Indications and contra-indications

Authors: Christian Kaare Paaskesen Stud. Med, Magnus Balslev Avnstorp, MD, & Hasan Gökcer Tekin MD.

Indications

NPWT can be used in cases with acute and chronic wounds, each with different indications.

Acute wounds:

• Larger wounds following surgery, trauma, infection or excision with large fluid production
• Thin skin flaps with decreased blood flow ex. Breast skin following mastectomy and primary breast reconstruction
• Large burns
• To secure skin graft in place to avoid maceration

Chronic wounds:

• Pressure ulcers
• Leg ulcers
• Diabetic foot ulcers
• Cavity wounds
• Previously critically colonized/infected wounds following debridement

Contra-indications

Clinicians should be aware of contra-indications before applying NPWT. The most important ones are visible infected or dry wounds no exudate. NPWT creates a moist and closed environment favorable for healing but this environment is also favorable for bacterial growth, and critically colonized/infected wound beds must be addressed before applying NPWT. The rate of revascularization and epithelization is greatly reduced in dry wounds, compromising wound healing when using NPWT. A moist wound bed is necessary before NPWT.

Other contra-indications are:

• Unexplored fistulas
• Exposed blood vessels and nerves
• Anastomotic sites
• Exposed Organs
• Malignant wounds
• Untreated osteomyelitis
• Necrotic tissue

Relative contraindications include patients with blood dyscrasias, active bleeding wounds or patients in anticoagulant treatment. However, immobilized patients often receive prophylactic anti-thrombotic treatment with low-molecular heparin.

Red flags

During NPWT, the clinician should be aware of several red flags:

• Active or excessive bleeding
• Erysipelas of surround skin
• Increasing pain
• Signs of infection
  • Fever, pus or foul-smelling drainage
• Allergy to the adhesive drape

Wound bed assessment

Before using NPWT, different properties of the wound bed must be considered to ensure optimal healing and prevent damage to the wound.

• Wound size, depth and location
• Level of exudate – low, moderate or high – Determine the frequency of canister change
• Surrounding skin maceration – use silicone dressings for protection of surrounding skin
• Infection – need of desloughing/debridement prior NPWT
• Pain – need of pain management treatment
• Undermining – the foam should be cut and adjusted to the cavity. Consider White Foam.  
• Necrotic tissue –debride prior NPWT
• Bleeding – haemostasias must be secured before treatment
• Exposed bone, mesh or metal – Consider using white foam

Before starting NPWT, always be aware of the patient’s ability to cooperate. This is essential to the outcome of the treatment.