Made EasyPostoperative incision management

Postoperative incision management

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

Dressing selection for wounds healing by primary intention
Dressing choice can significantly affect the outcome of postoperative wound healing and dressings should be chosen to optimise healing and minimise complications (eg select a dressing associated with a lower incidence of blistering) (Cosker et al, 2005).

Ideally dressings should maintain a moist wound environment conducive to optimal healing, while avoiding maceration or blistering of the surrounding skin (Figure 1). The choice of dressing depends on wound type, position and size/depth. Other points to consider are the range of dressing sizes available, conformability and acceptability to the patient. When placing a dressing careful consideration should be given to dressing orientation and tension and how patient movement postoperatively may affect this. This can be a significant problem when dressing wounds over joints where movement can result in skin damage and blistering due to shear (Leal and Kirby, 2008) (Figure 2).

Cosker et al (2005) set out the combination of features and properties of an ideal postoperative wound dressing that aims to provide good wound care and reduce the risk of postoperative complications.

Implementing NICE guidance on postoperative dressing selection

Where possible postoperative dressing choice should be aligned with NICE 2008 guidance or, where applicable, evidence-based guidelines. Low-adherent postoperative dressings or vapour-permeable polyurethane film dressings are usually used for uncomplicated surgical wounds with or without an incorporated, absorptive, central 'island' pad. However, dressing practice may differ and include the use of various types of wound dressing or coverings, such as non-woven dressings, or simple gauze held in place by tape. Increased rates of blistering are associated with tape methods (Bhattacharyya et al, 2005) and a significantly lower (p<0.001) incidence of blistering has been described when using a vapour-permeable polyurethane film dressing (Cosker at al, 2005).

Vapour-permeable film dressings offer a number of advantages over non-woven dressings (Roberts et al, 2011) in that they:

  • Provide a barrier to extrinsic contamination
  • Allow postoperative inspection of the periwound area (or inspection of the wound itself) without removal of the dressing in the first 24-48 hours
  • Allow easy removal as a result of low adhesion to the wound
  • Maintain a moist wound environment
  • Enable showering (ie are waterproof)
  • Can be left in place for up to 7 days.
  • Are conformable to body contours and tend to be more stretchy, allowing for postoperative movement/wearer comfort with reduced incidence of blistering.


Evidence base for following NICE guidance
A multicentre clinical study evaluated the performance of a vapour-permeable transparent film post-surgical dressing (OPSITETM Post-Op Visible, Smith & Nephew) in a typical clinical setting (O'Brien et al, 2010). Sixty-four patients who underwent clean surgery were treated with the film dressing. Duration of dressing wear, visibility through the dressing and ability to handle exudate were assessed and the product was rated in comparison to those normally used. Mean wear time was 4.5 days. Exudate management was rated very good or good at 96% of assessments. Visibility of the incision site was rated as very good or good at 72%, and as acceptable at 24% of assessments. Patient comfort was rated as very comfortable (63%) or comfortable (37%) at all assessments. Dressings were generally rated as satisfactory or exceeding expectations.

In a survey of postoperative dressing practice pre- and post-implementation of the 2008 NICE guidelines, Roberts et al (2011) reviewed 78 incisions before the change in practice, where the wounds were dressed with non-woven dressings, and 104 incisions where the wounds were dressed with vapour-permeable film dressings after the change in practice. They compared nine criteria, and in eight of these, film dressings were rated as being superior. The authors concluded that the vapour-permeable film dressing had a considerable advantage over non-woven dressings, which do not have a 'see-through' central absorbent pad. They suggested that as clinicians were able to clearly visualise the incision site while the dressing was in place, they were able to inspect the surgical site for evidence of complications. This offers a distinct advantage in detecting signs of wound complications and infection at an early stage, which can often be difficult because the wound is usually obscured by the dressing (Tustanowski, 2009).

Although Roberts et al (2011) reported an increase in the cost of film dressing per patient by £2.53 compared with non-woven dressings, they found that fewer dressing changes were needed when applying the film dressing, which had a positive impact on staff time and indirectly reduced overall costs.

Managing complex surgical wounds
Most postoperative wounds will usually heal within 7-14 days depending on the type of surgery.  Despite best practice, some surgical wounds fail to heal primarily or are deliberately left open to heal by secondary intention. Several tools exist to optimise healing by secondary intention. Wound bed preparation using the TIME concept, as first described by Shultz et al (2003) and its subsequent revisions (Dowsett and Ayello 2004; Leaper at al, 2012), is a practical tool for identifying barriers to healing and implementing a treatment plan to promote wound healing.

To improve the onward management of complex surgical wounds NICE (2008) suggests the onward referral to a tissue viability nurse (or another healthcare professional with tissue viability expertise) for advice on appropriate dressings for surgical wounds that either dehisce postoperatively or are electively left open to heal by secondary intention (eg pilonidal sinus). Negative pressure wound therapy may also be considered for more complex wounds such as abdominal wound dehiscence (WUWHS, 2008).

Summary
With the drive for ever shorter hospital stays and community care, staff education and reporting systems need to be in place so that clinicians are equipped to deal with postoperative complications and data reported so that real world practice can be monitored and improved. Choice of dressing can significantly affect the outcome of healing in patients with postoperative incisions. A postoperative wound dressing should not be arbitrary, nor based solely on the initial cost of the dressing (Cosker et al, 2005). Effective wound management will expedite and optimise healing, and reduce rates of complications that adversely affect patients' quality of life and healthcare costs.

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AUTHOR DETAILS
Milne J[1], Vowden P[2], Fumarola S[3], Leaper D[4]
1. Tissue Viability Nurse Specialist, South Tyneside NHS Foundation Trust
2. Vascular Surgeon, Bradford Teaching Hospitals
3. Senior Clinical Nurse Specialist, University Hospital of North Staffordshire
4. Visiting Professor, Cardiff UniversitySupported by Smith & Nephew


To cite this document:
Milne J, Vowden P, Fumarola S, Leaper D (2012) Postoperative incision management made easy. Wounds UK suppl. 8(4). Available from www.wounds-uk.com/made-easy