v.a.c.® therapy in the management of paediatric...

REVIEW ARTICLE

V.A.C.® Therapy in themanagement of paediatricwounds: clinical review andexperienceMona Baharestani, Ibrahim Amjad, Kim Bookout, Tatjana Fleck, AllenGabriel, David Kaufman, Shannon Stone McCord, Donald C. Moores,Oluyinka O. Olutoye, Jorge D. Salazar, David H. Song, Steven Teich, SubhasGupta

Baharestani M, Amjad I, Bookout K, Fleck T, Gabriel A, Kaufman D, McCord SS, Moores DC, Olutoye OO, Salazar JD,Song DH, Teich S, Gupta S. V.A.C.® Therapy in the management of paediatric wounds: clinical review and experience.Int Wound J 2009; 6:1–26

ABSTRACTUsage of negative pressure wound therapy (NPWT) in the management of acute and chronic wounds has grownexponentially in the past decade. Hundreds of studies have been published regarding outcomes and methods of therapyused for adult wounds. This treatment is increasingly being used to manage difficult-to-treat paediatric wounds arisingfrom congenital defects, trauma, infection, tumour, burns, pressure ulceration and postsurgical complications in children,although relatively few studies have been aimed at this population. Given the anatomical and physiological differencesbetween adults and children, a multidisciplinary expert advisory panel was convened to determine appropriate use ofNPWT with reticulated open cell foam (NPWT/ROCF) as delivered by Vacuum Assisted Closure® (V.A.C.® Therapy, KCILicensing, Inc., San Antonio, TX) for the treatment of paediatric wounds.The primary objectives of the expert advisory panel were to exchange state-of-practice information on paediatric woundcare, review the published data regarding the use of NPWT/ROCF in paediatric wounds, evaluate the strength of theexisting data and establish guidelines on best practices with NPWT/ROCF for the paediatric population. The proposedpaediatrics-specific clinical practice guidelines are meant to provide practitioners an evidence base from which decisionscould be made regarding the safe and efficacious selection of pressure settings, foam type, dressing change frequencyand use of interposing contact layer selections. The guidelines reflect the state of knowledge on effective and appropriatewound care at the time of publication. They are the result of consensus reached by expert advisory panel members basedon their individual clinical and published experiences related to the use of NPWT/ROCF in treating paediatric wounds.Best practices are described herein for novice and advanced users of NPWT/ROCF. Recommendations by the expert panelmay not be appropriate for use in all circumstances. Decisions to adopt any particular recommendation must be made bythe collaborating medical team, including the surgeon and wound care specialist based on available resources, individualpatient circumstances and experience with the V.A.C.® Therapy System.

Key words: Negative pressure wound therapy • NPWT • V.A.C. Therapy • Vacuum-assisted closure • Paediatric wound care •Abdominal compartment syndrome • astroschisis

Authors: Mona Baharestani, PhD, ANP, CWON, CWS, East Tennessee State University, Center for Nursing Research, Johnson City, TN, USA;Ibrahim Amjad, MD, Private Practice, Miami, FL, USA; Kim Bookout, MSN, RN, Children’s Medical Center, Dallas, TX, USA; Tatjana Fleck, MD,Department of Cardiothoracic Surgery, Medical University of Vienna, Vienna, Austria; Allen Gabriel, MD, The Department of Plastic Surgery, LomaLinda University School of Medicine, Loma Linda, CA, USA; David Kaufman, MD, Department of Pediatrics and Division of Neonatology Universityof Virginia, School of Medicine, Charlottesville, VA, USA; Shannon Stone McCord, MS, RN, Texas Children’s Hospital, Houston, TX, USA; DonaldC. Moores, MD, Division of Pediatric Surgery, Loma Linda University Children’s Hospital, Loma Linda, CA, USA; Oluyinka O. Olutoye, MD, PhD,Department of Surgery Baylor College of Medicine, Houston, TX, USA; Jorge D. Salazar, MD, Department of Surgery, University of Texas HealthScience Center, San Antonio, TX, USA; David H. Song, MD, Section of Plastic Surgery, University of Chicago Hospitals, Pritzker School of Medicine,Chicago, IL, USA; Steven Teich, MD, Department of Surgery, Children’s Hospital of Columbus, Columbus, OH, USA; Subhas Gupta, MD, PhD, TheDepartment of Plastic Surgery, Loma Linda University School of Medicine, Loma Linda, CA, USAAddress for correspondence: Mona Baharestani, PhD, Associate Professor, East Tennessee State University, Center for NursingResearch, Roy Nicks Hall, Office 1-112, Johnson City, TN 37614, USAE-mail: [email protected]

© 2009 The Authors. Journal Compilation © 2009 Blackwell Publishing Ltd • International Wound Journal • Vol 6 (suppl. 1) 1

V.A.C.® Therapy in the management of paediatric wounds

INTRODUCTIONAlthough advances in medical technologyhave enhanced patient survival in the pae-diatric population during the past 20 years,management of acute and chronic paediatricwounds of various aetiologies often remainsa healthcare challenge because of a lack ofknowledge and research upon which to guideclinical practice in this population (1). Epi-demiological studies and empirical evidencesuggest that the most commonly encounteredwound types among hospitalised neonates andchildren include epidermal stripping, extrava-sation injuries, surgical wounds, incontinence-associated dermatitis, chemical and thermalinjuries, wounds secondary to congenitalabnormalities and pressure ulcers (2,3). Majortissue loss or oedema often precludes imme-diate closure and when the normally rapidwound healing response of paediatric patientsis delayed, it can result in increased mortalityand morbidity and compounded anxiety levelsfor patients, families and clinicians (4). Specificchallenges of the paediatric population, includ-ing age appropriate communication styles,pain management, fluid volume maintenance,poor nutrition, early mobility, psychologicalassessment and product safety, contribute tothe complexity of these cases.

There are many therapies available tophysicians for treating paediatric wounds. Onesuch therapy is Vacuum Assisted Closure®

(V.A.C.® Therapy, KCI Licensing Inc., SanAntonio, TX), an integrated wound therapysystem that applies controlled, negative pres-sure to acute and chronic wounds via anopen cell, reticulated polyurethane foam orpolyvinyl alcohol (PVA) foam dressing. Thesystem prepares the wound bed for closureby removing excessive interstitial fluid andinfectious materials, decreasing oedema andpromoting perfusion and granulation tissueformation (5).

The methods and clinical effectiveness ofnegative pressure wound therapy with retic-ulated open cell foam (NPWT/ROCF) arewell documented in adult wounds throughpublished randomised controlled clinical tri-als. Although NPWT/ROCF has not yet beenformally evaluated in paediatric wounds incontrolled clinical trials, there is a small butgrowing number of peer-reviewed case seriesreflecting its safety and efficacy (4,6–17). Morerecently, Contractor et al. have provided an

overview summarising the results of a com-prehensive review of the literature on theuse of NPWT/ROCF exclusively in paediatricpatients (18). To date, adjunctive use of thetherapy has been reported in 27 paediatric-focused studies to treat a wide variety ofwounds and conditions including abdomi-nal compartment syndrome (ACS), pilonidaldisease, sternal and other dehiscences, giantomphalocele, gastroschisis, burns and extrem-ity wounds in paediatric patients of all ages.

Therapy advantages reported in the pae-diatric NPWT/ROCF literature mirror thosereported in adult studies, which includefacilitating wound closure (4,9,13,19), decreas-ing the need for muscle flaps (12), improv-ing wound bed preparation and grafttake (14,15), helping in controlling inflam-matory response (20), and reducing costs (6).Aspects of the therapy most often noted in theliterature as particularly beneficial to the paedi-atric population include less frequent dressingchanges, reduced need for pain medication,accountability for fluid loss across the wound,protection of intact and periwound skin, anda decreased hospital stay, which allows forearlier return of function.

Publication of paediatrics-specific literaturehas not kept pace with the growing usage ofNPWT/ROCF in paediatric wounds; thus, clin-icians have been forced to extrapolate applica-tion information from adult studies and adaptit. This dilemma is compounded further by theethical and litigious issues involved in carry-ing out research on this vulnerable population,leaving clinicians with less of an evidence basefrom which to render care (2). In an effortto bridge this gap, an expert advisory panelwas commenced to facilitate a knowledgetransfer of adult and paediatric NPWT/ROCF-treatment experience into comprehensive pae-diatric NPWT/ROCF-treatment guidelines.The objectives of the expert advisory panelwere to (i) exchange state-of-practice infor-mation on paediatric wound care, (ii) reviewthe published data regarding the use ofNPWT/ROCF in paediatric wounds, (iii) eval-uate the strength of the existing data and(iv) establish guidelines on best practices withNPWT/ROCF for paediatric wounds.

2 © 2009 The Authors. Journal Compilation © 2009 Blackwell Publishing Ltd and Medicalhelplines.com Inc


Table 1 Paediatric subgroups and ages

Paediatric subgroup Approximate age range

Newborn (neonate) Birth to 1 month of ageInfant Greater than 1 month, but 2

years or lessChild Greater than 2 years, but 12

years or lessAdolescent Greater than 12 years, but

less than 21 years

BACKGROUNDPaediatric age group definitionsConsidering the rapid changes in integumen-tary, physiologic, communicative and psycho-logical development from birth through ado-lescence, it is important to define the subgroupswithin the paediatric population. The newbornperiod includes the day of birth to 30 days post-natal, and infancy is defined as 30 days to 2years of life. Childhood starts at 2 years andextends until age 12. The adolescent periodis from 12 to 21 years. These are the paedi-atric subgroup age ranges as defined by theUS Food and Drug Administration listed inTable 1 (5).

Paediatric population characteristicsWounds in children typically follow the samewound-healing trajectory as adults, but exhibitfaster closure rates (18,21). This expectationof faster closure and innate integumentaryresiliency based on age, however, can resultin a lack of wound-care knowledge transferto the paediatric population (3). The paedi-atric element of wound care requires spe-cial expertise, precise management and aclear understanding of the diverse devel-opmental characteristics of each age seg-ment (22).

Wound healing in children can be com-promised by protein-calorie malnutrition,hypotension requiring inotropic therapy,impaired perfusion, oedema, infection andphysiological instability that prevents saferedistribution of pressure (18,23–25). Distinctintricacies of the neonatal and paediatric pop-ulations, such as integumentary immaturity, ahigh body surface to volume ratio, sensitivityto pain, increased potential for toxic percu-taneous absorption and an immature immunesystem create additional complexity in treatingthese age groups (2,3).

Possessing minimal to no antigen exposureand an immature skin barrier, neonates areat especially high risk for life-threateningsepsis secondary to bacterial proliferationand overgrowth within the wound bed (3).Decreased epidermal-to-dermal cohesionplaces neonates and infants at increased riskfor epidermal stripping. Children’s relativelylarge surface-area-to-volume ratio can lead toincreased, difficult-to-measure transepidermalwater loss with resultant heat loss (2,4,26,27).Pain management is paramount to patientand family compliance and can requiresedation or anaesthesia prior to dressingchanges.

Parent/patient educationThe family/paediatric patient component inthe treatment of paediatric patients is uniqueand more intricate than the family/adultpatient component. Paediatric care centreshave become more like family care centres,where the approach to wound care involvesdiscussions of the comprehensive treatmentplan with the patient and the family. It isimportant to convey to the patient/family thatthe interview is a form of consent and providesinformation on the treatment process and thebenefits and risks of treatment.

NPWT/ROCF (V.A.C.® THERAPY)NPWT/ROCF was developed at Wake ForestUniversity School of Medicine, Winston-Salem, NC, by Louis Argenta, MD, andMichael Morykwas, PhD, in 1995 (23,28,29).Since its introduction over a decade ago, useof the therapy has grown exponentially totreat wounds in a wide variety of patients,including paediatrics (29). Nearly 600 studies,16 of which are randomised, controlled clinicaltrials, have been published regarding itsefficacy in adult wounds.

The unique mechanisms of action forNPWT/ROCF contribute greatly to success-ful wound healing. NPWT/ROCF’s ability toprovide a moist, closed wound healing envi-ronment, draw wound edges together, removeinfectious materials, reduce oedema and pro-mote tissue perfusion and granulation tissueformation helps to prepare the wound bedfor delayed primary or secondary closure(Figure 1) (23,29–31). These actions specificallytarget both the macro- and micro-environmentof the wound bed. NPWT/ROCF produces

© 2009 The Authors. Journal Compilation © 2009 Blackwell Publishing Ltd and Medicalhelplines.com Inc 3


Reprinted with permission from KCI Licensing, Ltd, San Antonio, TX.

Figure 1. NPWT/ROCF Mechanism of Action.

macrostrains that draw the tissue against thefoam, causing the wound margins to contractand drawing the wound edges together forbetter approximation (32). Additionally, thenegative pressure through the ROCF inducesmicrostrains that cause cellular microdeforma-tions, which promote cellular migration andproliferation, and produce positive growthfactors that are important for wound heal-ing (33,34).

IndicationsThe US Food and Drug Administration hascleared the V.A.C.® Therapy System as anegative pressure device that creates an envi-ronment for promoting wound healing bysecondary or tertiary intention, preparing thewound bed for closure, reducing oedema,promoting granulation tissue formation andperfusion, and removing exudate and infec-tious material. It is intended as an adjunc-tive wound treatment. NPWT/ROCF is indi-cated for chronic, acute, traumatic, subacuteand dehisced wounds, partial-thickness burns,diabetic ulcers, pressure ulcers, flaps andgrafts.

It has been used to treat wounds ofdifferent aetiologies including gastroschi-sis, giant omphalocele, pilonidal sinus exci-sion, abdominal, sternal and other dehis-cences, pressure ulcers, burns and extremitywounds.

V.A.C.® THERAPYRECOMMENDATIONS FORTREATING PAEDIATRIC WOUNDSPatient size and weightThe size and weight of the patient must beconsidered when prescribing NPWT/ROCF.Children of all ages, particularly neonates,should be closely monitored for fluid loss anddehydration. Patients with highly exudatingwounds or large wounds in relation to thepatient size and weight should be in a closelymonitored environment such as a neonatalintensive care unit (NICU) or paediatric inten-sive care unit (PICU), as they have an increasedrisk of excessive fluid loss and dehydration.Extracellular water content decreases from 45%at term gestational birth to 20–25% consistentwith adult levels by 1 year of age (35). Chil-dren with moderate dehydration (6–10% loss)have histories of fluid losses plus physical find-ings (dry mucous membranes, skin tenting,weight loss, sunken eyes and fontanel, and/orslight lethargic mental status changes). Mostpatients with severe dehydration (11–15% loss)have cardiovascular and neurological insta-bility (skin mottling, tachycardia, hypoten-sion, irritability and/or coma). Patient careis directed to replace fluid volume losses andprovide maintenance fluid to sustain cardio-vascular and neurological stability (35).

Monitoring should include close trackingand replacement of input and output fluids.



Table 2 Recommended guidelines for NPWT/ROCF foam use for paediatric wounds

Wound type/condition Black (polyurethane) foam White (polyvinyl alcohol) foam Silver (polyurethane) foam

Sternal X X XOmphalocele/gastroschisis XEnterocutaneous fistula X XAbdominal compartment

syndromeX

Spinal X X XPilonidal disease X XPressure ulcer X XExtremity wounds X XFasciotomy wounds X XBurns X XPostgraft placement X X

When monitoring fluid output, consider thevolume of fluid in both the tubing and canister.The total tubing volume is 26.7 or 0.09 cc/linearcm from the T.R.A.C.™ Pad to the canister.To prevent excessive fluid loss for high riskpatients, it is recommended that the 300 cccanister should be prefilled with sterile wateror saline to accommodate for safe fluid output.

Foam use and pressure settingsThere are three different foam types to con-sider for paediatric use. Table 2 lists the rec-ommended foam usage for specific paediatricwounds.

Pressure settings should ensure the bestperfusion, oedema resolution, cellular defor-mation, bioburden reduction and exudateremoval to facilitate enhanced tissue growth.Historically, NPWT/ROCF pressure settingsfor adult patients were based on swine stud-ies by Morykwas et al. (36). However, therecommended pressure settings (Table 3) forpaediatric patients are suggestions based on lit-erature and panel expert opinion. Optimal lev-els are age dependent and depend on woundtype and size, wound location, comorbidities,perfusion, sensitivity of the skin area and paintolerance. Pressure increases should be grad-ual and only as tolerated, because of patientsize, weight and response to therapy.

Complications and precautionsAdverse events from NPWT/ROCF havebeen reported infrequently in the paediatricpopulation and have not differed from thosereported in adult literature. Table 4 lists themajor and minor complications reported inthe paediatric literature. There are also certain

precautions that need to be considered whenusing NPWT/ROCF for paediatric wounds(Table 5).

Wound typesFor ease of guideline usage, wound types havebeen classified into anterior trunk, posteriortrunk and extremity wound groups, andsubdivided as follows:

• Anterior trunk wounds

◦ Thoracic wounds◦ Abdominal wounds◦ Enterocutaneous fistulae (ECF)

• Posterior trunk wounds

◦ Spinal wounds◦ Pilonidal disease wound repair◦ Pressure ulcers

• Extremities

◦ Extremity wounds◦ Fasciotomy wounds◦ Burns◦ Postgraft wounds

Table 6 lists references that have focused onNPWT/ROCF use in paediatric wounds.

Anterior trunk woundsDepth of defect is an important considerationin the management of anterior trunk wounds.For simplicity within these guidelines, woundsin the thoracic area are considered deep whenthe sternum is not intact. Acquired abdom-inal wounds (postsurgical dehiscence, open



Table 3 Recommended guidelines of NPWT/ROCF pressure settings for paediatric wounds/conditions

Negative pressure setting (mmHg)

Newborn/infant AdolescentWound type/condition (birth to 2 years) Child (>2 to 12 years) (>12 to 21 years) References

Sternal −50 to −75∗

continuous−50 to −75†

continuous−50 to −75‡

continuous• Baharestani (4)∗

• Agarwal et al. (26)∗

• Salazard et al. (37)∗

• Kadohama et al. (38)∗

• McCord et al. (39)∗,†,‡

• Bookout et al. (40)‡

Omphalocele/gastroschisis

−50 to −75∗

continuous• Gabriel and Gollin (8)∗

• Kilbride et al. (9)∗

Enterocutaneous fistula −50 to −75∗


continuous−75 continuous • McCord et al. (39)∗,†

• Caniano et al. (6)†

Abdominal compartmentsyndrome

−50 to −75∗



continuous• Caniano et al. (6)∗,†

• Bookout et al. (40)†

• Gabriel et al. (19)‡

Spinal −50 to −75∗



continuous• Canavese et al. (41)∗,†

• Horn et al. (42)∗,†

• Butter et al. (11)‡

Pilonidal disease −50 to −75continuous

−50 to −125†


continuous• Caniano et al. (6)†,‡

• Butter et al. (11)‡

Pressure ulcer −50 to −75∗



continuous• McCord et al. (39)∗,†,‡

• Caniano et al. (6)†

• Gabriel et al. (19)†,‡

Extremity wounds −50 to −75∗



continuous• McCord et al. (39)∗,†,‡

• Mooney et al. (13)†

• Baharestani (4)†,‡

Fasciotomy wounds −50 to −75∗



continuous• Baharestani (4)∗,‡


Burns −50 to −75continuous

−75 to −125†


continuous• Schintler et al. (15)†

• Trop et al. (43)‡

Postgraft wounds −50 to −75∗



Continuous• Taub et al. (17)∗


Note: Pressure settings based on panel expert opinion and/or literature. Symbols (∗ † ‡) identify reference(s) supporting statedpressure level for specified wound type/condition and age range.

Table 4 Complications associated with NPWT/ROCF in paediatric wounds

Major complications References Minor complications

Enterocutaneous fistula Baharestani (4) Dermatitis or skin macerationRetained piece of foam in wound Caniano et al. (6) Minimal bleeding with dressing removalHaemorrhage from graft Trop et al. (43) Pain with dressing changesHaemorrhage from donor site Trop et al. (43) Device malfunction

abdomen compartment syndrome decompres-sion, ECF, and traumatic wounds) are consid-ered deep when they are below the level of therectus fascia.

Thoracic wounds (poststernotomy/mediastin-itis). NPWT/ROCF may be most effective in

paediatric thoracic wound care when the goalof therapy is to reestablish sternal stabilityand permit sternal salvage, promote formationof granulation tissue and wound closure,decrease long-term mortality compared withconventional treatment options or manage



Table 5 Precautions when using NPWT/ROCF for paediatricwounds

Precautions

Spinal cordinjury

Discontinue NPWT/ROCF to helpminimise sensory stimulation

Bradycardia Do not place dressing in proximity to thevagus nerve

Periwoundtissueprotection

Protect fragile/friable periwound skinwith additional drape, thinhydrocolloid or other transparent film

Repetitively applying and removingdrapes may lead to stripping ofperiwound skin

Do not allow foam to overlap onto intactskin

Temperature Closely monitor and maintaintemperature

wound infection. Treatment should be on opt-out basis if deep infection is suspected orconfirmed.

In paediatric cardiac surgery, mediansternotomy is a routine approach for thecorrection of congenital anomalies (50–52).Postoperative deep sternal wound infectionfollowing median sternotomy is a seriousand potentially life-threatening complicationassociated with significant morbidity andincreased healthcare costs. The reported inci-dence rate is 0.4–5.0% in the paediatric pop-ulation (24,53). While the reported incidenceof deep sternal wound infections is relativelylow in both adult (54,55) and paediatric (24,52)populations, mortality rates associated withpostoperative mediastinitis using conventionaltherapy range from 5% to 46% in both pop-ulations (24,27,39,53,56,57). Dehisced sternalwounds typically require additional surgeries,including multiple debridements and com-plicated tissue transfer to cover the exposedsternum (39). A growing number of paediatricstudies have shown that sternal wound closurecan be achieved safely and within a relativelyshort period of time with NPWT/ROCF, whichhas been deemed a first-line therapy option forpoststernotomy wound treatment at a numberof institutions (25,39,48).

A literature search showed nine publishedpaediatrics-specific case series or case studiesreporting on adjunctive use of NPWT/ROCFto treat sternal wounds in a total of 28 patients.Additionally, Agarwal et al. reviewed 103patients with open sternal wounds treatedwith NPWT/ROCF, 19 of whom were children

from ages 3 months to 14 years (26). Patientswere treated for an average of 11 days and allwounds subsequently closed − 68% by defini-tive surgical closure and 32% by secondaryintention. In one of the largest paediatric seriesto date, McCord et al. showed a significantreduction in wound volume of 88 ± 14% in 12days among 10 patients in the open sternalwound group. All wounds were aggressivelydebrided before initiation of NPWT/ROCFand healed completely by secondary intentionwithout requiring definitive primary or muscleflap closure (39). The study also reported supe-rior long-term aesthetic results, compared withwet-to-dry dressings or tissue transfer withgrafting, and the sternal bone was preservedin all cases.

Fleck et al. also noted preservation of thesternal bone for secondary closure in threeneonates with poststernotomy mediastinitistreated with NPWT/ROCF (48). Blood loss didnot occur during debridement, NPWT/ROCFsystem application or secondary closure. Noneof the three patients required transfusions.Salazard et al. reported reduction of localinfection, purulence and C-reactive proteinlevels within 72 hours of NPWT/ROCF in threechildren with mediastinitis (37).

There is consensus in the literature andbetween panel members that a lower, con-tinuous pressure (50–75 mmHg) should beused for sternal wounds of infants and chil-dren (25,38,48). Kadohama et al. showed in twoinfants and one child that 50 mmHg negativepressure with ROCF dressings was safe andeffective in managing poststernotomy medias-tinitis (38). Fleck et al. showed that at 50 mmHgnegative pressure, no haemodynamic changes,such as impaired ventricular compliance andfilling, elevated pulmonary venous pressureand reduced cardiac output were experi-enced (48). The authors did not observe anychanges in heart rate, blood pressure or respi-ration pattern, effects that could be an indica-tion of pain during the therapy (48). Althoughthorough debridement prior to NPWT/ROCFinitiation is recommended, Ramnarine et al.reported dramatic improvement following 24hours of NPWT/ROCF in a 5-month-old withpurulent mediastinitis who was too unstablefor surgical debridement (7).

Thoracic wound management recommendations.The most important aspects of managing



Tabl

e6

Lite

ratu

refo

cuse

don

V.A.

C.Th

erap

yan

dpa

edia

trics

Patie

nts(

n)Av

erag

edu

ratio

nTy

peof

stud

yAu

thor

/title

repo

rted

Age

cate

gory

Wou

ndae

tiolo

gies

ofN

PWT/

ROCF

repo

rted

(day

s)pe

rform

ed

Arca

etal

.(16

).Us

eof

vacu

um-a

ssist

edclo

sure

syst

emin

the

man

agem

ento

fcom

plex

wou

nds

inth

ene

onat

e

2Pr

emat

ure

infa

nt(2

)Ac

ute

soft

tissu

ew

ound

ofab

dom

en,a

ndpo

ster

iort

orso

32Ca

sede

scrip

tion

Arch

eret

al.(

10).

Reco

nstru

ctio

nof

anac

quire

dab

dom

inal

wal

ldef

ecti

na

neon

ate

usin

gac

ellu

larh

uman

derm

is

1N

eona

te(1

)N

ecro

tisin

gso

fttis

sue

infe

ctio

nem

anat

ing

from

surg

icali

ncisi

onin

abdo

men

56Ca

sede

scrip

tion

Baha

rest

ani(

4).U

seof

nega

tive

pres

sure

wou

ndth

erap

yin

the

treat

men

tofn

eona

tala

ndpe

diat

ricw

ound

s:a

rest

rosp

ectiv

eex

amin

atio

nof

clini

calo

utco

mes

248.

5ye

ars

(rang

e,14

days

–18

year

s)O

rthop

aedi

cw

ound

w/e

xpos

edha

rdw

are

(n=

6)Ab

dom

inal

wou

ndde

hisc

ence

(n=

4),

com

partm

ents

yndr

ome

(n=

3),l

umba

rsac

ral

wou

nds(

n=

5),s

tern

alw

ound

s(n

=4)

,de

glov

ing

inju

ry(n

=2)

10da

ys(ra

nge,

2–45

)Re

trosp

ectiv

ech

art

revi

ew

Bonn

etet

al.(

44).

Vacu

um-a

ssist

edclo

sure

for

the

reco

nstru

ctio

nof

aco

mpl

exw

ound

ofth

epe

nis

1Co

mpl

expe

nis

wou

ndCa

sede

scrip

tion

Bonn

etet

al.(

45).

Trea

tmen

tofa

larg

ede

fect

ofth

ech

estw

alli

na

child

usin

gne

gativ

epr

essu

rew

ound

dres

sing

18

year

sEx

pose

dpo

lytet

raflu

oroe

thyle

nepr

osth

esis

inla

rge

thor

acic

defe

ct4

wee

ksCa

sede

scrip

tion

Book

oute

tal.

(40)

.Cas

est

udie

sofa

nin

fant

,ato

ddle

r,an

dan

adol

esce

nttre

ated

with

ane

gativ

epr

essu

rew

ound

treat

men

tsys

tem

3In

fant

(1)

Todd

ler(

1)Ad

oles

cent

(1)

Surg

icalw

ound

post

haem

angi

oma,

ACS,

infe

cted

ster

nalw

ound

24Ca

sede

scrip

tion

Brow

net

al.(

46).

Vacu

um-a

ssist

edclo

sure

inth

etre

atm

ento

fa9-

year

-old

child

with

seve

rean

dm

ultip

ledo

gbi

tes

ofth

eth

orax

19

year

old

Dog

bite

traum

aw

ound

(one

patie

ntw

ith2

wou

nds)

8da

ysCa

sede

scrip

tion

Butte

reta

l.(1

1).V

acuu

m-a

ssist

edclo

sure

for

wou

ndm

anag

emen

tin

the

pedi

atric

popu

latio

n

1612

.1ye

ars

(rang

e,1

mon

th–1

8ye

ars)

Pilo

nida

ldise

ase

(n=

8),a

bdom

inal

dehi

scen

ce(n

=3)

,ste

rnal

dehi

scen

ce(n

=2)

,bac

kde

hisc

ence

(n=

1),l

egde

hisc

ence

(n=

1),

chro

nic

perin

ealfi

stul

a(n

=1)

23Re

trosp

ectiv

ech

art

revi

ew



Tabl

e6

Cont

inue

d

Patie

nts(

n)Av

erag

edu

ratio

nTy

peof

stud

yAu

thor

/title

repo

rted

Age

cate

gory

Wou

ndae

tiolo

gies

ofN

PWT/

ROCF

repo

rted

(day

s)pe

rform

ed

Cana

vese

etal

.(41

).Va

cuum

-ass

isted

closu

refo

rde

epin

fect

ion

afte

rspi

nali

nstru

men

tatio

nfo

rsc

olio

sis

1413

year

s(ra

nge,

3–19

year

s)De

epw

ound

infe

ctio

nfo

llow

ing

inst

rum

ente

dsp

inal

fusio

nin

paed

iatri

csc

olio

sis20

.5da

ysRe

trosp

ectiv

ech

art

revi

ew

Cani

ano

etal

.(6)

.Wou

ndm

anag

emen

twith

Vacu

umAs

siste

dCl

osur

e:ex

perie

nce

in51

peda

tric

patie

nts

51N

eona

test

oad

oles

cent

s16

year

s(ra

nge,

10–2

0ye

ars)

inpi

loni

dalg

roup

;oth

erw

ise,n

otno

ted

Pilo

nida

ldise

ase

(21)

,Sa

cral

and

extre

mity

ulce

rs(n

=9)

,Tr

aum

atic

soft

tissu

ew

ound

s(n

=9)

,ext

ensiv

etis

sue

loss

(n=

12)

44da

ysfo

rpilo

nida

ldise

ase

and

10da

ysfo

rtra

umat

icso

fttis

sue

wou

nds;

othe

rwise

not

note

d

Retro

spec

tive

char

tre

view

Chun

get

al.(

47).

Case

revi

ew:m

anag

emen

tof

life-

thre

aten

ing

seps

isan

dw

ound

heal

ing

ina

Klip

pel–

Tren

auna

ypa

tient

usin

gse

rials

urgi

cal

debr

idem

ents

and

vacu

um-a

ssist

edclo

sure

113

year

old

Klip

pel–

Tren

auna

ysy

ndro

me

and

seps

is9

days

prio

rto

graf

t;us

edpo

stgr

aft

Case

desc

riptio

n

Dedm

ond

etal

.(12

).Su

batm

osph

eric

pres

sure

dres

sings

inth

ete

mpo

rary

treat

men

tofs

oft

tissu

ein

jurie

sass

ocia

ted

with

type

IIIop

entib

ials

haft

fract

ures

inch

ildre

n

1513

.5(ra

nge,

2–17

year

s)O

pen

tibia

lsha

ftfra

ctur

e15

.8da

ysRe

trosp

ectiv

ech

art

revi

ew

Flec

ket

al.(

48).

Vacu

umas

siste

dclo

sure

ther

apy

fort

hetre

atm

ento

fste

rnal

wou

ndin

fect

ions

inne

onat

esan

dsm

alli

nfan

ts

3N

eona

tes(

mea

nag

e20

.3±

6da

ys)

Ster

nalw

ound

infe

ctio

n11

.3da

ys(ra

nge,

10–1

2da

ys)

Case

desc

riptio

n

Gab

riele

tal.

(8).

Man

agem

ento

fcom

plica

ted

gast

rosc

hisis

with

smal

lint

estin

alsu

bmuc

osa

(SIS

)and

vacu

um-a

ssist

edclo

sure

336

wee

ksCo

mpl

icate

dga

stro

schi

sis61

days

Case

desc

riptio

n

Gab

riele

tal.

(19)

.Out

com

esof

vacu

um-a

ssist

edclo

sure

fort

hetre

atm

ento

fwou

ndsi

na

paed

iatri

cpo

pula

tion:

case

serie

sof

58pa

tient

s

5810

year

s(ra

nge,

10da

ysto

16ye

ars)

Abdo

min

alw

ound

s(n

=17

)Su

rgica

lsof

ttiss

uede

ficit

(n=

15)

Trau

ma

(n=

18)

Stag

eIII

/IVpr

essu

reul

cers

(n=

5)Fa

scio

tom

yw

ound

s(n

=3)

Abdo

min

alw

ound

s:10

days

Surg

icals

oftt

issue

defic

it:12

days

Trau

ma:

7da

ysPr

essu

reul

cers

:15

days

Fasc

ioto

my

wou

nds:

5da

ys

Retro

spec

tive

char

tre

view



Tabl

e6

Cont

inue

d

Patie

nts(

n)Av

erag

edu

ratio

nTy

peof

stud

yAu

thor

/title

repo

rted

Age

cate

gory

Wou

ndae

tiolo

gies

ofN

PWT/

ROCF

repo

rted

(day

s)pe

rform

ed

Horn

etal

.(42

).Us

eof

wou

ndV.

A.C.

ther

apy

inpe

diat

ricpa

tient

swith

infe

cted

spin

alw

ound

s11

7to

19ye

ars

Deep

wou

ndin

fect

ion

follo

win

gin

stru

men

ted

spin

alfu

sion

inpa

edia

tric

scol

iosis

4to

186

days

Retro

spec

tive

char

trev

iew

Kado

ham

aet

al.(

38).

Vacu

um-a

ssist

edclo

sure

forp

edia

tric

post

ster

noto

my

med

iast

initi

s:ar

elo

wne

gativ

epr

essu

res

suffi

cient

?

313

mon

ths

Post

ster

noto

my

med

iast

initi

s10

days

Case

desc

riptio

n

Kilb

ride

etal

.(9)

.Vac

uum

-ass

isted

closu

re:a

new

met

hod

for

treat

ing

patie

nts

with

gian

tom

phal

ocel

e.20

063

Infa

nts

Gia

ntom

phal

ocel

e34

Pros

pect

ive

case

serie

sM

cCor

det

al.(

39).

Neg

ativ

epr

essu

reth

erap

yis

effe

ctiv

eto

man

age

ava

riety

ofw

ound

sin

infa

nts

and

child

ren

688.

5ye

ars

(rang

e,7

days

–18

year

s)Pr

essu

reul

cers

(n=

13),

extre

mity

wou

nds

(n=

18),

dehi

sced

surg

ical(

n=

19),

open

ster

nalw

ound

s(n

=10

),w

ound

sw

ithfis

tula

s(n

=3)

,com

plex

abdo

min

alw

alld

efec

ts(n

=6)

23da

ys(ra

nge,

4da

ys–3

mon

ths)

Retro

spec

tive

char

trev

iew

Moo

ney

etal

.(13

).Tr

eatm

ento

fsof

ttiss

uede

fect

sin

pedi

atric

patie

ntsu

sing

the

V.A.

C.sy

stem

273

days

old–

18ye

arol

d,no

med

ian

age

note

dCo

mpl

exso

fttis

sue

wou

nds(

acut

e,de

hisc

edin

cisio

ns,a

ndfa

iled

flaps

)N

otno

ted

Retro

spec

tive

char

trev

iew

Ram

narin

eet

al.(

7).V

acuu

m-a

ssist

edclo

sure

inth

epa

edia

tric

patie

ntw

ithpo

stca

rdio

tom

ym

edia

stin

itis

1In

fant

(5m

onth

s)Po

stca

rdio

tom

ym

edia

stin

itis

14Ca

sede

scrip

tion

Sala

zard

etal

.(37

).Va

cuum

assis

ted

closu

rein

the

treat

men

tof

post

ster

noto

my

med

iast

initi

sin

the

paed

iatri

cpa

tient

3Ra

nge,

9da

ysto

2ye

ars

old

Post

ster

noto

my

med

iast

initi

s12

to21

days

Case

desc

riptio

n

Schi

ntle

reta

l.(1

5).T

heus

eof

topi

caln

egat

ive

pres

sure

ina

paed

iatri

cpa

tient

with

exte

nsiv

ebu

rns

16

year

sO

verg

rafts

forb

urns

5da

ysCa

sede

scrip

tion

Shilt

etal

.(14

).Ro

leof

vacu

um-a

ssist

edclo

sure

inth

etre

atm

ento

fped

iatri

cla

wnm

ower

inju

ries

31(N

PWT/

ROCF

=16

);(tr

aditi

onal

treat

men

t=15

)

NPW

T/RO

CFgr

oup

aver

age

age

was

3.9

year

s;tra

ditio

nalg

roup

aver

age

age

was

8.5

year

s

Acut

ela

wnm

ower

traum

aw

ound

sN

PWT/

ROCF

-trea

ted

grou

p:17

days

;Tr

aditi

onal

grou

p:22

days

Pros

pect

ive

serie

sw

/hist

orica

lco

ntro

l

Taub

etal

.(17

).Re

visit

ing

vasc

ular

ized

mus

clefla

psfo

rst

erna

lwou

ndsi

nch

ildre

n1

Neo

nate

(2w

eeks

)Po

stop

erat

ive

ster

nald

ehisc

ence

10da

yspr

iort

ofla

p/gr

aftc

losu

re;2

days

post

closu

re

Case

desc

riptio

n

Trop

etal

.(43

).Ar

e1:

4m

esh

and

dono

rsite

cont

rain

dica

tions

forv

acuu

m-a

ssist

edclo

sure

devi

ce?

216

year

sBu

rns

20.5

hour

sCa

sede

scrip

tion

van

Rhee

etal

.(49

).Va

cuum

-ass

isted

wou

ndclo

sure

ofde

epin

fect

ions

afte

rins

trum

ente

dsp

inal

fusio

nin

sixch

ildre

nw

ithne

urom

uscu

lars

colio

sis

612

.6ye

ars

Deep

wou

ndin

fect

ion

follo

win

gin

stru

men

ted

spin

alfu

sion

inpa

edia

tric

neur

omus

cula

rsco

liosis

3m

onth

s(ra

nge,

2–4

mon

ths)

Pros

pect

ive

case

serie

s



deep mediastinal wound infections are ade-quate irrigation, thorough debridement, andtreatment of the primary infection duringthe first operation. NPWT/ROCF is initiatedafter debridement of devitalised tissue andthe sternum, when necessary and possible.Following debridement of all devitalised tis-sue, NPWT/ROCF can be initiated with aGranuFoam™ or GranuFoam Silver® dressing,starting at –50 mmHg negative pressure forneonates, infants and children, and –75 mmHgfor adolescents. Continuous mode is manda-tory for achieving thoracic cage stability, andit minimises movement.

The primary goal for the first stage ofNPWT/ROCF is to close the sternum, usu-ally at the first dressing change. While thesternum is open, the treating surgeon shouldperform the dressing change. Once the ster-num is closed, it is recommended that aninterposed layer be used between tissue andthe foam dressing to help protect exposedunderlying structures. Careful positioning ofthe non-adherent interposed layers and foamdressing is warranted to protect the heart andprevent adhesions and injury during ther-apy. Structures may shift with applicationof NPWT/ROCF, potentially causing contactbetween the heart and the sternal edges. Cau-tion should be taken to gently place and nottightly pack the wound with ROCF and toensure that the ROCF is not oversized as iscommonly done in the adult population. Overpacking might induce cardiac compressionwith the same symptoms as cardiac tampon-ade.

The clinician may choose not to close thewound completely and instead place approxi-mating stitches and then apply NPWT/ROCFbetween the spaces in order to progressivelydecrease the size of the wound. Once the ster-num is closed, NPWT/ROCF can be continueduntil the wound is ready for definitive closure.

Congenital abdominal defects. Congenitalabdominal wall defects, such as gastroschi-sis and omphaloceles, occur in the USA at arate of one case per 2000 births, translatingto 2360 cases diagnosed per year (6). Theserelatively common congenital abdominal walldefects range from small defects to very largedefects, wherein the entire abdominal vis-cera are exposed. Surgery for abdominal walldefects aims to return the abdominal organs

back into the abdominal cavity, and to repairthe defect, if possible (10).

Management of giant defects is challengingand often associated with complications (10).Gastroschisis is a congenital defect of theabdominal wall, which allows bowel toherniate outside the peritoneal cavity. Thebowel in this setting can become veryoedematous, matted and difficult to reduce.An omphalocele is a congenital herniation ofthe abdominal contents through the umbilicalcord and is covered by a sac that protects theunderlying viscera. In addition to bowel, theomphalocele sac often contains solid organssuch as the liver. These organs developedin the sac, outside the abdominal cavityand as a consequence, the abdominal spaceis usually inadequate to allow immediatereduction of the viscera. If the omphalocelesac ruptures, the abdominal viscera are thenexposed with no option for immediate repair.It may be challenging to close the facial defectin severe gastroschisis even after reduction ofthe protruding abdominal contents. With largeomphaloceles, time may be needed for the finalreduction into the abdominal cavity (10).

In neonates with gastroschisis, fascial clo-sure is usually achieved primarily or after siloreduction (58,59). If fascial closure of a gas-troschisis defect cannot be achieved after a silohas been in place for 7–10 days and visceralcontents are not reduced to the level of theabdominal wall, several strategies are avail-able (8,60–63). A prosthetic graft may be usedto cover exposed bowel, but is unlikely to resultin definitive closure unless skin coverage canbe obtained. Alternatively, a biological dress-ing can be used to cover the abdominal walldefect to achieve a temporary or permanentclosure. Recently, Gabriel et al. reported a novelapproach of using porcine small-intestinal sub-mucosa (SIS) augmented by NPWT/ROCF at–75 mmHg to treat complicated gastroschisisin three neonates who had previously failed inachieving fascial and skin closure. In each case,visceral coverage was achieved (8).

Management of an omphalocele differs.These patients have a large degree of visceraabdominal disproportion because of the under-development of the abdominal cavity. Neithersilo nor primary closure has been successful intreating all patients with a giant omphalocele.Kilbride et al. reported a temporising measureof managing complicated giant omphaloceles



using NPWT/ROCF (9). This therapy allowsfor cleansing the wound, control of drainage,decreasing bacterial bioburden and gradualreduction of the viscera into the abdominal cav-ity while the abdominal cavity of the neonategrows. Patients in the study were treated ata negative pressure of –75 mmHg with theGranuFoam™ Dressing and a non adherentinterposed layer.

In the rare situation in which fascial closureof gastroschisis or ruptured omphalocelecannot be achieved, the combination of SISand NPWT/ROCF has been shown to providea safe and effective means of visceral coverageand, in some cases, definitive abdominal wallclosure (8).

Congenital abdominal wound management rec-ommendations. Management of these woundsconsists of covering the viscera with an inter-posed layer and positioning a GranuFoam™Dressing over the layer. Recommended nega-tive pressure is –75 mmHg. For gastroschisispatients, once the fascial closure is achievedby primary or a secondary synthetic agent,the therapy at –75 mmHg can continue untilthe wound has contracted and the granulationtissue has covered the entire wound cavity.At this time, the therapy can be switched toa routine moist dressing as the final dressingmodality. In cases of complicated omphalo-cele, NPWT/ROCF can be continued until thecavity has enlarged enough to accommodatethe protruding viscera, or complete coverageof the exposed viscera is established.

Abdominal compartment syndrome. Clini-cians are seeing a rise in paediatric multi-trauma (64). An increasing number of childrenare being diagnosed with ACS requiring acutedecompression (65,66). However, the improve-ment of anaesthesia, a better understanding ofaseptic technique, blood banking and antibi-otics have led to safer abdominal surgeriesand improved survival rates in tertiary caresettings. To facilitate re-access to the abdom-inal cavity, an open abdomen is maintainedwith a temporary abdominal closure (TAC)device. Patients with open abdomens requiremultiple trips to the operating room usingstaged abdominal explorations. An ideal TACprotects abdominal contents, prevents eviscer-ation, preserves fascia, minimises desiccationand damage to the viscera, quantifies thirdspace fluid losses, allows for selective tam-ponade, minimises the loss of domain, lowers

bacterial counts, infection and inflammation,and keeps the abdomen dry and intact (67).

For definitive closure of some open abdom-inal defects, a temporary or permanent graftor patch may be used. The ideal material usedto repair an abdominal fascial defect shouldbe strong, biocompatible, and support growthof new tissue. Non-absorbable patches com-posed of material such as knitted polypropy-lene, polytetrafluoroethylene and polyester arestrong, but have a tendency to form intra-abdominal adhesions (68). They offer littlesupport for granulation tissue if skin cover-age cannot be achieved, and must be removedin cases of infection (10). Absorbable meshes,such as Polyglactin 910 and polyglycoloicacid mesh, are more biocompatible than non-absorbable materials, but increase the possiblerecurrence of hernia after the disappearance ofthe mesh (69).

Authors are now advocating an additionaloption of NPWT/ROCF for abdominal cov-erage after damage control laparotomy orACS (70). Six small case series or studiesreport on the use of NPWT/ROCF to treatacute open abdominal wounds in a totalof 17 paediatric patients. Successful closurewas reported for all 17 patients (19). Gabrielreported a mean NPWT/ROCF-treatment timeof 5 days to achieve 100% primary abdominalclosure for six paediatric ACS patients (19).McCord et al. concluded that NPWT/ROCFhelps manage fluid losses, reduce abdominalwall oedema, and in some cases, improve ven-tilation (39). Recently published articles alsoshow effective management of congenital andacquired abdominal wall defects in the neonateusing bioengineered tissues in conjunctionwith NPWT/ROCF (10,16).

ACS wound management recommendations.NPWT/ROCF can be used to close abdomi-nal wounds with intact fascia, approximate thewound edges in preparation for delayed pri-mary closure or to progress the wound until itcan be managed with a less advanced, absorp-tive dressing, such as a hydrofiber. In cases ofan open abdominal wound with exposed vis-cera, the V.A.C.® Abdominal Dressing System(ADS) should be used. The layers of non-adherent-covered foam are applied first underthe fascia and over the omentum or exposedinternal organs. The encapsulated foam withinthe non-adherent layer helps minimise dress-ing shift within the abdomen. Caution should



be used when placing the ADS on compro-mised bowel, even in the presence of a variant.A GranuFoam™ Dressing is placed over thenon-adherent layer and sealed with a drape.The dressing changes should occur under ster-ile conditions and be performed by the treatingsurgeon, with no exceptions.

Following immediate decompression of theACS, the use of NPWT/ROCF at lower nega-tive pressures of –50 to –75 mmHg is recom-mended. Once the fascia is closed, the pressurecan be incrementally increased to –125 mmHgor as tolerated. Early use of this therapy inadults has been found to enhance the chancesof an early and less complex primary closurebecause of rapid reduction in oedema and pro-tection of the intra-abdominal gutters from lossof domain. It is important to closely monitorthe paediatric patient’s fluid status prior tofascial closure because of the high volume ofthird space fluid evacuation that occurs withthe use of this therapy. In cases of intact fascia,GranuFoam™ is placed directly on the abdom-inal wound and a non-adherent interposedlayer is recommended to decrease adherenceand chance of bleeding. However, a non-adherent layer may be used to restrict ingrowthof granulation tissue into the foam if needed.

Enterocutaneous fistulae. ECF arise as com-plications in 0.8–2% of abdominal operations.Global mortality rates in adults have beenreported to be between 5% and 37%, andexceeding 60% in cases of high-output fis-tulae and when sepsis and malnutrition areinvolved (71). The term fistula defines anabnormal communication between two epithe-lialised surfaces. Intestinal fistulae can be inter-nal and external (enterocutaneous). In additionto their anatomic classification, fistulae aredefined according to their fluid output. Inadults, a daily discharge of less than 200 ml isdefined as low-output, 200–500 ml is moderateand greater than 500 ml is high-output (72–75).

Intestinal fistulae that drain into openabdominal wounds are difficult to manage.Enteric contents spill onto the abdominal vis-cera and surrounding skin, leading to per-sistent tissue inflammation, infection, and atworst, sepsis. Several unsuccessful attemptsat closure with surgical management can leadto life-threatening short bowel syndrome andcan also contribute to impaired wound healingas a result of contact with caustic, enzyme-containing discharge. Several methods have

been described to control this soilage includinglayered absorbent dressings, NPWT, applica-tion of fibrin glue, application of acellulardermal matrix, sump drainage, local repairand the application of large, custom ostomyappliances (73,76–79).

In certain circumstances, NPWT/ROCF hasbeen shown to promote healing in woundscontaining an enteric fistula. According tomanufacturer guidelines, NPWT/ROCF isnot recommended or designed for fistulaeffluent management or containment, butas an aid to wound healing. The goal oftherapy depends on whether the fistula beingtreated is considered acute or chronic. Inacute fistulae, the goal of NPWT/ROCF is topromote closure of the acute enteric fistula.In adults, NPWT/ROCF has been shown invarious studies to aid in the spontaneousclosure of large abdominal wounds with low-output ECF (72–75). In chronic fistulae, theenterocutaneous fistula is segregated from thesurrounding or adjacent abdominal woundand NPWT/ROCF is applied to the wound.The effluent from the fistula is diverted intoanother containment system. NPWT/ROCFis used in these chronic fistulae cases toallow conditioning of the wound and patient,providing for sufficient healing to occur tothe point where a subsequent repair can beperformed (80). Studies have noted its efficacyin controlling fistula effluent and promotinghealing of excoriated skin (78,80).

Interestingly, Gunn et al. found in a studyof 15 adult patients with ECF not amenable tosurgical treatment that the presence or absenceof visible intestinal mucosa is the single-mostimportant clinical factor when considering theuse of NPWT/ROCF to manage a patient withECF. In 11 adult patients who had no visibleintestinal mucosa on examination, the closurerate was 100%, and in 4 patients who did havegrossly visible intestinal mucosa, no closureoccurred (72).

Only two paediatric case series report on theuse of NPWT/ROCF to treat wounds witha fistula in a total of four patients. Butteret al. reported use of NPWT/ROCF to treatone boy with a chronic perineal fistula postab-dominoperineal resection. NPWT/ROCF wasinitiated in the operating room (OR) follow-ing reexcision of the fistula (11). Cessation ofthe therapy occurred after 12 days when thefistula was only 1 cm deep. However, the area



never completely healed, necessitating reexci-sion and primary closure. Almost 1 year later,the perineum remained healed with no demon-strable fistula (80). McCord et al. reported onthe use of NPWT/ROCF to treat three woundswith fistulae in patients under the age of 5. Onewound with a high-output enterocutaneousfistula did not close, and the other two woundswith non described fistulae closed without inci-dent (39).

Several authors have described success-ful adjunctive use of NPWT/ROCF in man-aging high-output fistulae in adults (81–83)but use in this manner remains experimen-tal. Fischer reported a higher mortality ratefrom subsequent fistula development follow-ing NPWT/ROCF treatment of gastrointestinalcutaneous fistulae (84). The therapy is con-traindicated for unexplored or non entericfistulae (72,73,78). Larger prospective stud-ies regarding NPWT/ROCF use in treatingabdominal wounds with fistulae in paediatricpatients are needed.

Enterocutaneous fistula management recommen-dations. The panel recommends negative pres-sure of –50 to –75 mmHg for management ofall explored ECF. It is the clinician’s discre-tion to use this therapy for high-output fis-tulae. Additional recommendations regardingNPWT/ROCF and fistula management onlyin adults are published in the V.A.C. TherapyClinical Guidelines; all manufacturer guide-lines should be followed.

Posterior trunk woundsPosterior trunk wounds include spinalwounds, pressure ulcers and complicatedpilonidal cyst wounds.

Spinal wounds. Advances in instrumenta-tion and anaesthesia have made it possible toperform spinal deformity-correction surgeryin children with severe spinal curves, manyof whom also have neuromuscular diseases.Despite the use of prophylactic antibiotics,advances in surgical techniques and postoper-ative care, postoperative wound infection afterspinal surgery is a serious problem that contin-ues to exist. Unfortunately, the rate of infectionis considerably higher in children with neu-romuscular scoliosis such as cerebral palsyand myelomeningocele than in those withidiopathic scoliosis (85). This greater incidencemay be as a result of greater resistance to antibi-otic therapy or because of undetected bladder

infections or incontinence that can contaminatethe lower lumbar wound (86–88). The rate ofoverall spinal wound infection in the literatureranges from 0.4% to 20%, increasing with thecomplexity of the procedure, the most complexbeing fusion with instrumentation (86,89–99.)The majority of infections occur after posteriorinstrumentation (87,100,101).

Surgical wound infections compromisepatient outcomes and result in significant mor-bidity. Costs are considerable in terms of pro-longed hospital stay, pain, time away fromschool or work, repeated surgical proceduresand risks for associated medical complica-tions (102). Hardware removal, in the worstcases, can lead to a loss of correction, collapseand/or pseudoarthrosis (103).

Various methods have been described formanaging infected spinal wounds. Someauthors advocate a one-stage techniqueof opening the wound, radical debride-ment, irrigation, primary closure and antibi-otic treatment (104,105). Successful use ofantibiotic impregnated polymethyl methacry-late beads (101) or irrigation–suction sys-tems (87,91,100) has also been reported.Recently, authors have shown in paedi-atric and adult patients that instrumen-tation salvage is possible with surgicaldebridement and wound temporisation withNPWT/ROCF until delayed primary closure isobtained (41,105–107). NPWT/ROCF has beenadvocated to reduce the dead space and helpwound conditioning of deep subfascial infec-tion after dorsal spine surgery (105). Authors ofa paediatric case series suggest that the closedNPWT/ROCF system may keep the back areaclean without leakage around the wound,thereby minimising incidence of infection (42).The study concludes that between surgicalinterventions and after the final debridement,NPWT/ROCF, combined with antibiotic ther-apy, is a better alternative than conventionalgauze therapy. NPWT/ROCF acts as a contin-uous dressing, keeps the environment clean,wicks away debris and promotes granulationtissue formation (42).

NPWT/ROCF management of deep woundinfection following instrumented spinal fusionin paediatric scoliosis has been described inthree small retrospective case series (41,42,49).In a prospective pilot study of six paediatricneuromuscular scoliosis patients, van Rheeet al. reported that with adjunctive NPWT,



wound closure averaged 3 months, infectionparameters were normalised within 6 weeksand removal of instrumentation was not nec-essary in any patient (49). Horn et al. reportedsimilar results in a retrospective chart review of11 paediatric patients who developed an infec-tion postspinal fusion and were treated withNPWT/ROCF (42). All 11 patients had comor-bid conditions including myelomeningocele,cerebral palsy and scoliosis after paraplegia.In 10 of the 11 cases, NPWT/ROCF was useduntil the wound healed to a superficial level.Some of the patients required minimal or totalinstrumentation removal because of breakage,looseness or because it was no longer neces-sary. However, all patients who developed aninfection within the first year of their fusionhad total instrumentation retention.

Canavese et al. concluded in a retrospectivereview of 14 patients with early deep spinalinfection that adjunctive use of NPWT/ROCFis a reliable and simple temporising measurethat allows for retention of the instrumentation,maintenance of spinal correction and enhancedsuccess with fusion (41). Wound closure wasachieved in all cases, but the authors notedan increased number of repeat proceduresand longer healing time required for children,versus adults with spinal wound infection.This is likely attributable to the high rate ofneuromuscular disorders among the children.The study also showed a reduction in C-reactive protein and white blood cell countfollowing the application of NPWT/ROCF inpatients with infected spinal wounds.

Spinal wound management recommendations.Irrigation and debridement remain as primaryimportance. On the basis of both paediatricand adult literature, the panel recommendsmanagement of these wounds with V.A.C.®

WhiteFoam and GranuFoam™, or GranuFoamSilver®. WhiteFoam can be used in the deepabscesses of the wound and directly overbone and exposed hardware. GranuFoam™can be placed over the WhiteFoam if needed,or over tissue (42). An interposed layer is rec-ommended with the regular GranuFoam™to prevent rapid up-growth of granulationtissue into the foam. All exposed vital struc-tures, including nerves, must be completelycovered and protected prior to placement ofthe NPWT/ROCF dressing. Coverage with amuscle flap or other thick layer of natural tis-sue provides the most effective protection. If

not available many clinicians have used nonadherent fine-meshed layer or bioengineeredtissue. The higher density WhiteFoam requiresa minimum pressure setting of –125 mmHg.With GranuFoam™ or GranuFoam Silver®,negative pressure should be started at –50 to–75 mmHg for all paediatric patients with deepor superficial infection. If needed, the pressurecan be gradually adjusted to a maximum of–125 mmHg, based on age, size, weight andresponse to therapy and clinician expertise.

Myelomeningocele patients who are insen-sate with no pain can have their dressingschanged in their room with or without antianx-iety medication as needed. It is recommendedthat patients who experience pain receivedressing changes in the PICU under conscioussedation to decrease pain and psychologicaltrauma (42).

Pilonidal disease. A pilonidal cyst, a cystnear or over the coccyx, affects approximately26 per 100,000 people. In adults, pilonidaldisease is far more prevalent in males thanin females (108,109). In children, however, theratio is the opposite – occurring in four femalesfor each male affected. It is usually seen inadolescence with a peak incidence betweenages 16 and 20 years. Pilonidal disease isa result of hair and cellular debris findinga portal of entry into the skin and hairfollicles (108,109). The ingrown hair causesan inflammatory reaction and oedema. Theoedema causes occlusion of the skin openingincreasing the hair follicle size. This results inan eventual spread of purulent material intothe subcutaneous tissue causing a foreign bodyreaction (110). Definitive treatment requireswide excision of all involved tissue followed bysecondary intention healing or reconstructivesurgery. An aggressive approach is warrantedfor recurrent pilonidal sinus disease, whichresults in a persistent, midline, non-healingwound. Methods to repair the soft tissuedefect have been reported but regardless of theprocedure used, a more definitive treatmentis often required because of a high recurrencerate of around 50% (110).

McGuinness et al. reported the first adult caseof a complex pilonidal sinus that was managedwith excision and NPWT/ROCF (110). Theauthors reported that the therapy shortenedthe length of hospital stay, the need forfurther surgery and provided a cosmeticallyacceptable result (110). Additional reports



have emerged highlighting the successful useof NPWT/ROCF in the management of thisdisease (111,112).

To date, three publications have reportedon NPWT/ROCF management of the defectin postsurgical treatment of both acute andrecurrent pilonidal disease in children. Inthe largest series of 21 patients, Caniano etal. reported healing in all six patients withprimary disease at an average of 37 days (30days in lean patients and 45 days in obesepatients). In patients with recurrent disease, 12healed in an average of 48 days (38 days inlean patients and 62 days in obese patients)and 3 developed recurrent sinuses. By thethird postoperative day, 87% of these patientshad returned to school and were managed ona thrice weekly dressing change schedule athome (6). Butter et al. reported slightly longerhealing times and a higher recurrence rate(100%) in patients with recurrent pilonidaldisease (11). An additional pilot series reportedon five NPWT/ROCF-treated patients withcomplex pilonidal disease, four of whom wereunder age 21. NPWT/ROCF was used foran average of 6 weeks and all patients weremanaged at home (113).

Pilonidal disease wound management recommen-dations. As previously emphasised, the keyto successful wound management is surgi-cal debridement of all devitalised or infectedtissue. NPWT/ROCF with GranuFoam™ orGranuFoam Silver® may then be initiated at anegative pressure of –125 mmHg in continuousmode for adolescents and –50 to –75 mmHg incontinuous mode for children 12 years oldand younger. If the wound is closed with askin graft, the management should be justlike the management of any skin substituteor skin graft placement, which is to main-tain NPWT/ROCF at a negative pressure of–75 mmHg in continuous mode over the graftfor 3–5 days. The continuous therapy is usedto provide a constant bolster. When the ther-apy is discontinued, a conventional dressing isinitiated for a limited time.

Pressure ulcers. Pressure ulcers are a seri-ous health issue, leading to clinical, financialand emotional challenges. One of the earlieststudies addressing pressure ulcer develop-ment in children was reported by Okamoto etal. (114). The authors studied 227 patients withmyelomengiocele who developed pressure

ulcers over a 20-year time frame. A prospec-tive, matched case study in a 14-bed PICUalso showed a 26% pressure ulcer incidencerate (115). Waterlow et al. conducted a multi-centre study of 300 children and identified thatplaster casts as well as friction from the pull ofthe traction are two additional major causativefactors of pressure ulcers in children (116).During a 4-year period, another study con-firmed that paediatric patients with spinabifida and spinal cord injuries were at a highrisk for development of pressure ulcers (117).

Pressure ulcer prevalence rates as highas 27% have been reported among patientsin PICU and 23% in NICU with mostulcers occurring within 2 days of admis-sion (117–119). Among non-critical hospi-talised paediatric patients, prevalence rates of0.47–13% and incidence rates of 0.29–6% havebeen reported (117–121). Several studies haveshowed the effectiveness of NPWT/ROCF forpressure ulcer treatment in adults (122–130).In addition, three case series reports onNPWT/ROCF treatment of paediatric pres-sure ulcers have been published, showing safeand effective use in this population (6,19,39.)Caniano et al. reported on nine patients withmyelomeningocele-related sacral and extrem-ity ulcers treated with NPWT/ROCF beforedefinitive skin grafting and/or flap closure.Following debridement, NPWT/ROCF wasinitiated for an average of 8 days with suc-cessful skin grafting and flap closure in eightof the nine children. Skin graft failure in onechild was managed with flap closure andan additional application of NPWT/ROCF (6).McCord et al. reported that the mean durationof NPWT/ROCF for 13 pressure ulcer patientswas 40 days with a 68 ± 23% average woundvolume reduction. The authors noted that anadvantage of NPWT/ROCF in children is thatthe system provides a secure, occlusive dress-ing that is not easily dislodged with movement,or cannot be easily pulled off (39). Gabriel et al.reported complete closure in two of five paedi-atric pressure ulcer patients. Closure was notattempted on the other three wounds becauseof poor nutritional and overall health status ofthe patients (19).

Pressure ulcer management recommendations.Management of pressure ulcers is complexin both adult and paediatric populations,because of the chronic nature of the woundscombined with patient comorbidities. The



generally accepted staging system for pressureulcers was updated by the National PressureUlcer Advisory Panel (NPUAP) in 2007 (131).NPWT/ROCF is recommended for treatmentof full-thickness Stage III and IV pressureulcers only. NPWT/ROCF can be used eitheras a definitive treatment or to optimise thewound bed prior to surgical closure. Gupta etal. developed an algorithm to assist cliniciansin making decisions about appropriate use ofNPWT/ROCF in pressure ulcer managementwith subsequent consensus guidelines beingpublished later that are applicable to paediatricpressure ulcer care (132,133).

Stage III and IV pressure ulcers may bemanaged with NPWT/ROCF after appropriatedebridement and in cases of underlyingtreated osteomyelitis. The patient should bestarted first on systemic antibiotics, andthen NPWT/ROCF can be initiated after thewound is adequately debrided of necrotictissue, pressure is offloaded, the host ismaximised and the patient’s nutritional indicesare addressed. GranuFoam™ or GranuFoamSilver® dressing is placed directly onto thewound base and NPWT/ROCF pressure is setto –50 to –75 mmHg of pressure at a continuoussetting for younger children or –125 mmHg inadolescents.

When using NPWT/ROCF for paediatricpressure ulcers, there is a risk of producinganother pressure ulcer caused by pressurefrom the tubing system. Care must betaken to prevent further trauma and/orpressure when placing NPWT/ROCF tubing,particularly over bony prominences. Anothercomplication can be the lack of a good sealat the ulcer site, which may be resolvedby using swabs, drapes or adhesive pasteto coagulate areas to be sealed. Additionaldetailed information regarding the completemanagement of these complex wounds canbe obtained from published pressure ulceralgorithms for adults (132,133).

ExtremitiesThe use of NPWT/ROCF to treat paediatric (i)upper and lower extremity wounds, (ii) fas-ciotomy wounds, (iii) partial-thickness burnsand (iv) postskin graft applications has beenshown to produce favourable results. How-ever, more research is still needed for some ofthese wounds to determine the best treatmentoptions for paediatric patients.

Extremity wounds. Soft tissue defects in thepaediatric population can lead to multiplesurgeries, which have significant aestheticand functional consequences. Severe extrem-ity injuries are frequently associated withsignificant complications, including infection,delayed union or non union, compartment syn-drome and long-term function deficits (134).Early bony stabilisation and soft tissue treat-ment are crucial in establishing limb salvageand limiting complications (12).

NPWT/ROCF’s combined effects of oedemareduction with improved granulation tissuegeneration, increased vascularity and woundcontraction have resulted in the ‘downstaging’of the reconstructive efforts so that woundspreviously requiring free tissue transfer maynow be covered by a local flap, skin substituteand/or skin graft (135–137). The aggressiveoedema reduction from this therapy appearsto result in better tissue mobility and tension-free closure. Downstaged procedures havemultiple benefits for the paediatric population,including decreased donor site morbidity andanaesthesia time, a reduction in later revisionsbecause of bulky tissue transfer coverage,as well as potentially faster restoration offunction (13).

Temporary treatment of traumatic soft tissueextremity wounds is the widest reportedindication for NPWT/ROCF use in paediatricwounds. Eight studies have reported onthe use of the therapy in a total of 102paediatric patients with extremity soft tissuedeficit wounds. Dedmond et al. showedthat temporary NPWT/ROCF treatment ofpaediatric type III open tibial shaft fracturesin 15 patients reduced the need for major softtissue coverage procedures by 50% comparedwith what would have been predicted basedon injury type. The need for follow-upprocedures, hospital stay and recovery timewere also reduced (12). A subsequent studyby Dedmond et al. reported in a series ofadult and paediatric patients that infectionand non-union rates of NPWT/ROCF-treatedgrade/type III open tibial shaft fractures weresimilar to those of historical controls (136).

Shilt et al. showed a trend towards a decreasein revision amputations and improvement infunction after NPWT/ROCF treatment in a16-patient case series. The authors concludedthat NPWT/ROCF was a safe and effectivemethod of treating soft tissue injuries resulting



from lawnmower accidents in children (14).In a series of nine paediatric patients whosustained significant soft tissue loss in theextremities from blunt trauma, gunshot injuryand intravenous extravasation, wound healingwith NPWT/ROCF occurred without the needfor skin grafting at an average of 10 days andwith acceptable limb function (6).

Extremity wound management recommenda-tions. Paediatric extremity wounds are largelysimilar to adult extremity wounds in termsof indications and complications, and aregenerally treated in the same manner. Fol-lowing appropriate operative debridement,GranuFoam™ or GranuFoam Silver® dressingcan be placed directly over fracture sites with orwithout exposed bone and/or hardware. Thepanel recommends if there is exposed hard-ware or bone, the wound will benefit from theGranuFoam™ Dressing with a non-adherentinterposed dressing. If tendons, ligaments andnerves are exposed, a non adherent layer isrecommended to avoid direct contact with thefoam dressings. Negative pressure should beinitiated at –50 to –75 mmHg and increasedto a maximum of –125 mmHg depending onthe age and size of the child. In the pres-ence of a skin substitute or skin graft, thepressure should be maintained at a continu-ous setting at –50 to –75 mmHg for infants,–75 to –100 mmHg for children and –100 to–125 mmHg for adolescents.

Fasciotomy wounds. Compartment syndrome(CS) is a limb- and life-threatening conditionobserved when the pressure within a closedanatomic space exceeds the perfusion pressureof the tissue within that space. In most cases,paediatric patients develop CS in the setting ofa fracture. Although long bone fractures are acommon cause of CS, vascular injury is also aknown antecedent to CS (138).

Pain out of proportion with the injury isthe most important early symptom. Severepain is experienced with passive stretchingof the muscles in the involved compartmentor on palpation of the involved muscles. Thediagnosis can be confirmed by measuringthe pressure in the compartment. In adults,when the compartment pressure is greaterthan 45 mmHg or when the pressure is within30 mmHg of the diastolic blood pressure, thenthe diagnosis is made. An urgent fasciotomyis indicated to maintain normal limb function.Because of the difficulty with cooperation in

physical examination of children with pain,early recognition of CS in children can bemore difficult. Unfortunately, the inability tomake a prompt and accurate diagnosis canlead to tissue necrosis, permanent functionalimpairment, and if severe, renal failure anddeath.

Studies have evaluated the efficacy ofNPWT/ROCF for treatment of fasciotomywounds for traumatic CS with positive out-comes both in the adult and paediatric popu-lations (19,25,139). In a retrospective review ofadults, Yang et al. found an average time toclosure of 6.7 days for NPWT/ROCF-treatedfasciotomy wounds following CS of the leg,versus 16.1 days (P < . 05) to closure for similarwounds in the non NPWT group (139). BothBaharestani and Gabriel et al. reported on verysmall subsets of paediatric patients with CS aspart of larger populated case series. Full clo-sure was reported for all paediatric fasciotomywounds with a mean time to closure of 5 days(range, 5–10 days) for three of them (19,25).

Fasciotomy wound management recommenda-tions. NPWT/ROCF can be initiated intra-operatively as a wound dressing, followinga two-incision fasciotomy to release all fourcompartments. Tarkin et al. recommend apply-ing gentle tension to the wound margins toprevent skin retraction in fasciotomy woundsamenable to delayed primary closure (140). Inthese cases, a GranuFoam™ or WhiteFoamDressing is cut and placed within the woundcavity. Crossed rubber bands, or other skinstretching material, are then stapled to theskin edge over the foam. The sealing drape isthen applied over the bands and dressing. Fol-lowing complete oedema reduction, delayedprimary closure may be achieved.

Fasciotomy sites that will require coveragewith a split-thickness skin graft can beprepared using NPWT/ROCF (see PostGraftplacement section of these guidelines). Thesubatmospheric pressure assists in coating themuscular tissues with a thin layer of vasculargranulation tissue to enhance graft take (141).

Partial-thickness burns. Over the last 50 years,the evolution of burn treatment has led to amajor decrease in mortality. Current survivalrates have improved to such an extent that thesurvival rate in children with burns involving100% total body surface area (TBSA) is50% (142). Major advances have been made inearly resuscitation, respiratory care, treatment



of inhalation injury, control of infection,modulation of the hypermetabolic responseand nutritional support. The greatest impacton survival, however, has been the changein the approach to burn wound treatment.Prior to 1970, burn wounds were allowed toseparate by means of human and bacterialcollagenases. Today, early tangential or fascialexcision and grafting by various techniquesmakes it possible to quickly remove all deadtissues and close the wound. By changing thenatural course of the burn injury, the incidenceof invasive wound infection and sepsis isminimised in paediatric burn patients (20).

Several case series have described the useof NPWT/ROCF in adult burn patients withimprovement in skin graft take and donor sitehealing without complications (15,143–146).Unfortunately, little has been publishedregarding NPWT/ROCF-treatment of paedi-atric burn wounds. In 2005, Schintler et al.presented the first case report of NPWT/ROCFuse in securing skin grafts in a paediatricpatient with a 40% body surface area full-thickness burn. NPWT/ROCF did not interferewith mechanical ventilation of the 6-year-oldchild, who was extubated successfully withoutdiscontinuation of NPWT/ROCF. The authorsreported an approximate 100% graft take rateand no sign of systemic or local infection. Theyalso reported simplified patient care and easyand measurable management of tissue fluidloss using NPWT/ROCF (15).

Recently, a report described complicationsof NPWT/ROCF in 17-year-old (40% TBSA)and 15-year-old (10% TBSA) burn patients (43).Extensive bleeding occurred within the graftedsite in the 17 year old and the donor sitein the 15 year old, requiring transfusions.The authors, who are experienced users ofNPWT/ROCF in children, theorised that the 17year old’s bleeding was a result of the widelymeshed and expanded grafts, and the 15 yearold’s bleeding was a result of haemostasis notbeing achieved prior to beginning treatmentwith the NPWT/ROCF. NPWT/ROCF wasdiscontinued in both cases after unsuccessfulattempts to achieve haemostasis, and thepatients ultimately healed. These two caseshighlight the potential for complications incompromised, large TBSA burn patients, andthe importance of achieving haemostasis priorto and during NPWT/ROCF. Complicationrates with NPWT/ROCF reported in the

literature are low; this is the first report wherea massive haemorrhage from the grafted areaand donor site, respectively, has occurred inyoung patients with burns.

Burn wound management recommendations.Successful use of NPWT/ROCF has occurredover grafts in cases of fascial-level excisionin children (15). The therapy can be especiallyuseful on uneven mobile surfaces and to securedermal substitutes. According to Schintler etal., the therapy is well tolerated by burned chil-dren, and is generally painless (15). The appli-cation technique and recommended pressureslisted in the PostGraft placement. Recommen-dations section should be followed for post-graft application of NPWT/ROCF in children.On the basis of known risks of uncontrolledbleeding following large tangential exci-sion (147), NPWT/ROCF is not recommendedover major burn areas in these instances.

Postgraft placement. Perioperative manage-ment of grafts in active young patients iscrucial to graft survival. The graft requiresa well-vascularised wound bed, stabilisationwith staples, sutures or fibrin glue and pre-vention of postoperative shearing. The use ofNPWT/ROCF as a dynamic bolster to bettersecure a meshed skin graft has been reportedin the literature (15,148,149). The dressing con-forms to the wound surface with applica-tion of negative pressure and promotes skingraft adherence while removing exudate andoedema from surrounding tissues. Adjunc-tive use of NPWT/ROCF can be especiallyefficacious in cases of irregularly contouredwounds or wounds with high levels of exu-date. Importantly, in treating children, theconformity of the foam dressing acts as afirm stabiliser that prevents graft shearingand removal. Immobilisation of skin graftson uneven or mobile surfaces such as nuchalarea, axilla, web spaces and perineal area hasbeen reported with NPWT/ROCF use in adultpatients (150).

Scherer et al. reported that NPWT/ROCFis an excellent alternative for securing skingrafts to the wound bed and achieving bettergraft outcomes in adults (151). Moisidis et al.also showed that use of NPWT/ROCF on split-thickness skin grafts significantly improved thequality of the skin graft’s appearance postop-eratively in adults (152). Besides the case study



described by Schintler et al., there are cur-rently no paediatric case series focused specifi-cally on postgraft application of NPWT/ROCF.However, general references are made to itspostgraft usage in children in larger paediatricstudies (6,19).

Postgraft placement recommendations. TheGranuFoam™ or GranuFoam Silver® dressingcan be used with skin grafts and skinsubstitutes in paediatric patients. A nonadherent surface must be placed as an interfacebetween the skin graft and foam dressing toprevent peeling the graft off when removingthe foam. On day five, the wound shouldbe inspected for adequate graft take. Onceadequate graft take is achieved, NPWT/ROCFshould be discontinued and the patientswitched to a moist wound managementalternative for 1–2 weeks.

CONCLUSIONPaediatric surgery for congenital and non-congenital conditions having the potential tocreate large complex wounds is increasingin frequency. Achieving wound closure inthese cases can be difficult because many ofthese wounds require bioengineered tissuesand multiple surgeries to approximate thegross deficits. To provide more timely clo-sure, decreased morbidity and mortality, andimproved quality of life, physicians/surgeonsor wound care specialists are becoming moreinnovative with early intervention and treat-ment. Bioengineered tissues are more plenti-ful but are not always readily incorporated.NPWT/ROCF can increase the rate of incor-poration of many bioengineered tissues andfacilitate the approximation of the gross deficitswhile maintaining a moist, closed wound envi-ronment that promotes wound healing, pro-tects otherwise exposed organs and reducesinsensible fluid and temperature loss.

Aggressive intervention to prevent wound-related complications can be lifesaving in thispopulation, with long-term implications inquality of life and functional capabilities. It wasthe consensus of the panel that NPWT/ROCFhas emerged as an optimal adjunctive therapyin situations where no prior options havebeen available. NPWT/ROCF has been usedeffectively and with minimal side effects in avariety of wound types from neonates to age21 with positive outcomes.

NPWT/ROCF does not replace standardmedical care for this severely at riskpopulation. Continuing to monitor vital signs,weight, fluid volume status, nutritional status,volume of wound exudate while paying partic-ular attention to cosmetic and functional out-comes based upon age-specific requirementsshould remain standard practice to ensure safeand effective outcomes.

Relatively few randomised controlled trials(RCTs) have been completed to evaluate theclinical effectiveness and safety of many med-ical devices in the paediatric population ascompared with the adult population. How-ever, US governmental regulatory bodies aremore strongly encouraging the completion ofclinical trials to ensure the safe and effectiveuse of medical therapies in the paediatric agegroup. We recommend the continued empha-sis upon establishing the clinical efficacy andsafety development of this innovative surgicaladjunct. As the science behind NPWT/ROCFbecomes more understood, better and innova-tive protocols will be developed to improvepatient satisfaction and outcomes.

DISCLAIMERThis is a practical guide for the use of Vacuum-Assisted Closure for the treatment of wounds inpaediatric patients. Negative pressure wound ther-apy using reticulated open cell foam (NPWT/ROCF)is delivered to the wound by way of the VacuumAssisted Closure® Therapy System (KCI Licensing,Inc., San Antonio, TX) in all instances and withinsupporting evidence included in the article. All Neg-ative Pressure Wound Therapy (NPWT) systems donot perform in the same manner, and recommenda-tions or outcomes using other systems may not besimilar.

The information in this guide was formulated byan expert panel with representation from the fieldsof cardiothoracic surgery, plastic and reconstructivesurgery, vascular surgery, general surgery, paedi-atric surgery, neonatology and advanced practicenursing with wound care certification. Additionalinput was received from specialists who were unableto attend the consensus group meeting. These rec-ommendations are not intended as a guarantee ofresults, outcomes or performance of the V.A.C.®

Therapy System. They are recommendations tohelp clinicians establish paediatrics-specific treat-ment protocols for the use of the system in acute,extended or home care. As with any application,follow all appropriate instructions and referenceguides for product use and operation. Please notethat use of V.A.C.® Therapy treatment does not pre-clude the use of other surgical techniques to managewounds. Always consult the relevant section of this



manuscript and any other product labelling andinstructions prior to initiating V.A.C.® Therapy.

CONFLICTS OF INTERESTS.M. is the primary investigator on a AACNVAC research grant. Additional funding hasbeen provided by KCI.

A.G. is on the speakers bureau to KCI Inc.J.D.S. has acted as a paid consultant to KCI

and has received funding for research carriedout in this work.

O.O. has received grant funding fromthe following companies for the namedresearch projects: Hutchinson Technologies,Inc: ‘‘Assessing gut oxygenation in prematureinfants using near infrared spectroscopy’’ andKinetic Concepts, Inc. ‘‘Negative PressureWound Therapy’’.

All other authors have declared that theyhave no conflict of interests.

REFERENCES1 Baharestani MM. Neonatal and pediatric wound

care: filling voids in knowledge and practice.Ostomy Wound Manage 2007;53:6–7.

2 Baharestani MM. An overview of neonatal andpediatric wound care knowledge and consid-erations. Ostomy Wound Manage 2007;53:34–6.

3 Baharestani MM, Pope E. Chronic wound care inneonates and children. In: Krasner D, Rode-heaver GT, Sibbald RG, editors. Chronic woundcare: a clinical source book for healthcare profes-sionals 4th edn. Wayne: HMP Communications,2007.

4 Baharestani MM. Use of negative pressure woundtherapy in the treatment of neonatal andpediatric wounds: a retrospective examinationof clinical outcomes. Ostomy Wound Manage2007;53:75–85.

5 Behrman RE, Kliegman R, Jenson HB. Nelson text-book of pediatrics 17th edn. Philadelphia: W.B.Saunders Company, 2003.

6 Caniano DA, Ruth B, Teich S. Wound managementwith Vacuum Assisted Closure: experience in 51pediatric patients. J Pediatr Surg 2005;40:128–32.

7 Ramnarine IR, McLean A, Pollock JC. Vacuum-assisted closure in the paediatric patient withpost-cardiotomy Mediastinitis. Eur J Cardiotho-rac Surg 2002;22:1029–31.

8 Gabriel A, Gollin G. Management of complicatedgastroschisis with porcine small intestinal sub-mucosa and negative pressure wound therapy.J Pediatr Surg 2006;41:1836–40.

9 Kilbride KE, Cooney DR, Custer MD. Vacuum-assisted closure: a new method for treatingpatients with giant omphalocele. J Pediatr Surg2006;41:212–5.

10 Archer LP, Billmire DA, Falcone RA Jr,Warner BW. Reconstruction of an acquiredabdominal wall defect in a neonate using

acellular human dermis. Plast Reconstr Surg2006;118:e e 163–6.

11 Butter A, Emran M, Al-Jazaeri A, Ouimet A.Vacuum-assisted closure for wound manage-ment in the pediatric population. J Pediatr Surg2006;41:940–2.

12 Dedmond BT, Kortesis B, Punger K, Simpson J,Argenta J, Kulp B, Morykwas M, Webb LX.Subatmospheric pressure dressings in the tem-porary treatment of soft tissue injuries associ-ated with type III open tibial shaft fractures inchildren. J Pediatr Orthop 2006;26:728–32.

13 Mooney JF, Argenta LC, Marks MW, Morykwas MJ,DeFranzo AJ. Treatment of soft tissue defects inpediatric patients using the V.A.C. system. ClinOrthop Relat Res 2000;376:26–31.

14 Shilt JS, Yoder JS, Manuck TA, Jacks L, Rushing J,Paterson SB. Role of vacuum-assisted closure inthe treatment of pediatric lawnmower injuries. JPediatr Orthop 2004;24:482–7.

15 Schintler M, Marschitz I, Trop M. The use of topicalnegative pressure in a paediatric patient withextensive burns. Burns 2005;31:1050–3.

16 Arca MJ, Somers KK, Derks TE, Goldin AB, AikkenJJ, Sato TT, Shilyansky J, Winthrop A, OldhamKT. Use of vacuum-assisted closure system inthe management of complex wounds in theneonate. Pediatr Surg Int 2005;21:532–5.

17 Taub PJ, Schulman MR, Sett S, Koch RM. Revisitingvascularized muscle flaps for complicatedsternal wounds in children. Ann Plast Surg2005;55:535–7.

18 Contractor D, Amling J, Brandoli C, Tosi LL. Neg-ative pressure wound therapy with reticulatedopen cell foam in children: an overview. J OrthopTrauma 2008;22:S167–76.

19 Gabriel A, Heinrich C, Shores J, Cho D, BaqaiW, Moores D, Gupta S. Outcomes of vacuum-assisted closure for the treatment of wounds in apaediatric population: case series of 58 patients.J Plast Reconstr Aesthet Surg 2008;61:302–305.

20 Trop M, Schintler M, Spendel S, StockenhuberA. Unhealed wounds, hypoalbuminaemia andcachexia in a burned child – where is the limit?Ann Burns Fire Disasters 2008;21:59–62.

21 Bale S, Jones V. Caring for children with wounds. JWound Care 1996;5:177–80.

22 Alterman DM, Daley BJ, Kennedy AP.Considerations in pediatric trauma.http://www.emedicine.com. [2006].

23 Argenta LC, Morykwas MJ. Vacuum-assistedclosure: a new method for wound control andtreatment: clinical experience. Ann Plast Surg1997;38:563–76.

24 Ohye RG, Maniker RB, Graves HL, Devaney EJ,Bove EL. Primary closure for postoperativemediastinitis in children. J Thorac CardiovascSurg 2004;128:480–6.

25 Baharestani, M. Use of negative pressure woundtherapy in the treatment of neonatal andpediatric wounds; a retrospective examinationof clinical outcomes. Presented at the 20thAnnual Symposium on Advanced Wound Careand 17th Annual Wound Healing Society



Meeting and Exhibition, 2007 April 28-May 1;Tampa, FL. 4-28-2007. 9-5-2007.

26 Agarwal JP, Ogilvie M, Wu LC, Lohman RF,Gottlieb LJ, Franczyk M, Song DH. Vacuum-assisted closure for sternal wounds: a first-line therapeutic management approach. PlastReconstr Surg 2005;116:1035–40.

27 Levy I, Ovadia B, Erez E, Rinat S, AshkenaziS, Birk E, Konisberger H, Vidne B, Dagan O.Nosocomial infections after cardiac surgery ininfants and children: incidence and risk factors.J Hosp Infect 2003;53:111–6.

28 Thompson JT, Marks MW. Negative pressurewound therapy. Clin Plast Surg 2007;34:673–84.

29 Argenta LC, Morykwas MJ, Marks MW, DeFranzoAJ, Molnar JA, David LR. Vacuum-assistedclosure: state of clinic art. Plast Reconstr Surg2006;117:127S–42S.

30 Morykwas MJ, Argenta LC, Shelton-Brown EI,McGuirt W. Vacuum-assisted closure: a newmethod for wound control and treatment:animal studies and basic foundation. Ann PlastSurg 1997;38:553–62.

31 Venturi ML, Attinger CE, Mesbahi AN, Hess CL,Graw KS. Mechanisms and clinical applicationsof the Vacuum-Assisted Closure (VAC) device:a review. Am J Clin Dermatol 2005;6:185–94.

32 Kasner D, Rodeheaver G, Sibbald G. (eds).Chronic wound care: a clinical source bookfor healthcare professionals. 4th edn. Malvern:HMP Communications, 2007.

33 Saxena V, Hwang CW, Huang S, Eichbaum Q,Ingber D, Orgill DP. Vacuum-assisted closure:microdeformations of wounds and cell prolifer-ation. Plast Reconstr Surg 2004;114:1086–96.

34 McNulty AK, Schmidt M, Feeley T, VillaneuvaP, Kieswetter K. Effects of negative pressurewound therapy on cellular energetics in fibrob-lasts grown in a provisional wound (fibrin)matrix. Wound Repair Regen 2009;17:192–199.

35 Snyder CL, Spilde TL. Fluid manage-ment for the pediatric surgical patient.http://www.emedicine.com. [2008].

36 Morykwas MJ, Faler BJ, Pearce DJ, Argenta LC.Effects of varying levels of subatmosphericpressure on the rate of granulation tissueformation in experimental wounds in swine.Ann Plast Surg 2001;47:547–51.

37 Salazard B, Niddam J, Ghez O, Metras D,Magalon G. Vacuum-assisted closure in thetreatment of poststernotomy mediastinitis in thepaediatric patient. J Plast Reconstr Aesthet Surg2008;61:302–5.

38 Kadohama T, Akasaka N, Nagamine A, NakanishiK, Kiyokawa K, Goh K, Sasajima T. Vacuum-assisted closure for pediatric post-sternotomymediastinitis: are low negative pressures suffi-cient? Ann Thorac Surg 2008;85:1094–6.

39 McCord SS, Naik-Mathuria BJ, Murphy KM,McLane KM, Gay AN, Basu CB, Downey CR,Hollier LH, Olutoye OO. Negative pressuretherapy is effective to manage a variety ofwounds in infants and children. Wound RepairRegen 2007;15:296–301.

40 Bookout K, McCord S, McLane K. Case studies ofan infant, a toddler, and an adolescent treatedwith a negative pressure wound treatmentsystem. J Wound Ostomy Continence Nurs2004;31:184–92.

41 Canavese F, Gupta S, Krajbich JI, Emara KM.Vacuum-assisted closure for deep infection afterspinal instrumentation for scoliosis. J Bone JointSurg Br 2008;90:377–81.

42 Horn PL, Ruth B, Kean JR. Use of wound V.A.C.therapy in pediatric patients with infected spinalwounds: a retrospective review. Orthop Nurs2007;26:317–22.

43 Trop M, Schintler M, Urban E, Roedl S, Stockenhu-ber A. Are 1:4 mesh and donor site contraindi-cations for vacuum-assisted closure device? JTrauma 2006;61:1267–70.

44 Bonnet F, Paraskevas A, Petit F, Lantieri L. Vacuum-Assisted Closure for the reconstruction of acomplex wound of the penis. Ann Chir PlastEsthet 2006;51:249–52.

45 Bonnet F, Pavy B, Beaudoin S, Dubousset J,Mitrofanoff M. Treatment of a large defect of thechest wall in a child using a negative pressurewound dressing. Scand J Plast Reconstr SurgHand Surg 2007;41:143–5.

46 Brown KM, Harper FV, Aston WJ, O’Keefe PA,Cameron CR. Vacuum-assisted closure in thetreatment of a 9-year-old child with severe andmultiple dog bite injuries of the thorax. AnnThorac Surg 2001;72:1409–10.

47 Chung CJ, David LR, Morykwas MJ, ArgentaLC. Case review: management of life-threatening sepsis and wound healing in aKlippel-Trenaunay patient using serial surgi-cal debridements and vacuum-assisted closure.Eur J Plast Surg 2003;26:214–6.

48 Fleck T, Simon P, Burda G, Wolner E, Wollenek G.Vacuum assisted closure therapy for the treat-ment of sternal wound infections in neonatesand small infants. Interact Cardiovasc ThoracSurg 2006;5:285–8.

49 van Rhee MA, de Klerk LW, Verhaar JA. Vacuum-assisted wound closure of deep infections afterinstrumented spinal fusion in six children withneuromuscular scoliosis. Spine J 2007;7:596–600.

50 Fleck TM, Fleck M, Moidl R, Czerny M, KollerR, Giovanoli P, Hiesmayer MJ, Zimpfer D,Wolner E, Grabenwoger M. The vacuum-assisted closure system for the treatment of deepsternal wound infections after cardiac surgery.Ann Thorac Surg 2002;74:1596–600.

51 Fleck T, Moidl R, Giovanoli P, Wolner E,Grabenwoger M. Early treatment of sternalwound infections with vacuum assisted clo-sure therapy reduces involvement of the medi-astinum and further diminishes the need ofplastic reconstructive surgery. Zentralbl Chir2004;129:S35–7.

52 Fleck T, Gustafsson R, Harding K, IngemanssonR, Lirtzman MD, Meites HL, Moidl R, PriceP, Ritchie A, Salazar J, Sjogren J, Song DH,Sumpio BE, Toursarkissian B, WaldenbergerF, Wetzel-Roth W. The management of deepsternal wound infections using vacuum assisted



closureTM (V.A.C.) therapy. Int Wound J2006;3:273–80.

53 Mehta PA, Cunningham CK, Colella CB, AlferisG, Weiner LB. Risk factors for sternal woundand other infections in pediatric cardiac surgerypatients. Pediatr Infect Dis J 2000;19:1000–4.

54 Baskett RJ, MacDougall CE, Ross DB. Is medias-tinitis a preventable complication? A 10-yearreview. Ann Thorac Surg 1999;67:462–5.

55 Brown IW Jr, Moor GF, Hummel BW, Marshall WGJr, Collins JP. Toward further reducing woundinfections in cardiac operations. Ann ThoracSurg 1996;62:1783–9.

56 Milano CA, Georgiade G, Muhlbaier LH, Smith PK,Wolfe WG. Comparison of omental and pec-toralis flaps for poststernotomy mediastinitis.Ann Thorac Surg 1999;67:377–80.

57 Loop FD, Lytle BW, Cosgrove DM, Mahfood S,McHenry MC, Goormastic M, Stewart RW,Golding LA, Taylor PC. J. Maxwell Chamberlainmemorial paper. Sternal wound complicationsafter isolated coronary artery bypass grafting:early and late mortality, morbidity, and cost ofcare. Ann Thorac Surg 1990;49:179–87.

58 Mulholland MW, Lillemore KD, Doherty GM,Maier RV, Upchurch GR. Greenfield’s surgery:scientific principles and paractice, 4th edn.Philadelphia: Williams and Wilkins, 2005.

59 Sydorak RM, Nijagal A, Sbragia L, Hirose S, TsaoK, Phibbs RH, Schmitt SK, Lee H, Farmer DL,Harrison MR, Albanese CT. Gastroschisis: smallhole, big cost. J Pediatr Surg 2002;37:1669–72.

60 Wu Y, Vogel AM, Sailhamer EA, Somme S, SantoreMJ, Chwals WJ, Statter MB, Liu DC . Primaryinsertion of a silastic spring-loaded silo forgastroschisis. Am Surg 2003;69:1083–6.

61 Kidd JN, Levy MS, Wagner CW. Staged reductionof gastroschisis: a simple method. Pediatr SurgInt 2001;17:242–4.

62 Kidd JN Jr, Jackson RJ, Smith SD, Wagner CW.Evolution of staged versus primary closure ofgastroschisis. Ann Surg 2003;237:759–65.

63 Schlatter M, Norris K, Uitvlugt N, DeCou J, Con-nors R. Improved outcomes in the treatment ofgastroschisis using a preformed silo and delayedrepair approach. J Pediatr Surg 2003;38:459–64.

64 Cullen ML. Pulmonary and respiratory complica-tions of pediatric trauma. Respir Care Clin NAm 2001;7:59–77.

65 DeCou JM, Abrams RS, Miller RS, Gauderer MW.Abdominal compartment syndrome in children:experience with three cases. J Pediatr Surg2000;35:840–2.

66 Beck R, Halberthal M, Zonis Z, Shoshani G, HavariL, Bar-Joseph G. Abdominal compartmentsyndrome in children. Pediatr Crit Care Med2001;2:51–6.

67 Badylak S, Meurling S, Chen M, Spievack A,Simmons-Byrd A. Resorbable bioscaffold foresophageal repair in a dog model. J PediatrSurg 2000;35:1097–103.

68 Matthews BD, Pratt BL, Pollinger HS, Backus CL,Kercher KW, Sing RF, Heniford BT. Assess-ment of adhesion formation to intra-abdominal

polypropylene mesh and polytetrafluoroethy-lene mesh. J Surg Res 2003;114:126–32.

69 Dumitriu S. Polymeric biomaterials. CRC Press,2001.

70 Kaplan M, Banwell P, Orgill DP, Ivatury RR,Demetriades D, Moore FA, Miller P, NicholasJ, Henry S. Guidelines for the management ofthe open abdomen. Wounds 2005;17:S1–S24.

71 Wainstein DE, Fernandez E, Gonzalez D, Chara O,Berkowski D. Treatment of high-output entero-cutaneous fistulas with a vacuum-compactiondevice. A ten-year experience. World J Surg2007;32:430–435.

72 Gunn LA, Follmar KE, Wong MS, Lettieri SC,Levin LS, Erdmann D. Management of enterocu-taneous fistulas using negative-pressure dress-ings. Ann Plast Surg 2006;57:621–5.

73 Erdmann D, Drye C, Heller L, Wong MS, LevinLS. Abdominal wall defect and enterocutaneousfistula treatment with the vacuum-assistedclosure (V.A.C.) system. Plast Reconstr Surg2001;108:2066–8.

74 Alvarez AA, Maxwell GL, Rodriguez GC.Vacuum-assisted closure for cutaneous gas-trointestinal fistula management. Gynecol Oncol2001;80:413–6.

75 Goverman J, Yelon JA, Platz JJ, Singson RC,Turcinovic M. The ‘‘Fistula VAC,’’ a techniquefor management of enterocutaneous fistulaearising within the open abdomen: report of 5cases. J Trauma 2006;60:428–31.

76 Dumanian GA, Llull R, Ramasastry SS, Greco RJ,Lotze MT, Edington H. Postoperative abdominalwall defects with enterocutaneous fistulae. AmJ Surg 1996;172:332–4.

77 Cro C, George KJ, Donnelly J, Irwin ST, GardinerKR. Vacuum assisted closure system in the man-agement of enterocutaneous fistulae. PostgradMed J 2002;78:364–5.

78 Girard S, Sideman M, Spain DA. A novel approachto the problem of intestinal fistulization arisingin patients managed with open peritonealcavities. Am J Surg 2002;184:166–7.

79 Subramaniam MH, Liscum KR, Hirshberg A. Thefloating stoma: a new technique for controllingexposed fistulae in abdominal trauma. J Trauma2002;53:386–8.

80 Draus JM Jr, Huss SA, Harty NJ, CheadleWG, Larson GM. Enterocutaneous fistula: aretreatments improving? Surgery 2006;140:570–8.

81 Dionigi G, Dionigi R, Rovera F, Boni L, Padalino P,Minoja G, Cuffari S, Carrafiello G. Treatment ofhigh output entero-cutaneous fistulae associatedwith large abdominal wall defects: single centerexperience. Int J Surg 2008;6:51–6.

82 de Weerd L, Kjaeve J, Aghajani E, Elvenes OP.The sandwich design: a new method to closea high-output enterocutaneous fistula and anassociated abdominal wall defect. Ann PlastSurg 2007;58:580–3.

83 Enker WE, Block GE. The operative treatmentof Crohn’s disease complicated by fistulae.A personal consecutive series. Arch Surg1969;98:493–9.



84 Fischer JE. A cautionary note: the use of vacuum-assisted closure systems in the treatment ofgastrointestinal cutaneous fistula may be asso-ciated with higher mortality from subsequentfistula development. Am J Surg 2008;196:1–2.

85 Szoke G, Lipton G, Miller F, Dabney K. Woundinfection after spinal fusion in children withcerebral palsy. J Pediatr Orthop 1998;18:727–33.

86 Wimmer C, Gluch H. Management of postoperativewound infection in posterior spinal fusion withinstrumentation. J Spinal Disord 1996;9:505–8.

87 Wimmer C, Gluch H, Franzreb M, Ogon M.Predisposing factors for infection in spinesurgery: a survey of 850 spinal procedures. JSpinal Disord 1998;11:124–8.

88 Tredwell SJ, Reilly CW. Complications of spinalsurgery. In: Weinstein SL, editor. Pediatric spinesurgery, 2nd edn. Philadelphia: Lippincott,Williams and Wilkins, 2001: 561–82.

89 Davne SH, Myers DL. Complications of lumbarspinal fusion with transpedicular instrumenta-tion. Spine 1992;17:S184–9.

90 Massie JB, Heller JG, Abitbol JJ, McPhersonD, Garfin SR. Postoperative posterior spinalwound infections. Clin Orthop Relat Res1992;284:99–108.

91 Malamo-Lada H, Zarkotou O, Nikolaides N, Kanel-lopoulou M, Demetriades D. Wound infec-tions following posterior spinal instrumentationfor paralytic scoliosis. Clin Microbiol Infect1999;5:135–9.

92 Soultanis K, Mantelos G, Pagiatakis A, Souca-cos PN. Late infection in patients with scol-iosis treated with spinal instrumentation. ClinOrthop Relat Res 2003;17:116–23.

93 Weinstein MA, McCabe JP, Cammisa FP Jr.Postoperative spinal wound infection: a reviewof 2,391 consecutive index procedures. J SpinalDisord 2000;13:422–6.

94 Prothero SR, Parkes JC, Stinchfield FE. Complica-tions after low-back fusion in 1000 patients. Acomparison of two series one decade apart. 1966.Clin Orthop Relat Res 1994;306:5–11.

95 Steffee AD, Biscup RS, Sitkowski DJ. Segmentalspine plates with pedicle screw fixation. A newinternal fixation device for disorders of thelumbar and thoracolumbar spine. Clin OrthopRelat Res 1986;203:45–53.

96 Faraj AA, Webb JK. Spinal instrumentation forprimary pyogenic infection report of 31 patients.Acta Orthop Belg 2000;66:242–7.

97 Roberts FJ, Walsh A, Wing P, Dvorak M, SchweigelJ. The influence of surveillance methods onsurgical wound infection rates in a tertiary carespinal surgery service. Spine 1998;23:366–70.

98 Wendt JR, Gardner VO, White JI. Treatment ofcomplex postoperative lumbosacral woundsin nonparalyzed patients. Plast Reconstr Surg1998;101:1248–53.

99 Thalgott JS, Cotler HB, Sasso RC, LaRoccaH, Gardner V. Postoperative infections inspinal implants. Classification and analysis–amulticenter study. Spine 1991;16:981–4.

100 Levi AD, Dickman CA, Sonntag VK. Managementof postoperative infections after spinal instru-mentation. J Neurosurg 1997;86:975–80.

101 Calderone RR, Garland DE, Capen DA, OsterH. Cost of medical care for postoperativespinal infections. Orthop Clin North Am1996;27:171–82.

102 Richards BR, Emara KM. Delayed infections afterposterior TSRH spinal instrumentation for idio-pathic scoliosis: revisited. Spine 2001;26:1990–6.

103 Lonstein J, Winter R, Moe J, Gaines D. Woundinfection with Harrington instrumentation andspine fusion for scoliosis. Clin Orthop Relat Res1973;96:222–233.

104 Perry JW, Montgomerie JZ, Swank S, GilmoreDS, Maeder K. Wound infections followingspinal fusion with posterior segmental spinalinstrumentation. Clin Infect Dis 1997;24:558–61.

105 Labler L, Keel M, Trentz O, HeinzelmannM. Wound conditioning by vacuum assistedclosure (V.A.C.) in postoperative infectionsafter dorsal spine surgery. Eur Spine J2006;15:1388–96.

106 Mehbod AA, Ogilvie JW, Pinto MR, Schwender JD,Transfeldt EE, Wood KB, LeHuec JC, Dressel T.Postoperative deep wound infections in adultsafter spinal fusion: management with vacuum-assisted wound closure. J Spinal Disord Tech2005;18:14–17.

107 Yuan-Innes MJ, Temple CL, Lacey MS. Vacuum-assisted wound closure: a new approach tospinal wounds with exposed hardware. Spine2001;26:E30–3.

108 Klin B, Heller ON, Kaplan I. The use of the CO2 laserin pilonidal sinus disease: preliminary results ofan ambulatory prospective study. J Clin LaserMed Surg 1990;8:31–7.

109 Solla JA, Rothenberger DA. Chronic pilonidaldisease. An assessment of 150 cases. Dis ColonRectum 1990;33:758–61.

110 McGuinness JG, Winter DC, O’Connell PR.Vacuum-assisted closure of a complex pilonidalsinus. Dis Colon Rectum 2003;46:274–6.

111 Lynch JB, Laing AJ, Regan PJ. Vacuum-assistedclosure therapy: a new treatment option forrecurrent pilonidal sinus disease. Report of threecases. Dis Colon Rectum 2004;47:929–31.

112 Duxbury MS, Finlay IG, Butcher M, Lambert AW.Use of a vacuum assisted closure device inpilonidal disease. J Wound Care 2003;12:355.

113 Bendewald FP, Cima RR, Metcalf DR, Hassan I.Using negative pressure wound therapy follow-ing surgery for complex pilonidal disease: a caseseries. Ostomy Wound Manage 2007;53:40–6.

114 Okamoto GA, Lamers JV, Shurtleff DB. Skinbreakdown in patients with myelomeningocele.Arch Phys Med Rehabil 1983;64:20–23.

115 Schmidt JE, Berens RJ, Zollo MB, Weisner M, WeigleCG. Skin breakdown in children and high-frequency oscillatory ventilation. Arch PhysMed Rehabil 1998;79:1565–9.

116 Waterlow JA. Pressure sore risk assessment inchildren. Paediatr Nurs 1997;9:21–4.

117 Curley MA, Quigley SM, Lin M. Pressure ulcersin pediatric intensive care: incidence and



associated factors. Pediatr Crit Care Med2003;4:284–90.

118 Weststrate JT, Hop WC, Aalbers AG, VreelingAW, Bruining HA. The clinical relevance of theWaterlow pressure sore risk scale in the ICU.Intensive Care Med 1998;24:815–20.

119 Baharestani, M. A neonatal and pediatric evidence-linked pressure ulcer and skin care performanceimprovement initiative. Presented at the Sym-posium on Advanced Wound Care and MedicalResearch Forum on Wound Repair; 2005 April21-24, San Diego.

120 Baldwin KM. Incidence and prevalence of pressureulcers in children. Adv Skin Wound Care2002;15:121–4.

121 Groeneveld A, Anderson M, Allen S, Bressmer S,Goldberg M, Magee B, Milner M, Young S. Theprevalence of pressure ulcers in a tertiary carepediatric and adult hospital. J Wound OstomyContinence Nurs 2004;31:108–20.

122 Baynham SA, Kohlman P, Katner HP. Treatingstage IV pressure ulcers with negative pressuretherapy: a case report. Ostomy Wound Manage1999;45:28–5.

123 Deva AK, Buckland GH, Fisher E, Liew SC,Merten S, McGlynn M, Gianoutsos MP, Bald-win MAR, Lendvay PG. Topical negative pres-sure in wound management. Med J Aust2000;173:128–31.

124 Ford CN, Reinhard ER, Yeh D, Syrek D, De LasMorenas A, Bergman SB, Williams S, HamoriCA. Interim analysis of a prospective, random-ized trial of vacuum-assisted closure versus thehealthpoint system in the management of pres-sure ulcers. Ann Plast Surg 2002;49:55–61.

125 Greer SE, Duthie E, Cartolano B, Koehler KM,Maydick-Youngberg D, Longaker MT. Tech-niques for applying subatmospheric pressuredressing to wounds in difficult regions ofanatomy. J Wound Ostomy Continence Nurs1999;26:250–3.

126 Hartnett JM. Use of vacuum-assisted woundclosure in three chronic wounds. J WoundOstomy Continence Nurs 1998;25:281–90.

127 Isago T, Nozaki M, Kikuchi Y, Honda T, NakazawaH. Negative-pressure dressings in the treatmentof pressure ulcers. J Dermatol 2003;30:299–305.

128 Mendez-Eastman S. Negative pressure woundtherapy. Plast Surg Nurs 1998;(18); 27–9, 33–7.

129 Voinchet V, Magalon G. Vacuum assisted closure.Wound healing by negative pressure. Ann ChirPlast Esthet 1996;41:583–9.

130 Wanner MB, Schwarzl F, Strub B, Zaech GA, PiererG. Vacuum-assisted wound closure for cheaperand more comfortable healing of pressure sores:a prospective study. Scand J Plast Reconstr SurgHand Surg 2003;37:28–33.

131 Black J, Baharestani MM, Cuddigan J, Dorner B,Edsberg L, Langemo D, Posthauer ME, RatliffC, Taler G. National Pressure Ulcer AdvisoryPanel’s updated pressure ulcer staging system.Adv Skin Wound Care 2007;20:269–74.

132 Gupta S, Baharestani M, Baranoski S, de LeonJ, Engel SJ, Mendez-Eastman S, Niezgoda JA,Pompeo MQ. Guidelines for managing pressure

ulcers with negative pressure wound therapy.Adv Skin Wound Care 2004;17:1–16.

133 Baharestani M, De Leon J, Mendez-Eastman S,Powell G, Weir D, Niezgoda J, Payne W, NanneyLB, Pelham F, Gupta S. Consensus statement: apractical guide for managing pressure ulcerswith negative pressure wound therapy utilizingvacuum-assisted closure- understanding thetreatment algorithm. Adv Skin Wound Care2008;21:1–20.

134 Parrett BM, Matros E, Pribaz JJ, Orgill DP. Lowerextremity trauma: trends in the managementof soft-tissue reconstruction of open tibia-fibulafractures. Plast Reconstr Surg 2006;117:1315–22.

135 Hope PG, Cole WG. Open fractures of the tibia inchildren. J Bone Joint Surg Br 1992;74:546–53.

136 Dedmond BT, Kortesis B, Punger K, Simpson J,Argenta J, Kulp B, Morykwas M, Webb LX.The use of negative-pressure wound therapy(NPWT) in the temporary treatment of soft-tissue injuries associated with high-energyopen tibial shaft fractures. J Orthop Trauma2007;21:11–7.

137 DeFranzo AJ, Argenta LC, Marks MW, MolnarJA, David LR, Webb LX, Ward WG, Teas-dall RG. The use of vacuum-assisted closuretherapy for the treatment of lower-extremitywounds with exposed bone. Plast Reconstr Surg2001;108:1184–91.

138 Paula R. Compartment syndrome, extremity.http://www.emedicine.com. [2008].

139 Yang CC, Chang DS, Webb LX. Vacuum-assistedclosure for fasciotomy wounds following com-partment syndrome of the leg. J Surg OrthopAdv 2006;15:19–23.

140 Tarkin IS. The versatility of negative pressurewound therapy with reticulated open cellfoam for soft tissue management after severemusculoskeletal trauma. J Orthop Trauma2008;22:S146–51.

141 Stone P, Prigozen J, Hofeldt M, Hass S,DeLuca J, Flaherty S. Bolster versus negativepressure wound therapy for securing split-thickness skin grafts in trauma patients. Wounds2004;16:219–23.

142 Barret JP, Desai MH, Herndon DN. Survival inpaediatric burns involving 100% total bodysurface area. Ann Burns Fire Disasters1999;12:139–41.

143 Molnar JA, DeFranzo AJ, Marks MW. Single-stageapproach to skin grafting the exposed skull.Plast Reconstr Surg 2000;105:174–7.

144 Genecov DG, Schneider AM, Morykwas MJ,Parker D, White WL, Argenta LC. A controlledsubatmospheric pressure dressing increases therate of skin graft donor site reepithelialization.Ann Plast Surg 1998;40:219–25.

145 Sposato G, Molea G, Di Caprio G, Scioli M, LaRusca I, Ziccardi P. Ambulant vacuum-assistedclosure of skin-graft dressing in the lower limbsusing a portable mini-VAC device. Br J PlastSurg 2001;54:235–7.

146 Blackburn JH, Boemi L, Hall WW, Jeffords K,Hauck RM, Banducci DR, Graham WP. Negative



pressure dressings as a bolster for skin grafts.Ann Plast Surg 1998;40:453–7.

147 Johansson PI, Eriksen K, Alsbjorn B. Rescuetreatment with recombinant factor VIIa iseffective in patients with life-threatening bleed-ings secondary to major wound excision:a report of four cases. J Trauma 2006;61:1016–8.

148 Schneider AM, Morykwas MJ, Argenta LC. A newand reliable method of securing skin grafts tothe difficult recipient bed. Plast Reconstr Surg1998;102:1195–8.

149 Deva AK, Moisidis E, Heath T, Boorer C, Ho K. Aprospective blinded randomized controlled clin-ical trial of topical negative pressure (TNP)use in skin grafting. Presented at the Euro-

pean Tissue Repair Society, Focus Group Meet-ing, Topical Negative Pressure (TN) Therapy,Museum of London 2003;December 4-6.

150 Chang KP, Tsai CC, Lin TM, Lai CS, Lin SD. Analternative dressing for skin graft immobi-lization: negative pressure dressing. Burns2001;27:839–42.

151 Scherer LA, Shiver S, Chang M, Meredith JW,Owings JT. The vacuum assisted closure device:a method of securing skin grafts and improvinggraft survival. Arch Surg 2002;137:930–4.

152 Moisidis E, Heath T, Boorer C, Ho K, Deva AK.A prospective, blinded, randomized, con-trolled clinical trial of topical negative pres-sure use in skin grafting. Plast Reconstr Surg2004;114:917–22.


Click here to confirm that you have read the article and receive Trauma Education Credit

http://w3.mccg.org/TS_IEP/completion_verification.asp?id=artacutecare001

http://w3.mccg.org/TS_IEP/completion_verification.asp?id=artacutecare001

v.a.c.® therapy in the management of paediatric...

Documents