Subatmospheric Wound Therapy With a Sealed Gauze Dressing
Introduction. Subatmospheric pressure wound therapy (SAWT) is commonly used to manage infected wounds. However, this practice remains controversial because the safety and efficacy of the technique has not been carefully documented.
Methods. The authors assessed the safety and efficacy of a sealed gauze dressing with wall suction applied (GSUC) compared to vacuum assisted-closure (VAC), both soaked with topical antimicrobials. Subjects included 31 hospitalized patients with acutely infected wounds compared with 56 patients with noninfected wounds.
Results. There were significant reductions in wound surface area and volume in both infected and noninfected groups; there was no significant difference in the rate of change observed in the GSUC vs the VAC arms of the study. In the infected group, the reduction in wound surface area was 4.4% per day for GSUC and 4.8% per day for VAC. Wound volume was 7.8% per day for GSUC, and 9.7% per day for VAC (P < 0.001 for all). Evidence of wound infection in all patients, regardless of treatment group, resolved by 96 hours of onset of treatment, and there were no complications specifically related to the use of a sealed dressing over infected wounds.
Conclusion. Gauze dressing with wall suction and VAC therapy can be used in selected acute, infected wounds and both methods of treatment appear to be similarly effective for reducing wound surface area and volume.
The application of a suction pump device for the treatment of suppurative wounds was first described in the 1980's by several authors from the former Soviet Union in a series of articles now known as the "Kremlin papers." In the early 1990's, Western European surgeons adopted subatmospheric pressure wound therapy (SAWT) for the treatment of open wounds, and by 1997 the technique was introduced in the United States and commercialized as the vacuum-assisted closure (VAC) device (KCI, San Antonio, TX). Although SAWT for infected wounds is still controversial, and is even considered contraindicated by some authors, the VAC system is now commonly used for treatment of colonized and infected wounds. Despite this, clinical trials documenting the effectiveness and safety of SAWT in the treatment of infected wounds have been lacking.
The patients described in this report are part of a larger investigation used to compare the effectiveness of 2 types of SAWT in a variety of hospitalized patients with acute wounds: the standard VAC system vs wall suction applied to sealed gauze dressings (GSUC). Although these methods of SAWT are generally similar, GSUC usually employs more frequent dressing changes and pressure settings in the range of 75 mm Hg to 80 mm Hg. The authors did not think it would be useful or practical to require the treatment details be identical in both arms of the trial; instead they opted to use the currently available best practice standards for each technique. This allowed outcomes to be compared for these 2 interventions as they are most often used in real-world clinical circumstances. The initial analysis showed GSUC was not inferior to VAC with respect to changes in wound volume and surface area, but was less costly and less painful than VAC.
Comparative effectiveness research often leaves open the question of whether or not one of the alternative interventions is more beneficial for a subset of the population. Stratified randomization schemes can help answer these questions in a prospective fashion. Thus, infection status was used as a stratification factor in the randomization scheme to ensure balance of the treatment groups with respect to infection, and to facilitate subgroup analysis. The primary objectives were to document any complications associated with the use of SAWT for infected wounds, and to compare the efficacy of VAC and GSUC as measured by changes in wound size. It was hypothesized that both GSUC and VAC could be used safely with selected infected wounds, and that both treatment methods would result in similar changes in wound surface area and volume for infected wounds. The secondary objective of the analysis was to assess the pain associated with each type of dressing. Anecdotally it was observed that the GSUC dressings seemed to cause less pain than VAC, and this was confirmed by initial analysis. It was expected that GSUC might be less painful than VAC for infected wounds, and that, overall, dressing changes for infected wounds would be more painful than for noninfected wounds, regardless of the type of dressing used.
Abstract and Introduction
Abstract
Introduction. Subatmospheric pressure wound therapy (SAWT) is commonly used to manage infected wounds. However, this practice remains controversial because the safety and efficacy of the technique has not been carefully documented.
Methods. The authors assessed the safety and efficacy of a sealed gauze dressing with wall suction applied (GSUC) compared to vacuum assisted-closure (VAC), both soaked with topical antimicrobials. Subjects included 31 hospitalized patients with acutely infected wounds compared with 56 patients with noninfected wounds.
Results. There were significant reductions in wound surface area and volume in both infected and noninfected groups; there was no significant difference in the rate of change observed in the GSUC vs the VAC arms of the study. In the infected group, the reduction in wound surface area was 4.4% per day for GSUC and 4.8% per day for VAC. Wound volume was 7.8% per day for GSUC, and 9.7% per day for VAC (P < 0.001 for all). Evidence of wound infection in all patients, regardless of treatment group, resolved by 96 hours of onset of treatment, and there were no complications specifically related to the use of a sealed dressing over infected wounds.
Conclusion. Gauze dressing with wall suction and VAC therapy can be used in selected acute, infected wounds and both methods of treatment appear to be similarly effective for reducing wound surface area and volume.
Introduction
The application of a suction pump device for the treatment of suppurative wounds was first described in the 1980's by several authors from the former Soviet Union in a series of articles now known as the "Kremlin papers." In the early 1990's, Western European surgeons adopted subatmospheric pressure wound therapy (SAWT) for the treatment of open wounds, and by 1997 the technique was introduced in the United States and commercialized as the vacuum-assisted closure (VAC) device (KCI, San Antonio, TX). Although SAWT for infected wounds is still controversial, and is even considered contraindicated by some authors, the VAC system is now commonly used for treatment of colonized and infected wounds. Despite this, clinical trials documenting the effectiveness and safety of SAWT in the treatment of infected wounds have been lacking.
The patients described in this report are part of a larger investigation used to compare the effectiveness of 2 types of SAWT in a variety of hospitalized patients with acute wounds: the standard VAC system vs wall suction applied to sealed gauze dressings (GSUC). Although these methods of SAWT are generally similar, GSUC usually employs more frequent dressing changes and pressure settings in the range of 75 mm Hg to 80 mm Hg. The authors did not think it would be useful or practical to require the treatment details be identical in both arms of the trial; instead they opted to use the currently available best practice standards for each technique. This allowed outcomes to be compared for these 2 interventions as they are most often used in real-world clinical circumstances. The initial analysis showed GSUC was not inferior to VAC with respect to changes in wound volume and surface area, but was less costly and less painful than VAC.
Comparative effectiveness research often leaves open the question of whether or not one of the alternative interventions is more beneficial for a subset of the population. Stratified randomization schemes can help answer these questions in a prospective fashion. Thus, infection status was used as a stratification factor in the randomization scheme to ensure balance of the treatment groups with respect to infection, and to facilitate subgroup analysis. The primary objectives were to document any complications associated with the use of SAWT for infected wounds, and to compare the efficacy of VAC and GSUC as measured by changes in wound size. It was hypothesized that both GSUC and VAC could be used safely with selected infected wounds, and that both treatment methods would result in similar changes in wound surface area and volume for infected wounds. The secondary objective of the analysis was to assess the pain associated with each type of dressing. Anecdotally it was observed that the GSUC dressings seemed to cause less pain than VAC, and this was confirmed by initial analysis. It was expected that GSUC might be less painful than VAC for infected wounds, and that, overall, dressing changes for infected wounds would be more painful than for noninfected wounds, regardless of the type of dressing used.
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