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Wound Management

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.

References

  1. Téot, Luc, Paul E. Banwell, Ulrich E. Ziegler, et al. , ‘Surgery in Wounds’, Anonymous Translator(, Berlin, Heidelberg, Springer Berlin Heidelberg, 2004).
  2. Agarwal P, Kukrele R, Sharma D. Vacuum assisted closure (VAC)/negative pressure wound therapy (NPWT) for difficult wounds: A review. J Clin Orthop Trauma. 2019 Sep-Oct;10(5):845-848. doi: 10.1016/j.jcot.2019.06.015. Epub 2019 Jun 20. PMID: 31528055; PMCID: PMC6739293.

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Procedures