Surgical dressings

1. SURGICAL DRESSINGS Dr. MUHIBULLAH BANGASH PG-1 Resident Surgical-E Unit KTH, Peshawar

2. CONTENTS Definitions History of Surgical Dressings Properties of Ideal wound Dressings Types of Surgical Dressings Commonly used Surgical Dressings Miscellaneous Dressings Conclusion Videos

3. DEFINITIONs 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 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. HISTORY 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. HISTORY 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. HISTORY 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. MODERN WOUND DRESSINGS 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 antiadhesive, 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. Primary vs. Secondary Dressings Primary Dressing: A dressing that touches the wound Secondary Dressing (Bandage): Keeps the primary dressing in site Some dressings function as primary dressing only. However some could function both as primary as well as secondary dressing

9. Ideal Wound Dressings 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

10. Ideal Wound Dressings . . . 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

11. TYPES OF DRESSINGS CLASSIFICATION: Dry dressings Moisture-keeping dressings Bioactive Dressings Skin Substitutes

12. 1. DRY DRESSINGS Most commonly available dressings Tend to absorb wound moisture. Tightly Adherent to granulation Tissue – will break upon removal EXAMPLES: Gauze and bandages Membranes and foils Foams Tissue adhesives

13. 2. Moisture Keeping Dressings Nonadherent to the wound Heals faster Do not break granulation tissue on removal Comparatively less painful

14. 2. Moisture Keeping Dressings EXAMPLES: Pastes, creams and ointments Nonpermeable , semipermeable membranes or foils, Hydrocolloids Hydrogels Combination products.

15. 3. BIOACTIVE DRESSINGS They play a significant active role in wound healing because enhance granulation tissue formation Reduce slough formation Inhibits bacteria Some provide growth factors

16. 3. BIOACTIVE DRESSINGS EXAMPLES : Antimicrobial dressings Interactive dressings Single-component biologic dressings Combination products

17. 4. SKIN SUBSTITUTES 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 .

18. 4. SKIN SUBSTITUTES EXAMPLES : Epidermal substitutes ( autologous or allogenic ) Acellular skin (dermis) substitutes ( allogenic or xenogenic ) Autologous and Allogenic skin Skin substitutes containing living cells.

19. COMMONLY USED DRESSINGS Gauzes Foams Polymeric films (Opsite) Tissue adhesives Tulles Hydrocolloids Hydrogels Debriding agents Enzymatic dressings Bead dressings Silicone dressings Human A mniotic Membrane Porcine skin

20. GAUZES 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.

21. GAUZES

22. FOAMS polyurethane porous sponges or polyurethane foam films Light-to-medium exuding wounds (Absorbent) 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.

23. FOAMS

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

25. POLYMERIC FILMS 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. POLYMERIC FILMS (Opsite)

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

28. TISSUE ADHESIVES 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

29. TISSUE ADHESIVES

30. TULLES 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

31. TULLES

32. BACTIGRAS / PARA-TULLE 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.

33. SUFRA TULLE . . . It consists of a cotton fabric, impregnated with a base composed of white soft paraffin, anhydrous lanolin , and 1.0% Framycetin Sulphate Framycetin is an antibiotic of the aminoglycoside group It is used for Infected wounds , combining low adherence with antimicrobial activity.

34. HYDROCOLLOIDS 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 . Constituents are methylcellulose, pectin, gelatin, and polyisobutylene .

35. HYDROCOLLOIDS 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!!

36. HYDROCOLLOIDS Brand: DueDERM ®

37. HYDROCOLLOIDS

38. HYDROGELS 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

39. HYDROGELS 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 ®

40. HYDROGELS GEL FORM SHEET FORM

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

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

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

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

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

46. SILICONE DRESSINGS

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

48. FIBROUS POLYMERS BRANDS: Kaltostat ® Sorbsan ®

49. 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

50. HUMAN AMNIOTIC MEMBRANE 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.

51. HUMAN AMNIOTIC MEMBRANE 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

52. 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) autografts

53. COLLAGEN DRESSINGS 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

54. BILAYER SKIN SUBSTITUTE ( BIOBRANE®)

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

56. 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

57. Tissue-Engineered Skin Substitutes 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

58. IN CONCLUSION Determine and address cause of wound Establish plan of care that includes dressings that will address principles of moist wound healing Keep dressings as simple as possible Assure Pain is addressed