Systematic review and evidence based recommendations for the use of negative pressure wound therapy in the open abdomen.

INTRODUCTION: Negative Pressure Wound Therapy (NPWT) is widely used in the management of the open abdomen despite uncertainty regarding several aspects of usage. An expert panel was convened to develop evidence-based recommendations describing the use of NPWT in the open abdomen. METHODS: A systematic review was carried out to investigate the efficacy of a range of Temporary Abdominal Closure methods including variants of NPWT. Evidence-based recommendations were developed by an International Expert Panel and graded according to the quality of supporting evidence. RESULTS: Pooled results, in non-septic patients showed a 72% fascial closure rate following use of commercial NPWT kits in the open abdomen. This increased to 82% by the addition of a 'dynamic' closure method. Slightly lower rates were showed with use of Wittmann Patch (68%) and home-made NPWT (vac-pack) (58%). Patients with septic complications achieved a lower rate of fascial closure than non-septic patients but NPWT with dynamic closure remained the best option to achieve fascial closure. Mortality rates were consistent and seemed to be related to the underlying medical condition rather than being influenced by the choice of dressing, Treatment goals for open abdomen were defined prior to developing eleven specific evidence-based recommendations suitable for different stages and grades of open abdomen. DISCUSSION AND CONCLUSION: The most efficient temporary abdominal closure techniques are NPWT kits with or without a dynamic closure procedure. Evidence-based recommendations will help to tailor its use in a complex treatment pathway for the individual patient.

Evidence-based recommendations for the use of negative pressure wound therapy in chronic wounds: steps towards an international consensus.

AIM: Negative Pressure Wound Therapy (NPWT) has become widely adopted over the last 15 years and over 1000 peer-reviewed publications are available describing its use. Despite this, there remains uncertainty regarding several aspects of usage. In order to respond to this gap a global expert panel was convened to develop evidence-based recommendations describing the use of NPWT. In this communication the results of the study of evidence in chronic wounds including pressure ulcers, diabetic foot ulcers (DFU), venous leg ulcers (VLU), and ischaemic lower limb wounds are reported. METHODS: Evidence-based recommendations were obtained by a systematic review of the literature, grading of evidence, drafting of the recommendations by a global expert panel followed by a formal consultative consensus development program in which 422 independent healthcare professionals were able to agree or disagree with the recommendations. The criteria for agreement were set at 80% agreement. Evidence and recommendations were graded according to the SIGN (Scottish Intercollegiate Guidelines Network) classification system. RESULTS: The primary treatment goal of NPWT in most chronic wounds is to achieve wound closure (either by secondary intention or preparing the wound for surgical closure). Secondary goals commonly include: to reduce wound dimensions, and to improve the quality of the wound bed. Thirteen evidence based recommendations were developed in total to address these treatment goals; 4 for pressure ulcers, 4 for DFU, 3 for ischaemic lower limb wounds and 2 for VLU. CONCLUSION: The present evidence base is strongest for the use of NPWT in non-ischaemic DFU and weakest in VLU. The development of evidence-based recommendations for NPWT with direct validation from a large group of practicing clinicians offers a broader basis for consensus than work by an expert panel alone.

Evidence-based recommendations for negative pressure wound therapy: treatment variables (pressure levels, wound filler and contact layer)--steps towards an international consensus.

Negative pressure wound therapy (NPWT) is becoming a commonplace treatment in many clinical settings. New devices and dressings are being introduced. Despite widespread adoption, there remains uncertainty regarding several aspects of NPWT use. To respond to these gaps, a global expert panel was convened to develop evidence-based recommendations describing the use of NPWT. In a previous communication, we have reviewed the evidence base for the use of NPWT within trauma and reconstructive surgery. In this communication, we present results of the assessment of evidence relating to the different NPWT treatment variables: different wound fillers (principally foam and gauze); when to use a wound contact layer; different pressure settings; and the impact of NPWT on bacterial bioburden. Evidence-based recommendations were obtained by a systematic review of the literature, grading of evidence and drafting of the recommendations by a global expert panel. Evidence and recommendations were graded according to the Scottish Intercollegiate Guidelines Network (SIGN) classification system. In general, there is relatively weak evidence on which to base recommendations for any one NPWT treatment variable over another. Overall, 14 recommendations were developed: five for the choice of wound filler and wound contact layer, four for choice of pressure setting and five for use of NPWT in infected wounds. With respect to bioburden, evidence suggests that reduction of bacteria in wounds is not a major mode of action of NPWT.

Evidence-based recommendations for the use of Negative Pressure Wound Therapy in traumatic wounds and reconstructive surgery: steps towards an international consensus.

Negative pressure wound therapy (NPWT) has become widely adopted over the last 15 years and over 1000 peer reviewed publications are available describing its use. Despite this, there remains uncertainty regarding several aspects of usage. In order to respond to this gap a global expert panel was convened to develop evidence-based recommendations describing the use of NPWT. In this paper the results of the study of evidence in traumatic wounds (including soft tissue defects, open fractures and burns) and reconstructive procedures (including flaps and grafts) are reported. Evidence-based recommendations were obtained by a systematic review of the literature, grading of evidence, drafting of the recommendations by a global expert panel, followed by a formal consultative consensus development program in which 422 independent healthcare professionals were able to agree or disagree with the recommendations. The criteria for agreement were set at 80% approval. Evidence and recommendations were graded according to the SIGN (Scottish Intercollegiate Guidelines Network) classification system. Twelve recommendations were developed in total; 4 for soft tissue trauma and open fracture injuries, 1 for burn injuries, 3 for flaps and 4 for skin grafts. The present evidence base is strongest for the use of NPWT on skin grafts and weakest as a primary treatment for burns. In the consultative process, 11/12 of the proposed recommendations reached the 80% agreement threshold. The development of evidence-based recommendations for NPWT with direct validation from a large group of practicing clinicians offers a broader basis for consensus than work by an expert panel alone.

Traumatic diaphragmatic disruption: a five-year experience at Spartanburg Regional Medical Center.

Diagnosing diaphragmatic disruption requires a high level of suspicion. Diaphragmatic disruption must be considered in all cases of severe thoracoabdominal trauma. Initial chest x-rays can provide much useful information. Pathognomonic signs of diaphragmatic disruption on chest x-ray are stomach gas bubble in the chest, contrast material in the chest after its introduction into the upper gastrointestinal tract, and a nasogastric tube positioned above the diaphragm. In some cases a diaphragmatic disruption may not be diagnosed until exploratory laparotomy is done for associated injuries. One must carefully inspect both hemidiaphragms at the time of surgery, especially in injuries associated with penetrating trauma. Repair of the disruption should be undertaken at the time of diagnosis. The repair should be approached through a midline abdominal incision. A chest incision should be considered in cases of right-sided diaphragmatic disruption, or to assist with the delivery of contents back into the abdomen. Non-absorbable suture is recommended for all repairs of diaphragmatic disruption.

Drainage of a pancreatic pseudocyst: an unusual complication.

A 34-year-old white woman had external drainage of a pancreatic pseudocyst. During sinography, contrast medium filled perigastric varices, causing septic shock. From this experience, we believe that although sinograms are helpful, they should be preceded by prophylactic administration of antibiotics and that contrast material should be sterile. The drainage catheter should be removed as soon as possible.