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03 advances in neonatal care june2010
1. Egyptian_Pediatric yahoo group Egyptian_Pediatric yahoo group
http://health.groups.yahoo.com/group/ http://health.groups.yahoo.com/group/
egyptian_pediatric/ egyptian_pediatric/
2. Don’t Put Off Your Education
Catherine L. Witt
T
he question of educational preparation for practitioners who must consider returning to school
nursing practice is not new. Forty-five years to obtain a doctorate of nursing practice and nurses
ago in 1965, the American Nurses Association who must consider earning a baccalaureate degree.
published a position paper calling for the baccalau- There are certainly many practicing nurses who do
reate degree as the minimum requirement for entry not have a baccalaureate degree and provide safe,
into professional nursing practice.1 It is interesting effective care to their patients. They have a wealth of
that nearly a half century later, we are no closer to experience that is invaluable. They may reasonably
achieving this standard. Many components of the question the value of returning to school in the mid-
debate have not changed. Healthcare continues to dle of a satisfying career. One author looked at bar-
become increasingly complex. The amount of knowl- riers that prevented nurses from pursuing a BSN
edge required to provide safe patient care has degree.6 Incentives included increased options in
increased substantially. Nurses are also required to their career, including improved mobility and oppor-
have an in-depth knowledge of healthcare systems, tunities. The possibility of pursuing an advanced
information technology, and research methodology. degree that would allow for advanced practice nurs-
An increasing number of studies have shown that ing, management opportunities, or teaching careers
there is a connection between baccalaureate nursing was another incentive. Barriers included not enough
education and lower mortality rates.2-4 time, lack of confidence, and lack of recognition by
Despite this evidence, in 2004, only 47.2% of RNs employers. Previous negative experiences in school
currently working have a baccalaureate or graduate were also noted as a barrier.
degree.5 Fifty-one percent of RNs currently working Employers can do more to encourage their staff to
have an associate degree or a diploma in nursing.5 This return to school. Tuition reimbursement and student
is in contrast to other healthcare professionals with loan forgiveness programs can help. Pay differentials
whom patients interact. Physical therapists, occupa- that reward education and requiring a BSN degree for
tional therapists, pharmacists, social workers, audiolo- leadership positions can also provide incentives.
gists, and speech therapists have not only a baccalau- Changing state or certification requirements have
reate degree but also graduate degrees. This argument proved to be a big incentive for advanced practice
has been used to justify requiring nurse practitioners to nurses. Schools of nursing can help by recognizing and
have a doctoral degree but should illustrate the need giving credit for educational and work experiences.
for a baccalaureate degree (BSN) as a minimum entry- Easy transfer of credits from associate degree pro-
level educational criterion for nurses. grams to 4-year schools should be made standard.
There are many other arguments for increasing the Increased federal funding of nursing education at the
requirement for entry into practice. Unfortunately, baccalaureate and graduate levels should be a priority.
despite 45 years of debate, we have not made much However, waiting for someone to make you pur-
progress as a system. Human nature being what it is, sue a degree is not very proactive. The desire to
many will put off pursuing this degree until it is increase one’s professional credibility and career
required. I would ask you to consider this waiting options should be a driving force. In fact, states, hos-
until someone makes you do something, meaning pitals, and certification boards can change rules and
that you might put it off until it is too late. Some nurse requirements for various positions with little warning,
practitioners have learned this to their detriment. meaning that by the time someone makes you get a
While most states have “grandfathered” those practi- degree, you will not have adequate time to make it
tioners who do not have a master’s degree, changing happen. Also, if you are waiting until you have time,
rules requiring certification, prescriptive authority, or consider that you will likely never have unlimited
other factors have limited the ability of a few to prac- free time in which to pursue a degree unhindered.
tice. It is possible that future changes in nurse prac- You have to make available the time. There are now
tice acts will limit the practice of those who do not more options than ever: online programs, acceler-
have the necessary education. This applies to nurse ated programs, traditional classroom programs, and
Advances in Neonatal Care • Vol. 10, No. 3 • pp. 105-106 105
3. 106 Witt
even on-site work programs in collaboration with 2. Aiken LH, Clarke SP, Cheung RB, Sloane DM, Silber JH. Educational levels of
hospital nurses and surgical patient mortality. JAMA. 2003;290:1617-1623.
hospitals and universities. Don’t wait until it is too 3. Aiken LH, Clarke SP, Sloane DM, Lake ET, Cheney T. Effects of hospital care
late. There is no time like the present. environment on patient mortality and nurse outcomes. J Nurs Adm.
2008;38:223-229.
4. Estabrooks CA, Midodzi WK, Cummings CG, Ricker KL, Giovanetti P. The
impact of hospital nursing characteristics on 30-day mortality. Nurs Res.
References 2005;54,72-84.
1. Nelson MA. Education for professional nursing practice: looking backward 5. American Association of Colleges of Nursing. Fact Sheet: creating a more
into the future. Online J Issues Nurs. 2002;7:3. Manuscript No. 3. highly qualified nursing work force. http://www.aacn.nche.edu/Media/
https://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ pdf/nursingworkforce.pdf. Accessed March 14, 2010.
ANAPeriodicals/OJIN/TableofContents/Volume72002/No2May2002/ 6. Megginson LA. RN—BSN education: 21st century barriers and incentives.
EducationforProfessionalNursingPractice.aspx. Accessed March 14, 2010. J Nurs Manag. 2008;16:47-55.
www.advancesinneonatalcare.org
5. 108 Stokowski
oration or critical illness at a later age, premedication
Severe Combined Immunodeficiency should be used for all endotracheal intubations in
Added to Uniform Newborn newborns. Medications with rapid onset and short
duration of action are preferable. Recommendations
Screening Panel
for premedication include the following:
A
historic unanimous vote early this year by • analgesic agents or anesthetic dose of a hypnotic
the Secretary’s Advisory Committee for drug should be given (fentanyl, remifentanil,
Heritable Disorders in Newborns and and morphine);
Children paves the way for severe combined immun- • vagolytic agents and rapid-onset muscle
odeficiency (SCID) to be the latest addition to the relaxants should be considered (atropine,
uniform newborn screening panel performed by state glycopyrrolate);
public health programs. • use of sedatives alone, such as benzodiazepines
The SCID is a rare group of generic disorders with (midazolam) without analgesic agents, should
an estimated incidence of 1 in 40,000—100,000 new- be avoided;
borns, and perhaps higher as a result of undiagnosed • a muscle relaxant should not be used without an
cases.1 The SCID is a lethal disorder of adaptive analgesic (pancuronium, vecuronium, etc);
immunity, characterized by the absence of T-lym- and
phocytes. With essentially nonfunctional immune • each NICU should develop protocols and
systems, infants with SCID are at the mercy of their lists of preferred medications to improve com-
surroundings and must live in protected environ- pliance and minimize medication errors and
ments (eg, “boy in the plastic bubble”) where expo- adverse effects.
sure to infectious agents can be minimized.
Without treatment, recurrent opportunistic infections A full table of medications, doses, and routes of
are eventually fatal. However, because SCID has no administration can be found in the article.1
overt signs or symptoms, the only way to save affected
newborns is to identify them with universal newborn Reference
screening and perform early stem cell transplantation. 1. Kumar P, Denson SE, Mancuso TJ; Committee on Fetus and Newborn,
Section on Anesthesiology and Pain Medicine. Premedication for non-
In 2005, the Advisory Committee for Heritable emergency endotracheal intubation in the neonate. Pediatrics. 2010;
Disorders in Newborns and Children adopted a list 125:608-615.
of 29 conditions recommended for newborn screen-
ing. Since that time, only 6 conditions (Fabry disease,
Krabbe disease, Niemann-Pick disease, Pompe dis- Sepsis in Late Preterm Infants
ease, spinal muscular atrophy, and SCID) have been
I
brought to the committee for consideration of inclu- t is now well known that late preterm infants
sion in the uniform newborn screening panel. The (born with estimated gestational ages of 34-36 wk)
SCID is the first condition to be added to the manda- are at high risk for numerous problems, such as
tory newborn screening panel since 2005. hyperbilirubinemia, hypoglycemia, and respiratory
distress. Early- and late-onset sepsis and sepsis-
Reference related mortality are also believed to occur more fre-
1. National Human Genome Research Institute. Severe combined immunod- quently in this gestational age group.
eficiency. http://www.genome.gov/13014325. Accessed March 19, 2010.
In the largest observational study conducted to
date, Cohen-Wolkowiez and colleagues1 prospec-
tively collected data from 119,130 late preterm
Premedication for Nonemergency infants admitted to 248 NICUs to determine specific
Intubation in the Neonate infection rates, pathogen distribution, and mortality
associated with early- and late-onset sepsis. A blood
A
recent evidence-based review of premedica- culture was obtained from most (69%) of these new-
tion for nonemergent intubation in the borns within the first 3 postnatal days. Whether these
neonate was published by the American blood cultures were prompted by clinical signs of
Academy of Pediatrics Committee on Fetus and sepsis or premature birth is unclear.
Newborn.1 An ideal strategy for premedication for A total of 531 episodes of early-onset sepsis (EOS)
intubation eliminates the pain, discomfort, and phys- were documented for a cumulative incidence of 4.42
iologic abnormalities of the procedure; helps to carry per 1,000 admissions. The highest rate of EOS
out intubation expeditiously; minimizes the chances occurred in Hispanic infants, who had a frequency of
for traumatic injury to the newborn; and has no 20%. Gram-positive organisms caused most episodes
adverse effects. of EOS (66.4%, 353/531), gram-negative organisms
Except for emergent intubation during resuscita- accounted for 27.3% of EOS, and yeast for 0.8%.
tion either in the delivery room or after acute deteri- Group B strep, Escherichia coli, and Staphylococcus
www.advancesinneonatalcare.org
6. Noteworthy Professional News 109
aureus accounted for most EOS episodes within this The high proportion of infants evaluated with a
group of infants. blood culture and the small number of infection
Late-onset sepsis (LOS) episodes numbered 803 episodes suggest that the yield from sepsis evalua-
for a cumulative incidence of 6.30 per 1,000 admis- tions in most late preterm infants is low.
sions. Like EOS, most LOS episodes were caused by
gram-positive organisms (59.4%), followed by gram-
Reference
negative organisms (30.7%), and yeast (7.7%). The
1. Cohen-Wolkowiez M, Moran C, Benjamin DK, et al. Early and late
highest mortality was associated with LOS and onset sepsis in late preterm infants. Pediatr Infect Dis J. 2009;28:1052-
gram-negative rods. 1056.
Advances in Neonatal Care • Vol. 10, No. 3
8. Grazel 111
transport were used to create a new guideline, only a physician can direct respiratory care services.
Neonatal Nursing Transport Standards: Guideline for Although this rule allows advanced practice regis-
Practice, being released by NANN in 2010. This is a tered nurses (APRNs) in all specialties to write respi-
must-have resource for all nurses involved in neona- ratory care orders, it also mandates that the “respon-
tal transport. For information on how to get your sible doctor of medicine or osteopathy must cosign
copy of this vital new publication from NANN, visit the order.” For APRNs in the 15 states that still re-
our Web site at www.nann.org. quire a physician—APRN relationship of “supervi-
sion or collaboration,” this requirement presents a
Other Valuable Resources Coming significant impediment to providing prompt and ap-
From NANN in 2010 propriate care. For the NNPs practicing in those
• RNC (registered nurse, certified) review course— states, this ruling causes significant duplication of
An Internet-based, modular, comprehensive work, complicated workflows, and unnecessary re-
review course. dundancy. The NNPs caring for critically ill infants
• Understanding Clinical Research: A Guide for the in the NICU can write hundreds of respiratory or-
New Researcher—An introductory guide to review- ders a day, depending on the size of the unit and the
ing, evaluating, and conducting research that in- acuity level of the patients. Following The Joint
cludes material on literature evaluation and a Commission’s support of this requirement, the com-
continuing education component. mittee made this issue a priority. A sample letter of
• Competencies and Orientation Tool Kit for Neonatal concern was sent to NANN’s advocacy e-mail dis-
Nurse Practitioners—A valuable tool kit that will cussion group, along with information about where
help neonatal nurse practitioners (NNPs) to assess to send letters of concern.
their practice and identify their own learning The committee has also initiated grassroots cam-
needs and will help preceptors and staff educators paigns in response to several US House and Senate
both to determine the learning needs of NNP stu- bills introduced this session, including bills about
dents and new NNPs and to evaluate the contin- fighting antimicrobial resistance, researching
ued competence of experienced NNPs. endocrine disrupters, and establishing an Office of
• Resource Guide for Cardiac Care in the NICU and the National Nurse. For more information about
accompanying quick reference guide—A handy these “calls to action,” please visit the NANN Web
resource that includes common medications, site and click on the Advocacy button on the right
dosages, and tips on bedside care. side.
Visit www.nann.org for product-ordering information.
State Liaisons
H EALTH POLICY AND ADVOCACY We are in the process of identifying a NANN or
NANNP member from each state to serve as a liaison
The Health Policy and Advocacy Committee of to our committee. The state liaison (SL) is a volunteer
NANN and NANNP has been extremely busy during who has a strong interest in advocacy, health policy,
the 111th US Congress. Although it sometimes seems and legislative issues. The SL will monitor and share
that global healthcare reform is the only item on the information about current or pending legislation of in-
congressional agenda, other issues that affect neonatal terest at the state level and act as liaison to the Health
nursing practice and neonates have arisen at both state Policy and Advocacy Committee. The SL need not
and federal levels. have previous experience in health policy and advoca-
cy. For more information about this role or to express
Issues of Interest your interest, please contact committee members
The committee is responding to the Centers for Joyce Stein (jazstein@mac.com) or Katie Malin
Medicare & Medicaid Services requirement that (kmmalin@gmail.com).
Advances in Neonatal Care • Vol. 10, No. 3
17. 120 Wilcinski
using a Surgisis graft (Cook Medical Products,
Bloomington, Indiana) that was placed over the defect FIGURE 1.
attaching circumferentially to the fascia. The skin was
then closed over the Surgisis graft. The repair was
completed without evidence of significant abdominal
compartment syndrome. A Broviac central venous
catheter was also placed at the time of surgery. She
received perioperative antibiotics, which were
continued for 5 days.
Six days postoperatively, a patch of wound opened
exposing the Surgisis mesh graft. The antibiotics
amikacin and vancomycin were started as well as
normal saline wet-to-dry dressing changes 3 times a
day. Five days later, on day 11, the wound was mal-
odorous and acetic acid wet-to-dry dressing changes
were begun twice a day. On day 14, healing of the Postoperative wound prior to application of the
wound was improved, the wet-to-dry dressing V.A.C.® therapy. Photograph courtesy of Presbyterian/
changes were stopped, and a nonocclusive dressing St. Luke’s Medical Center, Denver, Colorado.
was placed over the wound that has little granulation Reprinted with permission.
tissue over the mesh graft. Silvadene (silver sulfadi-
azine) was used topically daily beginning on day 17
for increased wound breakdown. During this time, IZ
received 2 more courses of antibiotics. Over the next embryonic disk. Migration and fusion of the cranial,
3 days, progressive wound breakdown developed caudal, and lateral folds normally result in an intact
and the decision was made to consult the wound care umbilical ring by 5-week gestation.1 Partial or com-
team located at the hospital. A wound punch biopsy plete arrest of this process results in an omphalocele,
was done and showed a full-thickness wound with with insertion of the umbilical cord onto the central
chronic infection of the SurgiSIS graft mesh. omphalocele sac with a surrounding facial defect.
Silvadene was stopped and Silvasorb was placed over The size of the defect may vary with large defects of
the wound twice a day. the entire midgut as well as the stomach, liver, and
On day 47, IZ was taken to the operating room spleen. In 50% of cases, the liver, spleen, and ovaries
where the wound was debrided and 90% of the or testes accompany the midgut.1 The abdominal
Surgisis graft mesh was excised. It was necessary to cavity remains small with the absence of the viscera.
leave a portion of the graft mesh in place because the One in 5000 babies has an omphalocele that involves
majority of the graft was adherent to the liver that the bowel only.1 Only 1 in 10 000 infants have a giant
made cautery dissection difficult. The fascial edges omphalocele that involves the liver.1
were joined by bolster sutures and the defect was Fetal omphalocele may occur in conjunction with
closed. Postoperatively, the incision was cleaned with other conditions, such as cardiac or genitourinary
half-strength hydrogen peroxide and triple antibiotic
ointment and she received 1-week dose of amikacin
and vancomycin. Wound culture specimens that FIGURE 2.
were taken intraoperatively were growing methi-
cillin-sensitive Staphylococcus aureus and Escherichia
coli. One week postoperatively, the skin broke down
around the retention sutures. Once again, Silvasorb
was used to treat the open wound. Progressive dehis-
cence developed, and 9 days postdebridement, the
open wound measured 5 2 cm and contained fas-
cia and Surgisis (Figure 1). At this time, the decision
was made to apply a V.A.C.® Therapy device (KCI)
(Figure 2).
GIANT OMPHALOCELE
Abdominal wall defects in infants have 3 subtypes: Device used for wound vacuum assisted closure
omphalocele, gastroschisis, and hernia of the cord. therapy, V.A.C.®, Kinetic Concepts, Inc (San Antonio,
Closure of the fetal abdominal wall depends upon Texas). Reprinted with permission.
appropriate craniocaudal and lateral infolding of the
www.advancesinneonatalcare.org
18. Use of a V.A.C.® Device in a Neonate With an Omphalocele 121
abnormalities, neural tube defects, and the genetic which collagen fibers are deposited, mature, and
defects trisomy 13 or 18. In addition, omphalocele strengthen. This gel-like substance keeps the wound
may be associated with Beckwith–Wiedemann moist, which facilitates healing.6 Vitamin C, zinc,
Syndrome or pentalogy of Cantrell. oxygen, and iron are required for this process.
Granulation occurs when collagen, capillaries, and
NORMAL WOUND HEALING cells begin to fill the wound space with new connec-
tive tissue. Granulation tissue is red and bumpy with
Wound healing is an ever-changing and delicate a meaty appearance. The wound contracts as myofi-
process that at times is taken for granted. The process broblasts align along the lines of contraction. This is
is an overlapping series of events, beginning with a unified process requiring cell-to-cell and cell-to-
injury to eventual repair. Normally, rapid wound matrix communication. The effect of contraction is to
healing occurs in infants and pediatric patients but decrease the area to be filled in with granulation tis-
healing can be delayed by a number of reasons sue. Reepithelialization begins as epithelial cells
including impaired perfusion, infection, prolonged migrate from surrounding skin. Epithelial cells need
pressure, poor nutrition, edema, and the wound envi- a viable wound edge and a moist wound surface to
ronment. Neonatal and pediatric wound care requires migrate across a wound bed.7 These cells eventually
special expertise and precise management. Infants begin to differentiate into various layers of the der-
and children have special characteristics such as skin mis. The initial scar is bright red, thick, and blanches
immaturity, a high body surface to weight ratio, sen- with pressure.
sitivity to pain, increased potential for percutaneous In the fourth stage, remodeling of the scar contin-
absorption of medication, and an immature immune ues for about 1 year. Scar tissue regains about two-
system that adds to the complexity of treating their thirds of its original strength and is never as strong as
wounds.2,3 Effective wound management is depend- the normal tissue and never fully retains tensile
ent upon an understanding both of the normal repair strength.4 Wounds slow down or stop their healing
process and of factors affecting this process and inter- process because of numerous factors. Tissue hypoxia
ventions that can impact the ultimate outcome. There is an important cause. Tissue hypoxia decreases
are 4 phases of wound healing. resistance of the wound to infection by interfering
The first stage includes a vascular response, so with phagocytosis. Hypoxia impairs collagen synthe-
within seconds of an injury, blood vessels constrict to sis and increases collagen lysis as well as decreases
stop any bleeding and to limit exposure to bacteria. epithelial proliferation and migration.8,9 A balanced
Platelets cluster together to form a clot, which is the nutrition is also very important for wound healing. A
result of conversion of thrombin to fibrinogen and neonate should optimally be in a good anabolic state
ultimately to fibrin.4 The second stage involves an with good protein intake. Some centers measure
inflammatory response, which is the body’s first albumin and prealbumin levels and consider them
defense system against bacterial invasion. Neutrophils markers of optimal protein intake during their man-
along with macrophages arrive and ingest bacteria. agement of chronic wounds.2 Full formula or breast
Monocytes, which play a critical role in the healing milk feedings should provide enough protein to opti-
process, arrive later. They phagocytose bacteria along mize wound healing. If oral feedings are not toler-
with damaged tissue, engulfing and destroying microbes ated, total parenteral nutrition with adequate protein,
present there. Macrophages secrete angiogenesis glucose, and fat along with vitamins and trace miner-
factor, which stimulates the formation of new blood als should be provided.
vessels.4,5 Ischemic cells release the vasoactive sub- Wounds that are chronically infected are very slow
stances bradykinin, histamine, and prostaglandin. to heal. Infection prolongs the inflammatory phase of
Vessels start to dilate, permeability increases, and healing, resulting in diminished levels of oxygen in
fluid begins to leak into the wound. Inflammation is a the tissue, with decreased fibroblast production and
sign of healing but prolonged inflammation due to diminished collagen formation. Many chronic
necrotic, infected tissue or foreign bodies slows the wounds require surgical debridement before they can
healing process and can lead to chronic wounds. begin the healing process.
The proliferative phase is the third stage of healing The use of corticosteroids can inhibit the inflam-
and involves intense multiplication of cells. matory response and phagocytosis, interfering with
Angiogenesis, collagen synthesis, contraction, and healing. In addition, these medications decrease col-
epithelialization are part of this phase.2 Angiogenesis lagen strength and can inhibit epithelial prolifera-
is the growth of new capillaries by which local blood tion.4 A dry wound bed should be avoided because
flow for healing is increased. Macrophages secrete this leads to slow healing.4 When a wound is dry,
lactate and growth factors into the wound, which keratinocytes, which are the major cell type of the
stimulate fibroblast proliferation. Fibroblasts secrete epidermis, to heal the wound, will need to burrow
collagen, which reconstructs connective tissue. down to a moist environment in the wound in order
Collagen is initially secreted as a gel matrix onto to secrete collagenase, which lifts the scab. These
Advances in Neonatal Care • Vol. 10, No. 3
19. 122 Wilcinski
cells later migrate, differentiate, and resurface the used for the treatment of acute and chronic
wound. A dry wound bed will also interfere with wounds.10,11 Since its introduction more than a
epithelial proliferation and migration. A very impor- decade ago, it was initially used in adult wound heal-
tant goal of wound healing is to provide a moist ing and has been applied to the pediatric population.
wound bed that stimulates the wound into its healing However, its use in neonates has been limited.
cascade.4,7 V.A.C.® therapy uses the application of controlled
Infants have multiple developmental considera- topical negative pressure across a wound surface in a
tions that place them at higher risk for skin injury and manner that produces rapid wound healing.10,12-14
slower wound healing. During the last trimester of This negative pressure system creates an environ-
pregnancy, collagen is deposited into the dermis. The ment within the wound bed that resists bacterial
dermis of a full-term baby is 60% as thick as that of an growth, encourages capillary growth, and establishes
adult.2 This lack of collagen places a neonate at microcirculation. Blood is drawn into the wound
greater risk of becoming edematous, making their bed and brings growth factor, neutrophils, and
skin more susceptible to injury. Differences in skin macrophages to the area. Again, neutrophils are the
pH place a neonate at greater risk of skin breakdown. first responders; they phagocytize bacteria and
A full-term infant has an alkaline skin surface at birth. breakdown fibrin. These cells activate fibroblasts and
Within 4 days, the pH drops to less than 5, creating keratinocytes and attract macrophages to the area.
an “acid mantle.” An acidic skin surface protects These macrophages engulf large particles such as
against bacterial invasion.8 Premature infants have an bacteria, yeast, and drying cells. They clean the
immature stratum corneum, which is the outer layer wound and secrete cytokines and growth factors.
of the dermis, and overall underdeveloped skin struc- Cytokines and growth factors attract fibroblasts
tures, and they are at risk for skin disruption and tox- and endothelial cells, which convert oxygen to
icity from topically applied substances. A number of superoxide. Superoxide serves as a natural antimicro-
studies involving wound cleansers indicated that sev- bial agent, inhibiting infection in the wound.
eral cleansers and disinfectants can destroy or dam- Keratinocytes migrate into the wound bed and begin
age fibroblasts and granulation tissue in healing epithelialization, which, in turn, stimulates secretion
wounds.8,9 These include Ivory Liqui-Gel, Dial of growth factors, cytokine activity, and angiogenesis.4,14
Antibacterial Soap, and Hibiclens. These products Negative pressure increases local blood flow and
were at a 1/100,000 dilution to be considered non- decreases edema, which improves oxygen delivery to
toxic.9 The skin and wound cleansers, povidone– the wound bed.12,14 Slough and loose necrotic
iodine surgical scrub (Betadine Surgical Scrub) and material are removed from the wound, cleaning
hydrogen peroxide, were found to be nontoxic to the wound and improving the blood supply.
fibroblasts at a 1/1000 dilution.9 Shur-Clens was Removing the necrotic tissue decreases bacterial
noted to be the least toxic to fibroblasts, requiring no colonization.12,14
dilution to maintain viable cells, with SAF-Clens and A good blood supply and a clean wound promote
saline not far behind. Acetic acid, Biolex, Cara- the formation of granulation tissue, which encourages
Klenz, and Puri-Clens had a toxicity index of 10, cor- wound closure and ensures that white blood cells are
responding to a 1/10 dilution.9 This was an in vitro supplied with necessary oxygen while ensuring that
study and it is difficult to establish a direct correlation aerobic bacteria in the wound bed die. V.A.C.®
of in vitro findings with in vivo results. There may not therapy provides a moist wound environment, which
be issues with the efficacy of cleansing actions but is essential for healing, preventing further necrosis
benefits to tissue repair should be cautiously exam- and tissue loss.
ined.9 It is possible that the use of hydrogen perox- V.A.C.® therapy is applied in a manner that was
ide and acetic acid on IZ’s wound added to its slow originally described in 1997, with clean wound tech-
healing, but there were other significant factors nique predominantly used.13 The choice of foam is
including chronic infection that added to nonhealing important. The black reticulated foam (GranuFoam™
of her wound. Silvadene, in addition, is not recom- Dressing; KCI), is the most common dressing used. It
mended for use in babies younger than 3 months is hydrophobic and does not absorb fluid, but it will
because of concern for absorption of silver.8 stay moist under the occlusive drape. This foam is the
most effective at stimulating granulation tissue and
PRINCIPLES OF MOIST WOUND HEALING wound contraction. This foam is cut to the exact size
of the wound. The White Foam™ Dressing (KCI) is
The goal of wound healing is to accomplish all of the an alternative, but it is a denser sponge. It is premoist-
principles listed with every wound. These include ened and nonadherent. It is more hydrophilic than
oxygenation and circulation, removal of necrotic tis- the Black Foam. It is used more commonly in
sue, control of exudates and infection, and provision wounds with exposed tendon, bone, organs, fistulas,
of a clean, moist, and protective environment. or tunnels. It is used to pack tunnels because of its
Vacuum-assisted closure V.A.C.® therapy has been higher tensile strength. A third type of foam,
www.advancesinneonatalcare.org
20. Use of a V.A.C.® Device in a Neonate With an Omphalocele 123
GranuFoam Silver™ dressing, is also available. It is a (Johnson & Johnson, New Brunswick, New Jersey) or
Black Foam microbonded with silver that acts as an Mepitel (Molynlycke Health Care, Eddyston,
effective barrier to bacterial penetration and may Pennsylvania) or applying a thin layer of a hydrogel
help to reduce infection. Because the foam is kept to the wound base can be used to line the wound
constantly moist with the suction force of the pump, before the Black Foam is placed.13-15 With wounds
care is needed not to overlap the intact skin because with extensive drainage, there is a collection canister
maceration of the wound edges can occur. In large that can accurately quantify the drainage.15,16
wounds, multiple pieces of Black Foam can be used.
The foam is placed into the wound without over- LITERATURE REVIEW
lapping the edges and an occlusive drape dressing is
placed over the wound extending on to the intact Negative pressure therapy has been accepted as a
skin to create an airtight seal. A 2-cm hole is cut into valuable adjunct for wound closure in adults since
the drape by pinching it over the foam. The 1993.13 Its use was originally reported for the treat-
SensaT.R.A.C.™ (Therapeutic Regulated Accurate ment of deep chronic wounds with moderate to high
Care; KCI) pad is placed directly over the hole in the exudate levels such as pressure ulcers, abscesses, and
drape and gentle pressure is applied. Then, the deep wounds secondary to trauma. A retrospective
SensaT.R.A.C.™ pad tubing is connected to the canis- study reported experience in 42 patients from 1999
ter tubing. The seal from the transparent drape needs to 2002 for conditions such as nonhealing sternal,
to stay intact and occlusive for the therapy to be effec- spinal, and lower extremity wounds. The use of the
tive since air leaks are common problems (Figure 3). V.A.C.® therapy provided faster wound healing,
The V.A.C.® therapy unit is then programmed for a there were shorter hospital stays, and a reduction in
specific amount of suction-negative atmospheric overall cost.16
pressure. For infants and children, there are no pub- Another study by Mooney et al17 reviewed 27
lished recommendations. Typically, the lowest nega- pediatric patients with complex wounds, which
tive pressure of 50 mm Hg is chosen. The negative included open fractures, failed flap closure, abdomi-
pressure settings vary from 50 to 200 mm Hg, admin- nal and sterna dehisced wounds, and spinal wound
istered continuously or intermittently. Continuous infection. V.A.C.® therapy proved to be advanta-
suction is typically used for the first 48 hours, later geous in this group, aiding in closure without need for
adjusted to intermittent suction. Dressing changes are complex surgical interventions.17
commonly performed at 48-hour intervals or 3 times A retrospective medical record review of children
a week.22 To prevent granulation tissue from growing and infants was conducted to evaluate the effective-
into the foam, more frequent dressing changes should ness of V.A.C.® therapy at a large pediatric hospital
be performed.22 To help minimize patient discomfort between January 2003 and 2005.18 Data were col-
during dressing changes, the White nonadherent lected on wound type, treatment method and dura-
foam or a nonadherent dressing layer of Adaptic tion, and complications. Sixty-eight patients with 82
wounds were identified. The mean age was
8.5 years and ranged from 7 days to 18 years. Twenty
patients (29%), including 8 neonates, were 2 years or
FIGURE 3.
younger. Wound types identified were pressure
ulcers, extremity wounds, dehisced surgical wounds,
open sterna wounds, wounds with fistula, and com-
plex abdominal wall defects. Following the use of
negative pressure therapy, 93% of wounds decreased
in volume. It was concluded that negative pressure
therapy by using the V.A.C.® therapy system can be
effectively used to manage a multitude of wounds in
children and neonates. No major complications were
identified.18
Another retrospective medical record review was
conducted on 24 neonatal and pediatric patients who
had received negative pressure wound therapy for
their wounds from 1999 to 2004.19 Their ages ranged
from 14 days to 18 years. The most common wound
Example of patient with the V.A.C.® therapy device in type was traumatic, with exposed hardware and
place. Photograph courtesy of Presbyterian/St. Luke’s bone. In a median time of 10 days, 11 wounds were
Medical Center, Denver, Colorado. Reprinted with closed by flap, 3 by split-thickness skin graft, 4 sec-
permission. ondarily, and 4 primarily. Results were promising.
Complete closure was achieved in 22 of 24 patients.19
Advances in Neonatal Care • Vol. 10, No. 3
21. 124 Wilcinski
A report in 2006 described V.A.C.® therapy of 3 bowel perforation secondary to necrotizing entero-
infants with giant omphalocele from 2002 to 2004.20 colitis.21 She received total parenteral nutrition
All patients had undergone unsuccessful attempts at through a percutaneously placed central venous
closure by using other methods. The first patient was catheter through a saphenous vein that infiltrated,
initially treated by staged silo reduction, which dis- and she developed on day 31 a 7 3.5-cm blister on
rupted after 21 days. The large mass of the bowel and her lower back. There was extensive full-thickness
liver made primary or skin flap closure impossible. necrosis from the T8/9 region to L5/S1 over the pos-
V.A.C.® therapy was applied for 45 days. The viscera terior torso and dehiscence of tissues between the
were subsequently covered with acellular dermal paraspinous muscles, involving the spinal laminae
matrix (AlloDerm). The dermal matrix that failed to and epidural tissue. The dura was exposed but viable.
integrate into the fascial rim was removed. The small Following intravenous antibiotic administration and
remaining defect was covered with split-thickness debridement, a 7 10-cm defect remained on her
skin graft at 3 months of age. In the second case, back. The V.A.C.® therapy system was applied ini-
mesh placement was performed 5 months after birth, tially by using the White Foam at a negative pressure
with subsequent necrosis of the infant’s abdominal of 50 mm Hg. Within a week, this was changed to the
skin within the immediate postoperative period. The Black Foam and the negative pressure was increased
mesh was removed and V.A.C.® therapy was applied to 75 mm Hg. The V.A.C.® therapy dressing was
for 22 days. The infant subsequently underwent acel- changed every 3 to 4 days for 21 days. Mepitel
lular dermal matrix replacement of the fascial defect (Molylycke Health Care) was applied to the wound
and full-thickness skin flap closure by tissue expan- and changed daily until the wound was completely
sion. The third case was of a full-term infant with a 6- epithelialized 10 days following V.A.C.® therapy
cm omphalocele that was initially treated by staged removal.21
silo reduction. After multiple suture line disruptions,
the silo was removed and gross-type skin flaps were NURSING IMPLICATIONS
used to cover the large defect. This procedure was
complicated by an enterocutaneous fistula. The mesh When a V.A.C.® therapy device is applied, it is the
was removed and V.A.C.® therapy was applied for 36 responsibility of the nurse to maintain its function
days. A healthy granulation bed developed and the and settings that are outlined by the wound care
V.A.C.® therapy device was allowed for the treatment team. A team-centered approach should be used and
of the fistula and coverage of the defect. This case a care plan for the V.A.C.® therapy changes should
series illustrated the challenges faced by pediatric sur- be instituted at the bedside.
geons in the management of giant omphalocele and Maintenance of the V.A.C.® therapy system is
demonstrates the usefulness of V.A.C® therapy.20 important and careful assessment is vital to ensure
In 2005, the V.A.C.® system was used in the care proper negative pressure. Air leaks from under the
of 2 premature infants, weighing less than 1500 g, with occlusive dressing are common problems. An air leak
extensive soft tissue defects.21 The first case involved can be identified when a hissing sound is heard;
a former 23-week gestation infant who at 6 weeks of smaller leaks may be auscultated with the use of a
age and 850 g was found to have an omphalomesen- stethoscope. An air leak would also be suspected when
teric duct fistula that became infected and ruptured the foam is observed to not being collapsed because
into the abdominal wall. At laparotomy, a 3-cm seg- the negative pressure has been lost. The pump will also
ment of ileum adjacent to the ruptured omphalome- alarm if negative pressure is lost. If an air leak devel-
sentric duct was resected. An ileostomy and mucus ops, it can be patched with an additional drape.15
fistula were placed but the patient had necrosis of the Pain assessment and treatment should be a prior-
midline musculature and the closure was not accom- ity. Initially, continuous suction is typically used. A
plished. A bovine pericardial patch was used for tem- pain assessment scale should be put into practice and
porary closure of the muscle defect, and the overly- a pain management plan instituted. Some patients
ing necrotic skin was debrided. One week following experience pain during the dressing change when the
surgery, V.A.C.® therapy was applied. The White pump is initially turned on and the foam is com-
Foam was placed over the defect and a negative pres- pressed. Pain medication should be given in 10 to
sure of 75 mm Hg was applied. The dressings were 30 minutes, depending on the route of medication
changed every 2 to 3 days for 43 days. V.A.C.® ther- before the dressing change. Most infants and children
apy was discontinued when the wound was at the with moderate wounds tolerate device changes with
level of the skin and the suction device was bigger oral pain medications. Typically, acetaminophen is
than the open wound. Later, wet-to-dry dressings used for pain control but with larger wounds, par-
were used and the wound was completely epithelial- enteral pain medication or conscious intravenous
ized 14 days after V.A.C.® therapy removal.21 In the sedation may be needed.10 If pain or bleeding seems
second case, the neonate was a former 27-week ges- excessive with V.A.C.® therapy dressing changes,
tation infant, born weighing 800 g, who developed a one should assess for invasion or adherence of
www.advancesinneonatalcare.org
22. Use of a V.A.C.® Device in a Neonate With an Omphalocele 125
granulation tissue to the Black Foam. Intermittent crib while the wound is healing. Range-of-motion
suction has been proven to accelerate the growth of exercises should also be considered as indicated.
granulation tissue faster than continuous suction.23 Optimally, a developmental specialist should be a
Therefore, switching to continuous suction may part of the care team.
diminish rapid growth of granulation tissue and Wound healing can test family members to the
dressing changes may be more comfortable. Lining limit of their endurance. A family may have to
the wound bed with a nonadherent, oil emulsion– endure multiple surgeries and a prolonged hospital-
type dressing (eg, Adaptic; Johnson & Johnson) or a ization when healing is nonexistent or slow.
contact lining (Mepitel; Molynlcke Health Care) Frustration with the lack of progress in healing is
may disrupt adherence of the V.A.C. sponge.23 common. Doubts and fears should be treated with
Decreasing the amount of suction used may also help respect. Depression can be avoided or improved with
with pain. More frequent dressing changes may also good psychological support. Information about
decrease the growth of granulation tissue into the wound healing and how a wound V.A.C. system
foam. The manufacturer of the wound V.A.C. device works should be provided.
recommends dressing changes every 48 hours for
most wounds.15 Denuded wound margins are noted IZ’S OUTCOME
by older patients and researchers to be a common
source of wound pain.23 To protect intact wound mar- Three days following the initial V.A.C.® therapy, IZ’s
gins under the occlusive V.A.C.® therapy drape, the wound was showing some granulation tissue and was
V.A.C.® therapy sponge should be cut to the exact epithelializing along the wound edges. One week fol-
size of the wound, avoiding overlapping of the lowing placement, there was marked improvement;
sponge on to good skin or to apply a water-soluble the wound showed healthy granulation tissue.
skin sealant (3M No Sting Barrier swab; 3M Fibrous tissue was noted to be present as well and this
HealthCare, St Paul, Minnesota) as primary preven- was treated with Accuzyme (DPT Laboratories, Ltd,
tion. If periwound skin margins break down, one San Antonio, Texas) during dressing changes to
source recommends applying 1-in strips of thin debride this tissue (Figure 4). The wound was
hydrocolloid (Duoderm Thin; Convatec, Princeton, assessed and the V.A.C.® therapy device was reap-
New Jersey) or thin adhesive form (Allevyn; Smith & plied every other day. Following 7 weeks of negative
Nephew, Largo, Florida) to protect the areas that are pressure wound therapy, the wound was healed
open before applying the V.A.C.® therapy drape.23 enough to stop the V.A.C.® therapy.
Include parents in comfort measures during and after IZ was discharged from the hospital at approxi-
dressing changes. Offering an oral sucrose solution mately 5 months of age. In addition to the difficult
may also help with pain. wound-healing course, IZ had feeding difficulties
Close monitoring of fluid loss from the wound into because of significant gastroesophageal reflux that
the canister is extremely important, especially in was related to her large abdominal wall defect. In
highly exuding wounds or large wounds in relation to
patient size. Neonates in particular can lose a signifi-
cant amount of extracellular fluid from the wound
bed and are at risk for dehydration. Accurate meas- FIGURE 4.
urement is required since fluid replacement may
need to be instituted.
Rapid contraction of the wound bed can occur
shortly after placing the V.A.C® therapy on an infant
with a large abdominal wound at risk for respiratory
embarrassment. Care should be taken to follow the
neonate’s work of breathing and oxygen requirement
and to stabilize as needed.
Developmental care issues need to be addressed.
Depending upon the site of the wound, neonates
may need to lie in a position that is not developmen-
tally supportive. For instance, IZ could lie only on
her back because of the limitation of her large
wound and the V.A.C.® therapy device. However,
positional supports and boundaries were provided to
optimize and facilitate appropriate postural align- Wound after 3 days of V.A.C® therapy. Photograph
ment. Her mother could not provide kangaroo care. courtesy of Presbyterian/St. Luke’s Medical Center,
Providing age-appropriate stimulation is important Denver, Colorado. Reprinted with permission.
since infants can be spending significant time in their
Advances in Neonatal Care • Vol. 10, No. 3
23. 126 Wilcinski
systems such as the V.A.C.® therapy system may be
FIGURE 5. helpful in some infants.
References
1. Magnuson DK, Parry RL, Chwals WJ. Abdominal wall defects. In: Martin RJ,
Fanaroff AA, Walsh MC, eds. Fanaroff and Martin’s Neonatal-Perinatal Medicine,
Diseases of the Fetus and Newborn. 8th ed. Philadelphia, PA: Mosby-Elsevier;
2006:1380-1386.
2. Lund, CH, Tucker JA. Adhesion and newborn skin. In: Hoath SB, Mailbach HI, eds.
Neonatal Skin Structure and Function. 2nd ed.; pp. 299-324. New York, NY:
Marcel Decker Inc; 2003.
3. Barharestani M, Pope E. Chronic wounds in neonates and children. In: Krasner D,
Rodheaver GT, Sibbald RG, eds. Chronic Wound Care: A Clinical Source Book for
Healthcare Professionals. 4th ed. Malvern, PA: HMP Communications; 2007:673-
693.
4. Strodtbeck F. Physiology of wound healing. Newborn Infant Nurs Rev.
2001;1:43-52.
5. Clark RAF. Wound repair: overview and general considerations. In: Clark RAF, ed.
The Molecular and Cellular Biology of Wound Repair. 2nd ed. New York, NY:
Plenum Press; 1995:3-50.
6. Flanigan KH. Nutritional aspects of wound healing. Adv Wound Care. 1997;10:
48-52.
Wound after 2 months V.A.C® therapy. Photograph 7. Waldrop J, Doughty D. Wound healing physiology. In: Bryant RA, ed. Acute and
courtesy of Presbyterian/St. Luke’s Medical Center, Chronic Wounds. Nursing Management. 2nd ed. St Louis, MO: Mosby; 1997:413-429.
8. Association of Women’s Health, Obstetric and Neonatal Nurses. Neonatal Skin
Denver, Colorado. Reprinted with permission. Care, Evidenced Based Clinical Practice Guidelines. 2nd ed. Washington DC:
AWONN; 2007.
9. Wilson J, Mills J, Prather I, Dimitrijevich SD. A toxicity index of skins and wound
cleansers used on in vitro fibroblasts and keratinocytes. Adv Skin Wound Care.
2005;18:373-378.
10. Caniano DA, Teich S, Ruth B. Wound management with vacuum-assisted closure:
experience in 51 pediatric patients. J Pediatr Surg. 2005;40:128-132.
addition, coordination and stamina were issues for 11. Jerome D. Advances in negative pressure wound therapy. J Wound Ostomy
her, which made nippling a challenge. She was dis- Continence Nurs. 2007;34:191-194.
12. Smith N. The benefits of VAC therapy in the management of pressure ulcers.
charged from the hospital with an indwelling nasal Br J Nurs. 2004;13:1359-1365.
gastric tube in place. She was not a candidate for sur- 13. Argenta L, Morykwas M. Vacuum-assisted closure: a new method for wound
control and treatment. Annu Plast Surg. 38:563-576.
gical treatment of her gastroesophageal reflux 14. Miller M, Glover D. Wound Management: Theory and Practice. London, England:
because of previous multiple abdominal wall surger- The Friary Press; 1999.
15. KCI The Clinical Advantage. V.A.C. Therapy Clinical Guidelines: A Reference
ies. She was nippling small volume of formula dur- Source for Clinicians; 2007. Accessed October 2008 from http://www.KCI1.
ing the day and was fed the remainder by her mother com/KCI1/vacapplicationsvideos
with gavage feedings. To improve growth, she was 16. Antony S, Terrazas S. A Retrospective study: clinical experience using vacuum
assisted closure of the treatment of wounds. J Natl Med Assoc. 2004;96:1073-1077.
discharged home on 27 cal/oz of formula and 17. Mooney JF, Argenta LC, Marks MW, et al. Treatment of soft tissue defects in pedi-
received continuous-drip nighttime feedings. atric patients using the VAC system. Clin Orthop Relat Res. 2000;376:26-31.
18. McCord SS, Murphy K, Olutoyeo L, Naik-Mathuria B, Hollier L. Negative pressure
Following discharge, she was followed by the wound therapy is effective to manage a variety of wounds in infants and chil-
Wound Healing Center and pediatric surgeons. One dren. J Wound Ostomy Continence Nurs. 2007;34:573-574.
19. Baharestani M. Use of negative pressure wound therapy in the treatment of
week following discharge, her wound began to break neonatal and pediatric wounds: a retrospective examination of clinical out-
down once again (Figure 5). V.A.C.® therapy was reap- comes. Ostomy Wound Manage. 2007;53(6):75-85.
plied and her mother was instructed on how to change 20. Kilbride K, Cooney D, Custer M. Vacuum-assisted closure: a new method for
treating patients with giant omphalocele. J Pediatr Surg. 2006;41:212-215.
the V.A.C.® therapy dressings. Three weeks later, the 21. Arca M, Somers K, Derks TE, et al. Use of vacuum assisted closure system in the
wound was completely healed and V.A.C.® therapy management of complex wounds in the neonate. Pediatr Surg Int. 2005;21:532-
535.
was discontinued. Her wound has remained closed. 22. Bookout K, McCord S, McLane K. Case studies of and infant, a toddler, and an
Wound healing can be difficult in neonates, partic- adolescent with a negative pressure wound treatment system. J Wound Ostomy
Continence Nurs. 2004;31:184-192.
ularly those with large wounds or surgical sites. The 23. Krasner D. Managing wound pain in patients with vacuum assisted closure
use of controlled topical negative pressure with devices. Ostomy Wound Manage. 2002;48(5):38-43.
www.advancesinneonatalcare.org
24. CE Test
Use of a Vacuum-Assisted Device in a Neonate With a
Giant Omphalocele
Instructions: • Questions? Contact Lippincott Williams & Wilkins: The ANCC’s accreditation status of Lippincott Williams &
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CE TEST QUESTIONS
GENERAL PURPOSE STATEMENT: To provide the registered 6. A wound’s resistance to infection is decreased by
professional nurse with the use of vacuum assisted closure (VAC) device to a. tissue osmolality.
assist wound healing in the neonate with a giant omphalocele. b. tissue hypoxia.
LEARNING OBJECTIVES: After reading this article and taking this test, c. release of angiogenesis factor.
the nurse will be able to: d. inhibition of bradykinin.
1. Identify normal wound healing in neonates. 7. Which of the following leads to slow healing?
a. a dry wound bed
2. Describe wound VAC therapy in neonates with giant omphalocele.
b. a wet wound bed
1. Following development of progressive dehiscence, a c. full formula feedings
wound VAC device was applied on Baby Girl IZ at how d. breastmilk feedings
many days post debridement?
8. A neonate is at greater risk of skin breakdown due to
a. 3 days
a. excessive collagen.
b. 5 days
b. a thick dermis.
c. 7 days
c. differences in skin pH.
d. 9 days
d. increased cardiac output.
2. Abdominal wall defects in infants include all of the
9. For Baby Girl IZ, use of which of the following wound
following except :
cleansers may have added to slow wound healing?
a. hiatal hernia.
a. hydrogen peroxide and acetic acid
b. gastroschisis.
b. antibacterial soap
c. omphalocele.
c. Shur-clens
d. hernia of the cord.
d. Hibiclens
3. Fetal omphalocele may occur in conjunction with
10. To produce rapid wound healing, VAC therapy uses the
a. cystic fibrosis.
application of controlled:
b. neutral tube defects.
a. topical negative pressure.
c. Down syndrome.
b. systemic negative pressure.
d. fetal alcohol syndrome.
c. topical positive pressure.
4. Which is a special characteristic that adds to the complex- d. systemic positive pressure.
ity of treating neonatal wounds?
11. VAC therapy encourages rapid wound healing by
a. a high body surface to weight ratio
a. constricting blood flow into the area.
b. a low body surface to weight ratio
b. drawing blood into the area.
c. decreased sensitivity to pain
c. preventing angiogenesis.
d. decreased potential for percutaneous absorption of medication
d. limiting granulation.
5. Which stage of wound healing involves intense multiplica-
12. Which is the most common dressing used with wound
tion of cells?
VAC?
a. first stage b. second stage
a. black foam b. white foam
c. third stage d. fourth stage
c. silver foam d. gold foam
Advances in Neonatal Care • Vol. 10, No. 3 127
25. 13. When using wound VAC therapy, the negative pressure 16. A priority of wound VAC therapy care is
typically chosen for infants is a. pain management.
a. 50 mmHg b. oxygen administration.
b. 100 mmHg c. fluid administration.
c. 150 mmHg d. antibiotic therapy.
d. 200 mmHg
17. To protect intact wound margins under the occlusive VAC
14. As described in this article, a retrospective chart review of drape, the VAC sponge should be
24 patients who received negative pressure wound therapy a. smaller than the wound.
found that complete closure was obtained in b. larger than the wound.
a. 12 of 24 patients. c. the exact size of the wound.
b. 18 of 24 patients. d. overlap the wound.
c. 22 of 24 patients.
18. Optimally, the team caring for the infant receiving wound
d. all patients.
VAC therapy should include
15. Which is a common problem with wound VAC therapy? a. an infection control specialist.
a. fluid leaks from under the occlusive dressing b. a developmental specialist.
b. air leaks from under the occlusive dressing c. a neurologist.
c. wound infection d. a cardiologist.
d. wound fistula
ANC0510
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Advances in Neonatal Care June 2010
Use of a Vacuum-Assisted Device in a Neonate With a Giant Omphalocele
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