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Negative pressure wound therapy for skin grafts and surgical wounds healing by primary intention.
Cochrane Database Syst Rev 2012; (4):CD009261CD

Abstract

BACKGROUND

Indications for the use of negative pressure wound therapy (NPWT) are broadening with a range of systems on the market, including those designed for use on clean, closed incisions and skin grafts. Reviews have concluded that the evidence for the effectiveness of NPWT remains uncertain. However, this is a rapidly evolving therapy. Consequently, a systematic review of the evidence for the effects of NPWT on postoperative wounds expected to heal by primary intention is required.

OBJECTIVES

To assess the effects of NPWT on surgical wounds (primary closure or skin grafting) that are expected to heal by primary intention.

SEARCH METHODS

We searched the following electronic databases to identify reports of relevant randomised clinical trials: the Cochrane Wounds Group Specialised Register (searched 11 November 2011); the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 4); Database of Abstracts of Reviews of Effects (The Cochrane Library 2011, Issue 4); Ovid MEDLINE (2005 to October Week 4 2011); Ovid MEDLINE (In-Process & Other Non-Indexed Citations 8 November 2011); Ovid EMBASE (2009 to 2011 Week 44); and EBSCO CINAHL (1982 to 04 November 2011). We conducted a separate search to identify economic evaluations.

SELECTION CRITERIA

We included trials if they allocated patients at random and compared NPWT with any other type of wound dressing or compared one type of NPWT with a different type of NPWT.

DATA COLLECTION AND ANALYSIS

We assessed trials for their appropriateness for inclusion and for their quality. This was done by three review authors working independently, using pre-determined inclusion and quality criteria.

MAIN RESULTS

We included five eligible trials with a total of 280 participants. Two trials involved skin grafts and three acute wounds. Only one of the five trials reported the proportion of wounds completely healed and in this study all wounds healed. All five studies reported adverse events. In the four trials that compared standard dressings with negative pressure wound therapy (NPWT) the adverse event rate was similar between groups (negative pressure 33/86; standard dressing 37/103); risk ratio (RR) 0.97 (95% confidence intervals (CI) 0.33 to 2.89). There was significant heterogeneity for this result, due to the high incidence of fracture blisters in the NPWT group in one trial. One trial (87 participants) compared a commercial negative pressure device VAC® system with a negative pressure system developed in the hospital (GSUC). The adverse event rate was lower in the GSUC group (VAC® 3/42; GSUC 0/45); the RR was 0.13 (95% CI 0.01 to 2.51). Results indicate uncertainty about the true effect of either method on adverse events. The mean cost to supply equipment for VAC® therapy was USD 96.51/day compared to USD 4.22/day for the GSUC therapy (P = 0.01). Labour costs for dressing changes were similar. Pain intensity score was also reported to be lower in the GSUC group when compared with the VAC® group (p = 0.02)

AUTHORS' CONCLUSIONS

Evidence for the effectiveness of NPWT on complete healing of wounds expected to heal by primary intention remains unclear. Rates of graft loss may be lower when NPWT is used; but evidence to date suggests that hospital-based products are as effective in this area as commercial applications. There are clear cost benefits when non-commercial systems are used to create the negative pressure required for wound therapy, with no reduction in clinical outcome. Pain levels are also rated lower when hospital systems are compared with their commercial counterparts. The high incidence of blisters occurring when NPWT is used following orthopaedic surgery suggests that the therapy should be limited until safety in this population is established. Given the cost and widespread use of NPWT, there is an urgent need for suitably powered, high-quality trials to evaluate the effects of the newer NPWT products that are designed for use on clean, closed surgical incisions. Such trials should focus initially on wounds that may be difficult to heal, such as sternal wounds or surgeries for obese patients.

Authors+Show Affiliations

Centre for Clinical Nursing, Royal Brisbane and Women’s Hospital, Brisbane, Australia. joan_webster@health.qld.gov.au.No affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info available

Pub Type(s)

Journal Article
Meta-Analysis
Research Support, Non-U.S. Gov't
Review
Systematic Review

Language

eng

PubMed ID

22513974

Citation

Webster, Joan, et al. "Negative Pressure Wound Therapy for Skin Grafts and Surgical Wounds Healing By Primary Intention." The Cochrane Database of Systematic Reviews, 2012, p. CD009261.
Webster J, Scuffham P, Sherriff KL, et al. Negative pressure wound therapy for skin grafts and surgical wounds healing by primary intention. Cochrane Database Syst Rev. 2012.
Webster, J., Scuffham, P., Sherriff, K. L., Stankiewicz, M., & Chaboyer, W. P. (2012). Negative pressure wound therapy for skin grafts and surgical wounds healing by primary intention. The Cochrane Database of Systematic Reviews, (4), p. CD009261. doi:10.1002/14651858.CD009261.pub2.
Webster J, et al. Negative Pressure Wound Therapy for Skin Grafts and Surgical Wounds Healing By Primary Intention. Cochrane Database Syst Rev. 2012 Apr 18;(4)CD009261. PubMed PMID: 22513974.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Negative pressure wound therapy for skin grafts and surgical wounds healing by primary intention. AU - Webster,Joan, AU - Scuffham,Paul, AU - Sherriff,Karen L, AU - Stankiewicz,Monica, AU - Chaboyer,Wendy P, Y1 - 2012/04/18/ PY - 2012/4/20/entrez PY - 2012/4/20/pubmed PY - 2012/7/24/medline SP - CD009261 EP - CD009261 JF - The Cochrane database of systematic reviews JO - Cochrane Database Syst Rev IS - 4 N2 - BACKGROUND: Indications for the use of negative pressure wound therapy (NPWT) are broadening with a range of systems on the market, including those designed for use on clean, closed incisions and skin grafts. Reviews have concluded that the evidence for the effectiveness of NPWT remains uncertain. However, this is a rapidly evolving therapy. Consequently, a systematic review of the evidence for the effects of NPWT on postoperative wounds expected to heal by primary intention is required. OBJECTIVES: To assess the effects of NPWT on surgical wounds (primary closure or skin grafting) that are expected to heal by primary intention. SEARCH METHODS: We searched the following electronic databases to identify reports of relevant randomised clinical trials: the Cochrane Wounds Group Specialised Register (searched 11 November 2011); the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 4); Database of Abstracts of Reviews of Effects (The Cochrane Library 2011, Issue 4); Ovid MEDLINE (2005 to October Week 4 2011); Ovid MEDLINE (In-Process & Other Non-Indexed Citations 8 November 2011); Ovid EMBASE (2009 to 2011 Week 44); and EBSCO CINAHL (1982 to 04 November 2011). We conducted a separate search to identify economic evaluations. SELECTION CRITERIA: We included trials if they allocated patients at random and compared NPWT with any other type of wound dressing or compared one type of NPWT with a different type of NPWT. DATA COLLECTION AND ANALYSIS: We assessed trials for their appropriateness for inclusion and for their quality. This was done by three review authors working independently, using pre-determined inclusion and quality criteria. MAIN RESULTS: We included five eligible trials with a total of 280 participants. Two trials involved skin grafts and three acute wounds. Only one of the five trials reported the proportion of wounds completely healed and in this study all wounds healed. All five studies reported adverse events. In the four trials that compared standard dressings with negative pressure wound therapy (NPWT) the adverse event rate was similar between groups (negative pressure 33/86; standard dressing 37/103); risk ratio (RR) 0.97 (95% confidence intervals (CI) 0.33 to 2.89). There was significant heterogeneity for this result, due to the high incidence of fracture blisters in the NPWT group in one trial. One trial (87 participants) compared a commercial negative pressure device VAC® system with a negative pressure system developed in the hospital (GSUC). The adverse event rate was lower in the GSUC group (VAC® 3/42; GSUC 0/45); the RR was 0.13 (95% CI 0.01 to 2.51). Results indicate uncertainty about the true effect of either method on adverse events. The mean cost to supply equipment for VAC® therapy was USD 96.51/day compared to USD 4.22/day for the GSUC therapy (P = 0.01). Labour costs for dressing changes were similar. Pain intensity score was also reported to be lower in the GSUC group when compared with the VAC® group (p = 0.02) AUTHORS' CONCLUSIONS: Evidence for the effectiveness of NPWT on complete healing of wounds expected to heal by primary intention remains unclear. Rates of graft loss may be lower when NPWT is used; but evidence to date suggests that hospital-based products are as effective in this area as commercial applications. There are clear cost benefits when non-commercial systems are used to create the negative pressure required for wound therapy, with no reduction in clinical outcome. Pain levels are also rated lower when hospital systems are compared with their commercial counterparts. The high incidence of blisters occurring when NPWT is used following orthopaedic surgery suggests that the therapy should be limited until safety in this population is established. Given the cost and widespread use of NPWT, there is an urgent need for suitably powered, high-quality trials to evaluate the effects of the newer NPWT products that are designed for use on clean, closed surgical incisions. Such trials should focus initially on wounds that may be difficult to heal, such as sternal wounds or surgeries for obese patients. SN - 1469-493X UR - https://www.unboundmedicine.com/medline/citation/22513974/Negative_pressure_wound_therapy_for_skin_grafts_and_surgical_wounds_healing_by_primary_intention_ L2 - https://doi.org/10.1002/14651858.CD009261.pub2 DB - PRIME DP - Unbound Medicine ER -