What are the guidelines for placing a wound vac on a complex, non-healing wound, such as a pressure ulcer, diabetic foot ulcer, or venous ulcer, in a geriatric patient in a long-term care setting?

Guidelines for Wound VAC Placement in Long-Term Care

Negative pressure wound therapy (NPWT/wound VAC) should be used selectively in long-term care settings—specifically for post-surgical wounds after debridement or minor amputation, but NOT for non-surgical chronic ulcers like pressure ulcers, diabetic foot ulcers, or venous ulcers. 1, 2

When to Place a Wound VAC

Appropriate Indications (Use NPWT)

• Post-surgical diabetic foot wounds after debridement or minor amputation when primary or delayed closure is not feasible 1
• Post-operative wounds following surgical debridement of infected tissue, abscess drainage, or necrotizing fasciitis 1
• Wounds after revascularization procedures that require staged closure 1
• Large wounds requiring preparation for skin grafting or two-stage primary closure 3

Contraindications (Do NOT Use NPWT)

• Non-surgical diabetic foot ulcers—this is a strong recommendation against use 1, 2
• Dry, non-exudative wounds—NPWT removes moisture and causes harm 2
• Pressure ulcers without surgical intervention—evidence shows no benefit over standard care 1
• Venous leg ulcers—insufficient evidence for benefit 4
• Wounds with inadequate perfusion (toe pressure <30 mmHg, TcPO2 <25 mmHg) until after revascularization 1, 5

Pre-Placement Requirements

Before considering wound VAC placement, ensure these conditions are met:

Vascular Assessment

• Measure ankle-brachial index (ABI), toe pressures, and transcutaneous oxygen pressure (TcPO2) 5
• Critical thresholds requiring revascularization FIRST: ABI <0.5, ankle pressure <50 mmHg, toe pressure <30 mmHg, or TcPO2 <25 mmHg 5
• Revascularization must precede or occur concurrently with NPWT—inadequate perfusion prevents healing regardless of wound VAC use 5

Infection Control

• Active infection must be resolved with surgical debridement and antibiotics before NPWT initiation 6
• Severe infections require IV antibiotics targeting MRSA and gram-negative bacteria 5

Surgical Debridement

• All nonviable tissue, necrotic material, and callus must be surgically removed before NPWT application 6, 3
• Sharp debridement is mandatory—NPWT is not a substitute for adequate surgical preparation 5

Application Protocol (When Indicated)

Technical Setup

• Apply sterile foam dressing to the debrided wound bed 7
• Embed fenestrated tubing in the foam 7
• Seal wound with adhesive tape to create airtight environment 7
• Set continuous or intermittent suction at 50-125 mmHg 7

Dressing Changes

• Change NPWT dressings every 48-72 hours (typically on 3rd day) 6, 7
• Perform serial sharp debridement at each dressing change 5

Expected Duration

• Average treatment duration is 8.2 weeks for lower extremity wounds 3
• Post-surgical diabetic foot wounds achieve satisfactory healing in approximately 22.8 days with NPWT versus 42.8 days with standard gauze 6

Alternative Standard Care (Preferred for Most Long-Term Care Wounds)

For non-surgical chronic wounds in long-term care, use this approach instead of NPWT:

For Pressure Ulcers

• Hydrocolloid or foam dressings to reduce wound size 1
• High-protein nutritional supplementation (30 energy percent protein) to prevent and heal pressure ulcers 1
• Appropriate support surfaces (air-fluidized beds superior to standard beds) 1

For Diabetic Foot Ulcers

• Hydrogels for dry wounds to maintain moisture and facilitate autolysis 2
• Total contact cast as gold standard offloading for plantar ulcers 2
• Sharp debridement at every visit to remove callus and nonviable tissue 2
• Consider hyperbaric oxygen therapy only after revascularization if standard care fails for 6 weeks 1, 2

For Wounds with Adequate Perfusion

• Optimize wound-healing environment: smoking cessation, glycemic control (HbA1c <7%), cardiovascular risk modification 1, 5
• Moisture-retentive dressings to maintain moist wound bed while controlling exudate 1

Critical Pitfalls to Avoid

• Never apply NPWT to non-surgical, dry wounds—this causes harm by removing essential moisture 2
• Never use NPWT as first-line therapy for chronic ulcers without surgical intervention 1
• Never apply NPWT before addressing inadequate perfusion—revascularization must come first 5
• Do not continue NPWT if wound has severe peripheral vascular disease (particularly forefoot/midfoot locations)—failure rate is high 3
• Avoid NPWT in frail elderly patients with multiple comorbidities unless post-surgical indication exists 1

Monitoring and Follow-Up

• Perform wound reassessment at least weekly to evaluate healing progress 5
• Monitor for systemic signs of infection: fever, tachycardia, spreading erythema 5
• If wound does not improve within 6 weeks despite optimal management, consider vascular imaging and revascularization 1
• Coordinate care through interdisciplinary team including vascular surgery, infectious disease, and wound care specialists 5