Closing the patient up

[Valadi]

Hey guys,

I'm an MSIV on a surgery research year and get to be in the OR a lot. The attendings here often ask, "What kind of dressing do you want to put on this?" And, in general, I know nothing about dressings.

Is there any material out there that can give a primer on when to use what type of dressing (e.g., open wound s/p debridement, free flap reconstruction, burn, skin-graft donor site, etc) and for how long? I'm totally lost on this subject and a pubmed search on this is giving me inconsistent information. I see the residents often asking what kind of dressings the attending would like, so I'm wondering if this is just something I'll have to pick up with time and search for each condition individually?

Thanks so much!

---

Members don't see this ad.

 

[ZagDoc]

Dressings are tough, a lot of it is just scrubbing a lot of cases and becoming familiar with routines for specific surgeries. You learn generalities that way but dressing preferences are also usually attending specific and have more to do with where the attending trained than anything.

 

[Dirt]

http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD003091.pub2/abstract

Cochrane review on surgical dressings.

It's all voodoo, every attending has their own voodoo method of closing from the sutures up to the tape.

 

[SLUser11]

Hey guys,

I'm an MSIV on a surgery research year and get to be in the OR a lot. The attendings here often ask, "What kind of dressing do you want to put on this?" And, in general, I know nothing about dressings.

Is there any material out there that can give a primer on when to use what type of dressing (e.g., open wound s/p debridement, free flap reconstruction, burn, skin-graft donor site, etc) and for how long? I'm totally lost on this subject and a pubmed search on this is giving me inconsistent information. I see the residents often asking what kind of dressings the attending would like, so I'm wondering if this is just something I'll have to pick up with time and search for each condition individually?

Thanks so much!

The truth is that it really doesn't matter. I typically leave the wound covered for 24 hours, mostly to sop up the serosanguinous drainage, then I take it off and leave it off. I let patients shower POD #1 and beyond, mostly because they're more mobile at that point.

There's some evidence, most of which is industry-sponsored, that silver-impregnated dressings lead to an SSI, but I'm not convinced. Also, I like to actually look at the wound, and most of those dressings are supposed to stay on for a while.

To be pimped on surgical dressings is sort of ridiculous since there's no right answer...however, I frequently ask the students and junior residents similar simple questions because they are simple things that we take for granted, and often we don't have a clue how to answer when it's finally up to us. Another example is asking the junior residents what sutures they want for closure, etc.

Now, for open or partially closed wounds, there are even more ways to dress them, none of which really have an effect on SSI.

 

[Guile]

The truth is that it really doesn't matter. I typically leave the wound covered for 24 hours, mostly to sop up the serosanguinous drainage, then I take it off and leave it off. I let patients shower POD #1 and beyond, mostly because they're more mobile at that point.

There's some evidence, most of which is industry-sponsored, that silver-impregnated dressings lead to an SSI, but I'm not convinced. Also, I like to actually look at the wound, and most of those dressings are supposed to stay on for a while.

To be pimped on surgical dressings is sort of ridiculous since there's no right answer...however, I frequently ask the students and junior residents similar simple questions because they are simple things that we take for granted, and often we don't have a clue how to answer when it's finally up to us. Another example is asking the junior residents what sutures they want for closure, etc.

Now, for open or partially closed wounds, there are even more ways to dress them, none of which really have an effect on SSI.

We take our dressings down POD 2 unless it's soaked. I thought there were data that keeping a dressing on until then decreased chance of an SSI.

 

[Buzz Me]

I was taught it takes 48 hours for phagocytes to migrate to the wound, so you want to keep the dressing on until POD #2. After that, take it off and leave it off, or the wound gets moist.

 

[SLUser11]

We take our dressings down POD 2 unless it's soaked. I thought there were data that keeping a dressing on until then decreased chance of an SSI.

I've never seen that data, but I'd definitely read it if you pointed me in the right direction. I was taught to leave it on for 24 hours for some basic science wound healing reasons, and I sort of adhere to that, but I don't think it really matters.

On a side note, would you treat a stapled wound different than a subcuticular wound? What about laparoscopic port sites?

Surgical site infection is a very interesting topic. There's so much that we routinely do that doesn't help (ioban, antibiotic irrigation, masks, clipping hair, bowel preps, changing scrubs, hibiclens showers, antibiotic-impregnated sutures)......

......and so many things that probably help that we don't do well or often (wound protectors, chloraprep, supplemental O2, normothermia).

I think that the evidence is poor for a lot of what we do and don't do to prevent SSI. It's sort of the wild wild west. One thing that I'm nearly certain of is that if something is recommended strongly by the AORN, then it probably doesn't matter.....


Since colorectal surgeries have a very high baseline SSI rate of 15-20%, I think I'll eventually get into the business of writing papers on the topic. Of course, I haven't done it yet....

 

[Rollo]

I've never seen that data, but I'd definitely read it if you pointed me in the right direction. I was taught to leave it on for 24 hours for some basic science wound healing reasons, and I sort of adhere to that, but I don't think it really matters.

On a side note, would you treat a stapled wound different than a subcuticular wound? What about laparoscopic port sites?

Surgical site infection is a very interesting topic. There's so much that we routinely do that doesn't help (ioban, antibiotic irrigation, masks, clipping hair, bowel preps, changing scrubs, hibiclens showers, antibiotic-impregnated sutures)......

......and so many things that probably help that we don't do well or often (wound protectors, chloraprep, supplemental O2, normothermia).

I think that the evidence is poor for a lot of what we do and don't do to prevent SSI. It's sort of the wild wild west. One thing that I'm nearly certain of is that if something is recommended strongly by the AORN, then it probably doesn't matter.....


Since colorectal surgeries have a very high baseline SSI rate of 15-20%, I think I'll eventually get into the business of writing papers on the topic. Of course, I haven't done it yet....

LOL What's with the AORN comment? I'm genuinely curious...

 

[Fah-Q]

The only dressing I use on a closed incision is bacitracin ointment. It protects and occludes the wound.

 

[Pir8DeacDoc]

The only dressing I use on a closed incision is bacitracin ointment. It protects and occludes the wound.

Same here

 

[SLUser11]

LOL What's with the AORN comment? I'm genuinely curious...

Most of their recommendations are based on theory, or possibly expert opinion. They even set out recommendations that are in direct opposition to the evidence. Since OR directors everywhere take AORN recs to be the infallible truth, it makes life difficult for surgeons everywhere.

Some examples:

1. Scrubs have to be changed in between each case, and have to be hospital-laundered from the hosting facility (i.e. no outside scrubs).

2. Patients need their hair clipped in pre-op instead of the OR for some mythical SSI benefit (this one is the most recent I've heard, and is ridiculous, especially since it subjects the patient to being shaved while completely awake and waiting nervously for their case to start)

3. scrub jackets should be worn at all times in the OR because of the possibility of forearms shedding non-sterile skin cells. Really?

 

[Pir8DeacDoc]

Most of their recommendations are based on theory, or possibly expert opinion. They even set out recommendations that are in direct opposition to the evidence. Since OR directors everywhere take AORN recs to be the infallible truth, it makes life difficult for surgeons everywhere.

Some examples:

1. Scrubs have to be changed in between each case, and have to be hospital-laundered from the hosting facility (i.e. no outside scrubs).

2. Patients need their hair clipped in pre-op instead of the OR for some mythical SSI benefit (this one is the most recent I've heard, and is ridiculous, especially since it subjects the patient to being shaved while completely awake and waiting nervously for their case to start)

3. scrub jackets should be worn at all times in the OR because of the possibility of forearms shedding non-sterile skin cells. Really?

Glad to hear the AORN police are in effect everywhere. We haven't implemented the above- they all seem silly. But we recently had a huge battle over wearing personal scrub caps versus disposable ones. We lost- the AORN police got their way and we have to wear shower caps or the goofy bearded ones. Our hospital is too cheap to actually get disposable surgeon caps.

The funny thing is in ENT almost none of our cases are sterile anyway- who cares what sort of hat we wear?

 

[Guile]

On a side note, would you treat a stapled wound different than a subcuticular wound? What about laparoscopic port sites?

We treat all wounds the same (unless left open of course). Dressings stay on for 48 hours, then no dressing, and showers daily.

Surgical site infection is a very interesting topic. There's so much that we routinely do that doesn't help (ioban, antibiotic irrigation, masks, clipping hair, bowel preps, changing scrubs, hibiclens showers, antibiotic-impregnated sutures)......

......and so many things that probably help that we don't do well or often (wound protectors, chloraprep, supplemental O2, normothermia).

Do you have the reference for supplemental O2 and Chloraprep? We are big on Chloraprep. Everyone gets it unless it's head and neck or open wound, or another contraindication. We have one surgeon who uses supplemental O2, but I didn't even know why. He never says. Everyone just knows--supplemental O2 on all of his patients.

Most of their recommendations are based on theory, or possibly expert opinion. They even set out recommendations that are in direct opposition to the evidence. Since OR directors everywhere take AORN recs to be the infallible truth, it makes life difficult for surgeons everywhere.

Some examples:

1. Scrubs have to be changed in between each case, and have to be hospital-laundered from the hosting facility (i.e. no outside scrubs).

2. Patients need their hair clipped in pre-op instead of the OR for some mythical SSI benefit (this one is the most recent I've heard, and is ridiculous, especially since it subjects the patient to being shaved while completely awake and waiting nervously for their case to start)

3. scrub jackets should be worn at all times in the OR because of the possibility of forearms shedding non-sterile skin cells. Really?

We don't do any of those. The only exception is if you go from a contact isolation patient to a room where an implant is going in. Then you change scrubs. I can't imagine changing scrubs between each patient. What a pain.

 

[Buzz Me]

I can't imagine changing scrubs between each patient. What a pain.

Plus there's no way the hospital would be able to keep up with the demand.

20 rooms x 3 cases per day x at least 3 scrubbed people per case (attending, resident, scrub tech, more needed if there are tech breaks for lunch, etc.) = at least new 180 pairs of scrubs daily. If you're including scrubs for the non-sterile people in the room (circulating nurse, Anesthesia, etc.) then that number goes way up.

 

[SLUser11]

We treat all wounds the same (unless left open of course). Dressings stay on for 48 hours, then no dressing, and showers daily.

Do you have the reference for supplemental O2 and Chloraprep? We are big on Chloraprep. Everyone gets it unless it's head and neck or open wound, or another contraindication. We have one surgeon who uses supplemental O2, but I didn't even know why. He never says. Everyone just knows--supplemental O2 on all of his patients.

Since wounds are a heterogeneous group, I don't think that treating "all wounds the same" could ever be an evidence-based approach. That being said, I don't actually see a fault in your approach, since you have to pick some arbitrary number....why not 48 hours?

For supplemental O2, there's 2 big articles that come to mind:
1. JAMA 2004
2. NEJM 2000

For Chloraprep, there's a lot of literature for CVLs. The famous one for SSI was NEJM 1/2010, which compared chloraprep to povidine-iodine scrub. However, I've always felt that the alcohol was what made the difference, and there's not much literature comparing Duraprep to Chloraprep. There's one study from University of Virginia that addressed the topic, but didn't really answer the question for me....and ultimately disagreed with my bias toward chloraprep.

Plus there's no way the hospital would be able to keep up with the demand.

20 rooms x 3 cases per day x at least 3 scrubbed people per case (attending, resident, scrub tech, more needed if there are tech breaks for lunch, etc.) = at least new 180 pairs of scrubs daily. If you're including scrubs for the non-sterile people in the room (circulating nurse, Anesthesia, etc.) then that number goes way up.

Agreed. It would be interesting to see how fast the OR directors would change their minds if people actually adhered to their recommendations, and the costs went up.

 

[45408]

For the OP, my experience in wounds has been (roughly) as follows:

Dermal closure - 3-0 Vicryl or Monocryl or plain gut (on the little peds patients' bellies, sometimes this is enough to close the wound completely, with a steristrip on top)
Subcuticular closure - 4-0 or 5-0 Monocryl
Skin closure - Nylon, caliber variable based on location (3-0 on the hand/body, 4-0 or 5-0 on the face), interrupted (mattress or simple) or running
Or you can use staples - they're faster (OR time is very expensive, and less time under anesthesia is better), and if you're only opening part of a wound to drain a hematoma/infected collection, then you don't have to pull the whole wound apart

Dressings - if it was subcuticular suture, you can use Steristrips, +/- Mastisol, then 4x4 gauze with a tegaderm or tape, or you could use an island dressing. If it was staples, then 4x4 gauze with a tegaderm or tape, or you could use an island dressing. For interrupted/running nylon sutures, I've seen all sorts of variations, but xeroform gauze + 4x4s is a pretty recurring theme.

If it's an open wound like a skin graft donor site or the recipient site, I've usually seen xeroform gauze, then covered by gauze. Additional coverage depends on where it is and how much you expect it to bleed (gauze wrap, ABDs, ACE bandage, splint, blah blah blah).

If it's an open wound on the abdomen with open fascia, you could be using all sorts of complex concoctions (ABThera, Wittman patch, hodge-podge dressings I've seen by military trauma surgeons). If the fascia is closed, you can VAC it or do wet-to-dry gauze packing, changed BID.

 

[Valadi]

Guys, this is awesome. Thanks so much for your help!

 

[Dirt]

If it's an open wound on the abdomen with open fascia, you could be using all sorts of complex concoctions (ABThera, Wittman patch, hodge-podge dressings I've seen by military trauma surgeons). If the fascia is closed, you can VAC it or do wet-to-dry gauze packing, changed BID.

Bogota bag baby!



Does anyone else think that Mastisol is the best smelling stuff around?

 

[GregsAnatomy]

Bogota bag baby!



Does anyone else think that Mastisol is the best smelling stuff around?

I'm partial to Benzoin myself

 

[Winged Scapula]

Bogota bag baby!



Does anyone else think that Mastisol is the best smelling stuff around?

Yes. I Mastisol.

 

[SocialistMD]

Yes. I Mastisol.

Colloidium.

 

[45408]

I love the smell of cautery in the morning.



/not

 

[SouthSideSteve]

I'm partial to Benzoin myself

by far the best part of vac-ing anything.

 

[Dirt]

Yes. I Mastisol.

I want to send a sample to Yankee Candle and see if they can make me a mastisol candle for my house.

 

[Buzz Me]

Yes. I Mastisol.

I'm partial to Benzoin myself!

 

[debvz]

LOL.

I know it's an old thread, but well worth a bump for the Mastisol Yankee Candle.

 

[Chemdocx]

Yeah mastisol smells good... As does esmarch...takes 48 hours for epitheliazation. Regardless the higher the inr or the more heparin I use the more I pack on top of the to buy time before somebody gets called

 

[45408]

Yeah mastisol smells good... As does esmarch...takes 48 hours for epitheliazation. Regardless the higher the inr or the more heparin I use the more I pack on top of the to buy time before somebody gets called

The neurosurgeons here take that to a whole new level. Their craniotomy dressings are ridiculous.

 

[Dr.LeoSpaceman]

Apropos to this discussion, a new article from the British Journal of Surgery


Walter, C. J., Dumville, J. C., Sharp, C. A. and Page, T. (2012), Systematic review and meta-analysis of wound dressings in the prevention of surgical-site infections in surgical wounds healing by primary intention. Br J Surg. doi: 10.1002/bjs.8812

BACKGROUND: Postoperative surgical-site infections are a major source of morbidity and cost. This study aimed to identify and present all randomized controlled trial evidence evaluating the effects of dressings on surgical-site infection rates in surgical wounds healing by primary intention; the secondary outcomes included comparisons of pain, scar and acceptability between dressings.

METHODS: Randomized controlled trials comparing alternative wound dressings, or wound dressings with leaving wounds exposed for postoperative management of surgical wounds were included in the review regardless of their language. Databases searched included the Cochrane Wounds Group Specialised Register and Central Register of Controlled Trials, Ovid MEDLINE, Ovid Embase and EBSCO CINAHL from inception to May 2011. Two authors performed study selection, risk of bias assessment and data extraction, including an assessment of surgical contamination according to the surgical procedure. Where levels of clinical and statistical heterogeneity permitted, data were pooled for meta-analysis.

RESULTS: Sixteen controlled trials with 2594 participants examining a range of wound contamination levels were included. They were all unclear or at high risk of bias. There was no evidence that any dressing significantly reduced surgical-site infection rates compared with any other dressing or leaving the wound exposed. Furthermore, no significant differences in pain, scarring or acceptability were seen between the dressings.

CONCLUSION: No difference in surgical-site infection rates was demonstrated between surgical wounds covered with different dressings and those left uncovered. No difference was seen in pain, scar or acceptability between dressings.