npwt guidelines - nebula.wsimg.com

NPWT Guidelines

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Guideline For Using & Applying ofNegative Pressure Wound Therapy (NPWT)

1. Introduction

NPWT involves applying sub-atmospheric pressure across a wound to manipulate the wound healing process. When using this therapy either a foam or gauze based dressing is cut to fit the shape of the wound and then placed inside it. A film adhesive drape is then placed over the foam or gauze dressed wound. The dressed wound is then attached by tubing to a NPWT device. This device then applies negative pressure to the dressing-wound interface whilst at the same time draws excess fluid into a canister on the NPWT device . The level of pressure used will depend on whether foam or gauze is used.There are two types of NPWT dressings that are used, with several negative pressure devices using one or both dressing types. The dressings used with the NPWT devices are either PU Foam or non adherent Gauze. Whether foam or gauze, It is often dependent on clinical judgement and the type of wound that NPWT will be applied to. There are two techniques used when applying a NPWT dressing. The foam-based technique, originally developed by Argenta and Morykwas (1997), uses a sealed polyurethane foam dressing attached by a tube to a vacuum device. The other technique utilises gauze and flexible drains based on the Chariker-Jeter technique (1989).These guidelines will deal with both techniques.

2. Evidence Base

Most of the clinical evidence for the use of NPWT is research where the foam based technique has been used. Principally, the mechanisms of actions for the therapy whatever dressing is used, is the same.

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3. Risk Management

- Wounds Suitable For NPWT :

NPWT is indicated for use on most wounds. The wounds it can be used on are : - Acute and chronic wounds.- Wounds from trauma.- Dehisced wounds.- Leg ulceration.- Pressure ulceration.- Burns.- Meshed grafts and flaps. Each patient should have a holistic assessment to identify the suitability for NPWT prior to its application.

- Wounds Not Suitable For NPWT :

- Non enteric, non explored fistulae to other organs or body cavities(unless instructed by medical/surgical staff)- Necrotic eschar- Untreated osteomyelitis- Malignancy in the wound (once any malignancy has been removed its use may be indicated following discussion with medical/surgical staff)- Direct placement of NPWT over exposed blood vessels

- Wounds Where Caution Is Required When Using NPWT :

- Enteric fistulae- Active bleeding- Patients on anticoagulants- Difficult wound haemostasis- Weakened, irradiated or sutured blood vessels.- Proximity to blood vessels- Haemophilia- Haemoglobinopathies (sickle cell)- Abnormal clotting- Underlying structures in the wound such as tendon, bone, organs and bowel. These structures will require protection with a non adherent dressing or liner before NPWT can be applied.

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4. Implementation of NPWT

Permission must always be sort from the patient’s consultant before applying NPWT to a wound. All patients should be given an information leaflet explaining the therapy, and given the opportunity to discuss any issues or concerns they may have. It should be written in the clinical record that the patient has given informedconsent to the therapy and that they can decline to have the therapy at any time.

Written consent is not a pre-requisite for the application of this therapy in treating a patients’ wound or wounds. Informed verbal consent will be sufficient.

The user of the therapy must be competent, and have experience or have had training in its use. Obtaining competency in the use of this therapy may be obtained in a number of ways. A self-directed competency document on the use of NPWT is available. Formal workshops are provided by the Tissue Viability Team and the NPWT medical representatives. Learning can also beachieved by shadowing Tissue Viability Nurses and colleagues competent and experienced in the use of NPWT.

Apart from the self-directed learning package which is not compulsory, all staff must be verified competent every three years for the use of the NPWT pumps as these are medical devices.

If a patient is discharged into the community with a NPWT device, it is the responsibility of the discharging nurse to ensure that the patient signs an End User Agreement form.

Patients commencing NPWT should have an individualized care plan completed.

The tissue viability team will see patients, and will give advice and support with complex wounds that require NPWT.

5. Equipment Needed For NPWT

NPWT Device NPWT Dressing (Foam or Gauze ) NPWT Device Canister Sterile Dressing Pack

Pair of Sterile & Non-Sterile Gloves Clinical Waste Bag Sterile Disposable Scissors

Possible ExtrasGel Strips Non-Adherent Dressing ( Silicon Sheet )

Y-ConnectorHydrocolloid Dressings for difficult to seal areas.

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6. Describing The Care Required

Action Rationale

( Patient Assessment )

Carry out an holistic assessment of the patient which will include:

1) Wound Aetiology And Position Of The Wound

1) NPWT is contraindicated in certain wound types. The underlying cause of the wound and any complications must be established to enable assessment of the appropriateapplication. The position of the wound may also prevent NPWT being applied effectively

2) Nutritional Assessment 2) Adequate nutrition plays a fundamental role in the process of wound repair and contributes significantly to the formation of white blood cells, antibodies, fibroblasts and collagen. Hb and serum albumin levels should also have been checked to ensure nutritional support is adequate for wound healing.

3) NPWT can cause discomfort and pain.Analgesia may be required prior to dressing changes. In cases of severe discomfort, Entonox may be required. Procedure for the administration of Entonox/Equanox for adult patients.

3) Pain

4) If NPWT is applied to a wound, the patient may be required to be nursed in bed. Appropriate preventative measures will need to be taken such as a pressure ulcer risk assessment and the commencement of a SSKIN bundle.

4) Level of Pressure Ulcer Risk

5) There needs to be at least a 2 cm border of unbroken skin surrounding the wound. A complete seal with the film drape is required for the vacuum to be created.

5) Level of Pressure Ulcer Risk

f) Patients may become anxious about starting the therapy. Agreement and concordance with the therapy is essential for it to be therapeutically effective. The provision ofinformation (patient information leaflet) is known to reduce anxiety and will help patients to understand the therapy prior to giving consent. If a patient has a NPWT device attached to their wound and he/she has to carry the pump around, this can affect the patient’s quality of life. Patients may not comply with the treatment if it affects their quality of life and this may have an impact on theeffectiveness of the therapy. Such a situation should not be a reason for denying this treatment unless the situation is contributing to possible risks or harm. An example of thiswould be a patient turning the device off during the night because of the pump being noisy. Attempts should be made with the patient to address any issues that may arise where the therapy is impacting on quality of life.

6) Assessment of Quality of Life & Issues of Diversity

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Action Rationale

7) Mobilization 7) The ability of a patient to mobilize with a NPWTdevice should be assessed. Mobilizing with such adevice may increase the risk of a fall.

7. Application Of NPWT

Action Rationale

( Application of NPWT Using Gauze Dressing )

1) To reduce the risk of cross infection.

2) Open the sterile dressing pack ontoa clean dressing trolley. Open the NPWT dressing pack and all the equipment needed for the dressing. Apply sterile gloves.

2) To organise all the equipment neededfor the procedure and to ensure you have everything at hand thus minimizing the introduction of infection.

3) If necessary, irrigate the wound with sterile saline.

3) This will aid assessment of the woundbed.

4) Ensure the surrounding skin and peri-wound area is clean and dry.

4) The film drape will not adhere and willnot seal if the surrounding skin is wet.

5) Place the drain in the wound bed/sinus to calculate length of drain required, remove and trim as necessary to fit.

5) Not all of the channel drain is needed. Only enough to sit in the wound. Placing too much drain in the cavity may cause discomfort and trauma.

6) If a non-adherent wound contact layer is used, cut a single layer to the approximate size and shape of the wound and lay across the wound bed.

6) Lining the wound bed where underlying structures are visible will reduce the potential risk of damage to these structures caused by adherence of the NPWT gauze.

7) Place a layer of saline-moistened(not saturated) gauze on the wound bed and place the drain on top of the gauze, withinapproximately 1 cm from the wound edge (alternatively, gauze can be wrapped around the drain if more suited to the wound). There should always be a layer of gauzebetween the drain and the wound bed, except if managing a sinus when the drain can be placed directly down the sinus tract.

7) This will allow for wound contractionas the wound heals.

1) Wash hands and apply apron and gloves in accordance with Infection Control procedures.

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Action Rationale

8) This will create uniformed healing to the whole of the wound bed.

9) Cut the gel-strip in to two separatesections. Apply one section next to the wound bed where the drain ascends from the wound. Use the other gel-strip to sandwich the drain to the skin.

9) The gel-strip will help maintain acomplete seal when the drape is applied.

10) Cover the filled wound and gel-stripwith the film drape ensuring contact with at least 2.5cm of intact skin beyond the wound edge. Pinch and crimp the film and gel around the drain to secure a proper seal.

10) To achieve the correct fit of the filmdrape this is necessary to ensure a good seal around the wound.

11) Open the canister pack and attach the canister into the NPWT device. Ensure the polystyrene cushion is removed from the pin connection on the canister..

11) To correctly install the canister intothe pump.

8) Fill the wound bed with the remaining saline-moistened gauze and fluff to above skin level.

12) Attach the drain tubing to the top right hand corner of the canister, lining up locator stud with notch on canister tubing receptacle. Twist clockwise to lock.

12) To connect the dressing to NPWTdevice.

13) Switch on the NPWT device and select the desired negative pressure setting.

13) To ensure the correct therapeuticpressure is applied to the wound.

14) The dressing should become firm to the touch and appear ‘dried raisin-like’

14) If the dressing fails to become firm,this is because the dressing is not completely sealed

15) The screen on the NPWT device should automatically lock within several seconds.

15) To prevent accidental alteration of thepressure settings on the device.

16) If several pieces of gauze were used to dress/pack the wound, write on the actual film of the dressing with a permanent marker how many pieces were used.

16) To let the nurse that change thedressing next time know that He/She hasremoved all the gauze from the wound.

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7. Application Of NPWT

Action Rationale

( Application of NPWT Using Foam Dressing )


2) Open the sterile dressing pack ontoa clean dressing trolley. Open the NPWT dressing pack and all the equipment needed for the dressing. Apply sterile gloves.

2) To organise all the equipment neededfor the procedure and to ensure you have everything at hand thus minimizing the introduction of infection.

3) If necessary, irrigate the wound with sterile saline.

3) To remove any debris and to aid wound assessment.

4) Ensure the surrounding skin and peri-wound area is clean and dry.

4) The film drape will not adhere and willnot seal if the surrounding skin is wet.

5) Cut the foam to size with sterile scissors. Aim to fill the cavity, including undermined areas, but do not pack tightly. More than one piece of foam can be used but all the foam pieces need to be in contact with each other. The sponge should extend above thelevel of the surrounding skin.

5) The foam should be in contact withthe wound bed; however it should not cause any pressure on the tissues by being packed in too tightly. The foam should not extend past the wound edges as this can damage the wound margin.

6) Avoid cutting the foam over the wound and avoid cutting lots of small pieces. When cut, ensure there are no small loose pieces of foam around the edges. Thenumber of pieces of foam inserted into the wound must be documented in the care plan.

6) Small pieces of foam could be left ina large wound and not accounted forif the wound is healing quickly.Fragments of foam debris in the wound may act as a focus for infection.

1) Wash hands and apply apron and gloves in accordance with Infection Control procedures.

7) Cut the film drape to cover the foamdressing. Allow at least a 3-5 cm border around the foam.

7) To achieve the correct fit of the filmdrape this is necessary to ensure a good seal around the wound for the vacuum to be maintained.

8) Apply film drape over the foam dressing. Seal down well at edges.

8) To achieve the correct fit of the film drape this is necessary to ensure good seal around the wound.

9) Cut a 1-2 cm² hole in the center of the drape.

9) To allow application of the Suction Bell.

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Action Rationale

10) Peel the backing off the Suction Bell and apply it over the film drape ensuring that the hole in the pad is in contact with the hole cut in the drape.

10) To provide an effective seal and sothat the vacuum applied will reach thewound bed.

11) Open canister pack (if new one needed) and push canister into NPWT pump until it clicks into place.

14) Switch on NPWT pump and select the desired pressure settings, the optimum pressure for healing is usually 125 mmHg, initially set on continuous pressure Record pressure settings in the patients careplan.

14) To ensure the correct therapeuticpressure is applied to the wound.

15) Switch on NPWT therapy. The foam should collapse down and become firm

16) The screen will lock automatically after switching on the therapy.

16) To prevent accidental alteration ofsettings.

17) Ensure circulation to limbs/digits isnot compromised by any constriction caused by NPWT therapy. Check pulses and question patient about presence of numbness and / or tingling.

17) Drape may require loosening if drapeor foam is applied circumferential.Constriction of blood vessels could occur.

11) To correctly install canister into pump,in order to contain the wound exudate.

12) Attach the Suction Bell tubing to thecanister connection tube.

12) To connect the dressing and the NPWT pump.

13) Open tubing clamps if any are closed. 13) To allow the suction to reach thedressing and allow free drainage.

Best Practice for Dressing Application

- The number of foam and gauze pieces must be written on the edge of the film drape with a permanent marker pen.- The manufacturer’s instructions and dressing application guidelines are detailed on the internet, so staff can refer to this for further information.- Following application, check that no tubing is causing pressure to the surrounding skin.- If for any reason during treatment it is necessary for the patient to be disconnected from the pump, the pump should be switched off, the tubing clamped and the canister removed from the pump so it can accompany the patient with the dressing and tubing intact. Patients should not be disconnected from the pump for any longer than an hour as exudate will pool in the dressing. This will result in the dressing loosing its seal.- Foam or Gauze must never be applied directly on, or be in any contact with intact skin!

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8. Removal Of NPWT

Action Rationale

1) To reduce the risk of the dressingadhering to the wound bed and to minimize patient discomfort

2) Raise the tube connector above the level of the pump unit and drain exudate into the canister.

2) To ensure there is no fluid which could leak at the disconnection site.

3) Clamp off both sections of tubing. 3) To prevent fluid from leaking out.

4) Wash hands and apply apron andnon-sterile gloves in accordance with Infection Control procedures.


5) Disconnect the dressing tubing from the canister tubing.

5) To separate the dressing from the NPWT device.

6) If the canister is either two thirds fullor has been in use for seven days it will need to be changed. If the same canister is to continue being used, ensure the connector end is covered with sterile gauze or a sterile field whilst disconnected.

6) The canister is a sealed unit that contains a solidifying agent. It should be changed regularly to prevent infection or overfilling of the canister. Changes in the exudate color and the amount of exudate should be recorded in the care plan.

1) The NPWT device should be switched off 15 – 30 minutes before removal of the foam

7) Gently stretch the occlusive filmhorizontally and slowly pull away from the skin. Do not peel back.

7) To break the film adhesive whilstminimizing trauma to the patient.

8) Gently remove the foam or gauze from the wound using saline to assist removal if necessary.

8) To minimize trauma to the wound tissue when removing the dressing.

9) Check the number of gauze and foam pieces removed from the wound is the same as the number that were originally placed in the wound.

9) To ensure all the dressing is removedas if retained will cause failure to heal and may require surgical removal.

10) All the NPWT consumables (tubing,canister and dressings) are all disposable items that when removed should be discarded in an orange infectious clinical waste bag.

10) To reduce the risk of infection

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Action Rationale

11) Remove apron and gloves. Discardthem in an orange infectious clinical waste bag. A clean apron and gloves should be applied and hands washed between removing the old dressing and applying anew one to the patient.

11) To reduce the risk of infection and toprevent contamination of the wound.

Best Practice for Dressing Removal

- If the foam dressing adheres to the wound, introduce 10-30 mls of normal saline into the dressing tubing with a syringe to soak the foam. Clamp off the tubing and wait 15-30 minutes before dressing removal.

- If the foam or gauze severely adheres to the wound base or if NPWT is being used on children it is advisable to use a single layer of non-adherent wound dressing between the wound base and the foam/gauze dressing.However this will reduce the effectiveness of the therapy.

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9. NPWT Pressure Therapy Settings ( Using Foam Based System )

Pressure settings may vary at the discretion of the tissue viability nurse or medical staff with particular reference to dressing change intervals.

Type Of Wound

Initial Cycle Subsequent Cycle

TargetPressure

Black Foam(PU)

DressingChangeInterval

Acute/TraumaticWounds

Surgical Wound

Dehiscence

Pressure Ulcers

Meshed GraftsAnd

BioengineeredTissues

Chronic Ulcersi.e. Leg Ulcers

Flaps

Continuous forfirst 48 hours

Continuous forDuration of

Therapy



Therapy



Therapy

Intermittent –5 minutes on,2 minutes off

for rest oftherapy


for rest oftherapy


for rest oftherapy

125 mm Hg

125 mm Hg

125 mm Hg

75 – 125 mmHgGraft requires covering

with wide meshed non-adherent dressing if black foam issued

50-125 mm Hg

125-150 mm Hg

Every 48 hoursEvery 12-24 hours

with infected wounds





Remove dressing after 4-5 days

when using either foam



Fresh flaps = 72 hrsIf there are

complications = 48hours. Every 12-24 hours with infection

The above table is a guide to therapy pressures. In certain circumstances these may not be the most suitable. For example the patient should remain on continuous therapy if :

- The patient is experiencing significant discomfort during intermittent therapy.- There are high levels of exudate. Wait until the amount of drainage tapers off before changing to intermittent therapy.- A patient has had a sternotomy or sternectomy. It is recommended to continue continuous therapy to aid in ‘splinting’ the wound and stabilizing the chest wall.- If the seal around the wound is difficult to maintain

Generally, when using gauze the pressure would be set at -80mmHg

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10. Additional Points & Troubleshooting

- Multiple wounds may be treated using one NPWT device. This can beachieved by using a Y connector or by bridging the foam. Contact the Tissue Viability Team for advice on how to do this. - If the pump is switched off or not working for more than two hours then thewhole dressing must be replaced.- Wound assessment should still take place and progress/deterioration documented as with any wound at each dressing change.- Observe the skin regularly around the tubing as localized pressure may occur. Position the tubing so the patient is not sitting or lying on it. Consider bridging the dressing so the risk of this occurring is eliminated or reduced.- When NPWT is applied, the patients’ mobility may be reduced especially ifit is applied to a lower limb, therefore pressure areas must be observed frequently.- The pump will alarm for several reasons i.e. if the canister is full, if the seal is lost or if the tubing is obstructed. Refer to the manufacturers guidelines to assess the problem.- If the pump alarms when patients are being treated at home the patient/carers should be aware of how to silence the alarm and who to call. If a dressing requires removal and the attending nurse is not familiar with reapplying NPWT therapy, then an alternative absorbent dressing should be applied until a nurse with the relevant experience can reapply the dressing. This should be within 24 hours.

11. Potential Problems

- The foam or gauze is adhering to the wound bed

- Irrigate around foam or gauze with saline.- If it is foam that is adhering to the wound, introduce saline into the dressing tubing to soak the foam. Close the clamp on the tubing and let this soak in for 15-30 minutes.- Use a Silicon non adherent dressing underneath the foam to line the wound bed.- Ensure dressing is not left in-situ for longer than the recommended time period.

- Skin damage from the tubing and Suction Bell

- This can occur if the Suction Bell is wider than the wound edges and steps need to be taken to protect the surrounding skin by applying film drape to the surrounding skin and placing a larger piece of foam over the wound opening.

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- The surrounding skin is red and irritated

- Apply a barrier film to the surrounding skin. Apply the drape over this.- Apply a thin hydrocolloid dressing onto the irritated skin. Apply drape over this.

The dressing does not collapse down when therapy is switched on, or the NPWT pump does not reach the desired pressure

- Listening for whistling to identify air leaks. Locate area of dressing drape that is not sealed. Patch with leftover drape or a film dressing.- Check both clamps are open.- Check seal around gel-strip on the gauze-based dressing.- Check connections.- Ensure pump is switched on properly.- Ensure the Suction Bell is over the hole cut in the film.- Ensure canister is clicked into place correctly on the pump.- If bridging technique is being used check all foam in the bridge is touching.

The patient is experiencing pain

- Assess the need for regular analgesia or prior to dressing changes.- If pain is due to dressing adherence, take steps to minimize this.- Keep therapy on continuous pressure.- Reduce pressure by 25 mmHg in stages until patient is comfortable.

The film drape is not sticking

- Ensure skin around the wound is clean and dry.- Apply a barrier film underneath the drape.- Use gel strips available or thin hydrocolloid dressing to achieve a seal on areas where the drape will not stick down.

The wound is not progressing to heal

- For shallower wounds cut the dressing slightly smaller than the wound edges to enhance inward epithelial migration.- Stop NPWT therapy for 1-2 days; use another appropriate conventional dressing then resume NPWT therapy.This may be effective in reinitiating the healing process.- Change the pressure setting from continuous to intermittent or vice versa.- Consider holistic reasons why the wound is not healing e.g. pressure, poor nutrition and infection.- If any of the above problems persist after steps have been taken to resolve them then contact your Tissue Viability Team or the NPWT company representative.

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12. References

Argenta, L.C., Morykwas, M.J. (1997). Vacuum assisted closure: a new methodfor wound control and treatment. Clinical experience. Annals of Plastic Surgery. 38(6): 563-7

Banwell, P.E. and Musgrave, M. (2004) Topical negative pressure therapy:mechanisms and indications. International Wound Journal 1(2): pp. 95-106.

Barrientos, S., Stojadinovic, O., Golinko, M.S., Brem, H., and Tomic-Canic, M.(2008) Growth factors and cytokines in wound healing. Wound Repair andRegeneration 16 pp. 585-601.

Bjarnsholt, T., Kirketerp-Møller, K., Jensen, P.O., Madsen, K.G., Phipps, R.,Krogfelt, K., Hølby, N. and Girskov, M. (2008) Why chronic wounds will not heal:a novel hypothesis. Wound Repair and Regeneration 16 pp. 2-10.

Bryant, R.A. (2003) Acute and chronic wounds: nursing management 2nded. St.Louis:Mosby.

Chariker, M.E., Jeter, K.F., Tintle, T.E., Bottsford, J.E. (1989). Effectivemanagement of incisional and cutaneous fistulae with closed suction wounddrainage. Contemporary Surgery. 34: 59-63.

Cutting, K. (1994) Criteria for identifying wound infection. Journal of woundCare. Resource File. Macmillan. London.

Davydov Yu, A., Malafeeva,E.V., Smirnov, A.P., Flegontov, V.B. (1986) Vacuumtherapy in the treatment of purulent lactation mastitis. Vestnik Khirurgii.Sept:66-70.

Davydov Yu, A., Larichev, A.B., Menkow, K.G. (1988) The bacterial andcytological assessment of vacuum therapy of purulent wounds. VestnikKhirurgii. 10:48-52.

Evans, D. and Land, L. (2001) Topical negative pressure for treating chronicwounds: a systematic review. British Journal of Plastic Surgery 54. pp. 238-242.

Falanga, V. (1992) Growth factors and chronic wounds: the need to understandthe microenvironment. The Journal of Dermatology 19. pp. 667-672.

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Ford, C.N., Reinhard, E.R., Yeh, D., Syrek, D., de las Morenas, A., Bergman,S.B., Williams, S. and Hamori, C.A. (2002) Interim analysis of a prospective,randomised trial of vacuum-assisted closure versus the healthpoint system in the management of pressure ulcers. Annals of Plastic Surgery 49(1): pp. 55-61.

Fox, A., Tadros, A. and Perks, A.G.B. (2004) An unusual complication ofVacuum Assisted Closure in the treatment of a pressure ulcer. Journal ofWound Care. 13(8): pp. 344-345.

Green, A.K., Puder, M., Roy, R., Arsenault, D., Kwei, S., Moses, M.A. andOrgill, D.P. (2006) Microdeformational wound therapy: effects on angiogenesisand matrix metalloproteinases in chronic wounds of 3 debilitated patients.Annals of Plastic Surgery 56(4): pp. 418-412.

Gustafsson, R., Johnsson, P., Algotsson, L., Blomquist, S. and Ingemansson,R. (2002) Vacuum-assisted closure therapy guided by C-reactive protein level inpatients with deep sternal wound infection. The Journal of Thoracic andCardiovascular Surgery 123(5): pp. 895-900.

Hampton, S. and Collins, F. (2004) Tissue viability: the prevention,treatment and management of wounds London:Whurr Publishers.

Hunter, J.E., Teot, L., Horch, R. and Banwell, P.E. (2007) Evidence-basedmedicine: vacuum-assisted closure in wound care management. InternationalWound Journal 4(3): pp. 256-269.

Joseph, E., Hamori, C.A., Bergman, S., Roaf, E., Swann, N.F. and Anastasi,G.W. (2000) A prospective randomised trial of vacuum-assisted closure versusstandard therapy of chronic non-healing wounds. Wounds 12(3): pp. 60-67.

Mc Nulty, A.K., Schmidt, M., Feeley, T. and Kieswetter, k. (2007) Effects ofnegative pressure wound therapy on fibroblast viability, chemotactic signallingand proliferation in a provisional wound (fibrin) matrix. Wound Repair andRegeneration 15 pp. 838-846.

Mendonca, D.A., Drew, P.J., Harding, K.G., (2007) A pilot study on the effect oftopical negative pressure on quality of life. Journal of Wound Care 16(2): pp.49-53.

Morykwas, M.J., Argenta, L.C., Shelton-Brown, E.I., and McGuirt, W. (1997)Vacuum-assisted closure: a new method for wound control and treatment: animal studies and basic foundation. Annals of Plastic Surgery 38(6): pp. 553-562.

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Mouës, C.M., Vos, M.C., van den Bemd, G.J., Stijner, E.R. and Hovius, S.E.(2004) Bacterial load in relation to vacuum-assisted closure wound therapy: aprospective randomised trial. Wound Repair and Regeneration 12: pp. 11-17.

Mouës, C.M., Toorenenbergen, A.W.V., Heule, F., Hop, W.C. and Hovius,S.E.R. (2008) The role of topical negative pressure in wound repair: expressionof biochemical markers in wound fluid during wound healing. Wound Repairand Regeneration 16: pp. 488-494.

Neubauer, G. and Ujlaky, R. (2003) The cost-effectiveness of topical negativepressure versus other wound healing therapies. Journal of Wound Care12(10): pp. 392-393.

Nottingham University Hospitals NHS Trust (2012) Consent to examination ortreatment policy [online]. Available at:http//nuhet/nuh_documents/Documents/Consent% [Accessed 16 January2013].

Nottingham University Hospitals NHS Trust (2011) ANTT Asceptic Non TouchTechnique Policy. [online] Available at:http://nuhnet/nuh_documents/Documents/Forms/Stuff%20view_aspx [Accessed22 January 2013]

Philbeck, T.E., Whittington, K.T., Millsap, M.H., Briones, R.B., Wright, D.G. andSchroeder, W.J. (1999) The clinical and cost effectiveness of externally appliednegative pressure wound therapy in the treatment of wounds in homehealthcare medicare patients. Ostomy Wound Management 45(11): pp. 41-50.

Saxena, V., Hwang, C., Huang, S., Eichbaum, Q., Ingber, D., and Orgill, D.(2004) Vacuum-assisted closure: microdeformations of wounds and cellproliferation. Plastic and Reconstructive Surgery 114(5): pp. 1086-1096.

Sen, C.K. (2009) Wound healing essentials: let there be oxygen. WoundRepair and Regeneration. 17 pp. 1-18.

Stechmiller, J.K., Kilpadi, D.V., Childress, B. and Schultz, G.S. (2006) Effect ofvacuum-assisted closure therapy of the expression of cytokines and proteasesin wound fluid of adults with pressure ulcers. Wound Repair and Regeneration14 pp. 371-374.

Teasdale, K. (1993) Information and anxiety: a critical appraisal. Journal ofAdvanced Nursing. 18: 1125-1132.

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Timmers, M.S., Le Cessie, S., Banwell, P. and Jukemal, G.N. (2005) Theeffects of varying degrees of pressure delivered by negative-pressure woundtherapy on skin perfusion. Annals of Plastic Surgery 55(6): pp. 665-671.

Ubbink, D.T., Westerbos, S.J., Nelson, E.A., and Vermeulen, H. (2008) Asystematic review of topical negative pressure therapy for acute and chronicwounds. British Journal of Surgery 95: 685-692.

Urschell, J.D., Scott, P.G., and Williams, H.T.G. (1988) The effect of mechanicalstress on soft and hard tissue repair: a review. British Journal of PlasticSurgery 41: pp. 182-186.

Yager, D.R. and Nwomeh, B.C. (1999) The proteolytic environment of chronicwounds. Wound Repair and Regeneration 7: pp. 433-441.

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13. Further Readings

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Copson D.L. (2003) Topical negative pressure and necrotizing fasciitis. NursingStandard (Tissue Viability Supplement) 18(6):71-80,

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