As the complexity of our patients’ needs increase, clinicians continue to innovate. Many novel ways utilizing products such as hydrocolloids, alginates, and ostomy supplies (e.g., pastes, formed rings, barrier strips, etc) have been developed to create secure seals in difficult anatomical areas. However, despite the availability of these products, one tenet of NPWT that is challenging to circumvent regardless of device manufacturer or anatomical area involved is the need for a relatively dry, intact area of skin for application of the adhesive drape medium in order to achieve a successful seal. Moisture prevents adhesion of the drape to the underlying tissue and causes a leak in the seal, disrupting therapy. A few techniques for achieving NPWT seal on moist areas have been described: for instance, stoma powder and silicone-based barrier film (also known as the "crusting" technique) [1] or medical silicone can be utilized over a slightly moist milieu.[2] However, these techniques may be time-consuming or expensive if applied over large surfaces, and may fail completely in the setting of a highly exudative surface.
CASE
A 46 year-old male presented to the emergency department (ED) of a Level II Trauma Center & Burn Center with 40% total body surface area (TBSA) mixed deep partial thickness and full-thickness burns to his face, anterior chest, abdomen, circumferential bilateral upper extremities, hands, anterior left lower extremity, and concomitant inhalational injury. He sustained injuries from a vehicular flash fire while performing repairs, with reports that he may have had gasoline on his clothing.
Initial stabilization
He was intubated in the field due to inhalational injury. He was admitted to burn intensive care unit (ICU) shortly after arrival to ED and advanced basic life support was initiated. Twenty-four hours following admission, he was taken for escharotomies of the forearms due to concerns for compartment syndrome; his operative time was limited secondary to incomplete resuscitation, limited diuresis, and poor thermal regulation.
Surgical management
The following day, he had begun diuresis and required lessened pressor support, allowing for complete burns excision of the anterior torso, with excision of burns and grafting of bilateral upper extremity and hands.
Infection and abdominal complication develop
Within the next 24 hours, the patient had developed malodorous oro- and nasopharyngeal secretions, as well as fever, for which Infectious Disease was consulted. Blood cultures returned with fungemia which was treated with intravenous micafungin.
He continued to require sedation, ventilatory support, and failed multiple breathing trials. He was receiving post-pyloric high calorie feedings and general critical care/ burn support. Six days later, he was taken for excision and grafting of the anterior torso and tracheostomy after 10 days of intubation. Grafting to his bilateral upper extremities had taken well, with some loss of the anterior torso/chest at this time.
After 5 days of marginal improvement, including weaning pressor support and sedation, he decompensated, developing hypotension, tachycardia, decreased urine output, abdominal distention, requiring increased sedation, pressors, and ventilatory support. A septic etiology was suspected. His chest/torso grafts had begun to slough away due to rapid onset of anasarca. Computerized tomography (CT) of the abdomen/pelvis revealed portal venous gas and small bowel pneumatosis, suggestive of small bowel obstruction and ischemic injury. He had no previous history of abdominal surgeries or adhesive disease.
He was taken to the operating room urgently for exploratory laparotomy, where it was discovered he had a shower-emboli type intermittent pattern of small bowel ischemia, necessitating 4 small bowel resections. His remaining bowel was left in discontinuity (i.e., was not immediately anastomosed) due to his state of undesirable perfusion requiring maximum pressor support, and to decrease operative time. To facilitate a second-look laparotomy, the team opted for a temporary abdominal closure, and an open abdomen NPWT system was placed.
Obtaining secure seal for open abdomen NPWT - a new technique
Application of open abdomen NPWT dressing
The patient's abdomen had exposed, draining dermis without any dry tissue to apply adhesive drape. A novel method for securing a seal to non-intact skin was utilized, successfully keeping a seal with negative pressure at the prescribed rate of -125mmHg continuous therapy and evacuating abdominal drainage for a period of 2 days on 4 separate occasions (see Figures 1 to 6 for index procedure with detailed procedural steps). A combination of commonly available wound care products were utilized in the process. No complications were observed during the application or treatment period, and no seal loss was reported. The total time of application was approximately 10 minutes, including trimming and placement of visceral protective layer and preparation of supplies on sterile field. To this author’s knowledge, the technique described below has not been described in the literature as of the date of this publication.
Removal of open abdomen NPWT dressing
The open abdomen NPWT dressing was removed according to manufacturer's instructions. The dressing removal process was actually expedited by the presence of exudate on the surrounding tissue, compared to removal of stoma paste from intact skin, which can be a difficult process. Removing the staples from the outermost layer of adhesive drape was the most time consuming step, with total removal time totaling less than two minutes.
DISCUSSION
Effectiveness of NPWT largely depends on an airtight dressing seal, which can be difficult to obtain and/or maintain in moist environments (e.g. exposed dermis, exudative/denuded skin) or anatomically challenging areas (e.g., with folds and crevices). Several reports describe use of products such as ostomy paste, ostomy baseplates, cyanoacrylate-based tissue skin adhesive, hydrocolloid dressing, and medical silicone to provide a more secure and accessible surface area, and create an airtight NPWT dressing seal.[3][4][2] However, existing case studies mostly focus on techniques for anatomically challenging areas, and not for periwound areas with significant tissue loss/high exudate. Some existing techniques for achieving NPWT seal over moist surfaces are summarized below:
- Application of medical silicone: silicone can be used in intracorporeal and extracorporeal medical devices, due to its biocompatibility and durability.[2] Medical silicone has also been used for sealing of intraoral vacuum dressing in a case of an extended keratocyst of the mandible.[5][2] Despite the advantages of silicone sealing, medical silicone is more expensive than other adjuvants such as stoma paste or hydrocolloid dressings. However medical silicone could be a suitable alternative if the patient is allergic to stoma paste.
- Application of stoma powder and silicone-based barrier film: also known as the "crusting" technique, this technique can be used to create a dry surface for better adherence of the drape.[1] To implement crusting, ostomy powder is sprinkled over the moist periwound area and then the excess is brushed off. A layer of silicone-based barrier film (spray or wipe form) is then applied. Layers of powder and barrier spray/wipe are repeated as necessary. Although widely used, in the case presented herein, crusting would have likely had minimal success, given the depth of tissue loss and diffuse exudate from the surrounding tissue.
This topic illustrates a complex case requiring open abdomen NPWT with the added complication of the periwound having exposed, exudating dermis. Stoma paste can be safely applied over exposed dermis on patients without allergy/sensitivity to paste components (e.g. copolymers).[6] Furthermore, stoma paste and latex-free cohesive bandage are often easily accessible at most facilities. The technique described here offers an affordable and practical option for achieving airtight seal over an extensive, exudative surface, which can potentially be applied to other NPWT modalities as well (e.g. traditional NPWT, NPWT with application of cleansing solution, etc).
Key Takeaways
Some of the main takeaways from this case study are:
- NPWT has the potential to expedite healing and may be applied in many clinical situations, but achieving and maintaining a reliable, occlusive seal is requisite to realize benefit and mitigate cost, regardless of type (traditional NPWT vs systems with application of cleansing solution, open abdomen dressings, etc).
- Innovation and creativity utilizing novel techniques or blending existing techniques using available products can afford the patient great benefit by diminishing interruptions in therapy. Reproducible, cost effective solutions using commonly available products is ideal for both sustainability and continuity of care.
- Consideration must also be given to overall practicality, including patient condition (e.g. ambulatory/non-ambulatory, alert/sedated), time required for application, cost of additional products to maintain seal, patient comfort during application and removal, patient sensitivity to specific products, and care setting or transitions (i.e. availability of products required for seal at the next level of care).
