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Clinician Panel Recommendations for
Use of Negative Pressure Wound
Therapy with Instillation
Melissa McKanna, RN; Jamie Geraci, CWON, BSN, RN; Kimberly Hall, DNP, RN, GCNS-BC, CWCN-AP; Brigitta Hauan, RN; Melania Howell, RN; Trudy Huey, MSN, RN, CWOCN; Adora Lucius,
RN; Susan Mendez-Eastman, RN, CWCN, CPSN; Kedrin Purcell, RN; Rose Raizman, PHCNP, ET;
Dawn Shepherd, BSN, RN, CWON, CFCN; and Allen Gabriel, MD
This supplement is provided as a courtesy to WOUNDS® readers.
It was peer reviewed according to the Ostomy Wound Management journal guidelines.
Ms. McKanna is a Wound and Ostomy nurse at Union Hospital, Terre Haute, IN
Ms. Geraci is an Inpatient WOC Nurse at Bethesda North Hospital, Amelia, OH
Dr. Hall is a Clinical Nurse Specialist at Carilion Clinic, Roanoke, VA
Ms. Hauan is a Surgical RN at UW Northwest Hospital, Seattle, WA
Ms. Howell is a Wound Care Consultant at Emanuel Medical Center, Turlock, CA
Ms. Huey is a Clinical Nurse Specialist at Catawba Valley Medical Center, Hickory, NC
Ms. Lucius is a Wound Care Nurse at UT Southwestern Medical Center, Dallas, TX
Ms. Mendez-Eastman is a Certified Wound Nurse at Nebraska Medicine, Bellevue, NE
Ms. Purcell is a Registered Nurse at Select Specialty Hospital, Newberry, FL
Ms. Raizman is a CNS/Manager, ET, at Shoshray Consulting, Toronto, ON
Ms. Shepherd is a Certified Wound Ostomy Care nurse at Parkland Health and Hospital System, Dallas, TX
Dr. Gabriel is Chief of the Department of Plastic Surgery at PeaceHealth Medical Group, Vancouver, WA
Please address correspondence to: Melissa McKanna, RN, Union Hospital, 1606 N 7th Street, Terre Haute, IN 47804; email: [email protected]
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Clinician Panel Recommendations for
Use of Negative Pressure Wound
Therapy with Instillation
Melissa McKanna, RN; Jamie Geraci, CWON, BSN, RN; Kimberly Hall, DNP, RN, GCNSBC, CWCN-AP; Brigitta Hauan, RN; Melania Howell, RN; Trudy Huey, MSN, RN, CWOCN;
Adora Lucius, RN; Susan Mendez-Eastman, RN, CWCN, CPSN; Kedrin Purcell, RN; Rose
Raizman, PHCNP, ET; Dawn Shepherd, BSN, RN, CWON, CFCN; and Allen Gabriel, MD
Abstract
Addition of an instilled topical wound solution to negative pressure wound therapy (NPWT) is designed to facilitate
regular wound cleansing to help improve outcomes of some complex wounds, but the addition of instillation to NPWT
adds a level of complexity to the wound care process. The paucity of knowledge and experience with instillation may
affect optimal use of this treatment modality. In an effort to address this knowledge gap, a 2-day panel meeting of
nurses (N = 11) with experience using negative pressure wound therapy with instillation and dwell time (NPWTi-d) was
convened to discuss their usage recommendations for managing wounds with this treatment modality in the acute
care setting. Panelists reviewed available evidence and presented recommendations for managing wounds treated
with NPWTi-d. Panelists agreed NPWTi-d is primarily suited to prepare surgical or nonsurgical wounds for delayed
primary closure and preparing/protecting periwound skin improves maintenance of a tight seal. Educating a team of
nurses on basic NPWTi-d troubleshooting, providing a short checklist of tasks to perform every shift, and organizing
needed supplies and resources may help continuity of care and prevent problems. Panelists also emphasized the importance of wound assessment and documentation and recommend educating the patient, family members, and other
members of the patient-care team. Research to compare the safety, efficacy, and effectiveness of NPWTi-d and other
irrigation techniques on patient outcomes and research to validate these recommendations is needed.
Keywords: negative pressure wound therapy, therapeutic irrigation, nursing care, clinical skills
Potential Conflicts of Interest: This panel and writing of this publication was supported by KCI, an Acelity
company, San Antonio, TX. All panel members were compensated for their time and participation in the
advisory panel meeting as well as for manuscript preparation.
I
n recent years, interest in the use of negative pressure
wound therapy (NPWT) with automated instillation of a
topical wound solution has increased,1 as shown by an increase in documented practical experience1,2 and a growing
body of comparative clinical literature.3-5 During NPWT
with instillation, a topical solution is slowly introduced into
the wound bed and dwells for a planned period of time before removal during a cycle of NPWT. The therapy is designed to provide automated cleansing of the wound bed
and removal of infectious materials and debris.4,5 Reviews
of the literature show NPWT with instillation may be used
to prepare the wound bed between operative debridements
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and/or to enhance granulation tissue formation.1 Retrospective analysis3 and a retrospective cohort study4 report
this approach can limit the need for additional surgical procedures in high-acuity wounds versus conventional NPWT.
A next-generation NPWT system with automated instillation capabilities and a dwell time (NPWTi-d; V.A.C. VERAFLO™ Therapy, KCI, an Acelity company, San Antonio,
TX) is designed to provide a simplified method of cyclically
instilling and dwelling topical wound solutions as compared
to previously commercialized systems.1,2,6 Among the literature pertaining to NPWTi-d is a review7 focused on nursing
aspects of managing patients receiving NPWTi-d.
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Key Points
• Evidence about the effectiveness of negative pressure wound therapy with instillation and dwell time
(NPWTi-d) is increasing, but many questions about
optimal usage and patient care strategies remain.
• During a 2-day panel meeting, nurses experienced in
the care of patients whose wounds are managed with
NPWTi-d discussed suggestions and tips for usage.
• Application, maintenance, and removal of NPWTi-d
may be facilitated by the suggestions provided by
the nurses on this panel.
• Research is needed to compare the safety, efficacy,
and effectiveness of NPWTi-d to other management
strategies of these wounds and to validate the usage
recommendations provided by the panel.
Although use of NPWTi-d is reported among general,
plastics, vascular, podiatric, and orthopedic surgeons in
hospital care settings,1,3-5,8-11 clinical and technical aspects
of the therapy remain relatively unknown among nurses
and other clinicians who are tasked with caring for these
wounds. In an effort to address this knowledge gap in
NPWTi-d usage recommendations aimed at nurses, a
panel meeting of nurses with extensive experience using
NPWTi-d was convened to discuss their recommendations
for managing wounds with this treatment modality. Although consensus statements about some topics (eg, when
to transition and device settings) have been explored, other usage subjects have not.
Methods
The sponsor of this panel meeting, Acelity, selected panel
members based on their level of clinical experience using
NPWTi-d. Panelists were selected from North America. All
nurses were invited to participate in the panel meeting based
on their knowledge and experience in wound healing and use
of NPWTi-d.
Participants consisted of 11 female wound nurses with
6–20 years of wound care experience and 1 plastic surgeon
with a wound care specialty. A booklet containing 13 peerreviewed NPWTi-d studies was sent in advance to each panel
member for review before the meeting. This review material was chosen by the sponsor and included the most recent
studies from its own internally updated database of publications on the topic of NPWTi-d.
Panelists met in Denver, CO on November 19–20, 2015.
The meeting was moderated by the plastic surgeon and taperecorded. Each panelist discussed the literature provided, presented their individual clinical experience, and offered suggestions for using this treatment modality. Each presentation
included a moderator-guided roundtable discussion among
presenters and other panelists.
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Table 1. Proposed goals of NPWTi-d13
Cleansing
Granulation tissue
formation
Remove infectious materials
Increase granulation
tissue formation
Reduce risk of compromised
wound healing due to
contamination or bioburden
Decrease wound
volume
Dilute and solubilize necrotic
devitalized tissue and slough
Cover exposed
structures
Decrease viscosity and
volume of exudate
Address malodor
After the meeting, all recommendations were grouped by
subject and summarized by a medical writer. Follow-up communication with the panelists continued throughout development of the recommendations via email. A short summary
of literature comparing outcomes of NPWT versus NPWTi-d
to help guide clinical decision making was provided to panel
members. Three NPWTi-d case examples were added to illustrate clinical outcomes. All recommendations were approved
by the panel members. In cases where a panel member edit
contradicted a previous edit, the first author and moderator
determined the final text to be included in the manuscript.
Literature Summary: NPWTi-d versus NPWT
Clinical studies9,10 report enhanced granulation tissue
formation with use of NPWTi-d with instilled saline versus conventional NPWT (V.A.C.® Therapy, KCI, an Acelity company, San Antonio, TX). Specifically, a retrospective
case series9 (N = 24) and a 131-patient case series10 showed
instillation of sterile saline instillation had a positive impact
on healing trajectory. In a porcine wound model,12 NPWTi-d with saline instillation resulted in a 43% increase over
conventional NPWT in granulation tissue formation after 7
days of therapy.
A prospective pilot study by Goss et al5 compared the efficacy of wound bed preparation between NPWT and NPWTid using 0.125% Dakin’s Solution (Century Pharmaceuticals,
Inc, Indianapolis, IN) in 13 patients with 16 chronic lower
leg and foot wounds requiring debridement. Patients in both
groups received sharp surgical debridement, followed by 1
week of NPWT or NPWTi-d. Although not statistically significant, wounds treated with NPWTi-d had a lower mean
colony forming units per gram of cultured tissue compared
with NPWT (2.6 x 105 ± 3 x 105 versus 2.79 x 106 ± 3.18 x 106,
respectively; P = 0.43).
In a retrospective, controlled cohort study of 142 patients with acute or chronically infected wounds who received NPWT alone or NPWTi-d using Prontosan® Wound
Irrigation Solution (B. Braun Medical, Inc., Bethlehem, PA)
and dwell times of 6 minutes or 20 minutes, Kim et al4 rewww.o-wm.com
Table 2. Panel recommendations for maintaining a seal
Prepare the periwound skin
Cleanse skin before dressing application. Avoid using lotions, emollients, or products with fragrances on the
periwound area. If an adhesive remover is utilized, be sure to clean away any residue that would affect the seal.
Shave or clip hair around wound as needed.
If possible, allow patients to assist in dressing removal to reduce pain and/or anxiety.
Use the barrier film provided in the dressing kit for optimal adherence of the drape. All barrier films are not created equal.
If the periwound skin is denuded from wound exudate or other moisture-related issues, the “crusting” technique can
be used to create a dry surface for better adherence of the drape. This may also reduce the risk of further breakdown
related to moisture. To implement crusting, sprinkle ostomy powder over the moist periwound area and then brush
off the excess. Follow with a layer of silicone-based barrier film (spray or wipe form) and repeat as necessary.
Create a frame around the periwound area to protect intact skin and enhance the surface for cover drape adhesion
by applying a silicone-based barrier film and thin strips of the drape around the perimeter of the wound.
Stoma paste or moldable paste strips, hydrofiber, hydrocolloid, or thin foam dressings may be used under the
“frame” as needed to fill contours and assist with sealing moist areas.
If utilizing stoma paste, consider squeezing paste through a 10-cc syringe to allow for controlled application of a thin
bead of paste. This helps limit excess or uneven application and reduces the risk of paste getting into the wound cavity.
If problems with drape adherence persist, povidone-iodine may be considered if the patient is not allergic. This may
help dry out macerated skin. It is important to note this product requires approximately 1 hour for the skin to be dry
enough to apply the drape.
If the dressing is placed over an area of loose skin or where the body flexes (eg, flank or abdomen), the skin must be
pulled smooth when applying both the frame and the final drape. This will ensure the body can stretch/flex where
needed without compromising the dressing or causing a medical adhesive-related skin injury.
Optimal dressing application for the best seal
Use the barrier film provided in the dressing kit around the edges of the dressing and on any overlapping drape to
seal any microleaks that may occur.
Adjust the device settings if needed
The fill-assist feature on the device can be used when setting up the initial NPWTi-d. Make sure the amount of
instilled topical solution just saturates the foam during each instill cycle. If the foam is oversaturated (ie, the dressing
is bulging or fluid is pooling around edges of wound or leaking out of the dressing), lower the volume instilled and
reseal the drape as needed.
Adjust the manufacturer default negative pressure setting, -125 mm Hg with NPWT for 3.5 hours at low intensity,
if needed. When appropriate, increase negative pressure slightly when using dressings that may be easily
compromised due to body contours or location. The intensity may also be increased to help secure the seal. Assess
for increases in patient pain levels. If pain increases, NPWT intensity should be returned to the previous setting.
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ported a significantly lower number of operative visits for
debridement in the NPWTi-d 6-minute and 20-minute
dwell time groups (2.4 ± 0.9 and 2.6 ± 0.9, respectively) versus the NPWT group (3.0 ± 0.9) (P ≤0.05). Hospital stay was
significantly shorter for the 20-minute dwell time NPWTi-d
group (11.4 ± 5.1 days) versus NPWT alone (14.92 ± 9.23
days) (P ≤0.05), and time to final surgical procedure was
significantly shorter for the 6- and 20-minute dwell time
groups (7.8 ± 5.2 days, 7.5 ± 3.1 days, respectively), compared to standard NPWT (9.23 ± 5.2 days) (P ≤0.05).4
A retrospective analysis by Gabriel et al3 showed significant differences between patients with extremity or trunk
wounds treated with NPWTi-d using saline or Prontosan
(n = 48) versus NPWT (n = 34), respectively, in terms of
mean operating room debridement (2.0 versus 4.4) (P
<0.0001), mean hospital stay (8.1 days versus 27.4 days) (P
<0.0001), mean length of therapy (4.1 days versus 20.9 days)
(P<0.0001), and mean time to wound closure (4.1 days versus 20.9 days) (P <0.0001).3
Using these data, Gabriel et al3 developed a hypothetical
economic model to estimate the cost of NPWTi-d versus
NPWT related to required number of OR debridements
(2.0 versus 4.4, respectively) and average length of therapy
(4.1 days versus 20.9 days, respectively) in complex extremity and trunk wounds. The NPWTi-d daily estimated cost
was $194.80 versus $106.08 for NPWT. The estimated cost
of an OR debridement was $3,393. The model showed a
potential average cost reduction of $8,143 for OR debridements between NPWTi-d ($6,786) and NPWT ($14,929)
patients, and a $1,418 difference in average therapy costs
between the NPWTi-d ($799) and NPWT ($2,217) groups.
Labor costs outside of OR debridement were not considered in the model.3
Results/Recommendations
The panelists developed several recommendations for
the use of NPWTi-d.
Types of Wounds That May Benefit Most From
NPWTi-d
The panelists concurred with published observations
that NPWTi-d is primarily suited to prepare surgical or
nonsurgical wounds for delayed primary closure. In a review
article, Gupta et al13 proposed a clinical approach for appropriate application of NPWTi-d. The approach recommends
consideration of NPWTi-d as part of the wound treatment
strategy if the therapy goal is to promote cleansing or granulation (see Table 1). The therapy is used adjunctively with
debridement and appropriate systemic antibiotics.
Addressing Challenges in Managing Patients
with NPWTi-d
The use of NPWTi-d utilizing various topical wound
solutions in conjunction with debridement and systemic
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Table 3. Panel-recommended checklist of device-related tasks/troubleshooting
Make sure the NPWTi-d device is plugged in and turned
on, and ensure the adapter cord and power cord are
securely in place.
Make sure there are no unaddressed alarms.
Make sure there is an extra empty canister at the
bedside at all times.
Check the canister frequently and change if needed.
Check the solution bag frequently and change if
needed.
Check device settings to make sure they are correct.
Check the dressing site to make sure the seal is
maintained.
Check that all connectors are secure.
antibiotics has been reported for complex extremity or
trunk wounds,3 ischemic, neuropathic, decubitus, or surgical wounds,4,11 infected soft tissue wounds,14 colonized and/
or large venous stasis ulcers,5,15 and open fractures, pressure
ulcers, nonhealing postoperative dehiscence, and infected hematoma wounds.10
Based on their experience, panel members made recommendations to address the key challenges nurses may face
when using the NPWTi-d system.
Maintaining a seal. The cyclical instillation of solutions
with NPWTi-d can cause difficulties in maintaining a seal.
The panelists believe these challegnes can be addressed
(see Table 2).
Gaining proficiency and confidence using the NPWTid device. Appropriate use of NPWTi-d within an institution
may be difficult. For example, nurses who do not understand the therapy may turn off the device when the alarm
sounds, instead of troubleshooting and fixing the problem
so the therapy remains active. Common issues with the device can be addressed by writing a note on the dressing itself so all nurses can easily check for accuracy, labeling the
solution bag with the therapy settings and projected change
time/date, and zip-tying a laminated “tips and tricks” sheet
onto the device as a troubleshooting reference that includes
the local manufacturer representative’s name and contact
information for real-time assistance. Table 3 presents a
checklist of quick tasks to be performed and provided for
every shift or per hospital policy.
Working as a team. Most of all, it is important to develop a team approach in managing NPWTi-d throughout
the hospital to encourage a seamless transition of therapy
knowledge between nursing shifts. However, educating all
nurses within a large hospital to manage NPWTi-d may be
unrealistic, and the challenges of educating nurses on different shifts may be problematic. Table 4 presents panel suggestions to help ensure successful management of NPWTi-d
within an institution during all shifts.
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Table 4. Panel recommendations on team building and
continuity
Table 5. Suggested NPWTi-d resource box items
Create an environment in which leadership promotes
accountability of all nurses in supporting NPWTi-d at
the bedside.
NPWTi-d canisters (500 mL, 1,000 mL)
When possible, divide NPWTi-d management tasks so
the wound care team manages the process of applying
the therapy, including dressing changes, while general
nurses change the canister and topical wound solution
and perform basic troubleshooting.
Products to protect periwound skin (stoma paste, stoma
powder, stoma paste strips)
When therapy is started, bedside education with
staff helps establish clear expectations of ongoing
assessment, monitoring, and care for the patient with
NPWTi-d.
NPWTi-d dressings
NPWTi-d cassette
Skin barrier film (to enhance seal)
Scissors
Permanent marker
Gauze
Extra drape
Photo guide for application of a sample dressing
When feasible, the wound dressing should be changed
by the same clinician each time for consistency in
wound evaluation.
Written instructions for dressing application, including where and/or how to obtain topical solution (if not
pharmacy)
Providers and/or the WOC nursing team should ensure
consistent, thorough documentation in the patient’s
medical record that outlines NPWT settings including
pressure, intensity, dwell times, frequency of instillation
cycles, and frequency of dressing changes.
Troubleshooting tips
Manufacturer’s training representatives can be used to
educate doctors, residents, and materials management
staff about NPWTi-d.
Use internal skin/wound champion nurses with the most
NPWTi-d experience to reinforce basic troubleshooting
techniques for NPWTi-d, including changing canisters
and solutions.
Wound care nurses should maintain a close working
relationship with prescribers with respect to managing
patients with NPWTI-d.
Ongoing quarterly or semi-annual educational opportunities to enhance previously learned concepts and
to introduce new nurses to NPWTi-d are valuable to
instruction and protocol.
Consolidate supplies for ease of use and education. A resource box should be accessible to all nurses. These resources,
which should include accessories needed to apply the product
safely and effectively, can be especially helpful for staff that
may not be familiar with NPWTi-d and its various components. The resource box may be kept in the OR near the
NPWTi-d device and supplies. These boxes can accompany
nurses when they are checking on or need help troubleshooting problems with patients receiving NPWTi-d. A photo
guide demonstrating the application for the current patient’s
dressing protocol may be helpful, especially if unique issues
such as periwound skin concerns, irregular contours, and the
like are present. Also, consider storing an extra canister in patient rooms for ready availability when a canister change is
needed. Table 5 lists items to include in the resource box.
Management of instillation solutions. Normal saline,
polyhexanide (0.01%), Dakin’s solution (0.125%, Oculus
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Labeled list of items to keep in the resource box (to refill
as necessary)
Phone number for 24/7 product support
Innovative Science, Petaluma, CA), and silver nitrate (0.5%)
have been instilled with NPWTi-d as reported in literature.2-5,7,11,13,16 A potential challenge in using NPWTi-d is accessibility of solutions; they must be obtained through the
pharmacy. Medication safety and delivery mechanisms can
be a difficult hurdle to overcome when working to first introduce the therapy into a facility. Table 6 lists tips to help
nurses introduce and ensure a steady supply of a solution to
be instilled with NPWTi-d.
Selection of appropriate instillation volume. Determining the appropriate volume to instill can seem complicated at first. The objective is to select enough volume to
bathe the wound bed without compromising the dressing
seal. Panel suggestions, in addition to experience over time,
can give nurses greater confidence in selecting the appropriate solution volume to instill (see Table 7).
Recommendations for Pain Management
Some data suggest pain during dressing changes may
be less pronounced with NPWTi-d compared to standard
NPWT.3 The regular flow of solution across the wound
bed can help reduce adhesion of the dressing and allow for
easier dressing removal. Nevertheless, dressing changes with
NPWTi-d can be painful depending on wound location
and severity. In cases where pain is a factor, panel members
have observed pain is usually the worst at the first dressing
change and then decreases progressively. The panel recommends several options to help address potential discomfort
or pain during dressing change (see Table 8).
Canister size. Two different disposable canister sizes are
available for NPWTi-d: 500 mL and 1,000 mL. Canisters
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Table 6. Panel recommendations for managing topical wound solutions for instillation
When starting NPWTi-d at your facility, consider first using a solution such as normal saline that is easily accessible to
nurses at your facility and doesn’t require additional regulations by pharmacy.
Calculate when the next bag of instillation fluid will be needed. For example, if you have a 500-mL bag instilling 50 mL
at each cycle and cycling every 2 hours (500 ÷ 50 = 10 cycles per bag; 10 x 2 = 20 hours), a 500-mL bag is needed in
20 hours. Label the bag with the estimated time of solution bag change.
When choosing a solution that involves pharmacy, choose a wound care leader who will be responsible for working
with the pharmacy. The pharmacy and wound care teams should develop a process that addresses product ordering
and any medication delivery safety issues.
Notify pharmacy of the availability of the 38-mm spikeable cap that is included in the NPWTi-d cassette. By utilizing the
cap, the instillation solution can be distributed in a bottle instead of an IV bag. This allows for a safer overall process.
Consider obtaining an order to use normal saline, should the prescribed solution not be available.
Make sure orders are clearly written in the electronic medical record regarding frequency, dose, and type of solution for
easier communication with pharmacy. Be proactive in letting pharmacy know when the next solution bag is needed.
When possible, involve patients and educate them about the process involved for wound healing, including the level
of solution needed in the bag and alarms, so they can play an active role in informing nurses when the amount of
solution is getting low.
Nurses should monitor the NPWTi-d fluid status each time they perform routine checks such as IV checks or vital signs.
Table 7. Panel recommendations for appropriate topical wound solution volume
Make sure dressed wound is parallel to the floor to get optimal benefits of NPWTi-d.
Nurses new to NPWTi-d should use the “fill assist” mechanism on the device to help determine the volume of solution to be instilled during each cycle. Fill assist allows a nurse to monitor initial wound fill by manually starting and
stopping instillation to determine correct instill volume after the dressing is applied. Once determined, this volume will
be the set point for each subsequent instill phase until wound volume changes notably.
Volume may also be approximated by using the calculation suggested by the manufacturer: 0.2 cc/cm2 of wound area.
A basic rule of thumb is to instill just enough solution to visibly saturate the foam. If the foam becomes oversaturated,
reduce the amount being instilled by approximately 10% to 20%.
Table 8. Panel recommendations for pain management
Before initiating therapy, develop a plan of care with the patient for pain management. Use a pain scale for the patient
to identify pain before therapy and at the end of the procedure so pain can be monitored and addressed. Ongoing
assessment of what was painful (eg, removal of the drape or foam) and addressing this with patients validates concerns and helps relieve anxiety.
Use the “dressing soak” feature on the NPWTi-d system before dressing changes, which will fill the foam with fluid
and allow for easier dressing removal.
Administer oral or intravenous pain and/or anxiety medication per provider order at least 30 minutes before dressing change.
For patients who may have pain during the instillation cycle, consider setting frequency of the cycle to coordinate with
ordered pain medication schedule.
Encourage the patient to do deep breathing and relaxation techniques; these are very helpful and work well.
Education about what to expect during the dressing change goes a long way in pain management.
add incremental cost to the therapy; thus it is important to
consider how much fluid will be going into the canister to
determine the appropriate size to order for each patient. The
1,000-mL canister is recommended by the panel for overall cost savings in cases of medium to large wounds, and
in most cases of frequent cleansing during NPWTi-d. The
1,000 mL canister is slightly less expensive per mL of volume
and can save time due to reduced canister change frequency, as long as it is filled to capacity. The amount of wound
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drainage output will be skewed, as the instilled solution will
be mixed in with wound drainage.
Based on the panelists’ recommendations, the following
calculation may help provide an estimate of canister capacity and how many canisters will be needed:
24 (hours per day) ÷ frequency of dwell cycles x mL of solution to be instilled x anticipated days of therapy
For example, with a small chronic (dry) wound and expected solution volume instillation of approximately 20 mL
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Table 9. Panel recommendations for positioning of patient and dressing
Position the patient so the instilled solution can flow evenly over the wound surface.
With medium- to large-sized wounds, consider using a duo tube set to enhance solution coverage of the wound bed.
One tube is positioned to instill on one side of the wound, and the other tube is positioned to remove the solution
from the other side of the wound.
Once the instillation therapy is turned on, make sure all areas of the wound bed are receiving instillation, including the
distal areas.
Table 10. Panel recommendations for determining instillation frequency
If the patient is mobile, reducing instillation frequency may simplify care as the instill cycle is most efficient if the
patient is stationary while the solution is dwelling. With this in mind, it is important to communicate timing of instill
cycles with physical and occupational therapy so they can coordinate their sessions accordingly.
Fluid appearance in the canister may help determine instillation frequency. If the canister contents have a dark color,
it may indicate the frequency of instillation should be increased.
Consider more frequent instillation and shorter dwell time in highly exudating wounds.
If the dressing is placed in an area where the seal may be easily compromised, less frequent instillation cycles may
be optimal.
Table 11. Panel recommendations for determining dwell time
Consider anatomy in selecting a dwell time; a shorter dwell time is recommended in cases where the wound is surrounded by contours, such as in the groin area or on the feet.
Wound size should be considered; a shorter dwell time may be optimal for larger wounds to decrease the chances of
leaks developing around wound edges.
Always check the product insert information for clinical recommendations when utilizing any solution compatible with
the NPWTi-d system.
Dwell time and frequency are not always independent of one another. If a shortened dwell time is needed related to
the solution or location of dressing, it may be necessary to increase the frequency to achieve the desired outcome
and vice versa.
Wounds should not appear “water-logged” at the end of a dwell cycle. If this or maceration occurs, dwell time should
be shortened.
every 3 hours for 3 days until discharge, the total estimated
output would be approximately 480 mL (24 ÷ 3 x 20 x 3 =
480 mL). A 500-mL canister may be appropriate for this size
of nondraining wound.
Patient and dressing positioning during instillation.
Patient positioning during instillation can influence overall effectiveness of the therapy. Table 9 provides tips to help
ensure the patient and the dressing are appropriately positioned during the instillation phase.
Instillation frequency. The negative pressure time between instillation cycles can be set between 1-12 hours. Most
studies report an instillation frequency of between 1 and 4
hours.2-4,10,11,13,16 Panel considerations for determining an appropriate frequency for instillation are included in Table 10.
Choosing a dwell time. The purpose of the dwell time is
to allow the instilled solution to deliver its cleansing properties to the wound bed. Dwell time can be set from 1 second to 30 minutes on an NPWTi-d device. Prolonged dwell
times can contribute to development of dressing leaks and
maceration. Selecting an appropriate dwell time depends
on a variety of factors and is not an exact science. Nursing
panel members reported using dwell times of 3-15 minutes;
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dwell times from 1-20 minutes are reported in literature,
with a dwell time between 5-10 minutes most often reported.2-5,9-11,16 Panel recommendations to help guide clinicians
in selecting an optimal dwell time are listed in Table 11.
When to discontinue NPWTi-d. During NPWTi-d,
the wound should appear markedly improved at each
dressing change. Based on their own experiences, panel
members recommended re-examining the patient’s condition if the wound does not make progress after 3 days
of NPWTi-d. Duration of NPWTi-d depends on the
wound and the goals of therapy for that wound.13 The
majority of nurse panel members reported an average
NPWTi-d treatment duration of approximately 1 week
per wound, but this can vary greatly. According to a recent literature review by Kim et al.,2 reported length of
NPWTi-d ranges from 2-60 days, with the majority of
studies reporting an average length of therapy between
7-14 days.2 Panel members also observed NPWTi-d can
be longer in the presence of: 1) slough cover, 2) fibrinous
exudate, 3) difficult dehisced wounds that require wound
closure before patient discharge, and 4) patients who will
be discharged to facilities that do not accomodate NPWAPRIL 2016 OSTOMY WOUND MANAGEMENT®
9
Table 12. Panel recommendations for documentation: what to include and when to document
Location
With each dressing change:
Wound characteristics
documentation
Wound type
Wound bed tissue
Drainage
Periwound
Odor
Type of foam and number of pieces applied/removed and contact layer if any
With each dressing change:
NPWTi-d device documentation
Instillation solution used
Amount of instillation solution
Dwell time
Frequency of instillation
Provision of pain medication and/or comfort measures before treatment
With each dressing change:
Therapy documentation
Use a valid pain assessment tool for pre- and post-recording of pain level identified by the patient
Periwound preparation
Removal of residual dressing (If NPWT, are all foam pieces accounted for?)
Application specifics (Were there any issues [eg, with seal, patient tolerance]?)
Periwound description
Verify foam is compressed in the wound bed
Verify therapy settings on LCD screen
Documentation with each shift:
Solution input/output
Instillation solution in (monitor if this is correct, given instillation orders for amount
and frequency)
Instillation solution out (monitor if this is appropriate, given instillation orders for
amount and frequency; this should be approximately equal to or more than what
is flowing in, as output contains solution mixed with wound drainage)
Weekly documentation:
PRN and/or per facility policy:
Discontinue documentation:
Wound length, width, depth (weekly)
Canister changes
Cassette changes
When NPWTi-d is discontinued, document why and the plan for an alternative
dressing/therapy
Ti-d. The panel recommends transitioning patients from
NPWTi-d when: 1) goals of therapy have been met (i.e.,
ready for coverage or closure), 2) clinical signs of infection are absent, and 3) good granulation tissue is present
and continuing to form (the wound has entered into the
proliferative phase of healing).
Sometimes the patient may need to be transitioned
before these criteria are achieved. For example, transition
can occur if the patient is being transferred to a longterm acute care (LTAC) or a skilled nursing facility where
NPWTi-d is not available, or if the patient meets criteria
for discharge home. NPWTi-d should not increase the
length of stay, but should be seen as an adjunct therapy
to be utilized within the patient’s hospital admission. It
should be noted the use of NPWTi-d is not intended or
cleared for home use.
10
OSTOMY WOUND MANAGEMENT® APRIL 2016
Documentation
Based on panel member experience, careful documentation is critical in gaining acceptance of NPWTi-d by hospital
administration. Wound status must be documented before
and throughout the use of therapy. Wound documentation provides a summary of progression or lack thereof and
should be performed per organizational policy. Table 12
lists documentation details recommended by panel members, as well as the appropriate frequency of documentation. If the electronic medical record is available, the current
wound documentation screen may be edited to include the
key components of documentation listed in Table 12.
Patient and Family Education
All panel members agreed educating the patient and family about NPWTi-d can be paramount to the therapy’s sucwww.o-wm.com
Table 13. Panel recommendations for establishing patient adherence with NPWTi-d
Take time with each patient. Ask questions of the patient to help establish a relationship: What are your goals for this
hospitalization? What is your job? Where do you live?
Individualize patient care plan and educate patient on factors that optimize wound healing, such as proper nutrition
and blood sugar control.
Teach patient and family breathing and relaxation techniques before the first dressing change. Utilize the family as a
resource to coach the patient through the procedure. This empowers both the patient and family.
Explain to patient and family in advance what will happen with the therapy, always with respect toward patient’s
culture and customs.
Educate patients about the therapy, including device and disposables, to empower them to feel in control. Ask
patients to repeat what they understand.
Share success about the therapy to offer support and give hope — i.e., how much the wound size is decreasing.
Do not make promises to patients regarding healing time; provide an open-ended time frame. “I don’t know,”
“Anything can happen along your journey to healing,” and “I will work my hardest” are acceptable answers.
Teach patients to advocate for themselves and to know how the dressing change should feel, when to change the
canister or solution, or how the wound should progress.
Establish ongoing rapport with the patient. Conversation can distract patients from their pain, which can be a great
help in certain wound types.
Mobilize patients when possible; get physical therapy or occupational therapy involved when needed.
Do your best to enhance the patient’s quality of life. Nurses observe that better quality of life means quicker closure.
Set limits with patients (e.g., discourage inappropriate language).
Be empathetic. Inject dignity and humor when appropriate.
cess. Getting the patient’s buy-in before the therapy starts
is important because patient nonadherence to prescribed
therapy can negatively affect outcomes. When properly educated, patients can be a first-line source for reporting leaks
and alarms.2 Table 13 lists panel member suggestions for establishing patient compliance during NPWTi-d.
Case Examples
The panel members wanted to provide case examples to
demonstrate the adjunctive use of NPWTi-d as part of their
overall management of wounds. These cases were selected
because they represent various wound types.
Case 1: Foot infection and ulceration in person with
Diabetes Mellitus. A 42-year-old man with a foot ulcer
present >6 months and a history of uncontrolled diabetes
presented with a diabetic foot infection of the left plantar
foot (12 cm x 5 cm x 1.5 cm with 0.3 cm undermining and
tunneling). The patient was admitted following 1 week of fever >100.1 and chill, left foot erythema and swelling consistent with cellulitis. The left foot wound had purulent drainage. Prehospitalization treatments lasted for 3 weeks and
included surgical irrigation and debridement and NPWT.
During hospitalization, in addition to broad-spectrum intravenous antibiotics, strict blood glucose control and strict
offloading using crutches/walker for transport to maintain
a non-weight baring lower extremity. Surgical and serial
sharp bedside debridement were performed 3 times. One
toe was amputated due to severe ingrown toenail, presence
of ulceration, cellulitis, and toe deformity. NPWTi-d was
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initiated 8 days after admission with instillation of normal
saline; dwell time was 10 minutes, followed by 3 hours of
continuous negative pressure at -125 mm Hg. A reticulated,
open-cell foam dressing was used. Dressings were changed
3 times per week. Goals of NPWTi-d therapy were wound
bed preparation, granulation tissue formation, and removal of infectious materials. NPWTi-d was continued for 1
week followed by NPWT in the home health setting for 2.5
months. The wound closed after 3 months of therapy. Figure 1 shows wound healing progression during 1 week of
NPWTi-d (see Figure 1).
Case 2: Fournier’s gangrene. A 69-year-old man presented with Fournier’s gangrene of the perineal region along
with an abdominal abscess. The patient was started on intravenous antibiotics. NPWTi-d was initiated with the goal
of wound bed preparation between debridements, granulation tissue formation, and removal of infectious materials.
A sodium hypochlorite solution (1:20) was instilled with a
10-minute dwell time followed by 4 hours of continuous
NPWT at -125 mm Hg. A reticulated, open-cell foam dressing was used. Dressings were changed 3 times per week, and
NPWTi-d was continued for 10 days. Therapy then changed
to conventional NPWT and collagen-oxidized regenerated
cellulose (C/ORC) dressings with silver (PROMOGRAN™
PRISMA Wound Balancing Matrix, Systagenix, an Acelity
company, San Antonio, TX). NPWT was discontinued after
2 weeks and the wound was treated with C/ORC dressings
with silver for the remainder of healing time. The wound
was >75% re-epithelialized at 40 days and nearly healed at
60 days post initiation of NPWTi-d (see Figure 2).
APRIL 2016 OSTOMY WOUND MANAGEMENT®
11
Figure 1. Diabetic foot infection with ulceration: a) wound before NPWTi-d initiation; b) wound following 2 days of
NPWTi-d and surgical debridement (including second toe amputation); c) wound after sharp bedside debridement
followed by 5 days of NPWTi-d.
(Patient information and photos courtesy of Kimberly Hall, DNP, RN, GCNS-BC, CWCN-AP).
Case 3: Pressure ulcer and necrotizing fasciitis. A 54-yearold man with a history of paraplegia, hypokalemia, protein
calorie malnutrition, and urinary tract infection presented
with a pressure ulcer on the ischial tuberosity (IT)/buttock.
The wound measured 8.5 cm x 28 cm x 4 cm with slough and
5.2 cm undermining extending from the right buttock to the
right groin. Necrotizing fasciitis infection was suspected and
confirmed via CT scan. Surgical debridement was performed,
followed by a second minor debridement 4 days later. Intravenous antibiotics (vancomycin and pireracillin/tazobactam)
were started and NPWTi-d initiated. NPWTi-d included instillation with 85 mL of 0.125% Dakin’s solution, 15-minute
dwell time, followed by 8 hours of continuous negative pressure at -150 mm Hg. No-Sting barrier spray was applied to
the periwound skin followed by the NPWTi-d drape. A reticulated, open-cell foam dressing specifically designed for
instillation and a double negative pressure tube set (V.A.C.
VeraT.R.A.C. Duo™ Tube Set, KCI, an Acelity company, San
Antonio, TX) were used to ensure solution coverage of the
buttock and groin wound. The dressings were changed 2
times per week. Wound progression with NPWTi-d is shown
in Figure 3. After 4 days of NPWTi-d, the wound measured
5 cm x 28 cm x 5.5 cm and was clean, pink and red. Granulation tissue was noted in the wound after 7 days of NPWTid. Granulation tissue formation continued after 11 days of
NPWTi-d. A tunnel in the ischial tuberosity region with purulent drainage was monitored, and after 15 days of NPWTi12
OSTOMY WOUND MANAGEMENT® APRIL 2016
d, the region was much improved and NPWTi-d was discontinued. The patient was discharged to a LTAC hospital. The
wound closed secondarily after 4 months.
Conclusion
A review of some of the available literature, plus the
panel discussions and recommendations suggest NPWTi-d,
in conjunction with debridement and systemic antibiotics,
may be a useful tool in the adjunctive management of heavily contaminated, colonized, or infected acute or chronic
wounds. The therapy appears to be particularly well suited
for challenging wounds that require delayed surgery and/or
when the goal is to cleanse the wound or facilitate granulation tissue formation. Compared to conventional NPWT,
NPWTi-d has been reported to lessen bacterial load and
enhance granulation tissue formation, while reducing the
average number of surgical debridements. However, this
new technology can present usage challenges. Compared
to NPWT, NPWTi adds the complexity of an instilled solution and new device settings, requiring a well-organized
approach for effective wound management.
In managing NPWTi-d, the panel agreed that it is
important to develop a team approach throughout the
hospital to encourage a seamless transition of therapy usage knowledge between nursing shifts and departments.
Building and educating a team of nurses who are responsible for basic troubleshooting will help ensure optimal
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Figure 2. Wound resulting from Fournier’s gangrene a) at presentation; b) after 6 days of NPWTi-d, slough was decreased and wound was granulating; c) 11 days following initiation of NPWTi-d, the wound was 100% granulated
and beefy red with healthy wound edges; d) therapy was changed from NPWTi-d to conventional NPWT with C/ORC
dressings with silver. NPWT was discontinued after 2 weeks and the wound was treated with C/ORC dressings with
silver for remainder of healing time; e) the wound was >75% re-epithelialized at 40 days; and f) nearly healed at 60
days post initiation of NPWTi-d.
(Patient information and photos courtesy of Rose Raizman, PHCNP, ET).
NPWTi-d functioning around the clock. The panel also
suggested all nurses should be armed with a short checklist of tasks to be performed at every shift, as well as readily accessible supplies to help ensure positive outcomes.
In addition, teamwork between wound care and pharmacy is encouraged to ensure a successful process for obtaining and maintaining instillation solutions.
Manufacturer representatives can provide ongoing education for nurses, doctors, residents, and others who would apply the therapy. They can assist in expanding knowledge about
optimal device usage, including patient positioning, device
settings, and pain management during NPWTi-d. Nurse education also should include tips in maintaining a seal during
NPWTi-d, including good periwound preparation, strategic
placement of the negative pressure connector pad, and appropriate instillation settings. Thorough wound assessment and
documentation is paramount for monitoring outcomes. Establishing a good rapport with the patient and family and educating them about NPWTi-d are also considered to be important
steps in achieving success. The panel suggested that improved
knowledge about and support for NPWTi-d throughout an
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institution would help empower nurses to provide the highest
standard of care in managing patients using NPWTi-d.
Currently, further research regarding NPWTi-d efficacy
and optimal clinical practices for a variety of wound types
is needed. The clinical effects of changes in negative pressure, instilled solution, dwell time and frequency need to
be further substantiated in comparative studies. In addition, controlled clinical studies measuring effectiveness of
pain reduction methods during dressing changes could aid
patient care. Future robust, controlled studies to examine
the effects of institutional factors (e.g., nurse/patient education and team building programs) on outcomes of care
using NPWTi-d are needed to validate the results of this
panel meeting and resultant recommendations.
Randomized, controlled clinical studies are needed to
compare the safety, efficacy, and effectiveness of NPWTi-d
to other, non-NPWT methods of care. Panel participants
also recommend that prospective, randomized, controlled
scientific and clinical studies should be conducted to investigate the effect of NPWTi-d versus standard irrigation
practices on bacterial counts and patient outcomes. n
APRIL 2016 OSTOMY WOUND MANAGEMENT®
13
Figure 3. a) Pressure ulcer following postoperative debridement. The wound measured 8.5 cm x 28 cm x 4 cm with
slough and 5.2 cm undermining extending from the right buttock to the right groin; b) after 4 days of NPWTi-d [AU:
and minor surgical debridement?], the wound measured 5 cm x 28 cm x 5.5 cm and was clean, pink, and red; c)
granulation tissue formed in the wound after 7 days of NPWTi-d; d) granulation tissue formation continued after 11
days of NPWTi-d. A tunnel in the ischial tuberosity (IT) region with purulent drainage was monitored; e) after 15 days
of NPWTi-d, the IT region was much improved and NPWTi-d was discontinued.
(Patient information and photos courtesy of Gina Rose, CWOCN, BSN, RN and Jamie Geraci, CWON, BSN, RN).
Acknowledgment
The authors thank Karen Beach and Ricardo Martinez
(Acelity) for their assistance in editing this manuscript and
are grateful to all of the panel participants: Melissa McKanna, RN, Union Hospital, Terre Haute, IN; Jamie Geraci,
CWON, BSN, RN, Bethesda North Hospital, Amelia, OH;
Kimberly Hall, DNP, RN, GCNS-BC, CWCN-AP, Carilion
Clinic, Roanoke, VA; Brigitta Hauan, RN, UW Northwest
Hospital, Seattle, WA; Melania Howell, RN, Emanuel Medical Center, Turlock, CA; Trudy Huey, MSN, RN, CWOCN,
Catawba Valley Medical Center, Hickory, NC; Adora Lucius,
RN, UT Southwestern Medical Center, Dallas, TX; Susan
Mendez-Eastman, RN, CWCN, CPSN, Certified Wound
Nurse, Nebraska Medicine, Bellevue, NE; Kedrin Purcell,
RN, Select Specialty Hospital, Newberry, FL; Rose Raizman,
PHCNP, ET, Shoshray Consulting, Toronto, ON; Dawn
Shepherd, BSN, RN, CWON, CFCN, Parkland Health and
Hospital System, Dallas, TX; and Allen Gabriel, MD, FACS,
PeaceHealth Medical Group, Vancouver, WA.
References
1. Kim PJ, Attinger CE, Steinberg JS, Evans KK. Negative pressure wound therapy with instillation: past, present, and future. Surg Technol Int. 2015;26:51–56.
2. Kim PJ, Attinger CE, Crist BD, et al. Negative pressure wound therapy with instillation: review of evidence and recommendations. Podiatr Today. 2015;suppl:1-20.
3. Gabriel A, Kahn K, Karmy-Jones R. Use of negative pressure wound
therapy with automated, volumetric instillation for the treatment of extremity and trunk wounds: clinical outcomes and potential cost-effectiveness. Eplasty. 2014;14:e41.
4. Kim PJ, Attinger CE, Steinberg JS, et al. The impact of negative-pressure
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OSTOMY WOUND MANAGEMENT® APRIL 2016
wound therapy with instillation compared with standard negative-pressure wound therapy: a retrospective, historical, cohort, controlled study.
Plast Reconstr Surg. 2014;133(3):709–716.
5. Goss SG, Schwartz JA, Facchin F, Avdagic E, Gendics C, Lantis JC
II. Negative pressure wound therapy with instillation (NPWTi) better reduces postdebridement bioburden in chronically infected lower
extremity wounds than NPWT alone. J Am Coll Clin Wound Special.
2014;4(4):74–80.
6. Gabriel A. Integrated negative pressure wound therapy system with volumetric automated fluid instillation in wounds at risk for compromised
healing. Int Wound J. 2012;9(suppl 1):25–31.
7. Gabriel A, Rauen B. Simplified negative pressure wound therapy with instillation: advances and recommendations. Plast Surg Nurs. 2014;34(2):88–92.
8. Gabriel A, Shores J, Heinrich C, et al. Negative pressure wound therapy
with instillation: a pilot study describing a new method for treating infected wounds. Int Wound J. 2008;5(3):399–413.
9. Fluieraru S, Bekara F, Naud M, et al. Sterile-water negative pressure instillation therapy for complex wounds and NPWT failures. J Wound Care.
2013;22(6):293–299.
10.Brinkert D, Ali M, Naud M, Maire N, Trial C, Teot L. Negative pressure
wound therapy with saline instillation: 131 patient case series. Int Wound
J. 2013;10(suppl 1):56–60.
11.Kim PJ, Attinger CE, Oliver N, et al. Comparison of outcomes for normal
saline and an antiseptic solution for negative-pressure wound therapy
with instillation. Plast Reconstr Surg. 2015;136(5):657e–664e.
12.Lessing C, Slack P, Hong KZ, Kilpadi D, McNulty A. Negative pressure
wound therapy with controlled saline instillation (NPWTi): dressing properties and granulation response in vivo. Wounds. 2011;23(10):309–319.
13.Gupta S, Gabriel A, Lantis J, Teot L. Clinical recommendations and
practical guide for negative pressure wound therapy with instillation. Int
Wound J. 2015 May 23. doi: 10.1111/iwj.12452. [Epub ahead of print].
14.Schintler MV, Grohmann M, Donia C, Aberer E, Scharnagl E. Management of an unfortunate triad after breast reconstruction: pyoderma gangrenosum, full-thickness chest wall defect and Acinetobacter baumannii
infection. J Plast Reconstruct Aesthetic Surg. 2010;63(7):e564–e567.
15.Raad W, Lantis JC, II, Tyrie L, Gendics C, Todd G. Vacuum-assisted closure instill as a method of sterilizing massive venous stasis wounds prior
to split thickness skin graft placement. Int Wound J. 2010;7(2):81–85.
16.Wolvos T. The use of negative pressure wound therapy with an automated, volumetric fluid administration: an advancement in wound care.
Wounds. 2013;25(3):75–83.
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*Kim PJ, Attinger CE, Steinberg JS, et al. The Impact of Negative-Pressure Wound Therapy with Instillation Compared with Standard Negative-Pressure Wound Therapy:
A Retrospective, Historical, Cohort, Controlled Study. Plast. Reconstr. Surg.2014; 133: 709-716.
NOTE: Specific indications, contraindication, warnings, precautions and safety information exist for the System. Please
consult the Clinician Guide Instructions for Use prior to application. Rx only.
©2016 KCI Licensing, Inc. All rights reserved. V.A.C., V.A.C.ULTA, and V.A.C. VERAFLO are trademarks of KCI Licensing, Inc. PRONTOSAN is a
trademark of B.Braun, Inc. 16-0174.US (2/16)
OWM
, LLC
™
an HMP Communications Holdings Company
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Supplement to April 2016
®
o s t o m y
F rom S cience
to
w o u n d
P r ac t ice : C on t emp or a ry A pproaches
m a n a g e m e n t
to
S k in , W ound , O s t om y,
a nd
I nc on t inence C a re
Clinician Panel Recommendations for
Use of Negative Pressure Wound
Therapy with Instillation
Melissa McKanna, RN; Jamie Geraci, CWON, BSN, RN; Kimberly Hall, DNP, RN, GCNS-BC, CWCN-AP; Brigitta Hauan, RN; Melania Howell, RN; Trudy Huey, MSN, RN, CWOCN; Adora Lucius,
RN; Susan Mendez-Eastman, RN, CWCN, CPSN; Kedrin Purcell, RN; Rose Raizman, PHCNP, ET;
Dawn Shepherd, BSN, RN, CWON, CFCN; and Allen Gabriel, MD
This supplement was subject to the OWM® peer review process.