clinical study managing acute wounds with negative...

Hindawi Publishing CorporationISRN Plastic SurgeryVolume 2013, Article ID 796254, 4 pageshttp://dx.doi.org/10.5402/2013/796254

Clinical StudyManaging Acute Wounds with Negative Pressure System ina Developing Country

J. Akpaloo,1,2,3,4,5 J. Yorke,2,3,4,5 P. Agbenorku,1,2,3,4,5 and E. M. T. Yenli2,3

1 Reconstructive Plastic Surgery & Burns Unit, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana2Department of Surgery, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana3 Komfo Anokye Teaching Hospital, Kumasi, Ghana4 School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana5 Kwame Nkrumah University of Science and Technology, Kumasi, Ghana

Correspondence should be addressed to P. Agbenorku; [email protected]

Received 22 April 2013; Accepted 30 May 2013

Academic Editors: C. Maldonado, M. Okazaki, E. Raposio, and J. Y. Yang

Copyright © 2013 J. Akpaloo et al. This is an open access article distributed under the Creative Commons Attribution License,which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Introduction.Thenegative pressure systemhas been found to be a valuable addition to the various procedures ofwoundmanagementand has been widely accepted to be safe and effective in promoting wound healing. Aim. The study seeks to find out the outcomeof the use of the VAC device in the treatment of patients with acute wounds. Materials and Methods. Between January 2009 andDecember 2011, a consecutive nonrandomized study was conducted among 48 patients who presented with acute wounds at theKomfo Anokye Teaching Hospital. Patients were made to undergo negative pressure wound therapy using the VAC device. Results.Forty-eight patients with various degrees of acute wounds were treated, of which 43 (89.6%) were females and 5 (10.4%) weremales.Ages of patients ranged from 19 to 78 years. Satisfaction with rate of wound healing revealed that 86.7% and 8.9% had excellent andgood healing, respectively, while 4.4% said theirs was satisfactory.Therapywas discontinued in three (6.3%) patients who developedsome complications. Conclusion. There was reduction in the hospitalization by patients thereby reducing costs. Also, quality of lifeof persons who had undergone the therapy with the VAC device had improved. Even though a few device-related complicationswere observed, patient satisfaction was high.

1. Introduction

Woundmanagement has been a challenging problemover theyears requiring innovative methods of treatment to improvewound granulation and contraction, minimize the dressingand nursing requirement, and dramatically reduce the costassociated with wound management [1–5]. Managing acutewounds with negative pressure wound therapy (NPWT) atsubatmospheric pressure is safe and effective [6, 7].The use ofsubatmospheric pressure to promote debridement andwound healing was first documented by Fleischmann et al.(1993) [8]. The NPWT also known as the vacuum-assistedclosure (VAC) technique promotes wound healing by suc-tioning of excess fluid from the wound, increasing localblood flow, and enhancing the formation of granulation tissue[6, 9, 10]. It also prevents an increase in infection [10]. TheNPWT also known as the vacuum-assisted closure (the VAC)

technique employs the use of an open cell foam dressing thatis placed into the wound cavity and the application of sub-atmospheric pressure (125mmHg below ambient pressure)[6, 11].

Argenta and Morykwas published a clinical report of avariety of complicated wounds of the torso and extremitiesthat responded successfully to NPWT in a system known asthe vacuum-assisted closure (VAC), Kinetic Concepts, Incor-porated (KCI; San Antonio, TX, USA) [6, 12].

A systematic review of the effectiveness and safety ofnegative pressure wound therapy revealed that NPWT is aseffective as or better than current local treatment for wounds[7].Thus, the VAC system is linkedwith complete wound clo-sure and shorter time to satisfactory healing compared withadvanced moist wound therapy and saline moistened gauzedressings, respectively [13, 14]. In recent years, VAC has beenshown to be an effective therapy for themanagement of large,

2 ISRN Plastic Surgery

complex, acute wounds as well as chronic wounds that havefailed to heal by conventional methods [15].

Acute wounds are caused by external damage to intactskin and include surgical wounds, bites, burns, minor cutsand abrasions, and more severe traumatic wounds such aslacerations, avulsions, and those caused by crush or gunshotinjuries [16].

The use of the VAC system in the treatment of extremitiesand orthopaedic trauma and treating degloving injuries andburns have also been documented [17–22]. The use of VACdevice results in improvement in the quality of life of patientsas a result of decreased hospitalisation and morbidity as wellas reduction in hospital expenses. The use of the VAC devicein treating burns has been useful for body sites with irregularor deep contours such as the perineum, hand, or axilla [23,24]. This study has been designed to find out the outcome ofthe use of the VAC device in the treatment of patients withacute wounds.

2. Materials and Methods

2.1. Study Setting. Komfo Anokye Teaching Hospital(KATH), located in Kumasi, is the second-largest hospital inGhana and the only tertiary health institution in the middlebelt of the country. It is the main referral hospital for theAshanti, Brong-Ahafo, northern, upper east, and upper westregions.

2.2. Patient Management. A consecutive nonrandomizedstudy was conducted between January 2009 and December2011 at theKomfoAnokyeTeachingHospital, Kumasi, Ghana.Patients who presented to the Accident and Emergency Unitwith acute wounds were enrolled into the study after writtenconsent was obtained. Adults who presented with acutewounds at theAccident and EmergencyCenter were includedin the study while subjects with chronic ulcers such asdiabetic ulcers were excluded as well as children and subjectswho did not give consent.

Before the start of the negative pressure therapy, thewounds were debrided to remove necrotic and infectedtissues in order to get a clean wound bed. The commerciallyavailable VAC device was then connected and therapy startedaccording to the manufacturer’s instruction (Kinetic Con-cepts, Incorporated (KCI; San Antonio, TX, USA) based onthe system developed by Argenta and Morykwas).

On the average, the device was used for 28 days. Thelength of admission ranged from 12 to 54 days. Split thicknessskin grafting (STSG) was done to completely cover allwounds.

3. Results

Forty-eight subjects with various degrees of acute woundswere treated using VAC negative pressure wound therapysystem. Of the 48 subjects treated, 43 (89.6%) were femalesand 5 (10.4%) were males. Ages of patients ranged from 19 to78 years. The length of admission ranged from 12 to 54 days.Table 1 shows the causes of wounds treated within the study

Table 1: Causes of wounds treated with NPWT system.

Causes and site of ulcer Frequency Percent (%)Avulsion injuries of the right upperlimbs 39 81.3

Postcellulitic leg ulcers 5 10.4Gluteal ulcers following intramuscularinjection 4 8.3

Table 2: Satisfaction rate of wound healing.

Grading Number of patients (𝑛) (%)Bad 0 (0.0%)Fair 0 (0.0%)Satisfactory 2 (4.4%)Good 4 (8.9%)Excellent 39 (86.7%)

Table 3: Complications arising from the use of the VAC device.

Grading Number of patients (𝑛) (%)Severe 1 (2.1%)Mild 2 (4.2%)None 45 (93.8%)

period.The therapywas discontinued in three (6.3%) patientswho developed some complicationswhich included bleeding,intolerance of device by patients, and severe wound infection.Patients were made to grade their satisfaction rate of woundhealing on a scale of 1–5: 1: bad, 2: fair, 3: satisfactory, 4: good,and 5: excellent (Table 2). Complications arising from the useof the VAC device were also assessed on a scale of 1–3: 1:severe, 2: mild, and 3: none (Table 3).

Figure 1 shows a patient, a 37-year-old woman, with agluteal ulcer following an intramuscular Gvither injection,who had undergone the negative wound pressure therapyusing the VAC device.

4. Discussion

Following the introduction of the VAC device over twodecades ago, negative pressure wound therapy (NPWT)appears to be safe treatment for wounds and serious adverseevents have been rarely reported [6, 7].

In a multicenter randomized controlled trial that com-pared NPWT with advanced moist wound therapy (pre-dominantly hydrogels and alginates), the NPWT achievedcomplete wound closure by 43.2% versus 28.9% for advancedmoist wound therapy during the treatment period [13].Whencompared with saline moistened gauze dressings, VAC wasassociated with a shorter time to satisfactory healing of 17.5 to22.8 days versus 37.5 to 42.8 days for saline moistened gauzedressings [14, 25].

In their study of VAC for the management of patientswith high-energy soft tissue injuries, Herscovici et al. demon-strated that there was no need for further treatment or tissuetransfer in nearly 57% of the subjects [18]. In our study,

ISRN Plastic Surgery 3

(a) Postinjection gluteal ulcer (b) Wound appearance 2 days after debride-ment and treatment with VAC

(c) At 4 days with VAC therapy

(d) At 14 days, the wound looks clean (e) At 35 days, woundwith healthy granulation tissue, ready for split thickness skingrafting

Figure 1: Gluteal ulcer following intramuscular injection.

however, all wounds had formal debridement of necrotictissue and also all wounds had tissue transfer in the form ofsplit thickness skin grafting because they were large.

The system was changed at every three-to-five day inter-val.This is consistent with work done by Chariker et al. (1989)[1]. Generally, changing the system every five days is anadvantage of continuous suction, and this method allows forwound contracture and epithelization.

While our study showed satisfactory healing to be as earlyas 12 days, McCallon and coworkers observed satisfactoryhealing on average of 22.8 (+/17.4) days [14] calculated fromdate of wound debridement. The shorter time to satisfactoryhealing observed in our study could be because our subjectspresented with acute ulcers while those studied by McCallonet al. were diabetic foot ulcers. Diabetic foot ulcers are chroniculcers and are generally more difficult to treat.

The use of the VAC device has facilitated wound healingin patients in this study. Patients who would have otherwisespent much time if the conventional methods were employedin the management of their wounds now showed a high levelof satisfaction having undergone therapy with this commer-cially available device; hence the use of VAC device impliesdecrease in hospital stay and cost. Cost effectiveness with theuse of the VAC device was also reported by Philbeck et al.(1999) [26].

The study showed both patients and clinicians weresatisfied with the use of the VAC device. Satisfaction with theuse of theVACdevice has also been documented byOzturk etal. (2009) [27]. Quality of life of patients has hereby improved.

The current study revealed complications in three pa-tients of which one suffered severe bleeding. Some compli-cations from the use of the VAC device, though uncommon,have been reported. Citak et al. (2010) reported a rare compli-cation after VAC therapy in the treatment of deep sore ulcersin a paraplegic patient. They recommended close clinicalmonitoring of the device by experienced medical profes-sionals [28]. Other complications such as pain, infection,bleeding, and fluid depletion have also been reported [29, 30].

5. Conclusion

Managing acute wounds with commercially available VACdevice has been very useful and well tolerated by the patients.Hospitalization days as well as comorbidity had reducedresulting in increase in the quality of life of these patients aswell as reduction in hospital cost. Patients showed muchsatisfaction with the use of the VAC device.

Ethical Approval

Ethical clearance was obtained from the Kwame NkrumahUniversity of Science and Technology School of MedicalSciences/Komfo Anokye Teaching Hospital Committee onHuman Research, Publication and Ethics, Kumasi, with ap-proval no. CHRPE/AP/030/12.

Conflict of Interests

No conflict of interests is declared by any of the authors.

4 ISRN Plastic Surgery

References

[1] M. E. Chariker, K. F. Jeter, T. E. Tintle, and J. E. Bottsford,“Effectivemanagement of incisional and cutaneous fistulaewithclosed suction wound drainage,”Contemporary Surgery, vol. 34,pp. 59–63, 1989.

[2] C. M. Moues, G. J. van den Bemd, W. J. Meerding, and S. E.Hovius, “An economic evaluation of the use of TNP on full-thickness wounds,” Journal of Wound Care, vol. 14, no. 5, pp.224–227, 2005.

[3] B. E. Leininger, T. E. Rasmussen, D. L. Smith, D. H. Jenkins, andC. Coppola, “ExperiencewithwoundVAC and delayed primaryclosure of contaminated soft tissue injuries in Iraq,” Journal ofTrauma, vol. 61, no. 5, pp. 1207–1211, 2006.

[4] D. G. Armstrong and L. A. Lavery, “Negative pressure woundtherapy after partial diabetic foot amputation: a multicentre,randomised controlled trial,”The Lancet, vol. 366, no. 9498, pp.1704–1710, 2005.

[5] J. Apelqvist, D.G.Armstrong, L. A. Lavery, andA. J.M. Boulton,“Resource utilization and economic costs of care based on a ran-domized trial of vacuum-assisted closure therapy in the treat-ment of diabetic foot wounds,”TheAmerican Journal of Surgery,vol. 195, no. 6, pp. 782–788, 2008.

[6] L. C. Argenta and M. J. Morykwas, “Vacuum-assisted closure:a new method for wound control and treatment: clinical ex-perience,” Annals of Plastic Surgery, vol. 38, no. 6, pp. 563–577,1997.

[7] P. Vikatmaa, V. Juutilainen, P. Kuukasjarvi, and A. Malmivaara,“Negative pressure wound therapy: a systematic review oneffectiveness and safety,” European Journal of Vascular andEndovascular Surgery, vol. 36, no. 4, pp. 438–448, 2008.

[8] W. Fleischmann, W. Strecker, M. Bombelli, and L. Kinzl,“Vacuum sealing for treatment of soft tissue injury in openfractures,” Unfallchirurg, vol. 96, no. 9, pp. 488–492, 1993.

[9] M. Trujillo-Martın, L. Garcıa-Perez, and P. Serrano-Aguilar,“Effectiveness, safety and cost-effectiveness of the negative pres-sure wound therapy on the treatment of chronic wounds: a sys-tematic review,’’MedicinaClinica,vol. 137,no.7, pp. 321–328, 2011.

[10] A. Adeyi, S. Muzerengi, and I. Gupta, “Leg ulcers in older peo-ple: a review of management,” The British Journal of MedicalPractitioners, vol. 2, no. 3, pp. 21–28, 2009.

[11] S. Thomas, “Worldwide wounds: an introduction to the use ofvacuum assisted closure,” http://www.worldwidewounds.com/2001/may/Thomas/Vacuum-Assisted-Closure.html.

[12] M. J. Morykwas, L. C. Argenta, E. I. Shelton-Brown, and W.McGuirt, “Vacuum-assisted closure: a new method for woundcontrol and treatment: animal studies and basic foundation,”Annals of Plastic Surgery, vol. 38, no. 6, pp. 553–562, 1997.

[13] P. A. Blume, J. Walters, W. Payne, J. Ayala, and J. Lantis, “Com-parison of negative pressure wound therapy usingVacuum-assisted closure with advanced moist wound therapy in thetreatment of diabetic foot ulcers,” Diabetes Care, vol. 31, no. 4,pp. 631–636, 2008.

[14] S. K.McCallon, C. A. Knight, J. P. Valiulus, M.W. Cunningham,J. M. McCulloch, and L. P. Farinas, “Vacuum-assisted closureversus saline-moistened gauze in the healing of postoperativediabetic footwounds,”Ostomy/WoundManagement, vol. 46, no.8, pp. 28–34, 2000.

[15] E. Joseph, C. A. Hamori, S. Bergman, E. Roaf, N. F. Swann, andG. W. Anastasi, “A prospective randomized trial of vacuum-

assisted closure versus standard therapy of chronic nonhealingwounds,”Wounds, vol. 12, no. 3, pp. 60–67, 2000.

[16] M. H. Davis, P. Dunkley, R. M. Harden, J. M. Laidlaw, A. M.Morris, andR. A.Wood,Types ofWound andUlcers:TheWoundProgramme, Centre for Medical Education, Dundee, UK, 1992.

[17] J. P. Stannard, J. T. Robinson, E. R. Anderson, G. McGwin, D. A.Volgas, and J. E. Alonso, “Negative pressure wound therapy totreat hematomas and surgical incisions following high-energytrauma,” Journal of Trauma, vol. 60, no. 6, pp. 1301–1306, 2006.

[18] D. Herscovici Jr., R. W. Sanders, J. M. Scaduto, A. Infante, andT. DiPasquale, “Vacuum-assisted wound closure (VAC therapy)for the management of patients with high-energy soft tissueinjuries,” Journal of Orthopaedic Trauma, vol. 17, no. 10, pp. 683–688, 2003.

[19] L. K.Wong, R. D. Nesbit, L. A. Turner, and L. A. Sargent, “Man-agement of a circumferential lower extremity degloving injurywith the use of vacuum-assisted closure,” Southern MedicalJournal, vol. 99, no. 6, pp. 628–630, 2006.

[20] I. C. Josty, R. Ramaswamy, and J. H. E. Laing, “Vacuum-assistedclosure: an alternative strategy in the management of deglovinginjuries of the foot,” The British Journal of Plastic Surgery, vol.54, no. 4, pp. 363–365, 2001.

[21] M. Adamkova, J. Tymonova, I. Zamecnıkova, M. Kadlcık, andH. Klosova, “First experience with the use of vacuum assistedclosure in the treatment of skin defects at the Burn Center,”ActaChirurgiae Plasticae, vol. 47, no. 1, pp. 24–27, 2005.

[22] L. P. Kamolz, H. Andel, W. Haslik, W.Winter, G. Meissl, andM.Frey, “Use of subatmospheric pressure therapy to prevent burnwound progression in human: first experiences,” Burns, vol. 30,no. 3, pp. 253–258, 2004.

[23] A.M. Schneider,M. J.Morykwas, and L. C. Argenta, “A new andreliable method of securing skin grafts to the difficult recipientbed,” Plastic and Reconstructive Surgery, vol. 102, no. 4, pp. 1195–1198, 1998.

[24] M. Pfau, H. O. Rennekampff, and H. E. Schaller, “Skin graftfixation by vacuum assisted topical foam dressing,” Journal ofBurn Care and Rehabilitation, vol. 21, article S219, 2001.

[25] M. U. Riaz, M.U. R. Khan, and A. Akbar, “Comparison of vac-uum assisted closure versus normal saline dressing in healingdiabetic wounds,” Pakistan Journal of Medical Health Services,vol. 4, no. 4, 2010.

[26] T. E. Philbeck Jr., K. T. Whittington, M. H. Millsap, R. B.Briones, D. G. Wight, and W. J. Schroeder, “The clinical andcost effectiveness of externally applied negative pressure woundtherapy in the treatment of wounds in home healthcare Medi-care patients,” Ostomy/Wound Management, vol. 45, no. 11, pp.41–50, 1999.

[27] E. Ozturk, H. Ozguc, and T. Yilmazlar, “The use of vacuumassisted closure therapy in the management of Fournier’sgangrene,” The American Journal of Surgery, vol. 197, no. 5, pp.660–665, 2009.

[28] M. Citak, M. Backhaus, R. Meindl, G. Muhr, and T. Fehmer,“Rare complication after VAC-therapy in the treatment of deepsore ulcers in a paraplegic patient,” Archives of orthopaedic andtrauma surgery, vol. 130, no. 12, pp. 1511–1514, 2010.

[29] J. G. McGuinness, D. C. Winter, and P. R. O’Connell, “Vacuum-assisted closure of a complex pilonidal sinus,” Diseases of theColon and Rectum, vol. 46, no. 2, pp. 274–276, 2003.

[30] P. Steenvoorde, A. van Engeland, and J. Oskam, “Vacuum-assisted closure therapy and oral anticoagulation therapy,”Plastic and Reconstructive Surgery, vol. 113, no. 7, pp. 2220–2221,2004.

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