Clinician Panel Recommendations for Use of Negative Pressure

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OWMo s t o m y w o u n d m a n a g e m e n tFrom science to Practice: contemPorary aPProaches to skin, wound, ostomy, and incontinence care

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Clinician Panel Recommendations for Use of Negative Pressure Wound Therapy with Instillation Melissa McKanna, RN; Jamie Geraci, CWON, BSN, RN; Kimberly Hall, DNP, RN, GCNS-BC, CW-CN-AP; Brigitta Hauan, RN; Melania Howell, RN; Trudy Huey, MSN, RN, CWOCN; Adora Lucius, RN; Susan Mendez-Eastman, RN, CWCN, CPSN; Kedrin Purcell, RN; Rose Raizman, PHCNP, ET; Dawn Shepherd, BSN, RN, CWON, CFCN; and Allen Gabriel, MD

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This supplement is provided as a courtesy to WOUNDS® readers.It was peer reviewed according to the Ostomy Wound Management journal guidelines.

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Ms. McKanna is a Wound and Ostomy nurse at Union Hospital, Terre Haute, IN Ms. Geraci is an Inpatient WOC Nurse at Bethesda North Hospital, Amelia, OHDr. Hall is a Clinical Nurse Specialist at Carilion Clinic, Roanoke, VAMs. Hauan is a Surgical RN at UW Northwest Hospital, Seattle, WAMs. Howell is a Wound Care Consultant at Emanuel Medical Center, Turlock, CAMs. Huey is a Clinical Nurse Specialist at Catawba Valley Medical Center, Hickory, NCMs. Lucius is a Wound Care Nurse at UT Southwestern Medical Center, Dallas, TXMs. Mendez-Eastman is a Certified Wound Nurse at Nebraska Medicine, Bellevue, NEMs. Purcell is a Registered Nurse at Select Specialty Hospital, Newberry, FLMs. Raizman is a CNS/Manager, ET, at Shoshray Consulting, Toronto, ONMs. Shepherd is a Certified Wound Ostomy Care nurse at Parkland Health and Hospital System, Dallas, TXDr. Gabriel is Chief of the Department of Plastic Surgery at PeaceHealth Medical Group, Vancouver, WA

Please address correspondence to: Melissa McKanna, RN, Union Hospital, 1606 N 7th Street, Terre Haute, IN 47804; email: [email protected]

APRIL 2016 OSTOMY WOUND MANAGEMENT® 3www.o-wm.com

Clinician Panel Recommendations for Use of Negative Pressure Wound Therapy with Instillation Melissa McKanna, RN; Jamie Geraci, CWON, BSN, RN; Kimberly Hall, DNP, RN, GCNS-BC, CWCN-AP; Brigitta Hauan, RN; Melania Howell, RN; Trudy Huey, MSN, RN, CWOCN; Adora Lucius, RN; Susan Mendez-Eastman, RN, CWCN, CPSN; Kedrin Purcell, RN; Rose Raizman, PHCNP, ET; Dawn Shepherd, BSN, RN, CWON, CFCN; and Allen Gabriel, MD

AbstractAddition of an instilled topical wound solution to negative pressure wound therapy (NPWT) is designed to facilitate regular wound cleansing to help improve outcomes of some complex wounds, but the addition of instillation to NPWT adds a level of complexity to the wound care process. The paucity of knowledge and experience with instillation may affect optimal use of this treatment modality. In an effort to address this knowledge gap, a 2-day panel meeting of nurses (N = 11) with experience using negative pressure wound therapy with instillation and dwell time (NPWTi-d) was convened to discuss their usage recommendations for managing wounds with this treatment modality in the acute care setting. Panelists reviewed available evidence and presented recommendations for managing wounds treated with NPWTi-d. Panelists agreed NPWTi-d is primarily suited to prepare surgical or nonsurgical wounds for delayed primary closure and preparing/protecting periwound skin improves maintenance of a tight seal. Educating a team of nurses on basic NPWTi-d troubleshooting, providing a short checklist of tasks to perform every shift, and organizing needed supplies and resources may help continuity of care and prevent problems. Panelists also emphasized the im-portance of wound assessment and documentation and recommend educating the patient, family members, and other members of the patient-care team. Research to compare the safety, efficacy, and effectiveness of NPWTi-d and other irrigation techniques on patient outcomes and research to validate these recommendations is needed.

Keywords: negative pressure wound therapy, therapeutic irrigation, nursing care, clinical skills

Potential Conflicts of Interest: This panel and writing of this publication was supported by KCI, an Acelity company, San Antonio, TX. All panel members were compensated for their time and participation in the advisory panel meeting as well as for manuscript preparation.

In recent years, interest in the use of negative pressure wound therapy (NPWT) with automated instillation of a

topical wound solution has increased,1 as shown by an in-crease in documented practical experience1,2 and a growing body of comparative clinical literature.3-5 During NPWT with instillation, a topical solution is slowly introduced into the wound bed and dwells for a planned period of time be-fore removal during a cycle of NPWT. The therapy is de-signed to provide automated cleansing of the wound bed and removal of infectious materials and debris.4,5 Reviews of the literature show NPWT with instillation may be used to prepare the wound bed between operative debridements

and/or to enhance granulation tissue formation.1 Retro-spective analysis3 and a retrospective cohort study4 report this approach can limit the need for additional surgical pro-cedures in high-acuity wounds versus conventional NPWT.

A next-generation NPWT system with automated instil-lation capabilities and a dwell time (NPWTi-d; V.A.C. VE-RAFLO™ Therapy, KCI, an Acelity company, San Antonio, TX) is designed to provide a simplified method of cyclically instilling and dwelling topical wound solutions as compared to previously commercialized systems.1,2,6 Among the litera-ture pertaining to NPWTi-d is a review7 focused on nursing aspects of managing patients receiving NPWTi-d.


Although use of NPWTi-d is reported among general, plastics, vascular, podiatric, and orthopedic surgeons in hospital care settings,1,3-5,8-11 clinical and technical aspects of the therapy remain relatively unknown among nurses and other clinicians who are tasked with caring for these wounds. In an effort to address this knowledge gap in NPWTi-d usage recommendations aimed at nurses, a panel meeting of nurses with extensive experience using NPWTi-d was convened to discuss their recommendations for managing wounds with this treatment modality. Al-though consensus statements about some topics (eg, when to transition and device settings) have been explored, oth-er usage subjects have not.

MethodsThe sponsor of this panel meeting, Acelity, selected panel

members based on their level of clinical experience using NPWTi-d. Panelists were selected from North America. All nurses were invited to participate in the panel meeting based on their knowledge and experience in wound healing and use of NPWTi-d.

Participants consisted of 11 female wound nurses with 6–20 years of wound care experience and 1 plastic surgeon with a wound care specialty. A booklet containing 13 peer-reviewed NPWTi-d studies was sent in advance to each panel member for review before the meeting. This review mate-rial was chosen by the sponsor and included the most recent studies from its own internally updated database of publica-tions on the topic of NPWTi-d.

Panelists met in Denver, CO on November 19–20, 2015. The meeting was moderated by the plastic surgeon and tape-recorded. Each panelist discussed the literature provided, pre-sented their individual clinical experience, and offered sug-gestions for using this treatment modality. Each presentation included a moderator-guided roundtable discussion among presenters and other panelists.

After the meeting, all recommendations were grouped by subject and summarized by a medical writer. Follow-up com-munication with the panelists continued throughout devel-opment of the recommendations via email. A short summary of literature comparing outcomes of NPWT versus NPWTi-d to help guide clinical decision making was provided to panel members. Three NPWTi-d case examples were added to illus-trate clinical outcomes. All recommendations were approved by the panel members. In cases where a panel member edit contradicted a previous edit, the first author and moderator determined the final text to be included in the manuscript.

Literature Summary: NPWTi-d versus NPWT Clinical studies9,10 report enhanced granulation tissue

formation with use of NPWTi-d with instilled saline ver-sus conventional NPWT (V.A.C.® Therapy, KCI, an Acel-ity company, San Antonio, TX). Specifically, a retrospective case series9 (N = 24) and a 131-patient case series10 showed instillation of sterile saline instillation had a positive impact on healing trajectory. In a porcine wound model,12 NPW-Ti-d with saline instillation resulted in a 43% increase over conventional NPWT in granulation tissue formation after 7 days of therapy.

A prospective pilot study by Goss et al5 compared the effi-cacy of wound bed preparation between NPWT and NPWTi-d using 0.125% Dakin’s Solution (Century Pharmaceuticals, Inc, Indianapolis, IN) in 13 patients with 16 chronic lower leg and foot wounds requiring debridement. Patients in both groups received sharp surgical debridement, followed by 1 week of NPWT or NPWTi-d. Although not statistically sig-nificant, wounds treated with NPWTi-d had a lower mean colony forming units per gram of cultured tissue compared with NPWT (2.6 x 105 ± 3 x 105 versus 2.79 x 106 ± 3.18 x 106, respectively; P = 0.43).

In a retrospective, controlled cohort study of 142 pa-tients with acute or chronically infected wounds who re-ceived NPWT alone or NPWTi-d using Prontosan® Wound Irrigation Solution (B. Braun Medical, Inc., Bethlehem, PA) and dwell times of 6 minutes or 20 minutes, Kim et al4 re-

Table 1. Proposed goals of NPWTi-d13

Cleansing Granulation tissue formation

Remove infectious materials Increase granulation tissue formation

Reduce risk of compromised wound healing due to contamination or bioburden

Decrease wound volume

Dilute and solubilize necrotic devitalized tissue and slough

Cover exposed structures

Decrease viscosity and volume of exudate

Address malodor

Key Points• Evidence about the effectiveness of negative pres-

sure wound therapy with instillation and dwell time (NPWTi-d) is increasing, but many questions about optimal usage and patient care strategies remain.

• During a 2-day panel meeting, nurses experienced in the care of patients whose wounds are managed with NPWTi-d discussed suggestions and tips for usage.

• Application, maintenance, and removal of NPWTi-d may be facilitated by the suggestions provided by the nurses on this panel.

• Research is needed to compare the safety, efficacy, and effectiveness of NPWTi-d to other management strategies of these wounds and to validate the usage recommendations provided by the panel.


Table 2. Panel recommendations for maintaining a seal

Prepare the periwound skin

Cleanse skin before dressing application. Avoid using lotions, emollients, or products with fragrances on the periwound area. If an adhesive remover is utilized, be sure to clean away any residue that would affect the seal.

Shave or clip hair around wound as needed.

If possible, allow patients to assist in dressing removal to reduce pain and/or anxiety.

Use the barrier film provided in the dressing kit for optimal adherence of the drape. All barrier films are not created equal.

If the periwound skin is denuded from wound exudate or other moisture-related issues, the “crusting” technique can be used to create a dry surface for better adherence of the drape. This may also reduce the risk of further breakdown related to moisture. To implement crusting, sprinkle ostomy powder over the moist periwound area and then brush off the excess. Follow with a layer of silicone-based barrier film (spray or wipe form) and repeat as necessary.

Create a frame around the periwound area to protect intact skin and enhance the surface for cover drape adhesion by applying a silicone-based barrier film and thin strips of the drape around the perimeter of the wound.

Stoma paste or moldable paste strips, hydrofiber, hydrocolloid, or thin foam dressings may be used under the “frame” as needed to fill contours and assist with sealing moist areas.

If utilizing stoma paste, consider squeezing paste through a 10-cc syringe to allow for controlled application of a thin bead of paste. This helps limit excess or uneven application and reduces the risk of paste getting into the wound cavity.

If problems with drape adherence persist, povidone-iodine may be considered if the patient is not allergic. This may help dry out macerated skin. It is important to note this product requires approximately 1 hour for the skin to be dry enough to apply the drape.

If the dressing is placed over an area of loose skin or where the body flexes (eg, flank or abdomen), the skin must be pulled smooth when applying both the frame and the final drape. This will ensure the body can stretch/flex where needed without compromising the dressing or causing a medical adhesive-related skin injury.

Optimal dressing application for the best seal

Use the barrier film provided in the dressing kit around the edges of the dressing and on any overlapping drape to seal any microleaks that may occur.

Adjust the device settings if needed

The fill-assist feature on the device can be used when setting up the initial NPWTi-d. Make sure the amount of instilled topical solution just saturates the foam during each instill cycle. If the foam is oversaturated (ie, the dressing is bulging or fluid is pooling around edges of wound or leaking out of the dressing), lower the volume instilled and reseal the drape as needed.

Adjust the manufacturer default negative pressure setting, -125 mm Hg with NPWT for 3.5 hours at low intensity, if needed. When appropriate, increase negative pressure slightly when using dressings that may be easily compromised due to body contours or location. The intensity may also be increased to help secure the seal. Assess for increases in patient pain levels. If pain increases, NPWT intensity should be returned to the previous setting.


ported a significantly lower number of operative visits for debridement in the NPWTi-d 6-minute and 20-minute dwell time groups (2.4 ± 0.9 and 2.6 ± 0.9, respectively) ver-sus the NPWT group (3.0 ± 0.9) (P ≤0.05). Hospital stay was significantly shorter for the 20-minute dwell time NPWTi-d group (11.4 ± 5.1 days) versus NPWT alone (14.92 ± 9.23 days) (P ≤0.05), and time to final surgical procedure was significantly shorter for the 6- and 20-minute dwell time groups (7.8 ± 5.2 days, 7.5 ± 3.1 days, respectively), com-pared to standard NPWT (9.23 ± 5.2 days) (P ≤0.05).4

A retrospective analysis by Gabriel et al3 showed signifi-cant differences between patients with extremity or trunk wounds treated with NPWTi-d using saline or Prontosan (n = 48) versus NPWT (n = 34), respectively, in terms of mean operating room debridement (2.0 versus 4.4) (P <0.0001), mean hospital stay (8.1 days versus 27.4 days) (P <0.0001), mean length of therapy (4.1 days versus 20.9 days) (P<0.0001), and mean time to wound closure (4.1 days ver-sus 20.9 days) (P <0.0001).3

Using these data, Gabriel et al3 developed a hypothetical economic model to estimate the cost of NPWTi-d versus NPWT related to required number of OR debridements (2.0 versus 4.4, respectively) and average length of therapy (4.1 days versus 20.9 days, respectively) in complex extrem-ity and trunk wounds. The NPWTi-d daily estimated cost was $194.80 versus $106.08 for NPWT. The estimated cost of an OR debridement was $3,393. The model showed a potential average cost reduction of $8,143 for OR debride-ments between NPWTi-d ($6,786) and NPWT ($14,929) patients, and a $1,418 difference in average therapy costs between the NPWTi-d ($799) and NPWT ($2,217) groups. Labor costs outside of OR debridement were not consid-ered in the model.3

Results/RecommendationsThe panelists developed several recommendations for

the use of NPWTi-d.

Types of Wounds That May Benefit Most From NPWTi-d

The panelists concurred with published observations that NPWTi-d is primarily suited to prepare surgical or nonsurgical wounds for delayed primary closure. In a review article, Gupta et al13 proposed a clinical approach for appro-priate application of NPWTi-d. The approach recommends consideration of NPWTi-d as part of the wound treatment strategy if the therapy goal is to promote cleansing or gran-ulation (see Table 1). The therapy is used adjunctively with debridement and appropriate systemic antibiotics.

Addressing Challenges in Managing Patients with NPWTi-d

The use of NPWTi-d utilizing various topical wound solutions in conjunction with debridement and systemic

antibiotics has been reported for complex extremity or trunk wounds,3 ischemic, neuropathic, decubitus, or surgi-cal wounds,4,11 infected soft tissue wounds,14 colonized and/or large venous stasis ulcers,5,15 and open fractures, pressure ulcers, nonhealing postoperative dehiscence, and infected he-matoma wounds.10

Based on their experience, panel members made recom-mendations to address the key challenges nurses may face when using the NPWTi-d system.

Maintaining a seal. The cyclical instillation of solutions with NPWTi-d can cause difficulties in maintaining a seal. The panelists believe these challegnes can be addressed (see Table 2).

Gaining proficiency and confidence using the NPWTi-d device. Appropriate use of NPWTi-d within an institution may be difficult. For example, nurses who do not under-stand the therapy may turn off the device when the alarm sounds, instead of troubleshooting and fixing the problem so the therapy remains active. Common issues with the de-vice can be addressed by writing a note on the dressing it-self so all nurses can easily check for accuracy, labeling the solution bag with the therapy settings and projected change time/date, and zip-tying a laminated “tips and tricks” sheet onto the device as a troubleshooting reference that includes the local manufacturer representative’s name and contact information for real-time assistance. Table 3 presents a checklist of quick tasks to be performed and provided for every shift or per hospital policy.

Working as a team. Most of all, it is important to de-velop a team approach in managing NPWTi-d throughout the hospital to encourage a seamless transition of therapy knowledge between nursing shifts. However, educating all nurses within a large hospital to manage NPWTi-d may be unrealistic, and the challenges of educating nurses on differ-ent shifts may be problematic. Table 4 presents panel sug-gestions to help ensure successful management of NPWTi-d within an institution during all shifts.

Table 3. Panel-recommended checklist of device-relat-ed tasks/troubleshooting

Make sure the NPWTi-d device is plugged in and turned on, and ensure the adapter cord and power cord are securely in place.

Make sure there are no unaddressed alarms.

Make sure there is an extra empty canister at the bedside at all times.

Check the canister frequently and change if needed.

Check the solution bag frequently and change if needed.

Check device settings to make sure they are correct.

Check the dressing site to make sure the seal is maintained.

Check that all connectors are secure.


Consolidate supplies for ease of use and education. A re-source box should be accessible to all nurses. These resources, which should include accessories needed to apply the product safely and effectively, can be especially helpful for staff that may not be familiar with NPWTi-d and its various com-ponents. The resource box may be kept in the OR near the NPWTi-d device and supplies. These boxes can accompany nurses when they are checking on or need help troubleshoot-ing problems with patients receiving NPWTi-d. A photo guide demonstrating the application for the current patient’s dressing protocol may be helpful, especially if unique issues such as periwound skin concerns, irregular contours, and the like are present. Also, consider storing an extra canister in pa-tient rooms for ready availability when a canister change is needed. Table 5 lists items to include in the resource box.

Management of instillation solutions. Normal saline, polyhexanide (0.01%), Dakin’s solution (0.125%, Oculus

Innovative Science, Petaluma, CA), and silver nitrate (0.5%) have been instilled with NPWTi-d as reported in litera-ture.2-5,7,11,13,16 A potential challenge in using NPWTi-d is ac-cessibility of solutions; they must be obtained through the pharmacy. Medication safety and delivery mechanisms can be a difficult hurdle to overcome when working to first in-troduce the therapy into a facility. Table 6 lists tips to help nurses introduce and ensure a steady supply of a solution to be instilled with NPWTi-d.

Selection of appropriate instillation volume. Deter-mining the appropriate volume to instill can seem compli-cated at first. The objective is to select enough volume to bathe the wound bed without compromising the dressing seal. Panel suggestions, in addition to experience over time, can give nurses greater confidence in selecting the appropri-ate solution volume to instill (see Table 7).

Recommendations for Pain ManagementSome data suggest pain during dressing changes may

be less pronounced with NPWTi-d compared to standard NPWT.3 The regular flow of solution across the wound bed can help reduce adhesion of the dressing and allow for easier dressing removal. Nevertheless, dressing changes with NPWTi-d can be painful depending on wound location and severity. In cases where pain is a factor, panel members have observed pain is usually the worst at the first dressing change and then decreases progressively. The panel recom-mends several options to help address potential discomfort or pain during dressing change (see Table 8).

Canister size. Two different disposable canister sizes are available for NPWTi-d: 500 mL and 1,000 mL. Canisters

Table 4. Panel recommendations on team building and continuity

Create an environment in which leadership promotes accountability of all nurses in supporting NPWTi-d at the bedside.

When possible, divide NPWTi-d management tasks so the wound care team manages the process of applying the therapy, including dressing changes, while general nurses change the canister and topical wound solution and perform basic troubleshooting.

When therapy is started, bedside education with staff helps establish clear expectations of ongoing assessment, monitoring, and care for the patient with NPWTi-d.

When feasible, the wound dressing should be changed by the same clinician each time for consistency in wound evaluation.

Providers and/or the WOC nursing team should ensure consistent, thorough documentation in the patient’s medical record that outlines NPWT settings including pressure, intensity, dwell times, frequency of instillation cycles, and frequency of dressing changes.

Manufacturer’s training representatives can be used to educate doctors, residents, and materials management staff about NPWTi-d.

Use internal skin/wound champion nurses with the most NPWTi-d experience to reinforce basic troubleshooting techniques for NPWTi-d, including changing canisters and solutions.

Wound care nurses should maintain a close working relationship with prescribers with respect to managing patients with NPWTI-d.

Ongoing quarterly or semi-annual educational oppor-tunities to enhance previously learned concepts and to introduce new nurses to NPWTi-d are valuable to instruction and protocol.

Table 5. Suggested NPWTi-d resource box items

NPWTi-d dressings

NPWTi-d canisters (500 mL, 1,000 mL)

NPWTi-d cassette

Products to protect periwound skin (stoma paste, stoma powder, stoma paste strips)

Skin barrier film (to enhance seal)

Scissors

Permanent marker

Gauze

Extra drape

Photo guide for application of a sample dressing

Written instructions for dressing application, includ-ing where and/or how to obtain topical solution (if not pharmacy)

Troubleshooting tips

Labeled list of items to keep in the resource box (to refill as necessary)

Phone number for 24/7 product support


add incremental cost to the therapy; thus it is important to consider how much fluid will be going into the canister to determine the appropriate size to order for each patient. The 1,000-mL canister is recommended by the panel for over-all cost savings in cases of medium to large wounds, and in most cases of frequent cleansing during NPWTi-d. The 1,000 mL canister is slightly less expensive per mL of volume and can save time due to reduced canister change frequen-cy, as long as it is filled to capacity. The amount of wound

drainage output will be skewed, as the instilled solution will be mixed in with wound drainage.

Based on the panelists’ recommendations, the following calculation may help provide an estimate of canister capac-ity and how many canisters will be needed:

24 (hours per day) ÷ frequency of dwell cycles x mL of solu-tion to be instilled x anticipated days of therapy

For example, with a small chronic (dry) wound and ex-pected solution volume instillation of approximately 20 mL

Table 6. Panel recommendations for managing topical wound solutions for instillation

When starting NPWTi-d at your facility, consider first using a solution such as normal saline that is easily accessible to nurses at your facility and doesn’t require additional regulations by pharmacy.

Calculate when the next bag of instillation fluid will be needed. For example, if you have a 500-mL bag instilling 50 mL at each cycle and cycling every 2 hours (500 ÷ 50 = 10 cycles per bag; 10 x 2 = 20 hours), a 500-mL bag is needed in 20 hours. Label the bag with the estimated time of solution bag change.

When choosing a solution that involves pharmacy, choose a wound care leader who will be responsible for working with the pharmacy. The pharmacy and wound care teams should develop a process that addresses product ordering and any medication delivery safety issues.

Notify pharmacy of the availability of the 38-mm spikeable cap that is included in the NPWTi-d cassette. By utilizing the cap, the instillation solution can be distributed in a bottle instead of an IV bag. This allows for a safer overall process.

Consider obtaining an order to use normal saline, should the prescribed solution not be available.

Make sure orders are clearly written in the electronic medical record regarding frequency, dose, and type of solution for easier communication with pharmacy. Be proactive in letting pharmacy know when the next solution bag is needed.

When possible, involve patients and educate them about the process involved for wound healing, including the level of solution needed in the bag and alarms, so they can play an active role in informing nurses when the amount of solution is getting low.

Nurses should monitor the NPWTi-d fluid status each time they perform routine checks such as IV checks or vital signs.

Table 7. Panel recommendations for appropriate topical wound solution volume

Make sure dressed wound is parallel to the floor to get optimal benefits of NPWTi-d.

Nurses new to NPWTi-d should use the “fill assist” mechanism on the device to help determine the volume of solu-tion to be instilled during each cycle. Fill assist allows a nurse to monitor initial wound fill by manually starting and stopping instillation to determine correct instill volume after the dressing is applied. Once determined, this volume will be the set point for each subsequent instill phase until wound volume changes notably.

Volume may also be approximated by using the calculation suggested by the manufacturer: 0.2 cc/cm2 of wound area.

A basic rule of thumb is to instill just enough solution to visibly saturate the foam. If the foam becomes oversaturated, reduce the amount being instilled by approximately 10% to 20%.

Table 8. Panel recommendations for pain management

Before initiating therapy, develop a plan of care with the patient for pain management. Use a pain scale for the patient to identify pain before therapy and at the end of the procedure so pain can be monitored and addressed. Ongoing assessment of what was painful (eg, removal of the drape or foam) and addressing this with patients validates con-cerns and helps relieve anxiety.

Use the “dressing soak” feature on the NPWTi-d system before dressing changes, which will fill the foam with fluid and allow for easier dressing removal.

Administer oral or intravenous pain and/or anxiety medication per provider order at least 30 minutes before dressing change.

For patients who may have pain during the instillation cycle, consider setting frequency of the cycle to coordinate with ordered pain medication schedule.

Encourage the patient to do deep breathing and relaxation techniques; these are very helpful and work well.

Education about what to expect during the dressing change goes a long way in pain management.


every 3 hours for 3 days until discharge, the total estimated output would be approximately 480 mL (24 ÷ 3 x 20 x 3 = 480 mL). A 500-mL canister may be appropriate for this size of nondraining wound.

Patient and dressing positioning during instillation. Patient positioning during instillation can influence over-all effectiveness of the therapy. Table 9 provides tips to help ensure the patient and the dressing are appropriately posi-tioned during the instillation phase.

Instillation frequency. The negative pressure time be-tween instillation cycles can be set between 1-12 hours. Most studies report an instillation frequency of between 1 and 4 hours.2-4,10,11,13,16 Panel considerations for determining an ap-propriate frequency for instillation are included in Table 10.

Choosing a dwell time. The purpose of the dwell time is to allow the instilled solution to deliver its cleansing prop-erties to the wound bed. Dwell time can be set from 1 sec-ond to 30 minutes on an NPWTi-d device. Prolonged dwell times can contribute to development of dressing leaks and maceration. Selecting an appropriate dwell time depends on a variety of factors and is not an exact science. Nursing panel members reported using dwell times of 3-15 minutes;

dwell times from 1-20 minutes are reported in literature, with a dwell time between 5-10 minutes most often report-ed.2-5,9-11,16 Panel recommendations to help guide clinicians in selecting an optimal dwell time are listed in Table 11.

When to discontinue NPWTi-d. During NPWTi-d, the wound should appear markedly improved at each dressing change. Based on their own experiences, panel members recommended re-examining the patient’s con-dition if the wound does not make progress after 3 days of NPWTi-d. Duration of NPWTi-d depends on the wound and the goals of therapy for that wound.13 The majority of nurse panel members reported an average NPWTi-d treatment duration of approximately 1 week per wound, but this can vary greatly. According to a re-cent literature review by Kim et al.,2 reported length of NPWTi-d ranges from 2-60 days, with the majority of studies reporting an average length of therapy between 7-14 days.2 Panel members also observed NPWTi-d can be longer in the presence of: 1) slough cover, 2) fibrinous exudate, 3) difficult dehisced wounds that require wound closure before patient discharge, and 4) patients who will be discharged to facilities that do not accomodate NPW-

Table 9. Panel recommendations for positioning of patient and dressing

Position the patient so the instilled solution can flow evenly over the wound surface.

With medium- to large-sized wounds, consider using a duo tube set to enhance solution coverage of the wound bed. One tube is positioned to instill on one side of the wound, and the other tube is positioned to remove the solution from the other side of the wound.

Once the instillation therapy is turned on, make sure all areas of the wound bed are receiving instillation, including the distal areas.

Table 10. Panel recommendations for determining instillation frequency

If the patient is mobile, reducing instillation frequency may simplify care as the instill cycle is most efficient if the patient is stationary while the solution is dwelling. With this in mind, it is important to communicate timing of instill cycles with physical and occupational therapy so they can coordinate their sessions accordingly.

Fluid appearance in the canister may help determine instillation frequency. If the canister contents have a dark color, it may indicate the frequency of instillation should be increased.

Consider more frequent instillation and shorter dwell time in highly exudating wounds.

If the dressing is placed in an area where the seal may be easily compromised, less frequent instillation cycles may be optimal.

Table 11. Panel recommendations for determining dwell time

Consider anatomy in selecting a dwell time; a shorter dwell time is recommended in cases where the wound is sur-rounded by contours, such as in the groin area or on the feet.

Wound size should be considered; a shorter dwell time may be optimal for larger wounds to decrease the chances of leaks developing around wound edges.

Always check the product insert information for clinical recommendations when utilizing any solution compatible with the NPWTi-d system.

Dwell time and frequency are not always independent of one another. If a shortened dwell time is needed related to the solution or location of dressing, it may be necessary to increase the frequency to achieve the desired outcome and vice versa.

Wounds should not appear “water-logged” at the end of a dwell cycle. If this or maceration occurs, dwell time should be shortened.


Ti-d. The panel recommends transitioning patients from NPWTi-d when: 1) goals of therapy have been met (i.e., ready for coverage or closure), 2) clinical signs of infec-tion are absent, and 3) good granulation tissue is present and continuing to form (the wound has entered into the proliferative phase of healing).

Sometimes the patient may need to be transitioned before these criteria are achieved. For example, transition can occur if the patient is being transferred to a long-term acute care (LTAC) or a skilled nursing facility where NPWTi-d is not available, or if the patient meets criteria for discharge home. NPWTi-d should not increase the length of stay, but should be seen as an adjunct therapy to be utilized within the patient’s hospital admission. It should be noted the use of NPWTi-d is not intended or cleared for home use.

DocumentationBased on panel member experience, careful documenta-

tion is critical in gaining acceptance of NPWTi-d by hospital administration. Wound status must be documented before and throughout the use of therapy. Wound documenta-tion provides a summary of progression or lack thereof and should be performed per organizational policy. Table 12 lists documentation details recommended by panel mem-bers, as well as the appropriate frequency of documenta-tion. If the electronic medical record is available, the current wound documentation screen may be edited to include the key components of documentation listed in Table 12.

Patient and Family EducationAll panel members agreed educating the patient and fam-

ily about NPWTi-d can be paramount to the therapy’s suc-

Table 12. Panel recommendations for documentation: what to include and when to document

With each dressing change:

Wound characteristics documentation

Location

Wound type

Wound bed tissue

Drainage

Periwound

Odor


NPWTi-d device documentation

Type of foam and number of pieces applied/removed and contact layer if any

Instillation solution used

Amount of instillation solution

Dwell time

Frequency of instillation


Therapy documentation

Provision of pain medication and/or comfort measures before treatment

Use a valid pain assessment tool for pre- and post-recording of pain level identi-fied by the patient

Periwound preparation

Removal of residual dressing (If NPWT, are all foam pieces accounted for?)

Application specifics (Were there any issues [eg, with seal, patient tolerance]?)

Documentation with each shift:

Periwound description

Verify foam is compressed in the wound bed

Verify therapy settings on LCD screen

Solution input/output

Instillation solution in (monitor if this is correct, given instillation orders for amount and frequency)

Instillation solution out (monitor if this is appropriate, given instillation orders for amount and frequency; this should be approximately equal to or more than what is flowing in, as output contains solution mixed with wound drainage)

Weekly documentation: Wound length, width, depth (weekly)

PRN and/or per facility policy:Canister changes

Cassette changes

Discontinue documentation:When NPWTi-d is discontinued, document why and the plan for an alternative dressing/therapy


cess. Getting the patient’s buy-in before the therapy starts is important because patient nonadherence to prescribed therapy can negatively affect outcomes. When properly edu-cated, patients can be a first-line source for reporting leaks and alarms.2 Table 13 lists panel member suggestions for es-tablishing patient compliance during NPWTi-d.

Case ExamplesThe panel members wanted to provide case examples to

demonstrate the adjunctive use of NPWTi-d as part of their overall management of wounds. These cases were selected because they represent various wound types.

Case 1: Foot infection and ulceration in person with Diabetes Mellitus. A 42-year-old man with a foot ulcer present >6 months and a history of uncontrolled diabetes presented with a diabetic foot infection of the left plantar foot (12 cm x 5 cm x 1.5 cm with 0.3 cm undermining and tunneling). The patient was admitted following 1 week of fe-ver >100.1 and chill, left foot erythema and swelling consis-tent with cellulitis. The left foot wound had purulent drain-age. Prehospitalization treatments lasted for 3 weeks and included surgical irrigation and debridement and NPWT. During hospitalization, in addition to broad-spectrum in-travenous antibiotics, strict blood glucose control and strict offloading using crutches/walker for transport to maintain a non-weight baring lower extremity. Surgical and serial sharp bedside debridement were performed 3 times. One toe was amputated due to severe ingrown toenail, presence of ulceration, cellulitis, and toe deformity. NPWTi-d was

initiated 8 days after admission with instillation of normal saline; dwell time was 10 minutes, followed by 3 hours of continuous negative pressure at -125 mm Hg. A reticulated, open-cell foam dressing was used. Dressings were changed 3 times per week. Goals of NPWTi-d therapy were wound bed preparation, granulation tissue formation, and remov-al of infectious materials. NPWTi-d was continued for 1 week followed by NPWT in the home health setting for 2.5 months. The wound closed after 3 months of therapy. Fig-ure 1 shows wound healing progression during 1 week of NPWTi-d (see Figure 1).

Case 2: Fournier’s gangrene. A 69-year-old man pre-sented with Fournier’s gangrene of the perineal region along with an abdominal abscess. The patient was started on in-travenous antibiotics. NPWTi-d was initiated with the goal of wound bed preparation between debridements, granula-tion tissue formation, and removal of infectious materials. A sodium hypochlorite solution (1:20) was instilled with a 10-minute dwell time followed by 4 hours of continuous NPWT at -125 mm Hg. A reticulated, open-cell foam dress-ing was used. Dressings were changed 3 times per week, and NPWTi-d was continued for 10 days. Therapy then changed to conventional NPWT and collagen-oxidized regenerated cellulose (C/ORC) dressings with silver (PROMOGRAN™

PRISMA Wound Balancing Matrix, Systagenix, an Acelity company, San Antonio, TX). NPWT was discontinued after 2 weeks and the wound was treated with C/ORC dressings with silver for the remainder of healing time. The wound was >75% re-epithelialized at 40 days and nearly healed at 60 days post initiation of NPWTi-d (see Figure 2).

Table 13. Panel recommendations for establishing patient adherence with NPWTi-d

Take time with each patient. Ask questions of the patient to help establish a relationship: What are your goals for this hospitalization? What is your job? Where do you live?

Individualize patient care plan and educate patient on factors that optimize wound healing, such as proper nutrition and blood sugar control.

Teach patient and family breathing and relaxation techniques before the first dressing change. Utilize the family as a resource to coach the patient through the procedure. This empowers both the patient and family.

Explain to patient and family in advance what will happen with the therapy, always with respect toward patient’s culture and customs.

Educate patients about the therapy, including device and disposables, to empower them to feel in control. Ask patients to repeat what they understand.

Share success about the therapy to offer support and give hope — i.e., how much the wound size is decreasing.

Do not make promises to patients regarding healing time; provide an open-ended time frame. “I don’t know,” “Anything can happen along your journey to healing,” and “I will work my hardest” are acceptable answers.

Teach patients to advocate for themselves and to know how the dressing change should feel, when to change the canister or solution, or how the wound should progress.

Establish ongoing rapport with the patient. Conversation can distract patients from their pain, which can be a great help in certain wound types.

Mobilize patients when possible; get physical therapy or occupational therapy involved when needed.

Do your best to enhance the patient’s quality of life. Nurses observe that better quality of life means quicker closure.

Set limits with patients (e.g., discourage inappropriate language).

Be empathetic. Inject dignity and humor when appropriate.


Case 3: Pressure ulcer and necrotizing fasciitis. A 54-year-old man with a history of paraplegia, hypokalemia, protein calorie malnutrition, and urinary tract infection presented with a pressure ulcer on the ischial tuberosity (IT)/buttock. The wound measured 8.5 cm x 28 cm x 4 cm with slough and 5.2 cm undermining extending from the right buttock to the right groin. Necrotizing fasciitis infection was suspected and confirmed via CT scan. Surgical debridement was performed, followed by a second minor debridement 4 days later. Intra-venous antibiotics (vancomycin and pireracillin/tazobactam) were started and NPWTi-d initiated. NPWTi-d included in-stillation with 85 mL of 0.125% Dakin’s solution, 15-minute dwell time, followed by 8 hours of continuous negative pres-sure at -150 mm Hg. No-Sting barrier spray was applied to the periwound skin followed by the NPWTi-d drape. A re-ticulated, open-cell foam dressing specifically designed for instillation and a double negative pressure tube set (V.A.C. VeraT.R.A.C. Duo™ Tube Set, KCI, an Acelity company, San Antonio, TX) were used to ensure solution coverage of the buttock and groin wound. The dressings were changed 2 times per week. Wound progression with NPWTi-d is shown in Figure 3. After 4 days of NPWTi-d, the wound measured 5 cm x 28 cm x 5.5 cm and was clean, pink and red. Granula-tion tissue was noted in the wound after 7 days of NPWTi-d. Granulation tissue formation continued after 11 days of NPWTi-d. A tunnel in the ischial tuberosity region with pu-rulent drainage was monitored, and after 15 days of NPWTi-

d, the region was much improved and NPWTi-d was discon-tinued. The patient was discharged to a LTAC hospital. The wound closed secondarily after 4 months.

ConclusionA review of some of the available literature, plus the

panel discussions and recommendations suggest NPWTi-d, in conjunction with debridement and systemic antibiotics, may be a useful tool in the adjunctive management of heav-ily contaminated, colonized, or infected acute or chronic wounds. The therapy appears to be particularly well suited for challenging wounds that require delayed surgery and/or when the goal is to cleanse the wound or facilitate granu-lation tissue formation. Compared to conventional NPWT, NPWTi-d has been reported to lessen bacterial load and enhance granulation tissue formation, while reducing the average number of surgical debridements. However, this new technology can present usage challenges. Compared to NPWT, NPWTi adds the complexity of an instilled so-lution and new device settings, requiring a well-organized approach for effective wound management.

In managing NPWTi-d, the panel agreed that it is important to develop a team approach throughout the hospital to encourage a seamless transition of therapy us-age knowledge between nursing shifts and departments. Building and educating a team of nurses who are respon-sible for basic troubleshooting will help ensure optimal

Figure 1. Diabetic foot infection with ulceration: a) wound before NPWTi-d initiation; b) wound following 2 days of NPWTi-d and surgical debridement (including second toe amputation); c) wound after sharp bedside debridement followed by 5 days of NPWTi-d.

(Patient information and photos courtesy of Kimberly Hall, DNP, RN, GCNS-BC, CWCN-AP).


NPWTi-d functioning around the clock. The panel also suggested all nurses should be armed with a short check-list of tasks to be performed at every shift, as well as read-ily accessible supplies to help ensure positive outcomes. In addition, teamwork between wound care and phar-macy is encouraged to ensure a successful process for ob-taining and maintaining instillation solutions.

Manufacturer representatives can provide ongoing educa-tion for nurses, doctors, residents, and others who would ap-ply the therapy. They can assist in expanding knowledge about optimal device usage, including patient positioning, device settings, and pain management during NPWTi-d. Nurse ed-ucation also should include tips in maintaining a seal during NPWTi-d, including good periwound preparation, strategic placement of the negative pressure connector pad, and appro-priate instillation settings. Thorough wound assessment and documentation is paramount for monitoring outcomes. Estab-lishing a good rapport with the patient and family and educat-ing them about NPWTi-d are also considered to be important steps in achieving success. The panel suggested that improved knowledge about and support for NPWTi-d throughout an

institution would help empower nurses to provide the highest standard of care in managing patients using NPWTi-d.

Currently, further research regarding NPWTi-d efficacy and optimal clinical practices for a variety of wound types is needed. The clinical effects of changes in negative pres-sure, instilled solution, dwell time and frequency need to be further substantiated in comparative studies. In addi-tion, controlled clinical studies measuring effectiveness of pain reduction methods during dressing changes could aid patient care. Future robust, controlled studies to examine the effects of institutional factors (e.g., nurse/patient edu-cation and team building programs) on outcomes of care using NPWTi-d are needed to validate the results of this panel meeting and resultant recommendations.

Randomized, controlled clinical studies are needed to compare the safety, efficacy, and effectiveness of NPWTi-d to other, non-NPWT methods of care. Panel participants also recommend that prospective, randomized, controlled scientific and clinical studies should be conducted to in-vestigate the effect of NPWTi-d versus standard irrigation practices on bacterial counts and patient outcomes. n

Figure 2. Wound resulting from Fournier’s gangrene a) at presentation; b) after 6 days of NPWTi-d, slough was de-creased and wound was granulating; c) 11 days following initiation of NPWTi-d, the wound was 100% granulated and beefy red with healthy wound edges; d) therapy was changed from NPWTi-d to conventional NPWT with C/ORC dressings with silver. NPWT was discontinued after 2 weeks and the wound was treated with C/ORC dressings with silver for remainder of healing time; e) the wound was >75% re-epithelialized at 40 days; and f) nearly healed at 60 days post initiation of NPWTi-d.

(Patient information and photos courtesy of Rose Raizman, PHCNP, ET).


AcknowledgmentThe authors thank Karen Beach and Ricardo Martinez

(Acelity) for their assistance in editing this manuscript and are grateful to all of the panel participants: Melissa McKa-nna, RN, Union Hospital, Terre Haute, IN; Jamie Geraci, CWON, BSN, RN, Bethesda North Hospital, Amelia, OH; Kimberly Hall, DNP, RN, GCNS-BC, CWCN-AP, Carilion Clinic, Roanoke, VA; Brigitta Hauan, RN, UW Northwest Hospital, Seattle, WA; Melania Howell, RN, Emanuel Medi-cal Center, Turlock, CA; Trudy Huey, MSN, RN, CWOCN, Catawba Valley Medical Center, Hickory, NC; Adora Lucius, RN, UT Southwestern Medical Center, Dallas, TX; Susan Mendez-Eastman, RN, CWCN, CPSN, Certified Wound Nurse, Nebraska Medicine, Bellevue, NE; Kedrin Purcell, RN, Select Specialty Hospital, Newberry, FL; Rose Raizman, PHCNP, ET, Shoshray Consulting, Toronto, ON; Dawn Shepherd, BSN, RN, CWON, CFCN, Parkland Health and Hospital System, Dallas, TX; and Allen Gabriel, MD, FACS, PeaceHealth Medical Group, Vancouver, WA.

References1. Kim PJ, Attinger CE, Steinberg JS, Evans KK. Negative pressure wound thera-

py with instillation: past, present, and future. Surg Technol Int. 2015;26:51–56.2. Kim PJ, Attinger CE, Crist BD, et al. Negative pressure wound therapy with instilla-

tion: review of evidence and recommendations. Podiatr Today. 2015;suppl:1-20.3. Gabriel A, Kahn K, Karmy-Jones R. Use of negative pressure wound

therapy with automated, volumetric instillation for the treatment of ex-tremity and trunk wounds: clinical outcomes and potential cost-effec-tiveness. Eplasty. 2014;14:e41.

4. Kim PJ, Attinger CE, Steinberg JS, et al. The impact of negative-pressure

wound therapy with instillation compared with standard negative-pres-sure wound therapy: a retrospective, historical, cohort, controlled study. Plast Reconstr Surg. 2014;133(3):709–716.

5. Goss SG, Schwartz JA, Facchin F, Avdagic E, Gendics C, Lantis JC II. Negative pressure wound therapy with instillation (NPWTi) bet-ter reduces postdebridement bioburden in chronically infected lower extremity wounds than NPWT alone. J Am Coll Clin Wound Special. 2014;4(4):74–80.

6. Gabriel A. Integrated negative pressure wound therapy system with vol-umetric automated fluid instillation in wounds at risk for compromised healing. Int Wound J. 2012;9(suppl 1):25–31.

7. Gabriel A, Rauen B. Simplified negative pressure wound therapy with instil-lation: advances and recommendations. Plast Surg Nurs. 2014;34(2):88–92.

8. Gabriel A, Shores J, Heinrich C, et al. Negative pressure wound therapy with instillation: a pilot study describing a new method for treating in-fected wounds. Int Wound J. 2008;5(3):399–413.

9. Fluieraru S, Bekara F, Naud M, et al. Sterile-water negative pressure in-stillation therapy for complex wounds and NPWT failures. J Wound Care. 2013;22(6):293–299.

10. Brinkert D, Ali M, Naud M, Maire N, Trial C, Teot L. Negative pressure wound therapy with saline instillation: 131 patient case series. Int Wound J. 2013;10(suppl 1):56–60.

11. Kim PJ, Attinger CE, Oliver N, et al. Comparison of outcomes for normal saline and an antiseptic solution for negative-pressure wound therapy with instillation. Plast Reconstr Surg. 2015;136(5):657e–664e.

12. Lessing C, Slack P, Hong KZ, Kilpadi D, McNulty A. Negative pressure wound therapy with controlled saline instillation (NPWTi): dressing prop-erties and granulation response in vivo. Wounds. 2011;23(10):309–319.

13. Gupta S, Gabriel A, Lantis J, Teot L. Clinical recommendations and practical guide for negative pressure wound therapy with instillation. Int Wound J. 2015 May 23. doi: 10.1111/iwj.12452. [Epub ahead of print].

14. Schintler MV, Grohmann M, Donia C, Aberer E, Scharnagl E. Manage-ment of an unfortunate triad after breast reconstruction: pyoderma gan-grenosum, full-thickness chest wall defect and Acinetobacter baumannii infection. J Plast Reconstruct Aesthetic Surg. 2010;63(7):e564–e567.

15. Raad W, Lantis JC, II, Tyrie L, Gendics C, Todd G. Vacuum-assisted clo-sure instill as a method of sterilizing massive venous stasis wounds prior to split thickness skin graft placement. Int Wound J. 2010;7(2):81–85.

16. Wolvos T. The use of negative pressure wound therapy with an auto-mated, volumetric fluid administration: an advancement in wound care. Wounds. 2013;25(3):75–83.

Figure 3. a) Pressure ulcer following postoperative debridement. The wound measured 8.5 cm x 28 cm x 4 cm with slough and 5.2 cm undermining extending from the right buttock to the right groin; b) after 4 days of NPWTi-d [AU: and minor surgical debridement?], the wound measured 5 cm x 28 cm x 5.5 cm and was clean, pink, and red; c) granulation tissue formed in the wound after 7 days of NPWTi-d; d) granulation tissue formation continued after 11 days of NPWTi-d. A tunnel in the ischial tuberosity (IT) region with purulent drainage was monitored; e) after 15 days of NPWTi-d, the IT region was much improved and NPWTi-d was discontinued.

(Patient information and photos courtesy of Gina Rose, CWOCN, BSN, RN and Jamie Geraci, CWON, BSN, RN).

Try V.A.C. VERAFLO™ Therapy InsteadIn an independent, retrospective study of 142 patients, physicians at MedStar

Georgetown University Hospital, Center for Wound Healing examined the impact of V.A.C. VERAFLO™ Therapy with PRONTOSAN® Wound Irrigation Solution versus

V.A.C.®Therapy and noted the following potential benefits:*

*Kim PJ, Attinger CE, Steinberg JS, et al. The Impact of Negative-Pressure Wound Therapy with Instillation Compared with Standard Negative-Pressure Wound Therapy: A Retrospective, Historical, Cohort, Controlled Study. Plast. Reconstr. Surg.2014; 133: 709-716.

REDUCED LENGTH OF STAY | REDUCED OR VISITS REDUCED TIME TO FINAL SURGICAL PROCEDURE

ARE YOU STILL MANAGING WOUNDS THE WAY YOU

DID 20 YEARS AGO?

NOTE: Specific indications, contraindication, warnings, precautions and safety information exist for the System. Please consult the Clinician Guide Instructions for Use prior to application. Rx only.

©2016 KCI Licensing, Inc. All rights reserved. V.A.C., V.A.C.ULTA, and V.A.C. VERAFLO are trademarks of KCI Licensing, Inc. PRONTOSAN is a trademark of B.Braun, Inc. 16-0174.US (2/16)

Supplement to April 2016www.o-wm.com

OWMo s t o m y w o u n d m a n a g e m e n tFrom science to Practice: contemPorary aPProaches to skin, wound, ostomy, and incontinence care

®

Clinician Panel Recommendations for Use of Negative Pressure Wound Therapy with Instillation Melissa McKanna, RN; Jamie Geraci, CWON, BSN, RN; Kimberly Hall, DNP, RN, GCNS-BC, CW-CN-AP; Brigitta Hauan, RN; Melania Howell, RN; Trudy Huey, MSN, RN, CWOCN; Adora Lucius, RN; Susan Mendez-Eastman, RN, CWCN, CPSN; Kedrin Purcell, RN; Rose Raizman, PHCNP, ET; Dawn Shepherd, BSN, RN, CWON, CFCN; and Allen Gabriel, MD

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Clinician Panel Recommendations for Use of Negative Pressure