The use of topical negative pressure in a paediatric patient with extensive burns

Negative Pressure Wound Therapy in Pediatric Burn Patients: A Systematic Review

Significance: Negative pressure wound therapy (NPWT) requires the placement of a dressing over a wound, covered with an adhesive film, and applying to these dressing a negative pressure in a controlled fashion. This therapy is a powerful complement to surgical care of wounds. Data are however poor on its use in pediatric burns. Recent Advances: This systematic review, including a total of 466 patients, shows that NPWT as the initial treatment for burned children and after skin grafting has been shown to produce promising results. In the majority of studies, skin graft take rate is close to 100%. This therapy is particularly beneficial in the pediatric population because of less frequent dressing changes and early mobilization. NPWT devices accurately quantify burns water losses and allow tailoring liquid resuscitation. Critical Issues: NPWT is not in the subject of controlled clinical trials in pediatric; most publications are case reports or retrospective reviews. The sporadic complications include bleeding, local infections, and mechanical device issues. Future Directions: NPWT has been used in 2-month up to 18-year-old children with deep second- to third-degree burn of multiple etiologies, from a few days up to several months, on small to 40% total body surface area (%), and in difficult areas. Data gathered provide empirical guidelines on NPWT use in pediatric burns using continuous mode with a pressure of -50 to -75 mmHg for children younger than 2 years, and -75 to -125 mmHg in children over 2 years of age. Prospective randomized studies are needed to provide validated rules.

Pediatric necrotizing soft tissue infection after elective surgery: A case report and literature review

INTRODUCTION

Necrotizing soft tissue infections (NSTIs) are rare but often lethal. Early diagnosis and aggressive surgical debridement are essential to achieve the best possible outcome.

CASE PRESENTATION

A 12-year old boy was diagnosed with a necrotizing soft tissue infection following elective revision surgery for functional impairment resulting from scar tissue of the neck. Fever and inflammation of the surgical wound manifested 24-36 hours postoperatively. Antibiotic therapy with amoxicillin-clavulanic acid was initiated, but the patient was unresponsive. Ultrasonography, a wound culture and surgical exploration confirmed the diagnosis. The culture was positive for a Streptococcus pyogenes infection and antibiotic treatment was switched to penicillin and clindamycin. Following the diagnosis, surgical debridement was performed subcutaneously, and only necrotic tissue was removed to preserve as much skin tissue as possible. After eradication of the infection, vacuum-assisted closure of the wound was used to close the subcutaneous space. The patient was discharged after 40 days.

CONCLUSION

In this patient, we treated a necrotizing soft tissue infection with antibiotics, skin sparing surgeries and negative pressure wound therapy (NPWT). We used ultrasonography as imaging technique to help with the diagnosis. The extensiveness of surgical debridement was rather limited. We focused on opening all affected fascial layers. The surgical debridement was subcutaneous, and only necrotic tissue was removed. Because of the location in the neck, we tried to avoid an aggressive skin debridement to preserve as much skin tissue as possible. Negative pressure wound therapy is not frequently used in this context but it contributed to an enhanced wound healing. Ultrasonography for diagnosing NSTIs is useful, but the clinical findings and an explorative surgery will remain most important.

A Descriptive Study of the Temporal Patterns of Volume and Contents Change in Human Acute Burn Edema: Application in Evidence-Based Intervention and Research Design

Edema after burn contributes significantly to burn wound depth conversion. In humans after burn injury, there is a lack of detailed understanding of the contents and temporal changes in volume of acute tissue edema. The novel findings of these studies relate to the collection of edema fluid after partial-thickness burn injury. Edema volume peaks on day 1 after burn without formal fluid resuscitation. The studies indicated that the peak was on day 2 for a resuscitated burn. In contrast, animal studies suggest that the peak of edema occurs by or before day 1 after injury. The findings confirm the pitfalls of evidence derived from animal models and assuming direct transference to humans. Postburn edema was demonstrated to be a high-protein fluid (ie, ≥10 g/L) for the duration of the inflammatory period. The presence of high-protein edema presents greater challenges to clinicians developing novel treatment options. The rate of volume change over time tapered to insignificant levels after day 4 following burn. Greater than 98% of the edema contents was fluid. However, the size of particulate matter did not preclude it passing through patent lymphatic collectors. The results indicate a necessity for urgent postburn intervention, which should incorporate the active stimulation of the lymphatic system to improve efficacy of edema removal.

Negative pressure wound therapy for partial-thickness burns

BACKGROUND

A burn wound is a complex and evolving injury, with both local and systemic consequences. Burn treatments include a variety of dressings, as well as newer strategies, such as negative pressure wound therapy (NPWT), which, by means of a suction force that drains excess fluids from the burn, tries to promote the wound healing process and minimise progression of the burn wound.

OBJECTIVES

To assess the effectiveness of NPWT for people with partial-thickness burns.

SEARCH METHODS

We searched the Cochrane Wounds Group Specialised Register (searched 04 September 2014); The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2014, Issue 8).

SELECTION CRITERIA

All randomised controlled trials (RCTs) and controlled clinical trials (CCTs) that evaluated the safety and effectiveness of NPWT for partial-thickness burns.

DATA COLLECTION AND ANALYSIS

Two review authors used standardised forms, and extracted the data independently. We assessed each trial for risk of bias, and resolved differences by discussion.

MAIN RESULTS

One RCT, that was an interim report, satisfied the inclusion criteria. We undertook a narrative synthesis of results, as the absence of data and poor reporting precluded us from carrying out any formal statistical analysis. The trial was at high risk of bias.

AUTHORS' CONCLUSIONS

There was not enough evidence available to permit any conclusions to be drawn regarding the use of NPWT for treatment of partial-thickness burn wounds.

Negative pressure dressing assisted healing in pediatric burn patients

BACKGROUND/PURPOSE

Pediatric burn patients traditionally require multiple dressing changes and significant amounts of narcotics. Negative pressure dressings (NPDs) have emerged as an effective wound therapy that may represent an alternative primary dressing for these patients.

METHODS

This is a single institution, retrospective study of pediatric burn patients treated with NPDs over a defined 2 year period. Twenty-two patients were identified and their charts reviewed for age, sex, mode of injury, location of injury, degree of burn, length of stay, length of dressing required, number of dressing changes, and narcotic use between dressing changes.

RESULTS

The average patient was 3.5 years old (range of 8 months to 10 years old) with partial thickness burns involving 8.5% (range 3-18%) body surface area. The average treatment regimen was 3.5 dressing changes more than 6.6 days, with a mean hospital stay of 9.6 days. The average child received 9.4 total doses of delivered narcotics during their inpatient care.

DISCUSSION

The use of NPD in pediatric burn patients does require sedation and narcotics which limits its usefulness in the general pediatric burn population. Yet, they adhere well and stay in place even on active children, they capture and quantify fluid losses, they only require changes every 2-4 days and promote the adherence of split thickness skin grafts making them useful in various clinical situations.

CONCLUSIONS

NPDs are a viable option for both partial and full thickness burns in pediatric patients that do not require transfer to a burn unit. NPDs may be advantageous in highly active children, those with extensive fluid losses, those that require sedation for dressing changes and those that will require grafting.

Negative pressure wound therapy for partial-thickness burns

BACKGROUND

A burn wound is a complex and evolving injury, with both local and systemic consequences. Burn treatments include a variety of dressings, as well as newer strategies, such as negative pressure wound therapy (NPWT), which, by means of a suction force that drains excess fluids from the burn, tries to promote the wound healing process and minimise progression of the burn wound.

OBJECTIVES

To assess the effectiveness of NPWT for people with partial-thickness burns.

SEARCH METHODS

For this third update we searched the Cochrane Wounds Group Specialised Register (searched 18 May 2012); The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 5); Ovid MEDLINE (2010 to May Week 2 2012); Ovid MEDLINE (In-Process & Other Non-Indexed Citations 17 May 2012); Ovid EMBASE (2010 to 2012 Week 19); and EBSCO CINAHL (2010 to 16 May 2012).

SELECTION CRITERIA

All randomised controlled trials (RCTs) and controlled clinical trials (CCTs) that evaluated the safety and effectiveness of NPWT for partial-thickness burns.

DATA COLLECTION AND ANALYSIS

Two review authors used standardised forms, and extracted the data independently. We assessed each trial for risk of bias, and resolved differences by discussion.

MAIN RESULTS

One RCT, that was an interim report, satisfied the inclusion criteria. We undertook a narrative synthesis of results, as the absence of data and poor reporting precluded us from carrying out any formal statistical analysis. The trial was at high risk of bias.

AUTHORS' CONCLUSIONS

There was not enough evidence available to permit any conclusions to be drawn regarding the use of NPWT for treatment of partial-thickness burn wounds.

Use of a nanocrystalline silver dressing and vacuum-assisted closure in a severely burned dog

OBJECTIVE

To describe the first veterinary use of a nanocrystalline silver dressing (NSD) and use of vacuum-assisted closure (VAC) to treat a severely burned dog.

CASE OR SERIES SUMMARY

A 1-year-old female intact American Staffordshire Terrier with 50% total body surface area burned was referred for definitive care approximately 18-24 hours post injury. The dog was treated with crystalloid fluids, hydroxyethyl starch, and antimicrobials based on culture and sensitivity results of wound cultures, fresh frozen plasma, human serum albumin, and packed red cells. Wound care initially consisted of daily debridement under anesthesia with silver sulfadiazine application and bandaging. Because of the extent and the location of the wounds and morbid state of the patient, early wound grafting was not an option. Because of its reported improvement in granulation tissue formation and decreased tissue edema, VAC was used once the majority of burned tissue was manually debrided. Because of the pain caused by VAC and traditional bandaging techniques with this extent of injury, an NSD was utilized. This strategy was chosen due to the antimicrobial properties of NSD and the reduced necessity for daily bandage changes, which was reduced to only every 3 days. This protocol reduced the need for daily sedation or anesthesia.

NEW OR UNIQUE INFORMATION PROVIDED

VAC and NSD were used successfully for the treatment of a severe burn injury in a dog. The use of NSD decreased the cost of therapy by reducing the need for daily bandage changes, thereby reducing the anesthetic and analgesic costs and allowing the patient to be managed on an outpatient basis.

Vacuum-assisted closure device: a useful tool in the management of severe intrathoracic infections

BACKGROUND

This study is an evaluation of the vacuum-assisted closure (VAC) therapy for the treatment of severe intrathoracic infections complicating lung resection, esophageal surgery, viscera perforation, or necrotizing pleuropulmonary infections.

METHODS

We reviewed the medical records of all patients treated by intrathoracic VAC therapy between January 2005 and December 2008. All patients underwent surgical debridement-decortication and control of the underlying cause of infection such as treatment of bronchus stump insufficiency, resection of necrotic lung, or closure of esophageal or intestinal leaks. Surgery was followed by intrathoracic VAC therapy until the infection was controlled. The VAC dressings were changed under general anesthesia and the chest wall was temporarily closed after each dressing change. All patients received systemic antibiotic therapy.

RESULTS

Twenty-seven patients (15 male, median age 64 years) underwent intrathoracic VAC dressings for the management of postresectional empyema (n=8) with and without bronchopleural fistula, necrotizing infections (n=7), and intrathoracic gastrointestinal leaks (n=12). The median length of VAC therapy was 22 days (range 5 to 66) and the median number of VAC changes per patient was 6 (range 2 to 16). In-hospital mortality was 19% (n=5) and was not related to VAC therapy or intrathoracic infection. Control of intrathoracic infection and closure of the chest cavity was achieved in all surviving patients.

CONCLUSIONS

Vacuum-assisted closure therapy is an efficient and safe adjunct to treat severe intrathoracic infections and may be a good alternative to the open window thoracostomy in selected patients. Long time intervals in between VAC changes and short course of therapy result in good patient acceptance.

Evidence-based recommendations for the use of Negative Pressure Wound Therapy in traumatic wounds and reconstructive surgery: steps towards an international consensus

Negative pressure wound therapy (NPWT) has become widely adopted over the last 15 years and over 1000 peer reviewed publications are available describing its use. Despite this, there remains uncertainty regarding several aspects of usage. In order to respond to this gap a global expert panel was convened to develop evidence-based recommendations describing the use of NPWT. In this paper the results of the study of evidence in traumatic wounds (including soft tissue defects, open fractures and burns) and reconstructive procedures (including flaps and grafts) are reported. Evidence-based recommendations were obtained by a systematic review of the literature, grading of evidence, drafting of the recommendations by a global expert panel, followed by a formal consultative consensus development program in which 422 independent healthcare professionals were able to agree or disagree with the recommendations. The criteria for agreement were set at 80% approval. Evidence and recommendations were graded according to the SIGN (Scottish Intercollegiate Guidelines Network) classification system. Twelve recommendations were developed in total; 4 for soft tissue trauma and open fracture injuries, 1 for burn injuries, 3 for flaps and 4 for skin grafts. The present evidence base is strongest for the use of NPWT on skin grafts and weakest as a primary treatment for burns. In the consultative process, 11/12 of the proposed recommendations reached the 80% agreement threshold. The development of evidence-based recommendations for NPWT with direct validation from a large group of practicing clinicians offers a broader basis for consensus than work by an expert panel alone.

Use of gauze-based negative pressure wound therapy in a pediatric burn patient

Negative pressure wound therapy (NPWT) is described as it is used in the treatment of an infant burn victim. This case highlights the ability and techniques used to maintain an airtight dressing seal in the perirectal region. Use of this dressing type post-skin grafting allowed for 100% graft adhesion and no bacterial contamination despite close proximity to the rectum. Favorable experience and outcome with this patient are strong indicators that NPWT should be considered as a viable treatment in pediatric populations and that situations where body contour or fluids may make NPWT difficult to administer should not be a deterrent to therapy.

V.A.C. Therapy in the management of paediatric wounds: clinical review and experience

Usage of negative pressure wound therapy (NPWT) in the management of acute and chronic wounds has grown exponentially in the past decade. Hundreds of studies have been published regarding outcomes and methods of therapy used for adult wounds. This treatment is increasingly being used to manage difficult-to-treat paediatric wounds arising from congenital defects, trauma, infection, tumour, burns, pressure ulceration and postsurgical complications in children, although relatively few studies have been aimed at this population. Given the anatomical and physiological differences between adults and children, a multidisciplinary expert advisory panel was convened to determine appropriate use of NPWT with reticulated open cell foam (NPWT/ROCF) as delivered by Vacuum Assisted Closure (V.A.C. Therapy, KCI Licensing, Inc., San Antonio, TX) for the treatment of paediatric wounds. The primary objectives of the expert advisory panel were to exchange state-of-practice information on paediatric wound care, review the published data regarding the use of NPWT/ROCF in paediatric wounds, evaluate the strength of the existing data and establish guidelines on best practices with NPWT/ROCF for the paediatric population. The proposed paediatrics-specific clinical practice guidelines are meant to provide practitioners an evidence base from which decisions could be made regarding the safe and efficacious selection of pressure settings, foam type, dressing change frequency and use of interposing contact layer selections. The guidelines reflect the state of knowledge on effective and appropriate wound care at the time of publication. They are the result of consensus reached by expert advisory panel members based on their individual clinical and published experiences related to the use of NPWT/ROCF in treating paediatric wounds. Best practices are described herein for novice and advanced users of NPWT/ROCF. Recommendations by the expert panel may not be appropriate for use in all circumstances. Decisions to adopt any particular recommendation must be made by the collaborating medical team, including the surgeon and wound care specialist based on available resources, individual patient circumstances and experience with the V.A.C. Therapy System.

An overview of negative pressure wound therapy for the lower extremity

Since its introduction into the market, negative pressure wound therapy (NPWT), also known as topical negative pressure, has become an important adjuvant therapy for the treatment of many types of wounds. Surgeons and physicians of all subspecialties have adopted NPWT into their practices. NPWT has become a mainstay in the management of lower extremity soft tissue pathology, especially in patients with traumatic, diabetic, postsurgical, and peripheral vascular disease-associated wounds. This article reviews the background, currently understood mechanisms of action, applications, contraindications, reported complications, advantages, criticisms, and techniques in the lower extremity.

Negative pressure wound therapy with reticulated open cell foam in children: an overview

This article summarizes the results of a comprehensive review of the literature on the use of negative pressure wound therapy with reticulated open cell foam (NPWT/ROCF) as delivered by V.A.C.(R) Therapy (KCI, San Antonio, TX) in pediatric patients. A review of the literature revealed 20 articles that discussed the use of NPWT/ROCF in exclusively pediatric patients. Nine articles were retrospective reviews, and 11 were case studies. This review discusses the insights from these articles. This review discusses the versatility of NPWT/ROCF for use with pediatric patients with infected wounds; full-thickness burns; open fractures; large soft tissue wounds; surgical wounds of the chest, abdomen, and spine; pilonidal disease; and pressure ulcers. NPWT/ROCF has been used in children as young as a few weeks of age, and in children with comorbidities such as congenital heart disease, immunosuppression, and spina bifida. Wound healing in children can be delayed by impaired perfusion, infection, edema, and poor nutrition. Clinical considerations for using NPWT/ROCF in children can include differences in healing due to higher granulation rates requiring more frequent dressing changes, poor nutritional status, small size, and low weight. With pediatric patients, there is no consensus on foam (white or black) selection, optimum amount of negative pressure, frequency of NPWT/ROCF dressing changes, and interposing contact layer selection. Randomized prospective studies are needed to make recommendations for safe and efficacious clinical practice. Research regarding the effects of dressing types, adjunctive treatment, and wound healing in neonates and children is needed.

Evidence-based medicine: vacuum-assisted closure in wound care management

A review of the evidence base for the use of vacuum-assisted closure (VAC) therapy is presented, analysing both experimental and clinical data.

Topical negative pressure (TNP) for partial thickness burns

BACKGROUND

A burn wound is a complex and evolving injury, with both local and systemic consequences. Treatment includes using variety of dressings, but newer strategies such as topical negative pressure therapy have been developed to try and promote the wound healing process and minimize burn wound progression to involve deeper tissue in the acute phase. Topical negative pressure uses a suction force to drain excess fluids.

OBJECTIVES

To assess the effectiveness of TNP for those people with partial thickness burns.

SEARCH STRATEGY

We searched the Cochrane Wounds Group Specialised Register (searched April 2007), the Cochrane Central Register of Controlled Trials (CENTRAL)(The Cochrane Library Issue 2, 2007), Ovid MEDLINE (1950 to April Week 4 2007), Ovid EMBASE (1980 to Week 18 2007) and Ovid CINAHL (1982 to April Week 4 2007).

SELECTION CRITERIA

All randomised controlled trials (RCTs) and controlled clinical trials (CCTs) that evaluated the safety and effectiveness of TNP for partial thickness burns.

DATA COLLECTION AND ANALYSIS

Two authors using standardised forms extracted the data independently. Each trial was assessed for internal validity with differences resolved by discussion. A narrative synthesis of results was undertaken as the absence of missing data, poor reporting, or both precluded the authors to undertake any formal statistical analysis.

MAIN RESULTS

One RCT satisfied the inclusion criteria. The methodological quality of the trial was poor.

AUTHORS' CONCLUSIONS

There is a paucity of high quality RCTs on TNP for partial thickness burn injury with insufficient sample size and adequate power to detect differences, if there are any, between TNP and conventional burn wound therapy dressings.