Should you consider using negative pressure wound therapy with instillation and dwell (NPWTi-d) on every wound ALWAYS? An experienced wound nurse discusses some contraindications.

I am a huge proponent of V.A.C. VERAFLO™ Therapy, but I would NEVER endorse that you should ALWAYS use V.A.C. VERAFLO™ Therapy to treat a wound.  There are only a handful of situations where I would NEVER consider use of the therapy.  Wound care is dynamic and should be considered a continuum where patients and wounds are kinetic – the status, and therefore the needs, change. Goals of care also change, so to say any wound care treatment or therapy should ALWAYS or NEVER be used would be closed minded and fail to address the variability of wound care and healing.

What is V.A.C. VERAFLO™ Therapy?

V.A.C. VERAFLO™ Therapy, also known as negative pressure wound therapy with instillation and dwell (NPWTi-d), provides negative pressure wound therapy (NPWT) along with an integrated system that facilitates delivery of topical solutions to the wound bed.  The user-defined amount of delivered solution soaks on the wound bed and into associated intricacies to cleanse the wound and solubilize devitalized tissue.  Once the soak or dwell time is complete, which is also user defined, the negative pressure re-engages, which removes the instilled fluid and solubilized exudate, providing the evidenced-based benefits of V.A.C® Therapy.

V.A.C. VeraFlo Cleanse Choice™ Dressing - NWPTi-d


So, you ask, why wouldn’t you use V.A.C. VERAFLO™ Therapy?  Once again, I would challenge every clinician to evaluate each patient and each wound with an identified goal in mind.  However, I would not consider V.A.C. VERAFLO™ Therapy appropriate over a closed surgical incision, a wound open to a body cavity, over cellular, acellular, or bioengineered tissues, wounds with fragile hemostasis, and wounds that require continuous negative pressure delivery, such as skin grafts or flaps.

Wound Types/Situations Where V.A.C. VERAFLO™ Therapy is Not Appropriate

Closed Surgical Incisions

Instillation of fluid over a closed incision could cause pooling and eventual maceration.

The benefits of incisional NPWT over a closed incision are evidenced-based.  Benefits include holding the edges of an incision together while reducing lateral tension, removal of fluids and potentially infectious materials, and acting as a physical barrier to external contamination.  Bench and preclinical studies have shown the bolstering effects of incisional NPWT to normalize the stress distribution over the approximated incision while increasing appositional strength.

Instillation of fluids into a body cavity could lead to fluid volume overload, or compartment syndrome.  Fluids in contact with organ structures could lead to thermoregulation alterations and/or organ damage.

ABTHERA™ Therapy provides negative pressure wound therapy to the open abdomen through a unique abdominal interface.  This interface, in conjunction with NPWT, helps reduce edema and provides medial tension, minimizing fascial retraction.

Over cellular, acellular, or bioengineered tissues

The unique qualities and benefits of most cellular, acellular or bioengineered tissues are dependent upon close and constant interface with a clean, unencumbered wound bed.  Instillation of fluids over these matrixes will compromise that interface and can dilute or destroy any seeded cellular components onto a tissue.

Wounds with fragile hemostasis

Patients with wounds that have a marginal hemostasis or are at risk for bleeding are not candidates for V.A.C. VERAFLO™ Therapy.  The instillation fluid could potentially dilute hemostatic agents applied to the wound to control bleeding and dislodge clots.

Once normalized hemostasis occurs, it would be appropriate to reassess the wound and the status of the patient for appropriateness of V.A.C. VERAFLO™ Therapy.

Wounds that require continuous negative pressure delivery, such as skin grafts or flaps:

The process of V.A.C. VERAFLO™ Therapy that allows for instillation of fluid and a dwell time pauses the negative pressure wound therapy and thus is not appropriate for wounds that require the continuous benefits of negative pressure wound therapy.  A split thickness skin graft has no blood flow.  It is placed on a prepared wound bed and is dependent on the plasma on the wound bed to survive as it forms capillaries to reattach and provide nutrients to the transplanted tissue.  Pauses in the negative pressure would compromise the nutrients to the graft and it would be at high risk for failure.

When the anatomy of the wound presents too great a challenge:

The above wound types/situations are those in which V.A.C. VERAFLO™ Therapy is not appropriate due to characteristics of the wound/wound bed.  In rare situations, the anatomy of the wound does not allow an adquate seal to the level required to perform V.A.C. VERAFLO™ Therapy.  Years of wound care experience with V.A.C.® Therapy have taught me a multitude of clinical “tricks of the trade” to achieve and enhance an airtight seal.  But sometimes, the effort, and resources needed to achieve the required air tight seal is not justified and an alternative makes more sense.  However, as the wound and patient progress toward healing and the wound would benefit from the use of V.A.C. VERAFLO™ Therapy, you can reconsider it as a treatment option.

The home care and long-term care settings do not currently offer the option of V.A.C. VERAFLO™ Therapy.  I work in the acute care setting, and when a wound is determined to be appropriate for V.A.C. Therapy, I will ALWAYS consider the potential benefits of V.A.C. VERAFLO™ Therapy.  V.A.C. VERAFLO™ Therapy is indicated for any V.A.C.® Therapy appropriate wound that would also benefit from the instillation of topical wound treatment solutions.   So I can initiate V.A.C. VERAFLO™ Therapy for the inpatient course, with discharge planning to include transitioning to V.A.C.® Therapy on transfer or discharge.

So, ALWAYS consider V.A.C. VERAFLO™ Therapy as a possible option for wound care treatment, but NEVER forget that V.A.C. VERAFLO™ Therapy has specific contraindications and that the patient’s overall status must be at the forefront of all care/treatment choices.

Copyright 2017 KCI Licensing, Inc. All rights reserved. All trademarks designated herein are proprietary to KCI Licensing, Inc., its affiliates and/or licensors. PRA001170-R0-US, EN (07/17)

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Susan Mendez-Eastman RN, CWCN, CPSN

Susan Mendez-Eastman RN, CWCN, CPSN is a freelance writer that covers topics like negative pressure wound therapy. She is also a consultant for Acelity.

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