If No Pressure Prevents Pressure Ulcers, Does Negative Pressure Heal Them?

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Perspective of Nursing Care from Past to Future by Matron Marley

by Margaret Heale, RN, MSc, CWOCN

So after I last wrote, I was to assist with a dressing change, as the resident is more relaxed with somebody having their focus on her and not also trying to do the procedure. I have done a million or two dressings in my time but had not seen a negative pressure wound therapy (NPWT) vacuum till I started helping out at the nursing home where my granddaughter works. I came across the treatment accidentally, very accidentally.

I went in to make the bed and got my foot caught in the NPWT device tubing. How I didn't end up in a heap, I don't know (my granddaughter would have killed me). I managed somehow to direct my forced dive toward the bed surface and ended up on the skid mark on the edge, aghh! I washed my arm and mentally noted how lucky I was to have not got a mark on me. I did not tell my granddaughter and so was saved from certain death at the hands of my offspring, for now anyway.

The woman connected to the device had a sacral pressure ulcer prior to admission and it was debrided with an enzyme. I had seen enzymatic debridement a long time back, not an ointment like your Santyl, but a Streptokinase (it was called Varidase). We injected it under the eschar. I was never very convinced we knew exactly where it was going but it worked. Lifting off an eschar is quite an experience but once the top was off we ended up with a fairly disagreeable stringy soup which would lead to infection on occasions, much as now with the ointment. When Streptokinase started to be used for heart attack victims, the use in wound care stopped at some point, I am not sure when.

I am under the impression surgeons today are no different from 50 years ago, having little interest in wounds, even the ones they create. I seem to remember Mr. Lock (British surgeons are not called 'Doctor' once fully fledged) saying, "I just make the wounds, I want nothing to do with them afterwards." Had you picked up I was an alien from abroad? Well you know now, a wrinkled alien, an E.T. from across the Atlantic.

It seems to me that negative pressure wound therapy caught the attention of surgeons because it is a gizmo; a new toy. Certainly the research done on moist wound healing never grabbed them in the way the NPWT device has, shame that.

The first time I saw suction used on a wound was as a sister on a surgical ward in 1976 (there it is fully out of the closet, not a religious sister but a female British ward manager). The woman had come in with back pain, was sat on for days by orthopedics before they asked for a surgical consult. The surgeons unconvinced of a surgical problem put off operating on her, but regretted it as on 'the table' was a perforated appendix with severe peritonitis. She was very sick and dehisced her wound day three after surgery, developing one of the worst post-operative wounds I ever saw in anyone under 30. She was the reason I became interested in wound care. We tried many things on her abdomen over the months she was with us and low pressure wall suction was one on them. Another was an ostomy pouch to the fistula she had and a new ostomy type wafer material, but that is a story for another day. Her dressing had to be done at least twice a shift and the skin around her wound was breaking open from moisture. So we used a Foley catheter along with low wall suction. Positioning her exactly right was important as the exudate pooled in one particular area and then undermined the wafer of the ostomy pouch. The dressing frequency went down to once a shift and the pouching system sometimes was able to be left for a whole day. The system always failed due to pieces of dressing material blocking the tubing. So that was then.

This is now. In we go, the three of us to change the NPWT device. The staff nurse had made sure everything necessary had been gathered together. After switching off the canister, clamping both tubes and alcohol wiping the connections, she tucked and taped the canister end into the alcohol prep pad foil and with the other tube (patient side) expertly held a NS loaded syringe to the opening as she released the clamp pushing in the saline while explaining to her junior that this helps release the foam from the wound bed. She quickly prepared the pull-out table with supplies while the new nurse positioned the resident, placed a folded chux and released the film covering. She did this with a new silicone product that unlike regular adhesive removers doesn't need to be washed off the skin in order to apply fresh film. I had always struggled teaching staff how to remove adhesive dressings correctly by supporting the skin and pulling the adhesive surface back over itself, not upward, so this was an interesting and very useful alternative.

I watched carefully as I held the residents hand and told her what we were doing. More saline went into the sponge at the edges and the squished black foam plumped up and was lifted out. The wound was sprayed from a bottle and the nurses closed their eyes as the person firing said, "I just never remember to bring goggles." She dried off the peri-wound skin, and they discussed how stoma powder can be used on denuded skin crusted over with skin prep but how much better it is if the wound edge is then protected with Duoderm. Yeasty issues often occur in such a moist environment and then the powder utilized can be an antifungal. She folded back the chux, removed her gloves and 'gelled her hands', reminding her colleague of this important transition from cleaning to 'doing' the dressing. The packaging was opened and a pair of sterile scissors used with gloves from the box on the wall. She trimmed the foam explaining that there were many shapes and sizes that meant being an artist was not an essential requirement, a relief for many I am sure. In went the sponge a little smaller than the hole, on went the drape in three strips for ease of application and so as no hole needed to be cut for the disc (apparently tiny pieces can be missed and then block the tube). The disc was placed and tubing connected. One of the nurses pressed gently on the dressing and sticky drape as the machine was started, I dutifully warned the resident and she hardly winced as the sponge became like a raisin.

I was left wondering: if an alcohol wipe is sufficient when tubing connections are draped on the floor to trip over volunteers, if the previous person delving into the glove box had ‘gelled their hands’, if surgeons close their eyes when operating (I do hope not). I am also in awe at how very useful packaging foam can be when sterilized but wonder why the cost is so great for such products...

As for the future, it is evident that negative pressure wound therapy has diversified from black foam to a variety of materials and suction apparatus. Describing and researching some of the problems with this therapy has to happen at some point. Granulation tissue meshing into the sponge, bleeding, pain at dressing removal all need some investigation as does scar formation.

About The Author
Based on her extensive nursing experience Margaret Heale, Wound, Ostomy and Continence Nurse, takes us into the blog journal of a fictitious matron, "Perspective of Nursing Care from Past to Future by Matron Marley."

The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.

Practical Guide to NPWT


Studies show that pressure ulcer formation is actually driven by inflammation - just as venous ulcers are a primarily inflammatory process. So no, NPT will not magically reverse the damage. A more logical approach would be to apply an inflammation reducing dressing.

It seems as if the marketing for NPT appeals to the ego of the nurses: you are so clever that you can even apply NPT! Meanwhile, reimbursement dramatically favors NPT, despite lack of evidence of efficacy - someone has really good lobbyists. Surgeons say they use it so that they can say, "We tried everything." Isn't that a bit lame? At a time when healthcare costs are being scrutinized, why would we saddle our patients with an expensive device that diminishes their quality of life without providing benefits beyond what can be obtained using modern moist dressings?

Read the research and all of the RTCs supporting the correct use of npwt - in particular the one company that has been the only one to do research or even have various independent studies done by large, prestigious institutions. How often does someone do a study without vendor input or support that has positive? Please base your comments that have fact and published data and do not insult the providers who improve and reduce the TCT (total cost to treat) for patients with wounds by practicing evidenced based medicine. By the way, there was a study on DFUs that showed reduced TCT, statistically significantly better 100% heal rates along with other improved secondary outcomes in which VAC (KCI tm) was compared to advanced moist wound therapies. Please support any comments with evidence.

How interesting, thank you (Nurselindab) for reminding us about the inflammatory aspect of the pathology of pressure ulcers. Inflammation is such a necessary part of our defenses, but so also destructive - nature is so clever.

I had thought nurses beyond liking 'new toys' and was surprised at the perspective you have taken but we all have our own experiences to draw from and I expect this is what you have seen, hopefully in time you will also see some of the positive outcomes that occur.

As "Anonymous" points out in her response to your post, there is some good evidence for the use of negative pressure wound therapy including a few randomized controlled trials (RCTs), though the early studies use moist gauze as a comparison. NPWT is definitely here to stay and will continue well into the future, hopefully for the right reason. You do have some interesting reminders and I share your view that there are people making a lot of money out there at everybody's expense (and not just with this therapy). I have seen some major skin defects and scaring from NPWT and though I have seen people whose quality of life has been reduced by NPWT, mostly my experience suggests their life is better because of how effectively it contains drainage.

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