Negative Pressure Wound Therapy (NPWT) for Adults and Children |
| Publication: 23/02/2022 |
| Next review: 23/02/2025 |
| Clinical Guideline |
| CURRENT |
| ID: 7404 |
| Approved By: Trust Clinical Guidelines Group |
| Copyright© Leeds Teaching Hospitals NHS Trust 2022 |
This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated. |
Negative Pressure Wound Therapy (NPWT) for Adults and Children
Summary of Guideline
These guidelines provide a framework to support professional practice at all levels in the effective and safe use of NPWT within LTHT, aiming to standardise care in accordance with the evidence base and best practice.
Background
Negative Pressure Wound Therapy (NPWT) also known as Topical Negative Pressure (TNP) is a medical device that is used in the management of acute and chronic wounds. It is a complex wound therapy using a dressing connected to a medical device (pump) which applies negative pressure to promote healing and manage exudate. It requires technical skills and knowledge of application by a competent practitioner (NMC, 2018). These guidelines will include correct application, and when the different types of NPWT might be used within LTHT, which includes foam, gauze, drains, InstillVAC, Abthera, and single use NPWT (PICO).
Clinical evidence indicates that for most wounds NPWT must not be viewed as first line management (Dumville et al, 2015). There is currently a lack of good quality randomised controlled trials (RCT) comparing the clinical effectiveness of NPWT compared with alternative treatments for a variety of wounds including pressure ulcers, wounds healing by secondary intention and surgical wounds (Chetter et al, 2021, Dumville et al, 2015, NICE 2013). However, the strongest body of evidence is in relation to management of diabetic foot wounds, the evidence suggests NPWT may increase the proportion of wounds healed through increasing perfusion where poor perfusion is delaying wound healing, although this evidence is of low certainty due to the quality of the included trials (Liu et al., 2018).
There is also a growing body of evidence regarding the use of NPWT, including single use NPWT, on closed surgical incisions for the prevention of surgical site infections (SSI) (NICE, 2019; Saunders et al. 2021). The evidence is primarily in patients deemed at high risk of SSI which includes BMI >30, smokers, and patients with diabetes mellitus (Foroutanjazi et al. 2021) with complex wounds such as vascular groin wounds (Gwilym et al. 2021), breast (Cagney et al. 2020) and general/colorectal surgical wounds (Sahebally et al. 2018). It remains largely unknown if NPWT on closed surgical incisions prevents seromas, dehiscence, or necrosis (NICE 2019).
Overall, the potential benefits and harms of using NPWT treatment for wounds and secondary outcomes such as quality of life, length of stay, and cost remain largely uncertain, therefore should not be considered as a first line in wound management.
PICO is a canister-free, single-use, negative pressure wound therapy system consisting of a sterile pump and multi-layered adhesive dressings. It is primarily designed to be used on closed surgical incision wounds for patients at high risk of wound break down, infection and dehiscence. It can also be used on superficial, low exuding chronic wounds. The pump is operated by 2 AA batteries and delivers a continuous negative pressure of 80 mmHg to a sealed wound. Once activated, using a push button, the battery drives the pump for up to 7 days and LEDs provide alerts for low-battery status and pressure leaks.
Evidence level A
NPWT may be considered for:
- Management of excessive exudate - where this could be affecting care, skin integrity or quality of life (e.g., where conventional dressings require changing more than once a day)
(Evidence level C) - Promote granulation tissue - where poor perfusion is delaying healing
(Evidence level A) - Prevention of SSI in high-risk patients - e.g. BMI >30, smokers, and patients with diabetes mellitus
(Evidence level A) - Reduction of oedema - e.g., compartment syndrome, bowel oedema with the open abdomen
(Evidence level B) - Support or stabilise a wound - e.g., sternotomy, abdominal cavity needing support to retain organs
(Evidence level C) - Reduce risk of contamination - e.g., sacral pressure ulcer at risk of faecal contamination
(Evidence level C) - Remove bacteria and manage infection - where bacterial colonisation/infection is causing a significant threat to the patient’s health,
(Evidence level C) - Where quality of life could be significantly be improved - e.g., excessive malodour, slow wound healing, reduced frequency of painful dressing changes
(Evidence level B)
Diagnosis
Prior to commencement of NPWT the wound must be assessed and deemed appropriate for NPWT by a registered healthcare professional that is competent in the use of NPWT, such as a senior member of the medical or surgical team, or wound care specialist (e.g., Tissue Viability, podiatry).
NPWT can be used on patients of all ages with difficult to heal wounds including:
- Acute wounds - a wound with an aetiology that occurs suddenly, either with or without infection, but then heals in a timely manner (e.g., surgical wounds, flaps and grafts, or traumatic wounds including skin tears, lacerations, burns)
- Chronic wounds - a wound that has a slow progress through the healing phases, or shows delayed, interrupted, or stalled healing due to intrinsic and extrinsic factors that impact on the individual and their wound (e.g., pressure ulcers, leg ulcers, dehisced surgical wounds, deep burns, diabetic foot ulcers, etc.)
- Dehisced surgical wounds
- Wounds healing by tertiary intention (e.g., open abdomens, fasciotomies)
NPWT should not be used in the following situations
- Neonates (unless under the direct supervision of a consultant or Tissue Viability Nurse Specialist)
- Malignancy is known or suspected in the wound (unless under the direction of the patient’s consultant)
- Untreated osteomyelitis
- Non-enteric and unexplored fistula
- Necrotic tissue present in the wound bed
- Active bleeding at the wound site
- Patients unable to carry the NPWT device safely or those considered a falls risk
Precautions should be taken with patients experiencing the following:
- Patients on anti-coagulant medication or those with a blood clotting disorder; Consult with medical staff prior to initiation of NPWT and check International Normalised Ration (INR) as per recommendations
- Exposed vessels or organs need protecting with protective liner (non-adherent layer e.g., Atrauman, mepitel or abthera for large open abdomens)
- Greater care is required with respect to weakened, sutured, or irradiated blood vessels or organs -discuss with medical team, use a lower pressure and a non-adherent liner
- Bone fragments or sharp edges could puncture the seal, protective barriers, vessels, or organs
- Renal patients on heparin/high dose anticoagulants should not have NPWT applied until 24 hours after the final dose/infusion has ended.
- Wounds with more than 40% slough covering the wound bed
Treatment/Management
The wound should be assessed at each dressing change by a competent, registered healthcare professional. Dressing changes should only be undertaken by highly trained staff, deemed competent in NPWT.
All practitioners are responsible for ensuring that they have the adequate knowledge and skills for wound assessment and management, relevant to their role. Registered clinicians will be accountable for developing, demonstrating, and maintaining their clinical competence. All staff within LTHT are responsible for following this guideline and escalating any difficulties in the implementation to their line manager.
Table 1: Procedure for Application for all types of NPWT
The following procedure for application should be followed for all types of NPWT
|
|
Action |
Rationale |
|
1 |
Where possible, prior to application the patient should be informed of how NPWT works, what the dressing will involve, and verbal consent gained. |
To improve patient outcomes, concordance and reduce anxiety |
|
2 |
Wash hands as per Trust policy http://nww.lhp.leedsth.nhs.uk/common/guidelines/detail.aspx?ID=673 |
To prevent contamination of the wound and spread of infection |
|
3 |
Remove any drape by gently stretching laterally, or use an adhesive remover if required (e.g., in paediatrics or where dressing is causing pain or trauma on removal) |
To maintain patient comfort and reduce risk of local skin trauma |
|
4 |
The wound only requires cleansing to remove pus, debris, or slough. |
As per wound care guidelines |
|
5 |
Body hair to surrounding skin may require clipping |
To provide a clean surface for the new dressing and to achieve an air tight seal |
|
6 |
There must be at least 2cm of adhesive drape in contact with the intact skin surrounding the wound margin. Multiple pieces of drape can be used |
To achieve an occlusive seal |
|
7
|
Decide where the suction tubing is going to go so it is easiest for the patient (e.g., going up or down depending on wound position and clothing) |
For patient comfort and to minimise impact of having dressing |
|
8 |
KCI: cut a hole in drape over the foam approx. size of £2 coin (approx. 3cm) and place track pad over this |
To ensure sensors are not blocked by foam or drape and correct pressure sensing is achieved |
|
9 |
Connect tubing from the dressing to canister for relevant system and connect canister to the pump. Program pump to correct pressure setting (Appendix) and start negative pressure - ensuring that a seal has been achieved and the pump is working |
To commence negative pressure and ensure that it is working effectively |
Table 2: Procedure for Application - Foam (KCI and Smith and Nephew)
The following procedure for application should be followed in addition to table 1
| Action |
Rationale |
|
For dressing changes ensure the system is switched off 15 minutes, but no more than 1 hour prior to dressing removal and tubing is clamped. |
To release pressure from the dressing and reduce risk of pain and trauma when foam is removed from the wound |
|
A non-adherent liner (e.g., mepitel or atrauman) must be used under black foam where there are exposed blood vessels, organs, tendons, nerves, bone. |
To prevent trauma to underlying structures |
|
The foam must be cut to the size of the wound using sterile scissors, with the aim of filling the entire cavity without compressing the wound - DO NOT OVERPACK |
To fit individual wounds and maintaining infection control procedures. |
|
If multiple pieces of foam and/or gauze are used these should all be in contact with one another |
To obtain negative pressure to all aspects of the wound |
|
Recommended dressing change is every 72 hours/3 times per week and canisters weekly unless full. |
As per manufacturers guidelines, to allow for regular wound bed monitoring |
Table 3: Procedure for Application - gauze (Smith and Nephew)
The following procedure for application should be followed in addition to table 1
| Action |
Rationale |
|
Moisten the Polyhexamethylene Biquanide (PHMB) gauze with sterile saline, and fill the entire wound cavity with the gauze, including undermining/sinuses. Gauze should sit 1cm proud of the skin level without being in touch with skin. |
To ensure granulation tissue does not occlude the entrance to an unidentified sinus |
|
Channel drain: These can be placed in direct contact with tissue, therefore can be placed in a sinus or tunnelling wound under the direction of Consultant/TVN |
For ease of drainage in tight sinuses |
|
If multiple pieces gauze are used these should all be in contact with one another |
To obtain negative pressure to all aspects of the wound |
|
Soft port: Position tubing and apply drape as per foam |
To achieve an air tight seal |
|
Recommended dressing change is twice weekly and canisters weekly unless full. |
As per manufacturers guidelines, to allow for regular wound bed monitoring |
Table 4: Procedure for Application - PICO
The following procedure for application should be followed in addition to section 1-7 on table 1
| Action |
Rationale |
|
Using a clean technique, peel off the first release handle and place the dressing centrally over the wound with the tubing to the top of the wound. Ensure the dressing lies flat to the wound and the surrounding skin. Remove the other remaining handle(s) and smooth the dressing around the wound to prevent creasing. Reposition if required to ensure border is not creased. Apply the fixation strips all the way around the dressing border. |
To make sure the wound is suitably covered, and a complete seal is achieved. |
|
Insert the batteries. Replace the cover. Following this all four indicators should illuminate for 3 seconds. Join the pump to the dressing tubes by twisting together the connectors. |
|
|
Press the orange button to start the application of negative pressure wound therapy. Depending on the size of the wound, the pump should take up to 65 seconds to establish therapy. If after 65 seconds the system has not established therapy, just the orange air leak indicator will flash. |
To establish whether a seal is achieved, and dressing is working |
|
Dressings should only be changed every 3-4 days. The pump will last for 7 days/2 dressing changes. |
PICO system only designed for 7 days |
| |
Provenance
| Record: | 7404 |
| Objective: | To provide evidence-based recommendations to ensure the safe and appropriate use of Negative Pressure Wound Therapy (NPWT) within Leeds Teaching Hospitals NHS Trust following a holistic wound assessment. This guideline should be used in conjunction with the Wound Assessment and Management Guideline. |
| Clinical condition: | Acute wounds, chronic wounds, open and closed surgical wounds, |
| Target patient group: | All patients cared for in LTHT |
| Target professional group(s): | Secondary Care Nurses |
| Adapted from: |
Evidence base
Cagney, D., Simmons, L., O’Leary, D. P., Corrigan, M., Kelly, L., O’Sullivan, M. J., ... & Redmond, H. P. (2020). The efficacy of prophylactic negative pressure wound therapy for closed incisions in breast surgery: A systematic review and meta-analysis. World journal of surgery, 44(5), 1526-1537. A
Chetter, Ian, et al. (2021) Negative pressure wound therapy versus usual care for surgical wounds healing by secondary intention (SWHSI-2 trial): study protocol for a pragmatic, multicentre, cross surgical specialty, randomised controlled trial." Trials 22:1 p1-14. B
Dumville, J.C., Owens, G.L., Crosbie, E.J. et al. (2015) Negative Pressure Wound Therapy for Treating Surgical Wounds Healing by Secondary Intention. Cochrane Data base Systematic Review. 6:6 CD011278. A
Foroutanjazi, S., Jonczyk, M., Chen, L., & Chatterjee, A. (2021). Closed incision negative pressure therapy: indications and adherence to protocol. The American Surgeon, 87(5), 760-764. B
Gwilym, B. L., Dovell, G., Dattani, N., Ambler, G. K., Shalhoub, J., Forsythe, R. O., & Bosanquet, D. C. et al. (2021). Systematic review and meta-analysis of wound adjuncts for the prevention of groin wound surgical site infection in arterial surgery. European Journal of Vascular and Endovascular Surgery 61(4), 636-646 A
Liu Z., Dumville J C. Hinchliffe R. J. et al. (2018) Negative pressure wound therapy for treating foot wounds in people with diabetes mellitus. Cochrane Data base Systematic Review. 10:10 CD010318 A
NICE Guidance IPG467 (2013) Negative pressure wound therapy for the open abdomen, National Institute for Health and Clinical Excellence A
NICE Medical Technologies Guidance MTG43 (2019) PICO negative pressure wound dressings for closed surgical incisions, National Institute for Health and Clinical Excellence B
Norman G., Goh E. L., Dumville J. C. et al (2020) Negative pressure wound therapy for surgical wounds healing by primary closure. Cochrane Data base Systematic Review. 2020(6): CD009261 A
Nursing and Midwifery Council (2018) The Code: Professional standards of practice and behavior for nurses, midwives, and nursing associates. https://www.nmc.org.uk/standards/code/ (Accessed 15th April 2021)
Sahebally, S. M., McKevitt, K., Stephens, I., Fitzpatrick, F., Deasy, J., Burke, J. P., & McNamara, D. (2018). Negative pressure wound therapy for closed laparotomy incisions in general and colorectal surgery: a systematic review and meta-analysis. JAMA surgery, 153(11), e183467-e183467. A
Saunders, C., Nherera, L. M., Horner, A., & Trueman, P. (2021). Single-use negative-pressure wound therapy versus conventional dressings for closed surgical incisions: systematic literature review and meta-analysis. BJS open, 5(1), A
Evidence Search Strategy
Updated search 24/06/2021
| Search Strategy: # |
Database |
Search term |
Results |
|
1 |
Medline |
("negative pressure wound therap*" OR NPWT).ti,ab |
2472 |
|
2 |
Medline |
"NEGATIVE-PRESSURE WOUND THERAPY"/ |
3234 |
|
3 |
Medline |
("vacuum assisted closure" OR VAC).ti,ab |
3717 |
|
4 |
Medline |
("topical negative pressure" OR TNP).ti,ab |
3852 |
|
5 |
Medline |
(1 OR 2 OR 3 OR 4) |
10781 |
|
6 |
Medline |
(guidance OR guideline*).ti,ab |
497062 |
|
7 |
Medline |
"PRACTICE GUIDELINES AS TOPIC"/ OR "GUIDELINES AS TOPIC"/ |
164853 |
|
8 |
Medline |
(6 OR 7) |
583544 |
|
9 |
Medline |
(5 AND 8) |
232 |
|
10 |
Medline |
9 [DT 2018-2021] [Languages English] [Humans] |
52 |
|
11 |
CINAHL |
("negative pressure wound therap*" OR NPWT).ti,ab |
1723 |
|
12 |
CINAHL |
("vacuum assisted closure" OR VAC).ti,ab |
960 |
|
13 |
CINAHL |
("topical negative pressure" OR TNP).ti,ab |
285 |
|
14 |
CINAHL |
"NEGATIVE PRESSURE WOUND THERAPY"/ |
2843 |
|
15 |
CINAHL |
(11 OR 12 OR 13 OR 14) |
3957 |
|
16 |
CINAHL |
(guidance OR guideline*).ti,ab |
199476 |
|
17 |
CINAHL |
"PRACTICE GUIDELINES"/ |
81704 |
|
18 |
CINAHL |
(16 OR 17) |
241515 |
Approved By
Trust Clinical Guidelines Group
Document history
LHP version 1.0
Related information
Not supplied
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