Surgical dressing

medical students

1. Surgical Dressing Dr. Shamima nasrin Silv i MBBS, FCPS

2. SURGICAL DRESSING A dressing is a sterile pad or compress applied to a wound to promote healing and prevent further harm.

3. BANDAGE A bandage is a piece of material used either to support a medical device such as a dressing or splint , or on its own to provide support to the body .

4. Historically, a dressing was usually a piece of material , sometimes cloth , but the use of cobwebs , dung, leaves and honey have also been described. Previously , the accepted wisdom was that to prevent infection of a wound, the wound should be kept as dry as possible .

5. 1860 , English surgeon, Joseph Lister, began treating his surgical gauze with carbolic acid , known today as phenol, and subsequently dropped his surgical team's mortality rate by 45 %.

6. 1870 , Robert Wood Johnson, co-founder of“ Johnson & Johnson” , began producing gauze and wound dressings treated with iodine . 1960 , George Winter published his controversial research on moist healing. He demonstrated that wounds kept moist healed faster.

7. 1990 , the surgical dressings 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 anti-adhesive , mostly silicone meshes; tissue adhesives; barrier films; and silver- or collagen-containing dressings , were introduced. Finally , combination products and engineered skin substitutes were developed.

8. Purpose of wound dressing - To promote wound healing by primary intention . - To prevent infection . - To assess the healing process. - To protect the wound from mechanical trauma . - To absorb drainage. - To prevent contamination from bodily discharge.

9. Dressing selection Dressing selection should be simple and promote moist wound healing ( Winter 1962). Avoid complex combinations of dressings which may be expensive and ineffective. Ensure that they are safe and research based. Wounds need to be reassessed and dressing selection changed accordingly .

10. The selection of wound dressing is based on Condition of wound bed Exudate Presence of infection

11. Properties of an ideal dressing Provide mechanical and bacterial protection Maintain a moist environment at the wound/dressing interface Allow gaseous and fluid exchange Remain nonadherent to the wound Nontoxic , nonsensitizing , and nonallergic Well acceptable to the patient (e.g., providing PAIN RELIEF and not influencing movement) Cost effective

12. Highly absorbable (for exuding wounds) Absorb wound odor Sterile Easy to use (can be applied by medical personnel or the patient) Require infrequent changing Available in a suitable range of forms and sizes

13. CLASSIFICATION Dry dressings Moisture-keeping dressings Bioactive Dressings Skin Substitutes

14. Most commonly available dressings Tend to absorb wound moistur e Tightly Adherent to granulation Tissue – will break upon removal EXAMPLES : Gauze and bandages Membranes and foils Foams Tissue adhesives

15. Nonadherent to the wound Heals faster Do not break granulation tissue on removal Comparatively less painful

16. EXAMPLES: Pastes, creams and ointments Nonpermeable, semipermeable membranes or foils, Hydrocolloids Hydrogels Combination products.

17. They play a significant active role in wound healing because E nhance granulation tissue formation Reduce slough formation Inhibits bacteria Some provide growth factors

18. EXAMPLES: Antimicrobial dressings Interactive dressings Single-component biologic dressings Combination products

19.  Skin substitutes are heterogeneous group of wound coverage materials that aid in would closure and replace the functions of the skin, either temporarily or permanently, depending on the product characteristics.

20. EXAMPLES:  Epidermal substitutes (autologous or allogenic) Acellular skin (dermis) substitutes (allogenic or xenogenic) Autologous and Allogenic skin Skin substitutes containing living cells.

21. Gauzes Foams Polymeric films (Opsite) Tissue adhesives Tulles Hydrocolloids Hydrogels Debriding agents Enzymatic dressings Bead dressings Silicone dressings Human Amniotic Membrane Porcine skin

22. Most 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.

23. polyurethane porous sponges or polyurethane foam films Light-to-medium exuding wounds (Absorbent) L e f t on the w ou n d sur f ace f o r u p t o 7 d a y s , depending on exudate volume. N o t r e c ommende d f o r a n y ki n d of dry wounds!! Ca n b e shaped to fi t dee p c a vit i es and granulating wounds.

24. Semipermeable film dressings Primary adhesive transparent Waterproof Impermeable to bacteria Breathable Ultra thin & high elasticity Examples: Opsite Bioclusive Tegaderm

25. Uses: General wound care Skin biopsies Donor sites Superficial partial thickness burns Surgical incisions Securing of peripheral IV lines central venous catheters Contraindicted in highly exudative wounds

26. 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 fine sutures, staples, or skin strips cosmetic results similar/better than traditional suturing

27. Needleless & 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

28. Tulle : A light, thin type of cloth that is like a net They comprise a gauze cloth impregnated with paraffin for non-traumatic removal  Antiseptics/Antibiotics are added for prevention or treatment of infection Does not stick to wound surface Suitable for flat, shallow wound Useful in patient with sensitive skin Require a secondary dressing

29. Soft paraffin dressing Contains chlorhexidine which is an ANTISEPTIC Allows the wound to drain freely into an absorbent secondary dressing Used for covering wounds such as superficial burns , lacerations, abrasions, graft sites and leg ulcers.

30.  I t c onsi s ts of a c o t t o n f abric, imp r egn a t ed with a base composed of white soft paraffin, lanoli n , and 1 . % F r a m y c e tin anhydrous Sulphate  F r a m y c e t in i s an a n t i b i o t i c of the aminoglycoside group  It is used for Infected wounds , combining low adherence with antimicrobial activity.

31. Hydrocolloids slowly absorb fluids, leading to a change in the physical state of the dressing & the formation of gel covering the wound. Thus, they are called interactive dressings Provide moist wound environment Promote the formation of granulation tissue Provide PAIN RELIEF by covering nerve endings with both gel and exudate. Con s titu e n ts a r e m e t h ylcel l ulose , pect i n, gelatin, and polyisobutylene.

32. USES: Both acute wounds and chronic wounds Desloughing purpose For different stages of light-to-heavily exuding wounds Initially, dressings need to be changed daily , but once the exudate has diminished, dressings may be left for up to 7 days Do not use on infected wounds!!

33.  Brand: DueDERM®

34. Contain WATER i.e., > 70-90% They have some important characteristics of an IDEAL DRESSING Cool the surface of the wound, resulting in MARKED PAIN REDUCTION Maintain the moist wound environment For use on dry or necrotic wounds or on lightly exuding wounds Can be used at all stages of wound healing except for infected or heavily exuding wounds

35. May MACERATE the healthy skin (mostly wound border areas), decreasing the keratinocyte reepithelialization ratio or leading to over wetting of split-skin donor sites. Available as sheet dressings or gels. Brands: Tegagel®, Intrasite®

36. GEL FORM SHEET FORM

37. Provide acidic environment Enhance healing via debriding action Only used in Necrotic sloughing skin ulcers EXAMPLE: Benoxyl-benzoic acid

38. Activate fibrinolysis and liquefy pus on CHRONIC SKIN ULCERS Example: Varidase-streptokinase/streptodornase

39. Remove bacteria and excess moisture by CAPILLARY ACTION Useful in Deep Granulating Wounds EXAMPLES: Debrisan® Iodosorb® Available as Sheeths & Pastes

40. May reduce Hypertrophic scarring and Keloid formation Work as Antiadhesives useful in covering split-skin donor sites or fresh meshgrafts

41. MAKING THE SCARS MORE COSMETICALLY ACCEPTABLE via: flattening of scarring tissue increasing elasticity reducing discoloration

42. 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 upto 20 times their own weight Available as Sheaths and Ropes

43. BRANDS: Kaltostat® Sorbsan®

44. 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

45. It is translucent, allowing inspection of the wound. Can be applied on superficial second-degree burns, 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.

46. Have to be 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

47. 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) autografts

48. 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 MMPs an alternative collagen source, leaving the body’s natural collagen available for normal wound healing. Mainly used for Chronic Nonhealing Wounds

49. 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 Severe burns and Donor sites significantly reduce local wound pain speed up the healing process

50. 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

51. EXAMPLES: 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

52. Promote healing in difficult wounds that fail to respond to established treatment modalities. The system is based on the application of negative pressure to the surface of the wound. Vacuum-assisted closure

53. The device removes chronic edema and increases local blood flow, enhancing granulation formation and wound healing

54. Intermittent or cycled treatment appears more effective than continuous therapy. Wound bacterial counts are decreased with VAC use compared to control wounds

55. Hyperbaric oxygen therapy Hyperbaric oxygen therapy involves breathing pure oxygen in a pressurized room. Conditions treated with hyperbaric oxygen therapy include serious infections, bubbles of air in blood vessels and wounds that won't heal as a result of diabetes or radiation injury.

56. In a hyperbaric oxygen therapy room, the air pressure is raised up to three times higher than normal air pressure. Under these conditions, lungs can gather up to three times more oxygen than would be possible breathing pure oxygen at normal air pressure.

57. Blood carries this oxygen throughout the body, stimulating the release of substances like growth factors and stem cells, which promote healing.

58. Stem cell therapy Plastic Surgery, 3 rd Edition, Peter C Neligan A list of stem cells growth factors are found and are in research but only PDGF has got received US FDA approval to use in wound management.

59. Vacuum Assisted Closure VAC

60. Vacuum assisted closure VAC

61. Vacuum Assisted Closure VAC Macrostrain - occurs when negative pressure contracts the foam. Draws wound edges together Removes exudate and infectious materials Microstrain - at the cellular level Reduces edema Promotes granulation - facilitates cell migration and proliferation

62. Vacuum Assisted Closure VAC Indications for use Large wounds Cavities Large amount of exudate

63. Avoid in chronic wounds Iodine ( Betadine ) Hydrogen peroxide Other toxic agents Do not apply gauze bandage tightly around limbs, digits – causes ischaemia • Use – plaster , crepe instead

64. When there is an indication to change  Soaking  Pain  Need to inspect