Indications and contra-indications
Authors: Christian Kaare Paaskesen Stud. Med, Magnus Balslev Avnstorp, MD, & Hasan Gökcer Tekin MD.
NPWT can be used in cases with acute and chronic wounds, each with different indications.
- 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
- Pressure ulcers
- Leg ulcers
- Diabetic foot ulcers
- Cavity wounds
- Previously critically colonized/infected wounds following debridement
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.
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.
- Téot, Luc, Paul E. Banwell, Ulrich E. Ziegler, et al. , ‘Surgery in Wounds’, Anonymous Translator(, Berlin, Heidelberg, Springer Berlin Heidelberg, 2004).
- 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.