infection and dehiscence - 10th ecet congress oporto 2009
TRANSCRIPT
INFECTION AND DEHISCENCE OF AN ABDOMINAL SURGICAL WOUND AFTER REVERSION – THECORRECT USE OF ADVANCED WOUND DRESSINGS
ET. G. MILITELLO – Ostomy Centre ASL 4 Prato – [email protected] – [email protected]. M. ANTONINI – Ostomy Centre ASL 11 Empoli – [email protected] – [email protected]
INTRODUCTIONThe infections in modern surgery still represent a huge problem for health care professionals. Most of surgical wounds heal by first intention. Healing by second intention happens, instead, in case of dehiscence of the surgical wound due to infections, lost of substance, formation of haematomas and seromas. C. L., a 72 years old woman, underwent to an emergency surgical operation due to a diverticulum perforation and she had a terminal sigmoid ostomy sec. Hartmann about 9 months ago. During the recovery period following the surgery, the patient shows classic sympthoms of infection of surgical wound.
AIMS & METHODSBecause of the presence of abundant necrotic tissue, a debridement of the wound in operating theatre was necessary. According to the Southampton Wound Scoring System, the wound is classified as follow: Level V: Deep infection of the surgical wound with or without loss of substance, haematoma which requires aspiration. The dressings are made with the application of a cleansing solution plugging with Propil Betaina e Poliesanide for 10-15 minutes. This time is necessary to allow the cleansing solution to obtain its effect of removing biofilm on the wound (if it is present). Inside the wound, there is Hydrofiber + Ag, an antimicrobial dressing to manage the infective process.
RESULTSThis case study showed a right progression in the use of dressings. The wound got quickly the granulation phase, thanks to the right timing on dressings’ choice. This phase has stopped and just because of the net rejection from the organism.
DISCUSSIONThe nurse has therefore the skills to manage in first person the healing process of infected wounds and dehiscences. It is also important to highlight the team working among the nurse, the surgeon and the plastic surgeon, in order to definitively resolve the problem of rejection and skin grafting.
ASEPSIS WOUND SCORE
Proportion of wound affected
Wound Characteristic 0 <2
0
20-39 40-59 60-79 >80
Serous exudate 0 1 2 3 4 5
Erythema 0 1 2 3 4 5
Purulent exudate 0 2 4 6 8 10
Separation of deep tissues 0 2 4 6 8 10
Points are scored for daily wound inspection.
Criterion Points
Additional treatment:
Antibiotics
Drainage of pus under local anaesthesia
Debridement of wound (general anaesthesia)
Serous discharge*
Erythema *
Purulent exudates*
Separation of deep tissues*
Isolation of bacteria
Stay as inpatient prolonged over 14 days
10
5
10
Daily 0-5
Daily 0-5
Daily 0-10
Daily 0-10
10
5
*Given score only on five of seven days. Highest weekly score used
Category of infection: total score 0-10 = satisfactory healing; 11-20 = disturbance of healing; 20-30 = minor wound infection; 31-40 =
moderate wound infection; >40 = seere wound infection.
(Adapted from Wilson AP et al, Lancet 1986).
CASE REPORT
Infection of the surgical site and the dehiscence of wounds still represent an important and underestimated problem. Nursing staff
should know their mechanisms and take care of the surveillance of the wound.
Nowadays, thanks to the technology innovations, there are many advanced dressings available which can give a great support to the
healing process, but which can even delay the reepithelization, if they are not properly known.
The nurse is on the firing line in this field and, therefore, he/she is responsible of taking care of the patient, both in the hospital or at
home. So it is necessary that they get a deep knowledge of advanced dressings.
This case study showed a right progression in the use of dressings. The wound got quickly the granulation phase, thanks to the right timing on dressings’ choice. This phase has stopped and just because of the net
rejection from the organism.
The nurse has therefore the skills to manage in first person the healing process of infected wounds and dehiscences.
It is also important to highlight the team working among the nurse, the surgeon and the plastic surgeon, in order to definitively resolve the
problem of rejection and skin grafting.
SOUTHAMPTON SCORING SYSTEM
Grade Appearance
0 Normal healing
I Normal healing with mild bruising or erythema:
A Some bruising
B Considerable bruising
C Mild erythema
II Erythema plus other signs of inflammation:
A At one point
B Around sutures
C Along wound
D Around wound
III Clear or haemoserous discharge:
A At one point only (<2cm)
B Along wound (>2cm)
C Large volume
D Prolonged (>3 days)
Major complication
IV Pus:
A At one point only (<2cm)
B Along wound (>2cm)
V Deep or severe wound infection with or without tissue breakdown; haematoma requiring aspiration
The wound grading system used was simplified for the use of analysis. By using the worst wound score recorded and information about any treatment
instituted either in hospital or the community, wounds were regarded in four categories:
(A) Normal healing;
(B) Minor complication;
(C) Wound infection-wounds graded IV or V or wounds treated with antibiotics after discharge from hospital, irrespective of the wound grading given to
them by the nurse; and
(D) Major haematoma-wound or scrotal haematomas requiring aspiration or evacuation.
(Adapted from Bailey IS et al, BMJ 1992)