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The Effects of Normal Saline Instillation in Conjunction With

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					                                                                                         TE
 ORIGINAL RESEARCH

                                           The Effects of Normal Saline
                                           Instillation in Conjunction With




                                                                      A
                                           Negative Pressure Wound Therapy
                                           on Wound Healing in a Porcine




                                                                   IC
                                           Model

                                           Braden K. Leung, PhD; Lori A. LaBarbera, BS; Christopher A.
                                           Carroll, MS; Diwi Allen, MS; Amy K. McNulty, PhD



WOUNDS 2010;22(7):179–187

From Kinetic Concepts, Inc.,
San Antonio, Texas                                   PL
                                             Abstract: Acute and chronic wounds impact the lives of millions of
                                             patients. Since its introduction, negative pressure wound therapy
                                             using reticulated open cell foam (NPWT/ROCF) has significantly
                                             improved the healing outcome for many of these wounds. Methods.
                                             The effects of intermittent instillation of normal saline in conjunction
                                    DU
Address correspondence to:                   with NPWT were investigated to determine if instillation therapy pro-
Braden K. Leung, PhD                         vides additional benefits in wound healing. Conventional NPWT/ROCF
Kinetic Concepts, Inc. (KCI)                 as delivered by V.A.C.® Therapy was compared to V.A.C. Instill®
Global Research and Development              Therapy with normal saline in the treatment of porcine full-thickness
6203 Farinon Dr.                             excisional wounds. Wounds were treated with NPWT/ROCF or
San Antonio, TX 78249                        NPWT/ROCF with instillation therapy at approximately 4 cycles of nor-
Phone: 210-515-4026                          mal saline instillation per day and dwell times of either 5 or 60 min-
Email: braden.leung@kci1.com                 utes for the instilled saline on the wound bed. Results. Instillation
                                             therapy with normal saline at either dwell time elicited a faster rate of
Disclosure: Financial support for execu-     wound filling with granulation tissue that contained an increase in
                        T


tion of this study was provided by           total collagen content compared to continuous NPWT/ROCF alone.
Kinetic Concepts, Inc. (KCI)                 Analyses of wound contraction and the hydration state of the treated
                                             tissue exhibited no apparent differences between the experimental
                                             instillation therapy groups and the control NPWT/ROCF group.
    NO



                                             Conclusion. Collectively, these data suggest that instillation therapy
                                             with normal saline may lead to wound fill with higher quality granula-
                                             tion tissue composed of increased collagen following wounding of
                                             cutaneous tissue compared to the use of NPWT/ROCF alone.




                                                    egative pressure wound therapy using reticulated open cell foam

                                           N        (NPWT/ROCF) has proven to be effective in healing wounds faster
DO




                                                    than traditional moist wound healing approaches.1–4 More than 500
                                           publications, including at least 20 randomized controlled trials (RCTs), have
                                           shown the benefits of NPWT/ROCF in wound healing. This enhancement in
                                           wound healing may occur through multiple mechanisms including, but not
                                           limited to, uniform drawing of the wound edges together, stimulation of per-
                                                                                  Vol. 22, No. 7 July 2010           179
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  Leung et al


fusion, and removal of fluids and infectious materials that      face for a predetermined amount of time. At the end of
may be present within the wound.5,6 These outcomes of            the specified dwell time, vacuum is once again applied,
NPWT, among many others, promote the ability to fill a           thereby removing the irrigation fluid and wound exu-




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wound defect with granulation tissue,7,8 which is a key          date. Current indications for use of instillation therapy
requirement for proper wound closure.The rate at which           include patients who would benefit from NPWT/ROCF
a wound heals is highly dependent on the granulation             in conjunction with the controlled delivery and drainage
process.                                                         of topical wound solutions to and from the wound bed,




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    Traditional wound care routinely involves cleansing          respectively. Specifically, this system has proven to be
the wound with aqueous solutions such as water or nor-           effective for the removal of infectious material and for
mal saline.Typically, wounds are cleansed at least at every      decreasing the bacterial burden in infected wounds.15,16
dressing change, if not more frequently. Keeping the             However, to date, the effects of combining saline instilla-
wound properly cleansed is believed to mitigate factors          tion with NPWT/ROCF on the rate and quality of granu-
that impair wound healing.9 Wound cleansing with a non-          lation tissue formation as part of the wound healing con-




                                                       PL
toxic fluid (eg, water or normal saline) has been shown          tinuum are unknown.
to remove debris, wound exudates, and detrimental cel-               A combinatorial therapy approach with both
lular products that may be present in the wound bed              NPWT/ROCF and normal saline instillation was hypoth-
while also removing any nidus for bacterial infection.10         esized to result in improved wound bed preparation,
This, in turn, may aid in creating an optimal wound bed          enhance the rate of wound filling, and potentially
environment for wound healing. Instillation therapy              enhance the quality of granulation tissue present in a
combines NPWT/ROCF with the ability to instill fluids            wound bed due to intermittent cleansing of the wound
                                    DU
into the wound during breaks in the application of               during NPWT/ROCF Therapy. Since published RCTs
NPWT. Based on its potential wound cleansing attributes,         have shown the benefits of NPWT/ROCF over moist
the goal of this strategy would be to combine these two          wound healing,4,17 the current study was designed to
therapies (ie, wound cleansing and NPWT/ROCF) to                 examine whether or not combining instillation therapy
determine if there is a synergistic effect, leading to fur-      with normal saline to NPWT/ROCF would offer addi-
ther acceleration of the wound healing process and the           tional benefits. This study examined the rate of wound
development of granulation tissue beyond that seen with          filling in full-thickness excisional dermal wounds in
the use of NPWT alone.                                           swine over a 9-day period. During this time,
    Various types of solutions have been recommended             NPWT/ROCF was applied either alone or in conjunction
for use in the cleansing of wounds. For example, fluids          with the instillation of normal saline at defined time
                        T


with antiseptic properties have been traditionally used          points each day. Tissue biopsies were isolated at the end
for the treatment of infected wounds; however, pub-              of the in-life phase and processed to determine the
lished preclinical research has suggested that antiseptic        wet:dry tissue weight ratio and for HPLC analysis of total
      NO



solutions may hinder the healing process.11 As such, nor-        collagen content. The results of the present study sug-
mal saline (0.9% NaCl) is currently the favored wound            gest that instillation of saline in conjunction with
cleansing solution for non-infected wounds because it            NPWT/ROCF increases the rate of wound fill and leads
is isotonic, and as such, does not interfere with the nor-       to better quality of granulation tissue as determined by
mal healing process, induce tissue damage, cause sensi-          the total content of collagen when compared to use of
tization/allergies, or alter the normal bacterial flora of       continuous NPWT/ROCF alone.
the skin.12
    As a means to combine NPWT/ROCF with a wound                 Methods
cleansing lavage or the ability to introduce antiseptic flu-        The Institutional Animal Care and Use Committee
ids to reduce bioburden, the V.A.C. Instill® Therapy             (IACUC) at the University of Texas Health Science
System (instillation therapy) was introduced. It combines        Center at San Antonio (UTHSCSA) approved the experi-
DO




NPWT/ROCF with the ability to intermittently instill a           mental protocol for this study. Eight domestic castrated
solution in a controlled fashion.13,14 Specifically, instilla-   male Yorkshire pigs (Sus scrofa), with a mean body
tion therapy allows for the controlled instillation of fluid     weight of 135.0 lb ± 17.2 lb, were quarantined for 14
onto the wound bed, whereby the fluid dwells at the              days prior to the surgical procedures. During this accli-
interface between a ROCF dressing and the wound sur-             mation period, the swine were housed individually and
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                                                                                                            Leung et al



Table 1. Negative pressure settings, therapy time per cycle, number of instillation cycles, and hold times for the
treatment groups.




                                                                      A
 Treatment                            Type of      Negative pressure NPWT time     No.     Instillation Saline
 group                                 NPWT         applied (mmHg)    applied   cycles/day of saline hold time
                                                                     (hr/cycle)               (Y/N)     (min)

 Continuous NPWT/ROCF                Continuous           125              ~ 24           1            N          N/A




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 (control)

 Saline instillation therapy        Intermittent          125                5          ~ 4.7           Y          5
 (5-min dwell)

 Saline instillation therapy        Intermittent          125                5            4             Y          60
 (60-min dwell)




                                                    PL
had access to food and water ad libitum. All of the ani-      given animal was assigned to an experimental or control
mals received care in compliance with the Guide for the       group with the three treatment groups shown in Table 1.
Care and Use of Laboratory Animals from the National          All of the wound sites were treated with NPWT, consist-
Academy Press, 1996.                                          ing of a ROCF dressing,T.R.A.C.® pad connector with tub-
    Anesthesia and surgical procedures. The swine             ing (KCI), and when necessary, an Instill® pad connector
were fasted for a minimum of 12 hours prior to admin-         with tubing (KCI), all connected to a V.A.C. Instill (KCI)
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istration of the anesthetic. The animals were then anes-      set to deliver 125 mmHg of negative pressure to the
thetized with Telazol® (4.5 mg/kg–5.5 mg/kg; Wyeth,           wound. Each pair of wounds was bridged with strips of
Fort Dodge, IA) or a combination cocktail of keta-            the ROCF dressing to evenly distribute the negative pres-
mine/xylazine (5:1 v/v) dosed at 3 cc per 50 lb, intra-       sure and instill saline to each pair of adjacent wound
muscularly. Following intubation, a surgical plane of         sites. Each pair was then sealed with transparent adhe-
anesthesia was maintained using 1.5% to 3.0% isoflu-          sive drape (V.A.C.® Drape, KCI), which overlapped the
rane. Eight paraspinal wound sites were outlined by tat-      periwound margins. A flexible, protective layer was
too using a round, 5-cm diameter template and an elec-        placed over the wound dressings and secured in place
tric tattoo device (Spaulding & Rogers Mfg., Inc.,            with the adhesive drape. Each pair of wounds was con-
Voorheesville, NY). Four wound sites were demarcated          nected to a single V.A.C. Instill, and with the exception of
                        T


on each side of the spine with the two columns located        the control continuous NPWT/ROCF group, a corre-
between the crest of the shoulders and the coccygeal          sponding peristaltic pump (Variable-Speed Pump; Cat.
tuberosity.                                                   No. 13-876-2; Fisher Scientific; Waltham, MA). The peri-
    NO



    Eight full-thickness, round, excisional wounds (5 cm in   staltic pumps were used with instillation therapy to auto-
diameter) were created on each animal by vertically           matically deliver saline to each pair of wounds at speci-
excising the skin immediately interior to the tattooed        fied intervals without supervision. Animals were main-
margins down to the level of the subcutaneous fascial         tained on treatment by securing the V.A.C. Instill units
layer above the muscle (approximately 1 cm deep). The         and peristaltic pumps to a customized aluminum
excised tissues were removed and snap frozen in dry ice       turntable placed above the animal cages. This setup
for subsequent biochemical analysis. Hemostasis at the        allowed the animals to move freely within their cages
wound sites was obtained through the application of           without restriction.
direct pressure. The dressings were applied following            Therapy settings. Control group wounds were treat-
wound creation and hemostasis.                                ed with continuous NPWT/ROCF at a negative pressure
    Experimental design. This study was designed to           of 125 mmHg. For the other two treatment groups, ther-
DO




assess the effects of two different treatment regimes of      apy was applied at a negative pressure of 125 mmHg for
instillation therapy with varying dwell times of normal       5 consecutive hours followed by instillation of 100 mL of
saline (5 or 60 minutes) compared to a control continu-       normal saline to each pair of wound sites, with a dwell
ous NPWT (V.A.C.® Therapy, KCI, San Antonio, TX)/ROCF         time of either 5 or 60 minutes prior to resumption of
(GranuFoam™, KCI) group alone. Each wound site on a           negative pressure therapy for another 5-hour cycle.
                                                                                  Vol. 22, No. 7 July 2010              181
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  Leung et al


    The ROCF dressings were changed every 2 days dur-        biochemical processing. For processing, approximately
ing the first 4 days following wound creation and every      100 mg of the frozen tissue biopsies were pulverized
day thereafter until the end of the in-life phase, which     and lyophilized overnight. The lyophilized tissues were




                                                                     A
was 9 days following surgery. As such, the dressings were    defatted by treatment with 70% ethyl alcohol, sonicat-
changed at 2, 4, 5, 6, 7, and 8 days following wound cre-    ing for 5 minutes, and incubating at room temperature
ation with euthanization of the animal on day 9. At each     for 15 minutes. Samples were pelleted using centrifuga-
dressing change, photographs of the wound bed were           tion at 13,000 rpm for 15 minutes. The pellet was treat-




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taken and wound contraction and wound volumes were           ed sequentially as described above with the following
measured. On day 9, two 8-mm diameter punch biopsies         exceptions: 100% ethyl alcohol and acetonitrile were
were taken from the medial and lateral sides of the          used, followed by two acetone washes. The washed
wound site, and two corresponding punch biopsies were        samples were dried and hydrolyzed using 5 mg/mL 6N-
also taken from the adjacent periwound areas in the          HCl and overnight heating at 110˚C followed by
same orientations. A punch biopsy from the wound and         overnight drying in a vacuum oven at 60˚C. The sam-




                                                   PL
adjacent periwound biopsy were analyzed for wound            ples were reconstituted in water and buffered to pH 9.0
hydration measurements. A similar pair of biopsies was       with 50 mM sodium bicarbonate. Amino acids in
analyzed biochemically for total collagen content. In        hydrolyzed tissue were derivatized using a 1.3 mg/mL
each case, the periwound biopsy was considered control       solution of dabsyl chloride in acetone. Following dab-
tissue and wound biopsy values were compared to peri-        sylation, the samples were lyophilized and reconstitut-
wound (control) values.                                      ed with 70% ethyl alcohol. Samples were then filtered
    Wound volume and area measurements. In order             with polysulfone (PSU) syringe filters and injected into
                                 DU
to determine wound volumes, the wound sites were cov-        the Waters Alliance 2695 HPLC system equipped with a
ered with adhesive drape, which was not stretched            Waters 2996 photodiode array detector (Waters Corp.,
excessively in order to prevent wrinkling. The drape was     Milford, MA). Dabsylated amino acids were detected
maintained level to the surrounding tissue in the peri-      and quantified by measuring the absorption at 436 nm.
wound margins and sterile saline was introduced into         The reverse phase HPLC method utilized a
the wound cavity with a syringe. The volume of saline        Phenomenex Gemini™ C18, 15 cm x 4.6 mm, 3 µm ana-
required to fill the defect was recorded.                    lytical column with a Phenomenex Gemini C18, 4 mm
    Digital planimetry was used to determine wound area      x 3.0 mm, Security Guard Cartridge. The mobile phase
and the degree of contraction of the wound.The margins       was 70:30 potassium phosphate buffer (pH 11.0):ace-
of each tattooed wound site were traced onto a clear         tonitrile and the amino acids were eluted from the col-
                      T


plastic grid (Visitrak®, Smith & Nephew, Hull, UK). Defect   umn isocratically at a flow rate of 0.5 mL/minute with
contraction and wound area were then calculated using        a total run time of 45 minutes. Data were acquired using
imaging software (SigmaScan® Pro 5.0, Systat, Inc.,          Waters Empower Software. Analyte concentrations
      NO



Chicago, IL).                                                were calculated for hydroxyproline, glycine, and pro-
    Tissue hydration determination. Punch biopsies           line using calibration curves for each analyte and per-
(8-mm) were set aside from tissue removed during sur-        cent total collagen determined by summation of the
gery as well as at necropsy. These biopsies were placed      concentrations of the three amino acids.
into 2-mL tubes and subsequently weighed to obtain
their wet weights. The samples were lyophilized under        Statistical Analysis
pressure for at least 72 hours. The lyophilized samples         The wound volumes, wound areas, and total collagen
were then weighed to obtain their dry weight. The            content were analyzed using one-factor repeated meas-
wet:dry tissue weight ratio was then calculated based on     ures analysis of variance (ANOVA). The Dunnett’s test
these two readings.                                          was performed to compare each treatment group with
    Biochemical analysis of total collagen content.          the control group (ie, continuous NPWT/ROCF).This test
DO




The total collagen content of the tissue biopsies was        was implemented at different days and was not adjusted
analyzed using a protocol adapted from a method              for multiplicity.The wet:dry tissue weight ratios between
described previously.18 Punch biopsies (8-mm) collect-       the wound and periwound areas for each treatment
ed during surgery as well as at necropsy were placed         group were analyzed using a paired t-test. P values < 0.05
into 2-mL cryovials and frozen at -80˚C until time of        were considered to be significant, while P values
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                                                                                                              Leung et al




                                                                           A
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over the 9-day, in-life period. The wound volume was


mean ± SEM at each time point (n = 8).
                                                        PL
Figure 1. Percentage reduction of the initial wound volume

measured at defined time points by measuring the volume of
saline required to fill the wound. Data are presented as the
                                                                   Figure 2. Percentage of the initial wound area over the 9-
                                                                   day, in-life period. The wound area was assessed by
                                                                   performing digital planimetry on tracings of the tattooed
                                                                   wound margins taken at each time point.
                                                                   Data are presented as the mean ± SEM (n = 8).
                                    DU
* and # represent instillation therapy values at 5- or 60-
  minute dwell time, respectively, that are significantly higher
  than control NPWT/ROCF values (P < 0.05).
^ Instillation therapy values at 5 minutes dwell time that
  exhibit highly suggestive trends toward an increase
  compared to control NPWT/ROCF values (0.05 < P < 0.10).
                       T
  NO




Figure 3. Percentage of moisture in tissue biopsies taken          Figure 4. Total collagen content normalized to the mean
from the wound and periwound areas 9 days following                content of the uninjured tissue at Day 0. Punch biopsies
wound creation. Punch biopsies (8 mm) were taken from              (8-mm) were taken from the granulation tissue and
the granulation tissue as well as the adjacent periwound           processed via HPLC to determine the total content of
area and weighed to determine the wet weight. Following            hydroxyproline, proline, and glycine.
lyophilization of the tissue samples, the biopsies were            Data are presented as the mean ± SEM (n = 5).
weighed to determine the dry weight. The difference in wet
DO




                                                                   * Significant difference compared to control NPWT/ROCF
to dry weights of the biopsies divided by the wet weight             values at P < 0.05.
provided a ratio of moisture present in the tissue.                ^ Highly suggestive trend compared to control
Data are presented as the mean ± SEM (n = 8).                        NPWT/ROCF values at 0.05 < P < 0.10.
# Significant differences compared to the wet:dry weight
  of the wound biopsies at P < 0.0001.


                                                                                       Vol. 22, No. 7 July 2010            183
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  Leung et al


between 0.05 and 0.10 were considered as exhibiting a        (dry) biopsy weight from the wet weight and dividing
trend toward significance.                                   this value by the wet weight. These data were plotted as
                                                             the mean percentage of moisture in the tissue for each




                                                                     A
Results                                                      instillation therapy and control NPWT/ROCF group
    The experimental instillation therapy and control        (Figure 3). Differences in hydration observed across
NPWT/ROCF groups were compared to examine the                treatment groups for the wound biopsies were not
effects of saline instillation. Any differences due to the   found. Therefore, instillation therapy with normal saline




                                                                  IC
introduction of normal saline to the wound bed were          did not alter the hydration levels of the underlying gran-
noted.The two primary endpoints for the study included       ulation tissue in pig wounds.
measurement of wound volume fill over time and quan-            Total collagen content. Impaired wound healing can
tification of total collagen content in punch biopsies       often be attributed to the synthesis of poor quality colla-
taken from the granulation wound bed at necropsy. The        gen or due to increased collagen degradation. Therefore,
two secondary endpoints were the degree of wound             the total collagen content in the wound biopsies was eval-




                                                   PL
contraction, as determined from wound area measure-          uated as an indirect measure of the quality of the newly
ments/tracings, and the wet:dry tissue weight ratio as a     formed granulation tissue. A distinctive hallmark of colla-
measure of tissue hydration.                                 gen is the regular arrangement of amino acids in each of
    Wound volume reduction and area measure-                 the three chains that comprise collagen microfibrils. The
ments. Figure 1 shows the percentage change in wound         sequence often follows the pattern Glycine-Proline-X or
volume over time. Instillation therapy with normal saline    Glycine-Y-Hydroxyproline.19 Thus, the total content of the
and dwell times of both 5 and 60 minutes exhibited           amino acids hydroxyproline, glycine, and proline were
                                 DU
either a trend or a significantly higher percentage of       used to determine the total collagen content in punch
wound volume filled with granulation tissue on days 6        biopsies taken from both the wound and periwound
and 7. Specifically, there were significant differences in   areas.The total collagen content from the wound biopsies
the percentage of wound filling observed between con-        were then normalized to the periwound values and plot-
tinuous NPWT/ROCF and instillation therapy at dwell          ted for each experimental and control group (Figure 4). A
times of 5 minutes (P = 0.025) and 60 minutes (P =    (P     significant increase in total collagen content was
0.002) on day 6 and at a dwell time of 60 minutes on days    observed in the instillation therapy group with a dwell
7 (P = 0.023) and 8 (P = 0.038).A highly suggestive trend    time of 60 minutes compared to the NPWT/ROCF group
toward differences in the percentage of wound filling        (P = 0.015). A highly suggestive difference was also
was observed between continuous NPWT/ROCF and                observed in total collagen content between the
                      T


instillation therapy at a dwell time of 5 minutes on day 7   NPWT/ROCF-treated wounds and wounds instilled with
(P = 0.077, [Figure 1]).                                     normal saline with a 5-minute dwell time (P = 0.072).
    Wound area was evaluated over time to ascertain the
                                                             Discussion
      NO



degree of wound contraction over the course of the
granulation phase. These data were plotted as the mean           Alterations in the integrity of the skin lead to an
area inside the tattoo lines as a function of time (Figure   ordered healing process consisting of four main phases.
2). Statistical analysis of the area values for each time    These phases are, in sequential order, hemostasis, inflam-
point indicated that there were no differences between       mation, proliferation, and maturation or remodeling.20
the experimental and control groups, which suggests          While the hemostatic and inflammatory phases are criti-
that the differences in volume observed at days 6 and 7      cal for restoring tissue homeostasis, much of the wound
between the instillation therapy and control                 fill process occurs during the proliferative phase. In this
NPWT/ROCF groups are not due to wound contraction,           phase, the migration and proliferation of fibroblasts and
but rather due to granulation tissue filling the defect.     the subsequent production of collagen and other extra-
    Tissue hydration. The wet:dry tissue weight ratio        cellular matrix proteins are crucial for the formation of
DO




from punch biopsies taken from the wound sites on day        granulation tissue and resultant wound closure.
9 was evaluated to determine if the instillation of normal       NPWT/ROCF has proven to be effective in healing a
saline affected the hydration levels of the underlying       wide range of wounds including acute, chronic, traumat-
granulation tissue. The amount of moisture in the tissue     ic, and dehisced wounds, as well as partial-thickness
biopsies was determined by subtracting the lyophilized       burns, diabetic ulcers, pressure ulcers, flaps, and grafts.1–3
184     WOUNDS www.woundsresearch.com
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                                                                                                              Leung et al



NPWT/ROCF facilitates and promotes wound healing via               tion therapy and control NPWT/ROCF groups for any of
secondary or tertiary intention through multiple mecha-            the time points evaluated. This suggests that there were
nisms including increasing perfusion,7,21 reducing                 no differences in wound contraction between groups.




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edema,22 reducing inflammation,7,23,24 and creating an             Since a fairly large volume (100 mL) of normal saline
environment that promotes granulation tissue forma-                was instilled into each pair of wound sites, there was
tion.7,8 The effects of NPWT/ROCF on wounds are medi-              also a possibility that local tissue edema may have
ated, presumably, through the microstrain that is mani-            occurred. Evaluation of the tissue hydration in punch




                                                                        IC
folded to the tissue through the ROCF dressing during              biopsies taken from the granulation tissue showed that
NPWT.25 The V.A.C. Instill capitalizes on the advantages of        there were no differences in the ratio of the wet:dry tis-
NPWT/ROCF combined with the added benefits of con-                 sue weight between the instillation therapy groups and
trolled instillation of topical wound solutions to the             the control NPWT/ROCF group. This suggests that the
wound bed.13,14 Much of the previously reported research           increased fill observed in the instillation therapy groups
with instillation therapy has focused on the effects of            was due to increased granulation tissue formation rather




                                                        PL
instilling normal saline, antibiotics, or antiseptics as it        than due to increased tissue edema.
pertains to bioburden reduction and/or treatment of                    The effects of saline instillation on constituents of the
infection.15,16 While the effects of using fluid instillation in   dermal extracellular matrix, and collagen in particular,
conjunction with NPWT/ROCF on infection clearance                  were also evaluated. Fibroblasts, which are the predom-
and wound healing have been investigated, its effects on           inant cells in the dermis, produce structural extracellu-
the rate of granulation tissue formation and quality have          lar matrix proteins in the proliferative phase of wound
not specifically been determined. The present study                healing to help restore tissue integrity following dermal
                                     DU
investigated how instillation therapy with approximately           injury.28 As part of this proliferative response, collagen
four cycles per day of normal saline instillation and hold         types I and III are the major constituents of the extra-
times of 5 or 60 minutes affects wound healing com-                cellular matrix (ECM) in cutaneous tissue. Type I colla-
pared to NPWT/ROCF alone. This study utilized a full-              gen and, to a lesser extent, type III collagen combine
thickness acute wound-healing model in normal healthy              with newly formed vasculature elements to form granu-
swine.26,27                                                        lation tissue. The presence of collagen provides tensile
    The primary measure of wound healing was wound                 strength, integrity, and structure to the regenerating der-
volume reduction over time. The data showed that the               mal tissue.8 In order to ascertain the degree of collagen
use of NPWT/ROCF in conjunction with instillation ther-            present in the granulation tissue, a technique was adapt-
apy elicited an increased rate in wound filling compared           ed based on a published method to quantify the amount
                         T


to wounds treated with NPWT/ROCF alone. For exam-                  of hydroxyproline, proline, and glycine (ie, the main
ple, at 6 days following wound creation, the wound was             amino acids in collagen) using high performance liquid
filled with 15% to 20% more granulation tissue in the              chromatography (HPLC).The data indicated a significant
    NO



instillation therapy groups compared to the                        increase in total collagen content in granulation tissue
NPWT/ROCF control group. The instillation of normal                that was treated with NPWT/ROCF in conjunction with
saline also led to trends towards a significant increase in        saline instillation and a dwell time of 60 minutes. In addi-
wound filling on day 7. Additionally, comparison of the            tion, the collagen data was highly suggestive of an
percentage of the wound that was filled in the instillation        increase in total collagen content in wounds treated
therapy groups compared with the control NPWT/ROCF                 with instillation therapy and a dwell time of 5 minutes.
group for any given day from day 5 onward indicated a              Since collagen is the predominant structural ECM mole-
shift of nearly a day in the percentage of wound volume            cule in cutaneous tissue and is crucially important for
that was filled. In other words, instillation therapy              providing tensile strength and integrity to the regener-
appeared to lead to filling of the wound defect 1 day              ated skin, an increase in total collagen content in the
faster than when continuous NPWT/ROCF was applied.                 granulation tissue is suggestive of an increase in the
DO




    Evaluation of the wound area was done using digital            quality of the regenerated granulation tissue. A key limi-
planimetry to ascertain how much wound closure was                 tation to this assessment was that wound biopsies were
occurring due to contraction. The results indicated that           only taken at day 9. This was done to avoid affecting the
there were no differences in the area within the tat-              wound volume measurements that were obtained dur-
tooed margins of the wound sites between the instilla-             ing the study. Future experiments will look at the effects
                                                                                       Vol. 22, No. 7 July 2010             185
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     Leung et al


of instillation therapy on the extracellular matrix at var-          new method for wound control and treatment: clinical
ious time points to correlate these results with the                 experience. Ann Plast Surg. 1997;38(6):563–576.
                                                                                             Surg.
wound volume measurements.                                     2.    Joseph E, Hamori CA, Bergman S, et al. New therapeutic




                                                                        A
                                                                     approaches in wound care. A prospective randomized
Conclusion                                                           trial of vacuum-assisted closure versus standard therapy
   The data presented herein indicate that in a preclini-            of     chronic     nonhealing        wounds.       WOUNDS.
cal wound model, instillation therapy with saline pro-               2000;12(3):60–67.




                                                                     IC
vides an additional benefit to NPWT/ROCF. The instilla-        3.    McCallon SK, Knight CA,Valiulus JP, et al.Vacuum-assisted
tion of saline 4 times per day led to significantly                  closure versus saline-moistened gauze in the healing of
increased wound fill at days 6 and 7. Not only was the               postoperative diabetic foot wounds. Ostomy Wound
wound fill increased but the quality of granulation tissue           Manage. 2000;46(8):28–34.
                                                                     Manage.
was also increased as evidenced by increased collagen          4.    Armstrong DG, Lavery LA; Diabetic Foot Study
content.Together, these data indicated an improved heal-             Consortium. Negative pressure wound therapy after par-




                                                     PL
ing response in this model during treatment with saline              tial diabetic foot amputation: a multicentre, randomised
instillation therapy. An additional consideration is that            controlled trial. Lancet 2005;366(9498):1704–1710.
                                                                                       Lancet.
NPWT/ROCF was shut down for either 5 or 60 minutes             5.    Isago T, Nozaki M, Kikuchi Y, et al. Effects of different neg-
around 4 times per day during instillation therapy. As               ative pressures on reduction of wounds in negative pres-
such, this could be considered a form of intermittent                sure dressings. J Dermatol. 2003;30(8):596–601.
NPWT, which may have a role in the results that were           6.    Scherer SS, Pietramaggiori G, Mathews JC, et al.The mech-
observed in this study since intermittent NPWT/ROCF                  anism of action of the vacuum-assisted closure device.
                                  DU
has previously been shown to increase granulation tissue             Plast Reconstr Surg 2008;122(3):786–797.
                                                                                      Surg.
formation compared to continuous NPWT/ROCF.29                  7.    Morykwas MJ, Argenta LC, Shelton-Brown EI, McGuirt W.
However, unpublished data from our group showed an                   Vacuum-assisted closure: a new method for wound con-
added benefit with the instillation of normal saline ver-            trol and treatment: animal studies and basic foundation.
sus intermittent NPWT alone. Future studies will define              Ann Plast Surg. 1997;38(6):553–652.
the role of intermittency as part of instillation therapy as   8.    Morykwas MJ, Faler BJ, Pearce DJ, Argenta LC. Effects of
well as how to optimize these conditions.This will allow             varying levels of subatmospheric pressure on the rate of
us to determine if additional benefit may be achieved by             granulation tissue formation in experimental wounds in
varying the dwell time and/or the number of instillations            swine. Ann Plast Surg. 2001;47(5):547–551.
per day.                                                       9.    Kaehn K, Eberlein T. In-vitro test for comparing the effi-
                       T


                                                                     cacy of wound rinsing solutions. Br J Nurs.
Acknowledgments                                                      2009;18(11):S4–S10.
   The authors would like to acknowledge Sander                10.   Whaley S. Tap water or normal saline for cleansing trau-
      NO



Hacker, DVM and James Elliott, DVM from the University               matic      wounds?      Br     J     Community          Nurs.
of Texas Health Science Center at San Antonio (UTHSC-                2004;9(11):471–478.
SA) for their assistance with wound creation and imple-        11.   Hellewell TB, Major DA, Foresman PA, Rodeheaver GT. A
mentation of instillation therapy for the experimental               cytotoxic evaluation of antimicrobial and non-antimicro-
animals. We also would like to acknowledge Angelique                 bial wound cleansers. WOUNDS. 1997;9(1):15–20.
Colby, RVT, Lisa Jones, Tina Sandoval, and other associat-     12.   Fernandez R, Griffiths R. Water for wound cleansing.
ed staff at UTHSCSA for their assistance during the exper-           Cochrane Database Syst Rev. 2008;23(1):CD003861.
imental procedures. Finally, we would also like to             13.   Plikaitis CM, Molnar JA. Subatmospheric pressure wound
acknowledge Charles Seegert, PhD of KCI for assisting                therapy and the vacuum-assisted closure device: basic
with experimental design, Zhenmei Liu and Herman                     science and current clinical successes. Expert Rev Med
Chavarria of KCI for statistical analyses, and Sandra                Devices. 2006;3(2):175–184.
DO




Garcia, PhD of KCI for constructive comments during            14.   Jerome D. Advances in negative pressure wound therapy:
the preparation of this manuscript.                                  the VAC instill. J Wound Ostomy Continence Nurs.
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