F. PRINCIPLES OF TREATMENT BASED ON ETIOLOGY (TREAT THE CAUSE) F.5 SURGICAL WOUND (CLOSED AND OPEN) 5.1 Background to Etiology Closed surgical wounds are well-approximated with a palpable healing ridge (area of raised tissue) along the incision line, healing by primary intention. The incision is clean, dry, and not reddened. Open surgical wounds include: Non-healing incisions with separation OR incisional necrosis OR signs and symptoms of surgical site infection (SSI) OR no palpable healing ridge OR those healing by secondary intent OR tertiary intent Instructions for use 5.2 Algorithm This algorithm is based on the Wound Bed Preparation Algorithm but incorporates specific client-centered care considerations, is from the Orsted et al. 2010 article, and is used with permission. 5.3-5.5 Client Education tools found in on-line toolkit: The NICE (2008) Guidelines for prevention and treatment of SSI includes the following recommendations: Offer patients and carers clear, consistent information and advice throughout all stages of their care. This should include the s&s and risks of surgical site infections, what is being done to reduce them and how they are managed. These are regional tools that can be adapted to all sectors. 5.3 Open Surgical Wound Self-Care Teaching Guide 5.4i. My JP Drain Care 5.4.ii My Hemovac Drain Care 5.4.iii Head_Neck_Face_Skin graft patient information 5.5 Patient Handbook My Surgical Wound 5.6 Evidence-Based Clinical Interventions. Also see Toolkit Section H.5 Wound Cleansing and Dressing Selection Enabler 5.6.1 CLOSED SURGICAL WOUND: General Health: Assess for and report signs and symptoms of infection Personal Hygiene: The NICE (2008) Guidelines for prevention and treatment of SSI includes the following recommendations: Advise patients that they may shower safely 48 hours after surgery (but this is dependent on agreement of responsible surgeon). There is no evidence to support the use topical antimicrobial agents for surgical wounds that are healing by primary intention to reduce the risk of surgical site infection. SWRWC Toolkit: F.5 Surgical Open Wounds Background and Introduction_June_21_2011, Aug 20_2012, Jan_2013 1
Common dressing supplies for closed surgical incisions healing by primary intention (NICE 2008) Cover the wound with an appropriate interactive dressing for a period of 48 hours unless otherwise clinically (or ordered by the surgeon) indicated, for example, if there is excess wound leakage or haemorrhage. There is no robust evidence to support the use of one dressing over another. However, in the majority of clinical situations a semi-permeable film membrane with or without an absorbent An island is preferable (one that has a non-stick absorbant strip of dressing in the centre, surrounded by an adhesive of some sort e.g. cloth-like tape, transparent film, thin hydrocolloid. Avoid the use of gauze as a primary dressing because of its association with pain and disruption of healing tissues at the time of dressing change. The Mölndal Technique (developed with surgical orthopedic incisions) involves the use of hydrofiber or hydrofiber Ag folded into 4 thicknesses covered with a film dressing. Selection of a Hydrofiber dressing versus Hydrofiber Ag is dependent on the individual patient s risk of wound infection The Jubilee (Clarke et al.2009) technique (developed with surgical orthopedic incisions) involves three layers of hydrofiber folded over the incision and secured with thin hydrocolloid- applied with no tension and changed a mean of 3.7 days. 5.6.2 OPEN SURGICAL WOUND: General Health: Assess for and report signs and symptoms of infection Determine client s goals: Wound healing Client/Caregiver will be independent with treatment Decrease dressing changes Debridement, bacterial balance, exudate control, and protect peri-wound skin. Health teaching to prevent infection and deterioration of wound, improve nutrition and general health status. Maintenance Service Plan (Unusual for this wound type) Prevent deterioration Healing and Maintenance: Use a validated and reliable wound assessment tool Assess for and report signs and symptoms of infection. SWRWC Toolkit: F.5 Surgical Open Wounds Background and Introduction_June_21_2011, Aug 20_2012, Jan_2013 2
For open surgical wounds healing by secondary intention (where the base of the wound can be visualized): The NICE (2008) Guidelines for prevention and treatment of SSI recommends: Do not use Eusol (Hygeol) and gauze, or moist cotton gauze or mercuric antiseptic solutions. Use an appropriate interactive dressing. Hydrofiber or alginate (layered to 80% of the depth) covered by a secondary absorbant dressing. For tunneling or undermined surgical wounds where the wound base cannot be seen: Only use a packing or cavity filler dressing that can be removed in one piece, with adequate tensile strength so that it does not fall apart in the wound, allowing fragments to be retained. Wound packing must be firm enough to prevent premature bridging of granulation tissue in the base, causing pockets and future abscesses, yet: o allow the wound to contract and heal from the base and o serve as a conduit or wick to allow the exudate to drain. Avoid packing tightly at the opening of a tunnel or sinus- it can plug the exit, causing increased pressure within the cavity as the exudate volume increases, and extension of the cavity (Birchall & Taylor 2003). Cover with absorbent secondary dressing For tunneling or undermined surgical wounds with localized infection - See Section E.3 Wound Infection Treatment Gauze ribbon packing may be appropriate to deliver Cadexomer Iodine or other antimicrobial products. An alternative to this is PHMB (polyhexamethylene biguanide) antimicrobial ribbon packing, which can be left insitu for up to 3 days. To date, there is no concern between the use of these antimicrobial dressings and the development of antibiotic resistant organisms. If you are not sure of the nature of the infection, choose a non-occlusive dressing as the cover dressing. Maintenance Service Plan (Unusual for this wound type) Choose dressings that are lower-cost and focus on exudate management and odour control. 5.6.3 INCISION AND DRAINAGE (I&D) OF ABSCESSES I&D is historically the treatment of choice for cutaneous abscesses (Korwnyk and Allan 2007). These are either sutured primarily or left open and packed loosely, and treated with or without an oral antibiotic (Hankin and Everett 2007). Community-associated (CA) MRSA is considered to be endemic in North America, and is a frequent cause of abscesses, making it important to: Confirm the diagnosis of MRSA infection (Stevens et al. 2005) by Levine method swab culture Treatment with systemic antimicrobial therapy to which the bacterial isolate is susceptible is controversial (Korwnyk and Allan 2007). SWRWC Toolkit: F.5 Surgical Open Wounds Background and Introduction_June_21_2011, Aug 20_2012, Jan_2013 3
For cases of mild illness: (patient afebrile, abscess <5 cm, no other medical comorbidities - I&D with or without topical antibiotics may be a sufficient and definitive therapy (Lee et al. 2004). Wound Assessment: Use a validated and reliable wound assessment tool I&D wounds should be healable. Other: Teach self-care if anatomically possible Maintenance Service Plan This would be unlikely with this type of wound, unless in the presence of a chronic abscess-causing disease such as hidradenitis suppurativa, in a client with other comorbidites. Wound Bed Preparation includes decreasing bacterial balance, treating infection, local wound care. Flush wound without increasing pressure within the cavity, debridement, bacterial balance, exudate control, protect periwound skin. Health teaching to prevent infection and deterioration of wound. CA-MRSA is contagious and may affect not only the client but also their household contacts. Transmission on the hands or gloves of healthcare workers is a common method of spread. Daily dressings with gauze packing alone do not reflect advanced wound care principles, yet generally, the small size of the opening in these wounds precludes the use of thicker dressings. Common dressing supplies: Only use a packing or cavity filler dressing that can be removed in one piece, with adequate tensile strength so that it does not fall apart in the wound, allowing fragments to be retained. Wound packing must be firm enough to prevent premature bridging of granulation tissue in the base, causing pockets and future abscesses, yet: o allow the wound to contract and heal from the base and o serve as a conduit or wick to allow the exudate to drain. Avoid packing tightly at the opening of a tunnel or sinus- it can plug the exit, causing increased pressure within the cavity as the exudate volume increases, and extension of the cavity (Birchall & Taylor 2003). Cover with absorbent secondary dressing For tunneling or undermined I&D wounds with localized infection - See Section E.3 Wound Infection Treatment Gauze ribbon packing may be appropriate to deliver Cadexomer Iodine or other antimicrobial products. SWRWC Toolkit: F.5 Surgical Open Wounds Background and Introduction_June_21_2011, Aug 20_2012, Jan_2013 4
An alternative to this is PHMB (polyhexamethylene biguanide) antimicrobial ribbon packing, which can be left insitu for up to 3 days. To date, there is no concern between the use of these antimicrobial dressings and the development of antibiotic resistant organisms. If you are not sure of the nature of the infection, choose a non-occlusive dressing as the cover dressing. Maintenance Service Plan Use lower cost dressings if healing is not expected and focus on exudate management and odour control 5.7 Resources NICE Guideline Prevention of Surgical Site Infection is available for free download at http://guidance.nice.org.uk/cg74/guidance/pdf/english Orsted, H.L., Keast, D.H., Kuhnke, J., Armstrong, P., Attrell, E., Beaumier, M., Landis, S., Mahoney, J.L., Todoruk-Orchard, M. (2010) Best Practice Recommendations for the Prevention and Management of Open Surgical Wounds. Wound Care Canada, 8 (1)pp. 6-34. Erratum Table 3 WCC 8(2)pp. 34. See PDF. Used with Permission. SWRWC Toolkit: F.5 Surgical Open Wounds Background and Introduction_June_21_2011, Aug 20_2012, Jan_2013 5