Wound Healing and Classification 2016 Chesapeake Bay Perioperative Consortium

Transcription

1 Wound Healing and Classification 2016 Chesapeake Bay Perioperative Consortium Objectives Novice perioperative team member will be able to: Identify different layers of skin Describe the process of wound healing List different types of wounds and wound classification List several factors that affect wound healing List 3 wound healing complications Describe 3 ways to prevent wound infections History of Wound Care The Greeks: Identified wounds as acute and chronic or fresh and non-healing Ancient Egypt: Used lint, animal grease, & honey for open wounds Ignaz Philipp Semmelweis ( ): Decreased incidences of puerperal fever when MD s wash hand with chlorinated lime water Louis Pasteur ( ): Father of Germ Theory, germs caused disease Joseph Lister (1865): Using of phenol for soaking instruments & spraying OR, reduce mortality rate from 50 to 15% Ernst von Bergmann (1886): Introduced heat sterilization to sterilize surgical instruments 1

2 History of Wound Care Henry Drysdale Dakin (WWI): Deveoped Dakin solution made with sodium hypochlorite (bleach) and boric acid, to wash out traumatic wounds of soldiers 1950 s: Fibrous synthetics, such as, nylons, polyethylene (plastic), polypropylene provided new materials for protection of wound and accelerated wound healing 1960 s: Winter and Maibach reported benefit of moist wound dressings (moist to dry dressings) 1990 s: New expansion of different of materials used for wound dressings, grafting, and biotechnology Today 21 st Century: Focus on prevention of wounds and infections; treating and promoting wound healing Composed of several thin layers: stratum basale stratum spinosum stratum granulosum stratum lucidum stratum corneum Anatomy of Skin Epidermis Several thin layers of the epidermis contain: melanocytes - produces melanin which gives skin its color and protects it damaging effects of ultraviolet radiation keratinocytes - produces keratin, a water repellent protein that gives the epidermis its tough protective quality Dermis Anatomy of Skin Subcutaneous Tissue Composed of a thick layer of skin that contains: collagen and elastic fibers, nerve fibers, blood vessels, sweat and sebaceous glands, and hair follicles Key layer in wound repair and tissue healing Composed of a fatty layer of skin that contains: blood vessels, nerves, lymph, and loose connective tissue filled with fat cells 2

3 Mechanisms of Healing First Intention/Primary Union Secondary Intention Third Intention/Delayed Primary Closure First Intention/ Primary Union Key Elements: Clean Cut Well-approximated edges Minimal swelling No separation of wound edges Minimal scar formation First Intention/ Primary Union Inflammatory Response Phase First 5 days tissue fluids containing plasma, proteins, blood cells, fibrin, and antibodies form around wound to holding it together Healing or Proliferation Phase Fibroblast multiply rapidly bridging wound edges & restore body structures. Healing phase begins rapidly and ends progressively around day 14 to day 20 Maturation Phase Scar formation occurs by depositing fibrous connective tissue Begins around day 14 and continues until wound is fully healed, up to 6-12 months Scar tissue is only 80% as strong as the original tissue 3

4 Secondary Intention Mechanism of Healing: Healing by granulation, eventual reepithelialization, and wound contraction Will heal spontaneous if dermal base is preserved Key Elements: Infection, excessive trauma, loss of tissue is common Wound left open to heal from inner to outers surface Healing is delayed, may need grafting High risk of secondary infection Excessive scar formation Pronounced contracture of the skin Third Intention/Delayed Primary Closure Rational: Approximation and suturing is delayed for the purpose of walling off an area of gross infection or where extensive tissue was removed Edges are closed 4 to 6 days post-operatively Key Elements: Initially wound cleaned and debrided Area is packed to promote drainage & granulation Usually deeper and wider scar Types of Wounds Intentional Wounds Surgical wounds created with scalpel, scissor, curette, or other cutting instrument Thermal wounds created through heat and vaporization of tissue Occlusion banding created using clips or silastic bands Chemical wounds created by directly applying chemicals to tissue Traumatic Wounds Closed Intact closed wound but underlying tissue is injured Open Simple wound without loss or destruction of tissue Complicated lost or destroyed tissue caused by a crush, burn, or foreign body Chronic Wounds Sores and ulcers due to compromised circulation, usually have tissue loss and high bacterial contamination 4

5 Classification of Surgical Wounds Class I or Clean Incision was made under ideal surgical conditions Primary closure, wound not drained No break in sterile technique during procedure No inflammation was encountered No entry into alimentary, respiratory, and genitourinary tracts or oropharyngeal cavity Expected Infection Rate: 1-5% Examples: breast biopsy, arthroscopy, total joint replacement, hernia repair, mastectomy, exploratory laparotomy, neck dissection, vascular, etc. Classification of Surgical Wounds Class II or Clean-Contaminated Primary closure, wound drained Minor break in sterile technique during procedure No inflammation or infection was encountered Alimentary, respiratory, and genitourinary tracts or oropharyngeal cavity under controlled conditions without significant spillage or unusual contamination Expected Infection Rate: 8-11% Examples: cholecystectomy, small bowel resection, Whipple, gastric surgery, bronchoscopy, colon resection, hysterectomy (vaginal & abdominal), etc. Classification of Surgical Wounds Class III or Contaminated Open, fresh traumatic wound of less than 4 hours duration Major break in sterile technique occurred Acute non-purlent inflammation present Gross spillage/contamination from gastrointestinal tract Entrance into geniturinary or biliary tracts with infected urine or bile present Expected Infection Rate: 15-20% Examples: inflamed appendix, bile spillage during cholecystectomy, diverticulitis, rectal surgery, penetrating wounds, etc. 5

6 Classification of Surgical Wounds Class IV or Dirty and Infected Wound Old traumatic wound of more than 4 hours duration from dirty source or with retained necrotic tissue, foreign body, or fecal contamination Organisms present in surgical field before procedure Existing clinical infection: acute bacterial inflammation encountered, with or without purulence; incision to drain abscess Perforated viscus Expected Infection Rate: 27-40% Examples: incision & drainage of abscess, perforated bowel, peritonitis, wound debridement, positive culture pre-op, etc. Factors Influencing Wound Healing Primary Considerations: Smoking Age Nutritional status Obesity Disease (chronic or acute) Immunosuppression and immunocompromise Radiation therapy Secondary Considerations: Incision (place, length, and direction) Method of hemostasis Tissue handling and approximation Wound closure Third Consideration: Aseptic technique Wound Complications Dehiscence: Partial or total separation of tissue layer(s) Frequently occurs between days 5-10 post-op Evisceration: Protrusion of the viscera through edges of a totally separated wound Surgical emergency Hemorrhage: Can be concealed or evident Frequently seen first few postop days May require surgery to achieve hemostasis Adhesion: Caused by fibrous tissue within the peritoneal cavity Can cause pain and/or bowel obstructions Herniation: Result of wound dehiscence Often occurs in lower abdominal incisions Fistula: Abnormal tract between two epithelium-lined surfaces and open at both end Sinus tract: Abnormal tract between two epithelium-lined surfaces and only open at one end Suture complications: Sutures fails to absorb or causes irritation and inflammation Compartment Syndrome: Swelling between fascial layers Frequently seen in limbs Surgical emergency 6

7 Wound Infections Incisional Infection: Can occur up to 30 days post op at site of incision Involves skin, subcutaneous tissue, or muscle Purulent drainage or an organism identified by culture May need to open and drain wound Deep wound infection: Infection occurs within 30 days if a prosthesis was not implanted or within 1 year around site of an implant Involves tissues or spaces at or beneath the fascia Pus may be present, wound may spontaneously dehisce Need to open and drain wound or remove implant Necrotizing Fasciitis Flesh eating bacteria S&S: swelling, bright red surface, pain, and fever High mortality due to toxic effects of necrosis 3 Types: Type I: Aerobic (gram negative) and Anaerobic (gram positive) Type II: Most common, beta hemolytic Streptococcus Type III: Water-borne microorganisms from fish or insects Prevention of Wound Infections Frequent hand washing Adhere to aseptic and sterile techniques Appropriate use of prophylactic antibiotics Time & Dose(s) Watch for sources of contamination Adhere to When in doubt, throw it out Pre-op skin preps with CHG baths Proper removal of hair with clippers Maintain normothermia Tight glucose control Wound Classification Game Kahoot.com Game PIN

8 Reference Ross, T. (2014). Wound Healing, Sutures, Needles, and Stapling Devices. In Surgical Technology for the Surgical Technologist: A Positive Care Approach (4th ed., pp ). Clifton Park, NY: Delmar. Surgical Site Management. (2007). In N. Phillip (Ed.), Berry & Kohn's Operating Room Technique (11th ed., pp ). St. Louis, MO: Mosby. Questions? 8