Dressing

surgical dressing

1. Surgical Dressing Dr. Shruti Devendra JR1 (General Surgery, RMCH Bareilly)

2. Definition Surgical dressing : a dressing is a sterile pad or compress applied to a wound to promote healing and prevent further harm Bandage : a bandage is defined as a piece of material used to cover, support, immobilize, or exert pressure to a part of the body.

3. History The history of wound healing is, in a sense, the history of humankind. One of the oldest medical manuscripts known to man is a clay tablet that dates back to 2200 BC. This tablet describes, perhaps for the first time, the “three healing gestures”—washing the wounds, making the plasters, and bandaging the wound. These plasters were mixtures of substances including mud or clay, plants, and herbs. Plasters were applied to wounds to provide protection and to absorb exudate. One of the most common ingredients used in plasters was oil. Oil may have provided some protection from infection as bacteria grow poorly in oil, and oil would have prevented the bandage from sticking to the wound as a nonadherent dressing. In 1867, Lister introduced antiseptic dressings by soaking lint and gauze in carbolic acid

4. 1870, Robert Wood Johnson, co-founder of “Johnson & Johnson”, began producing gauze and wound dressing treated with iodine. 1960, George Winter published his controversial research on moist healing. He demonstrated that wounds kept moist heal faster. 1990, the surgical dressing expanded into the well-recognized groups of products, such as vapor-permeable adhesive films, hydrogels, hydrocolloids, alginates, and synthetic foam dressings. Additionally, new groups of products such as antiadhesive, mostly silicon meshes; tissue adhesives; barrier films; and silver- or collagen – containing dressing, were introduced. Finally, combination products and engineered skin substitutes were developed.

5. Desired characteristics of wound dressing Promote wound healing (maintain moist environment) Comfortability Pain control Odour control Non-allergic and non-irritating Permeability to gas Safety Non-traumatic removal Convenience

6. Principles Covering a wound with a dressing mimics the barrier role of epithelium and prevents further damage In addition, application of compression provides haemostasis and limits edema . Occlusion of a wound with dressing material helps healing by controlling the level of hydration and oxygen tension within the wound. It also allows transfer of gases and water vapour from the wound surface to the atmosphere. Occlusion also helps in dermal collagen synthesis and epithelial cell migration and limits tissue desiccation. As it may enhance bacterial growth, occlusion is contraindicated in infected and highly exudative dressing

7. Primary and secondary dressing Primary dressing is placed directly on the wound and may provide absorption of fluids and prevent desiccation, infection and adhesion of a secondary dressing. Secondary dressing is one that is placed on the primary dressing for further protection, absorption, compression, and occlusion. Some dressings function as primary dressing only. However some could function both as primary as well as secondary dressing.

8. Types of dressing Dry dressings Moisture-keeping dressings Bioactive dressings Skin substitutes

9. Dry dressing Most commonly available dressings Tend to absorb wound moisture Tightly adherent to granulation tissue – breaks upon removal Example, gauze and bandage, membranes and foils, foams, tissue adhesives Gauze Tissue adhesive

10. Moisture keeping dressings Nonadherent to the wound Heals faster Do not break granulation tissue on removal Comparatively less painful Example, pastes, creams and ointments; non-permeable, semi-permeable membranes or foils; hydrocolloids; hydrogels; combination products.

11. Bioactive dressing Enhance granulation tissue formation Reduce slough formation Inhibits bacteria Some provide growth factors Example, antimicrobial dressing; interactive dressings; single-component biologic dressings; combination products

12. Skin substitutes These are heterogenous groups of wound coverage materials that aid in wound closure and replace the function of the skin, either temporarily or permanently, depending on the product characteristics Examples, Epidermal substitutes (autologous or allogenic) Acellular skin (dermis) substitutes (allogenic or xenogenic ) Autologous and allogenic skin Skin substitutes containing living cells

13. Commonly used dressings Gauzes Foams Polymeric films ( opsite ) Tissue adhesives Tulles Hydrocolloids Hydrogels Debriding agents Enzymatic dressings Bead dressings Silicon dressings Human amniotic membrane Porcine skin

14. Gauzes Mostly readily available simple wound dressings Non-adherent coating Absorbs exudate Promote desiccation in wounds Can be used as a primary or secondary dressing Inexpensive Highly permeable Relatively non-occlusive FORMS: squares, sheets, rolls, and packing strips

15. Foams Polyurethane porous sponges or polyurethane foam films Acts as absorbent in light-to-medium exuding wounds Left on the wound surface for up to 7 days, depending on exudate volume Not recommended for any kind of dry wounds Can be shaped to fit deep cavities and granulating wounds.

16. Polymeric films Semi-permeable film dressings Primary adhesives Transparent Waterproof Impermeable to bacteria Breathable Ultra thin and high elasticity Example , opsite , bioclusive , tegaderm Indicated in the following conditions General wound care Skin biopsies Donor sites Superficial partial thickness burns Surgical incisions Securing peripheral iv lines Central venous catheters Contraindicated in highly exudative wounds Opsite Tegaderm

17. Tissue Adhesives Contain cyanoacrylate which polymerize in an exothermic reaction on contact with either a fluid or a basic substance Used for simple lacerations, which otherwise might require the use of the fine sutures, staples, or skin strips Cosmetic results similar/better than traditional suturing Needleless and painless method of wound repair Does not require follow-up visits for suture removal Strength of healed tissue seen at 7 days Ensure that wound edges are appropriately adapted and that no adhesive passes between wound borders

18. Tulles A light thin type of cloth that is like a net impregnated with paraffin for non-traumatic removal Antiseptic/antibiotics are added for prevention or treatment of infection Does not stick to wound surface Suitable for flat, shallow wounds Useful in patients with sensitive skin Require a secondary dressing

19. Bactigras or Para-tulle Soft paraffin dressing which contains chlorhexidine which is an antiseptic It allows the wound to drain freely in the absorbent secondary dressing It is used for burns, lacerations, abrasions, graft sites and leg ulcers

20. Sufra tulle It consists of cotton fabric impregnated with soft paraffin, anhydrous lanolin and 1 % framycetin sulfate . Framycetin is an antibiotic of aminoglycoside group It is used for infected wounds, combining low adherence with antimicrobial activity.

21. Hydrocolloids Hydrocolloids slowly absorb fluids, leading to a change in the physical state of the dressing and the formation of gel covering the wound. Thus, they are called interactive dressings. The constituents are methycellulose , pectin, gelatin , and polyisobutylene Provide moist wound environment, promote granulation tissue formation and provide pain relief by covering nerve ending with both gel and exudate. Uses: for acute and chronic wounds, light-to-heavy exuding wounds, helps in desloughing . Initially dressing needs to be changed daily and later on it can be left for a week when exudate is diminished. It is not used in infected wounds.

22. Hydrogels Hydrogels contains more than 70-90 % water content for this reason it has many characteristics of ideal dressing It cools the wound surface resulting in marked pain relief Maintains moist environment Used in dry necrotic wound or on lightly exuding wound Used in all stages of wound healing except for infected or heavily exuding wound May macerate the healthy skin, mostly at wound borders, by decreasing keratinocyte re-epithelization ratio or leading to over wetting of split-skin donor sites Example tegagel , intrasite

23. Debriding agents Provide acidic environment Enhance healing via debriding action Only used in necrotic sloughing skin ulcers Example, benoxy -benzoic acid

24. Enzymatic agents Activate fibrinolysis and liquefy pus on chronic skin ulcers Example, varidase -streptokinase/streptodornase Papain-urea ointment is a digestive enzyme with proteolytic action which accelerate controlled digestion and removal of the necrotic tissue. Especially used to prepare recipient site for graft purpose. Used in burns, chronic wounds.

25. Bead dressings Remove bacteria and excess moisture by capillary action. Useful in deep granulating wounds example, Iodosorb (available in sheets and pastes) Iodosorb

26. Silicon dressing May reduce hypertrophic scarring and keloid formation. Works as antiadhesives. Useful in covering split-skin donor sites or fresh meshgrafts . Purpose: making the scars more cosmetically acceptable by: Flattening of scarring tissue Increasing elasticity Reducing discoloration

27. Fibrous polymers An alginate dressing is a natural wound dressing derived from different types of algae and seaweeds. Best used on wounds that have a large amount of exudate. Can absorb exudate up to 20 times their own weight. It is available as sheaths and ropes. Example, Kaltostat , sorbsan

28. Human amniotic membrane Obtained from the placenta after delivery, to cover burn wounds. Can be prepared relatively inexpensively. Characteristics of an ideal skin substitute: Excellent adherence to the wound Very low immunogenicity Decrease of pain Bacterial control Stimulation of healing

29. It is translucent, allowing inspection of the wound. Can be applied on superficial second-degree burn, deep second-degree burns after early debridement and donor sites. To cover 1:3 meshed autografts. Extremely effective in sterilizing contaminated wounds and cleaning burns of bacteria within 3-5 days It have to changed daily Need to be covered with gauze to prevent desiccation Can be kept refrigerated for 6 weeks They can be frozen for longer storage

30. Porcine skin Porcine skin is the most common source of xenograft because of its high similarity to human skin Well-suited temporary dressing for the coverage of second-degree burns, especially after early excision. It usually promotes scar-free healing Average healing period of about 10 days Suitable overlay to cover widely meshed (1:8 to 1:12) autographs

31. Collagen dressing Promote the deposit of newly formed collagen in the wound bed These dressings chemically bind to matrix metalloproteinases (MMPS) found in the extracellular fluid of wounds. MMPs normally attack and break down collagen, so dressings containing collagen give MPS an alternative collagen source, leaving the body’s natural collagen available for normal wound healing Mainly used for chronic non healing wounds

32. Biobrane Bilayer skin substitute Constructed of a silicon film with a nylon fabric partially imbedded into the film to which collagen has been chemically bound and cross-linked Used in sever burn and donor sites Significantly reduce local wound pain Speed up the healing process Biobrane dressing in burn patients

33. Tissue-engineered skin substitutes Tissue engineering is the use of a combination of cells, engineering and materials methods to improve or replace biological functions Engineered skin substitutes have been developed to address the need for wound coverage and tissue repair as conventional wound dressings have significant limitations for skin regeneration Example, TransCyte was the first human-based, bioengineered, temporary skin substitute for the treatment of full and partial thickness burns Integra serves to prepare the wound bed in preparation for transplantation with autologous split-thickness skin three weeks later Currently, no engineered skin substitute can replace all of the functions of intact human skin

34. Thank You!