Multidisciplinary expert consensus statements and recommendations for use of hypochlorous acid as a solution for negative pressure wound therapy with instillation.

BACKGROUND: HOCl (eg, pHAp) preserved solutions have antimicrobial properties and are considered safe and effective for wound management. NPWTi-d (or NPWTi) is an established adjunctive wound modality for a variety of wound etiologies in various anatomic locations in which an instillate solution dwells on the surface of the wound to assist in wound bed preparation. A variety of solutions have been used, including 0.9% normal saline wound cleansers and antiseptics. pHAp is growing in popularity as the solution of choice for NPWTi-d. OBJECTIVE: To evaluate consensus statements on the use of NPWTi-d with pHAp. METHODS: A 15-member multidisciplinary panel of expert clinicians in the United States, Canada, and France convened in person in April 2023 in Washington, D.C. and/or corresponded later to discuss 10 statements on the use of pHAp with NPWTi-d. The panelists then replied "agree" or "disagree" to each statement and had the option to provide comments. RESULTS: Ten consensus statements are presented, along with the proportion of agreement or disagreement and summary comments. Although agreement with the statements on NPWTi-d with pHAp varied, the statements appear to reflect individual preferences for use rather than concerns about safety or efficacy. CONCLUSION: The consensus indicates that NPWTi-d with pHAp can have a beneficial effect in wound care.

Rotation flap closure of pressure injuries following negative pressure wound therapy with instillation for wound cleansing.

INTRODUCTION: Wound cleansing is integral during early-stage wound management and affords the transition to modalities promoting granulation tissue formation and reepithelialization, or preparation for wound coverage/closure. NPWTi-d includes periodic instillation of topical wound cleansing solutions and negative pressure for infectious material removal. MATERIALS AND METHODS: This was a retrospective study of 5 patients who were admitted to an acute care hospital and treated for PI. After initial wound debridement, NPWTi-d instilled normal saline or HOCl solution (40 mL-80 mL) onto the wound for a dwell time of 20 minutes followed by 2 hours of subatmospheric pressure (-125 mm Hg). NPWTi-d duration was 3 to 6 days with 48-hour dressing changes. RESULTS: NPWTi-d helped cleanse 10 PIs in 5 patients (age, 39-89 years) with comorbidities to facilitate primary closure using rotation flaps. In 4 patients, rotation flap closures were performed without immediate postoperative complications, followed by hospital discharge within 72 hours. In one patient, closure was preempted due to an unrelated medical issue. A stoma was created to prevent further contamination. The patient returned for flap coverage post colostomy. CONCLUSION: The findings herein support the use of NPWTi-d in the cleansing of complex wounds and suggest that it may facilitate an expedited transition to rotation flap closure for this wound type.

Surgical Reconstruction of Stage 3 and 4 Pressure Injuries: A Literature Review and Proposed Algorithm from an Interprofessional Working Group.

OBJECTIVE: Stage 3 and 4 pressure injuries (PIs) present an enormous societal burden with no clearly defined interventions for surgical reconstruction. The authors sought to assess, via literature review and a reflection/evaluation of their own clinical practice experience (where applicable), the current limitations to the surgical intervention of stage 3 or 4 PIs and propose an algorithm for surgical reconstruction. METHODS: An interprofessional working group convened to review and assess the scientific literature and propose an algorithm for clinical practice. Data compiled from the literature and a comparison of institutional management were used to develop an algorithm for the surgical reconstruction of stage 3 and 4 PIs with adjunctive use of negative-pressure wound therapy and bioscaffolds. RESULTS: Surgical reconstruction of PI has relatively high complication rates. The use of negative-pressure wound therapy as adjunctive therapy is beneficial and widespread, leading to reduced dressing change frequency. The evidence for the use of bioscaffolds both in standard wound care and as an adjunct to surgical reconstruction of PI is limited. The proposed algorithm aims to reduce complications typically seen with this patient cohort and improve patient outcomes from surgical intervention. CONCLUSIONS: The working group has proposed a surgical algorithm for stage 3 and 4 PI reconstruction. The algorithm will be validated and refined through additional clinical research.

Reducing the Risk of Postoperative Problems With Panniculectomies Using the Prevena Plus™ 125 Incisional Management Dressing.

Abdominal wall reconstruction procedures have become increasingly popular in recent years as technology and surgical techniques have improved. The downside to these procedures has been the high rate of postoperative complications. Surgical site infections have been reported as high as 33.7% of the $9.8 billion spent annually on these complications. I present the case of a 62-year-old morbidly obese woman who underwent a combined procedure of abdominal wall reconstruction and panniculectomy. A total of 45 lbs of pannus was removed through a transverse incision that extended from hip to hip, measuring 90 cm in length. Following panniculectomy, abdominal wall reconstruction was performed by mobilizing the abdominal skin flap from the lower abdominal panniculectomy incision (avoiding a T-shaped incision with a traditionally high risk of dehiscence), and placement of biologic mesh as an underlay followed by fascial closure. Prevena Plus™ 125 (3M + KCI, San Antonio, TX) was applied for postoperative closed incisional negative pressure therapy (ciNPT) and continued for 10 days. No postoperative complications occurred. The incision healed without incident with no hernia recurrence at one year. ciNPT in high-risk patients can help minimize the risk of postoperative wound healing complications and should be considered in high-risk patients. Those patients undergoing combined procedures and especially morbidly obese patients undergoing combined abdominal wall reconstruction and panniculectomy are at particularly high risk for wound healing complications. ciNPT should be considered as a postoperative dressing of choice in this challenging patient population.

Initial Experience Using Disposable Negative Pressure Wound Therapy for Closed Incisions Following Outpatient Wound Reconstruction.

Wound reconstruction surgeries are at high risk for failure. Outpatient wound reconstruction (OWR) describes these procedures performed in the outpatient setting under local anesthesia. The use of closed incision negative pressure therapy (ciNPT) has been shown to protect the incision and help minimize the risk of postoperative complications. To date, this has not been readily adopted in the outpatient setting. The authors report their initial experience with 3 cases of OWR with ciNPT used by the application of disposable negative pressure wound therapy (dNPWT) to the closed, postsurgical incision. The results of these 3 cases were favorable. While more data are needed, the authors believe the use of dNPWT with OWR will help optimize surgical outcomes and serve as an alternative to surgery with acute hospitalization.

Use of mechanically powered disposable negative pressure wound therapy: recommendations and reimbursement update.

Use of ultra-portable, mechanically powered disposable negative pressure wound therapy (dNPWT) has grown as an adjunctive modality to manage wounds in outpatient care and to expedite transition of inpatients to an outpatient setting. This technology has demonstrated similar efficacy and usability for mobile outpatients when compared with electrically powered negative pressure wound therapy devices. It was designed for patients with smaller, low to moderately exudating wounds and does not require batteries or a power source. However, very few studies address best practices for using dNPWT in a variety of wound types. There is a need for comprehensive clinical recommendations to better direct clinicians and patients in using this therapy. In addition, it is critical that providers are knowledgeable about processes for obtaining reimbursement for placement of dNPWT since codes and procedures differ drastically from standard NPWT. A panel meeting of experts with a high level of experience with dNPWT in varied wound types was convened to develop clinical recommendations and summarize current US reimbursement coding guidelines for the use of dNPWT. This publication summarizes the recommendations from panel members, in addition to supporting evidence, to help guide appropriate use of dNPWT. Panel recommendations regarding optimal patient and wound selection, wound preparation, proper patient training, and use of dNPWT in various wound types are included as well as clinical techniques for dressing application, bridging under offloading devices and compression, maintaining a seal, and protecting intact skin. Processes and codes for obtaining reimbursement for dNPWT are reviewed by care setting. Clinical recommendations and reimbursement guidelines summarized in this publication are meant to provide direction to clinicians in using dNPWT that potentially could translate into improved clinical and economic value.

Inpatient and Outpatient Wound Treatment Recommendations: Assessing Use of Negative Pressure Wound Therapy Systems or Oxidized Regenerated Cellulose (ORC)/ Collagen/Silver-ORC Dressings.

The increase in wound prevalence means more patients with wounds are being transferred through care settings than ever before. Although the goals of therapy may be the same in both settings, wound care therapies and dressings differ in availability and appropriateness for each setting. Negative pressure wound therapy (NPWT) modalities and oxidized regenerated cellulose (ORC)/collagen (C)/silver-ORC dressings are available in both inpatient and outpatient care settings, but (to-date) lack comprehensive information regarding best practices in transitioning use of these therapies between various care settings. A panel meeting was convened to provide literature- and experience-based recommendations in transitioning wound care patients between various care settings. The use of NPWT with instillation and dwell time was recommended in wounds contaminated with debris and/or infectious materials or heavy exudate. In addition, ORC/C/silver-ORC dressing application was recommended for surface bleeding and for placement into explored areas of undermining to help promote development of granulation tissue. When transitioning a patient from inpatient to outpatient care, overall health, access to services, severity and complexity of the wound, and equipment availability should be taken into consideration. Treatment modalities to bridge the gap during care transition should be used to help maintain continuous care. For outpatient care, NPWT use was recommended for removal of infectious materials and exudate management. The ORC/C/silver-ORC dressings also may be used to help manage exudate and promote granulation tissue development and moist wound healing. In addition, practice challenges and potential solutions for patient adherence, interrupted care during patient transition, and troubleshooting after hours and weekend device alarms were discussed.

All Hands on Deck! A Challenging Case with a Multidisciplinary Team Using Negative-pressure Wound Therapy as the Cornerstone for Treatment.

The use of negative-pressure wound therapy (NPWT) has become the new standard of care for complex wounds. NPWT with instillation (NPWTi) has been shown to assist wound progression in a variety of wound types in an acute hospital setting with increased progression toward healing.  We present the case of a 70-year-old male with Crohn's disease, who had post-operative life-threatening complications following hernia repair. His complex abdominal wound and a high-output fistula required the assistance of an entire clinical team. The multidisciplinary team's approach toward the patient was equivalent to the team's approach to the complex wound: "All Hands On Deck!" The cornerstone of our management was NPWT, specifically NPWTi. Instillation therapy was initiated. Complex foam application and innovative strategies to keep a grossly contaminated wound from becoming the final straw to a patient's demise appeared our greatest challenge. NPWTi was utilized and optimized, where every type of foam, bridge, and securement was needed to gain success. This patient's progress could be wholly attributed to the commitment and experience of a group of care providers who were led by their knowledge and experience in NPWT in the most challenging circumstances.

Proactive and Early Aggressive Wound Management: A Shift in Strategy Developed by a Consensus Panel Examining the Current Science, Prevention, and Management of Acute and Chronic Wounds.

Normal wound healing is accomplished through a series of well-coordinated, progressive events with overlapping phases. Chronic wounds are described as not progressing to healing or not being responsive to management in a timely manner. A consensus panel of multidisciplinary wound care professionals was assembled to (1) educate wound care practitioners by identifying key principles of the basic science of chronic wound pathophysiology, highlighting the impact of metalloproteinases and biofilms, as well as the role of the extracellular matrix; and (2) equip practitioners with a systematic strategy for the prevention and healing of acute injuries and chronic wounds based upon scientific evidence and the panel members' expertise. An algorithm is presented that represents a shift in strategy to proactive and early aggressive wound management. With proactive management, adjunct therapies are applied preemptively to acute injuries to reduce wound duration and risk of chronicity. For existing chronic wounds, early aggressive wound management is employed to break the pathophysiology cycle and drive wounds toward healing. Reducing bioburden through debridement and bioburden management and using collagen dressings to balance protease activity prior to the use of advanced modalities may enhance their effectiveness. This early aggressive wound management strategy is recommended for patients at high risk for chronic wound development at a minimum. In their own practices, the panel members apply this systematic strategy for all patients presenting with acute injuries or chronic wounds.

Zafirlukast (Accolate): A new treatment for capsular contracture.

BACKGROUND: Capsular contracture after breast augmentation or reconstructive breast surgery is a difficult problem. Previous studies have suggested that alteration of the inflammatory response could have a role in reducing the incidence of capsular contracture. OBJECTIVE: We report a series of patients with Baker class III or IV capsular contracture who underwent treatment with zafirlukast. METHODS: Patients received a regimen of zafirlukast 20 mg by mouth 2 times daily for 3 months. RESULTS: In many cases, dramatic softening of the breast capsule was evident after 1 to 3 months of treatment. CONCLUSIONS: Zafirlukast appears to effectively soften early capsular contracture and may prevent the formation of capsular contracture in those patients at risk. (Aesthetic Surg J 2002;22:329-336.).