, infection in the area of the implant bed (in many cases, asepsis was achieved even without removing the osteosynthesis material). (22–27) However, treatment of such wounds may be limited due to the risk of fluid retention.
— Necrotizing fasciitis and gas gangrene. (28–30)
— Chronic wounds, such as diabetic ulcers of the lower extremities. (31–37)
— Uncomplicated wounds, where instillation therapy may additionally improve the patency of the polyurethane foam sponge, which maintains tightness and increases the intervals between dressing changes. For aseptic wounds, Ringer's solution may be used for instillation to increase the formation of granulation tissue. (38–40)
— Painful wounds (postoperative wounds or infection-related pain may benefit from time to time from instillation of local anesthetics; it may also be an option when a painful dressing change is expected). (41)
Solutions for vacuum-instillation therapy
Usually, the course of vacuum-instillation therapy (VIT) constituted 7–14 days; however, one group of authors used VIT for up to 3 weeks. (42) The application of VIT continues with various instillation fluids:
• 0.9% physiological saline solution: the average duration of VIT is 12 days, 4 cycles per day, exposure 5 or 60 minutes. (12, 43–45)
• Polyhexanide: 0.02% or 0.04%, exposure time 20 minutes, for 4–8 days, 4–8 cycles per day. (22, 46–51)
• Octenidine-based irrigation solution: exposure time 3 minutes, 4–8 days, 2 cycles per day. (2, 52)
• Acetic acid solution: 1% solution, exposure time 20 minutes, for 4–8 days, 4–8 cycles per day. (48, 53)
• Super-oxidized water: repeated every 2–4 hours with an exposure time of 5–10 minutes. (31, 54)
• Dakin's solution: 10 minutes every hour, diluted to 12.5%, for 10 days. (54, 55)
• Potassium permanganate solution: 1:5000. (56)
• Antibiotic solution: such as doxycycline, colistin and rifampicin. (16, 57, 58, 59)
• Insulin. (60, 61)
VIT is increasingly used as adjunctive therapy for a wide range of acute and chronic wounds.
In particular, over the past ten years, VIT has played a role in the treatment of postoperative infected wounds. The use of instillation has permitted to enhance the possibilities of traditional vacuum wound therapy in difficult situations using antiseptic and antibiotic solutions. Nevertheless, the literature shows that the role of vacuum-instillation therapy continues to expand and may be used today also for the treatment of both acute and chronic infected wounds to support the wound healing process, mainly due to the supply of physiological saline solution into the wound chamber.
Despite the growing popularity, there are few publications on this technique. However, available studies show that VIT is an effective treatment protocol. It has been shown to help reduce healing time, ensure long-term functional and positive cosmetic results in patients with severe difficult clinical situations, and potentially help accelerate wound closure.
Review and analysis of the literature show that vacuum-instillation therapy in certain clinical situations is more useful than the traditional vacuum wound treatment method for the additional treatment of acute and chronically infected wounds requiring hospitalization. (39) In addition, there are clinical observations proving that VIT with physiological saline solutions is more effective for healing than simple vacuum wound therapy. As a future trend, it should be clarified from a scientific point of view and evaluated from the point of view of economic efficiency, whether all uninfected wounds should be treated using vacuum-instillation therapy with physiological saline solution. (62–64)
Materials used in the article:
1. Apelqvist, J., Willy, C., Fagerdahl, A.M. et al. Negative Pressure Wound Therapy — overview, challenges and perspectives. J Wound Care 2017; 26: 3, Suppl 3, S1–S113.
2. Matiasek, J., Djedovic, G., Mattesich, M. et al. The combined use of NPWT and instillation using an octenidine based wound rinsing solution: a case study. J Wound Care 2014; 23: 11, 590–596.
3. Fleischmann, W., Lang, E., Russ, M. [Treatment of infection by vacuum sealing]. [Article in German] Unfallchirurg 1997; 100: 4, 301–304.
4. Fleischmann, W., Suger, G., Kinzl, L. Treatment of bone and soft tissue defects in infected nonunion. Acta Orthop Belg 1992; 58 Suppl 1, 227–235.
5. Dunford, C.E. Treatment of a wound infection in a patient with mantle cell lymphoma. Br J Nurs 2001; 10: 16, 1058–1065.
6. Gerber-Haughton, R. et al. VAC-Therapie bei gasbildenden Anaerobiern. [The use of V.A.C. in gas producing anaerobic infections]. ZfW 2000; 5: 60–61.
7. Müller, G. [Vacuum dressing in septic wound treatment]. [Article in German] Langenbecks Arch Chir Suppl Kongressbd 1997; 114: 537–541.
8. Wongworawat, M.D., Schnall, S.B., Holtom, P.D. et al. Negative pressure dressings as an alternative technique for the treatment of infected wounds. Clin Orthop Relat Res 2003; 414: 414, 45–48. Medline doi:10.1097/01.blo.0000084400.53464.02.
9. Stang, H.P. [Fast and effective VAC-therapy in abdominal wall infections and Fournier gangrene] [In Dutch]. Eur Surg 2003; 35: supplement 191.
10. Zeininger, D. VAC-therapy of patients after streptococcus infections. J Wound Healing 2000; 13: 2, 48.
11. Gupta, S., Gabriel, A., Lantis, J., Teot, L. Clinical recommendations and practical guide for negative pressure wound therapy with instillation. Int Wound J 2016; 13: 2, 159–174. Medline doi:10.1111/iwj.12452.
12. Fluieraru, S., Bekara, F., Naud, M. et al. Sterile-water negative pressure instillation therapy for complex wounds and NPWT failures. J Wound Care 2013; 22: 6, 293–299.
13. Brinkert, D., Ali, M., Naud, M. et al. Negative pressure wound therapy with saline instillation: 131 patient case series. Int Wound J 2013; 10: s1 Suppl 1, 56–60.
14. Willenegger, H. Local treatment of infections in traumatology. The irrigation-suction drainage system. Indication, principle of function and the technique of irrigation-suction drainage. Aktuelle Probl Chir Orthop 1979; 12: 68–70.
15. Tao, Q., Ren, J., Ji, Z. et al. VAWCM-Instillation Improves Delayed Primary Fascial Closure of Open Septic Abdomen. Gastroenterol Res Pract 2014; 2014: 245182.
16. Dondossola, D., Cavenago, M., Piconi, S. et al. Negative Pressure Wound Treatment of Infections Caused By Extensively Drug-Resistant Gram-Negative Bacteria After Liver Transplantation: Two Case Reports. Transplant Proc 2015; 47: 7, 2145–2149.
17. Morodomi, Y., Takenoyama, M., Yamaguchi, M. et al. Application of continuous negative pressure irrigation and negative pressure fixation to treat a bronchopleural fistula with thoracic empyema. J Am Coll Surg 2014; 218: 5, e87–e90.
18. Karaca, S., Kalangos A. Vacuum-assisted closure (VAC)-Instill® with continuous irrigation for the treatment of Mycoplasma hominis mediastinitis. Int Wound J 2015; 12: 5, 595–597.
19. Sziklavari, Z., Ried, M., Neu, R. et al. Mini-open vacuum-assisted closure therapy with instillation for debilitated and septic patients with pleural empyema. Eur J Cardiothorac Surg 2015; 48: 2, e9–e16.
20. Sziklavari, Z., Ried, M., Hofmann, H.S. [Intrathoracic Vacuum-Assisted Closure in the Treatment of Pleural Empyema and Lung Abscess]. [Article in German] Zentralbl Chir 2015; 140: 3, 321–327.
21. Meybodi, F., Sedaghat, N., French, J. et al. Implant salvage in breast reconstruction with severe peri-prosthetic infection. ANZ J Surg 2015 doi:10.1111/ans.13379. [Epub ahead of print].
22. Lehner, B., Fleischmann, W., Becker, R., Jukema, G.N. First experiences with negative pressure wound therapy and instillation in the treatment of infected orthopaedic implants: a clinical observational study. Int Orthop 2011; 35: 9, 1415–1420.
23. Borrero Esteban, M.P., Begines Begines, R., Rodríguez Llamas, S., Díaz Campos, T. [Managing complications in severe traumatic injury with VAC therapy with instillation]. [Article in Spanish] Rev Enferm 2013; 36: 11, 42–47.
24. Norris, R., Chapman, A.W., Krikler, S., Krkovic, M. A novel technique for the treatment of infected metalwork in orthopaedic patients using skin closure over irrigated negative pressure wound therapy dressings. Ann R Coll Surg Engl 2013; 95: 2, 118–124.
25. Bollero, D., Degano, K., Gangemi, E.N. et al. Long-term follow-up of negative pressure wound therapy with instillation: a limb salvage procedure? Int Wound J 2016; 13: 5, 768–773.
26. Sharr, P.J., Buckley, R.E. Current concepts review: open tibial fractures. Acta Chir Orthop Traumatol Cech 2014; 81: 2, 95–107.
27. Temiz, G., Sirinoglu, H., Güvercin, E., Yesiloglu, N. et al. A useful option to obtain maximal foreign body removal and better prognosis in high pressure injection injuries: Negative pressure wound therapy with instillation. J Plast Reconstr Aesthet Surg 2016; 69: 4, 570–572.
28. Crew, J.R., Varilla, R., Allandale Rocas Iii, T. et al. Treatment of acute necrotizing fasciitis using negative pressure wound therapy and adjunctive neutrophase irrigation under the foam. Wounds 2013; 25: 10, 272–277.
29. Frankel, J.K., Rezaee, R.P., Harvey, D.J. et al. Use of negative pressure wound therapy with instillation in the management of cervical necrotizing fasciitis. Head Neck 2015; 37: 11, E157–E160.
30. Hu, S.X., Gold, D.M. Maximising vacuum drainage prior to wound closure. Ann R Coll Surg Engl 2015; 97: 1, 82.
31. Dalla Paola, L. Diabetic foot wounds: the value of negative pressure wound therapy with instillation. Int Wound J 2013; 10: s1 Suppl 1, 25–31.
32. Matiasek, J., Djedovic, G., Unger, L. et al. Outcomes for split-thickness skin transplantation in high-risk patients using octenidine. J Wound Care 2015; 24: 6 Suppl, S8, S10–S12.
33. Dale, A.P., Saeed, K. Novel negative pressure wound therapy with instillation and the management of diabetic foot infections. Curr Opin Infect Dis 2015; 2: 2, 151–157.
34. Hasan, M.Y., Teo, R., Nather, A. Negative-pressure wound therapy for management of diabetic foot wounds: a review of the mechanism of action, clinical applications, and recent developments. Diabet Foot Ankle 2015; 6: 27618.
35. Tian, G., Guo, Y., Zhang, L. Non-invasive treatment for severe complex pressure ulcers complicated by necrotizing fasciitis: a case report. J Med Case Reports 2015; 9: 1, 220.
36. Wen, H., Li, Z., Zhang, M. et al. [Effects of vacuum sealing drainage combined with irrigation of oxygen loaded fluid on wounds of patients with chronic venous leg ulcers]. [Article in Chinese] Zhonghua Shao Shang Za Zhi 2015; 31: 2, 86–92.
37. Yang, C.K., Alcantara, S., Goss, S., Lantis, J.C. 2nd. Cost analysis of negative-pressure wound therapy with instillation for wound bed preparation preceding split-thickness skin grafts for massive (>100 cm²) chronic venous leg ulcers. J Vasc Surg 2015; 61: 4, 995–999.
38. Zhang, M., Li, Z., Wang, J. et al. [Effects of vacuum sealing drainage combined with irrigation of oxygen loaded fluid on chronic wounds in diabetic patients]. [Article in Chinese] Zhonghua Shao Shang Za Zhi 2014; 30: 2, 116–123.
39. Wen, H., Li, Z., Zhang, M. et al. [Effects of vacuum sealing drainage combined with irrigation of oxygen loaded fluid on wounds of patients with chronic venous leg ulcers]. [Article in Chinese] Zhonghua Shao Shang Za Zhi 2015; 31: 2, 86–92.
40. Kim, Y.H., Hwang, K.T., Kim, J.T., Kim, S.W. What is the ideal interval between dressing changes during negative pressure wound therapy for open traumatic fractures? J Wound Care 2015; 24: 11, 536–542.
41. Wolvos, T. Wound instillation — the next step in negative pressure wound therapy. Lessons learned from initial experiences. Ostomy Wound Manage 2004; 50: 11, 56–66.
42. Morinaga, K., Kiyokawa, K., Rikimaru, H. et al. Results of intra-wound continuous negative pressure irrigation treatment for mediastinitis. J Plast Surg Hand Surg 2013; 47: 4, 297–302.
43. Derrick, K.L., Lessing, M.C. Genomic and proteomic evaluation of tissue quality of porcine wounds treated with negative pressure wound therapy in continuous, noncontinuous, and instillation modes. Eplasty 2014; 14: e43.
44. Allen, D., LaBarbera, L.A., Bondre, I.L. et al. Comparison of tissue damage, cleansing and cross-contamination potential during wound cleansing via two methods: lavage and negative pressure wound therapy with instillation. Int Wound J 2014; 11: 2, 198–209.
45. Kim, P.J., Attinger, C.E., Oliver, N. et al. Comparison of Outcomes for Normal Saline and an Antiseptic Solution for Negative-Pressure Wound Therapy with Instillation. Plast Reconstr Surg 2015; 136: 5, 657e–664e.
46. Timmers, M.S., Graafland, N., Bernards, A.T. et al. Negative pressure wound treatment with polyvinyl alcohol foam and polyhexanide antiseptic solution instillation in posttraumatic osteomyelitis. Wound Repair Regen 2009; 17: 2, 278–286.
47. Back, D.A., Scheuermann-Poley, C., Willy, C. Recommendations on negative pressure wound therapy with instillation and antimicrobial solutions — when, where and how to use: what does the evidence show? Int Wound J 2013; 10: s1 Suppl 1, 32–42.
48. Davis, K., Bills, J., Barker, J. et al. Simultaneous irrigation and negative pressure wound therapy enhances wound healing and reduces wound bioburden in a porcine model. Wound Repair Regen 2013; 21: 6, 869–875.
49. Nolff, M.C., Layer, A., Meyer-Lindenberg, A. Negative pressure wound therapy with instillation for body wall reconstruction using an artificial mesh in a Dachshund. Aust Vet J 2015; 93: 10, 367–372.
50. Gabriel, A., Kahn, K.M. New advances in instillation therapy in wounds at risk for compromised healing. Surg Technol Int 2014; 24: 75–81.
51. Kim, P.J., Attinger, C.E., Oliver, N. et al. Comparison of Outcomes for Normal Saline and an Antiseptic Solution for Negative-Pressure Wound Therapy with Instillation. Plast Reconstr Surg 2015; 136: 5, 657e–664e.
52. Vowden, K., Pilcher, M. Early experience with instillation negative pressure wound therapy. The EWMA 2015 conference May 13, 2015; London: EWMA; 2015.
53. Jeong, H.S., Lee, B.H., Lee, H,K. et al. Negative pressure wound therapy of chronically infected wounds using 1% acetic Acid irrigation. Arch Plast Surg 2015; 42: 1, 59–67.
54. Wolvos, T. The use of negative pressure wound therapy with an automated, volumetric fluid administration: an advancement in wound care. Wounds 2013; 25: 3, 75–83.
55. Raad, W., Lantis, J.C. 2nd., Tyrie, L. et al. Vacuum-assisted closure instill as a method of sterilizing massive venous stasis wounds prior to split thickness skin graft placement. Int Wound J 2010; 7: 2, 81–85.
56. Hu, N., Wu, X.H., Liu, R. et al. Novel application of vacuum sealing drainage with continuous irrigation of potassium permanganate for managing infective wounds of gas gangrene. J Huazhong Univ Sci Technolog Med Sci 2015; 35: 4, 563–568.
57. Scimeca, C.L., Bharara, M., Fisher, T.K. et al. Novel use of doxycycline in continuous-instillation negative pressure wound therapy as wound chemotherapy. Foot Ankle Spec 2010; 3: 4, 190–193.
58. Wolvos, T. The evolution of negative pressure wound therapy: negative pressure wound therapy with instillation. J Wound Care 2015; 24: Sup4b Suppl, 15–20.
59. Fleischmann, W., Russ, M., Westhauser, A., Stampehl, M. [Vacuum sealing as carrier system for controlled local drug administration in wound infection]. [Article in German] Unfallchirurg 1998; 101: 8, 649–654.
60. Scimeca, C.L., Bharara, M., Fisher, T.K. et al. Novel use of insulin in continuous-instillation negative pressure wound therapy as wound chemotherapy. J Diabetes Sci Tech 2010; 4: 4, 820–824.
61. Sun, Y., Fan, W., Yang, W. et al. [Effects of intermittent irrigation of insulin solution combined with continuous drainage of vacuum sealing drainage in chronic diabetic lower limb ulcers]. [Article in Chinese] Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi 2015; 29: 7, 812–817.
62. Rycerz, A.M., Allen, D, Lessing, M.C. Science supporting negative pressure wound therapy with instillation. Int Wound J 2013; 10: s1 Suppl 1, 20–24.
63. Kim, P.J., Attinger, C.E., Olawoye, O. et al. Negative pressure wound therapy with instillation: review of evidence and recommendations. Wounds 2015; 27: 12, S2–S19.
64. Lessing, M.C., James, R.B., Ingram, S.C. Comparison of the effects of different negative pressure wound therapy modes — continuous, noncontinuous, and with instillation — on porcine excisional wounds. Eplasty 2013; 13: e51.
We offer an innovative approach to wound care, improving efficiency and patient comfort.
