Data from 13 studies comprising 720 patients showed negative pressure wound therapy with instillation and dwell time (NPWTi-d) performed better than standard of care (SOC) in multiple wound types. The reported results indicated that NPWTi-d had significantly fewer surgical debridements, a shorter duration of therapy, and were more likely to close in comparison with the control group (ie, SOC). This systematic literature review and meta-analysis of randomized controlled studies and observational studies was published as a supplement in the January issue of Plastic and Reconstructive Surgery.1
Despite evidence-based studies confirming the combination of NPWT and irrigation for decades,2 the debut NPWTi-d device was introduced to the market in 2002.3 In 2011, a next-generation NPWTi-d unit entered the market, allowing a clinician to visually assess and automate the instilled topical solution volume, run a test cycle, and soak the dressing with solution prior to removing the dressing.1
In 2021, Gabriel et al1 identified a lack of existing data across multiple studies that would provide a more precise estimate of the clinical effects of NPWTi-d. The authors conducted this review to determine the clinical impact of outcomes of NPWTi-d vs SOC among the aforementioned study types.
The methodology of the study included a literature search of relevant studies published between January 1, 2004, and December 31, 2019, in the PubMed, EMBASE, OVID, and QUOSA databases. In order to be eligible for inclusion, the publications had to have undergone peer review prior to December 31, 2019; include a population of 10 subjects at minimum; and was a comparative study involving NPWTi-d (V.A.C. VERAFLO Therapy or V.A.C. Instill Wound Therapy System; 3M) versus any other comparative treatment. Studies also needed to assess at least one of the following: (1) time to wound closure/final surgical procedure, (2) length of hospital stay, (3) number of surgical debridements, (4) number of wounds closed, (5) wound size reduction, (6) duration of therapy, (7) level of bacterial colonization, or (8) clinical signs of infection. Studies involving pediatric patients or instilling the topical solution into the thoracic or abdominal cavity as well as meta-analyses, reviews, preclinical studies, and animal models comprised the exclusion criteria. In terms of data collection and analysis, a weighted standardized mean difference or odds ratios and 95% CI were calculated using random-effects models to pool study and control group results for each of the studies included.
In total, 1228 publications were identified initially; after inclusion/exclusion criteria, 13 studies4-16 met the previously mentioned qualifications for inclusion in the meta-analysis. The included studies comprised a total of 720 patients (subject number range, 13–142 patients/study) with 720 wounds. The instillation fluids used included polyhexamethylene biguanide solution (n = 6), saline (n = 4), Dakin’s solution (n = 3), and silver nitrate (n = 1). The controls in the studies were NPWT without instillation (n = 9), wet-to-moist dressings (n = 3), and gentamicin polymethylmethacrylate beads (n = 1).
The meta-analysis outcomes showed a significant reduction in the number of surgical debridements in the NPWTi-d groups vs control groups (P = .01). In addition, patients in the NPWTi-d groups had a faster time to readiness for closure or final surgical procedure compared with the control groups (P = .03). The results indicated that NPWTi-d outperformed standard of care in the control groups in the 13 studies, especially when good clinical practice (eg, debridement, antibiotics) was employed. However, similar results were reported for duration of hospital stay.
In summary, the results of the meta-analysis reported by Gabriel et al1 demonstrated that NPWTi-d had positive effects on a variety of wound types. Due to various factors, most notably including high patient and wound population heterogeneity, clinicians should use caution when interpreting these results. Future research should include conducting larger scale, randomized, controlled trials.
- Gabriel A, Camardo M, O’Rorke E, Gold R, Kim PJ. Effects of negative-pressure wound therapy with instillation versus standard of care in multiple wound types: systematic literature review and meta-analysis. Plast Reconstr Surg. 2021;147(1suppl-1):S68–S76. doi:10.1097/PRS.0000000000007614
- Svedman P. A dressing allowing continuous treatment of a biosurface. IRCS Med Sci Biomed Technol. 1979;7:1.
- Wolvos T. The evolution of negative pressure wound therapy: negative pressure wound therapy with instillation. J Wound Care. 2015;24(4 suppl):15–20. doi:10.12968/jowc.2015.24.Sup4b.15
- Timmers MS, Graafland N, Bernards AT, Nelissen RG, van Dissel JT, Jukema GN. Negative pressure wound treatment with polyvinyl alcohol foam and polyhexanide antiseptic solution instillation in posttraumatic osteomyelitis. Wound Repair Regen. 2009;17:278–286. doi:10.1111/j.1524-475X.2009.00458.x
- Kim PJ, Attinger CE, Steinberg JS, et al. The impact of negative-pressure wound therapy with instillation compared with standard negative-pressure wound therapy: a retrospective, historical, cohort, controlled study. Plast Reconstr Surg. 2014;133(3):709–716. doi:10.1097/01.prs.0000438060.46290.7a
- Yang CK, Alcantara S, Goss S, Lantis JC II. Cost analysis of negative-pressure wound therapy with instillation for wound bed preparation preceding split-thickness skin grafts for massive (>100 cm2) chronic venous leg ulcers. J Vasc Surg. 2015;61(4):995–999. doi:10.1016/j.jvs.2014.11.076
- Goss SG, Schwartz JA, Facchin F, Avdagic E, Gendics C, Lantis JC II. Negative pressure wound therapy with instillation (NPWTi) better reduces post-debridement bioburden in chronically infected lower extremity wounds than NPWT alone. J Am Coll Clin Wound Spec. 2014;4(4):74–80. doi:10.1016/j.jccw.2014.02.001
- Kim PJ, Lavery LA, Galiano RD, et al. The impact of negative-pressure wound therapy with instillation on wounds requiring operative debridement: pilot randomised, controlled trial. Int Wound J. 2020;17(5):1194–1208. doi:10.1111/iwj.13424
- Gabriel A, Kahn K, Karmy-Jones R. Use of negative pressure wound therapy with automated, volumetric instillation for the treatment of extremity and trunk wounds: clinical outcomes and potential cost-effectiveness. Eplasty. 2014;14:e41.
- Chowdhry SA, Wilhelmi BJ. Comparing negative pressure wound therapy with instillation and conventional dressings for sternal wound reconstructions. Plast Reconstr Surg Glob Open. 2019;7(1):e2087. doi:10.1097/GOX.0000000000002087
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- DeFazio MV, Economides JM, Anghel EL, Mathis RK, Barbour JR, Attinger CE. Traction-assisted internal negative pressure wound therapy with bridging retention sutures to facilitate staged closure of high-risk wounds under tension. Wounds. 2017;29(10):289–296. doi:10.25270/wnds/2017.10.289296
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- Jurkovič A, Bartoš J, Benčurik V, Martínek L, Škrovina M. Instilačná podtlaková terapia ULTRAVAC v terapii infikovaných laparotómií s fascitídou − priebežné výsledky prospektívnej randomizovanej štúdie. Negative pressure therapy with the ULTRAVAC instillation in the therapy of infected laparotomies with fascitis – temporary results of a prospective randomized study. Rozhl Chir. 2019;98(4):152–158.
- Omar M, Gathen M, Liodakis E, et al. A comparative study of negative pressure wound therapy with and without instillation of saline on wound healing. J Wound Care. 2016;25(8):475–478. doi:10.12968/jowc.2016.25.8.475.