Negative pressure wound therapy for skin grafts and surgical wounds healing by primary intention.

BACKGROUND: Indications for the use of negative pressure wound therapy (NPWT) are broadening with a range of systems on the market, including those designed for use on clean, closed incisions and skin grafts. Reviews have concluded that the evidence for the effectiveness of NPWT remains uncertain. However, this is a rapidly evolving therapy. Consequently, a systematic review of the evidence for the effects of NPWT on postoperative wounds expected to heal by primary intention is required. OBJECTIVES: To assess the effects of NPWT on surgical wounds (primary closure or skin grafting) that are expected to heal by primary intention. SEARCH METHODS: We searched the following electronic databases to identify reports of relevant randomised clinical trials: the Cochrane Wounds Group Specialised Register (searched 11 November 2011); the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 4); Database of Abstracts of Reviews of Effects (The Cochrane Library 2011, Issue 4); Ovid MEDLINE (2005 to October Week 4 2011); Ovid MEDLINE (In-Process & Other Non-Indexed Citations 8 November 2011); Ovid EMBASE (2009 to 2011 Week 44); and EBSCO CINAHL (1982 to 04 November 2011). We conducted a separate search to identify economic evaluations. SELECTION CRITERIA: We included trials if they allocated patients at random and compared NPWT with any other type of wound dressing or compared one type of NPWT with a different type of NPWT. DATA COLLECTION AND ANALYSIS: We assessed trials for their appropriateness for inclusion and for their quality. This was done by three review authors working independently, using pre-determined inclusion and quality criteria. MAIN RESULTS: We included five eligible trials with a total of 280 participants. Two trials involved skin grafts and three acute wounds. Only one of the five trials reported the proportion of wounds completely healed and in this study all wounds healed. All five studies reported adverse events. In the four trials that compared standard dressings with negative pressure wound therapy (NPWT) the adverse event rate was similar between groups (negative pressure 33/86; standard dressing 37/103); risk ratio (RR) 0.97 (95% confidence intervals (CI) 0.33 to 2.89). There was significant heterogeneity for this result, due to the high incidence of fracture blisters in the NPWT group in one trial. One trial (87 participants) compared a commercial negative pressure device VAC® system with a negative pressure system developed in the hospital (GSUC). The adverse event rate was lower in the GSUC group (VAC® 3/42; GSUC 0/45); the RR was 0.13 (95% CI 0.01 to 2.51). Results indicate uncertainty about the true effect of either method on adverse events. The mean cost to supply equipment for VAC® therapy was USD 96.51/day compared to USD 4.22/day for the GSUC therapy (P = 0.01). Labour costs for dressing changes were similar. Pain intensity score was also reported to be lower in the GSUC group when compared with the VAC® group (p = 0.02) AUTHORS' CONCLUSIONS: Evidence for the effectiveness of NPWT on complete healing of wounds expected to heal by primary intention remains unclear. Rates of graft loss may be lower when NPWT is used; but evidence to date suggests that hospital-based products are as effective in this area as commercial applications. There are clear cost benefits when non-commercial systems are used to create the negative pressure required for wound therapy, with no reduction in clinical outcome. Pain levels are also rated lower when hospital systems are compared with their commercial counterparts. The high incidence of blisters occurring when NPWT is used following orthopaedic surgery suggests that the therapy should be limited until safety in this population is established. Given the cost and widespread use of NPWT, there is an urgent need for suitably powered, high-quality trials to evaluate the effects of the newer NPWT products that are designed for use on clean, closed surgical incisions. Such trials should focus initially on wounds that may be difficult to heal, such as sternal wounds or surgeries for obese patients.

Gauze and tape and transparent polyurethane dressings for central venous catheters.

BACKGROUND: Central venous catheters (CVCs) facilitate venous access, allowing the intravenous administration of complex drug treatments, blood products and nutritional support, without the trauma associated with repeated venepuncture. However, CVCs are associated with a risk of infection. Some studies have indicated that the type of dressing used with them may affect the risk of infection. Gauze and tape, transparent polyurethane film dressings such as Tegaderm® and Opsite®, and highly vapour-permeable transparent polyurethane film dressings such as Opsite IV3000®, are the most common types of dressing used to secure CVCs. Currently, it is not clear which type of dressing is the most appropriate. OBJECTIVES: To compare gauze and tape with transparent polyurethane CVC dressings in terms of catheter-related infection, catheter security, tolerance to dressing material and dressing condition in hospitalised adults and children. SEARCH METHODS: For this third update, we searched The Cochrane Wounds Group Specialised Register (10 May 2011); The Cochrane Central Register of Controlled Trials (CENTRAL; The Cochrane Library 2011, Issue 2), Ovid MEDLINE (1950 to April Week 4 2011); Ovid MEDLINE (In-Process & Other Non-Indexed Citations, May 11, 2011); Ovid EMBASE (1980 to 2011 Week 18); and EBSCO CINAHL (1982 to 6 May 2011). SELECTION CRITERIA: All randomised controlled trials (RCTs) evaluating the effects of dressing type (e.g. gauze and tape versus transparent polyurethane dressings) on CVC-related infection, catheter security, tolerance to dressing material and dressing condition in hospitalised patients. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trial quality and extracted data. We contacted study authors for missing information. MAIN RESULTS: Six studies were included in earlier versions of the review. In this update two of the previously included papers have been excluded and two new trials have been added. Of these six trials, four compared gauze and tape with transparent polyurethane dressings (total participants = 337) and two compared different transparent polyurethane dressings (total participants = 126). Catheter-related bloodstream infection was higher in the transparent polyurethane group when compared with gauze and tape; OR 4.19 (95%CI 1.02 to 17.23) however these small trials were at risk of bias so this evidence is graded low quality. There was no evidence of a difference between highly permeable polyurethane dressings and other polyurethane dressings in the prevention of catheter-related bloodstream infection (low quality evidence). No other significant differences were found. AUTHORS' CONCLUSIONS: We found a four-fold increase in the rate of catheter related blood stream infection when a polyurethane dressing was used to secure the central venous catheter however this research was at risk of bias and the confidence intervals were wide indicating high uncertainty around this estimate; so the true effect could be as small as 2% or as high as 17-fold. More, better quality research is needed regarding the relative effects of gauze and tape versus polyurethane dressings for central venous catheter sites.

Nurses' attitudes to and perceptions of knowledge and skills regarding evidence-based practice.

The study evaluated the effect of an evidence-based practice (EBP) educational programme on attitudes and perceptions of knowledge and skills, of registered nurses, towards EBP. The study was conducted using a quasiexperimental interrupted time series design. Participants were clinical nurses in educational and leadership roles within a Health Service District in south-east Queensland. The data were collected using a self-administered questionnaire at three points. Nurses' belief in the value of EBP for practice was high prior to the programme and did not change subsequently. There was an improvement following the intervention in nurses' attitudes to organizational support for EBP and their perceptions of their knowledge and skills in locating and evaluating research reports. Providing educational courses in a clinical setting is useful in improving clinicians' attitudes to and perceptions of knowledge and skills related to EBP.