Post Discharge Management of Spinal Surgery Wounds

1. Post Discharge Management of Spinal Surgery Wounds Skye Koturaj Clinical Nurse Specialist C West - Neurosurgery Brisbane Private Hospital June 2013

2. How do Surgical Wounds Heal? There are three main steps in the process by which surgical wounds heal: • Inflammation – this lasts for a short time as the blood flow is increased to the wound • Proliferation – new blood vessels grow to bring nutrients to the wound and remove dead tissue • Maturation – new skin seals the wound and forms a scar Skin edges usually form a seal within a day or two of an operation, but this can vary from person to person and from operation to operation. Closing awound surgically (with stitches, clips and staples) encourages the wound to heal faster

3. Purpose of Surgical Wound Dressings The purpose of a dressing is to: • absorb any leakage from the wound • improve conditions for healing • reduce the risk of infection • protect the area until the wound has healed • prevent stitches or clips catching on clothing Not all surgical wounds need dressings

4. Dressings for Acute Surgical Incisions Island dressings provide post-operative protection for acute surgical incisions • Absorbent pad with an adhesive backing, absorb excess wound fluid, maintain a sterile environment and provide a protective barrier against further trauma • Non-Woven Island Dressing e.g. Primapore • Cheaper • Low allergy adhesive • Soft and Conformable • Film island dressings e.g. Cutifilm Plus, Tegaderm+Pad • waterproof

5. http://www.umm.edu/ency/carepoints/Incision-closures.htm

6. Non-Healing Surgical Wounds Main cause for a surgical wound not to heal is infection. Most infections of surgical sites are caused by bacteria from the skin, but can come from other parts of the body as well. Patients are more likely to get a wound infection if they: • smoke • have diabetes or a condition that affects healing • are immuno-compromised, e.g. have leukaemia or are undergoing chemotherapy

7. Signs and Symptoms of Wound Infections • increased pain • red, inflamed or swollen • leak or weep liquid, pus or blood • smell unpleasant • high temperature

8. Goals when Dressing Non-Healing/Infected Surgical Wounds • Maintain a moist environment at wound interface • Remove excess exudate without allowing 'strike through’ to surface of dressing • Provide thermal insulation and mechanical protection • Act as a barrier to micro-organisms • Allow gaseous exchange • Be non adherent and easily removed without trauma • Leave no foreign particles in wound • Be non-toxic, non-allergenic and non-sensitising • No single dressing is appropriate for all wound types and all stages of healing

9. Hydrocolloids  • e.g. Comfeel, Duoderm • When hydrocolloid comes into contact with wound exudate it forms a hydrophilic gel that facilitates autolytic debridement of the wound • Hydrocolloid dressings are indicated for low to moderately exuding wounds • waterproof and generally impermeable to bacteria • Hydrocolloid dressings should be gently warmed between the hands before use to improve adhesion • Can remain in place for up to a week • Over-granulation can occur • Should be avoided if infection

10. Alginates • e.g. Kaltostat, Curasorb • Calcium and sodium salts of alginic acid obtained from seaweed • Calcium alginates tend to swell, whereas sodium alginates tend to dissolve or gel in the wound bed • Highly absorbent (up to 20 times their weight in fluid) • Useful in medium to heavily exudatingwounds • Forms a gel in contact with wound exudate and this gel formation can also promote autolytic debridement of the wound

11. Foam dressings • e.g. Polymem, Lyofoam, Allevyn, Biatain, Mepilex • Useful for moderate and heavy exudating wounds • Foams that absorb exudate and keep it off the wound will decrease maceration to the surrounding tissue • Desloughs wounds by maintaining a moist environment • Very absorbent, can frequently be left undisturbed for 3 - 4 days • Comfortable and conformable 

12. Hydrogels  • e.g. IntrasiteGel • Available in gels, gel covered gauze, or sheets • They contain hydrophilic polymers in a solution containing mostly water (usually >80%), this high water content creates a moist wound surface • Debrides wounds by hydration and promotion of autolysis • Hydrogels offer cooling effects to relieve pain and discomfort • Will absorb a light exudate therefore not appropriate for heavily exudating wounds

13. Negative Pressure/Vac Dressing Applying negative pressure to the wound bed via the VAC pump achieves three main objectives: • It removes excess exudate and promotes a moist, rather than wet, wound-healing environment. It also reduces oedema in the surrounding tissues that, if left, can impair wound-healing by reducing localised blood flow • It promotes granulation tissue through increased angiogenesis • It reduces bacterial count at the wound bed Ideal for clean dehisced surgical wounds

14. Negative Pressure/Vac Dressing Mechanism of use: • Foam dressing is cut to shape of wound • Foam is covered with adhesive dressing with a small hole • Therapeutic regulated accurate care (TRAC) pad applied over the hole • TRAC pad is connected to a negative pressure generator • Pressures achieved at TRAC pad - foam interface are regulated • Pressure used is approximately 125 mmHg • Intermittent application of pressure may be advantageous • Dressings are changed every 48-72 hours

15. References & Acknowledgements • http://www.bupa.co.uk/individuals/health-information/directory/s/surgical-wounds#textBlock197502 • http://www.woundcarecenters.org/wound-types/nonhealing-surgical-wounds.html • http://www.surgical-tutor.org.uk/default-home.htm?specialities/plastic/dressings.htm~right • http://www.nursingtimes.net/understanding-wound-dressings-hydrocolloids/203533.article • http://www.smith-nephew.com/australia/products/product-types/island-dressings/cutifilm--plus/ • http://www.nursingtimes.net/nursing-practice/clinical-zones/wound-care/vacuum-assisted-closure/200663.article