Any wound care provider is going to continuously seek new approaches to wound therapies that improve patient healing times. Negative pressure wound therapy (NPWT) has grown to be an important adjunctive therapy in any wound care setting due to its ability to promote wound healing in different types of wounds with granulation tissue formation. NPWT also has shown improvement in decreasing local edema and has proven to help reduce bacterial levels in tissue. The use of NPWT is further bolstered when it’s coupled with certain advanced wound care dressings that, when used together, have further quickened healing rates and improved the patient care experience. This article discusses the efficacy of these treatment modalities and offers product recommendations for the wound care clinic.
Addressing Pain & MacerationOne of the most common complaints that wound care nurses hear when it comes to application of NPWT is the pain that occurs when trying to remove foam dressings that can adhere firmly to granulation tissue. The use of a nonadherent wound contact layer such as ADAPTIC TOUCH™ (Systagenix) that features a silicone coating to the contact layer allows comfort and ease of removing the foam dressing from the wound bed.1 Another option is to ensure that lidocaine (liquid) is available to soak through the foam dressing before trying to remove the dressing. This not only loosens the foam dressing from the wound bed but decreases the level of pain felt while doing so. Another common complication that can arise with NPWT is when the edges of a wound become macerated. This can be minimized through the application of a skin preparation to the surrounding periwound skin before providing the initial drape. This skin prep forms a film that prepares the skin for the adhesiveness of the drape, allowing skin to adhere better by removing oils in the skin while reducing the possibility of abrasion when removing the drape. Most brands of skin prep now offer an alcohol-free wipe that doesn’t cause a stinging sensation. However, clinicians should ensure that the foam dressing is never overlapping wound margins and that it’s cut to fit the wound appropriately in order to minimize maceration. If the skin has already become macerated, a solution to prevent further breakdown of the surrounding periwound is to apply a calcium alginate along the border of the wound bed. If the skin prep is applied first, apply the alginate along the edge of the wound margins followed by the draping, which should be allowed to extend the length of the alginate for a guaranteed secure seal and prevention of further moisture and skin deterioration. Regarding the seal, there are instances when the NPWT can “spring a leak.” This can happen quite frequently, especially when trying to apply the NPWT around an ankle or the toe(s). To lessen the risk of a leak, apply compression to the limb needing NPWT. The Setopress® high-compression bandage (Mölnlycke Health Care) can help stabilize NPWT and provide enough pressure to prevent possible leaks, especially if the patient is able to ambulate. When applying NPWT near the dorsal foot/toes, also use podiatry felt or foam between the toes to give a better seal and to assist with any drainage that can accumulate in this area and cause maceration.
Handling Wound ComplexityThose wounds that are more complex with deep tunneling can benefit from the use of PROMOGRAN® or PROMOGRAN PRISMA (Systagenix), collagen dressings that contain oxidized regenerated cellulose (ORC).2 The difference between the two products is that Prisma has a 1% silver ORC added into its suspension before the freeze-drying stage. Both dressings have shown to reduce matrix metalloproteinase (MMP) activity in chronic wound fluid.3 MMPs are from an enzyme family that is very important in wound healing and are normally produced in low levels of cell migration. But when they develop in high concentrations, they can destroy extracellular matrix proteins and allow no support for cell adhesion. When applying this collagen dressing to the base of the wound bed before applying the foam dressing, time of tissue growth can be accelerated by several weeks. Although the white foam for tunneling or undermining wounds is recommended, its density can allow for less suction and can be more difficult to get into those areas. Collagen is applied more easily and has shown to fill tunneling and undermining areas quickly while allowing needed suction to that area. One technique for tunneling wounds is to roll Promogran or Prisma into a cylinder and tuck it in gently, then applying a foam dressing on top. For undermining wounds, tuck the collagen into the specific areas and add several layers if needed, then apply the foam dressing to the remainder of the wound bed. The biological skin substitute Dermagraft® (Shire Regenerative Medicine) has also shown great results when applied with NPWT in wounds that are healing. The physician should prepare the skin substitute as directed by the manufacturer. Once applied to the wound, the skin substitute can be fastened with Steri-Strips™ (3M), and ADAPTIC TOUCH can be applied on top of the graft to guarantee fewer disturbances to the graft site and protect the graft from being pulled into the foam dressing. Dermagraft works well with NPWT because it helps maintain the exudate level of the wound, which allows the skin substitute to adhere and be better absorbed into the wound bed. When these therapies are used together, a decrease in the amount of time the patient required NPWT has been noted. Christina Le is lead clinical nurse with Wound Care Advantage, Sierra Madre, CA.
References1. International case studies using Adaptic Touch non-adhering silicone dressing: Case Studies. Accessed online at www.systagenix.com/our-products/lets-comfort/adaptic-touch-42. 2. Cullen B, Ivins N. Promogran & Promogran Prisma made easy. Wounds Int. 2010;1(3). 3. Cullen B, Smith R, McCulloch E, et al. Mechanism of action of Promogran, a protease modulating matrix, for treatment of diabetic foot ulcers. Wound Repair Regen. 2002; 10(1):16-25.