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The authors present a case of a surgical wound that was inappropriately packed to the extent that a significant and major deterioration occurred in the expected healing by secondary intention. This is intended to alert surgeons to the fact that careful supervision is required of such seemingly simple and straightforward tasks as the topical treatment of open wounds by inexperienced caregivers.
The third article in this series on surgical wound care discusses the types of dressings currently available, and selection of the correct dressing for a particular wound type. There is an abundance of information on the types of dressings available. Wound management for the individual patient must be decided using best evidence and taking into account patients' increased involvement in their care, new technology and the push to mobilize early, leading to early discharge from hospital. The nurse needs to have a good knowledge of the types of dressings available, the properties of individual dressings and a sound understanding of wound healing, in order to make an informed decision on wound management. General factors such as safety, comfort, pain management and convenience must be borne in mind when deciding which dressing is the best for individual patients, given that dressings now have to be cost-effective as well as clinically effective.
Post-operative bleeding is a life-threatening complication encountered following cardiac surgery. In cases where bleeding cannot be controlled by correcting clotting derangements and using standard surgical techniques, packing the chest may be an important salvation method. The aim was to determine the outcome of patients having primary chest packing in theatre for intractable bleeding following heart surgery. The method used was retrospective analysis of patients' medical records. Over a 9-year period, 6890 patients had open-heart surgery at the Manchester Royal Infirmary. Twenty (0.29%) of these patients had their chests packed prior to leaving theatre, 19 for uncontrolled bleeding, and one for inaccessible bleeding. Five (25%) of these patients required one further packing. The majority of patients (85%) survived. None developed a sternal wound infection. The conclusion drawn was that chest packing could be a life-saving procedure following heart surgery.
Delayed primary closure (DPC) is an accepted method in the management of contaminated abdominal wounds. Clinical factors predicting its success have not been studied. Over a 14-year period 181 patients presenting to a single surgeon with Class IV abdominal wounds were managed by a standardized protocol. Initial saline gauze packing was left undisturbed until the wound was visually inspected on postoperative day 3. Clean wounds were closed using SteriStrips. Visible purulence was managed by dressing changes. There were 103 males and 78 females with an average age of 48.5 years (range, 11-92 years). DPC was performed on 144 patients of whom four (2.8%) developed wound infections. The factors associated with the development of wound pus before DPC in the remaining patients were: requirement for mechanical ventilation for more than 72 hours, presence of severe pre-existing systemic disease, and trauma. Other diagnoses, length and type of incision, and presence of shock had no effect on outcome. An intra-abdominal abscess developed in 11 patients with early wound purulence versus none in those undergoing DPC (P < 0.001). DPC is a safe wound management technique that can be effectively applied in the large majority of patients with dirty abdominal wounds. The appearance of wound purulence before DPC is a harbinger that identifies those patients at risk for late intra-abdominal infections.
Most surgical wounds are closed primarily, but some are allowed to heal by secondary intention. This usually involves repeated packing and dressing of the raw wound surfaces. Although the long-term care of such wounds has devolved to the care of nurses in the community or out-patient setting, the initial wound dressing or cavity packing is done by the surgeon in the operating theatre. Many surgeons are unaware of the growth of the discipline of wound care, and still use traditional soaked gauze for dressing and packing open surgical wounds and cavities.
This review summarises the some of the modern alternatives available and the evidence--or the lack of it--for their use in both the acute and chronic setting.