Wound dressing

Aseptic surgical dressing technique and its different types of dressing.

1. Wound dressing Made by: Dr. Sagarika Panday (Intern)

2. Dressings are the materials used to cover wounds to provide support, adequate environment for healing and retain moisture. A dressing is designed to be in direct contact with the wound.  

3. History: Wound dressings have been used since the time of antiquity. Treatment of wounds originally consisted of homemade remedies and evolved very little for many years. In 1867, Joseph Lister introduced antiseptic dressing by soaking lint and gauze in carbolic acid, which lead to the development of more sophisticated methods of dressing henceforth.

4. Principle of dressing: Wound healing is most successful in a moist, clean and warm environment. Two concepts are critical when selecting appropriate dressings for wounds: Occlusion Absorption

5. Occlusive dressing T he rate of epithelialization under an occlusive dressing is twice that of a wound that is left uncovered and allowed to dry. Placement of an occlusive dressing over the wound provides a mildly acidic pH and low oxygen tension on the wound surface , which is a good environment for the proliferation of fibroblasts and formation of granulation tissue.

6. Absorptive dressing: Wounds that have a significant amount of exudate or wound with high bacterial counts will require a dressing that reduces the bacterial load within the wound while removing the exudate produced. Placement of a pure occlusive dressing without bactericidal properties will allow bacterial overgrowth and worsen the infection.

7. Characteristics of ideal dressing: Creates a moist environment Removes excess exudates Prevents dessication Allows for gaseous exchange Impermeable to microorganisms Thermally insulating Prevents particulate contamination Nontoxic to beneficial host cells Provides mechanical protection Non-traumatic Easy to use Cost effective

8. Types of dressing: Dry dressing: It is used in clean sutures, operated wounds. They can be changed after certain intervals 2. Wet dressing: They are made wet by using jelly, paraffin, antibiotic solutions, etc. They are to be changed from time to time, and are used in ulcers commonly.

9. Components of dressing: Inner contact layer: It is non-absorbent and only allows secretion to pass into the absorbent layer. It does not allow penetration of granulation tissue. It is usually kept wet. Commonly mesh gauze is used. Intermediate absorbent layer Made up of cotton which absorbs the secretion Outer supportive layer

10. Classes of wound dressing: Non-adherent fabrics Absorptive dressings Occlusive dressings Creams, ointments and solutions

11. NON-ADHERENT FABRICS

12. FUNCTION- Protection,moist environment CHARACTERISTICS- Fine-mesh gauze with supplement to augment occlusive and nonadherent properties healing facilitating capabilities antibacterial characteristics

13. Examples:Scarlet Red, Vaseline gauze, xeroform , Xeroflo , Mepitel , Adaptic , Telfa

14. ABSORPTIVE DRESSING

15. 1. Absorptive Gauze: These are wide mesh gauze which help in removing exudates and prevent maceration . For example-Wide-mesh gauze

16. 2. Foams: These are hydrophobic polyurethane sheets that provide protection and absorption of exudate. For example- Lyofoam , Allevyn , Curafoam,Flexzan , Vigifoam

17. OCCLUSIVE DRESSING

18. NON-BIOLOGIC OCCLUSIVE DRESSING Films-Clear polyurethane membranes with acrylic adhesive on one side Hydrocolloids- Hydrocolloid matrix(gelatin , pectin, carboxymethyl cellulose),absorbs water from wound exudates , swells then liquefies to form moist gel Alginates-Cellulose-like polysaccharide fibers derived from calcium salt of alginate ( sea weed). calcium alginate conversion to soluble sodium salt following contact with wound exudates results in hydrophilic gel Hydrogels- Polyethylene oxide or carboxymethyl cellulose polymer and water (80 %). It is a rehydrating agents for dry wounds ; little water absorption ( high water content)

19. BIOLOGIC OCCLUSIVE DRESSING: Homograft-Derived from genetically unique humans, eg:Cadaver skin Xenograft -Interspecies graft (e.g., pig) Amnion-Human placenta Skin substitutes

20. Creams, Ointments, and Solutions Antibacterial Ointments Enzymatic Others: Normal saline wet to dry gauze dressing

21. Antibacterial Solutions Acetic acid — impairs wound healing Dakin’s — toxic to fibroblasts I odine-containing solutions —toxic to fibroblasts, impairs wound healing Silver nitrate —treats burns, slows epithelialization , hyponatremia,stains clothes black Mafenide acetate — penetrates eschar , painful application, inhibits reepithelialization , carbonic anhydrase inhibitor Silver sulfadiazine —transient neutropenia, accelerates epithelialization of partial-thickness burns, neovascularization , commonly used for burns Acticoat —silver impregnated occlusive dressing, antibacterial activity lasts 3 days

22. Antibacterial Ointments Used to treat infected wounds soothing to apply lubricates wound surface occlusive antibacterial activity lasts 12 hours

23. Some examples : Bacitracin (gram-positive cocci and bacilli) N eomycin ( gram-negative) P olymyxin B sulfate ( gramnegative ) Polysporin ( polymyxin B,bacitracin ) Neosporin ( polymyxin B,bacitracin , neomycin) Triple antibiotic ointment ( polymyxin B,bacitracin , neomycin

24. Enzymatic Removal of necrotic tissue For example: Sutilains (derived from Bacillus subtilis ) C ollagenase ( Santyl;derived from Clostridium histolyticum ) P apain (derived from vegetable pepsin)

25. TRANSPARENT DRESSING Thin sheet of see-through material(generally polyurethane) Typically used to protect the skin in pressure points, acting as second skin Able to see the wound-healing progress and any drainage Keep area moist for optimal healing

26. BENEFITS Moist environment Flexible-can conform to wounds in difficult to apply areas Impermeable to bacteria and contaminants Water-proof Excess moisture vapor and carbon dioxide are able to escape via one way passage

27. CONTRAINDICATIONS Wound having moderate to heavy exudates Active bacterial or fungal infection Third-degree burn Skin is fragile or thin, as removal can cause tearing or epidermal stripping Risk of peri -wound maceration

28. APPLICATION AND REMOVAL Should be smoothed out Large enough that there is at least 1-inch border surrounding the wound Remove by lifting slowly and carefully from edges towards center Require changing every 3-5 days Change immediately if there is skin irritation, leakage, loosening of film or exudates seen

29. TECHNIQUE FOR ANTISEPTIC DRESSING

30. Dressing is started 48-72 hours after suturing as epithialization begins during this period Done every 24 hours, unless soakage is present If dressing is to be done for a large area or wound is present in sensitive area then anesthesia is to be considered for comfort of patient

31. Requirements A clear available work space, such as a stainless steel trolley. The space must be big enough for the dressing pack to be opened on A sterile dressing/procedure pack Access to hand washing sink or alcohol hand wash Non-sterile gloves to remove old dressing Apron Appropriate dressings Appropriate solution for cleaning the wound, if needed.

32. Preparation Introduction and explain what you are doing and why. If possible, provide privacy. Position the patient comfortably Check the patient's care notes Wash your hands and put on an apron. Clean the trolley using soap and water, or disinfectant Place the sterile dressing/procedure pack on the top of the trolley. Open the sterile dressing pack on top of the trolley. Open the sterile field using the corners of the paper. Open any other sterile items needed onto the sterile field without touching them.

33. Removing an old dressing Wash your hands and put on non-sterile gloves (to protect yourself) Dispose of this dressing in a separate dirty clinical waste bag . Complete a wound assessment and evaluate. This includes a visual check and comparing and evaluating the smell, amount of blood or ooze (excretions) and their colour , and the size of the wound . Use aseptic non-touch technique

34. Cleaning and dressing the wound

35. Make sure that you have selected the correct dressing type and materials to provide full and appropriate coverage of the type, size and location of the wound as per the care plan.

36. Wash your hands and put on sterile gloves . Start cleaning from the dirty area and then move out to the clean area. Be very careful when doing this as the tissue or skin may be tender and there may also be sutures in place. Clean the area without causing further damage or distress to the patient.

37. Make sure you do not re-introduce dirt or ooze by ensuring that cleaning materials (i.e. gauze, cotton balls) are not over-used. Change them regularly (use once only if possible) and never re-introduce them to a clean area once they have been contaminated.

38. POST-OPERATIVE CLEANSING Use sterile saline for wound cleansing u pto 48 hours after surgery Tap water can be used after 48 hours

39. PRIMARY INTENTION HEALING Do not use topical antimicrobial agents that are healing by primary intention to reduce the risk of surgical site infection

40. SECONDARY INTENTION HEALING Do not use moist cotton gauze, mercuric antiseptic solutions or Eusol and gauze Use appropriate interactive dressing

41. SIGNS OF WOUND INFECTION Change in wound size-wound getting bigger Redness or streaking Swelling Pain Discharge, pus or odor

42. After the procedure Fold up the dressing/procedure pack and place all contaminated material in a bag designated for clinical waste, making sure all sharp objects are removed and disposed of in a sharps container. Remove gloves and place in waste bag. Wash your hands. Provide the patient with some dressing management education and answer any questions before you go.

43. NEGATIVE PRESSURE WOUND THERAPY

44. INTRODUCTION Also called vacuum-assisted wound closure Wound dressing system that continuously or intermittently applies sub atmospheric pressure to the surface of the wound Accelerates wound healing

45. INDICATIONS Open abdomen Following surgical debridement of acute or chronic wounds( eg . Necrotizing infection, pressure ulcer) Diabetic foot ulcers Reconstructive surgery

46. CONTRAINDICATIONS Exposed vital structures-NPWT, in the presence of exposed organs, blood vessels, or vascular grafts, increase the risk for tissue erosion, which can lead to hemorrhage or fistula formation