JBUR-4746; No.

of Pages 9
burns xxx (2016) xxxxxx

Available online at www.sciencedirect.com

ScienceDirect
journal homepage: www.elsevier.com/locate/burns

Extra-large negative pressure wound therapy

dressings for burns Initial experience with
technique, fluid management, and outcomes
Sebastian Fischer a,b, Jennifer Wall c, Bohdan Pomahac a, Robert Riviello c,
Eric G. Halvorson a,*
a

Division of Plastic Surgery, Brigham and Womens Hospital, Harvard Medical School, 75 Francis St, 02115 Boston,
MA, United States
b
Department of Hand, Plastic and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen,
Research Group Trauma meets Burn, University of Heidelberg, Ludwig-Guttmann-Strasse 13, 67071 Ludwigshafen,
Germany
c
Division of Trauma, Burns, and Surgical Critical Care, Brigham and Womens Hospital, Harvard Medical School,
75 Francis St, 02115 Boston, MA, United States

article info

abstract

Article history:

Objective: The use of negative-pressure-wound-therapy (NPWT) is associated with im-

Accepted 25 August 2015

proved outcomes in smaller burns. We report our experience using extra-large (XL) NPWT
dressings to treat 15% total body surface area (TBSA) burned and describe our technique

Keywords:

and early outcomes. We also provide NPWT exudate volume for predictive fluid resuscita-

Negative pressure wound therapy

tion in these critically ill patients.

Fluid resuscitation

Methods: We retrospectively reviewed patients treated with XL-NPWT from 2012 to 2014.

Burn wound

Following excision/grafting, graft and donor sites were sealed with a layered NPWT dress-

Vacuum assisted closure device

ing. We documented wound size, dressing size, NPWT outputs, graft take, wound infections,
and length of stay (LOS). Mean NPWT exudate volume per %TBSA per day was calculated.
Results: Twelve burn patients (mean TBSA burned 30%, range 1560%) were treated with XLNPWT (dressing TBSA burned and skin graft donor sites range 1744%). Average graft take
was 97%. No wound infections occurred. Two patients had burns 50% TBSA and their LOS
was reduced compared to ABA averages. XL-NPWT outputs peaked at day 1 after grafting
followed by a steady decline until dressings were removed. Average XL-NPWT dressing
output during the first 5 days was 101  66 mL/%BSA covered per day. 2 patients developed
acute kidney injury.
Conclusion: The use of XL-NPWT to treat extensive burns is feasible with attention to
application technique. NPWT dressings appear to improve graft take, and to decrease risk
of infection, LOS, and pain and anxiety associated with wound care. Measured fluid losses
can improve patient care in future applications of NPWT to large burn wounds.
# 2015 Elsevier Ltd and ISBI. All rights reserved.

* Corresponding author. Tel.: +1 617 732 6387; fax: +1 617 525 7386.
E-mail address: ehalvorson@partners.org (E.G. Halvorson).
http://dx.doi.org/10.1016/j.burns.2015.08.034
0305-4179/# 2015 Elsevier Ltd and ISBI. All rights reserved.

Please cite this article in press as: Fischer S, et al. Extra-large negative pressure wound therapy dressings for burns Initial experience with
technique, fluid management, and outcomes. Burns (2016), http://dx.doi.org/10.1016/j.burns.2015.08.034

JBUR-4746; No. of Pages 9

burns xxx (2016) xxxxxx

1.

Introduction

Negative pressure wound therapy (NPWT) has expanded our

ability to treat acute and chronic wounds and belongs in the
standard repertoire of every surgical department [1]. NPWT
provides a sterile occlusive wound healing environment that
promotes re-epithelialization [2]. Studies have shown that
wound healing improves due to increased diffusion of blood
and nutrients to the healing site [3,4]. For patients with large
burn wounds, the inability of deep wounds to epithelialize is a
significant source of infectious morbidity and mortality [5].
Dermal vessels are damaged leading to a depletion of
erythrocytes and immune cells in the wound bed [69]. In
addition, burns exceeding 15% TBSA result in the release of
inflammatory mediators that provoke immunosuppression,
increased vascular permeability and fluid shifts to extravascular spaces [1012]. As a sterile occlusive dressing that
promotes re-epithelialization, NPWT has the potential to
reduce infectious complications and improve wound healing
in burn patients. The widespread use of NPWT in burn surgery
has been limited, however, likely due to challenges with
dressing application in this patient population.
A sterile wound environment, proper wound healing and
adequate fluid resuscitation are mandatory for survival in
critically ill burn patients. Although the latter is more crucial
in the initial phase of large burns, fluid replacement regains
importance after surgical debridement and autologous skin
grafting due to enlargement of the affected body surface area
from the donor site [13]. In current clinical practice, insensible
fluid losses are estimated using body weight, heart rate, blood
pressure, urine output, laboratory values, and other parameters. These attempts to estimate the patients fluid status and
volume repletion are often imprecise and can lead to
pulmonary edema or renal failure with life-threatening
consequences [1417]. In order to limit the effects of dramatic
shifts in wound area, a staged approach to excision and
autografting is often implemented, which on the other hand
has the potential to prolong hospitalization and increase the
risk of wound infections and other nosocomial complications
[18]. By quantifying wound exudate, NPWT has the potential to
improve one of the most vexing problems in current burn care:
fluid management. More informed fluid management may
lead to reduced pulmonary and renal complications.
Kamolz et al. recently reported about feasibility of NPWT
for large-scale burns exceeding 25% TBSA burned in 37
patients [19]. Although this excellent study clearly demonstrates beneficial effects of NPWT for severely burned
patients and thus increases the demand for more evidence
supporting this technique, detailed data regarding complications and fluid losses associated with NPWT were not
provided.
Several studies have demonstrated that NPWT is capable of
reducing infection rates and enhancing graft take after burn
wound excision and autografting [1,20]. These studies,
however, are limited to small burns that do not exceed an
average of 10% TBSA. Based on these studies it is impossible to
know if NPWT has a beneficial effect on the systemic
alterations associated with larger burns. Finally, there is
some data to suggest that NPWT has a beneficial effect on

re-epithelialization of skin graft donor sites [21]. Nevertheless,

this data is based on an animal study and case reports
involving small wounds.
The aim of this study was to evaluate our outcomes using
extra-large NPWT (XL-NPWT) dressings in burn patients with
wounds 15% TBSA burned, and provide a description of
technical refinements that make dressing application feasible
for large burn wounds. A secondary aim was to quantify
wound exudates using NPWT in an effort to predict estimated
fluid losses after excision and autografting. We sought to
compare these outputs to estimated insensible losses using
standard calculations, and to suggest measuring NPWT
exudate as a useful tool for clinicians managing burn patients.

2.

Patients and methods

An IRB-approved retrospective review was performed of

patients admitted to our burn center from April 2012 to April
2014. We included patients that received NPWT after burn
excision and grafting with wounds 15% TBSA burned.
Wounds were covered with xenografts or autografts using a
power dermatome (0.100.12 inches) and 2:1 or 3:1 mesher.
Patient records were reviewed to determine graft take (%),
donor site healing (time to 95% re-epithelialization), ventilation days, complications, length of stay (LOS), and volume of
wound exudate. Dressing size was measured manually with a
conventional ruler and also calculated as a percentage of the
TBSA via Lund and Browder method [22]. Estimates of
insensible losses were calculated by the formula of DuBois
and DuBois involving body weight and height [23]. Wound
exudate was gathered daily and provided in total (grafted + donor sites) as well as separately for graft and donor sites.
Wound exudate output was calculated in mL per percentage of
VAC covered body surface area per day and given in average of
the first 5 days after grafting as well as for each of the first 5
days separately. NPWT dressings placed over xenografts were
excluded from these calculations to simplify our analysis.
Daily burn related evaporative losses (BREL) were calculated
according to the following formula [24]:
BREL = (25 + %TBSA)  (BSA in cm2)  24.
Hospital LOS was compared with average LOS provided by
the American Burn Association (ABA) according to patients
age and TBSA burned.

3.
Negative pressure wound therapy dressing
application
NPWT dressings were applied to both burn wounds and donor
sites. In the majority of cases, tangential excision and
autografting was performed. Less often, fascial excision with
or without grafting was performed. Xenografts were used in
certain cases to test the wound bed or provide temporary
biologic coverage. Graft recipient sites were covered with nonadherent fine mesh gauze (N-TERFACE, Winfield Laboratories,
Richardson, Texas, USA and/or Xeroform Covidien, Mansfield,
MA, USA) and donor sites with thin silver-impregnated nonadherent foam (Mepilex Ag, Molnlycke Health Care, Gothenburg, Sweden). All surfaces were then covered with NPWT

Please cite this article in press as: Fischer S, et al. Extra-large negative pressure wound therapy dressings for burns Initial experience with
technique, fluid management, and outcomes. Burns (2016), http://dx.doi.org/10.1016/j.burns.2015.08.034

JBUR-4746; No. of Pages 9

burns xxx (2016) xxxxxx

Fig. 1 On extremities, a seal was obtained by sandwiching

the limb between large sheets of occlusive dressing.

dressings consisting of polyurethane foam (V.A.C. GranuFoam, KCI, San Antonio, TX), transparent self-adhesive drape
(V.A.C. Drape, KCI, San Antonio, TX and/or Ioban, 3 M, St. Paul,
MN) and a suction pad (Sensa T.R.A.C. Pad, KCI, San Antonio,
TX).
Recognizing that prolonged maintenance of seal was
critical to the success of the NPWT, multiple application
strategies were employed. On extremities, a seal was
obtained by sandwiching the limb between large sheets of
occlusive dressing (Fig. 1). Tincture of benzoin was used to
prepare the dried skin prior to application of adhesive
drapes. Wall suction was utilized to provide the initial seal
and the most difficult areas were sealed last, after wall
suction was applied, so an immediate seal was obtained. In
areas of shear or moisture (e.g. perineum, non-excised burn,
open tissue), a double layer of occlusive dressing was applied
and secured by stapling or suturing to the moist tissue
(Figs. 25). Suction pads were applied to the most dependent
areas. Negative pressure was provided by 26 suction pumps
(V.A.C. Therapy Unit, KCI, San Antonio, TX) per patient. In
general, 1 pump was used per 9% TBSA body area as defined
by Lund and Browder [22]. For example, one pump was used
per arm and two pumps per leg. NPWT was applied at
125 mmHg. Range of motion was permitted at postoperative day 13 with NPWT turned down to 50 mmHg, at the
discretion of the attending burn surgeon. When a seal was

Fig. 2 XL-NPWT of the lower two thirds of the body.

Extremities were circumferentially wrapped and sealed by
occlusive dressings in sandwich technique. Of note,
popliteal fossas were left free from foam to facilitate
mobilization.

unable to be maintained via the KCI device, despite standard

trouble shooting, that suction pad was switched to wall
suction. Dressings were taken down in the operating room
57 days after application.

Fig. 3 Two rows of staples and sutures facilitated

maintenance of seal in the groin area to overcome shear
forces and moisture.

Please cite this article in press as: Fischer S, et al. Extra-large negative pressure wound therapy dressings for burns Initial experience with
technique, fluid management, and outcomes. Burns (2016), http://dx.doi.org/10.1016/j.burns.2015.08.034

JBUR-4746; No. of Pages 9

burns xxx (2016) xxxxxx

Fig. 4 Stapling and suturing provided seal in the gluteal

crease area that is highly exposed to moisture and shear
forces.

A fluid replacement guideline was developed and followed

after the first case. When XL-NPWT output was predicted to be
>3 L/d (based on current output), output was replaced with
lactated ringers solution in a 1:1 ratio calculated every 4 h
shift. Electrolytes were checked twice daily, and corrected per
standard ICU management.

4.

Results

Twelve patients were included in this study with an average

age of 35.5 years (median: 28, range: 1863). The mean burn

size was 29.6% TBSA burned (median: 25, range: 1560%). Six
patients (50%) also suffered inhalation injury. Mechanical
ventilation was undertaken in 11/12 (92%) patients for an
average of 16.5 days (median: 15, range 240 days). Initial
wound debridement was performed on average 4.4 days after
burn (mean: 5, range 27 days). Xenograft application was
performed in 6 cases as a temporary measure. Mean time from
burn to autografting was 7.75 days (median: 7.5, range: 217
days). TBSA covered with a NPWT dressing was on average
35.1% TBSA (burned and skin graft donor sites, median: 32,
range: 1744%). Average graft take was 97% (median: 100,
range: 85100%). Donor sites were re-epithelialized after an
average of 11.25 days (median: 11, range: 1014 days), although
this information was only available for 4 patients.
Two patients (17%) developed acute kidney injury (AKI), of
which one occurred subsequent to NPWT. Hematoma
occurred in 1 patient under a donor site dressing within
the first 12 h after surgery, undergoing evacuation under the
dressing. The dressing was then re-sealed with no subsequent complication. LOS averaged 37.9 days (median: 32.5,
range: 1966). Two patients with burns exceeding 35% TBSA
had shorter LOS than the average LOS according to ABA Burn
Repository national averages (39 vs. 62 days and 50 vs. 68
days, respectively). An overview of all patients is given in
Table 1. There were no wound infections and every patient
survived.
Average NPWT dressing output during the first 5 days
after grafting was 101  66 mL/% BSA covered per day. Donor
site output was more than double recipient site output.
Average output of recipient sites was 61  37 mL/%BSA/day
and average output of donor sites was 132  83 mL/%BSA/
day. Peak output was observed on the first day for both
combined and recipient sites (154  85 mL/%BSA/day and
93  30 mL/%BSA/day) and over the first two days for donor
sites (175  92 mL/%BSA/day on day 1 and 169  92 mL/
%BSA/day on day 2 after grafting) (Table 2 and Fig. 6). Of
note, the reduced output observed on the day of NPWT
application (day 0) is mainly attributed to the time point of
surgery, as outputs were usually not recorded until late
afternoon. Mean calculated BREL was 2519 mL/day. BREL did
not correlate with NPWT dressing output during the first 5
postoperative days, and was typically higher than peak
NPWT output.

5.

Fig. 5 Two rows of staples can be used to seal wounds

exposed to moisture and shear.

Discussion

This study demonstrates that NPWT is safe and effective in

burn patients with wounds exceeding 15% TBSA burned.
Although there is a steep learning curve, with attention to
proper technique a seal is possible in larger burns previously
thought to be unamenable to NPWT. After excision and
autografting, NPWT seemed to prevent wound infection and
promote excellent graft take and re-epithelialization of donor
sites. In addition, fluid management decisions were informed
by NPWT output measurements that revealed a mean output
of 101 mL/%BSA/day and a peak of 154 mL/%BSA/day on day 1
after grafting. These measurements may be useful to estimate
fluid losses in cc per %TBSA (both burned and skin graft donor
sites) during post surgical XL-NPWT in burn patients, and

Please cite this article in press as: Fischer S, et al. Extra-large negative pressure wound therapy dressings for burns Initial experience with
technique, fluid management, and outcomes. Burns (2016), http://dx.doi.org/10.1016/j.burns.2015.08.034

JBUR-4746; No. of Pages 9

Pt.

1
2
3
4
5
6
7
8
9
10
11
12

Mechanism

Inhal.
injury

Flame
Scald
Flame
Flame
Flame
Flame
Flame
Flame
Flame
Flame
Flame
Flame

N
N
N
Y
N
N
Y
N
Y
Y
Y
N

Mean
Median
Range

SD

Age
years

18
27
34
24
25
52
29
24
59
53
63
18
35.5
28.0
18 63

%TBSA

60
25
15
50
25
22
22
22
23
32
34
25
29.6
25.0
15 60

Ventilation
days

32
15
2
24
9
9
3
40
30
16
2
16.5
15.0
2 40

Days to
debrid.

Xenograft

Days to
STSG

5
7
7
5
5
3
3
5
3
5
3
2

Y
Y
N
Y
Y
N
N
N
N
Y
Y
N

14
17
7
11
8
3
3
5
3
11
9
2

4.4
5.0
2 7

7.8
7.5
2 17

Peak
NPWT
%TBSA

44
17
28
42
36
30
25
34
26
50
61
28
35.1
32.0
17 44

LOS
days

ABA
avg.
LOS

Graft
take %

50
30
20
39
29
30
26
35
64
66
47
19

68
19
11
62
19
28
19
19
28
40
42
20

100
100
100
100
96
100
100
85
100
99
88
97

NA
NA
9
10
11
NA
NA
NA
NA
NA
NA
NA

97.1
100.0
85 100

10.0
10.0
9 11

37.9
32.5
19 66

31.3
24.0
11 68

Days
to 95%
heal
graft

Calculated
BREL/day

VAC
output
ml/%BSA/d
total

NA
NA
14
10
11
NA
NA
NA
NA
NA
NA
10

4875.5
1524.0
1708.8
3078.0
2028.0
2109.4
2368.8
1917.6
2361.6
2270.9
4063.9
1920.0

115.4
75.4
104.5
71.7
203.2
52.4
69.0
56.3
147.2
124.4
147.1
44.9

207.4
149.7
151.0
134.8
369.0
70.5
117.9
77.9
209.5
147.7
203.8
86.7

11.3
10.5
10 14

2518.9

101.0

160.5

1006.2

65.9

81.5

Days
to 95%
heal
donor

Peak VAC
output
total
ml/%BSA/d
(on day)
(1)
(1)
(3)
(1)
(1)
(1)
(1)
(2)
(1)
(4)
(1)
(1)

burns xxx (2016) xxxxxx

Please cite this article in press as: Fischer S, et al. Extra-large negative pressure wound therapy dressings for burns Initial experience with
technique, fluid management, and outcomes. Burns (2016), http://dx.doi.org/10.1016/j.burns.2015.08.034

Table 1 Overview of all patients and outcomes.

TBSA = total body surface area, LOS = length of stay, NPWT = negative pressure wound therapy, ABA = American Burn Association, STSG = split thickness skin graft, NA = not available, BREL = burn
related evaporative losses, SD = standard deviation.

JBUR-4746; No. of Pages 9

burns xxx (2016) xxxxxx

Table 2 NPWT output of both grafted and donor sites

(total) and grafted and donor-sites, separately,
SD = standard deviation.
Day after grafting
Total VAC output
Mean
SD
Grafted VAC output
Mean
SD
Donor VAC output
Mean
SD

81.6
64.2

154.0
84.7

123.5
57.1

102.6
46.1

79.9
49.2

61.0
51.4

55.0
56.8

93.4
30.3

70.1
16.0

60.5
27.5

51.5
35.3

26.7
18.3

109.7
84.5

175.3
91.9

168.8
91.5

136.3
88.7

92.5
66.1

64.2
52.0

perhaps following excision/autografting in general (without

the use of NPWT).
In 1998, Schneider et al. introduced NPWT to secure skin
grafts to difficult recipient beds [25]. Since then several
authors have reported their experience with NPWT for skin
graft fixation and revealed improved graft-take and accelerated healing [26,27]. With respect to burn wounds Petkar
et al. applied NPWT to 30 patients with a mean wound size
of 244 cm2 and revealed an average graft-take of 96.7% [28].
Waltzmann et al. reported a mean graft take of 99.5%, in 76
patients with an average burned surface area of 367 cm2
[29].
In our study the average graft take was 97%, thus
comparable to results achieved in the literature. Wound size,
however, was significantly higher, as none of the aforementioned studies involved wounds that exceeded 10% TBSA
burned. This demonstrates that the efficacy of NPWT is not
limited to small burns. Moreover, NPWT may be more effective
in larger burns where a higher rate of graft loss has been the

norm due to shear forces (especially in mobile joints, the

posterior trunk, the perineum, etc.) (Fig. 7).
Attempts to accelerate re-epithelialization of autograft
donor sites include various types of dressings and applications. With respect to NPWT, Genecov et al. assessed healing
of donor sites histologically at day 7 after grafting in 4 pigs
and 10 humans and demonstrated a statistically significant
increase in the rate of re-epithelialization due to NPWT
application [21]. In our study complete healing of donor sites
was obtained an average of 11.25 days after skin graft
harvest. Wound infections were not observed and apart from
NPWT removal a maximum of two dressing changes were
necessary.
It is important to note that the wounds treated in this study
(including both burns and donor sites) were significantly larger
than those included in the aforementioned studies. The only
studies that address wounds in comparable size were
performed by Kamolz et al., Chong et al. and Low et al.
[19,30,31]. By applying NPWT to 37 patients with at least 25%
TBSA burned, Kamolz et al. were able to demonstrate
favorable results regarding graft-take, infections and survival
as well as its feasibility of skin graft fixation in areas of
irregular wound surfaces or subject to movement. Although
these results are well in accordance to our findings and clearly
substantiate beneficial attributes related to NPWT for largescale burns, fluid losses were not evaluated in this study. In
contrast Chong et al. and Low et al. (both from the same unit)
demonstrated the applicability of total body wrap NPWT in
burns of 2260% TBSA and provided information about the
body fluids collected [30,31]. After wound excision and
autografting, limbs and trunks of 8 patients (combining both
studies) were sandwiched with large polyurethane dressings.
A thin strip of sponge was placed in the dependent part of the

Fig. 6 Volume losses through NPWT per day for donor (green line) and grafted (red line) sites and combined (blue line).
BSA = body surface area. (For interpretation of the references to color in this figure legend, the reader is referred to the web
version of this article.)
Please cite this article in press as: Fischer S, et al. Extra-large negative pressure wound therapy dressings for burns Initial experience with
technique, fluid management, and outcomes. Burns (2016), http://dx.doi.org/10.1016/j.burns.2015.08.034

JBUR-4746; No. of Pages 9

burns xxx (2016) xxxxxx

Fig. 7 Perianal area sealed by double layer of occlusive

dressing, staples and sutures.

dressing only, and therefore this application is quite different

from traditional technique and may not provide the same
fixation of grafts. Average daily exudate was collected in one
study [30] for 3 patients and ranged from 526 to 1211 mL during
the first 3 postoperative days, but output did not seem to
correlate with TBSA (2260%). The authors concluded that
total body wrap NPWT is feasible and improved healing,
patient comfort and management of the extensively burned
patient.
Our study substantiates these findings. Although applied
in conventional technique with sponges that covered the
entire wound area, sealing was achieved by sandwiching
extremities and by stapling or suturing occlusive drapes in
areas of shear or moisture. To provide initial seal wall suction
was utilized and the most difficult areas were sealed at last.
Furthermore, fluid resuscitation was beneficially assisted by
VAC output measurements. In detail, average fluid loss
during the first 5 days after grafting was 100.98 ml/%BSA/
day, with a peak on day 1 and subsequently declined over the
following days after grafting. In this context, it is important to
mention, that the reduced output on the day of VAC
application (day 0) is mainly attributed to the time point of
surgery and should be considered for half or even less of the
day of application.
Lamke et al. evaluated evaporative water losses depending
on burn depth in an experimental study and found superficial
second degree burns to be equal to donor sites and both losing
higher amounts of fluid than third degree burns [32]. In the
same study wound evaporation was reduced by 8085% after
autologous skin grafting making water loss of donor sites after
grafting about 3 times higher compared to grafted sites (1.2 vs.
0.36 mL/cm2/day).
Our study showed comparable results, as donor sites
yielded more than twice as much NPWT output compared to
grafted sites. Interestingly, by calculating our NPWT output in
mL per cm2 of affected BSA per day (data not shown), grafted
sites have similar but donor sites much less output compared
to the studies of Lamke et al. (0.36 vs. 0.35 mL/cm2/day and
0.7 vs. 1.2 mL/cm2/day, respectively). The latter might be

attributed to the inner layer of the donor site dressing we used

that may contain fluid exudate despite suction. This effect
might be irrelevant on grafted sites as a seal is predominantly
provided by skin grafts and the additional contribution of the
sponges is insignificant.
Proper fluid resuscitation is necessary to prevent lifethreatening complications, like acute kidney injury (AKI) and
lung edema. AKI is seen more frequently during the
resuscitation period and incidence varies between 14.6 and
39.1% among burn patients [33,34]. In contrast lung edema
occurs more often after than during the fluid-resuscitation
phase of burn [35]. Clinical studies suggest, that lung
edema is more related to inhalation injury, followed by
hypoproteinemia then by fluid overdose or retention,
respectively [3638]. Nevertheless, fluid restriction (a dry
or conservative strategy) has been proven effective to
overcome lung injury and acute respiratory distress syndrome (ARDS) [39].
With respect to complications associated with adequacy
of fluid resuscitation, 2 patients in our study developed AKI. It
is possible that lack of experience with large-scale NPWT and
consequent underestimation of fluid resuscitation may have
attributed to the occurrence of AKI. On the other hand none of
our patients developed clinically significant lung edema and
mechanical ventilation could be discontinued earlier compared to data from burn patients provided in the literature
[40].
There are several limitations to our study. To prove an
improvement in outcomes due to NPWT, a control group
would be necessary. Our early results are so encouraging,
however, that we are reluctant to recommend a randomized
study. The only comparisons that were feasible involved LOS
and BREL with ABA registry data and the formula according to
Warden et al., respectively [28]. All other advantages of XLNPWT are only suggested in accordance and compared with
data provided in the literature. In addition, our determination
of re-epithelialization was based on subjective assessment in
a non-blinded fashion. Therefore, further studies are needed
to substantiate our findings and verify the beneficial attributes
of XL-NPWT in burn patients.
The aim of this study was to demonstrate the feasibility of
XL-NPWT in burn patients, describe our technique, demonstrate our early results, and assess wound exudate outputs. By
providing the average fluid output related to wound area
covered with NPWT, further studies involving XL-NPWT can
be performed with more proactive fluid replacement strategies.

6.

Conclusion

XL-NPWT is safe and effective in large burns. In addition to

promoting epithelialization of both grafted and donor sites, we
observed excellent graft take, no wound infections and
significantly less anxiety and pain. Following excision and
autografting, fluid management was informed by NPWT
output measurements, potentially reducing the risk of AKI
and pulmonary edema. As a result of the above findings, XLNPWT has now been incorporated into the standard of care for
large burns at our institution.

Please cite this article in press as: Fischer S, et al. Extra-large negative pressure wound therapy dressings for burns Initial experience with
technique, fluid management, and outcomes. Burns (2016), http://dx.doi.org/10.1016/j.burns.2015.08.034

JBUR-4746; No. of Pages 9

burns xxx (2016) xxxxxx

Conflict of interest
[18]

The authors have no conflict of interest.

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Please cite this article in press as: Fischer S, et al. Extra-large negative pressure wound therapy dressings for burns Initial experience with
technique, fluid management, and outcomes. Burns (2016), http://dx.doi.org/10.1016/j.burns.2015.08.034