Unavoidable pressure injury: state of the science and consensus outcomes.

In the vast majority of cases, appropriate identification and mitigation of risk factors can prevent or minimize pressure ulcer (PU) formation. However, some PUs are unavoidable. Based on the importance of this topic and the lack of literature focused on PU unavoidability, the National Pressure Ulcer Advisory Panel hosted a multidisciplinary conference in 2014 to explore the issue of PU unavoidability within an organ system framework, which considered the complexities of nonmodifiable intrinsic and extrinsic risk factors. Prior to the conference, an extensive literature review was conducted to analyze and summarize the state of the science in the area of unavoidable PU development and items were developed. An interactive process was used to gain consensus based on these items among stakeholders of various organizations and audience members. Consensus was reached when 80% agreement was obtained. The group reached consensus that unavoidable PUs do occur. Consensus was also obtained in areas related to cardiopulmonary status, hemodynamic stability, impact of head-of-bed elevation, septic shock, body edema, burns, immobility, medical devices, spinal cord injury, terminal illness, and nutrition.

Use of negative pressure wound therapy in the management of infected abdominal wounds containing mesh: an analysis of outcomes.

The purpose of this study was to examine the clinical outcomes of negative pressure wound therapy (NPWT) using reticulated open-cell foam (ROCF) in the adjunctive management of abdominal wounds with exposed and known infected synthetic mesh. A non randomised, retrospective review of medical records for 21 consecutive patients with infected abdominal wounds treated with NPWT was conducted. All abdominal wounds contained exposed synthetic mesh [composite, polypropylene (PP), or knitted polyglactin 910 (PG) mesh]. Demographic and bacteriological data, wound history, pre-NPWT and comparative post-NPWT, operative procedures and complications, hospital length of stay (LOS) and wound healing outcomes were all analysed. Primary endpoints measured were (1) hospital LOS prior to initiation of NPWT, (2) total time on NPWT, (3) hospital LOS from NPWT initiation to discharge and (4) wound closure status at discharge. A total of 21 patients with abdominal wounds with exposed, infected mesh were treated with NPWT. Aetiology of the wounds was ventral hernia repair (n = 11) and acute abdominal wall defect (n = 10). Prior to NPWT initiation, the mean hospital LOS for the composite, PP and PG meshes were 76 days (range: 21-171 days), 51 days (range: 32-62 days) and 19 days (range: 12-39 days), respectively. The mean hospital LOS following initiation of NPWT for wounds with exposed composite, PP and PG mesh were 28, 31 and 32 days, respectively. Eighteen of the 21 wounds (86%) reached full closure after a mean time of 26 days of NPWT and a mean hospital LOS of 30 days postinitiation of NPWT. Three wounds, all with composite mesh left in situ, did not reach full closure, although all exhibited decreased wound dimensions, granulating beds and decreased surface area exposure of mesh. During NPWT/ROCF, one hypoalbuminemic patient with exposed PP mesh developed an enterocutaneous fistula over a prior enterotomy site. This patient subsequently underwent total mesh extraction, takedown of the fistula and PP mesh replacement followed by reinstitution of NPWT and flap closure. In addition to appropriate systemic antibiotics and nutritional optimisation, the adjunctive use of NPWT resulted in successful closure of 86% of infected abdominal wounds with exposed prosthetic mesh. Patient hospital LOS (except those with PG mesh), operative procedures and readmissions were decreased during NPWT compared with treatment prior to NPWT. Future multi-site prospective, controlled studies would provide a strong evidence base from which treatment decisions could be made in the management of these challenging and costly cases.

Negative pressure wound therapy in the adjunctive management of necrotizing fascitis: examining clinical outcomes.

Prompt diagnosis and treatment of necrotizing fascitis reduces the morbidity and mortality rates of this devastating disease. To examine the clinical outcomes of using negative pressure wound therapy in the adjunctive management of wounds secondary to necrotizing fascitis, a retrospective review of medical records was conducted. Participants included 11 consecutive patients (16 wounds) with a diagnosis of necrotizing fascitis admitted to a teaching hospital between 2000 and 2005 and treated on an inpatient basis with negative pressure wound therapy. The patients included seven men, four women (average age 54 years; range 18 to 82 years). Variables abstracted from the medical records and consultation notes included: demographic information, tissue and blood bacteriological data, wound history, wound healing outcomes, duration of negative pressure wound therapy, length of hospital stay, and mortality and morbidity information. Variables were entered into an electronic database and analyzed. Operative tissue biopsies were obtained and all participants received serial surgical debridements as well as infection, nutrition, and hemodynamic support. Negative pressure wound therapy was applied to the wound(s) at 125 mm Hg continuous negative pressure until reconstructive closure could be performed. Most wounds (10) were on lower extremities, seven patients presented with sepsis, and beta-hemolytic Streptococcus was identified in nine wounds. Mean number of negative pressure wound therapy treatment days was 25 (range: 7 to 74), mean length of stay was 67 days (range: 21 to 186). All wounds were successfully closed--73% received split-thickness skin grafts, 27% required flaps, 100% limb salvage was achieved, and all patients survived. No negative pressure wound therapy or dressing-associated complications were observed. Negative pressure wound therapy was found to be a viable adjunctive treatment in the management of wounds associated with necrotizing fascitis.

An overview of neonatal and pediatric wound care knowledge and considerations.

Despite significant technological advances in the care of premature neonates and chronically ill children, the knowledge and evidence base for the management of this population's wound care lag far behind its adult counterpart. Updating antiquated care regimens is an uphill battle. This review of the literature seeks to illuminate key anatomical/structural differences in neonatal skin with particular attention paid to percutaneous absorption and tolerance of adhesives. The article also presents anatomically and physiologically based recommendations for the selection of prevention and treatment modalities, including specific dressing types, appropriate dressing change and securement procedures, and pain management. Commonly encountered wound types (epidermal stripping; surgical wounds; extravasation and thermal injuries; chemical burns; pressure ulcers; diaper dermatitis; and wounds secondary to congenital conditions) are discussed. Opportunities for research abound and are considered.

Use of negative pressure wound therapy in the treatment of neonatal and pediatric wounds: a retrospective examination of clinical outcomes.

The clinical effectiveness of negative pressure wound therapy for the management of acute and chronic wounds is well documented in the adult population but information regarding its use in the pediatric population is limited. A retrospective, descriptive study was conducted to examine the clinical outcomes of using negative pressure wound therapy in the treatment of pediatric wounds. The medical records of 24 consecutive pediatric patients receiving negative pressure wound therapy were reviewed. Demographic data, wound etiology, time to closure, closure method, duration of negative pressure wound therapy, complications, dressing change frequency, dressing type used, and pressure settings were analyzed. All categorical variables in the dataset were summarized using frequency (count and percentages) and all continuous variables were summarized using median (minimum, maximum). The 24 pediatric patients (mean age 8.5 years [range 14 days to 18 years old]) had 24 wounds - 12 (50%) were infected at baseline. Sixteen patients had hypoalbuminemia and six had exposed hardware and bone in their wounds. Twenty-two wounds reached full closure in a median time of 10 days (range 2 to 45) following negative pressure wound therapy and flap closure (11), split-thickness skin graft (three), secondary (four), and primary (four) closure. Pressures used in this population ranged from 50 to 125 mm Hg and most wounds were covered with reticulated polyurethane foam. One patient developed a fistula during the course of negative pressure wound therapy. When coupled with appropriate systemic antibiotics, surgical debridement, and medical and nutritional optimization, in this population negative pressure wound therapy resulted in rapid granulation tissue and 92% successful wound closure. Future neonatal and pediatric negative pressure wound therapy usage registries and prospective studies are needed to provide a strong evidence base from which treatment decisions can be made in the management of these challenging cases, especially pertaining to the safety and efficacy of pressure settings, dressings, and interposing contact layer selection.

Pressure ulcers in neonates and children: an NPUAP white paper.

Acutely ill and immobilized neonates and children are at risk for pressure ulcers, but a paucity of evidence-based research exists on which to base guidelines for clinical practice. Most prevention and treatment protocols for pressure ulcers in the pediatric population are extrapolated from adult practice. Clinical practice guidelines for prevention and treatment of pressure ulcers that specifically address the needs of the pediatric population are needed. The purpose of this article is to highlight the research that is currently available and to identify gaps that need to be addressed so that science-based, age-appropriate prevention and treatment pressure ulcer guidelines can be developed.