Post-Operative Wound Management: Best Practices

Introduction:

In the community setting, effective management of post-operative wounds is crucial to mitigate the risk of complications such as surgical site infections and wound dehiscence. Given their pivotal role in the sub-acute management of post-operative wounds, general practitioners (GPs) must possess a comprehensive understanding of wound healing physiology and the fundamental principles of post-operative wound care. (1)

The successful healing of surgical wounds relies on a complex interplay of biological processes that occur in distinct phases. (2) Understanding these phases is essential for healthcare providers, including GPs, to facilitate optimal wound management and prevent adverse outcomes. Additionally, adherence to evidence-based wound care principles ensures timely healing and minimizes the risk of complications, ultimately promoting better patient outcomes. (3)

This review aims to elucidate the physiological mechanisms underpinning wound healing and provide practical insights into the principles of post-operative wound care. By equipping GPs with this knowledge, we aim to enhance their ability to deliver high-quality care in the community, thereby optimizing patient recovery and reducing the burden of post-operative complications.

Wound healing

The process of wound healing is traditionally divided into three distinct phases, regardless of the nature of the injury. These phases include the inflammatory phase, the proliferative phase, and the remodeling phase. (4)

During the inflammatory phase, which immediately follows the formation of the wound, the body initiates a natural response to the injury. This response involves the release of inflammatory mediators, leading to vasodilation and increased blood flow to the affected area. Phagocytic leucocytes, such as neutrophils and macrophages, are recruited to the site to help digest bacteria and remove dead tissue. The inflammatory phase is characterized by classic signs of inflammation, including redness, warmth, swelling, pain, and reduced function. (5)

In the proliferative phase, the wound begins to repair itself. Granulation tissue, composed of collagen and extracellular matrix, fills the wound cavity, and new blood vessels form through angiogenesis. As the wound fills, it gradually contracts, and epithelial tissue starts to cover the wound surface. Eventually, complete epithelialization occurs, with epithelial cells fully covering the wound.(6)

The final phase of wound healing is remodeling, which occurs once the wound is closed. During this phase, collagen fibers within the wound remodel and reorganize, restoring the wound's tensile strength.(7) Additionally, the wound undergoes devascularization, returning to its original state of blood supply.

Types of wound healing:

Wound healing can generally be categorized into two main types: primary healing and secondary healing.

Primary healing typically occurs in surgical wounds with minimal tissue loss, where the wound edges can be closely brought together (approximated). This allows for rapid epithelialization of the wound and results in minimal scarring.

On the other hand, secondary healing refers to the deliberate management of full-thickness wounds left open, either due to infection or the inability to satisfactorily bring the wound edges together. In secondary healing, the wound undergoes a natural process involving granulation tissue formation, gradual wound contraction, and slow epithelialization. Wounds healing by secondary intention often lead to larger scars compared to those healing by primary intention.

Post-operative wound care

Principles

Post-operative wound care is guided by fundamental principles aimed at promoting rapid and complication-free healing, while also ensuring optimal functional and aesthetic outcomes, regardless of the mechanism of wound healing.

For wounds intended to heal through primary intention, it is essential to achieve a precise approximation of the wound edges. During the initial stages of healing, the wound lacks significant tensile strength as collagen fiber remodeling has not yet taken place. Therefore, additional support in the form of sutures, staples, or tapes is necessary until complete remodeling and epithelialization of the wound occur. (8)

Recommendations for Preventing SSIs in the Post-operative Phase:

Dressing and Cleaning the Wound:

• Utilize an aseptic, non-touch technique when changing or removing dressings.
• Aim to keep the wound undisturbed for up to 48 hours post-surgery, using sterile saline for wound cleansing only if necessary during this period.
• Advise patients that they can safely shower 48 hours after surgery.
• If the wound has separated or been surgically opened to drain pus, use tap water for wound cleansing after 48 hours.
• Employ interactive dressings for surgical wound healing by secondary intention.
• Consult a tissue viability nurse or another healthcare professional with expertise in tissue viability for advice on appropriate dressings for surgical wound healing by secondary intention.

Antibiotic Treatment:

• Administer antibiotics if an SSI is suspected, either de novo or due to treatment failure.
• Choose antibiotics based on coverage of the most likely causative organisms, considering local resistance patterns and microbiological test results.

Debridement:

• Avoid using Eusol and gauze, dextranomer, or enzymatic treatments for debridement of surgical site infections.

Specialist Wound Care Services:

• Employ a structured approach to care and provide enhanced education to improve the management of surgical wounds.

Avoid the Following Practices to Reduce the Risk of SSIs:

• Use of topical antimicrobial agents for surgical wound healing by primary intention.
• Use of Eusol and gauze, moist cotton gauze, or mercuric antiseptic solutions for surgical wound healing by secondary intention.

In certain instances, it becomes necessary to cleanse a wound to eliminate debris such as devitalized tissue or excessive exudates, which could potentially impede the wound healing process. In such scenarios, it is recommended to perform gentle irrigation of the wound using warm sterile saline or water, as advised by NICE, employing a syringe instead of swabbing or bathing. This approach helps minimize trauma to the wound and ensures the maintenance of an optimal healing environment. (9)

It's important to note that wound cleansing is not required for the removal of exudates within normal limits. Furthermore, it's crucial to recognize that wound cleansing itself can interfere with the wound-healing process, particularly if performed excessively. Therefore, healthcare providers must exercise caution and adhere to appropriate guidelines when engaging in wound-cleansing practices.

Dressing:

The selection of appropriate dressings is crucial in post-operative wound management, aiming to foster an environment conducive to healing while protecting against contamination. Dressings should ideally maintain a moist wound environment, facilitate the removal of excessive exudate, and serve as a barrier against bacterial infiltration. Moreover, they should adhere to the skin without causing trauma during removal. Dressing choices should be individualized based on factors such as wound location, size, depth, and exudate level.

Various types of dressings cater to specific wound characteristics. Gauze dressings, for instance, are cost-effective and easy to apply, while also allowing for non-adherent properties to preserve moisture. Impregnated gauze dressings possess similar benefits but offer added antimicrobial properties. Alternatively, foam dressings are absorbent and suitable for wounds with moderate exudate, while films provide an occlusive barrier while permitting gas exchange. Hydrogels are ideal for minimal exudate absorption or wound rehydration, while silver-based dressings offer broad-spectrum antimicrobial coverage. (10)

Possible complications

Complications such as infections and wound dehiscence can arise post-operatively. Signs suggestive of infection, including fever, hematoma, or purulent discharge, necessitate active management. Antibiotics may be initiated based on suspected pathogens, guided by wound swabs and culture results. Debridement of non-viable tissue is crucial in addressing infections. For wound dehiscence, various management strategies are employed based on the severity, ranging from secondary intention closure to specialized devices and dressings. Notably, patient factors such as surgical type, medications, and comorbidities like diabetes or immunosuppression influence the risk of complications, necessitating comprehensive management strategies tailored to individual needs. (11)

Conclusion:

By equipping general practitioners with a fundamental understanding of wound healing physiology and the principles of post-operative wound care, this review aims to empower them to deliver high-quality care in the community setting. By appreciating the intricate phases of wound healing and adhering to evidence-based practices, such as appropriate wound cleansing, dressing selection, and infection management, GPs can play a pivotal role in optimizing patient recovery and minimizing the burden of postoperative complications.

Furthermore, recognizing the influence of patient-specific factors on wound healing outcomes underscores the importance of individualized care planning and collaboration with multidisciplinary teams when necessary. In conclusion, this review emphasizes the critical role of GPs in facilitating effective post-operative wound management, ultimately promoting better patient experiences and improved healthcare outcomes.

Reference:

1.            Gilmore MA. Phases of Wound healing. Dimens Oncol Nurs 1991;5:32–34. Search PubMed.

2.            Hunt TK, Hopf H, Hussain Z. Physiology of Wound healing. Adv Skin Wound Care 2000;13:6–11.

3.            Broughton G 2nd, Janis JE, Attinger CE. Wound healing: an overview. Plast Reconstr Surg 2006;117(7suppl):1–32eS.

4.            Wound Healing Phases - StatPearls (2021) Authors: Sharma, A., & Shetty, V.

5.            Velnar T, Bailey T, Smrkolj V. The wound healing process: an overview of the cellular and molecular mechanisms. J Int Med Res 2009;37:1528–42.

6.            Rivera AE, Spencer JM. Clinical aspects of full thickness wound healing. Clin Dermatol 2007;25:39–48.

7.            Witte MB, Barbul A. General principles of wound healing. Surg Clin North Am 1997;77:509–28.

8.            Heng MC. Wound healing in adult skin: aiming for perfect regeneration. Int J Dermatol. 2011 Sep;50(9):1058-66.

9.            Singhal H, Kaur K, Zammit C. Medscape reference: wound infection treatment and management. Available at emedicine.medscape.com/ article/188988 [Accessed 13 July 2013].

10.         Chronic Wound Healing: A Review of Current Management and Treatments (2021) Authors: Kumar, A., Sharma, S., & Rai, V.K. Journal: Journal of Young Pharmacists.

11.         Biomaterials for Wound Healing: A Review of Material-Related Complications (2019) Authors: Elsner, P., Bergmeister, H., & Hinterdorfer, G. Journal: Advanced Healthcare Materials.

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