Vacuum instillation therapy (VIT)

It is a modernization of vacuum wound therapy technology which provides the possibility of automatic medical solution supply into the wound bed without removing a dressing. Therapeutic effect is achieved when the system operates in three different phases: Vacuum phase, Solution supply phase and Solution exposure phase. Due to this, solution is evenly distributed and does not leave the wound chamber before a preset time.

 Functional principles of vacuum instillation therapy

 This is a modification of traditional vacuum therapy, which provides the possibility to instill physiological saline solution, antiseptic or antibiotic into the wound chamber (2). Use of automatic operation algorithms permits to control the level and time of negative pressure maintenance, solution supply volume, solution exposure time, and also permits to use a therapy in cyclic mode. VIT is successfully used in the world practice for treatment of acute wound infections (3.4-10) however some international studies suggest the application of vacuum instillation therapy (VIT) to non-infected wounds, where VIT with a physiological saline solution has some advantages in comparison with a traditional vacuum wound therapy or other traditional treatment methods. (11, 12, 13)

Method of action

Instillation therapy is conducted together with a traditional vacuum wound therapy; the required amount of a medicinal solution is supplied into the polyurethane foam sponge through the additional port, then the medicinal solution is evenly distributed in the wound chamber with a solution exposure within a preset period of time (vacuum motor is turned off during a solution exposure); vacuum phase activates and solution is drained after completion of the exposure phase. Cycle of operation and time of each phase is set individually by the specialist. To achieve a sufficient therapeutic effect, the instillation phase shall be carried out several times a day. Solution supply time (depending on the solution volume, may vary from 10 to 280 seconds), solution exposure time (depending on the solution and wound type, for example, 20 minutes) and vacuum phase period (for example, 2-3 hours).

 The first phase (instillation) lasts for 10-280 seconds, the vacuum line is closed at this time, and the instillation line is open and supplies the solution firstly to the sponge through the additional port; the solution is distributed evenly over the entire wound surface. Solution is distributed evenly in the wound during instillation due to the difference between atmospheric pressure and pressure in the wound. Wound surface completely contacts with a medicinal solution. The second phase starts after the achievement of a preset solution volume.

The second phase (solution exposure)

 Medicinal solution has a therapeutic effect after the achievement of a preset solution volume in the wound chamber. Vacuum and instillation lines are closed, preventing a solution leakage from the system and allowing it to reach the entire area of the wound. The duration of this phase is based on the pharmacodynamics of the solution used, and the particular characteristics of wound. Phase operation time is usually constitutes 5-30 minutes.

 The third phase (vacuum)

 The initial negative pressure is restored at the beginning of the third phase, at the same time the solution is drained together with the wound fluid. Duration of vacuum phase depends on the clinical aspects, exudate viscosity and specialist’s opinion. It may take from 30 minutes to some hours.

 Due to VIT hardware algorithms and the possibility to supply a medicinal solution, a number of required dressings reduces, even in comparison with a traditional vacuum wound therapy, because the instillation phase provides for a constant, systematic wound cleaning that opens new possibilities in wound treatment.

 A number of long durable and often painful dressings is significantly reduced for both doctors and patients. Thus, Vacuum Instillation Therapy (VIT) improves patient comfort, convenience and quality of life. In addition, use of VIT significantly saves costs for the treatment of acute and chronic wounds. First of all, it is the automation of treatment process, ensuring safety (reinfection), efficiency and comfort. Container for exudate collection also serves for the collection of “used” medicinal solution.

Comparison of vacuum instillation therapy and passive drainage

 Vacuum instillation therapy (VIT) shall not be confused with irrigation-suction drainage (14), when a continuous directed liquid flow of fluid is ensured; this directed liquid flow naturally follows the shortest path along the pressure gradient between the inflow through the infusion line and the output through the drainage tube. Use of irrigation-suction drainage implies the creation of dead zones in the vicinity of these “irrigation routes”. These areas are no longer washed even after several cycles, and thus may be saved as septic pockets. With VIT, wound is completely filled with a polyurethane foam sponge, system is closed, and method is not-flowing, so that a creation of “dead zones” is improbable.

Indications for vacuum instillation therapy

 Current experience of VIT application includes the following indications for its use:

 - Septic wounds: soft tissues after the initial surgical treatment (acute infections, especially postoperative infections, are considered as the most favorable indications for VIT), osteitis, osteomyelitis (chronic soft tissue and bone infections after surgical removal of septic focus)

 - General surgery: abdominal sepsis, resistant bacterial wound infection after liver transplantation (15.16)

 - Thoracic surgery: para- and post-pneumonic pleura empyema, bronchopleural fistula with thoracic empyema, mediastinitis after cardiac surgery (however, this is for purposes other than intended) (17-20)

 - Severe periprosthetic infection in the result of breast reconstruction (21)

 - Injury and orthopedics: complex fracture, acute complex wounds of the lower extremities, endoprosthesis infections, infection in the area of the implant bed (in many cases, aseptic was achieved even without removing material for osteosynthesis). (22-27) However, treatment of such wounds may be limited due to fluid retention risk.

 - Necrotic fasciitis and gas gangrene. (28-30)

 - Chronic wounds, such as diabetic ulcers of the lower extremities. (31-37)

 - Uncomplicated wounds, where instillation therapy may additionally improve the patency of polyurethane foam sponge that maintains tightness and increases the intervals between dressing changes. Ringer's solution may be used for instillation in case of aseptic wounds to increase the formation of granulation tissue. (38-40)

 - Painful wounds (postoperative wounds or infection-related pains may be useful from time to time during instillation of local anesthetics; it may also be an option when a painful dressing change is expected). (41)

Solution for Vacuum Instillation Therapy

 Usually, the course of vacuum instillation therapy (VIT) constituted 7-14 days, however, one group of authors used VIT for up to 3 weeks. (42) Continuing the application of VIT using various instillation fluids:

 • 0.9% physiological saline solution: the average duration of VIT for 12 days, 4 cycles per day, exposure for 5 or 60 minutes. (12.43-45)

 • Polyhexanide: 0.02% or 0.04%, exposure time - 20 minutes, for 4-8 days. 4-8 cycles per day. (22.46-51)

 • Octenidine-based irrigation solution: exposure time - 3 minutes, 4-8 days, 2 cycles per day. (2.52)

 • Acetic acid solution: 1% solution, exposure time - 20 minutes, for 4-8 days, 4-8 cycles per day (48.53)

 • Super-oxidized water: repeated every 2-4 hours with the exposure time of 5-10 minutes (31.54)

 • Dakin's solution: every hour for 10 minutes, diluted by 12.5% for 10 days (54.55)

 • Potassium permanganate solution: 1:5000 (56)

• Antibiotic solution: such as doxycycline, colistin, and rifampicin (16, 57, 58, 59)

• Insulin (60.61)

 VIT is increasingly used as the adjunctive therapy for a wide range of acute and chronic wounds.

In particular, over the past ten years, VIT is very important for the treatment of postoperative infected wounds. Use of instillation permitted to enhance the possibilities of traditional vacuum wound therapy in difficult situations using solutions of antiseptics and antibiotics. Nevertheless, the literature shows that the role of vacuum of instillation therapy continues to enhance and may be used today also for the treatment of both acute and chronic infected wounds to support the wound healing process, mainly due to the physiological saline solution supply into the wound chamber.

 Despite the growing popularity, there are few publications on this technique. However, available studies show that VIT is an effective treatment protocol. It has been shown that it helps to reduce healing time, ensures long-term functional and positive cosmetic results in patients with severe difficult clinical situations, and potentially helps to accelerate wound closure.

 Review and analysis of literature shows that vacuum instillation therapy in certain clinical situations is more useful than the traditional vacuum wound treatment method, for the additional treatment of acute and chronically infected wounds requiring hospitalization. (39) In addition, there are clinical observations proving that VIT with physiological saline solutions is more effective for healing than simple vacuum wound therapy. As a future trend, it shall be clarified from the scientific point of view and evaluated from the point of view of economic efficiency, whether all uninfected wounds shall be treated using vacuum instillation therapy and physiological saline solution. (62-64)

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