Current Dialogues in Wound Management - Summer 2019 …...4 SPECIAL SUMMER 2019 EDITION | Current...

Current Dialogues in

PERSPECTIVES, INSIGHTS AND ISSUES IN WOUND MANAGEMENTWound Management

THISISSUE:V.A.C. VERAFLO™ Therapy: Recipe for Success Cindy Miller-Mikolajczyk, RN

pp 2-6

Clinical Recommendations for Application of V.A.C. VERAFLO™ Therapy on Wounds with Complex GeometriesElizabeth Faust McElroy, MSN, CRNP, CWS, CWOCN-AP

pp 11-13

Maintaining Negative Pressure Wound Therapy with Instillation Dressing Seal Integrity when Dealing with Incontinence and DiaphoresisDona Lyndhia Isaac,RN, MSN/ED, CWON

pp 14-17

Clinical Strategy to Managing and

Maintaining a Seal on Wounds in Ambulatory

Patients Using V.A.C. VERAFLO™ Therapy

Valerie Messina, RN, CWCN

pp 18-19

Clinical Recommendations for

Application of V.A.C. VERAFLO™ Therapy

on Wounds Over Points of Pressure

Thalia A. Attinger, RN, MS, FNP-BC

pp 20-22

Utilizing Instillation with Negative

Pressure in the Management of Large Wounds

Laurie Punch, MD

pp 7-10

Special Summer 2019 Edition:NPWTi-d Application Excellence

2 SPECIAL SUMMER 2019 EDITION | Current Dialogues in Wound Management

V.A.C. VERAFLO™ Therapy: Recipe for Success

INTRODUCTIONAnyone who has ever undertaken a new cooking recipe, and who desires an optimal outcome, typically follows the written ingredient amounts and method/timing of cooking. This ensures the best chance for a successful outcome. Once that recipe has been validated, small tweaks can be made to customize the recipe to alter the outcome. Use of negative pressure wound therapy (NPWT) with instillation and dwell time (NPWTi-d) can be viewed in much the same manner once an appropriate patient has been identified, especially for clinicians who have not yet gained experience with it. There are a few basic steps to using NPWTi-d that, if followed, may help increase the likelihood of a positive experience for the patient.1-3

Use of NPWT for wound management is well established in the literature as well as in clinical practice. The addition of an instilled topical wound solution with dwell time, which alternates with negative pressure

wound therapy, facilitated wound cleansing that helped promote wound healing.1-3 Compared with standard NPWT, NPWTi-d involves the use of unique dressing options as well as knowledge of how to access and use the instillation-specific pump program, which allows the automated, volumetric delivery of topical wound solutions. These changes in practice from standard NPWT are important for clinicians to understand when being introduced to NPWTi-d. While some clinicians who are experienced with NPWTi-d employ advanced features to match various wound characteristics,4 other experienced clinicians prefer to stick with the basics of the therapy.5-7

The purpose of this article is to describe, in simplified steps (a “recipe”, if you will), how to apply NPWTi-d to an appropriate patient using basic therapy unit settings, topical wound solutions, and components. Following these steps may help optimize the use of the therapy in most appropriate wounds and help increase the clinician’s

comfort level when instituting this therapy. The recommendations here are based on clinical experience and published evidence of best practices.8;9

Once the wound has been thoroughly assessed and it has been established that the wound is indicated and not contraindicated for the use of NPWTi-d, the following steps can be instituted along with the products’ instructions for use. Prior to applying the therapy, the patient and wound bed should be adequately prepared using good wound care principles.10 A prescription is required to start NPWTi-d.

Cindy has been a Registered Nurse since 1978. For the past 26 years, Cindy has worked in various sales, clinical, marketing as well as research and development roles at KCI. For 2 years (2009-2011) she devoted her energies to the launch of V.A.C. Therapy in Japan, India and China, where she educated KCI’s sales force and lectured at major universities across those countries. Cindy is the senior author of 2 posters that have been presentated at international and national wound care conferences She is currently the Senior Director of Clinical Science and Education at KCI Corporate Headquarters and lectures extensively in the U.S. and abroad on the entire portfolio KCI has to offer.

Cindy Miller-Mikolajczyk, RN

STEPS FOR APPLYING NPWTI-D

1. Gather all needed components:

• V.A.C.ULTA™ Therapy Unit

• V.A.C.ULTA™ Canister

• VERALINK™ Cassette

• V.A.C. VERAFLO™ Dressing Kit of clinician’s choice (Table 1)

– V.A.C. VERAFLO™ Dressing, V.A.C. VERAFLO CLEANSE™ Dressing or V.A.C. VERAFLO CLEANSE CHOICE™ Dressing

• V.A.C. VERAT.R.A.C.™ Pad with tubing (included in dressing kit)

– V.A.C. VERAT.R.A.C.™ Pad included in Medium and Small dressing kit

– V.A.C. VERAT.R.A.C.™ DUO Tube Set included in large dressing kit

– V.A.C. VERAT.R.A.C.™ DUO Tube Sets are also available separately

• 3M™ Cavilon™ No Sting Barrier Film wipes (included in dressing kit)

• V.A.C.® Advanced Drape (included in dressing kit)

• Manufacturer’s approved topical wound solution of clinician’s choice (Table 2)


SPECIAL SUMMER 2019 EDITION | Current Dialogues in Wound Management 3

Dressing image

Shape

Wound type example

Wound characteristics

Key goals of therapy when used with V.A.C. VERAFLO™ Therapy

Spiral-cut (pre-cut) foam

Open wounds, including wounds with shallow undermining or tunnel areas where the distal aspect is visible; may be ideal for bridging

• Facilitate removal of wound exudate and infectious material

• Generation of granulation tissue

Foam pre-slit into2 layers

Large surface area wounds with minimal depth


• Generation of granulation tissue in large wounds

Tubular shape

Cavity wounds with complex geometries, including explored tunnels or undermining where the distal aspect is not visible; can be used with V.A.C. VERAFLO™ dressing


• Easy application into tunneling and undermining

Foam split into 3 layers including the contact layer with through holes

Wounds with thick exudate, such as fibrin, slough, and infectious material; wounds that need immediate wound cleansing when surgical debridement must be delayed or is not possible. Use Large size when necessary.

• Help facilitate

removal of thick wound exudate, such as fibrin, slough, and other infectious material

• Provide wound cleansing option for clinicians when surgical debridement is delayed or is not possible or appropriate

TABLE 1. DRESSING SELECTION GUIDE

V.A.C. VERAFLO™ V.A.C. VERAFLO™ V.A.C. VERAFLO V.A.C. VERAFLO Dressings Large Dressing CLEANSE™ Dressing CLEANSE CHOICE™ (Small or Medium) Dressing (Medium or Large)


TABLE 2. CHOOSING A TOPICAL SOLUTION

CHOOSING A TOPICAL SOLUTION:

• Saline is the most widely used solution for all wound types5 and may be a good choice for clinicians who are new to the therapy as well as clinicians who are experienced NPWTi-d users.

• Many clinicians have success with instilling saline with NPWTi-d and do not use other topical wound solutions.

• Once familiar with the therapy, the healthcare provider may want to consider other topical wound solutions, depending on wound characteristics. Solutions indicated for topical wound treatment that were tested and approved for compatibility are listed here:

GENERIC SOLUTION CLASS TRADE NAME(S)

Sodium hypochlorite solutions Dakin’s Solution (solution should not be used in concentrations greater than 0.125%, quarter strength)

Hypochlorous acid solutions* Vashe®, Puracyn®, NeutroPhase®

Oxidized water/sodium Dermacyn®, Microcyn® hypochlorite/hypochlorous acid solutions

Sulfur-based solutions Mafenide acetate, Sulfamylon® (sulfonamides)

Biguanides (Polyhexanide) Prontosan® Wound Irrigation Solution

Lidocaine HCl Various, e.g., Xylocaine 2%

Isotonic solutions Normal saline for irrigation, USP Lactated Ringers Solution

Acetic acid Acetic Acid Irrigation USP (diluted to 0.25%)

Caution: The listing of the above solutions is neither an endorsement nor an indication of a solution’s clinical efficacy. These solutions are included based on KCI in-house testing of disposables, mechanical properties, biocompatibility, and solution interaction and found to be compatible with the V.A.C.ULTA™ Therapy System components. If wound healing goals are not being achieved, consider an alternate instillation frequency, solution concentration, or solution type deemed appropriate by a physician. Please follow solution manufacturer’s Instructions for Use prior to use with V.A.C. VERAFLO™ Therapy.

Dermacyn® and Microcyn® are trademarks of Sonoma Pharmaceuticals (Petaluma, CA). Sulfamylon® is a trademark of Mylan Institutional Inc. (Rockford, IL). Prontosan® is a trademark of B. Braun Medical, Inc. (Bethlehem, PA). Vashe® is a trademark of SteadMed Medical (Fort Worth, TX). Puracyn® is a trademark of Innovacyn, Inc. (Rialto, CA). NeutroPhase® is a trademark of NovaBay Pharmaceuticals, Inc. (Emeryville, CA).

*Please consult your KCI Representative for more information on the use of these solutions.

2. Assemble the system

a. Attach VERALINK™ Cassette to side of V.A.C.ULTA™ Unit.

b. Raise solution container arm and rotate 180 degrees. Lock into place.

c. Clamp tubing on solution tubing.

d. Spike solution bag and hang on hanger arm.

e. Do not prime the system with the topical solution as the system will do this automatically.

f. Tuck bag inside the VERALINK™ Cassette when necessary.

g. Attach the canister to the right side of V.A.C.ULTA™ Unit.


3. Apply the dressing

a. Wipe the periwound area with 3M™ Cavilon™ No Sting Barrier Film, as needed.

b. In hard-to-seal locations, consider applying drape strips around the wound in windowpane fashion.

c. Assess wound dimensions.

d. Protect sensitive structures, vessels, and organs.

e. Cut foam to fit wound dimensions and place into wound cavity ensuring direct contact with all surfaces of the wound, including

tunnels and undermining. Keep count of all foam pieces placed in the wound and record on drape and in patient record, as per

facility protocol.

– Dressing foam types can be used in combination as appropriate.

– Refer to Instructions for Use for detailed information on applying each dressing type.

f. Apply V.A.C.® Advanced Drape to cover wound plus 3-5 cm of intact skin.

g. Cut 2.5 cm diameter hole in V.A.C.® Advanced Drape.

h. Apply VERAT.R.A.C.™ Pad over hole(s) in the drape.

4. Connect dressing tubing to device

a. Connect appropriate V.A.C. VERAT.R.A.C.™ Pad tube to the canister tubing to allow for negative pressure application and

solution removal.

b. Connect the small lumen V.A.C. VERAT.R.A.C.™ Pad tube to V.A.C. VERALINK™ Cassette tubing to allow for solution delivery.

Be sure the connection is secure.

c. Ensure all white tubing clamps are open.

5. Choose device settings

a. Choose V.A.C. VERAFLO™ Therapy program from the touch screen.

b. Select “OK” to use default settings for therapy.

Default settings are:

a. Fill Assist (ON)

b. Start Phase (Instill)

c. Soak Time (10 minutes)

d. V.A.C.® Therapy Time (3.5 hours)

e. Target Pressure (-125 mmHg)

f. Intensity (Low)

c. Use fill assist tool to determine solution volume; don’t overfill (Table 3).

TABLE 3. QUICK GUIDE FOR FILL ASSISTBRIEF OVERVIEW:

The fill assist feature allows the clinician to manually start and stop the amount of fluid and logs the amount of fluid used for each instillation.

INSTRUCTIONS FOR USING FILL ASSIST:

1. Press start for fill assist and stop just when the foam appears moist, but don’t overfill as this increases the chance for leaks.

2. If you overfill, press the minus button to reduce the amount of solution for the next time.


CONCLUSIONCompared with standard NPWT, use

of NPWTi-d involves unique dressing options as well as accessing and using the instillation-specific pump program. A firm understanding of these changes in workflow required with use of NPWTi-d is important for any clinician using the therapy. However, when it comes to choosing configurations and settings for the NPWTi-d system, starting with basic therapy settings, topical wound solutions and components may offer the best recipe for success with appropriate patients, especially for clinicians who are new to the therapy. The simplified steps outlined in this article may be used as a guide to optimize use of the topical wound instillation therapy in most appropriate wounds, increasing the likelihood of a positive patient and clinician experience.

References:1. Ludolph I, Fried FW, Kneppe K, Arkudas A, Schmitz M, Horch

RE. Negative pressure wound treatment with computer-controlled irrigation/instillation decreases bacterial load in contaminated wounds and facilitates wound closure. Int Wound J. 2018;15(6):978-984. doi: 10.1111/iwj.12958.

2. Anghel EL, Kim PJ, Attinger CE. A solution for complex wounds: the evidence for negative pressure wound therapy with instillation. Int Wound J. 2016;13 Suppl 3:19-24. doi: 10.1111/iwj.12664.

3. Gabriel A, Kahn K, Karmy-Jones R. Use of negative pressure wound therapy with automated, volumetric instillation for the treatment of extremity and trunk wounds: Clinical outcomes and potential cost-effectiveness. Eplasty. 2014;14:e41.

4. Yang C, Goss SG, Alcantara S, Schultz G, Lantis Ii JC. Effect of negative pressure wound therapy with instillation on bioburden in chronically infected wounds. Wounds. 2017;29(8):240-246.

5. Kim PJ, Attinger CE, 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. doi: 10.1097/PRS.0000000000001709.

6. 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.

7. Brinkert D, Ali M, Naud M, Maire N, Trial C, Téot L. Negative pressure wound therapy with saline instillation: 131 patient case series. Int Wound J 2013;10 Suppl 1:56-60. doi: 10.1111/iwj.12176.

8. McKanna M, Geraci J, Hall K, et al. Clinician panel recommendations for use of negative pressure wound therapy with instillation. Ostomy Wound Manage. 2016;62(4):S1-S14.

9. Kim PJ, Attinger CE, Crist BD, et al. Negative pressure wound therapy with instillation: review of evidence and recommendations. Wounds. 2015;27(12):S2-S19.

10. Snyder RJ, Fife C, Moore Z. Components and quality measures of DIME (devitalized tissue, infection/inflammation, moisture balance, and edge preparation) in wound care. Adv Skin Wound Care. 2016;29(5):205-215. doi: 10.1097/01.ASW.0000482354.01988.b4.

6. Check that therapy is activated

• Start therapy.

• The foam will draw down while the therapy unit performs a seal check. This may take a few minutes, depending on the size of

wound and presence of microleaks.

• Make sure the dressing has wrinkled appearance after therapy is initiated and that there are no hissing sounds or other evidence

of leaks. The SEAL CHECK™ Feature will assist the clinician in this important step.

There are a few basic steps to using NPWTi-d that, if followed, may help increase the likelihood of a positive experience for the patient.1-3


BACKGROUNDSoft tissue injury and infection both create inflammation which, in turn, creates edema and pain. When these processes lead to loss of the skin, fat, fascia, and muscle there are, from my personal experience, three distinct challenges that confront patients and clinicians: 1. Ongoing control of infection and

contamination;2. Ongoing management of fluid loss,

inflammation, and edema;3. Maintenance of tissue integrity and

domain that will facilitate eventual soft tissue coverage and closure.

Over the course of my career, I have observed surgical and traumatic wounds with a large surface area as the result of a myriad of different processes such as necrotizing soft tissue infection, pressure injury, degloving injury, postoperative infection, intrinsic skin disease such as hidradenitis, and ulcers related to lymphatic or venous insufficiency. While definitive care requires appropriate system support of the patient overall, the process of wound healing and coverage can be supported through intentional tissue resuscitation. This resuscitation, in response to the above three challenges, includes:1. Ongoing removal of infectious and

necrotic material;2. Reduction of tissue edema while

maintaining wound moisture balance;3. Wound edge approximation with

promotion of new tissue growth.

Large inflamed and infected wounds are best treated with a combination of both negative pressure wound therapy with instillation and dwell (NPWTi-d) and

can be used as an adjunctive therapy in the management of these wounds, along with appropriate clinical protocol of debridement and antibiotic therapy. These modes of wound management together provide these three components of tissue resuscitation extremely well as described throughout the literature.1-3

The challenge then is the successful application of NPWTi-d to large wound beds. While the addition of instillation to negative pressure therapy after application is not uniquely challenging, ensuring there is an adequate seal and appropriate parameters set for NPWTi-d are essential for the dressing to be successful. In addition, the anatomical location of the large wound can influence the function of the dressing. Factors like patient movement, continence, positioning, and mobility may have a significant impact, all of which can be managed or mitigated with careful planning.

Many wound types demonstrate these three challenges as well as the benefits of applying NPWTi including:1. Acute wounds resulting from necrotizing soft

tissue infection of the torso, groin, and axilla;

2. Pressure injury of the ischium or sacrum including septic arthritis;

3. Traumatic wounds such as large burns or degloving injuries.

CASE STUDY #1 We present a case of a patient with

severe panniculitis, refractory to treatment with antibiotics, with worsening swelling, induration, redness, and now fever (see Figure 1A). The patient required surgery for debridement due to a rapidly declining clinical status, but with a body mass index (BMI) of 80 kg/m2, he was at extremely high risk for the use of anesthesia. In addition, the patient had marked tenderness with touch to the affected area and was not likely to tolerate dressing changes while awake. Thus, he was a very good candidate for NPWTi-d. The considerations for using NPWTi-d included:1. A high burden of devitalized tissue

and infection which could benefit from wound cleansing;

2. A large wound with edema which needed to be resuscitated;

3.

NOTE: As with any case study, the results and outcomes should not be interpreted as a guarantee or warranty of similar results. Individual results may vary depending on the patient’s circumstances and condition.

ON THE COVER

Dr. Laurie Punch is an acute care surgeon with three areas of focus including surgical education, gun violence prevention and the management of soft tissue infection and injury. With a strong foundation in the management of necrotizing soft tissue infection at the University of Maryland where Dr. Punch trained as a resident and fellow,

she has developed clinical expertise and an extensive curriculum in the management of soft tissue.

Utilizing Instillation with Negative Pressure in the Management of Large Wounds

Laurie J. Punch, MD

Figure 1: Panniculitis wound. A. Panniculitis with deep infection before surgery; B. Wound after debridement and placement of NPWTi.



Repeated dressing changes would be unbearable for him and repeated anesthetics too high risk.

However, there were challenges in applying this dressing.1. There was a large surface area to the

wound with portions of the wound being much more dependent on body position (lying flat versus sitting up);

2. The surrounding skin was excoriated, weeping, and indurated;

3. The wound, after debridement, was 35 cm x 8 cm x 10 cm.

To address the unique challenges of this application, there are 2 key modifications in placing the dressing after debridement.1. The instillation port and suction port of

the V.A.C. VERAT.R.A.C. DUO™ Tube Set were supported by 2 extra layers of foam underneath to prevent blockage.

2. The V.A.C. VERAT.R.A.C. DUO™ Tube Set was used with the instillation port anterior on the wound to ensure the dependent passage of instill fluid throughout the entire wound.

3. Utilizing this dressing type on this wound bed allowed for assistance in solubilizing infectious material and wound debris, and wound cleansing without dressing changes as the patient was unable to undergo repeated episodes of anesthesia and was also very tender at the site. The wound site was continually monitored for any changes or signs of infection.

4. Instillation was evaluated for adequacy at the time of placement using the fill-assist mode on the V.A.C.ULTA™ Therapy Unit with a short-term plan of utilizing only standard negative pressure therapy and then beginning instillation the following morning. This ensured that the wound had good hemostasis before starting instillation and avoided early seal failure as consistent negative pressure can reduce the leak rate on large wounds like this one.

The dressing was placed and instillation was initiated utilizing normal saline (150 mL) with a dwell time of 10 minutes, followed by continuous negative pressure (-125 mmHg) for 3.5 hours (see Figure 1B). Normal saline was used as the patient had a gram-positive infection and no significant wound odor. In my practice, antimicrobial solutions such as 1/8 strength Dakins are reserved for gram-negative infections as saline has been proven

to be effective in most wounds. The patient’s overall treatment plan included aggressive systemic antibiotics, critical care support for his respiratory failure, and septic shock, as well as nutritional supplementation through a feeding tube. After 3 days, he returned to the operating room for a repeat debridement and dressing change. At this time his overall stability had greatly improved. The dressing was replaced and another course of NPWTi-d given. After 1 week of therapy, the patient was able to transition to bedside dressing changes with standard V.A.C.® Therapy.

Typically, a wound of this size and contamination would require frequent explorations and dressing changes due to concern for ongoing uncontrolled infection and bioburden within the dressing itself. Instead, the patient’s infection was treated with systemic antibiotics and surgical debridement. The use of NPWTi-d assisted in the reduction of bacterial burden and removal of fluid from the wound without being exposed to anesthesia for these purposes, a reality that was significant for this patient with a very large wound and complex medical comorbidities.

CASE STUDY #2 We present the case of a young man

with a history of paraplegia secondary to a gunshot wound with bilateral greater

trochanter stage IV pressure ulcers with osteomyelitis of the femoral head. He failed appropriate offloading, prolonged wound care, and a course of intravenous antibiotics. The patient was treated with Girdlestone pseudoarthroplasty for the removal of his femoral head and neck (see Figure 2).4 This surgery allowed for the eradication of his osteomyelitis but resulted in a large deep wound emanating from his acetabulum. The wound was highly inflamed and at risk for desiccation and non-healing. Because of this, he was a very good candidate for NPWTi-d with similar challenges as demonstrated in the first case, including a large space with significant edema, recent invasive infection, and the need to maintain wound tension to allow for eventual primary closure.

A plan was made for placement of a V.A.C. VERAFLO CLEANSE CHOICE™ Dressing utilizing normal saline (50 mL) with a 10-minute dwell time followed by 3.5 hours of continuous negative pressure at -125 mmHg (see Figure 3).

Figure 2. Stage IV pressure ulcer of the greater trochanter with osteomyelitis. A. Preoperative appearance of the stage IV pressure ulcer of the greater trochanter with osteomyelitis; B. Postoperative week 5 of the surgical site with completely successful primary healing. The drain was removed at week 7.

Figure 3. Example of a V.A.C. VERAFLO CLEANSE CHOICE™ Dressing application in a large open hip wound after Girdlestone procedure.

The use of NPWTi-d assisted in the reduction of bacterial burden and removal of fluid.


Once again, the instillation setting was held overnight and started once the hemoglobin was assessed to be stable and the dressing intact the following morning. Also, the instillation port was buttressed with additional foam to prevent blockage or obstruction. In this case, the foam cover layer can hold a very large amount of fluid when first beginning instillation and the foam is dry. A near 20% reduction in the calculated instill fluid is often required once the foam is wet to avoid over-filling the dressing.

CASE STUDY #3 A 70-year-old woman was previously

involved in a high-speed motor vehicle collision and required right above-the-knee amputation after a severe degloving injury with a failed attempt at limb salvage. The patient was referred for care 7 weeks after the surgery (a total of 3 months after the initial injury). The patient’s previous medical history included obesity (BMI of 55 kg/m2). The large upper leg wound was infected and shown to have an invasive polymicrobial infection including a mold species (see Figure 4). The patient remained in the intensive care unit, critically ill with atrial fibrillation, renal failure on dialysis, and dependent on mechanical ventilation.

A multidisciplinary plan of care was created for this patient including consultation with infectious disease specialists, orthopedic surgery, and trauma surgery for removal of the devitalized tissue, revision of the amputation stump, and long-term antimicrobials. Despite appropriate treatment, the patient had progressive destruction of the tissue likely related to an invasive mold infection. Thus,

several clinical applications for NPWTi-d are demonstrated in this case including:1. A very large wound bed with a high

burden of devitalized tissue and refractory infection which could benefit from wound cleansing;

2. A large amount of edema and wound edge retraction;

3. Difficulty with adequate bedside dressing changes due to pain and wound size;

4. Multiple medical comorbidities contributing to a lack of wound healing

To address these factors the patient underwent surgical debridement followed by NPWTi-d with 150 mL of 1/8 strength Dakins solution. Given the large size of the wound, 2 medium sized V.A.C. VERAFLO CLEANSE CHOICE™ Dressings and a medium V.A.C. VERAFLO™ Dressing Kit were utilized (see Figure 5). To support successful instillation, the nursing staff had developed the plan for no turning of the

patient during the installation phase and was updated on the likelihood of frequent canister changes. A single port was placed in the middle of the wound as the inferior portion of the wound elevation level changed based on the patient’s activity. The wound site was continually monitored for any changes or signs of infection.

After 5 weeks of therapy, the patient was returned to the operating room with a small area of wound necrosis which was debrided. V.A.C. VERAFLO™ Therapy with V.A.C. VERAFLO CLEANSE CHOICE™ Dressings were initiated (Figure 6A). After 4 days of V.A.C. VERAFLO™ Therapy, the wound depth was reduced (8 cm x 3 cm x 2 cm) and healthy granulation tissue was noted (see Figure 6B). Post redo closure can be seen at 3 weeks (see Figure 7) and 2 months (see Figure 8).

References:1. Lambert KV, Hayes P, McCarthy M. Vacuum assisted closure:

A review of development and current applications. Eur J Vasc Endovasc Surg. 2005;29(3):219–226. https://doi.org/10.1016/j.ejvs.2004.12.017.

2. Gabriel A. Integrated negative pressure wound therapy system with volumetric automated fluid instillation in wounds at risk for compromised healing. Int Wound J. 2012;9 Suppl 1:25-31. doi: 10.1111/j.1742-481X.2012.01014.x.

3. Gabriel A, Shores J, Heinrich C, et al. Negative pressure wound therapy with instillation: A pilot study describing a new method for treating infected wounds. Int Wound J. 2008;5(3):399-413. doi: 10.1111/j.1742-481X.2007.00423.x.

4. Jain N, Horn CB, Andrade EG, Punch L. Combination of Girdlestone pseudoarthroplasty and negative pressure wound therapy with instillation and dwell in the treatment of invasive osteomyelitis of the proximal femur. Cureus. 2018;10(11):e3552. doi:10.7759/cureus.3552.

Photos and patient information courtesy of Dr. Laurie Punch, MD; St. Louis, MO.

Figure 4. Open above knee amputation wound, 45 cm x10 cm x 5 cm with deep tunneling.

Figure 5. Application of V.A.C. VERAFLO™ Dressings over the open wound following surgical debridement.


Figure 6. Above the knee wound. A. Above the knee wound with V.A.C. VERAFLO CLEANSE CHOICE™ Dressing; B. Wound after 4 days of V.A.C. VERAFLO™ Therapy with V.A.C. VERAFLO CLEANSE CHOICE™ Dressing.

Figure 7. 3 weeks post redo closure. Figure 8. 2 months post redo closure.

After 4 days of V.A.C. VERAFLO™ Therapy, the wound depth was reduced (8 cm x 3 cm x 2 cm) and healthy granulation tissue was noted.


Liz McElroy is a Nurse Practitioner in Wound, Ostomy, and Continence Care at the Reading Hospital in West Reading, PA. She graduated from Gwynedd Mercy University with her MSN in Adult Nurse Practitioner in

2009, became a Certified Wound Specialist (CWS) in 2010, and certified in Wound, Ostomy, and Continence (CWOCN) in 2012. She serves as an in-patient wound, ostomy, and continence specialist for a 700+-bed Level I Trauma Center. She focuses on care of the perioperative, post-operative, cardiac and critical care

patients, with an interest in nursing and physician education and V.A.C. VERAFLO™ Therapy.

Clinical Recommendations for Application of V.A.C. VERAFLO™ Therapy on Wounds with Complex Geometries

Elizabeth Faust McElroy, MSN, CRNP, CWS, CWOCN-AP


Negative pressure wound therapy (NPWT) has been a staple in complex wound management for over two decades now. As I entered my career as a graduate registered nurse at a small community hospital, I had my first experience using NPWT on complex wounds. I had no prior exposure to this therapy during my nursing training. I can remember that it seemed so complex when I first saw the kit, but luckily I had a mentor who did a great job of showing me the ropes. As I advanced through my nursing career, I gained experience with NPWT; however, the wound care team or the Certified Wound Ostomy Continence Nurse (CWOCN) was consulted for application and management of the more complex wounds. Years later when I came into the role of a Certified Wound Specialist (CWS) and CWOCN, I found that I was the person that others turned to for complex wounds.

Occasionally, when I received a consult for a complex wound, the physician would ask for a dressing recommendation because the physician felt a wound was “un-vac-able.” After a professional conversation with the consulting physician, I observed that there were four common themes that distinguished these complex wounds from non-complex ones:

1) Wound location (i.e., close to the rectum, groin, or perineum);

2) Large wounds;3) Wounds with multiple contours;4) Wounds with a less than favorable

periwound skin condition. (see Figure 1,2)

The providers often wanted to use NPWT, but the perceived complexities of utilizing the therapy seemed too challenging, and they did not want to fail. I took great pride in being able to apply NPWT to many of these complex

wounds. However, I never came to the bedside without my pockets packed full of tricks. Over the years, with clinical and industry support, I found a playbook of wound care techniques that has left not only my service, but the providers who consulted our service, confident in the therapy they wanted and therapy they felt would be best for their patient.

What are some of my recommendations on using NPWT with complex wounds and their complex geometries? How does NPWT with instillation and dwell time or V.A.C. VERAFLO™ Therapy affect those recommendations? V.A.C. VERAFLO™ Therapy has been shown to be an advanced therapy

to help manage complex wounds, especially in contaminated wounds or wounds requiring further wound bed preparation.1 In my clinical experience, there are some basic rules to follow, with room for the clinician to incorporate the unique needs of the patient, wound, and clinical setting allowing for customization of the therapy settings and application. Instillation therapy is often viewed as a therapy that could increase the risk of leakage alarms. Certainly, when a good seal is questionable, to add the instillation of a solution makes that therapy seem impossible. However, with appropriate periwound skin preparation, use of accessory products, and innovative application techniques, the impossible is often very possible.

What is in my toolbox? The four major items are: skin protectant, barrier rings, drape application techniques, and settings. Skin preparation is key. A no-sting skin preparation solution is included with every V.A.C. VERAFLO™ Dressing kit for good reason. Once the periwound is appropriately dry, the application of the no-sting skin preparation solution will help with the adhesion of the drape. In my experience, this skin preparation step allows the wound cleansing solution to be

instilled to the wound edge without causing a lifting of the drape. When the traditional no-sting skin preparation is not enough, there are additional options, such as the use of a cyanoacrylate, mastisol, or benzoin.

Figure 1. Example of a complex V.A.C. VERAFLO™ Therapy application on the hand.

Figure 2. Example of a complex wound geography with V.A.C. VERAFLO™ Therapy on the hand.

Wound care is both an art and a science



When it comes to wound location, wounds close to the groin, rectum, and perineum are often challenging to achieve or maintain a good seal, especially in the presence of incontinence (see Figure 3-6). Whenever I apply NPWT in the groin or posterior trunk, I use barrier rings, skin protectant, and stoma paste. I also typically bridge away from these areas to keep the tubing away from pressure points. The use of barrier rings has proven to be extremely beneficial in my practice. Barrier rings are made with pectin-based, hydrocolloid-type ingredients, although composition varies by brand. They are moldable and customizable to meet clinician and patient needs.2 The pectin is the same substance used in jams and jellies. With the addition of pectin, the liquid thickens and creates a gel. When using barrier rings, the rings will often turn light in color when they encounter a liquid. They swell and create a “turtle neck” to prevent leaks of any liquid. This inhibits liquid from getting in (e.g., incontinence) and inhibits any liquid from getting out (e.g., the topical wound instillation solution). When applying the barrier rings or paste products, it is important to place them within 0.5 cm from the wound edge. If applied directly on the edge, the product may migrate into the wound when NPWT is turned on. When utilizing V.A.C. VERAFLO™ Therapy, I prefer to use the barrier rings instead of the paste, as I find it easier to remove the barrier rings at the next dressing change.

Table 1 lists the pastes and barrier products (not inclusive) I have used in my practice.

Drape application technique can make a difference in maintaining a seal that is needed with NPWT. Generally, with NPWT, the less overlapping of drape(s), the less likelihood of a trigger for a leak alarm. However, when the wound area is large, the clinician must use multiple pieces of drape to ensure a good seal. If a larger sheet of drape is used and there is a large wound area, this could lead to gaps between the skin and the drape, a phenomenon I refer to as tenting. When there are lots of hills and

valleys, I would recommend a technique that I refer to as shingling. Shingling occurs when the clinician cuts multiple strips of drape

and overlaps them by 50%. When a contractor applies shingles to a roof, it is for the purpose of keeping the elements (rain, ice, snow, etc.) on one side, and the other side dry. The same principle can be applied to the use of V.A.C. VERAFLO™ Therapy. When utilizing this technique, there is less risk for tenting, so the drape stays in good

contact with the periwound skin, despite

there being a large wound area. Care should

Figure 4. V.A.C. VERAFLO™ Therapy on a complex wound close to the groin.

Figure 5. Scrotal wounds can be a challenge with application.

Figure 6. Use of barrier rings and shingling drape application helps to obtain a good seal.

Figure 7. When applying drape over the toes, be sure to use an absorptive dressing between them.

Figure 8. Drape application when “shrink wrapping” the toes.

Figure 9. Shrink wrapping the toes to maintain a good seal with interdigital lesions.

TABLE 1: PASTES AND BARRIER PRODUCTS

Eakin Cohesive® Skin Barrier Eakin Cohesive® Seal

Stomahesive® Strips and Paste Adapt Barrier Ring and Strips

Flextend Skin Barrier Adapt and Karaya Paste

Brava® Moldable Rings and Strip Paste Brava® Elastic Barrier Strips

Coloplast Skin Barrier Rings Brava® Paste

Securi-T® Conformable Seal and Skin barrier TRIO SILKEN® Silicone Stoma Gel

Cohesive is a trademark of T.G. Eakin Limited. Stomahesive is a trademark of E.R. Squibb & Sons, Inc. Flextend and Adapt are trademarks of Hollister Incorporated. Brava is a trademark of Coloplast A/S Corporation. Securi-T is a trademark of Genairex, Inc. Trio Silken is a trademark of Trio Ostomy Care US

Figure 3. Example of complex geography near the groin.


be taken at the time of application to stretch the skin as flat as possible to prevent any wrinkles.

Another technique used, especially on the distal foot, is to encompass the toes in the drape to “shrink wrap” them. When there is a wound between the toes or at the metatarsal head, obtaining a good seal can prove challenging. I would apply an absorptive dressing such as a silver alginate between the toes, use a barrier ring around the periwound, and apply the drape from the plantar aspect to the dorsal aspect, which would encompass all the toes (see Figure 7-9). Certainly, the clinician needs to consider sensation and weight-bearing status when determining if this technique could be utilized.

Of course, in the presence of too much liquid, the barrier rings and the drape can fail, which is why the settings on V.A.C. VERAFLO™ Therapy can be important to allow a successful therapy (see Figure 10-12). Overfilling the foam dressing will cause any dressing to fail. When there is a high concern for a leak, the clinician can lessen the volume of instillation and lessen the dwell time to help prevent any leaks.3

When the clinician takes the time to prepare the periwound skin and uses the appropriate accessories to apply the V.A.C. VERAFLO™ Therapy, a good seal can typically be achieved. While wound care is both an art and a science, highly geometrical wounds tend to allow clinicians to use their artistic side, in addition to merging the evolving science on this advanced wound therapy.

References:1. Gupta S, Gabriel A, Lantis J, Téot L. Clinical recommendations

and practical guide for negative pressure wound therapy with instillation. Int Wound J. 2016;13:159-174. doi: 10.1111/iwj.12452.

2. McKanna M, Geraci J, Hall K, et al. Clinician panel recommendations for use of negative pressure wound therapy with instillation. Ostomy Wound Manage. 2016;62(4):S3-S14.

3. Kim PJ, Applewhite A, Dardano AN, et al. Use of a novel foam dressing with negative pressure wound therapy and instillation: Recommendations and clinical experience. Wounds. 2018;30 (3 Suppl):S1-S17.

Photos and patient information courtesy of Elizabeth McElroy, RN, MSN, CRNP, CWS, CWOCNAP; Tower Health System, West Reading, PA.

Figure 10. Use of barrier ring in a complex foot wound.

Figure 11. Application of drape to protect incision line and prevent leaks.

Figure 12. Intact V.A.C. VERAFLO™ Therapy dressing on a complex foot wound.


INTRODUCTIONOver the past 8 years, the evolution of negative pressure wound therapy with instillation and dwell (NPWTi-d) has offered clinicians an effective tool to manage a plethora of complex wound types including pressure injuries, diabetic foot ulcers, and other chronic and acute wounds in different anatomical locations.1 NPWTi-d promotes granulation tissue formation by assisting with wound cleansing along with the removal of exudate, debris, and infectious materials. The adaptation of this therapy in current practice integrates negative pressure with automated, intermittent volume-controlled instillation of a topical wound cleansing solution with a dwell time for a prescribed period followed by a user-defined length of negative pressure. This modality helps to cleanse wounds, loosen exudate, and then remove these materials during the negative pressure phase.2,3 According to Ahearn, intermittent pressure may lead to granulation tissue in lieu of continuous NPWT.4 Further, in a porcine study, wounds treated with NPWTi-d with saline solution were reported to have 43% thicker granulation tissue compared with wounds treated with standard NPWT in continuous mode.5 However, these results have not been confirmed in human studies.

The aforementioned benefits of NPWTi-d may come with a few challenges with maintaining a seal when patients are incontinent, wounds have increased drainage, or patients are diaphoretic. This article will use 2 case studies to provide clinicians with some recommendations based on personal experience to help overcome these hurdles.

CASE STUDY #1 Background

A 69-year-old obese female, who had undergone abdominal perineal resection with sacrectomy in October 2016, presented for care. Her post-operative course was complicated by a myocardial infarction and she was transferred to another hospital for cardiac catheterization. Once the patient returned to our facility for post-care, the perianal wound was found to be infected and required sharp debridement. This was performed at the bedside due to the patient’s poor cardiac status.

DescriptionThe sacral wound measurement was 7

cm x 3 cm x 5 cm with undermining from 4-7 o’clock of 9 cm (see Figure 1). The wound base was intact and no tunnel was noted. The periwound bed was also intact, and the wound bed had 50% nonadherent slough/necrotic tissues and 50% granulation tissue with odor present. The coccyx bone was visible in the upper aspect of the wound. Drainage from the wound was pale brown in

color. After consultation with cardiology, subsequent operating room debridement was warranted to remove any devitalized tissues. Our center initiated the use of V.A.C. VERAFLO™ Therapy in the operating room after the debridement.

Tips for the Incontinent PatientOf note, this patient suffered from stress

urinary incontinence. This unintentional leakage of urine can interfere with the dressing integrity. To mitigate any seal failure between the perineum region using a liquid skin protectant such as Marathon® (Medline Industries, Inc., Northfield, IL) can offer long-lasting protection. It is important to review the patient’s allergies to any adhesive to avoid any skin reactions. In the presence of skin damage, patients often complain of a burning sensation with direct contact from liquid skin protectant. Lightly apply Stomahesive® powder (ConvaTec, Inc, Greensboro, NC) over the skin irritation and follow with the application of a liquid skin sealant. To fill the gap in the perineum area and facilitate the absorption from surrounding drainage or urine, an eakin Cohesive® Seal (ConvaTec) can be used to improve the dressing wear time (see Figures 2 and 3). This cohesive ring is moldable and will fill any intricate contours or folds. In the event the tail-end of the dressing


Maintaining Negative Pressure Wound Therapy with Instillation Dressing Seal Integrity when Dealing

with Incontinence and DiaphoresisDona Lyndhia Isaac, RN, MSN/ED, CWON

Lyndhia is a board certified Wound Ostomy (CWON) nurse at a major cancer center in New York City. She has twenty-five years of oncological experience in an acute-care setting. She works as a unit-based WOC nurse on the Colorectal and Gastric Mixed Tumor service for the past 12 years. Her area of expertise includes the management of complex surgical wounds, enterocutaneous fistulas, & ostomies. Lyndhia has designed & coordinated many educational programs for staff nurses, licensed independent practitioners (LIPs), and WOC nurses.

Figure 1. Wound before application of V.A.C. VERAFLO™ Therapy.

V.A.C. VERAFLO™ Dressings are specifically designed for instillation therapy.



from the perineum becomes moist, apply a thin spread of paste over the marginally compromised area and let it dry before applying Tegaderm™ (3M) for reinforcement (see Figure 4).

For patients with fecal incontinence, a bowel management device should be considered, if appropriate. This device recommendation will help reduce moisture-associated skin damage. In addition, lowering the amount of topical wound solution can facilitate durable dressing integrity. Meticulous skin care and patient assessment are necessary during instillation therapy. For the dressing application, simply

follow the tips discussed earlier for urinary incontinence.

Dressing SelectionV.A.C. VERAFLO™ Dressings are

specifically designed for instillation therapy. These dressings utilize a new reticulated open-cell foam with a greater tensile strength and are more hydrophilic, which helps to provide better fluid distribution across the wound bed during the instillation phase. The options available include the: V.A.C. VERAFLO™ Dressing, V.A.C. VERAFLO Cleanse™ Dressing, and V.A.C. VERAFLO CLEANSE CHOICE™ Dressing. At our center, for wounds that require cleansing and granulation we consider the V.A.C. VERAFLO™ Dressings. For wounds with the requirements noted and that have thick exudate, slough, infectious materials, or when wound debridement is delayed, V.A.C. VERAFLO CLEANSE CHOICE™ Dressings have worked well. For wounds with complex geometries, tunnels, and undermining, V.A.C. VERAFLO CLEANSE™ Dressings are a good option.6-7

Dressing Case #1In this scenario we used the V.A.C.

VERAFLO CLEANSE™ Dressing to fill the tunnels and the wound base. We also moved the V.A.C. VERAT.R.A.C.™ Pad away from the wound by bridging the foam up over the patient’s hip. Practice Pearl: The patient did not like the feeling of the room temperature solution traveling across her hip and down the bridge. Given her dislike of the cool feeling during instillation cycles, the skin contact layer of the bridge base was changed from Tegaderm™ (3M, St. Paul, MN) to a thicker hydrocolloid. The thickness of the hydrocolloid base increased the patient’s comfort and allowed V.A.C. VERAFLO™ Therapy to continue. In our experience, this complaint is rare and Tegaderm™ (3M) or V.A.C.® Drape is usually sufficient (see Figures 5 and 6).

Topical Wound Solution SelectionA number of solutions are compatible

with V.A.C. VERAFLO™ Therapy. In published guidelines, clinicians have used the following solutions: Prontosan® (surfactant and 1% betadine) (B. Braun Medical, Inc., Bethlehem, PA), Lavasept® (polyhexanide 0.04%) (B. Braun Medical, Inc.), Dakin’s (quarter strength 0.125 %) Nebacetin, Saline, and Bacitracine solution.8 Nevertheless, Kim et al suggested that 0.9% normal saline may be just as effective as antiseptic Prontosan® (B. Braun Medical) for

NPWTi when used in the management plan of infected wounds along with appropriate wound care, including debridement and systematic antibiotics.9,10

Solution for Case #1

As a clinician, the topical wound solution choice is determined by each individual patient’s needs. In the presence of odor in the wound bed, a quarter strength 0.125% Dakin’s Solution® (Century Pharmaceuticals, Inc., Indianapolis, IN) was used for one week. Careful attention should be focused on the periwound bed to prevent skin damage given the nature of the topical wound solution. Protecting the periwound with a hydrocolloid barrier or eakin Cohesive Slims® (ConvaTec) will help prevent skin damage from the topical wound solution. After using Dakin’s Solution® (Century Pharmaceuticals) for 1 week, the NPWTi-d was continued with normal saline for an additional 2 weeks. After 3 weeks of treatment, the size of the wound decreased and the patient was clinically ready for discharge.

Setting Fill Volume, Dwell time, Pressure Phase Selection

Prior to instillation, patients should be made aware that as the topical wound solution begins to fill the wound, it will feel cold but not wet. When using the Fill Assist function, carefully observe the foam—it should become darker in color and be no more than 80% saturated. Too

Figure 2. Application of ostomy paste and eakin Cohesive Slims® (ConvaTec).

Figure 4. Application of a thin coat of skin protectant paste prior to placement of Tegaderm dressing.

Figure 3. Application of barrier before bridging.

Figure 6. Placement of V.A.C. VERAT.R.A.C.™ Pad in the direction of the wound.

Figure 5. Hole cut in foam.


much fluid will cause leakage. We find that pre-moistening the foam and squeezing out any excess solution can be helpful. If leakage occurs at the chosen volume, lower the amount by 20%. Once the volume is set, the V.A.C. VERAFLO™ Therapy automatically proceeds to the instillation phase. During the course of this patient’s treatment, the dwell time (soak phase) was set for 5 minutes while using quarter strength 0.125% Dakin’s Solution® (Century Pharmaceuticals) and was extended to 10 minutes while using saline solution. A shorter dwell time could be used in cases with significant urinary incontinence. There is little scientific evidence for optimal dwell time and it is dependent on individual cases. The negative pressure phase or the length of time that negative pressure is applied is at the clinician’s discretion. In this case, the negative pressure phase was 5 hours in part because of the type of topical wound solution used, the presence of urinary incontinence, and the wound location being in the sacral area. The pressure setting for negative pressure remained at the default setting of -125 mmHg.

OutcomeThe goal for this wound was to improve

granulation tissue. The patient did not need further wound debridement. She was transitioned home with NPWT for 6 weeks and complete closure was achieved.

Key points to Share with Patient and Staff:

• Inform patients to call nursing staff for leakage and alarm situations.

• For leakage, staff can suggest the license independent practitioner (LIP) decrease the instill volume by 20% and reinforce the dressing as needed.

• If the source of the leakage cannot be resolved, then staff can suggest the LIP temporarily switch therapy to NPWT if managing service is not available.

• Check the alarm and therapy alarm history to retrieve any information.

• Have extra canisters available at the bedside.

CASE STUDY #2 Background

This is a 59-year-old obese male with rectal cancer who had undergone lower anterior resection with chronic leak and other failed interventions. The patient later

required an abdominal perineal resection with gluteal flap in 2017 which eventually failed, and the superior wound tracked to the pelvis and prostate. His past medical history included diabetes and hypertension. The inferior part of the wound was superficial. With the presence of exposed organs, the wound was managed with V.A.C. VERAFLO™ Therapy and ADAPTIC TOUCH™ Non-Adhering Silicone Dressings at the wound base. He was on a specialty bed because of the flap and was not compliant with his ambulation.

DescriptionDespite initial wound management,

there was no major improvement with the wound and the patient reported increased pain in the coccyx bone. The wound measured 18 x 11 x 13 cm at this time (Figure 7), and the orthopedic department was consulted. A subsequent MRI was negative for osteomyelitis and a 6-week course of intravenous antibiotics was initiated for possible osteomyelitis. The plastic surgery team was doubtful of the pressure injury wound diagnosis in the coccyx region since the remaining gluteal flaps healed well. The wound base was covered with granulation tissue (Figure 8) and V.A.C. VERAFLO™ Therapy was re-started once the wound size measured 17 x 10 x11 cm. Since the patient was in bed most of the day, there was a lot of moisture present in the wound bed after the first dressing removal.

Tips for Patients with Diaphoresis For patients with excessive moisture

like this one, 3M™ Cavillon™ Advanced Skin Protectant (3M) offers a superior skin barrier for moderate-to-severe skin damage and this was applied prior to the dressing application. eakin Cohesive Slims™ (ConvaTec) were also used to fill any intricate areas such as the gluteal cleft and perineum. Window framing the periwound was essential to create a durable seal. Applying an ostomy paste at the distal portion of the perineum and letting the alcohol dissipate are recommended before covering it with another moisture-resistant drape or Tegaderm™ (3M) that has been cut in small pieces. In this case, the skin protectant helped to maximize the life of the dressing.

Dressing Selection for Case #2To fill this deep irregular contour, the

wound was loosely packed with V.A.C. VERAFLO CLEANSE™ Dressing. V.A.C. VERAFLO™ Dressing was used for bridging the V.A.C. VERAT.R.A.C™ Pad onto a non-pressure surface. For a larger wound it is best to use the V.A.C. VERAT.R.A.C Duo™ Tube Set.

Solution, Setting Volume, Dwell time, Pressure Phase Selection

The initial goal was to clean the wound. Our NPWTi-d approach consisted of instillation of quarter strength 0.125% of Dakin’s Solution® (Century Pharmaceuticals

Figure 7. Wound at presentation.


(120 mL), with 5 minutes of dwell time, followed by 4 hours of continuous negative pressure at -125 mmHg. One week after V.A.C. VERAFLO™ Therapy was initiated, the patient went to the operating room for a wound debridement where part of the coccyx bone was excised. The wound’s final defect measured 15 cm x 8 cm x 9 cm; extending now 9 cm cephalad from the coccyx (versus 11 cm at the last dressing change). The V.A.C. VERAFLO™ Therapy was continued using normal saline (100 mL), with 5 minutes of dwell time, followed by 4 hours of NPWT. After 2 more weeks, the patient went to the operating room for a debridement and bilateral gluteus maximus myocutaneous advancement flap (see Figure 9). The cavity could have handled more fluid, but the decision was dependent on the excess moisture and maceration.

OutcomeThis case was unique and challenging

because of the patient’s poor compliance with ambulation, which may have contributed to delayed wound healing and the development of a pressure injury. The patient was discharged to a rehabilitation facility and the sacral flap was intact. The flap remained intact a year later.

Conclusion Managing wounds requires a

comprehensive assessment by addressing physiological factors as well as intrinsic and extrinsic factors. Failure to address these factors can have a negative outcome on wound healing. In our center’s experience, NPWTi-d is beneficial for the management of various wounds. The solution choice and settings are tailored to each patient. For the patient who is incontinent or diaphoretic, the adaptation of accessory products can

help ensure the full function and benefit of the therapy. This treatment modality was proven efficacious for the 2 complex case studies presented here. In these instances, wounds went to complete wound closure and did not require a readmission or additional debridement.

References:1. Argenta LC, Morykwas MJ. Vacuum-assisted closure: A new

method for wound control and treatment: Clinical experience. Ann Plast Surg. 1997;38(6):563-576.

2. 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.

3. Gabriel A. Integrated negative pressure wound therapy system with volumetric automated fluid instillation in wounds at risk for compromised healing. Int Wound J. 2012;9 Suppl 1:25-31. doi: 10.1111/j.1742-481X.2012.01014.x.

4. Ahearn C. Intermittent NPWT and lower negative pressures exploring the disparity between science and current practice: A review. Ostomy Wound Manage. 2009;55(6):22-28.

5. Lessing MC, James RB, Ingram SC. Comparison of the effects of different negative pressure wound therapy modes – continuous, noncontinuous, and with instillation – on porcine excisional wounds. Eplasty. 2013;13:e51.

6. Téot L, Boissiere F, Fluieraru S. Novel foam dressing using negative pressure wound therapy with instillation to remove thick exudate. Int Wound J. 2017;14(5):842-848. doi: 10.1111/iwj.12719.

7. Kim PJ, Applewhite A, Dardano AN, et al. Use of a novel foam dressing with negative pressure wound therapy and instillation: Recommendations and clinical experience. Wounds. 2018;30(3 Suppl):S1-S17.

8. Kim PJ, Attinger CE, Steinberg JS, et al. Negative-pressure wound therapy with instillation: International consensus guidelines. Plast Reconstr Surg. 2013;132(6):1569-1579. doi: 10.1097/PRS.0b013e3182a80586.

9. Kim PJ, Attinger CE, 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. doi: 10.1097/PRS.0000000000001709.

10. Mckanna M, Geraci J, Hall K, et al.Clinician panel recommendations for use of negative pressure wound therapy with instillation. Ostomy Wound Manage. 2016;62(4):S1-S14.

Photos and patient information courtesy of Dona Lyndhia Isaac, RN, MSN/ED, CWON; New York, NY.

Figure 9. Wound after bilateral gluteus maximus myocutaneous advancement flap.

Figure 8. Wound after 2 weeks of V.A.C. VERAFLO™ Therapy.

Window framing the periwound was essential to create a durable seal.


Clinical Strategy to Managing and Maintaining a Seal on Wounds in Ambulatory Patients

Using V.A.C. VERAFLO™ Therapy


Valerie Messina, RN, CWCN

Valerie has over 40 years of experience in wound care as a clinician, educator, researcher, and administrator of wound care programs. She helped develop and teaches the NPWTi-d (VAC Veraflo) class in Long Beach, CA. She currently is a nurse consultant for a Wound Care & Hyperbaric Program in Long Beach, CA and for KCI An Acelity Company.

The use of negative pressure wound therapy with instillation (NPWTi-d, V.A.C. VERAFLO™ Therapy, KCI, an ACELITY company, San Antonio, TX) is growing for patients with complex wounds of varying etiologies and has become the preferred technology for hospitalized wound care patients in my center. If patients are candidates for NPWT, they will most likely receive V.A.C. VERAFLO™ Therapy. Concurrently, early mobility is promoted for hospitalized patients, including those patients with wounds treated with NPWTi-d. As noted in the article by Cain, “Nurse-facilitated early mobility has been reported to reduce incidence of delirium, improve muscle strength, increase independent functional status after discharge, and improve overall quality of life.”1 Other opportunities to integrate patients’ mobility activities include passive range of motion exercises, dangling legs at the bedside, or sitting/standing at the bedside.1 These mobility activities can often be accomplished on patients with NPWTi-d dressings in place.

Mobilizing and ambulating the patient is an interprofessional responsibility including the physician who orders the mobility status, as well as nurses, and physical and occupational therapists who facilitate ambulation. The wound care nurse has the unique distinction of being the expert on training the patient and staff on the preferred procedure for placement of the dressings, and for adjusting the settings of the V.A.C. ULTA™ 4 Therapy System prior to ambulation or mobility of the patient. Our clinical experience has shown that NPWTi-d can be utilized on ambulatory patients. The following techniques for success will hopefully lessen the fear of the dreaded “leaking dressing” or dislodgement of the dressing and help to facilitate early mobility and ambulation for patients.

CASE INTRODUCTION A young adult male was admitted with

a crush injury post-motorcycle accident resulting in a complex wound of the lower extremity. His physical therapy regimen included ambulating around the wound care unit twice daily, and his wound care regimen included application of NPWTi-d to the leg wound to assist with wound cleansing.

a. What will you do with the therapy/dressing kit that will help to overcome the challenge of keeping the V.A.C. VERAFLO™ Dressing intact during ambulation and mobility and why?First, prepare the periwound adequately by drying the skin, then apply 3M Cavilon™ Skin Prep (3M, St. Paul, MN) and allow it to get sticky. After this has been done, you may windowpane the periwound with the drape provided in the dressing kit and place (do not pack) the foam into the wound. It is important to take adequate time during the initial drape placement and apply the drape as uniformly as possible, minimizing the amount of wrinkles, folds, or kinks. Place the adhesive side over the foam and apply the V.A.C.® Advanced Drape to cover the foam and intact skin, ensuring that the V.A.C.® Advanced Drape covers at least a 3-5 cm border of intact periwound tissue. Consider gently rubbing the skin preparation over any wrinkles or folds to seal any microleaks that may compromise the seal. Make sure to select an adequate volume of fluid to instill and avoid overfilling as that may increase the risk of leakage. Minimize leaks in anatomical areas where movement is common, like joints or the perineum, by applying the drape in a chevron pattern to provide flexibility.

b. What ancillary supplies/support will/could you use to overcome the challenge of keeping the V.A.C. VERAFLO™ Dressing intact during ambulation and mobility, and why? If the dressing kit does not include enough drape to extend on the skin the recommended 3-5 cm beyond the foam, an additional drape may be needed. The addition of a hydrocolloid ring or strip around the wound is helpful to prevent leakage of fluid, especially where skin folds, deep crevices, or ridges are present.

Under Utilities select “Leak Alarm Threshold”

Set V.A.C.® Therapy Leak Alarm Threshold to “High” and V.A.C. VERAFLO™ Therapy Leak Alarm Threshold to “High”



c. How does plan of care play a role in your action plan?The placement of the dressing and the V.A.C. VERAT.R.A.C.™ Pad is an important step in order to let gravity work to completely remove the instillation fluid prior to ambulating the patient. You may also consider the V.A.C. VERAT.R.A.C. DUO™ Tube Set to help manage the dwell and removal of fluid. Adjusting the leak alarm to the “high” setting helps to prevent an alarm signal when the dressing is intact. This can be done prior to initial placement of NPWTi-d on the patient.

At the time the patient is to be mobilized or ambulated, make sure that the device is in the “negative pressure mode.” If it is on soak/instill mode, either reschedule the ambulation time, or adjust the mode to remove the instill fluid and place the device in the negative pressure mode. Attaching a note to the machine to alert any staff of this requirement may be helpful. Once the patient is returned to bed, the settings should be returned to the appropriate cycle. It is important to assess the dressing and V.A.C. ULTA™ Therapy System for any leaks or dislodgement, and repair as required post ambulation.

The location of the wound with V.A.C. VERAFLO™ Therapy also affects the needs of the dressing application and plans for mobility. For example, on the upper extremities, applying the dressing to allow for mobility for eating, and other activities of daily living, need to be addressed.

On the trunk, application to prevent dislodging during mobility in and out of bed is a concern. For lower extremities, the concern is making sure the dressing and tubing do not present a trip hazard or safety risk for falling or dislodging the dressing by pulling on the tubing. Making sure additional equipment is available is also necessary, such as a sling for a hand wound, or an IV pole or walker to place the pump on for all patients ambulating.

d. What therapy settings will you use?i. Does the topical wound solution choice influence these?I have found the use of Dakin’s antimicrobial irrigation solution may require additional care to prevent leakage at the wound’s edge in order to minimize damage to the periwound skin.ii. Does the dressing that has been chosen influence your selected settings?I have found that the use of the V.A.C. VERAFLO CLEANSE CHOICE™ Dressing may require placement of a hydrocolloid strip or ring to help avoid leakage as the foam is less flexible and more prone to leakage at the wound’s edge and where skin folds, deep crevices, or ridges are present. This can help minimize the potential for periwound skin maceration and irritation.

e. Is there anything you can/should share with the floor nurses, patients, or the patient’s family members, or is there anything you can/should ask of them?

Patient and family education includes ensuring that the patient, who is an independent ambulator, asks for assistance when preparing to ambulate or mobilize in or around the bed. The nurses and physical therapists are trained to make sure the system’s setting is on “negative pressure” mode and the instill fluid has been removed when ambulating, to help decrease the risk of leakage. Attaching the V.A.C. ULTA™ Therapy System to a pole or walker that can be rolled safely with the patient may be needed. Ensure tubing and the power cord are secured to prevent a trip hazard and so as not to interfere with ambulation.

Our experience with using NPWTi-d has shown that leakage and dislodging of the dressing during mobility in or out of bed, or ambulation, can often be minimized or prevented with proper dressing placement, utilizing additional hydrocolloid strips, and making sure the NPWTi-d is in the negative pressure mode during ambulation (see Table 1). Our experience has also shown that education and training for patients and staff are key for successful outcomes using this therapy.

Reference:1. Cain C. No time for early mobility? Am J Crit Care.

2018;27(3):204. doi: 10.4037/ajcc2018441.

Photos and patient information courtesy of Valerie Messina, RN, CWCN; Long Beach, CA.

TABLE 1. MANAGING AND MAINTAINING A SEAL ON WOUNDS IN AMBULATORY PATIENTS USING V.A.C. VERAFLO™ THERAPY

STANDARD WORK

Apply dressing with attention to sealing the drape.

Set leak alarm on high.

Adjust settings for ambulation making sure cycle is on negative pressure and not on soak/dwell.

Assist patient during ambulation with V.A.C. VERAFLO Therapy.

After ambulation, assess the dressing for leaks/ dislodgement. Adjust settings back to prescribed cycle.

EQUIPMENT

V.A.C. VERAFLO™ Foam, V.A.C. ULTA™ Therapy System, hydrocolloids

V.A.C. ULTA™ Therapy System


IV pole or walker


DESCRIPTION

Apply drape with 3 cm beyond foam, apply 3M Cavilon Skin Prep under and over drape, use hydrocolloid to seal around wound.

Helps to prevent an alarm signal when dressing is intact

If it is on soak,/instill mode, either reschedule the ambulation time, or adjust the mode to remove the instill fluid and place the device in the negative pressure mode.

Use assistive devices to hold V.A.C. VERAFLO™ Therapy Unit during ambulation. Secure all tubing.

Assess the dressing during negative pressure and soak/dwell cycle for leaks and repair as needed.


INTRODUCTIONAs a surgical service, our team traditionally turns to surgical debridement to remove thick exudate. However, with a patient population plagued by ever-worsening morbidity and mortality, surgical intervention is not always possible or even appropriate. Negative pressure wound therapy with instillation and dwell (NPWTi-d) has been shown to help cleanse the wound bed and prepare the tissue for closure.1,2 The advent of the V.A.C. VERAFLO CLEANSE CHOICE™ Dressing with NPWTi-d provides clinicians with options for patients who may not be surgical candidates by assisting with wound cleansing through the removal of thick exudate and infectious materials. Often these wounds are found over points of pressure, which can create some challenges in both proper application and maintenance of the NPWTi-d dressing. We aim to provide you with some common pitfalls and suggestions to avoid these challenges.

WHEN TO USE V.A.C. VERAFLO CLEANSE CHOICE™ DRESSING

When choosing an intervention, not only must the wound always be considered but also the patient as a whole. For the purpose of this discussion, we will solely focus on wounds over points of pressure,

though all of these techniques can be applied to wounds in a variety of locations. We have found that there are 2 subsets of patients who are prime candidates for developing pressure ulcers and as well as being suboptimal surgical candidates: intensive care unit (ICU) patients and decompensated chronically ill patients. ICU patients often spend prolonged periods of time bedbound or chairbound with limited movement and may have an added insult due to the addition of vasopressor medications. These conditions set them up for skin breakdown. In the critically ill patient, as medical instability increases, blood flow to the extremities and the sacrum decreases, causing the wound to become more and more tenuous without safe surgical options, whilst the decompensated chronically ill patient’s activity status can vary greatly. More often than not, these patients seem to lead rather sedentary lives due to a variety of reasons including heart failure, obesity, diabetic wounds, and limb loss. There are also those who suffer from chronic immobility such as those who are wheelchair-bound or bedbound. This patient population is plagued with multiple comorbidities in conjunction with the added risk of inadequate nutritional status making them poor surgical candidates and their capacity to heal even more tenuous. Cardiac and respiratory instability can make an additional trip to the operating room less than ideal. It is in this patient population for whom we find V.A.C. VERAFLO CLEANSE CHOICE™ Dressing to be particularly valuable.

DRESSING POINTS OF PRESSURE

From the shape of the wound bed, the periwound tissue, as well as the high

Clinical Recommendations for Application of V.A.C. VERAFLO™ Therapy on Wounds

Over Points of PressureThalia A. Attinger, RN, MS, FNP-BC

Thalia Attinger is a family nurse practitioner, board certified by the American Nurses Credentialing Center. She obtained her Bachelor of Arts as well as Bachelor in Science and Master of Science dergrees from Georgetown University in Washington, DC. Prior to joining the Center for Wound Healing and Hyperbaric Medicine, where she serves as an in-patient nurse practitioner focusing on the perioperative, post-operative and wound care management, she spent over five years working in the Medical Intensive Care Unit at MGUH.

Figure 1. Sacral ulcer prior to therapy.

Figure 2. At first dressing change, note area 2A lacks foam imprint.

Figure 3. At second dressing change, wound bed after foam corrections made.

When choosing an intervention, not only must the wound always be considered but also the patient as a whole.



incidence of friction and moisture, a host of challenges arise when dealing with wounds over points of pressure. One challenge is to avoid creating new points of pressure in the process of applying the V.A.C. VERAFLO CLEANSE CHOICE™ Dressing. We will set out to tackle each of these issues and how best to handle them to maximize the chances of achieving a tight and durable seal.

Wound Bed: One of the biggest challenges when placing NPWT over points of pressure is the wound bed itself. These uneven wound beds often have bony prominences that lead to curvatures of differing depths. To achieve optimal outcomes with the V.A.C. VERAFLO CLEANSE CHOICE™ Dressing, our experience has shown the wound contact layer must lie flat against the wound bed. Figure 1 shows such a wound prior to V.A.C. VERAFLO™ Therapy. As seen in Figure 2, a lift in the base layer of foam led to uneven disruption of slough. Noting the lack of foam indentations and inadequate removal of slough in the lower left-hand portion of the wound bed (marked 2A within Figure 2), the foam’s shape and size were corrected to ensure a proper fit. The difference is clear at the next dressing change (see Figure 3) where there is more uniform granulation

tissue throughout the wound bed. To prevent the same mistake from happening, measure the wound bed carefully to ensure that the contact layer is not cut too large because if it cannot fit easily into the wound bed, it will tent. Ideally, the contact layer should be cut in one piece, but if the wound shape is creating a challenge, it may be necessary to cut additional pieces to cover the entire wound bed with a flush layer of contact foam. If the wound requires multiple pieces of foam, ensure there is foam-to-foam contact to allow for an even distribution of fluid and negative pressure. This is especially true over a bony prominence such as a protruding trochanter, knee, or heel. Once there is a properly fitting

base layer, we recommend that it is covered with enough of the cover layer foam to put pressure on the contact layer foam, to keep it flush with the wound bed. The top cover layer of foam should at least come up to the level of the periwound skin to ensure adequate padding.

Proper Seal: A proper seal is the key to any good dressing application. However, when it comes to wounds in areas of pressure, there is the added complication of friction and moisture along with the frequent poor periwound skin quality. When dealing with sacral wounds, it is likely that poor quality periwound skin will be encountered in addition to folds and crevices that are prone to moisture. For bony prominences, there will be difficult angles that don’t lend themselves to laying down a nice flat sheet of drape. In both cases, there are a few key steps to take to improve the quality of their seal. As with all V.A.C.® Therapy utilization, ensuring that the periwound skin is clean, dry, and well prepped is crucial. Begin by cleaning the periwound area and removing any loose tissue. Ensure the wound is dried well before using a skin preparation agent. Allowing the skin preparation to dry completely is absolutely imperative. For large wounds,

using additional barrier sprays (often used in ostomy care) can also be beneficial. Lining the perimeter of the wound with a hydrocolloid or ostomy barrier ring is invaluable when creating a tight seal in these tricky areas. Once the hydrocolloid or barrier is placed, use strips of V.A.C.® Drape to create a border around the wound (i.e., windowpane the wound edges). This will not only protect the periwound skin, but it will also help to provide a better seal.

Friction and Moisture: These areas are also highly prone to friction and moisture and can cause the V.A.C.® Drape to roll and loosen. We have seen this compromise the integrity of the seal. For those wounds on pressure points of the extremities, covering

the V.A.C.® Dressing with cast padding or AMD gauze dressing and elastic bandage wraps will help to protect the integrity of the dressing as patients move about. Using offloading devices and strategically placed pillows can also help to protect the wound and the V.A.C.® Dressing. For those wounds on the torso, consider fecal and urinary containment devices (either internal or external pouching) to protect the dressing from incontinence issues. For the obese patient with folds near the dressing, using a product such as InterDry® (Coloplast, Minneapolis, MN) to wick moisture away from the body can be extremely helpful. No matter where the wound is, it is imperative that the integrity of the dressing be checked frequently to identify dressing compromise as early as possible.

Bridging: When treating a wound on a pressure point, it is of the utmost importance that care is taken to place the V.A.C. VERAT.R.A.C.™ Pad in a location that will not create a new pressure point. Proper bridging can be time consuming but is well worth it. For wounds on dorsal surfaces (in particular neck/spine, sacral, and heel wounds), it behooves the wound care team to create a bridge to the ventral side and place the V.A.C. VERAT.R.A.C.™

Pad on an offloaded area. First, line the intact skin with V.A.C.® Drape where it is planned to place the bridging foam to create a protective barrier. Next, ensure that the V.A.C. VERAFLO CLEANSE CHOICE™ contact layer foam, cover layer foam, and the bridge foam are all in tight contact prior to sealing with V.A.C.® Drape. Place the V.A.C. VERAT.R.A.C.™ pad on the ventral side of the patient with the tubing positioned to drain away from the patient as this will help to prevent any obstruction in the tubing.

MULTIDISCIPLINARY APPROACH

As with anything in medicine, the best result comes when a multidisciplinary

A proper seal is the key to any good dressing application. However, when it comes to wounds in areas of pressure, there is the added complication of friction and moisture along with the frequent poor periwound skin quality.


team works together. Floor nurses are the first line of defense; our institution asks nurses to check the V.A.C.® Dressing and therapy settings every shift, at a minimum. Ideally, the dressing is checked during each assessment so early signs of leakage or destruction of dressing integrity can be identified. Ideally, patients are placed on units that are staffed by nurses well trained in V.A.C.® Therapy and feel comfortable reinforcing dressings or troubleshooting alarms until a member of the surgical team can make an assessment. Additionally, our team relies greatly on the wound ostomy and continence nurses (WOCN) to help come up with creative new ways to tackle

hard-to-place dressings. Not only do these nurses have an arsenal of skin preparation techniques and barrier sprays, powders, and rings to help create an optimal seal, they are also able to advise as to the best offloading devices such a specialty beds, boots, foam wedges, etc.

Not to be discounted are the patients and their families and making them active participants in the patient’s care is beneficial in a multitude of ways. For the V.A.C. Ulta™ Therapy unit itself, making them aware of the different alarms and possible problems is key. For any pump that has been “off” or alarming for over 2 hours, it can be helpful to completely remove and reapply the dressing. If patients begin to notice a weakness in the dressing or leaking, they can alert the nursing staff and the problem can be tended to prior to the dressing going down completely. Patient education on offloading and positioning can also be of great value when trying to avoid excess friction.

SETTINGS AND TOPICAL SOLUTIONS

Once there is a tight seal, the next step is to decide on a topical solution

and settings. In general, a 20-minute dwell time and 2 hours with -125 mmHg negative pressure is our standard of care. This time frame was chosen due to the fact that polyhexanide plus 0.1% betaine was shown to be more effective at 20 minutes than at 6 minutes.1 We have since applied the time frame to other types of topical solutions. When it comes to topical instillation solution, our team has found that normal saline 0.9% was just as, if not more, effective when used with NPWTi-d than polyhexanide + betaine.2 As a result, our team generally uses normal saline as its first-line agent. For wounds with Pseudomonas, we often opt for acetic acid

1% solution. For those wounds with residual devitalized tissue or severe infection, Dakin’s (dilute sodium hypochlorite) quarter strength solution has been our instill agent of choice.

Finally, one must settle on an instill volume. It is important not to overfill and choose too large a volume or there will be leaks. That said, one must take into consideration the length of bridge and not just the wound bed itself or the opposite problem will result of too little, thereby causing the solution to never reach the wound bed. Using the “fill assist” feature, the provider can start and stop instillation to determine the appropriate amount of volume for each specific wound. Remember this volume may change as the wound heals or if the bridge length is changed. Always reassess the instill volumes when a new dressing is applied.

DISCUSSIONBased on our experience, the V.A.C.

VERAFLO CLEANSE CHOICE™ Dressing has unique properties that may provide an option for the cleansing of wounds that may contain infectious material or nonviable tissue. For wounds found on pressure

points, achieving an adequate fit, tight seal, and avoiding the creation of new points of pressure can be a challenge.

When changing the dressing, look at the wound bed and assess for areas that did not achieve as much granulation as others. Make corrections to the size and shape of the dressing contact layer accordingly. Utilize the clinical expertise in the institution. The WOCN can help identify additional materials that often will create a better seal and find innovative ways to help offload pressure. Remember that when treating a pressure ulcer, one must take care not to create new points of pressure with the negative pressure dressing. Always check tubing and clip placement to help preserve skin integrity. When placed correctly, the V.A.C. VERAFLO CLEANSE CHOICE™ Dressing can potentially have a remarkable effect on wound healing.

References:1. Kim PJ, Attinger CE, Steinberg JS, et al. The impact

of negative-pressure wound therapy with instillation compared with standard negative-pressure wound therapy: a retrospective, historical, cohort, controlled study. Plast Reconstr Surg. 2014;133(3):709-716. doi: 10.1097/01.prs.0000438060.46290.7a.

2. Kim PJ, Attinger CE, 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.

Based on our experience, the V.A.C. VERAFLO CLEANSE CHOICE™ Dressing has unique properties that may provide an option for the cleansing of wounds that may contain infectious material or nonviable tissue.


YOUR WOUND CARE OPTIONS JUST GOT BETTER

NOW YOU HAVE ANOTHER CHOICE

For more information, visit veraflo.com

FIGURE 1. WOUND AT PRESENTATION*

WOUND AFTER 1 DAY OF V.A.C. VERAFLO™ THERAPY

Therapy: V.A.C. VERAFLO™ Therapy with V.A.C. VERAFLO CLEANSE CHOICE™ Dressing

Settings: 10 minute Dwell, 3 hour NPWT, -125mmHg

Solution: VASHE® Wound Solution

NOTE: Specific indications, contraindications, warnings, precautions and safety information exist for KCI products and therapies. Please consult a physician and product instructions for use prior to application.

Copyright 2018 KCI Licensing, Inc. All rights reserved. VASHE Wound Solution is a trademark of SteadMed Medical, LLC. All other trademarks designated herein are proprietary to KCI Licensing, Inc., its affiliates and/or licensors. PRA-PM-US-00203 (02/18)

A 72-year-old male presented with an unstageable sacral wound with >60% adherent non-viable tissue and measuring 15cm X 11cm (Figure 1). Patient comorbidities included essential hypertension, cerebrovascular accident, and moderate to severe malnutrition. This patient also had moderate dementia/hospital acquired confusion leading him to be non-compliant with his treatment. Patient was transferred to a skilled nursing facility.

Patient data and photos courtesy of Luis G. Fernández, MD, FACS, FASAS, FCCP, FCCM, FICS

WOUND CARE IS FILLED WITH SURPRISESTRY V.A.C. VERAFLO CLEANSE CHOICE™ DRESSING WITH V.A.C. VERAFLO™ THERAPY

Note: As with any case study, the results and outcomes should not be interpreted as a guarantee or warranty of similar results. Individual results may vary, depending on the patient’s circumstances and condition.

Supported by an unrestricted educational grant from KCI.

NOTE: Specific indications, contraindications, warnings, precautions and safety information may exist for Systagenix and KCI (Acelity companies) products. Please consult a healthcare provider and product instructions for use prior to application. Rx only.

Copyright 2019 KCI Licensing, Inc. All rights reserved. Unless otherwise noted, all trademarks designated herein are proprietary to KCI Licensing, Inc., Systagenix Wound Management, Ltd., or Crawford Healthcare, Ltd. LIT# 29-D-381 • PRA-PM-US-01391 (05/19)

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