Vacuum-Assisted Closure™ (V.A.C.)® System for Wounds
Contents
1. Rationale Special Considerations 1 18 19 Secure tubing with an additional piece of drape or tape pad underneath tubing several centimeters away from the dressing Level I Manufacturer s recommendations only Use excess drape to patch leaks and secure borders as needed Applying the V A C Device Remove canister from the sterile packaging and push it into the V A C unit until it clicks Connect the dressing tubing to the canister tubing making sure both clamps are open Place the V A C unit on a level surface or hang from the footboard Level I Manufacturer s recommendations only Press the green lit power button Adjust the V A C unit settings based on individual patient s needs Variable negative pressure settings can be chosen as well as a continuous or intermittent mode Table 141 2 Level IV Limited clinical studies to support recommendations Slowly increase negative pressure on suction device to desired setting of 125 mm Hg Level I Manufacturer s recommendations only Prevents pull on the primary dressing area which can cause leaks Leaks prevent activation of the V A C system If the canister is not engaged properly it will not function and an alarm will sound Closed clamps prevent activation of the negative pressure The V A C unit will alarm and deactivate therapy if the unit is tilted beyond 45 degr2. Air leaks most often occur around tubing Physician or advanced practice nurse will order desired negative pressure settings Lower pressure settings may be ordered for special wound beds meshed grafts higher pressure settings 125 175 mm Hg may be ordered for high effluent wounds 1357 13 V A C therapy is delivered for 48 hr After this period the dressing is removed and the wound cleansed assessed and prepared for V A C therapy to From Lynn McHale Wiegand D J amp Carlson K K 2005 AACN Procedure Manual for Critical Care 5th ed St Louis Elsevier 141 Vacuum Assisted Closure V A C System for Wounds TABLE 141 2 M EA Recommended Guidelines for Treating Wound Types with V A C System Target Pressure for Target Pressure Subsequent Black Polyurethane Polyvinylalcohol Dressing Change Wound Type Initial Cycle Cycles Dressing Soft Foam Interval Acute traumatic Continuous for Intermittent 5 min 125 mm Hg 125 175 mm Hg Every 48 hr every wound first 48 hr on 2 min off for 12 hr with infection rest of therapy Surgical wound Continuous for Intermittent 5 min 125 mm Hg 125 175 mm Hg Every 48 hr every dehiscence first 48 hr on 2 min off for titrated up for 12 hr with infection rest of therapy increased drainage Meshed graft Continuous Continuous 75 125 mm Hg 125 mm Hg titrated None remove up for increased dressing after drainage 4 5 days when using either foam Pressure u
3. impregnated gauze between the dressing and the wound when reapplying the dressing The nonadherent material must have wide enough pores to allow unrestricted passage of air and fluid Because tissue growth into the V A C dressing may cause adherence also consider more frequent dressing changes These conditions should be reported if they persist despite nursing interventions e Tissue breakdown e Loss of seal e Raised foam dressing e Wound drainage suddenly decreasing in amount or stopping e Erythema at drainage site e Heat edema pain e Elevated temperature and white blood cell count e Cloudy or foul smelling wound drainage e Increased wound drainage e Excess bleeding e Discolored tissue in wound bed e Macerated periwound skin e New tunneling or undermining e Signs or symptoms of infection erythema heat discolored or purulent drainage fever From Lynn McHale Wiegand D J amp Carlson K K 2005 AACN Procedure Manual for Critical Care 5th ed St Louis Elsevier 141 Vacuum Assisted Closure V A C System for Wounds 1139 Patient Monitoring and Care Continued Steps Rationale Reportable Conditions 5 Monitor the mode continuous or intermittent and level of suction 50 175 mm Hg Level IV Limited clinical studies to support recommendations 6 Maintain an air tight seal Level I Manufacturer s recommendation only 7 Use sterile technique with
4. Plast Surg 40 219 25 2 Banwell P E 1999 Topical negative pressure therapy in 11 Hersh R E et al 2001 The vacuum assisted closure wound care J Wound Care 8 79 84 device as a bridge to sternal closure Ann Plast Surg 3 Bates Jensen B M et al 2001 Management of the wound 46 250 4 environment with advanced therapies In Sussman C and 12 Joseph E et al 2000 A prospective randomized trial of Bates Jensen B M eds Wound Care 2nd ed Gaithersburg vacuum assisted closure versus standard therapy of chronic MD Aspen Publication 272 92 nonhealing wounds Wounds 12 60 7 4 Bergstrom N et al 1994 Treatment of pressure ulcers 13 Kirby J P et al 2002 Novel uses of a negative pressure Clinical Practice Guideline No 15 Rockville MD U S wound care system J Trauma 53 117 21 Department of Health and Human Services Public Health 14 McCallon S K et al 2000 The effectiveness of vacuum Service Agency for Healthcare Policy and Research AHCPR assisted closure vs saline moistened gauze in the healing of Publication No 95 0652 post operative diabetic foot wounds Ostomy Wound Manage 5 Chua Patel C T et al 2000 Vacuum assisted wound 46 28 35 closure Am J Nurs 100 45 8 15 Meara J G et al 1999 Vacuum assisted closure in the 6 d Udekem Y et al 1998 Radical debridement and omental treatment of degloving injuries Ann Plast Surg transposition for post sternoto
5. commer cially available Sterile foam dressing Sterile adhesive drape Noncollapsible evacuation tube Adhesive drape Sterile scissors Additional equipment to have available as needed includes the following Razor PATIENT AND FAMILY EDUCATION Assess patient and family readiness to learn and any fac tors that may affect learning It is also important to identify how best the patient learns Rationale Allows the nurse to develop the most appropriate teaching strategy for each patient Provide information about the V A C system the proce dure and the equipment Rationale May decrease or alleviate anxiety by assisting patient and family to under stand the procedure why it is needed and the preferred outcomes Explain the procedure and the reason for changing wound dressing Rationale Decreases patient anxiety and discomfort Discuss patient s role in dressing change procedure and maintenance of V A C Rationale Elicits patient cooper ation prepares patient for wound management on discharge PATIENT ASSESSMENT AND PREPARATION Patient Assessment Fully assess wound to determine its characteristics and appropriateness for the procedure Rationale Insures that there is no contraindication to use of the V A C From Lynn McHale Wiegand D J amp Carlson K K 2005 AACN Procedure Manual for Critical Care 5th ed St Louis Elsevier 1132 Unit VII Integumentary System system Provide
6. increased mobility The V A C device requires an electrical outlet for therapy however some units have limited battery reserve Optimal therapy is achieved by delivering uninterrupted therapy at least 22 out of 24 hours battery power is maintained 1129 From Lynn McHale Wiegand D J amp Carlson K K 2005 AACN Procedure Manual for Critical Care 5th ed St Louis Elsevier 1130 Unit VII Integumentary System Bone FIGURE 141 1 Components of the Vacuum Assisted Closure System Kinetic Concepts Inc San Antonio TX Subcutaneous XJ tissue Capillaries es FIGURE 141 2 V A C Therapy Fluid exudate and debris removed from wound bed Courtesy Kinetic Concepts Inc San Antonio TX From Lynn McHale Wiegand D J amp Carlson K K 2005 AACN Procedure Manual for Critical Care 5th ed St Louis Elsevier 141 Vacuum Assisted Closure V A C System for Wounds 1131 FIGURE 141 3 A Wound defect B Wound defect with V A C therapy applied Courtesy Kinetic Concepts Inc San Antonio TX Contraindications to use of the V A C system include malignancy in the wound margins untreated osteomyelitis fistulas to organs or body cavities necrotic tissue with eschar present exposed arteries or veins in the wound Precautions should be used for wounds with active bleed ing difficult wound hemostasis or patients taking anticoagulants Negative therapy
7. new dressing application 8 Label dressing with date and time of application 9 Keep canister position level If previous dressings were difficult to remove make sure the dressing tubing is unclamped introduce 10 to 30 ml of NS solution into the tubing to soak underneath the foam for 15 to 30 min NS can be injected directly into the foam while low vacuum 50 mm Hg is applied to the dressing Clamp the tube when the NS starts to flow into the dressing tube Wait 15 to 30 min then gently remove dressing If the patient experiences pain during dressing change 1 lidocaine solution may be ordered by the physician or advanced practice nurse This can be introduced down the tubing or injected into the foam with the pump turned on at a lower pressure 50 mm Hg After instilling the lidocaine clamp the tube and wait 15 to 20 min before gently removing the dressing Removal of edema and debris alleviates compressive forces thus improving perfusion Suctioning fluid from within the wound may remove factors that inhibit healing Negative pressure wound therapy decreases the bacterial load of deliberately infected wounds Application and release of force on tissue stimulates cell proliferation and protein synthesis Mechanical stretch on the tissue by the negative pressure draws the wound toward the center closing the defect 6 Once edema of the wound has resolved typically after 48 hr of con
8. 6 Shave hair on the border around the wound if needed and thoroughly cleanse skin surrounding wound Level I Manufacturer s recommendations only Dry and prepare the periwound tissue as appropriate Skin degreasing medical cleansing agents may be necessary to apply to periwound tissue Level I Manufacturer s recommendations only Choose V A C soft foam white a hydrophilic water attracting material or the black foam polyurethane a hydrophobic water repelling dressing Table 141 1 Level I Manufacturer s Improves dressing adherence Moisture from perspiration oil or body fluids may cause difficulty in achieving an air tight seal with V A C dressing White polyvinyl alcohol foam is denser with smaller pores which restricts granulation tissue growth into the foam and may be used in cases in which black foam cannot The white V A C dressing holds moisture but also allows exudate to be removed through it It is nonadherent and can be used in tunnels recommendations only be tolerated due to pain Larger pores in black foam are considered to be most effective in stimulating granulation tissue and wound contraction and shallow undermining due to its higher tensile strength The black V A C dressing does not hold moisture and allows exudates to be removed Its design results in rapid growth of new granulation 9 Remove gloves Wash hands Apply sterile glove
9. CQVZTIZ http evolve elsevier com PROCEDURE Vacuum Assisted Closure V A C PURPOSE System for Wounds To apply subatmospheric negative pressure to the wound bed to stimulate granulation and reduce edema thus enhancing wound healing PREREQUISITE NURSING KNOWLEDGE e Negative pressure wound therapy or Vacuum Assisted Closure V A C therapy V A C Kinetic Concepts Inc San Antonio TX Fig 141 1 is an exclusive system for wound closure that applies subatmospheric negative pressure evenly over a wound bed Fig 141 2 This mechanical stress creates a noncompressive force on the wound bed that dilates the arterioles increasing the effectiveness of local circulation and enhancing the proliferation of granulation tissue The system also enhances lymphatic flow and removal of excessive fluid decreasing wound edema and bacterial load at the wound site further aiding wound healing Fig 141 3A and B Wound healing is best achieved through adequate cleans ing debridement and dressing of the wound bed based on patient and wound characteristics Wounds heal by either primary or secondary intention see Fig 136 1 Most clean or clean contaminated surgi cal wounds heal by primary intention Suturing each layer of tissue approximates the wound edges These wounds typically heal quickly and require minimal wound care Contaminated surgical or traumatic wounds open wounds heal by secondary intenti
10. Decreased time to satisfactory healing may decrease e Ischemia and necrosis hospital length of stay and cost e Skin erosion or maceration around wound sites or pressure breakdown at dressing tubing site or both Patient Monitoring and Care Steps Rationale Reportable Conditions 1 Assess location of wound and placement of V A C evacuation tube to avoid excessive pressure on surround tissue structures 2 Assess patency of V A C system 3 Monitor condition of wound bed and periwound skin with dressing changes observe for signs of wound infection 4 Change the dressing every 48 hr If infection is present increase the frequency of dressing change to every 12 to 24 hr Level IT Theory based no research data to support recommendations recommendations from expert consensus group may exist Excessive pressure may result in tissue breakdown at evacuation tube site The V A C dressing should be collapsed when seal is maintained and negative pressure is being delivered in a consistent manner Alarms on the device indicate loss of seal raised foam dressing indicates loss of negative pressure therapy Identifies any evidence of wound healing or of any changes or abnormalities indicative of complications Removes infectious material from a healing wound bed If dressing adheres to the wound base consider imposing a single layer of nonadherent porous material e g wide meshed Vaseline
11. ees Activates subatmospheric pressure therapy Continuous vacuum mode removes cellular edema and debris enhancing perfusion through vessels previously compressed 0 2 14 17 18 Healing inhibitory factors present in this fluid are also removed After edema has been sufficiently withdrawn the intermittent mode promotes granulation tissue formation and prevents wound dehydration 181617 Negative pressures ranging from 50 to 175 mm Hg can be chosen depending on the amount of exudate and granulation tissue within the wound and the type of foam used see Table 141 2 Negative pressure may be initiated at 75 mm Hg and gradually increased to 125 mm Hg Maintain therapy continuously Subatmospheric pressure therapy should not be off for more than 2 hr per day Treatment is discontinued when goals for V A C therapy are achieved or after 1 to 2 weeks without improvement in the condition of the wound In less than 1 min of operation the V A C dressing will collapse unless leaks are present Premedicate patient if necessary Application of negative pressure systems may cause mild discomfort for the patient during initial activation of the V A C system Blood flow may be inhibited by application of higher negative pressures If you suspect a leak small leaks may create a whistling noise gently press around the tubing to better seal the drape Excess drape can also be used to patch over leaks
12. ga V ed 2000 Text Atlas of Wound Management London Martin Dunitz Ltd Falanga V ed 2001 Cutaneous Wound Healing London Martin Dunitz Ltd Irion G 2002 Comprehensive Wound Management Thorofare NJ Slack Incorporated Kinetic Concepts Inc 2001 VA C Physician and Caregiver Reference Manual San Antonio Kinetic Concepts Inc Kloth L C and McCulloch J M eds 2002 Wound Healing Alternatives in Management 3rd ed Philadelphia F A Davis Company Krasner D L et al 1999 Nursing management of chronic wounds Nurs Clin N Am 34 933 949 Krasner D L 2002 Managing wound pain in patients with vacuum assisted closure devices Ostomy Wound Manage 48 38 43 Mendez Eastman S 2001 Guidelines for using negative pressure wound therapy Adv Skin amp Wound Care 14 314 22 Mendez Eastman S 1999 Use of hyperbaric oxygen and negative pressure therapy in the multidisciplinary care of a patient with nonhealing wounds J Wound Ostomy Continence Nurs 26 67 76 CIZLUZ ittp evolve elsevier com From Lynn McHale Wiegand D J amp Carlson K K 2005 AACN Procedure Manual for Critical Care 5th ed St Louis Elsevier
13. h all cleansing supplies and materials for appropriately sized V A C dressing 3 Position the patient to facilitate cleansing and dressing application 4 Cleanse the wound according to orders see Procedure 136 and or institution protocol Level VI Clinical studies in a variety of patient populations and situations to support recommendations 5 Physician or advanced practice nurse may debride see Procedure 137 necrotic tissue or eschar if applicable Level VI Clinical studies in a variety of patient populations and situations to support recommendations of microorganisms The V A C dressing size should be chosen so that it will fill the entire wound cavity Provides for patient comfort and allows for visualization and access to the wound Exudate and debris are removed prior to dressing application This process facilitates healing and decreases bacterial burden 4 If extensive debridement is necessary it may require an operative suite Healthy vascularized tissue is reached and with a clean wound bed there is enhanced granulation tissue development 5 2 23 From Lynn McHale Wiegand D J amp Carlson K K 2005 AACN Procedure Manual for Critical Care 5th ed St Louis Elsevier for Vacuum Assisted Closure V A C System for Wounds Continued Steps 141 Vacuum Assisted Closure V A C System for Wounds 1133 Rationale Special Considerations
14. ion consensus group may exist drainage may also result in some e Oliguria protein loss Nutritional consult e Decreasing serum protein to replace protein loss from wound levels exudates may be indicated 12 Encourage patient hygiene shower or bath during V A C dressing changes Documentation Documentation should include the following e Patient and family education e Wound debridement procedure if applicable wound e Patient tolerance of the procedure cleansing procedure completed dated and timed e Condition of the wound bed and periwound skin description e Size of the wound measured by length width and depth e Characteristics of wound drainage consider obtaining a photograph of the wound depending e Degree of suction mm Hg and continuous or intermittent mode on institution policy e Nursing interventions e Size and type of V A C foam dressing applied and total e Premedication given and patient s response to the number placed in the wound pain medication e Unexpected outcomes reportable conditions healthpoint system in the management of pressure ulcers References Ann Plast Surg 49 55 61 1 Argenta L C and Morykwas M J 1997 Vacuum assisted 10 Genecov D G et al 1998 A controlled subatmospheric closure A new method for wound control and treatment pressure dressing increases the rate of skin graft donor site clinical experience Ann Plastic Surg 38 563 76 re epithelialization Ann
15. l the exudate in the canister tubing into the canister then tighten clamps on the canister tube 5 Press Therapy button Off Gently stretch drape horizontally and slowly pull up from skin Do not peel Gently remove Discard disposables according to institution policy Document procedure in patient record canister Prevents leakage Allows canister to be emptied and or discarded Removes any remaining fluid from the dressing Deactivates pump Decreases patient discomfort and potential for skin and wound trauma Reduces transmission of microorganisms universal precautions From Lynn McHale Wiegand D J amp Carlson K K 2005 AACN Procedure Manual for Critical Care 5th ed St Louis Elsevier 1138 Expected Outcomes Unexpected Outcomes Unit VII Integumentary System e Wound healing granulation enhanced by consistent e Infection negative pressure therapy early signs of contraction e Bleeding of wound margins e Fistula formation e Decreased volume of wound exudate over time e Disruption of underlying tissue structures and absence of foul odor or color e Pain e Enhanced wound healing because of effective wound e Misplacement over exposed vessel ligaments fluid edema removal other structures e Decrease in size of wound with ability for surgical e Lack of improvement in wound after 1 to 2 weeks closure with flap graft or skin graft complete of therapy healing of wound e Tissue loss e
16. lcer Continuous for Intermittent 5 min 125 mm Hg 125 175 mm Hg Every 48 hr every first 48 hr on 2 min off for titrated up for 12 hr with infection rest of therapy increased drainage Chronic ulcer Continuous Continuous 50 125 mm Hg 125 175 mm Hg Every 48 hr every titrated up for 12 hr with infection increased drainage Fresh flap Continuous Continuous 125 150 mm Hg 125 175 mm Hg Every 72 hr every titrated up for 12 hr with infection increased drainage Compromised Continuous Continuous 125 mm Hg 125 175 mm Hg Every 48 hr every flap titrated up for 12 hr with infection Responsible physician or advanced practice nurse should be consulted for individual patient conditions guidelines before use increased drainage Consult device user manual and manufacturer s recommended 1137 Courtesy Kinetic Concepts Inc San Antonio TX for Vacuum Assisted Closure V A C System for Wounds Continued Steps Rationale Special Considerations continue if needed If infection is present the dressing change interval should be every 12 to 24 hr Negative pressure may enhance bacterial clearance from the wound Dressing Removal 1 To remove the dressing raise the Drains fluid from tubing into tubing connector above the level of the pump unit Tighten clamps on the dressing tube 3 Separate canister tube and dressing tube by disconnecting the connector Allow the pump unit to pul
17. may be applied to the wound by select ing continuous or cycling pressure intervals of 5 min on 2 min off After this period the dressing is removed and the wound is cleansed assessed and prepared for V A C therapy to continue if needed V A C dressings are usually changed every 48 hours However infected wound beds may require more fre quent dressing changes every 12 hours V A C dress ings over grafts may be changed less frequently every 3 5 days 3 gt 713 The wound bed should be free of necrotic tissue and debris prior to applying the V A C In highly exudating wounds draining from the wound bed may be significant in the first 24 48 hours of therapy requiring monitoring of urine output and hemodynamic stability Studies have not suggested fluid replacements have been necessary to ensure hemostasis in highly exudating wounds Nutritional requirements for wound healing are great These needs must be assessed met and monitored frequently as fluids and some proteins are removed via V A C therapy Inflammatory cytokines and protein degrading enzymes impair wound healing and can be removed with negative pressure systems such as the V A C EQUIPMENT Personal protective equipment gown goggles Nonsterile and sterile gloves sterile field Sterile water or normal saline NS for cleansing Liquid skin barrier to protect periwound skin and or hydro colloid wafer V A C collection chamber and suction pump
18. my mediastinitis Cardiovasc 42 589 94 Surg 6 415 8 16 Morykwas M J and Argenta L C 1997 Nonsurgical 7 Evans D and Land L 2001 Topical negative pressure for modalities to enhance healing and care of soft tissue wounds treating chronic wounds The Cochrane Database of J South Ortho Assoc 6 279 88 Systematic Reviews 4 CD001898 17 Morykwas M J et al 1997 Vacuum assisted closure a 8 Fabian T S et al 2000 The evaluation of subatmospheric new method for wound control and treatment Animal studies pressure and hyperbaric oxygen in ischemic full thickness and basic foundation Ann Plast Surg 38 553 62 wound healing Am Surg 66 1136 43 18 Mullner T et al 1997 The use of negative pressure to 9 Ford C N et al 2001 Interim analysis of a prospective promote the healing of tissue defects A clinical trial using the randomized trial of a vacuum assisted closure versus the vacuum seal technique Br J Plast Surg 50 194 9 From Lynn McHale Wiegand D J amp Carlson K K 2005 AACN Procedure Manual for Critical Care 5th ed St Louis Elsevier 141 Vacuum Assisted Closure V A C System for Wounds 1141 19 Obdeijn M C et al 1999 Vacuum assisted closure in the treatment of poststernotomy mediastinitis Ann Thorac Surg 68 2358 60 20 Philbeck T E et al 1999 The clinical and cost effectiveness of externally applied negative pressure wound therapy in the treatment of w
19. nded guidelines before use Courtesy Kinetic Concepts Inc San Antonio TX From Lynn McHale Wiegand D J amp Carlson K K 2005 AACN Procedure Manual for Critical Care 5th ed St Louis Elsevier E FIGURE 141 4 A and B Cut the V A C foam to appropriate size to fill the wound defect C Apply V A C foam into wound bed D Apply V A C tubing to foam in the wound E Cover foam and 3 to 5 cm of surrounding healthy tissue with transparent dressing drape to ensure an occlusive seal Courtesy Medical Media Department Thomas Jefferson University Hospital Philadelphia PA From Lynn McHale Wiegand D J amp Carlson K K 2005 AACN Procedure Manual for Critical Care 5th ed St Louis Elsevier 141 Vacuum Assisted Closure V A C System for Wounds 1135 for Vacuum Assisted Closure V A C System for Wounds Continued Steps Rationale Special Considerations 12 13 14 15 16 17 Size and trim the dressing drape to cover the foam plus a 3 5 cm border of intact skin Do not discard excess drape Gently place the foam into the wound cavity covering the entire wound base and sides as well as areas of tunneling and undermining Fig 141 4C Level IV Limited clinical studies to support recommendations Apply tubing to foam in the wound Tubing can be laid on top of the foam or inside the foam dressing The tubing should be positioned away fr
20. om bony prominences Fig 141 4D Level I Manufacturer s recommendations only Cover foam and 3 to 5 cm of surrounding healthy tissue with drape to ensure an occlusive seal Fig 141 4 Level IV Limited clinical studies to support recommendations Lift the tubing and pinch 1 to 3 cm of drape together under the tubing to help hold the tubing away from the skin and pad underneath the tubing Avoid stretching the drape and compressing the foam into the wound with transparent occlusive drape Simply cover and seal around the foam Level I Manufacturer s recommendations only and closes the entrance to the tunnel Bacterial invasion and impaired healing results from unfilled dead space 4 Excess drape may be needed later as a patch Capillaries could be compressed if packed too tightly and pressure on newly formed granulation tissue may prevent or delay healing 4 If periwound skin is fragile use a skin preparation Matisol No Sting prior to drape application or frame the wound with a skin barrier or hydrocolloid dressing This affords protection for periwound skin This will prevent the development of pressure The vacuum will not function without an occlusive seal The drape may also help maintain a moist wound environment This will reduce pressure on the skin from the tubing Avoids tension and shearing forces on wound and surrounding tissue Allows distribution of pres
21. on Wounds healing by secondary intention granulate from the base of the wound to the skin surfaces care must be taken to allow for uniform granulation and prevention of open pockets tunneling Eleanor R Fitzpatrick Mary Beth Flynn Makic Open wounds must be clean and moist to promote effec tive and efficient wound healing To that end open wound care strives to maintain a clean moist wound bed that allows for effective wound healing under the support of a dressing Openly granulating wounds heal more slowly must remain moist to enhance tissue granulation and may be more painful for the patient Open wounds may have excessive wound drainage requiring application of absorptive dressings protection of periwound skin and more frequent dressing changes to facilitate healing The V A C system is indicated for wounds in which subatmospheric pressure may promote wound healing for example chronic acute traumatic subacute and dehisced wounds diabetic ulcers pressure ulcers flaps and grafts The V A C will draw wound edges together and create a less edematous clean vascularized wound bed The wound may fully heal or improved adherence of the flap or graft closure can be achieved The V A C has been approved by the Food and Drug Administration FDA for clinical use in the treatment of these wounds A newer system called the Mini VAC is portable and battery powered and can be carried by the patient allowing for
22. ounds in home healthcare Medicare patients Ostomy Wound Manage 45 41 50 21 Rodeheaver G et al 1994 Wound healing and wound management Focus on debridement Adv Wound Care 7 22 4 26 9 32 6 22 Sibbald R G et al 2000 Preparing the wound bed debridement bacterial balance and moisture balance Ostomy Wound Manage 46 14 35 23 Steed D L et al 1996 Effect of extensive debridement and treatment on the healing of diabetic foot ulcers Diabetic Ulcer Study Group J Am Coll Surg 183 61 4 24 Stotts N 1997 Co factors in impaired wound healing In Krasner D and Kane D eds Chronic Wound Care A Clinical Source Book for Healthcare Professionals 2nd ed Wayne PA Health Management Publications Inc 25 Wysocki A B 1996 Wound fluids and the pathogenesis of chronic wounds J WOCN 23 283 90 26 www kcil com clinicalevidence index VAC Accessed May 17 2004 Additional Readings Barker D E et al 2000 Vacuum pack technique of temporary abdominal closure A 7 year experience with 112 patients J Trauma 48 201 7 Casey G 2003 Nutritional support in wound healing Nurs Stand 17 55 6 58 Dolynchuk K 2000 Best practices for the prevention and treatment of pressure ulcers Ostomy Wound Manage 46 38 52 Erdman D et al 2001 Abdominal wall defect and entero cutaneous fistula treatment with the vacuum assisted V A C system Plast Reconstr Surg 108 2066 8 Falan
23. s 10 Open the V A C dressing onto sterile dry surface inspect it for any defects 11 Cut the V A C foam with sterile scissors in a location away from the wound Fig 141 4A Level IV Limited clinical studies to support recommendations Faulty dressings should be replaced This prevents small particles from the dressing falling into the wound The dressing should be cut to fit the size and shape of the wound including tunnels and undermined areas Fig 141 4B Tunneling can result in a cyst or abscess when the main body of a wound heals Any exposed tendons nerves or blood vessels should be protected by moving muscle or fascia over exposed structures or by placing a layer of nonadherent dressing over them Procedure continues on the following page TABLE 141 1 m SEE Recommended Guidelines for Foam Use V A C Polyurethane Black Foam V A C Soft Foam Both Either Deep acute wounds with moderate X granulation tissue growth Deep wounds with extremely rapid growth X in granulation tissue Deep pressure ulcers X Superficial wounds Shallow chronic ulcers Postgraft therapy X Compromised flaps Fresh flaps Tunneling sinus tracks undermining X Diabetic ulcers X Dry wounds X Deep trauma wounds X Superficial trauma wounds X xx xx Responsible physician or advanced practice nurse should be consulted for individual patient conditions Consult device user manual and manufacturer s recomme
24. s data that can be used for comparison at successive dressing changes e Monitor for signs and symptoms of wound infection including the following Erythema at drainage site Heat gt Edema gt Pain gt Elevated temperature and white blood cell count gt Wound drainage becoming cloudy and foul smelling Increasing in amount of wound exudate Rationale Although negative pressure wound therapy assists with removal of excessive fluid thus reducing the presence of bacteria in the wound bed assessment for signs and symptoms of wound infection is necessary especially in compromised patients e Determine baseline pain assessment of the patient Rationale Provides data that can be used for compari son with past procedure assessment data Allows the nurse to plan for pre and intraprocedure analgesia e Determine baseline nutritional status and fluid volume status Rationale Fluids and protein may be lost during V A C therapy e Assess past medical history especially related to prob lems with bleeding fistula formation or malignancy gt Rationale The use of the V A C may be contraindicated in these conditions e Assess current medications specifically related to antico agulant use Rationale Identify possible areas of caution which should be monitored with V A C use e Assess current laboratory values especially coagulation studies and protein levels Rationale Identifies abnor malities possibly a
25. ssociated with risks or areas to monitor related to V A C use Patient Preparation e Ensure patient and family understanding of preproce dural teaching Reinforce teaching points as needed Rationale Evaluates understanding of previously taught information and provides a conduit for questions e Validate presence of patent intravenous access Rationale Access may be needed for administration of analgesic medications e If debridement or other invasive intervention is to be per formed in conjunction with the V A C procedure ensure that informed consent has been obtained Rationale Allows patient to make decision with appropriate information and health care providers can docu ment this e Position the patient in a manner which will facilitate dressing application and patient comfort Rationale Prepares patient to undergo procedure e Sedate the patient or administer prescribed analgesics if needed Rationale Improve comfort level and tolerance of the procedure Decreases patient anxiety and discom fort Typically pain medication is not required for V A C therapy however if the patient required analgesia for previous dressing therapy pain medications may be required for V A C therapy for Vacuum Assisted Closure V A C System for Wounds Steps Rationale Special Considerations 1 Wash hands and don gloves Reduces possibility of transmission 2 Establish a sterile field wit
26. sure throughout all wounds with the use of one pump Drape can be placed over prepared skin or the barrier More than one dressing may be needed for larger wounds More than one piece of foam may be used to fill the wound bed Foam pieces should be in contact but not overlapping each other to allow equalization of negative pressure applied to the wound bed by the suction device 1357 13 For deeper wounds the tubing should be repositioned regularly to minimize pressure on wound edges Cushion skin under tubing with excess foam The drape is vapor permeable and allows for gas exchange It also protects the wound from external contamination Foam will contract into wound bed if seal is obtained If foam does not contract reassess outer dressing for possible leaks in the system or dressing sea 1357 13 More than one wound of similar pathology in close proximity can be managed with one negative pressure pump Such wounds can be bridged by placing the V A C drape on intact skin and a strip of foam from one wound bed to the other All edges of the foam should be in contact and the tubing placed in a central location Procedure continues on the following page From Lynn McHale Wiegand D J amp Carlson K K 2005 AACN Procedure Manual for Critical Care 5th ed St Louis Elsevier 1136 Unit VII Integumentary System for Vacuum Assisted Closure V A C System for Wounds Continued Steps
27. tinuous therapy the intermittent mode allows a more aggressive stimulus for granulation tissue formation possibly due to rhythmic perfusion or increased cell mitosis stimulated by a rest and stimulation cycle 817 Loss of an air tight seal can result in a decreased amount of drainage removal and in desiccation of the wound Prevents bacterial contamination of system Identifies when system should be changed Prevents malfunction of suction apparatus and an inoperative status e Patient discomfort e Excess granulation tissue overgrowth into the dressing when removed Continued edema within wound bed Procedure continues on the following page From Lynn McHale Wiegand D J amp Carlson K K 2005 AACN Procedure Manual for Critical Care 5th ed St Louis Elsevier 1140 Unit VII Integumentary System Patient Monitoring and Care Continued Steps Rationale Reportable Conditions 10 The V A C canister should be changed Controls odor e Wound drainage becoming when full unit will alarm or at least foul smelling and cloudy weekly Label with date and time of change 11 Monitor amount of wound drainage If a wound produces excessive fluid e Increasing amounts of Level II Theory based no research the patient may experience a fluid drainage data to support recommendations imbalance requiring intravenous e Tachycardia recommendations from expert or oral fluid replacements Excess e Hypotens
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