V.A.C. Therapy in the management of paediatric wounds: clinical review and experience.

Usage of negative pressure wound therapy (NPWT) in the management of acute and chronic wounds has grown exponentially in the past decade. Hundreds of studies have been published regarding outcomes and methods of therapy used for adult wounds. This treatment is increasingly being used to manage difficult-to-treat paediatric wounds arising from congenital defects, trauma, infection, tumour, burns, pressure ulceration and postsurgical complications in children, although relatively few studies have been aimed at this population. Given the anatomical and physiological differences between adults and children, a multidisciplinary expert advisory panel was convened to determine appropriate use of NPWT with reticulated open cell foam (NPWT/ROCF) as delivered by Vacuum Assisted Closure (V.A.C. Therapy, KCI Licensing, Inc., San Antonio, TX) for the treatment of paediatric wounds. The primary objectives of the expert advisory panel were to exchange state-of-practice information on paediatric wound care, review the published data regarding the use of NPWT/ROCF in paediatric wounds, evaluate the strength of the existing data and establish guidelines on best practices with NPWT/ROCF for the paediatric population. The proposed paediatrics-specific clinical practice guidelines are meant to provide practitioners an evidence base from which decisions could be made regarding the safe and efficacious selection of pressure settings, foam type, dressing change frequency and use of interposing contact layer selections. The guidelines reflect the state of knowledge on effective and appropriate wound care at the time of publication. They are the result of consensus reached by expert advisory panel members based on their individual clinical and published experiences related to the use of NPWT/ROCF in treating paediatric wounds. Best practices are described herein for novice and advanced users of NPWT/ROCF. Recommendations by the expert panel may not be appropriate for use in all circumstances. Decisions to adopt any particular recommendation must be made by the collaborating medical team, including the surgeon and wound care specialist based on available resources, individual patient circumstances and experience with the V.A.C. Therapy System.

Negative pressure therapy is effective to manage a variety of wounds in infants and children.

Negative pressure therapy (NPT) has been accepted as a valuable adjunct for wound closure in adults; however, reports on its effectiveness in young children and infants, including neonates, are limited. A retrospective chart review was conducted on children treated with NPT at a single institution between January 2003 and December 2005. Wound volumetric measurements were calculated at the start and end of therapy. Sixty-eight patients with 82 wounds were identified. The mean age was 8.5 years (range 7 days-18 years). Twenty patients (29%) were 2 years of age or younger, including eight neonates. Wound types included: pressure ulcers (n=13), extremity wounds (n=18), dehisced surgical wounds (n=19), open sternal wounds (n=10), wounds with fistulas (n=3), and complex abdominal wall defects (n=6). Low suction pressures (<100 mmHg) were generally used in children younger than 4 years of age. Following NPT, 93% of wounds decreased in volume. The average wound volume decrease was 80% (p<0.01, n=56). NPT can be effectively used to manage a variety of wounds in children and neonates. No major complications were identified in our retrospective review. Prospective studies are required to better refine the use of this technology in children.

Risk factors associated with pressure ulcers in the pediatric intensive care unit.

OBJECTIVE: To identify risk factors that are associated with the development of pressure ulcers in children admitted to the pediatric intensive care unit (PICU). DESIGN: Case control study with no interventions held in a 30-bed PICU of Texas Children's Hospital, Houston. SETTING AND SUBJECTS: The study included 59 patients who developed pressure ulcers in the PICU and 59 patients who were critically ill who did not develop pressure ulcers during the same time period. INSTRUMENTS: Risk assessment data collection tool and Braden scale. METHODS: A comparison was done to identify risk factors between 2 groups of pediatric patients with and without pressure ulcers. A 45-indicator assessment tool was used. Physical assessment including staging of pressure ulcers was performed. RESULTS: Risk factors associated with pressure ulcers include edema (P = .0016), length of stay > 96 hours (P = .001), increasing positive end expiratory pressure (P = .002), not turning the patient or use of a specialty bed in the turning mode (P = .0001), and weight loss (P < .0001). CONCLUSIONS: The presence of edema, increasing length of stay, patients on increasing positive-end expiratory pressure, not turning the patient, use of a specialty bed in the turning mode, and weight loss are associated with the increased risk of development of pressure ulcers in patients in the PICU.

Case studies of an infant, a toddler, and an adolescent treated with a negative pressure wound treatment system.

Three pediatric case studies (infant, toddler, and adolescent) using negative pressure wound treatment system (NPWS) in a children's hospital are described. Each child had complex surgical wounds and different goals for the therapy. The infant had an ulcerating labial hemangioma surgically removed, and the NPWS was used to expedite granulation tissue in preparation for a split-thickness skin graft. The critically ill toddler required abdominal fasciotomies for compartment syndrome, and the NPWS was applied to reduce interstitial abdominal edema and manage the excessive wound drainage. The adolescent initially had surgery to correct a pectus excavatum; when the sternal wound became infected and required debridement, the NPWS was used to expedite wound healing. The results of the NPWS were positive. Although this therapy has been used more commonly in adults, these case studies demonstrate its efficacy in several different types of wounds and age groups of children. The wound, ostomy, continence nurse should include the NPWS in his or her treatment differential as a valuable option for pediatric patients.

The 2003 national pediatric pressure ulcer and skin breakdown prevalence survey: a multisite study.

OBJECTIVE: The purpose of this study was to document the prevalence of pressure ulcers and other types of skin breakdown in hospitalized children. DESIGN: This descriptive study included documentation of findings from chart reviews and physical assessments of children. SETTING AND SUBJECTS: Nine children's hospitals from throughout the United States participated for a total sample of 1064 children. Subjects were inpatients in the children's hospitals between the ages of neonate to 17 years. INSTRUMENTS: The data collection tools included the interrater reliability quiz, the patient data collection form, FAST data collection software, the Braden Q Risk Assessment Scale, and the Neonatal/Infant Braden Q Risk Assessment Scale. METHODS: Prevalence of pressure ulcers and skin breakdown was measured on a predetermined day during an 8-hour period at each institution. Eight hospitals required a signed informed consent before study participation; 1 hospital's institutional review board waived consent. A physical skin assessment was done on each inpatient, and all pressure ulcers found were staged according to the National Pressure Ulcer Advisory Panel staging system. A chart review was done on all subjects to collect information on patient demographics and potential risk factors. The Neonatal/Infant Braden Q Risk Assessment was scored for infants younger than 1 year old, and the Braden Q Risk Assessment for children 1 year and older. Patient data collection forms were completed, and all data were entered into the FAST data collection software at the end of the study day. Analyses of data and reports were generated from a central site. RESULTS: There were 1,064 children surveyed, with a pressure ulcer prevalence of 4.0% and other skin breakdown prevalence of 14.8%. Ninety-two percent of the pressure ulcers were partial thickness, Stages I and II. Sixty-six percent of the pressure ulcers were facility associated. Locations of pressure ulcers were predominately in the head area 31%, seat area 20%, and foot area 19%. The 3 most common types of skin breakdown were excoriation/diaper dermatitis, skin tear, and IV extravasation. Predominant locations for skin breakdown were seat area 35%, foot area 20%, and upper extremities 18%. CONCLUSIONS: The prevalence of pressure ulcers was low in the pediatric population studied, but skin breakdown prevalence (excluding pressure ulcers) was higher, with 74% of all wound types consisting of excoriation/diaper dermatitis, skin tears, and IV extravasation sites. Future studies are needed to evaluate prevention and treatment options for pressure ulcers and skin breakdown in this population. Repeating this multisite study at intervals may be beneficial to continue to build and modify the benchmark data.

Comparison of interface pressures in the pediatric population among various support surfaces.

OBJECTIVE: The purpose of this study was to evaluate the interface pressures under the bony prominences of children on several support surfaces to evaluate benefit, in terms of the lowest interface pressures, and cost-effectiveness. DESIGN: A descriptive study design was used. SETTING/SUBJECTS: A convenience sample of 54 healthy children from the community ranging in age from infancy through 16 years was enrolled through advertisements in the hospital newsletter. The study was conducted in the General Clinical Research Center located within Texas Children's Hospital, Houston, Texas. INSTRUMENTS: The instrument used to measure the interface pressures was the Mini-Texas Interface Pressure Evaluator. METHODS: A comparison was done to evaluate interface pressures under the occiput for infants to children younger than 6 years of age and under the occiput, coccyx, and heel for 6- to 18-year-olds. Five surface combinations were used for measurements: a standard hospital bed or crib mattress; mattress with Delta foam overlay; a mattress with a Gel-E-Donut pillow; a mattress with a Delta foam overlay plus Gel-E-Donut pillow; and an Efica low-air-loss bed. RESULTS: The standard hospital mattress yielded the highest interface pressures. The Delta Foam overlay alone or in combination with the Gel-E-Donut pillow produced the lowest occipital pressures in all age groups. The Delta foam overlay produced comparable pressures to the Efica low-air-loss bed when measuring the coccyx and heel interface pressures. CONCLUSIONS: The Delta Foam overlay alone or in combination with the Gel-E-Donut pillow is a cost-effective and therapeutic choice for pressure reduction as demonstrated in this study of healthy children.