Table Box 1 .

Special care should be taken in the following circumstances (adapted from ref 11)

1. In the presence of exposed blood vessels, nerves or organs. These structures must be protected using overlying fascia, tissue or other protective barrier, such as one or more layers of a non adherent, vapour‐permeable interposed dressing. The use of a non adherent interposed dressing layer is particularly important in the sternal wound setting to prevent right ventricular rupture 23, 44 during therapy.

2. Where the patient has vascular anastomoses, including coronary artery bypass grafts, or weakened, irradiated or sutured blood vessels or organs.

3. In the presence of existing or potential bleeding problems, e.g. uncontrolled bleeding, coagulopathy or concomitant therapy with anticoagulant medication.

4. Where the wound contains bone fragments or sharp edges that could puncture protective barriers, vessels or organs. This can be managed by debriding sharp edges and using one or more layers of a non adherent interposed dressing.

5. In paediatric patients and neonates, in whom the potential for haemodynamic effects of V.A.C. therapy are more significant than in adults.

6. In the presence of postcardiotomy syndrome. V.A.C. therapy can be used as a temporary closure technique, usually after 24 hours, when bleeding is controlled and the patient is haemodynamically stable.

7. In fluid overload and systemic inflammatory response syndrome. V.A.C. therapy may be helpful in decreasing tissue fluid overload and increasing the microcirculation.