INDICATION FOR TOPICAL NEGATIVE PRESSURE THERAPY MANAGING THE OPEN WOUND: INDICATION FOR TOPICAL NEGATIVE PRESSURE THERAPY DR. K. SUTHARSHAN REGISTRAR IN SURGERY

INTRODUCTION Open wounds encountered in surgical practice Primarily closed wounds fail to heal- dehisce intentionally left open at the onset Chronic wounds fails to heal by 2ry intention Chronicity > 12 weeks

TYPE OF WOUND AND AETIOLOGY Wounds closed primarily which has brokendown Wound infection Tissue ischaemia Malnutrition Excessive wound tension Foreign body Drugs: corticosteroids Medical illness: DM, RA Wound intentionally left open Abdominal compartment syndrome Extensive wound debridement: Necrotizing fascitis Therapeutic packing Chronic wounds Diabetic foot ulcers Venous ulcers Malignant ulcers Trophic ulcers

PRINCIPLES OF TOPICAL NEGATIVE PRESSURE WOUND THERAPY( TNP) Several other names: Sub atmospheric pressure therapy/ Vacuum- sealing technique/ Sealed surface wound suction/ Vacuum assisted closure/ Negative pressure wound therapy( NPWT). Applying sub atmospheric pressure to a healing wound. Wound healing enhanced by removal of fluid collecting within it. Tissue growth associated with wound healing might respond positively to forces of distraction.

Principles…… System contains foam or porous dressing- placed in contact with wounds Vacuum device Connected by drain.

SYSTEM…… Wound made air- tight by placing a polyurethane foam over it and 2 cm beyond the wound edge. Vacuum pressure: - 50mmHg to -125 mmHg Pressure applied constantly or intermittently to wound. Porous nature enables equal distribution of pressure to all parts of the wound. Dressing changed initially every 48 hours. Portable/ stationary pump. Portable pump more benefit.

MECHANISM OF ACTION Increasing wound ( dermal) perfusion Reducing oedema Stimulating the formation of granulation tissue Improving the removal of wound exudate reducing the bacterial load Sealed dressing produce requied moist environment which promote re – epithelialization 30-40% more effectively. recent evidence , mechanical stress increase the expression of genes which promote wound healing. Eg: GF, TGF- B, genes for angiogenesis

INDICATIONS FOR TNP Acute wounds: Chronic wounds: Soft tissue trauma Burns Surgical wounds Open abdomen Open sternal wounds Chronic wounds: Pressure ulcers Diabetic foot wounds venous leg ulcers

SOFT TISSUE TRAUMA One of the best established treatment 2. specially with extensive tissue loss 3. As a bridge to skin grafting or flap coverage of open extremity wounds with exposed bones or tendons 4. It reduces the size of the defect that needs to be covered and ensuring that local conditions for definitive wound healing are optimized.

BURNS Improve dermal blood flow Reduce the degree of secondary tissue injury Evidance not yet well established

SURGICAL WOUNDS Open abdominal and sternal wounds Open wounds following fasciotomy Wounds following extensive surgical debridement Wounds needs plastic surgical flaps

OPEN ABDOMINAL WOUNDS Defined as ‘wound in which all the layers of the abdominal wall are open. LAPROSTOMY wounds are created if a planned second look laparotomy is required or if abdominal compartment syndrome is expected. TNP proven benefit especially in severe abdominal trauma and sepsis. Catastrophic complication of TNP- intestinal fistula, incidence is higher if the mx of open wound takes longer time.

BENEFITS CLAIMED FOR MANAGING THE OPEN ABDOMEN WITH TNP Reduction in abdominal compartment pressure Avoidance of trauma to internal viscera with repeated dressings Better removal of peritoneal exudate Reduction in intestinal odema- improved perfusion, motility Better protection of skin edges

OPEN STERNAL WOUNDS SKIN FLAP WOUNDS Deep sternal wound infections Poststernotomy mediastinitis SKIN FLAP WOUNDS One of the first reported uses of TNP Increase the rapidity of re- epithelialization and decrease the rate of graft loss.

CHRONIC WOUNDS Diabetic foot wound Venous leg ulcers Ulcers present a significant health burden and a medical challenge causing increased disability . TNP proved to be benefit. Venous leg ulcers Successful indication No trials yet that have assessed TNP as a primary therapy for healing venous ulcers without subsequent skin grafting. Helps to reduce the time for healing and prepare the ulcer bed for skin grafting.

SUMMARY….. Enormous progress in the commercial development of system that allows clinician to deliver TNP Undoubtedly become a key part of clinical management ranging from open abdomen to diabetic leg ulcers. Expensive therapy Whether TNP will continue to be supported in a healthcare system under closer financial scrutiny that increasingly focuses on evidence of cost- effectiveness remains to be seen.

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