Principles and Practice of Wound Care

Management of Upper Extremity Wounds
385
Figures 14C to E
Figures 14A to E: Radial artery forearm free fl ap: (A) Soft-tissue
defect with exposed bone following road traffi c accident; (B) Radial
artery forearm fl ap design; (C) Soft issue defect following debridement
and harvested free fl ap; (D) Immediately after fl ap transfer; (E) Two
weeks postoperative
elevated in the postoperative period to decrease swelling. It is
preferable to have the patient simply elevate a hand on pillows
at home, but a sling can be applied if possible.
SUMMARY
The prime objective in the management of upper extremity
wounds is to obtain early closure and good wound healing.
Hand is particularly susceptible to develop complications
leading to serious disability. Surgical options include primary
closure, skin grafts and fl aps. Recent advances in wound
dressing, debridement procedures, and surgical reconstruction
allow treatment of any complicated wound. Reconstructive
surgeons continue to improve the functional and esthetic
outcome of upper extremity wounds.
BIBLIOGRAPHY
1. Altman R, Harris G, Knuth C. Initial management of hand
injuries in emergency patients. AM J Emerg Med 1987;5:400.
2. Argenta LC Morykwas MJ. Vaccum-assisted closure: a new
method for wound control and treatment: clinical experience.
Ann Plast Surg 1997;38(6):553-76.
3. Atasoy E, Loakimidis E, Kasdan M, et al. Reconstruction of
the amputated fi nger tip with a triangular volar fl ap. J Bone
Joint Surg Am 1970;52:921.
4. Attinger CE, Janis JE, Steinberg J, et al. Clinical approach to
wounds: debridement and wound bed preparation including the
use of dressings and wound healing adjuvants. Plast Reconst
Surg 2006;117(7S):72-109.
5. Bailey BN,Godfrey AM. Lattismus dorsi muscle free fl aps. Br
J Plast Surg. 1982;35:47-52.
6. Basadre JO, Parry SW. Indication for Surgical debridement in
125 human bites to hand. Arch Surg 1991;126:65.
7. Beasley R. Fingernail injuries. J Hand Surg 1983;2:784.
8. Brown RL, Greenhalgh DG, Kagan RJ, Warden GD. The
adequacy of limb escharotomies/fasciotomies after referral to
major center. J Trauma 1994;37:916.
9. Gonzalez MH. Necrotizing fasciitis and gangrene of the upper
extremity. Hand Clin 1998;14:635-45.
10. Hing DN, Buncle HI, Alpert BS. Use of temporoparietal fascial
free fl ap.Plast Reconstr Surg 1988;534.
11. Kutler W. A new method for fi nger tip amputation. JAMA
1947;133:29.
12. Leclercq C. Management of fi ngertip injuries. J Hand Br 1993;
18:411.
13. McGregor IA, Jackson IT. The groin fl ap. Br J Plast Surg
1972;25:3.
C
D
E

Types of Wounds and their Management
386
14. Mlakar JM, Dougherty WR. Reconstruction of the burned
hand. In Herndon DN: TotalBurn Care, 2nd ed. Phiadelphia,
WB Saunders, 2002:628-55.
15. Robson MC. Wound infection. A failure of wound healing
caused by imbalance of bacteria. Surg Clin North Am
1997;77:637-45.
16. Scheke LR, Kleinert HE, Handel DP. Lateral arm composite
transfer to ipsilateral hand defects. J Hand Surg AM. 1987;12:
665-72.
17. Snyder CC. Animal bites wound. Hand Clin 1989;5:571.
18. Soutar DS, Tanner NSB. The radial forearm fl ap in the manage-
ment of soft tissue injuries of hand. Br J Plast Surg 1984;37:18.
19. Tredget E. Management of the acutely burned upper extremity.
Hand Clin 2000;16:187-202.
20. Upton J,Rogers C,Durhan- Smith G, Swartz WM. Clinical
application of free temporoparietalfl aps in hand reconstruction.
J Hand Surg AM 1986;11:475-83.
21. Wexler MR, Yeschua R, Newman Z. Early treatment of burns
of the hand by tangential excision and skin grafting. Plast.
Reconstr Surg 1974;54:268-73.

• Introduction

– Anatomy and Structural Development of Neonatal Skin

– Factors Affecting Wounds Healing in Neonates
• Types of Wounds

– Epidermal Stripping

– Chemical Burns

– Thermal Injuries

– Pressure/Ischemic Injuries

– Extravasation Injuries

– Ischemic Injuries

– Excoriation

– Wounds due to Congenital Conditions

– Wounds due to Birth Trauma
• Guidance and Recommendations for Prevention of
Neonatal Wounds
• Best Practice at Dressing ­Changes

– Choice of Dressing

– Dressing Procedure
• Pain Assessment and Management
• Communication with Parents
• Documentation
INTRODUCTION
With the advanced modern neonatal care, as we all know the
survival of neonates has improved considerably in the past few
years. This is especially true for the premature and extremely
premature babies. However, despite unprecedented advances,
the issues regarding neonatal wound care and management
still lacks evidence based guidelines. The purpose of this
overview is to illuminate key anatomical/structural differences
in neonatal skin, prevention and treatment modalities; and to
review the evidence for commonly encountered wound types.

The next section briefly discusses the development and
maturity of the neonatal skin at different gestations.
Anatomy and Structural Development
of Neonatal Skin
The skin of a neonate originates from two of the three germ
cell layers that make up the embryo; the ectoderm serves as
the origin of the epidermis and the mesoderm for the dermis1
(Rudy 1991). In the uterus the skin has two distinct periods
of development–the embryonic period and the fetal period.
During the embryonic period (0–8 weeks) the dermis and
epidermis can be distinguished, with the latter only consisting
of two layers. The major development takes place during the
fetal period (9–40 weeks). This period is subdivided into four
stages, with the complete formation of the epidermis occurring
during the third stage.

At 24 weeks gestation, premature neonates have little stratum
corneum. Their skin is red, wrinkled, translucent, and gelatinous
in appearance. They lack subcutaneous tissue; therefore, their
dermis is lying directly over the muscle2 consequently, skin
stripping secondary to adhesive dressing and/or tape removals
can result in full-thickness tissue loss. Between 26 and 29
weeks’ gestation, subcutaneous fat deposition begins and skin
wrinkling lessens. However, the barrier function of the skin
remains poor resulting in increased trans epidermal losses.
At 30 weeks, subcutaneous tissue is evident and the stratum
corneum is two to three cell layers thick, compared to 40 weeks
when it is 30 layers thick.2 Functional integumentary maturity
occurs at 33 weeks. The epidermis is fully keratinized and the
dermal/epidermal junction is stronger but remains fragile and
Issues in Neonatal Wound
­Management
Harish Chellani, Pratima Anand
34
Chapter

Types of Wounds and their Management
Section 3
388
Table 1: Types of wounds and causes
Type of wound
Causes
1.  Epidermal stripping
Handling, removal of adhesive tapes used to secure tubes/lines
2.  Excoriation
Frequent diarrhea, loose runny stools, urine; Candida albicans infection
3.  Chemical burns
Contact with alcohol based skin preparation solutions, e.g. chlorhexidine and
iodine
4.  Thermal burns
Heat from probes. On rare occasions ‘cold light’ used to identify veins/arteries for
inserting cannula/central lines
5.  Pressure sores
Tubing
Saturation probes if not resited often enough
Nasal septum if receiving nasal continuous positive airway pressure (CPAP)
Edematous babies* and failure to Loosen tapes/clothing
6.  Extravasation injuries
Infusion irritates vein causing vasoconstriction and swelling at cannula site
Cannula tip dislodges or punctures vein
Device or needle poorly secured
Obstruction of tip caused by fibrin, thrombus
Cannulae left in place too long
7.  Ischemic injuries (auto amputation, amniotic
bands)
Extravasation of a peripheral arterial line
Amniotic banding in utero
8.  Surgical wounds
9.  Congenital conditions:

(i) Epidermolysis bullosa

(ii) Periumblical trauma

(iii) Exposed bowel (gastrochisis) and spina
bifida
easily damaged. At 36 weeks (full-term), the skin is structurally
similar to the adult but the epidermal and dermal layers are up
to 60 percent as thick as an adult.3
Factors Affecting Wound Healing
in ­Neonates
Although they follow the same wound healing trajectory as
adults, wounds in neonates and children typically exhibit faster
rates of closure.4-6 Fibroblasts are present in greater numbers,
collagen and elastin are more rapidly produced, and granulation
tissue forms more quickly compared to adults.6,7 In fact, rapid,
uncomplicated wound healing requiring limited healthcare
professional intervention is the “normative expectation” in
pediatrics.8 This expectation of rapid, uneventful healing and
innate age—related integumentary resiliency has, in part, resulted
in the lack of wound care knowledge transfer to the pediatric
population.8 The normally rapid wound healing response of
neonates and children is often compromised by hypotension
requiring inotropic therapy, edema, infection, and physiological
instability that prevents safe redistribution of pressure.5,7

Possessing minimal to no antigen exposure, neonates are at
especially high-risk for overwhelming life-threatening sepsis
secondary to bacterial proliferation and over growth within the
wound bed.9,10 Their decreased epidermal-to-dermal cohesion,
deficient stratum corneum, impaired thermoregulation, body
surface/weight ratio nearly five times greater than the adult, and
immature immune system—as well as hepatic and renal func-
tion—places neonates at increased risk for epidermal stripping,
infection, increased transepidermal water loss with resultant
heat loss, and toxicity from percutaneous absorption.9,11,12
Types of Wounds
Because of the above mentioned structural and physiological
immaturity, the neonatal skin is predisposed to different kinds
of wounds. These wounds may be related to frequent handling,
prolonged sedation and lack of postural changes, chemical
and ischemic causes, and extravasations injuries due to the
small caliber of the newborn vessels. Next group involves the
surgical wounds and birth trauma injuries (forceps, vacuum
delivery) and excoriations due to diaper, prolonged wetting
and Candida infection. Yet another group of skin wounds
are those related to deficiencies in the skin due to genetically
determined conditions, like epidermolysis bullosa. In this
section, we will be discussing the different types of wounds
in detail. On review of literature there is not enough material
regarding the classification and management of neonatal
*Edema can occur post delivery (often a few days after birth) and in preterms ventilated for respiratory distress syndrome (RDS)

Issues in Neonatal Wound ­Management 
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389
wounds. However, international guidelines from Mölnlycke
Health Care Wound Academy,13 Neonatal Advisory Group14
has classified the wounds found in neonates which have been
incorporated in the section. Table 1 summarizes the different
types of wounds and their causes.
Epidermal Stripping
Epidermal stripping is a particular risk for neonates born
before 27 weeks’ gestation (Irving, 2001a).15 The skin damage
can easily occur, for example, when removing adhesive tapes
that are used to secure tubes or dressings, as these products
may bond to the epidermis more strongly than the epidermis
does with the dermis (Gunderson and Kenner, 1995).16
Chemical Burns
Chemical burns can be caused by contact between alcohol-based
skin preparation solutions and the fragile skin of the neonate
(Harpin and Rutter, 1982;17 Watkins and Keogh, 1992).18
Thermal Injuries
Thermal injuries can be caused by heat from monitoring
electrodes or, more rarely, the fiber optic ‘cold light’ used to
identify veins or arteries for insertion of cannula or central lines.
Pressure/Ischemic Injuries (Figure 1)
Pressure ulcer rates as high as 27 percent in pediatric intensive
care units, 23 percent in neonatal intensive care units, and
20 to 43 percent among outpatients with spina bifida have
been reported. Lack of pressure redistribution measures and
the presence of friction/shear-related forces result in micro-
vascular soft tissue damage and resultant partial-to full-
thickness pressure ulcers.

Pressure/ischemic injuries are relatively rare in neonates
due to their body’s large surface area to weight ratio. However,
neonates who are sedated or paralyzed and therefore unable
to make spontaneous movements are at risk of pressure
injuries (Gunderson and Kenner, 1995).16 Infants with low
blood pressure and receiving inotropes are also at increased
risk, as this medication causes vasoconstriction in peripheral
blood vessels in an effort to improve the blood pressure. The
reduction in blood flow to the peripheries can result in poor
perfusion, which increases the risk of pressure damage (Lund,
1999)19 and this also can occur with edematous babies. Pressure
ulcers or ischemic injuries may occur on the ears or the occiput
if the neonate is nursed supine, or on the knees if nursed prone
and a program for repositioning babies should be developed to
prevent pressure ulcers or ischemic injuries occurring.

Stage I to IV ulcers, unstageable ulcers, and suspected deep
tissue injuries should be documented in accordance with the
National Pressure Ulcer Advisory Panel’s (NPUAP) updated
definitions (Table 2).
Extravasation Injuries (Figures 2 and 3)
Extravasation injuries occur when vesicant fluid inadvertently
leaks from a vein/Cannula site into surrounding tissue.
This leakage can be caused by dislodgement of the tip of
the Cannula or puncturing of the vein, and quick action is
essential to minimize further injury. Neonates most at risk
of extravasation injury include those receiving IV caffeine,
glucose (>10%), calcium, or total parenteral nutrition (TPN),
particularly when these are given through a peripheral
line (Blatz and Paes, 1990).20 Infants receiving hypertonic
solutions (Hecker, 1993)21 or IV inotropes, which cause
Figure 1: Small pressure sore in the back of a neonate
Figure 2: Extravasation injury in newborn

Types of Wounds and their Management
Section 3
390
Table 2: Pressure ulcer staging system23
Stage
Characteristics
Suspected deep tissue injury
Purple or maroon localized area of discolored skin due to damage of underlying soft tissue as
a result of ischemia from pressure and/or shear. This area initially presents as intact skin or a
blood-filled blister and may rapidly evolve to expose additional layers of tissue even with optimal
treatment. Variations in skin pigmentation may change visual presentation and thus early deep
tissue injury may be difficult to discern. Other characteristics of the area may include pain, firmness,
softness, or a difference in temperature as compared to adjacent tissue
Stage 1
Persistent redness of a localized area of intact skin usually over a bony prominence. Other
characteristics of the area may include delayed capillary refill, pain, firmness, softness, or a
difference in temperature as compared to adjacent tissue. Usually a minor and resolvable condition.
Variations in skin pigmentation may change visual presentation
Stage 2
Partial-thickness loss of epidermis or dermis presenting as a shallow open ulcer without slough.
May present as an intact or open/ruptured serum-filled blister
Stage 3
Full-thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle are
not exposed. Slough may be present, but does not obscure the depth of tissue loss. Other
characteristics may include undermining and tunneling. Rolled edge of dermis may be seen
Stage 4
Full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present
on some parts of the wound bed. Other characteristics often include undermining and tunneling
Unstageable
Full-thickness tissue loss in which actual depth of the ulcer is completely obscured by slough
(yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed. Blood
blisters are not débrided and therefore placed in the DTI group
vasoconstriction, are also at risk. These injuries are graded as
shown in Table 3.
Ischemic Injuries (Figures 4 and 5)
Ischemic injuries can result from extravasation of a peripheral
arterial line, as stated above, but more frequently, they will be
caused by arterial spasm.

During the antenatal period, amniotic banding injuries
can occur. This rare birth condition is caused by rupture of
the amniotic sac early in the pregnancy, which leaves the
developing fetus exposed to the placenta’s fibrous tissues.
These can become entangled with the developing limbs, acting
as a tourniquet as the baby grows and causing varying degrees
of damage that ultimately may result in poorly perfused or
ischemic and gangrenous limbs. Immediate surgery may be
Grading of severity of wounds
Figures 3A and B: (a) Necrosis of skin of entire dorsum of hand following extravasation at the intravenous site;
(B) Same wound in healing phase
A
B

Issues in Neonatal Wound ­Management 
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391
Figure 4: Amniotic band in a baby NICU
Table 3: Staging of infiltrates and extravasation 24
Stage
Characteristics
0
Absence of redness, warmth, pain, swelling, blanching,
mottling, tenderness or drainage flushes with ease
1
Absence of redness, swelling
Flushes with difficulty
Pain at site
2
Slight swelling at site
Presence of redness
Pain at site
Good pulse at site
1 to 2 seconds capillary refill below site
3
Moderate swelling above or below site
Blanching
Pain at site
Good pulse below infiltration site
1 to 2 seconds capillary refill below infiltration site
Skin cool to touch
4
Severe swelling above or below site
Blanching
Pain at site
Decreased or absent pulse
Capillary refill >4 seconds
Skin cool to touch
Skin breakdown or necrosis
Figures 5A to C: Newborn with severe amniotic band syndrome
with raw areas over chest bilaterally. The fibrotic bands can be seen
extending even to the upper arm and thigh causing constricting bands
A
B
C

Types of Wounds and their Management
Section 3
392
required in these cases in order to save the affected limb or
digit.
Excoriation
Excoriation in the nappy area is generally caused by prolonged
contact with urine-soaked material, which can be exacerbated
by frequent diarrhea or fungal colonization by the resident gut
flora Candida albicans (Boiko, 2000).22 The prevalence of
diaper dermatitis among hospitalized neonates and children
has been reported to be between 16 and 42 percent.24 In fact,
diaper dermatitis is one of the most common dermatological
conditions encountered among neonates and children who
are diapered. Diaper dermatitis can be staged according to
the integrity of the epidermis and the presence/absence of
Candida albicans skin infection (Table 4).
Wounds due to Congenital Conditions
(Figures 6 to 8)
This category includes epidermolysis bullosa (EB), a group of
skin conditions where the common factor is a tendency for the
skin to blister or shear away in response to minimal friction or
trauma. These mechano-bullous disorders vary in course and
severity from minor disability to death in early infancy. The
prevalence of severe forms of EB is approximately 1:175,000
live births and these infants require specialized handling
techniques to avoid epidermal stripping as a result of friction
and shearing forces.

Meningomyelocele is also predisposed to rupture or
become septic due to thinning of the overlying skin.

Even sometimes cases of sternal cleft can present with
necrosis of skin overlying the cleft as shown in Figures 6A
and B. Aplasia cutis congenita, which occurs in 0.03 percent
of births, is a defect of the skin manifested by absent areas
of epidermis and subcutaneous tissue. Wounds are partial- or
full thickness; 80 percent occur on the scalp. Life-threatening
bleeding and infection have been reported in the literature.
At times a neonate going into sepsis due to any cause
(meningococcal sepsis or staphylococcal sepsis) may manifest
cutaneous lesions also (Figures 7 and 8).
Table 4: Staging of diaper dermatitis 25
Stage
Characteristics
0
Absence of redness, warmth, pain, swelling, blanching,
mottling, tenderness or drainage flushes with ease
1
Absence of redness, swelling
Flushes with difficulty
Pain at site
2
Slight swelling at site
Presence of redness
Pain at site
Good pulse at site
1 to 2 seconds capillary refill below site
3
Moderate swelling above or below site
Blanching
Pain at site
Good pulse below infiltration site
1 to 2 seconds capillary refill below infiltration site
Skin cool to touch
4
Severe swelling above or below site
Blanching
Pain at site
Decreased or absent pulse
Capillary refill >4 seconds
Skin cool to touch
Skin breakdown or necrosis
Figures 6A and B: Small necrotic skin patch over pulsating heart in
a newborn with sternal cleft
A
b

Issues in Neonatal Wound ­Management 
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393
Wounds due to Birth Trauma
Forceps or vacuum assisted deliveries occasionally result in
superficial and sometimes deep lacerations over face and the
skull (Figure 9).
Guidance and Recommendations
for Prevention of neonatal
wounds
1. Epidermal Stripping

• Handle with extreme care, rings can cause damage.

• Avoid products that bond to the skin.

• Secure intravenous cannula with clear sterile film
dressings, which allow monitoring of the site so that
frequent removal is unnecessary. An alcohol free skin
barrier film may reduce skin stripping on removal of
film dressings.

• Mepiform (soft silicone dressing) is useful as a tape,
particularly for those with blistering disorders, e.g.
epidermolysis bullosa (EB).

• Using pad splints and padded Velcro™ straps over
splints rather than tape and using soft silicone dressings
to treat areas of denudation secured with tubular latex-
free stretchy gauze netting can offset the stripping
phenomenon.
2. Chemical Burns

• If the alcohol based agents are applied before insertion
of umbilical lines, IV cannulae or drains, they should be
rinsed off immediately with sterile water.

• However, it is better to avoid them totally and instead use
aqueous based skin preparations such as chlorhexidine
(West et al, 1981).26

• All solutions should be applied sparingly and exposure
limited, as overgenerous application can result in the
baby lying on alcohol-saturated bedding during the
procedure, which can lead to full thickness burns due to
the prolonged contact.

• Repeated use of iodine-based solutions can cause
hypothyroidism due to iodine absorption and should be
avoided in the preterm infant (Linder et al, 1997).27
Figure 7: Neonate with a small infective lesion on the buttock and
extending into surrounding areas leading to a large wound due to
staphylococcal sepsis
Figure 8: Large infective wound on the back of an infant following
meningococcal sepsis
Figure 9: Laceration wound in neonate (Forceps delivery) in NICU

Types of Wounds and their Management
Section 3
394
3. Thermal Injuries

• Burns from electrodes that heat the skin (to cause dilation
of blood vessels for monitoring of transcutaneous O2
and CO2), can be avoided by reducing the temperature
and the length of their application time, according to
the age and gestation of the neonate (Gunderson and
Kenner, 1995).16

• Cold light burns may be prevented by minimizing usage
time of the fiber optic light, and the use of a protective
guard will prevent direct contact with the skin.

• A literature review28 on the use of Biobrane (Bertek
Pharmaceutical Inc., Research Triangle, NC), a
biosynthetic dressing consisting of a layer of peptides
derived from porcine dermal collagen incorporated into
silicone and nylon, has demonstrated clinical efficacy
over conservative treatment in terms of pain control,
wound healing, and hospital length of stay in children
with partial-thickness burns. Further randomized
controlled trials are required to examine the incidence of
hypertrophic scarring and to compare clinical outcomes
to other skin substitutes.28
4. Ischemic injuries

• Inspection of arterial lines every 30 to 60 minutes is
recommended and once a problem has been identified,
the line should be removed immediately.

• A loss of trace on the blood pressure transducers that
are attached to peripheral arterial lines indicates that
the line is not functioning properly, and any difficulty
in sampling blood from the line may suggest a
predisposition to arterial spasm or clot formation and
the line should be removed to prevent an ischemic
injury from occurring.
5. Extravasation Injuries

• This risk can be reduced by ensuring that the cannula
is carefully sited using tributaries of the cephalic and
basilic veins on the dorsum of the hand, the dorsal
venous arch and the medial and lateral marginal veins
in the foot.

• Scalp veins should be used only as a last resort as
shaving off the hair around the area is necessary and
Cannula are difficult to secure (Blatz and Paes, 1990).29

• Although the median lifespan of an IV Cannula in
neonates is 36 hours (Hecker et al, 1991),30 the tip may
become obstructed by fibrin or thrombin, especially if left
in place for too long. Therefore, lines should be checked
for signs of leakage, dislodgement, swelling, edema or
blanching at least hourly, so that the practitioner is able
to respond quickly to any reduction in patency (Bravery,
1999).31

• Although there is no consensus on best practice for
extravasation wound treatment, experts recommend
application of hydrogels covered with silicone
dressings, applying a hydrogel filled glove or boot to
the affected site or using a hydrofiber covered by a thin
hydrocolloid.

• The periwound skin can be protected against maceration
through use of an alcohol-free liquid skin barrier in
neonates >30 days of age. If necrotic tissue is present,
surgical consultation should be obtained, coupled with
use of auto lytic debridement.
6. Pressure wounds

• Programme for repositioning babies should be deve­
loped to prevent pressure ulcers or ischemic injuries
occurring.

• Pressure-reducing surfaces that are suitable for
incubators will reduce the risk further. These include
gel/viscous fluid pads, air-filled mattresses and pressure-
redistributing foam mattresses (Lund, 1999).12

• Pressure ulcers may also be avoided by making sure that
infants are not lying on tubing and by using IV Cannula
that do not have wings.

• Saturation probes should be repositioned every three to
four hours, or more frequently for very preterm babies
(National Association for Neonatal Nurses, 1997)

• If the baby is receiving nasal continuous positive airway
pressure (CPAP), care must be taken to ensure that the
nasal prongs fit correctly and that the pressure under the
prongs is relieved on a regular basis, otherwise damage
may occur to the nasal septum (Glynn, 2004).32 There
are no set recommendations for the frequency with
which this must be done, so it should be performed on
an individual basis.

• Babies may become edematous postdelivery, and
clothing or tapes must be loosened if this occurs, to
reduce the risk of pressure ulcers developing.
7. Excoriation

• If colonization by C. albicans is suspected then a skin
swab should be taken and antifungal therapy given
while waiting for swab results. Topical and enteral
nystatin therapy should be prescribed and continued
until there are two clear swabs. If the initial swab is
negative, therapy can be discontinued immediately.

• Nappies should be changed frequently (every 4–6 hours)
and the skin gently cleansed with warm water only;
wipes are not necessary, as they expose the preterm
infant to unnecessary chemicals, but may be used in an
older infant.

• Alkaline soaps or perfumed baby bath products should
be avoided for the first few weeks of a preterm infant’s
life; because the skin’s protective acid mantle will not
yet be developed, making it vulnerable to pH alteration
by these products, leaving it more prone to bacterial

Issues in Neonatal Wound ­Management 
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395
colonization. The products also contain dyes and
perfumes that may irritate the skin (NANN, 1997).33

• A layer of hydrocolloid or zinc paste, or nappy cream
will serve as an effective barrier to protect the injured
skin. However, if too thick a layer is applied then it may
interfere with the absorptive properties of the nappy,
leading to maceration of the skin as the urine will not be
absorbed into the nappy. Skin barrier films can also be
used but care must be taken regarding the potential for
absorption of the product and the possible consequences
due to toxicity. If the baby’s condition is very unstable
then handling should be reduced to a minimum and all
care given at one time, depending on the policy of the
neonatal unit.
8. Surgical Wounds

• Surgical wounds in neonates are often closed
subcutaneously (with no external sutures) or sutured and
covered with a film dressing so the wound site is visible.
It is important that these wounds are viewed with each
set of care procedures for signs of infection (such as
redness, swelling, increased exudates or presence of
pus) that can prevent the wound from healing, and all
assessments documented appropriately.

• Film dressings can be left in place for seven days to
reduce the potential for infection, although advice from
the appropriate surgical team and/or tissue viability
or medical teams should be followed, alongside
manufacturers’ recommendations.
9. Congenital Wounds

• The wounds should be dressed with appropriate non-
adherent material but care must be taken because
many dressings described by the manufacturer as ‘non-
adherent’ behave differently on those affected by EB
(Epidermolysis bullosa).

• Products that bond to the skin, such as adhesive
dressings or tapes, must be avoided and cardiac and
oxygen saturation monitors fixed in place with a non-
adherent dressing to prevent skin injury.

• In particular, soft silicone dressings can be useful as a
tape for patients with EB. However, if bonding does
occur, the adhesive can be dissolved using a greasy
emollient white soft paraffin (WSP) and liquid paraffin
(LP) 50:50 mixture, applied liberally over the dressing/
tape and worked underneath, to allow the dressing/tape
to be removed without damaging the skin.

• Humidity and heat can increase the rate of blistering in
those with EB and blisters must be immediately lanced
or aspirated using a hypodermic needle.

• It is also recommended that clothing is turned inside out
to avoid seams rubbing on the skin; alternatively, flat
seamed garments can be used.

• Affected infants should be nursed in a cot rather than an
incubator, unless medically indicated for reasons such
as prematurity.

• Friction and adherence of nappies can cause excoriation
in those with EB, but this can be avoided by cleaning
the skin with WSP/LP 50:50 and lining the nappy with
soft material, the easiest being a commercial nappy liner
that overlaps the edges of the nappy.

• Periumblical trauma to the skin can occur from a cord
clamp in babies with EB. In order to avoid this, the
clamp should be removed and replaced with a ligature.
Best practice at dressing
­changes
Choice of Dressing
Ideally, any wound dressing used on a neonate should be
able to protect the wound while being atraumatic, i.e. prevent
trauma and pain to the wound or surrounding skin on removal.
Painful stimuli can be avoided by choosing dressings that are
easy to apply, do not need to be changed too frequently and
promote wound healing. Where appropriate, the dressing
should be cut to the correct size of the wound to prevent it
coming into contact with the surrounding skin; however,
in a humidified environment, there may be problems with
dressings staying in place. Non-interactive dressing products,
such as soft silicone wound contact layers or hydrocolloids,
hydrogels, foams and semipermeable films, are routinely used.
Dressings that create a moist wound-healing environment
encourage autolytic debridement (Miller, 2000).34 However,
if surgical debridement is required, it must be performed
in a controlled environment by an appropriately qualified
person; for this group of patients a surgeon usually carries out
this procedure. There is limited research-based evidence to
guide the selection of the most suitable products and so it is
important to liaise with the tissue viability team, refer to local
wound management guidelines and contact other neonatal
units to ascertain their practices.
Various types of dressings available are mentioned below:

Silicone dressings: Silicone dressings are available as
contact layers, absorbents, antimicrobials, exudates transfer
rants, gel sheets for scar management, and as fixation tapes.
They are commonly used in neonatal and pediatric wound
management because they are versatile and lack adhesives.
Their use should be avoided in patients with known silicone
allergy.

Nonalcohol-based liquid barrier films: Nonalcohol-based
liquid barrier films are applied to the skin to prevent epidermal
stripping secondary to adhesive removal and to protect against
chemical erosion from wound fluid.

Types of Wounds and their Management
Section 3
396

Hydrocolloids: The neonatal and pediatric literature35-38
contains multiple references to the successful use of
hydrocolloids in maintaining wound bed moisture, providing
autolytic debridement, and providing a waterproof and
bacterial barrier, as well as a barrier for other adhesives.

Specific benefits provided by thin hydrocolloids in the
treatment of neonatal and pediatric wounds include prevention
of tissue damage, reduction of epidermal water loss, allowance
of full limb range-of-motion, easy application to small body
surfaces, sterile dressing delivery, suitability for use in
incubators/humidified environments, and provision of a barrier
to viral and bacterial transmission.

Hydrogels: Hydrogels are available in two basic forms—
solid sheet and amorphous gels. The primary components
are crosslinked polymers and water. Neonatal and pediatric
case studies describe use of hydrogels in the management of
toxic epidermal necrolysis, wound dehiscence, Extravasation
injuries, pressure ulcers, fungating lesions, and burns.39,40

Foam dressings: Foam dressings are polymeric materials
with hydrophilic contact layers and hydrophobic outer layers.
These dressings vary in thickness and may be impregnated
with surfactants, glycerin, charcoal, or silver. Anecdotal
pediatric case studies document successful use of these
products.

Composite dressings: Composite dressings are multilayered
superabsorbent dressings designed for the management of
moderate to heavily draining wounds.

Semipermeable films: Semipermeable films are versatile,
transparent, thin, polyurethane moisture-vapor permeable
dressings designed to maintain a moist environment. These
dressings facilitate epithelialization of minimally exuding
partial-thickness wounds and provide autolysis of non-
infected wounds. Film dressings also can be used to secure
primary dressings while promoting a moist environment.

Hydrofiber dressings: Hydrofiber dressings are composed
of carboxymethylcellulose hydrofibers. Highly absorbent,
these dressings transform into solid sheet gels once in contact
with fluid. Anecdotal success has been reported in pediatric
case studies.

Negative pressure wound therapy: Negative pressure
wound therapy involves application of sterile hydrophobic,
open-pore reticulated polyurethane foam or hydrophilic,
polyvinyl alcohol foam dressings (KCI, San Antonio, Tex) cut
to the appropriate wound geometry, covered with a transparent
film drape, and fitted with a TRAC® Pad (KCI) attached to
a computerized, calibrated microprocessor unit to deliver
controlled NPWT. Patient age, exposed structures within the
wound, bacterial load, and treatment goals influence selection
of dressing type, pressure setting, dressing change frequency,
and use of interposing layer(s). A clinical series of 51 children
with acute and chronic wounds successfully treated with
NPWT was reported by Caniano et al.41

Alginates: Alginates are seaweed-based dressings designed
for the management of moderately draining wounds. In adults,
these dressings usually are used to control light bleeding;
this has not been studied in the pediatric patient population.
Calcium alginates are not recommended for use in neonates
secondary to calcium absorption concerns.16,42

Topical enzymes: While the safety and efficacy of topical
enzymes in the pediatric population has not been studied,
successful use in the management of pediatric burns and
extravasation injuries has been anecdotally reported.43
Although not specifically contraindicated, topical enzyme
preparations have not been tested for safety or efficacy in the
neonatal populations. The manufacturer’s recommended use
of these drugs is only for persons >18 years of age.7
Dressing Procedure
Ideally, two people should assist during dressing changes for
neonates, one to contain and comfort the baby, and one to change
the dressing. Dressing changes should be kept to a minimum
and tapes or dressings only removed when necessary. Stress to
the infant during the dressing procedure can be reduced further
by minimizing noise levels, and avoiding bright lighting and
too much handling. No equipment should be placed on top of
the incubator, even when space is limited, because of noise
transmission (American Academy of Pediatrics, 1997).43

The dressing should be prepared before uncovering the
baby in order to minimize the length of time that the wound
is exposed as well as the baby undressed or uncovered. This
is for thermoregulatory reasons and to minimize stress. If the
wound requires irrigation, use warm and not cold fluids because
these will reduce the temperature of the wound bed and, as a
result, polymorphic and macrophagic activity will cease until
the temperature increases again. Nursing staff should conform
to the principles of aseptic technique during all dressing
procedures to prevent cross contamination (Figures 10A and B).
Pain Assessment and Management
The assessment of the baby’s pain is based on behavioral
characteristics, including crying, facial expressions, motor
responses, body posture, activity, restlessness or undue quietness
(Royal College of Nursing, 2002). Although various tools have
been developed to assist in this process, it is important that they
are not used in isolation (Royal College of Nursing, 2002).
Assessment must also include consideration of the infant’s
overall clinical condition, gestational age, the environment and
the views of the parents (Royal College of Nursing, 2002).

Treatment of acute pain or pain with short duration
can include nonpharmacological interventions such as
containment, non-nutritive sucking or the use of pacifiers,
along with sucrose. However, pain from skin injuries or wounds

Issues in Neonatal Wound ­Management 
Chapter 34
397
will not be relieved by these methods and pharmacological
preparations may be required, such as paracetamol (Choonara,
1992)44 or opioids (Anand, 2001).45 Treatment of pain is a
vast subject that is beyond the scope of this chapter, so it is
recommended that readers should refer to local policies and
guidelines.
Communication with Parents
Parents may feel guilty or anxious that their baby has been
born prematurely or that the baby might be in pain. They
may need reassurance that the appropriate treatment is being
carried out. It is therefore important to identify their level of
understanding and how much they want to know about their
baby’s wound. Parents should be encouraged to be involved in
their baby’s care if they wish. If a dressing is to be left in place
for up to a week, then the rationale needs to be explained,
as the parent may be accustomed to everything else being
changed at least daily.
Documentation
It is important that all wound care objectives and management
plans are documented, and details of the wound assessment
recorded, including:
• The type of wound
• The position of the wound
• Wound dimensions (length, width and depth)
• The nature of the wound bed
• The condition of surrounding skin
• Exudate level
• Color and consistency
• Presence of odor and infection
• Level of pain (Bale and Morison, 1998).
Conclusion
Skin and wound complications are a source of morbidity in
neonates and the appropriate prevention and management
of pain are central to the care of these vulnerable infants.
Minimizing trauma and pain at wound dressing changes
therefore must be considered as a key component of healthcare
provided to neonates. Adult-based wound care practices
provide a rudimentary foundation for neonatal and pediatric
wound care but do not negate the need for developmentally
specific evidence-based guidelines. Most currently available
guidelines and information are based on expert opinions and
case studies. This chapter has combined the experience of
specialist practitioners in neonatal care and in wound care to
provide practical guidance on how to preserve skin integrity
in neonates where possible and how to minimize trauma and
pain during wound care procedures.
References
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2. Eichen Field L, Hardaway C. Neonatology dermatology. Curr
Opin Pediatr. 1999;11(5):471-4.
3. Campbell JM, Banta-Wright SA. Neonatal skin disorders:
a review of selected dermatologic abnormalities. J Perinat
Neonat Nurs. 2000;14(1):63-83.
Figures 10A and B: Baby with birth injury (Laceration over face) due to forceps, managed
with Dermabond dressing (suture less, tissue adhesive)
A
b

Types of Wounds and their Management
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4. Bale S, Jones V. Caring for children with wounds. J Wound
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5. Garvin G.Wound healing in pediatrics. Nurs Clin North Am.
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6. Wysocki AB. Anatomy and physiology of skin and soft tissue.
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care: minimizing trauma and pain. April 2004. Molnlycke
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8. Baharestani MM, Pope E. Chronic wounds in neonates
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in neonatal burns. Burns. 2005;31(7):878-82.
10. Keener KE. The surgical neonate. In: Wise BV, McKenna
C, Garvin G, Harmon BJ, eds. Nursing Care of the General
Pediatric Surgical Patient. Gaithersburg, Md: Aspen Publishers,
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11. Irving V. Neonatal iatrogenic skin injuries: anursing per
spective. J Neonatal Nurs. 1999;5(5):10-3.
12. Lund CH, Tucker JA. Adhesion and newborn skin. In: Hoath
SB, Maibach, HI, eds. Neonatal Skin Structure and Function,
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13. Issues in neonatal wound care: Minimizing trauma and pain,
Independent Advisory Group Mölnlycke Health Care Wound
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14. Val Irving, Elaine Bethell, Fiona Burton, et al. Neonatal wound
care. Clinical Practice Development Wounds UK, 2006,Vol 2(1).
15. Irving V. Caring for and protecting the skin of pre-term
neonates. J Wound Care. 2001a;10(7):253-6.
16. Gunderson L, Kenner C (1995). Care of the 24 and 25 week
gestational age infant: a small babyprotocol (2nd edn). NICU
Ink, Petaluma (CA).
17. Harpin V, Rutter N. Percutaneous alcohol absorption and skin
necrosis in a preterm infant. Archives of Disease in Childhood.
1982;57:477-9.
18. Watkins A, Keogh E. Alcohol burns in the neonate. Journal of
Pediatric and Child Health. 1992;28:306-8.
19. Lund C. Prevention and management of infant skin breakdown.
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20. Blatz S, Paes B. Intravenous infusion by superficial vein in the
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21. Hecker J. Survival of neonatal intravenous infusion sites. The
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22. Boiko S. Making rash decisions in the diaper area. Pediatric
Annals. 2000;29(1):50-6.
23. Black J, Bahrestani MM, Cuddigan J, et al. National Pressure
Ulcer Advisory Panel’s updated staging system. Adv Skin
Wound Care. 2007; In press
24. Flemmer L, Chan J. A pediatric protocol for management of
Extravasation injuries. Pediatr Nurs. 1993;19(4):355-58,424
25. Noonan C, Quigley S, Curl ey MAQ. Skin integrity in
hospitalized infants and children—a prevalence survey. J Ped
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27. Linder N, Davidovitch N, Reichman B, et al. Topical iodine-
containing antiseptics and subclinical hypothyroidism in
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the best treatment available? Int Wound J. 2007;4(1):15-9.
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32. Glynn G. A low technology type of device for nasal CPAP.
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National Association Neonatal Nurses, California.
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34. Miller M (2000). Moist wound healing. In: Essential Wound
Healing, Part 1. EMAP Healthcare, London.
35. Association of Women’s Health, Obstetric and Neonatal
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clinical practice guideline. Washington, DC: Association of
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January 2001.
36. Lund C. Prevention and management of infant skin breakdown.
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37. Quigley SM, Curly MAQ. Skin integrity in the pediatric
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of extravasation injury in neonates. Available at: www.
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40. McCord S, Bookout K, McLane K, Helmrath M. Use of
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44. Choonara I. Management of pain in newborn infants. Seminars
in Perinatology. 1992;16(1):32-40.
45. Anand KJ, International Evidence-Based Group for Neonatal
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of pain in the newborn. Arch Pediatr Adolesc Med. 2001;
155(2):173-80.

Miscellaneous
Section

• The Physical Basis of RNPT

– Suction Forces

– Reversal of Lymphatic Flow

– Topical Pressure

– Shearing Forces

– Modifi cation of Wound Atmospheric Composition
• Clinical Applications of RNPT and RO-NPT

– Indications

– Contraindications
• Suction Forces and Acute Bleeding
• Clinical Applications of RNPT and RO-NPT—
Case Presentations
INTRODUCTION
Wound healing is a complex process involving many potential
mechanisms and variables that are controlled in an orchestrated
healing process. The etiology of injury, dimension of damage, type
of wound—whether acute or chronic non-healing, infl ammatory
response, location, tissue perfusion, hypoxia reperfusion state,
wound milieu, as well as the overall patient condition (just to
mention a partial list), infl uence healing at molecular, cellular,
and tissue levels. The healing of a wound requires integration
of intricate biological events during sequential—at times
overlapping or stagnated phases of coagulation, infl ammation,
cell migration, proliferation, and extracellular matrix deposition
and remodeling. These phases may be further infl uenced by
extrinsic factors such as local level of contamination–bacterial
burden, bacterial colonization, composition and form, infection,
metabolic environmental conditions, local mechanical forces,
temperature, wound, overlying atmospheric composition, and
means of systemic and/or topical treatment.

Wound infection is a major impediment to healing. All
chronic wounds are colonized by bacteria, often without
systemic clinical manifestation and signifi cance, when a low
level of bacteria is involved; yet infection may play a signifi cant
role in wound healing when high level bacterial counts subsist
with deep invasion. Host-microbial interactions determine
the progression of colonization to tissue invasion, infection,
local damage, septicemia, and sepsis. Diverse microbial
fl ora invade the wound bed of chronic nonhealing wounds,
initially, gram-positive skin contaminants and gradually
changing to various pathogenic species including aerobic
gram-negative rods as well as anaerobic bacteria, some in
complex communities of aggregated bacteria embedded in an
extracellular polymeric matrix of polysaccharides, forming a
barrier defi ned as biofi lm. Biofi lm contributes to a signifi cant
increase in bacterial resistance to host defense mechanisms
and antibiotic treatment compared with their planktonic state.

Chronicity of wounds is associated with colonization;
higher bacterial counts; production of biofi lm, endo- and exo-
toxins that lead to extended elevation of pro-infl ammatory
cytokines such as IL-1 and TNF-α; and an increase in matrix
metalloproteinases and a decrease in production of growth
factors (GF).

The introduction of antisepsis techniques and antibiotics has
dramatically changed the course of wound healing. Still, with
advancements in technologies, traffi c congestion of high-speed
methods of transportation, enhanced capacity of destructive
weaponry, extension of life-expectancy, excessive use of
antibiotics, and increase in chronic diseases, wound-healing is
of even more substantial global, medical, and fi nancial impact.
Any signifi cant enhancement in wound healing will lead to a
major improvement in health on a global scale.
Moris Topaz
Role of Regulated Negative
Pressure Therapy in
Wound Healing
35
Chapter

Miscellaneous
402

Regulated negative pressure-assisted wound therapy
(RNPT) utilizes sub-atmospheric pressure (vacuum, negative
pressure) to promote and optimize the environment for wound
healing. This physical, non-pharmaceutical technology applies
regulated sub-atmospheric pressure to the wound, infl icting a
variety of phenomena with the desired end point of enhanced
healing of hard-to-cure, acute and chronic wounds. Through
multiple publications on its clinical applications during the
last decade, RNPT has been established as an important
technology, which has been developed and practiced to
enhance wound healing.1

At the core of RNPT, it is the application of negative
pressure, generated by a pump presided over by a computerized
regulated control that determines through modulation of basic
functions of the pump modes of pressure that are being applied
to the wound. Negative pressure is directed through tubing to a
fl exible mold with porosity in the range of 100–600 µm, covering
or embedded in the wound. The multi-porous, compressible
mold is sealed by an air-tight sealed drape, isolating the wound
from the atmosphere above, and applying near—uniform sub-
atmospheric pressure to the entire surrounding wound area,
serving as an ideal drainage system (Figure 1).

Indications for RNPT have widened during the last decade
and now include:

• Chronic wounds

• Wounds in diabetic and PVD-affected limbs

• Decubitus ulcers

• Dehisced and infected surgical wounds

• Traumatic wounds

• Deep and partial—thickness small—to—medium size
burns

• Treatment of skin grafts and fl aps.

When properly applied, RNPT is relatively simple, safe,
and effective tool that can be utilized under a wide range of
conditions, without the need for sophisticated technologies
or elaborate surgery and as a means to reduce antibiotic
usage. Although in clinical practice for over two decades,
the basic mechanisms of action have not been fully clarifi ed.
Nonetheless, it is mandatory to improve this technology and
lessen potential risks by better understanding the scientifi c
basis of its mechanisms through thorough basic science
research, observant clinical application, analysis of patient-
risk factors, and careful determination of contraindications for
certain clinical conditions and wound types.
THE PHYSICAL BASIS OF RNPT
Regulated negative pressure-assisted wound therapy (RNPT)
affects tissue through multiple, at times confl icting, physical
effects:
1. Suction forces
2. Topical pressure

3. Shearing forces

4. Modifi cation of wound’s atmospheric composition.

The combined mechanisms lead to complex environmental,
physical, chemical and biological conditions that affect
and determine wound healing. These physical mechanisms
will be reviewed in an integrated manner with emphasis on
their implications on various clinical conditions. Several
mechanisms that were previously suggested for RNPT–tissue
interactions will be disputed and contradicted, and alternative
mechanisms will be suggested, based on new data revealed
through laboratory research and careful clinical evaluation of
many patients treated by RNPT for various applications.
Suction Forces
Regulated negative pressure-assisted wound therapy (RNPT)
creates a pressure gradient between the sealed wound and its
covering atmosphere.

Suction forces applied into the wound cavity have been
classically reported to:

i. Induce granulation tissue formation
ii. Evacuate wound fl uids and decompress tissue edema
iii. Reduce bacterial count.
Induction of Granulation Tissue Formation
The most prominent reported effect of RNPT is the rapid
growth of granulation tissue inside the wound. RNPT was
Figure 1: Illustration of RNPT system setup: sub-atmospheric pressure
is generated by a pump, regulated by computerized predetermined
controls, and directed through tubing extension to a porous fl exible
mold covering the wound. The multi-porous compressible mold is
sealed air-tight by a drape applying an even negative pressure to the
wound

Role of Regulated Negative Pressure Therapy in Wound Healing
403
reported to induce and accelerate granulation tissue formation
in porcine and rabbit wound models.2,3 Studies by Morykwas
et al (2006) and Chen et al (2005) showed that applied vacuum
resulted in increased local perfusion in swine and rabbit as
measured by laser Doppler. The studies showed changes in
blood fl ow during wound healing.4,5 Studies examining the
rate of granulation tissue formation in swine wounds showed
that the 125 mm Hg pressure-treated wound fi lled with
granulation tissue signifi cantly faster than 25 mm Hg and 500
mm Hg treated wounds.6

Chen et al evaluated the effect of RNPT on granulation tissue
formation in a rabbit model by removing a full thickness of skin
from the back of the ear.7 It was demonstrated in the RNPT-
treated group that granulation tissue began to structure three
days after the wound was formed. Migration of epithelium to
close the wound was observed, along with neogenetic vessels,
followed by marked fi broblast proliferation and copious
extracellular matrix on day six, and completes healing on day
nine. Control groups had lower rates of healing.
Evacuation of Wound Fluids and Decompression
of Tissue Edema
There have been several studies comparing levels of various
soluble mediators in fl uid removed from vacuum- and non-
vacuum-treated wounds. The variations measured (e.g. timing
of sample collection, removal of fl uid with promoting and
inhibiting soluble factors that may affect measurements) were
too wide-ranging and provided confl icting and inconclusive
results.8

Several studies showed that removal of pathologic soluble
elements due to envenomation or extravasation by locally
applied vacuum limited the extent of tissue damage. Effects
of applied vacuum in preventing doxorubicin extravasation
ulcers showed lower incidence of ulcer formation for vacuum-
treated wounds. RNPT can be used in treatment of snake and
insect bites. Further research is suggested.9

Crush injuries, complex fractures, acute vascular ischemia,
and deep burns may be associated with self-perpetuating
infl ammatory response, soft tissue edema, and increased
interstitial pressure. The integrity of the capillary basement
membrane of blood vessels is damaged during wounding,
leading to increased permeability of capillaries and edema,
followed by decreased peripheral perfusion and ischemia as
characterized in compartment syndrome. Chen et al. reported
restoration of the integrity of the basement membrane and
narrowing of the endothelial spaces following RNPT.10 RNPT
may have a role in the treatment of small and medium size,
deep burns by decongestion of edema in the zone of stasis,
thereby improving the chance for recovery of tissue in the zone
of stasis. RNPT can be applied in conjunction with surgical
decompression of compartment syndrome and can be applied
directly on the fasciotomy wounds to further decompress the
limb by sucking fl uid and assisting in decompression of the
internal tension.
Reduced Bacterial Count
Bacterial clearance was claimed to result from a decrease
in wound surface area in vacuum-treated wounds. Case
reports also showed a signifi cant decrease in nonfermentive
gram-negative rods (e.g. Pseudomonas) in biopsy specimens
harvested from vacuum-treated wounds.11 In a study by
Wagner et al examining growth factor levels in acute and
infl amed wounds, case reports showed positive smear cultures
in infl amed wounds before vacuum treatment but, negative
smear cultures during vacuum treatment.12
Reversal of Lymphatic Flow
The effect of negative pressure on tissue lymphatic fl ow was
demonstrated in our laboratory in yet, unpublished data in a
rabbit model by subcutaneous injection of methylene blue
at various distances from the wound edges and evaluating
the lymphatic fl ow distribution pattern (Figures 2A to F).
A distortion from the regular elliptical pattern of lymphatic
fl ow towards regional lymph nodes was demonstrated by the
application of suction into the wound. Dye injected in close
approximation to the wound’s margins was shown to reverse
the fl ow pattern and shift towards the wound, indicating
a reversal of lymphatic fl ow from the surroundings of the
wound towards the suction, low pressure source.

This basic mechanism of reversal of lymphatic fl ow
induced by suction forces during RNPT action may be added
as a fundamental mechanism of suction forces affecting wound
healing. It also should be considered of signifi cant clinical
value, elucidating the mechanism of bacterial clearance from
the wound and main reason for the reduced need for antibiotic
treatment associated with RNPT.

Suction forces applied into the wound cavity thus mainly
affect tissue through a cascade of mechanisms by:

i. Reversal of lymphatic fl ow
ii. Reduction of bacterial count
iii. Evacuation of wound fl uids and decompression of tissue
edema
iv. Induction of granulation tissue formation.
Topical Pressure
Application of sub-atmospheric pressure through a mold to the
wound was shown, by laser Doppler measurements, to result
in immediate increase in tissue perfusion and was claimed to

Miscellaneous
404
be an important factor accounting for the favorable effects of
RNPT.13,14

This hypothesis was questioned and challenged by our as-yet
unpublished laboratory fi ndings of the topical (compression)
pressure infl icted on tissue beneath circumferential and non-
circumferential RNPT dressings of both a live leg and an
artifi cial lower limb model, simulating clinical application
of RNPT. We detected a near-linear rise of topical pressure
beneath the dressings, by increasing negative pressure of
RNPT (Figure 3). In vivo, experimental measurements of
topical pressure underneath circumferential dressings of the
lower limbs of volunteers were carried out up to the range
of 250 to 300 mm Hg, where topical pressure was infl icting
hard-to-bear pain. Measurements of an artifi cial limb model
correlated well with in vivo measurements and were carried up
to 550 mm Hg by a wall suction negative pressure infl icting
topical pressure beneath the dressings. These fi ndings should
contradict the reported increase of blood fl ow in wounds
treated by RNPT and suggest the relative reduced perfusion
that may lead to local ischemia infl icted by the topical pressure
underneath the circumferential RNPT dressing.

The actual pressure under RNPT system, dressings may be
further determined by tissue plasticity, underlying skeleton
structure, presence of foreign bodies and their pliability, as
well as the physical characteristics of the mold.

Kairinos et al have also challenged previous reports
claiming increased blood fl ow by RNPT based on Doppler
measurements. They suggest that the application of negative
pressure to the wound may, initially, partially, occlude the
underlying compressible vessels with the compensating
increase in blood velocity in the wound’s capillaries,
misinterpreted by laser Doppler readings as “increased
perfusion.” This phase of increased velocity is followed by
total occlusion of blood vessels and cessation of blood fl ow
through direct topical compression as the topical pressure
infl icted by RNPT dressing is further increased. Kairinos et
al therefore, suggested that laser Doppler is unsuitable for
measurements of tissue perfusion in RNPT.15

This positive compression pressure infl icted on tissues
by circumferential and topical RNPT dressings may be of
considerable, and at times of critical, clinical signifi cance
in patients with predisposed peripheral vascular disease,
with reduced (below 0.5) ankle-brachial ratio and low tissue
perfusion pressure, as well as in treatment of damaged tissue
with compromised blood circulation due to trauma. In these
situations, even the application of RNPT in the range of
100 to 125 mm Hg may lead to excessive topical pressure,
tissue ischemia, and necrosis. Negative pressure levels and
modes of application of RNPT should be tailored and adjusted
to the specifi c circumstances and patient’s need. Either ankle
Figures 2A to F: Reversal of lymphatic fl ow pattern in experimental RNPT treatment in a rabbit model. (A) Open wound down to the deep
fascia; (B and C) Application of porous mold and suction system to the wound; (D) Multiple sites of methylene blue injection; (E and F)
Reversal of lymphatic fl ow, marked by dye stain shift towards negative pressure area under the mold. Dotted lines in (F) Mark imprint of
mold on the fascia
A
D
B
E
C
F

Role of Regulated Negative Pressure Therapy in Wound Healing
405
blood pressure measurements or Doppler monitoring, while
recognizing their limitations, should precede and monitor
RNPT of ischemia predisposed treated areas. Thus, another
basic mechanism of action of intermittent application of
RNPT is ischemia/reperfusion that is generated by cyclical
pressure on the skin, stimulating wound healing.
Shearing Forces
Continuous application of RNPT generates static pressure on
the underlying tissues that can be utilized to mechanically
stabilize the wound. This method may be applied for fi xation
of skin grafts, stabilization of sternal wounds, and open
fractures.

Intermittent operation of RNPT was reported to improve
wound healing and blood fl ow in animal studies, as well as
in clinical applications, by stimulating angiogenesis and
granulation tissue,16-18 but not providing an explanation for
the mechanism involved.

Chin et al demonstrated in a mouse model, the effect
of a servo-controlled skin-stretching device inducing pre-
determined cyclical stretching forces on skin growth.19 It was
demonstrated that the application of cyclical tensile force
generated transient, alternating hypoxia and reperfusion that
led to accelerated tissue growth. These mechano-transduction
signaling pathways were found to up-regulate epidermal
proliferation, angiogenesis, skin perfusion, and principal
growth factors. The cyclical time that was investigated in their
study was restricted to two minutes of stretching (on) followed
by one minute of relaxation (off). Cyclically stretched skin
led to increased tissue oxygenation, suggesting that cyclical
stimulation may confer increased tissue oxygenation and
improve skin viability. Together with the residual up-
regulation of HIF-1α, these results suggest that hypoxia is
transiently induced during active tension, but reperfusion
occurs when stretching ceases.

Intermittent operation of RNPT imposes cyclical negative
pressure to the mold attached to the underlining wound,
relaying intermittent, cyclical shearing forces to the wound
surface. This directly correlates with the application of
cyclical stretching forces to the wound described by Chin
et al in a mouse model as described above. Thus, one of the
Figure 3: Experimental graphs demonstrating the relations between the negative pressure applied to the wound and the
topical pressure infl icted by circumferential dressing of RNPT underneath the dressings in a simulated lower limb and
artifi cial lower limb wound models. Pressure transducers were located at: (a) Distal lower extremity of healthy volunteers;
(b) Distal artifi cial leg model; (c) In vitro proximal artifi cial leg; (d) In vivo proximal leg. Water-fi lled fl exible pressure gauges
were placed between the skin and the mold to monitor the internal topical pressure induced by the increasing negative
pressure. A near-linear rising of internal pressure beneath the mold was observed. In vivo experiments were carried up to
tolerated pressure levels (250–300 mm Hg) and extended to further higher pressure in the in vitro model (up to -550 mm Hg).
Topical pressure measurements in human limbs and in artifi cial legs correlated well in the treated range

Miscellaneous
406
basic mechanisms that induces wound healing by intermittent
negative pressure may be associated with cyclical stretching
forces on the underlying tissues, generating mechano-
transduction signaling that may induce wound healing.
Investigation of a wider range of waveforms and pressures
may reveal an optimal negative pressure and ratio for
intermittent RNPT mode.
Modifi cation of Wound
Atmospheric Composition
Although RNPT has been applied in clinical practice for
over two decades and extensive data have been published
in recent years attempting to clarify the scientifi c basis of its
mechanisms of action and physiologic effects, an important,
fundamental physical aspect associated with the very basics of
relevant gas laws have been ignored.

Henry’s law of gases, formulated in 1803, states that the
solubility of a given gas in a volume of liquid at a constant
temperature is directly proportional to the partial pressure of
that gas p in the overlying atmosphere in equilibrium with that
liquid. When applied to the solubility of oxygen in water:
pO2 = KO2 CO2

Where pO2 is the partial pressure of oxygen in torr, CO2 is
the mole fraction of oxygen in oxygen-saturated water, and KO2
is the Henry’s law equilibrium constant for oxygen in water.20
Lowering external pressure decreases pO2 in accordance with
Dalton’s Law, reduces the number of molecules per unit gas
volume and subsequently increases the rate of evaporation
from the underlying solution to maintain the equilibrium.

In order to confi rm this hypothesis and to better understand
the physiology of wounds treated with RNPT, an in vitro
experimental model was designed to determine the spectrum
levels of pO2 in the environment of wounds treated with
RNPT and oxygen-enriched RNPT (Figure 4).21

pO2 was measured at various oxygen fl ows and negative
pressure ranges as indicated in clinical applications for wound
treatment. pO2 values were recorded in relative percent units
following calibration of the sensor. Negative pressure was
regulated to the desired pressure levels that could be applied
in clinical cases. Oxygen fl ow was controlled and delivered to
the simulated wound by an oxygen regulator in predetermined
1 L/min fl ow increments in a range of 1 to 10 L/min. Hundred
percent oxygen was administered to the opposite edge of
the vacuum source so that oxygen fl ow was homogeneously
distributed through the sponge cavities in contact with the
wound over the entire wound surface area. pO2 in the wound
atmosphere was continuously monitored by a pO2 detector.
pO2 values in the RNPT investigated system revealed a linear
decrease of pO2 values (Figure 5), in direct correlation with the
Figure 4: Scheme of experimental setup: A phantom leg was used to
simulate RNPT and RO-NPT systems. (A) Circumferential dressing of
leg by a sponge sealed entirely by a drape; (B) Inlet of oxygen fl ow;
(C) Vacuum outfl ow insert; (D) Oxygen monitor; (E) Oxygen sensor at
the vacuum outfl ow
Figure 5: Reduced pO2 values in simulated wound atmosphere at various RNPT vacuum pressure level ranges
(torr below atmospheric pressure) without supplemental oxygen

Role of Regulated Negative Pressure Therapy in Wound Healing
407
sub-atmospheric pressure that was applied to the simulated
wound. Simultaneous administration of oxygen to the system
in the RO-NPT set up increased the pO2 measured under a
clinical range of applied sub-atmospheric pressure in direct
correlation with oxygen infl ow (Figure 6).

Greater oxygen fl ow was needed with concomitant greater
negative pressures to achieve the same pO2 as at lower
negative pressures. pO2 increased in direct correlation with
supplemental oxygen fl ow until reaching a plateau (Figure 6).

Anaerobes proliferate in an oxygen-depleted environment,
can be a major setback to the healing process of various
wounds, becoming a potentially life-threatening risk in severe,
complicated cases such as necrotizing fasciitis (NF).22

Anaerobes cannot grow in the presence of oxygen because
they lack enzymes and antioxidants that can effectively
scavenge intracellular and membranal toxic oxidizing agents.
Numerical data concerning the sensitivity of anaerobic
bacteria to oxygen have suggested that the size of growth-
inhibition zones is directly proportional to the logarithm of
the partial pressure of oxygen used.23,24

Anaerobes are the predominant fraction of normal
human skin and mucous membrane bacterial fl ora, and are
consequently, a common cause of endogenous infection.
Because of their fastidious nature, they are diffi cult to isolate
and are often undetected.25

In a recent study, biofi lms appeared to be more abundant
in chronic wounds, and molecular analysis of the specimens
revealed diverse polymicrobial communities, including strictly
anaerobic bacteria, not revealed by cultures.26

Necrotizing fasciitis (NF) is a life-threatening, rapidly
progressive bacterial infection spreading through the deep
fascial plane, with secondary necrosis of the fascia and
subcutaneous tissues. This deep fascial infection causes
vascular occlusion, ischemia, tissue discoloration, and
necrosis. Superfi cial nerves are damaged, producing the
characteristic localized loss of sensation.27

Once NF is suspected, treatment should be initiated
without delay. Empirically, broad spectrum antibiotics must
be administered immediately. Early, aggressive, and frequent
surgical debridement and exploration of necrotic tissue is
essential, combined with intensive medical care and HBO as
an adjunctive therapy.28 The mortality rate of patients with NF
is in the range of 20 to 30 percent. The strongest prognostic
factor associated with NF is age; patients under the age of 35
years have a signifi cantly lower (0%) mortality rate compared
to mortality (65%) for patients over the age of 70.29 HBO
is considered standard treatment in cases where anaerobic
infection of soft tissue is documented or suspected.24,30

Following tissue injury, three phases of repair mechanisms
are activated: infl ammation, proliferation, and remodeling.
Physiologically, all active processes involved in these phases
are in need of an adequate supply of oxygen.31 Problems with
delayed healing and infection of wounds in most cases are
related to reduced oxygen delivery to the wound tissue.27

Wounds that are well-oxygenated have been shown to
be less likely to become infected. The effect of oxygen
as a therapeutic agent essential for wound healing and its
importance in the defense mechanism against infections has
long been recognized. Destruction by oxidation, oxidative
killing is the most important defense against pathogens and
depends on the oxygen partial pressure in the contaminated
tissue.32 The ability of supplemental O2 to reduce infection is
Figure 6: Measured relative pO2 (in %) and calculated pO2 (in torr) values at various clinically relevant
sub-atmospheric pressures and oxygen fl ows

Miscellaneous
408
mediated by reactive oxygen species generated by NADPH
oxidases in wound neutrophils and macrophages.27

For therapeutic applications, O2 can be given systemically
or be delivered locally to the wound using a topical device.
Systemically administered, O2 relies on the vascular bed to
deliver oxygen to the healing tissue. It is therefore reasonable
to assume that ischemic areas of the wound will not
signifi cantly benefi t from this form of oxygen administration.
These wounds will be more susceptible to infections.27

The concept of topical oxygen therapy as an alternative to
HBO has also been acknowledged. Not only it is potentially
less toxic, it may also be much more accessible and convenient,
less expensive, and have few, if any, complications. Topical
delivery of oxygen can oxygenate the wound directly when
the wound is severed from circulation or when the vascular
bed is impaired.33

The few case reports that relate to the development
of infection associated with RNPT recommend the
discontinuation of RNPT in anaerobic wound infections.34
In order to minimize this complication, it was recommended
to use VAC only on clean healthy wounds, thus limiting the
scope of indications for RNPT. None of the reports, however,
refer to the basic physical laws of gases to substantiate this
recommendation.

A combined, staged treatment using the VAC® system and
HBO was recently studied in a rabbit ear model, evaluating the
signifi cance of consecutive use of sub-atmospheric pressure by
the VAC® system and HBO in an ischemic full thickness wound.
The conclusion of this study was that HBO did not signifi cantly
improve the rate of healing, whereas, the sub-atmospheric
pressure signifi cantly increased the wound healing process.35
This model, however, did not address the simultaneous
combination of these modalities or the treatment of infected
wounds.

The optional advantages of simultaneously joining the two
strategies of supplemental oxygen together with sub-atmospheric
pressure for the combined prevention and treatment of anaerobic
wound infections and the enhancement of wound healing seem
to have signifi cant merit. Laboratory measurements, jointly
with positive wide clinical experience, point to the benefi ts of
enriching the wound atmosphere with oxygen (Figure 4).

In light of the above, those sporadic reports suggesting
treatment of NF with VAC36, 37 should be reassessed. Type 1
NF is an example of an infection involving anaerobic bacteria
in which RNPT is contraindicated, where RO-NPT may be
of imperative clinical signifi cance, making it an alternative
or even at times preferable treatment to intermittent tissue
oxygenation with HBO. Oxygen levels in the wound, treated
with RO-NPT, can be monitored, calculated, and adjusted by
altering oxygen infl ow and/or sub-atmospheric pressure to
attain the desired pO2 level, as seen in Figure 4. These levels of
pO2 may be suffi cient for prevention or inhibition of anaerobic
infection, or treatment of apparent anaerobic infections.

RO-NPT may routinely be applied in NF cases, as
prophylaxis in major trauma injury, in diabetic and PVD
wounds. All anaerobic infections were rapidly terminated with
no need for HBO and no anaerobic infection has developed in
any of the treated cases of RO-NPT in our institution. Even in
severe cases, most of the treated wounds could be healed by
simple surgical procedures such as skin grafts.

The same rationale of hyperbaric oxygen treatment
goes with the synergistic effect of continuous oxygen fl ow,
increasing oxygen partial pressure in the isolated ground
atmosphere of wounds for the treatment of most soft tissue
infections by RO-NPT.
CLINICAL APPLICATIONS
OF RNPT AND RO-NPT
Indications
Regulated negative pressure-assisted wound therapy (RNPT)
was originally applied to enhance healing of chronic wounds
for treatment of diabetic foot and PVD-affected limbs.
Indications have been recently widened to include treatment
of various traumatic wounds, deep and partial-thickness small
to medium size burns, dehisced surgical wounds, and for the
enhancement of skin grafts and fl aps survival.

Treatment of chronic wounds by RNPT includes clinical
conditions such as trophic ulcers, and venostatic, arterial,
diabetic, neuropathic, post irradiation, and pressure sores.
RNPT has been applied for various surgical applications,
including dehiscence of surgical wounds, post-operative
wound infections, and complications of failed sternal closures.

Regulated negative pressure-assisted wound therapy
(RNPT) has been extensively applied in treatment of acute
trauma, in extensive tissue losses, for treatment of open
fractures, and destructive deep burn injuries. There is a
special indication for treatment of RNPT in crush injuries
and compartment syndromes. RO-NPT was designed for the
prevention of anaerobic wound infections and as a supplemental
mode of treatment of apparent anaerobic infections. Currently,
the author is using RO-NPT for most major trauma and skin
defects that are treated with negative pressure.
Contraindications
Regulated negative pressure-assisted wound therapy (RNPT)
is contraindicated in acute uncontrolled bleeding. A meticulous
hemostasis should be established prior to the application of
RNPT. The care provider should ensure that no exposed blood
vessels, nerves, and internal organs are in direct contact with

Role of Regulated Negative Pressure Therapy in Wound Healing
409
the vacuum system. RNPT should be restricted in patients
with open wounds who are treated with anticoagulants.
Ulcerated malignant wounds are contraindicated for treatment
by RNPT as vacuum treatment may accelerate tumor growth
within the wound cavity. RNPT is contraindicated for
treatment of unexplored fi stulas. Exploration of a fi stula and
determinations of its extensions and content should precede
RNPT application. As mentioned above, the use of RNPT is
contraindicated in apparent anaerobic infection, where RO-
NPT should be applied.

The care provider should never leave a wound covered
for an extended time without effective negative pressure.
Constant effi cient negative pressure should be applied to
the wound in order to avoid bacterial overgrowth and super-
infection.

RNPT should be restricted to small and medium size burns
as treatment of wide deep and partial-thickness burns may lead
to extensive extracellular fl uid loss and electrolyte imbalance
by the applied suction.

Osteomyelitis was considered to be contraindicated for
RNPT treatment with no apparent reasoning. The author has
substantial experience treating these conditions with RNPT
and RO-NPT with signifi cant success (see representative
clinical case 1 to 15 at the end of this chapter).
SUCTION FORCES AND ACUTE BLEEDING
Negative pressure has not infrequently been applied to the
wound by direct connection to wall suction or portable non-
dedicated suction machines, devices regulating vacuum levels
of suction only (Figures 7A and B).

By these methods, the wound may be exposed to continuous
negative pressures of 300 mm Hg and greater, with limited
or no regulation of negative pressure and no alarm systems,
alluding to various important physiological consequences with
potential catastrophic outcome of uncontrolled, undetected
bleeding, into a typically large volume canisters. In November
2009, the FDA issued a preliminary Public Health Notifi cation
of serious complications associated with negative pressure
wound therapy systems.38 In its notifi cation, healthcare
practitioners were alerted to deaths and serious complications,
especially bleeding and infections, associated with the use of
Negative Pressure Wound Therapy (NPWT) systems, and were
provided with recommendations to reduce the risk. Although
rare, these complications can occur wherever NPWT systems
are used, including acute and long-term healthcare facilities
and at home. In its preliminary notifi cation, the FDA reported
six deaths and 77 injuries associated with NPWT systems over
a period of two years prior to the notifi cation. This catastrophic,
yet expected complication should have been anticipated to
occur with any negative pressure system that is applied to the
wound. It would be logically anticipated that the greater the
vacuum applied to the wound the greater the risk of bleeding.
Bleeding should be anticipated when treating post-traumatic,
post-operative, recently debrided wounds in RNPT and RO-
NPT systems applied on exposed organs or vessels and in
patients with compromised coagulation systems (patients
treated with anticoagulants or patients with clotting disorders).
Strict measures should be taken in order to avoid uncontrolled
bleeding. Evaluation of risk/benefi t should precede RNPT.
Meticulous hemostasis should be confi rmed with continuous
monitoring of the patient’s hemodynamic status. The minimal
effective negative pressure that would be clinically benefi cial
should be applied. RNPT systems should incorporate systems
that would indicate active bleeding with immediate cessation
of suction and arouse instant audio-visual alarms to alert both
care provider and patient of possible active bleeding.
Recommended Vacuum Pressure, Level Range,
Span, Frequency of Operation, Mode and
Exchange of Dressing in RNPT
Vacuum pressure in RNPT should be tailored to each specifi c
wound and adjusted according to patient’s clinical condition.
Greater negative pressure should be strictly avoided during
the early stage of trauma treatment. Severe, life-threatening
bleeding may result from the application of RNPT in treatment
of acute trauma, immediately after surgery, and at early stages,
following debridement of wounds.

The past determination and recommendation of 125
mm Hg as the suggested ideal negative pressure should be
regarded as obsolete and ignored. A higher range of negative
pressures should be regarded as an ischemia-inducing setting
that may aggravate clinical ischemic conditions such as in
Figures 7A and B: Types of suction applied for NPT (A) Wall suction;
(B) Portable suction
A
B

Miscellaneous
410
peripheral vascular disease, diabetic leg, and traumatized
tissue. Excessive topical pressure may lead to compromised
blood circulation and impairment of wound healing. We have
been applying lower negative pressure in the range of 60 to
80 mm Hg in the intermittent mode, for routine treatment
of diabetic foot and PVD-induced limb ulcerations. Patients
with an ankle-brachial ratio less than 0.5 should be treated
with the lowest effective negative pressure and should be
closely monitored for distal perfusion impairment, mainly
when having circumferential RNPT dressing. Higher levels
of negative pressure (deeper vacuum) may be needed for
the initial treatment of heavily contaminated wounds. Tissue
ischemia can be managed and avoided by short term higher
negative pressure values applied in an intermittent mode.

The clinically based range of recommended vacuum
pressure for various conditions is presented in Table 1. The
practicing physician should recognize the need for specifi c
settings for vacuum work/pause ratio and the frequency of
Table 1: Guidelines for clinical application of RNPT*.
Intended use –
type of wound
Pressure
range
(mm Hg)
Rate of
dressing
change
(every- x
days)
Operation mode
frequency range
(on/off min)
Remarks*
Trauma
Acute phase
40-60
1–2
2–3/1–2
Stop active bleeding before starting RNPT treatment.
Watch for active bleeding. Do not apply on blood vessels
or internal organs. Apply lowest pressure possible in range.
Increase pressure and frequency of dressing change for
treatment of infected traumatic wounds. Apply non-adhesive
antimicrobial dressing to the wound below the sponge.
Intermittent mode is preferable.
Stable
condition
70–120
2–4
3–5/1–3
Chronic wounds
Decubitus
ulcers
70-120
2–4
3–4/1–2
Conservatively debride necrotic tissue prior to application of
RNPT. Start treatment with greater vacuum in intermittent
mode when wounds are heavily infected. Reduce pressure
as the wound becomes cleaner. Consider combined
systemic antibiotic treatment.
Peripheral vascular disease, diabetic foot
Chronic
50–70
2–5
Correlate RNPT with measured Ankle-brachial pressure
ratio. Use lowest pressure possible in range. Extremely
greater negative pressure (140–100 mm Hg) may be
applied for a few days for treating heavily infected wounds,
applying a 2/1 ratio of intermittent mode and frequent
dressing changes. Reduce pressure as soon as the wound
becomes cleaner. Evaluate distal perfusion.
Acute
60–90
(intermittent
use only!)
1–2
1/3, 1/2
Burns
Burns
60–80
2–4
3–5/1–2
Limit application to small to medium sized deep burns. Limit
surface area to be treated according to the amount of fl uid
discharge from the wound. Stop treatment if excessive fl uid
is drained. Watch for acute bleeding. Determine electrolyte
balance, evaluate need for systemic antibiotic treatment.
Skin graft
Skin graft
50–80
4–7
Continuous
for 2–3 days
followed by
intermittent
mode 6–4/1–2
Stop active bleeding before starting treatment. Use
lowest pressure possible in range. Apply non-adhesive
antimicrobial dressing to the wound below sponge
*Safety measures regarding the use of RNPT should always be considered and implemented. Effective vacuum should be applied to the wound at all
times in order to avoid super-infection. If vacuum is ineffective for over 30 min, aeration of the wound by removal of occlusive dressing or other form
of ventilation should be considered. Conservatively debride necrotic tissue prior to the application of RNPT. Always consider the necessity for RO-NPT.
Evaluate the need for initiation and cessation of systemic antibiotic treatment in conjunction with RNPT.

Role of Regulated Negative Pressure Therapy in Wound Healing
411
dressing changes adjusted to the varying clinical conditions
for each individual wound.

The above presented guidelines should be regarded as
general recommendations by the author only. The treating
physician should amend and adjust treatment to each
individual clinical condition.
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Accessed
November 22, 2009.
CLINICAL APPLICATIONS OF RNPT
AND RO-NPT—CASE PRESENTATIONS
RNPT in Minor Injuries (Trauma)
Case 1
An 86-year-old patient with necrotic tissue overlying open
fractured tibia: (A) Wound was treated by RNPT set at
intermittent mode, three min on, one min off, and negative
pressure set at 60 mm Hg. (B) Debridement of the necrotic
tissue exposed the implanted hardware. (C to E) Hardware
was covered with local rotation fl aps and donor area with split
thickness skin graft. Flap and skin graft were treated with RNPT,
set at continuous mode, and negative pressure set at 50 mm Hg.
(F) Complete closure of wound at 2 months postoperative.
RNPT in Soft Tissue Trauma
Case 2
A 70-year-old female following crash injury to her left forearm
and hand: (A) Injury of skin equivalent to deep second degree
thermal burn. RNPT was applied and set at intermittent mode,
three min on, one min off, and negative pressure set at 60
mm Hg. (B) 10 days following RNPT. (C) After additional
conservative debridement of necrotic tissue and coverage
with STSG. (D) RNPT was applied to circumferentially cover
and secure skin graft to its bed. Vacuum settings were at
continuous mode, and negative pressure was set at 60 mm Hg.
(E and F) Complete wound healing with full range of motion
and aesthetically acceptable scars, 12 months after injury.
RNPT in Major Trauma
Case 3
An 11-year-old boy injured in a car accident: (A and B)
Severe mutilation of right upper limb. Following preliminary
stabilization and evaluation of wounds in ER, patient was
A
D
B
C
F
E
Case 1

Role of Regulated Negative Pressure Therapy in Wound Healing
413
transferred to OR. (C) Despite the extent of the soft tissue
trauma and gross contamination of the wound, near total primary
closure, by wound edges approximation could be achieved
after thorough exploration, pressure irrigation, conservative
debridement, and bone fi xation. RNPT evacuates contamination,
and reduces edema and congestion of surrounding tissue,
enabling better circulation of lymphatics, and better perfusion
and oxygenation of skin fl aps. (D) The application of RNPT
was endorsed only after meticulous hemostasis was reassured.
RNPT settings: intermittent mode, three min on, one min off,
A
B
D
F
C
E
Case 2

Miscellaneous
414
and negative pressure at 60 mm Hg. (E) Exploration of wound
in OR after 48 hours revealed clean wound with relatively small
skin loss that required coverage with split thickness skin graft.
(F) Patient seen at three years following injury.
A
C
E
F
D
B
Case 3

Role of Regulated Negative Pressure Therapy in Wound Healing
415
RNPT in Open Bone Fractures
Case 4
76-year-old patient injured in a car accident. (A) Open,
infected fracture of tibia and fi bula, exposure of tibial shaft
with severe mutilation of soft tissues of right leg treated
by external fi xation of the tibia, IV antibiotics, and topical
dressing to the wound. Because of the severity of the injury,
patient had been scheduled for BK amputation. (B) RNPT was
tried in order to avoid amputation.

(C and D) Rapid improvement of wound following RNPT
showing fast growth of granulation tissue covering exposed,
partially desiccated tibia.

Moist atmosphere under RNPT promotes granulation
tissue, avoids desiccation of exposed bones, and helps remove
contamination from open fractures. (E and F) Close-up photos
demonstrate clean granulation tissue overlying exposed
moistened bone.

(G) Coverage of exposed bone under RNPT and, (H)
gradual closure of wound gap with granulation tissue.
A
B
D
F
C
E
Case 4 (Contd)

Miscellaneous
416
(I and J) RNPT facilitated defi nitive coverage of wound with
split thickness skin graft and, (K and L) removal of external
fi xator and insertion of intra-medullary nail.

(M) Four and-a half-months after injury, patient can move
about independently with the use of crutches. (N) Four years
after injury, showing complete healing. Bone is stabilized
with IMN and patient has full mobility.

Major limb trauma that has been treated with RNPT and
STSG, diminishing the need for major fl ap coverage over
exposed bones, providing simple solutions for complex
problems.
Treatment of Fasciotomy with RNPT
Case 5
RNPT is the treatment of choice following fasciotomy. It
decompresses the compartment by reducing tissue edema
G
H
J
L
I
K
Case 4 (Contd)

Role of Regulated Negative Pressure Therapy in Wound Healing
417
and reducing the possibility of local infection by reversal of
lymphatic fl ow. (A) Treatment of compartment syndrome by
open fasciotomy. (B) Application of Micromat, non-adhesive
gauze impregnated with slow release chlorhexadine. (C) RNPT
is routinely applied to decongest the compartment. RNPT
settings: three min on, one min off and vacuum set at 50 mm Hg.
M
N
A
B
C
Case 5
Case 4 (Contd)

Miscellaneous
418
Case 6
Nine-year-old patient sustained fracture of radius and ulna
Lt. forearm, leading to compartment syndrome following
plate-fi xation. (A and B) Fasciotomy was performed for
decompression with immediate application of RNPT.
(C) Clean granulation tissue with early decompression of
compartments, enabling relatively fast closure of wound.
Topical negative pressure helps reduce tissue edema and local
infection, facilitating early closure of wounds after fasciotomy.

RNPT should be applied in all cases of compartment
syndrome, after performing fasciotomy in order to reduce
edema and decrease infection.
RNPT in Minor Burns
(3rd Degree Limited-Area Burns)
RNPT and RO-NPT may have limited use in treatment of
extensive burns, as they may exacerbate the shift of fl uids,
leading to increase of fl uid and electrolyte loss. Also, it would
be technically diffi cult to water-seal extensive area burns.

RNPT and RO-NPT do have a role in the treatment of small
to medium area deep burns by decongestion of edema in the
zone of stasis and by removal of tissue contamination, thereby
improving the chance for recovery of tissue in the zone of stasis.
Case 7
(A and B) Third-degree burn from close contact with a hot
radiator in a patient with diabetic-foot-associated neuropathy.
(C and D) Treatment of injured areas on both feet connected
to the same RNPT system. Early application of RNPT
to deep burn area on both feet can reduce or avoid tissue
contamination. (E) Demarcation of necrotic tissue at one week
with no clinical sign of infection. (F) Following amputation
of fi fth toe and conservative debridement of necrotic tissues.
(G and H) Complete wound healing six weeks following injury.
A
B
C
Case 6

Role of Regulated Negative Pressure Therapy in Wound Healing
419
A
C
D
E
F
B
Case 7 (Contd)

Miscellaneous
420
RNPT in Major Burns (3rd-4th Degree,
Medium-Area, Burns)
High voltage electric burns are relatively common in heavy
industry workers. These burns are characterized by deep,
extensive tissue damage, and relatively, small visible skin
damage and fl uid loss at the initial stage, but with potentially
devastating outcome. These injuries can ideally be treated with
RNPT or RO-NPT at the initial stage in order to avoid early
infection, “buying time” to better evaluate the extent of damage
and the exact need for debridement and amputation level.
Case 8
High voltage electric burns are relatively common in heavy
industry workers. (A) A 22-year-old patient sustained a
third degree electric burn necessitating fasciotomy and
debridement. (B and C) Immediate coverage of wound with
RNPT for tissue decongestion and decreased contamination.
(D and E) After demarcation necrotic tissue was excised up
to a level that required AK amputation. (F and G) RNPT of
stump for topical compression and infection control. (H)
Viable tissue in stump after removal of RNPT.
RNPT in Treatment of Chronic Wounds:
Diabetic Foot, Peripheral Vascular Disease
Diabetic foot and PVD-affected limbs require a unique
approach and combined techniques to close acute and chronic
wounds. RNPT should be considered as a breakthrough
in diabetic and PVD wound treatment and; one of the most
important technologies developed and applied in plastic
surgery during the past two decades for these indications.
G
H
A
B
Case 8 (Contd)
Case 7 (Contd)

Role of Regulated Negative Pressure Therapy in Wound Healing
421
C
D
F
H
G
E
Case 8 (Contd)

Miscellaneous
422
Though it is a simple and safe tool that can be utilized in both
hospital and ambulatory setups, the understanding of its basic
mechanism of action should be clear to the care provider
in order to avoid topical ischemia as well as the possible
exacerbation of infection.
Diabetic Foot
Case 9
An 87-year-old patient with diabetic foot. (A) Infected open
traumatic wound with intra-medullary nailing. (B) RNPT after
conservative debridement. RNPT set at intermittent mode, 3
min, on 1 min off, and negative pressure set at 50 mm Hg.

(C) Three weeks following closure of wound with STSG
under local anesthesia. (D) Patient at fi ve months follow-up.
Case 10
A 45-year-old diabetic man, following amputation of 2nd
toe. (A to C) Various stages of treatment with RNPT until
complete coverage with clean granulation tissue. RNPT was
set at intermittent mode, 3 min on, 1 min off, and negative
pressure set at 50 mm Hg.

(D) RNPT was applied to cover and secure skin graft to its
bed. Settings at continuous mode, and negative pressure set
at 50 mm Hg. (E) Complete wound coverage with STSG two
weeks and (F) Three weeks after skin grafting.
A
B
D
C
Case 9 (Contd)

Role of Regulated Negative Pressure Therapy in Wound Healing
423
Peripheral Vascular Disease
Case 11
(A) A 58-year-old woman with a medical history of peripheral
vascular disease and scleroderma, presented with gangrene of
additional toe and unhealed stump of previous amputations
of the fi rst–third toes of her right foot. (B) Wound was treated
with RNPT set at intermittent mode, three min on, one min
off, and negative pressure was set at 75 mm Hg. (C) Wound
was seen at one week. (D) 15 days after commencing RNPT.
(E) Granulation tissue was covered with meshed STSG with
continuous drip irrigation of Gentamycin and covered with
RNPT set at continuous mode and negative pressure set at 50
mm Hg. (F) Complete take of the STSG at one week following
surgery and with (G) Full weight bearing four months later.
RNPT in Fixation of Skin Graft
Application of controlled vacuum helps remove fl uid,
mechanically stabilizes the graft, and decreases bacterial
load. The effect of vacuum application on skin graft donor-
site re-epithelialization was studied in a swine model, and
subsequently in human series. Histology and gross examination
showed that vacuum-treated sites re-epithelialized are faster
than opsite-covered sites.
A
D
B
E
C
F
Case 10

Miscellaneous
424
A
B
C
D
F
E
Case 11 (Contd)

Role of Regulated Negative Pressure Therapy in Wound Healing
425

Graft take is technically dependent. Low vacuum in the
range of 40 to 80 mm Hg is recommended. Careful separation
of the covering sponge layer is crucial. Adherence of the
applied skin to the coarse (large porous) sponge may avulse
the skin graft during removal of dressing. Micromat, a non-
adhering material with slow release chlorhexedine dressing is
recommended for coverage of meshed SG separating between
the graft and the sponge.
Advantages of RNPT in Skin Grafting

• RNPT helps stabilize skin graft on to its bed.

• Negative pressure prevents fl uid accumulation under
the graft.

• SSRAA provides an interface that treats local infection
and avoids adhesion of the graft to the mold.

• RNPT provides moist atmosphere for improved healing
conditions.

• RNPT helps remove interstitial fl uid allowing tissue
decompression.

• RNPT helps remove contaminations.
RNPT Reduces the Need
for Antibiotic Treatment
Case 12
(A and B) A 42-year-old male sustained crash injury to his
Lt. distal forearm and hand. (C) Patient was treated with
RNPT set at intermittent mode, three min on, one min off,
and negative pressure set at 75 mm Hg. (D to F) Following
additional conservative debridement and RNPT, skin grafting
of injured area was covered by circumferential dressing with
RNPT system. (G) Clean wound surface ready for STSG.
(H) Mesh STSG is covered with porous non-adhering gauze
and (I) Splinted with circumferential sponge that collapses and
G
A
B
C
F
E
D
Case 12 (Contd)
Contd.
Case 11 (Contd)

Miscellaneous
426
fi xates the STSG to its wound bed by application of vacuum
to the sponge. (J). Complete skin graft take, six days and (K)
Two months after skin grafting.
Case 13
An 84-year-old patient injured while riding her bicycle. (A)
Patient sustained large hematoma in her left leg. (B) After
demarcation of injured skin, necrotic tissue and (C) Organized
hematomas were debrided. (D) Wound was lined and packed
with non-adherent gauze and RNPT. Negative pressure was
set at intermittent mode four min on, one min off, and vacuum
set at 50 mm Hg. (E) Wound seen at one week and (F) Two
weeks following surgery. Wound is covered with clean
granulation tissue that fi lls the entire skin thickness loss. Skin
loss is now well-prepared for grafting. (G and H) Coverage
of entire wound with mesh STSG and graft secured to its bed
with circumferential RNPT. Vacuum settings at continuous
mode, and negative pressure set at 50 mm Hg. (I) One week
and (J) Three weeks following skin grafting. Complete skin
graft take and healing of wound.
Combined RO-NPT with Application of
TopClosure 3S Skin Stretching System
TopClosure 3S is an innovative device for skin stretching,
securing wound closure, and approximating wound edges.
At the core of the TopClosure technology is the distribution
of force needed to stretch the skin on a relatively extremely
wide area of adherence applying minimal stress to the skin,
away from the damaged wound edges, with fl exible, selective
force vectors, and versatile methods of attachment, in either
invasive or non-invasive manners.

The TopClosure 3S system is comprised of two attachment
plates at its undersurface and pairs of oval openings for
invasive attachment to the skin with either staples or sutures.
Topclosure 3S has been designed to harness mechanical creep
and stress-relaxation principles.
Case 14
(A) A 29-year-old female with dehisced infected abdominal
wall following gynecological surgery. (B) A combination
G
H
I
J
K
Case 12 (Contd)
Contd.

Role of Regulated Negative Pressure Therapy in Wound Healing
427
A
B
D
C
E
F
Case 13 (Contd)

Miscellaneous
428
G
H
J
B
I
A
Case 13 (Contd)
Case 14 (Contd)

Role of Regulated Negative Pressure Therapy in Wound Healing
429
treatment with RO-NPT and TopClosure 3S skin stretching
device was applied to both drain the infected wound and for
gradual approximation of wound edges.

TopClosure 3S system allows “second look” and local
treatment of wound without the need for suturing. RO-
NPT served for prophylaxis, to prevent anaerobic infection.
(C) RO-NPT could be applied simultaneously with
TopClosure for topical treatment of wound and for wound
edge approximation. (D) Five days after commencement of
RO-NPT showing clean granulation tissue in wound bed.
TopClosure’s approximation strap is released to allow access
for topical treatment and then reattachment to the adhesion
plates. (E) Showing patient two months following treatment
with complete wound healing and scheduled for later revision
of scar.
Treatment of Necrotizing Fasciitis (NF)
Case 15
A 66-year-old diabetic female presented with severe signs of
sepsis and NF. (A) Gas was present in the deep tissue along
the fascia involving the right inguinal region, (B) The lateral
thigh, and along the medial aspect of the right lower limb
down to the ankle. (C) Extensive fasciectomy, debridement
of necrotic tissues, and pressure irrigation were performed
followed by insertion of sponges into the wound to serve as
conduit for oxygen simultaneously with negative pressure.
(D) RO-NPT was set by infl ow of eight liters/min of oxygen
simultaneously with continuous negative pressure to
provide vacuum of 80 mm Hg. Cultures revealed facultative
C
D
E
Case 14 (Contd)

Miscellaneous
430
A
B
D
C
F
E
Case 15 (Contd)

Role of Regulated Negative Pressure Therapy in Wound Healing
431
bacteria—Pseudomonas aeruginosa. (Although classifi ed as
an aerobic organism, P. aeruginosa is considered by many to
be a facultative anaerobe as it is well adapted to proliferate in
conditions of partial or total oxygen depletion.)

By applying RO-NPT, we could increase the oxygen
partial pressure in the enclosed infected wounds and still,
benefi t from the well-demonstrated advantages of RNPT.
The anaerobic infection was successfully terminated.
(E to H) Patient was frequently taken to the operating room
for exploration of wounds, pressure irrigation of wounds,
debridement, and change of dressings done every second
day, all while under RO-NPT. Secondary closure of wound
was performed in stages and skin grafts were applied to clean
granulation tissue.
G
H
Case 15 (Contd)

• Normal Nutritional Requirements

– Energy

– Protein

– Carbohydrate

– Fat

– Water

– Micronutrients
• Nutritional Assessment
• Pathophysiology of Wound Healing

– Metabolic Response to Injury
• Role of Nutrients in Wound Healing

– Carbohydrates in Wound Healing

– Fat and Fatty Acids in Wound Healing

– Protein and Wound Healing

– Amino Acids and Wound Healing

– Vitamins and Wound Healing

– Trace Elements in Wound Healing

– Other Dietary Supplements for Wound Healing

– Nutrition and Wound Healing in Infants and Elderly
Introduction
For good health a combination of good nutritional components
are regularly required. Wound care requires a holistic approach
that encompasses taking care of coexisting physical factors,
psychological factors, nutritional status of the person and
associated disease states, e.g. diabetes, cancer, arthritis, etc.
besides drugs, radiation, smoking, hypoxia, etc. Best practice
requires the assessment of the patient as a whole.

The objective in wound healing is to achieve the healing
in the shortest period of time with minimal pain, discomfort
and scarring on the body surface. Researchers who have
explored the complexity and dynamics of the process of
healing, have identified several macro and micronutritional
factors involved in tissue repair. Every individual requires
protein, carbohydrate and fat, which are energy providing
macronutritional components. Along with these, there is
always a need for micronutrients like vitamins, minerals
and water. To be more specific the nutritional requirement
includes several essential amino acids, several fatty acids,
fat soluble vitamins, water soluble vitamins and choline. The
diet should also supply the essential minerals, trace elements,
electrolytes and several ultra trace elements. They will be
dealt with here in detail.
Normal Nutritional
Requirements
Energy
For an individual to maintain an ideal, stable weight, energy
consumption should equal energy spent. The total energy
output is a combination of resting energy expenditure (REE)
+ energy spent on physical activity + energy expenditure on
metabolizing food material + additional energy requirement
for thermoregulation in case of shivering, etc. The daily
energy requirement of an individual is calculated based on the
weight of a person.1

REE for males (kcal/day) = 900 + 10 × weight in kg.

REE for females (kcal/day) = 700 + 7 × weight in kg.
Further, for physical activity the energy requirement is
adjusted depending upon the degree of activity.1 Total energy
requirement is calculated as:

Sedentary = 1.2 × REE
Karoon Agrawal
Role of Nutrition in Wound
Healing
36
Chapter

Role of Nutrition in Wound Healing 
Chapter 36
433

Moderately active = 1.4 × REE

Highly active = 1.8 × REE

Considering this formula, an average Indian male of 70 kg
with moderate activity requires 2240 kcal/day, while an average
woman of 60 kg with moderate activity should consume 1820
kcal/day. Energy requirement can also be calculated using
Harris-Benedict equation based on body weight, height and age:

For women: BMR = 655 + (9.6 × weight in kilos) + (1.8 ×
height in cm) – (4.7 × age in years).

For men: BMR = 66 + (13.7 × weight in kilos) + (5 × height
in cm) – (6.8 × age in years)

To determine your total daily calorie needs, BMR is
multiplied by the appropriate activity factor, as follows:

For sedentary – 1.2

For moderately active – 1.375

For very active – 1.55

For very hard working – 1.725

The energy requirement differs at the extremes of age. It is
inversely proportional to the age. The daily requirement could
be roughly calculated as follows:

Infant – 90 to 120 kcal/kg/day

Elderly– 15 to 20 kcal/kg/day

Normal nutrient requirements and recommended dietary
allowances for Indians has been published by the Expert
Group of the Indian Council of Medical Research in 2009.
The calorie requirement given in the table is little higher than
will be calculated with above formulae (Table 1).
Protein
Protein is an important source of energy and should be of relatively
high biological value. Ten to fourteen percent of calorie require-
ment should be met from proteins. Dietary protein is required for
energy production and some of them like alanine are required for
synthesis of carbohydrates. The non essential amino acids are:
histidine, isoleucine, leucine, methionine, cystine, phenylalanine,
tyrosine, threonine, tryptophane and valine. Many other amino
acids are also required for energy production. For an adult the
recommended daily allowance (RDA) is = 0.8 gm of protein/kg
body weight/day. The requirement of protein increases during
growth, pregnancy, lactation, rehabilitation after malnutrition,
healing phase of wound, etc.
1 gm protein = 1 gm nitrogen
Carbohydrate
Majority of the energy requirement of an individual (~ 55%)
should be met with carbohydrates. Brain and RBCs are
obligatory carbohydrate consumers and accept energy derived
from exogenous carbohydrates and from muscle proteolysis.
Availability of carbohydrate may reduce the requirement of
fat by providing the substrate for fatty acid synthesis.
Recommended intake: Fortyfive to sixtyfive percent (Average
55%) of total daily calories from carbohydrates. A moderately
active 70 kg male who requires 2240 calories a day would need
to get 1232 calories from carbohydrates and a moderately active
60 kg female who requires 1820 calories a day would need to get
~1000 calories from carbohydrate sources.
Fat
Fats are a rich source of energy. For perfect health saturated
fat and trans-fat should constitute <10 percent of the energy
source and unsaturated fats another <10 percent. The fats
provide building blocks for the cell membranes and certain
inflammatory mediators.
Water
Water is essential for life. It is an important component of
nutritional requirement. On an average 1.0 to 1.5 ml of water
is required per kcal of energy expenditure. Additional water
losses due to exhaustion, sweating, pregnancy, lactation, loose
motions, vomiting, etc. need to be added. Infants require more
water because of larger body surface area to volume and hence
more is lost during sweating.

For healthy life one has to clearly strike an optimum balance
in the daily intake of protein, carbohydrate, fat and water.
Micronutrients
Micronutrients play a key role in biochemical reactions of
macronutrients. These are basically cofactors in different reactions,
e.g. protein synthesis requires adequate quantity of vitamin B6,
zinc and copper. Collagen synthesis will be compromised
if adequate vitamin C, iron and copper are not available.
Carbohydrate utilization requires chromium and manganese, etc.

With balanced daily food intake, the daily requirement of
most of the nutrients are adequately met. However, too much
or too little of these nutrients may affect the health adversely.
Nutritional Assessment
Nutritional assessment is often required in a clinical situation.
This involves:
• Screening for malnutrition/over nutrition.
• Assessing food and dietary supplement intake.
• Recognizing the absence or presence of malnutrition.
• Planning for most appropriate nutritional therapy.

Full nutritional status assessment is required only in
seriously ill patients. This is performed by:

• Health history including documentation of dietary intake

• Clinical evaluation including body weight

• Anthropometric measurements

Miscellaneous
Section 4
434
Table 1: Recommended daily allowances for Indians 20102
Group
Type of
work
Body
weight
in kg
Reqd.
Net
Energy
kcal/d
Protein
gm/d
Fat
gm/d
Calcium
mg/d
Iron
mg/d
Vitamin
A
Retinol
µgm/d
Vitamin A
Carotene
µgm/d
Thiamine
mg/d
Riboflavin
mg/d
Niacin
mg/d
Pyri­-
doxine
mg/d
Vitamin
C
mg/d
Folate
gm/d
Vitamin
B12
gm/d
Magne-
sium
mg/d
Zinc
mg/d
Man
Sedentary
60
2320
60
25
600
17
600
4800
1.2
1.4
16
2.0
40
200
1.0
340
12
Moderately
active
2730
30
1.4
1.6
18
Heavy work
3490
40
1.7
2.1
21
Woman
Sedentary
55
1900
55
20
600
21
600
4800
1.0
1.1
12
2.0
40
200
1.0
310
10
Moderately
active
2230
25
1.1
1.3
14
Heavy work
2850
30
1.4
1.7
16
The calorie requirements in this table differ from the calculated REE using given formulae. This table is reproduced from the Indian Council of Medical Research document.