Made EasyPostoperative incision management

Postoperative incision management

Complex wounds, Infection, Surgical wounds | Milne J, Vowden P, Fumarola S, Leaper D

Postoperative incision management In the UK approximately 11 million surgical procedures or interventions are performed annually (DH, 2009; ONS, 2010). Most result in a break in the natural protective barrier provided by the skin, increasing the risk of contamination from exogenous or endogenous bacteria.Postoperative wound sepsis carries high morbidity and additional costs. However, most postoperative complications are preventable and their incidence can be reduced by taking appropriate measures in the pre, intra- and postoperative phases of care to reduce the risk of infection. This made easy reviews the strategies that can minimise the risk of postoperative complications and offers recommendations for best practice, based on the latest NICE guidance (2008) and expert opinion, on effective postoperative incision management.

Understanding the risk of postoperative complications
Most surgical wounds are categorised as acute wounds, healing without complication in an expected timeframe. However, like all wounds, healing may be affected by intrinsic and extrinsic factors that may result in postoperative wound complications, such as surgical site infections (SSIs), which delay healing (Baxter, 2003).  

It has been highlighted that there may be a misperception among some surgeons that these complications are rare (Clarke et al, 2009). In the UK, infection rates vary greatly between different types of surgery, ranging from 0.6% to 0.8% after knee and hip prosthetic surgery, to 10.1% and above for surgery involving the bowel or limb amputation (HPA, 2011). The difference in these figures may relate to whether the surgical procedure was clean, clean-contaminated or contaminated.

However, these figures are considered to be an under-estimation as they include inpatient and readmission data only, and there is limited provision for reporting and follow-up in the community. The trend towards shorter hospital stays means that infection rate figures often do not reflect wound breakdown and infections that occur once the patient has been discharged. For example, Reilly et al (2006) found that for breast surgery, Caesarean section, hip replacement, and abdominal hysterectomy, the rate of SSI when post-discharge surveillance (PDS) was performed was significantly higher than that when it was not.

 

Surgical site infection
Surgical site infection (SSI) is the most common postoperative incisional complication (others include postoperative blistering and wound dehiscence, which may often be related to SSI) and comprises approximately 20% of all healthcare associated infections (HCAIs). At least 5% of patients develop an SSI after a surgical procedure (NICE, 2008).

An SSI can range from a spontaneously limited wound discharge, recognised usually within 7-10 days of an operation, to a life-threatening postoperative complication, such as abdominal wound dehiscence or a sternal infection with mediastinitis and dehiscence after open heart surgery.

An SSI can have a considerable impact on a patient's quality of life, carry a higher risk of morbidity and mortality, and lead to a prolonged hospital stay (Coello et al, 2005) or rehospitalisation with greater use of healthcare resources and higher costs. Based on an SSI rate of 5%, NICE (2008) estimated each episode to cost £3500, and the overall cost to the NHS of managing SSIs to be around £700 million per year.

Principles of managing postoperative incisions
A multidisciplinary approach to postoperative care involving the surgical team is required to improve the overall management of surgical wounds.

To support clinicians, a strategy for the prevention of HCAIs, including SSIs, and specific guidelines have been issued to prevent and manage complications (Pratt et al, 2007; NICE, 2008). They highlight the importance of a thorough and structured approach to pre-, intra- (Table 1) and postoperative care.

This has led to the development of a High Impact Intervention (HII) care bundle, which is based on the 2008 NICE guidelines and expert advice. This comprises three clinical actions which, if all elements are performed every time and for every patient, will reduce the risk of infection. However, the risk of infection increases when one or more actions of a care bundle are excluded or not performed (DH, 2011). Regular auditing of the care bundle actions and review of clinical practices are aimed at improving the quality of care.

 

Preoperative phase
Patients at higher risk of postoperative incisional complications may be identified using a comprehensive preoperative assessment. Factors increasing a patient's risk of wound healing problems, such as wound dehiscence or blistering, include poor nutritional status, obesity, smoking/living with a smoker, and belonging to particular patient groups. These include those with diabetes, rheumatoid arthritis and patients taking steroids or immunosuppressants.

Intraoperative phase
Operating staff are required to use an aseptic technique during surgical procedures and to prepare the skin at the surgical site immediately before incision using an antiseptic preparation. Surgical incisions anticipated to heal by primary intention should be covered by a film membrane, with or without a central absorbent pad (NICE, 2008). This should be left in place for 3-5 days providing no adverse events occur (eg wound pain, pyrexia or wound discharge).



Postoperative phase
After the initial postoperative phase (3-5 days) recommendations include:

  • Use an aseptic, non-touch technique for changing and removing dressings.
  • Keep the frequency of dressing changes to a minimum to avoid disrupting healing tissue.
  • Use sterile saline for wound cleansing up to 48 hours after surgery.
  • Use tap water for wound cleansing after 48 hours if the wound has separated or has been surgically opened to drain pus. Antiseptic agents are considered unnecessary for general wound cleansing but may be of value when irrigating an infected cavity wound.
  • Where periwound skin maceration occurs or is considered to be a risk (eg if an enteral fistula is present or if there are excessive exudate levels) consider skin barrier products.
  • Use an interactive dressing (ie one that promotes the wound healing process through the creation and maintenance of a local, warm, moist environment underneath the chosen dressing) for surgical wounds that are healing by secondary intention (NICE, 2008). The dressing should be left in place for as long as indicated. A continual assessment process ensures dressing changes are kept to a minimum.
  • Advise patients that they can shower safely 48 hours after surgery.
  • Do not use topical antimicrobial agents for surgical wounds that are healing by primary intention.
  • Refer the patient to wound care specialists if required for advice on appropriate dressings and care
  • Educate patients and carers and other healthcare professionals on optimal wound care, how to identify a wound that is failing to heal and who to contact if they are concerned about a possible SSI (NICE, 2008).


A postoperative dressing should be removed earlier than the recommended 48 hours if there are clear signs of complications, eg signs of excessive inflammation which may suggest infection, specific wound pain or pressure reported by the patient that is difficult to control with analgesia, evidence of wound separation (partial or full thickness dehiscence), excessive exudate, strikethrough or leakage, or evidence of periwound skin stripping or blisters (Bhattacharyya et al, 2005; Cosker at al 2005).

If an SSI is suspected (ie cellulitis or a collection of pus with systemic complications such as sepsis), antibiotics may need to be considered. Intervention and release of pus must be a priority. Antibiotic choice should be based on the most likely causative organisms and patient allergy status, with consideration given to local antibiotic resistance patterns and, when possible, the results of available microbiological culture and sensitivity tests from the patient as a whole.