EFFECTIVENESS OF NEGATIVE PRESSURE WOUND THERAPY IN THE TREATMENT OF DIABETIC FOOT ULCERS
According to W.H.O. (2014), the number of people with diabetes has increased four-fold from 1980 with an estimate of 422 million affected adults in 2014. Diabetes Australia (2016) has declared it as a 21st century epidemic causing a big challenge in the Australian health care system.
The disease process can cause various complications that are detrimental to a person’s health and lifestyle. One of the serious complications from this disease is diabetic foot ulcers. It is associated with peripheral neuropathy and poor circulation the lower limbs, either of which may lead to foot ulcers and infections, and eventually to amputations. Diabetes is the leading cause of non-traumatic lower limb amputation (Siitonen et al., 1993, The Global Lower Extremity Amputation Study Group, 2000).
To address this particular complication and avoid lower limb amputation, a number of researches have been aimed on avoiding and treating diabetic foot ulcers. One method is known as Negative Pressure Wound Therapy and according to research
“is a recently developed wound treatment modality based on vacuum-sealing drainage and vacuum-assisted closure to create a localized controlled negative-pressure environment. There is a large body of data showing that negative-pressure wound therapy promotes granulation tissue growth and wound healing by increasing local blood flow, eliminating tissue edema, removing exudates and proinflammatory cytokines, inhibiting bacterial growth, and promoting cell hyperplasia.” (Chen, Guo, Hu, Tang, Zhu, 2014)
This research aims to study the effectiveness of Negative Pressure wound therapy for diabetic foot ulcers and explore the benefits of this treatment. This could be a vital aid for the healthcare worker to appreciate the effectivity of NPWT and understand the various advantages this method will give the patients with diabetic foot ulcers.
Ayala, Blume, Lantis, Payne and Walters (2008) conducted a study comparing NPWT and Advanced Moist Wound Therapy (AMWT). Randomized controlled trial was utilized for the study involving 342 screened subjects. Debridement, if necessary, was done before the start of the trial. 169 subjects underwent NPWT, 166 received AMWT, while 7 subjects did not undergo any treatment. NPWT was performed every 2-3 days as needed but not lesser than three days a week. AMWT was performed utilizing the product guidelines. Check up and examination was done weekly for a month and then every other week there after until ulcer closure or research end date. The healing process not only involved the two main methods, the research had to utilize various methods as well to aid in the proper healing of the wound ulcer such as “debridement, assessment, and treatment of infection, and revascularization if indicated, and sufficient off-loading of the foot” (Ayala et al., 2008). It has been well established in the study that debridement was a vital procedure in order to fully achieve positive NPWT and AMWT results. The study concluded that the “results of the largest NPWT RCY to date demonstrate that NPWT is as safe and more efficacious than AMWT in the treatment of DFUs” (Ayala et al., 2008). It is very important for us nurses to evaluate and assess patient’s condition to be able to give the patient the optimum care. Understanding the healing process and the right intervention for each stage of healing are essential skills to be able to give the best outcome possible. In the outpatient setting, compliance to treatment and follow up check ups are very important. It is the nurse’s job to follow up and educate well the patient regarding adherence to doctor’s orders.
Another study by Etöz, Özcan, Özgenel (2004) compared both NTPW and traditional moist gauze dressing as a management for diabetic foot ulcers before undergoing surgical closure. On the first week, presence of granulation was observed with the conjunction of decreased edema on the leg. The treatment went on an average of 11.25 days on for the NPWT group while it took an average of 15.75 days for the control group to achieve intended results. “The mean length of treatment was 11.25 days in the NPWT group and 15.75 in control group (p=0.05). After the therapy, the mean diabetic wound surface area decreased from 109cm2 to 88.6cm2 (20.4cm2) in the NPWT group and decreased from 94.8cm2 to 85.3cm2 (9.5cm2) in the control group (p=0.032)” (Etöz, Özcan, Özgenel, 2004). One patient who underwent NPWT did not require a surgical procedure for the closure of the wound ulcer. From the results, NPWT not only decreases the possible hospital stay of the patient but may also lessen the cost of hospitalization especially if no surgical intervention would be necessary at the end of the treatment plan. In countries like the Philippines, a significant percentage of the population refuses to undergo treatment due to lack of financial resources. NPWT may be expensive at first glance, but the amount of money saved from fewer days of hospitalization and possibly avoidance of surgical intervention makes it a cost-effective approach to treating diabetic wound ulcers.
The research of Cunningham, Nielson, Stover and Zelen (2011) studied the effectiveness of negative pressure wound therapy with integrated irrigation of diabetic foot ulcers. The study utilized the same method as the first two studies with minimal emphasis on irrigation with 1000cc sterile normal saline before NPWT, which may lead to additional benefits. Although not much was divulged about this aspect of the therapy since the focus was on the use of NPWTs and their effectiveness. The trial went on for 6 weeks and, using the different inclusion criteria, there were 19 subjects who were qualified to undergo treatment. In an average of 34 days (range, 9-124), 14 out of the 19 subjects completed the treatment and showed complete healing through NPWT. Patients whose DFUs haven’t completely healed after the six week evaluation period and saw the benefits of NPWT opted to continue with the treatment. Out of the nineteen, one patient developed cellulites and infection on the site. Because of the complications, patient was admitted to the hospital but despite medical interventions, limb amputation was decided.
“Annually, there are about 10 000 hospital admissions for diabetes-related foot ulcers (DRFUs) in Australia, with lower limb amputation a common outcome” (Alford, Allard, Bergin, Gurr, Holland, Horsley, Kamp, Lazzarini, Nube, Sinha, Warnock, Wraight, 2012). Limb amputations have a big impact on the life of the patient not only physically but emotionally, psychologically and socially as well. It is for that reason that nurses must educate the patients of managements that would help them avoid this life changing complication.
In conclusion, Negative Pressure Wound Therapy is very well known to improve the healing process in diabetic foot ulcers. This procedure decreases wound size and wound healing time as well. As nurses who are aware of the minor and major complications of diabetes mellitus, we have to work hand in hand with the healthcare team and the patient in making sure that minor complications such as diabetic foot ulcers do not develop with the need to amputate the limb. Strategies such as Negative Pressure Wound Therapy not only aid in the healing process of the wound ulcer but at the same time provide other benefits to the patient involved. Compliance and proper management with NPWT will lead to decreased length of hospital stay and reduced risk for surgical interventions therefore decreasing hospital costs.