Features of Dressings after Aseptic Surgeries

Basic tactics and emergency indications

Routine management of an aseptic postoperative wound implies minimal intervention. After the physician performs the dressing change the day after surgery, further changes of the aseptic dressing are not required if the regeneration process proceeds without deviations.

However, there are situations that require immediate wound inspection. Indications for urgent dressing change include:

• Development of hemorrhage.
• Appearance of local signs of inflammatory reaction: pronounced pain syndrome or soaking of the gauze with blood and purulent exudate.
• Onset of systemic inflammation symptoms, such as hyperthermia, tachycardia, and elevated white blood cell count in the blood (leukocytosis).

During each dressing change of wounds closed with primary or secondary sutures, the surgeon is obliged to carefully assess the condition of the tissues. First of all, local signs of inflammation (edema, skin erythema) are ruled out. The condition of the sutures themselves is also checked: whether cutting-in or cutting-through of the surgical threads has occurred.

Wound care and suture removal algorithm

Manipulations with a healed wound are possible only in the absence of inflammatory changes and good approximation of the wound edges. The suture line is treated with a 1% alcohol solution of brilliant green or ethyl alcohol. An aseptic gauze pad is placed on top and secured with an adhesive bandage, tubular bandage, or standard gauze bandage.

Safe suture removal technique:

1. The skin around the wound is pre-cleaned with a special mixture consisting of camphor spirit, diethyl ether, and a 0.5% ammonia solution.
2. The suture line itself is treated with a skin antiseptic.
3. The surgeon grasps the knot with forceps and slightly elevates it, shifting the skin until a white section of the thread appears from the suture canal (this part was inside the tissues and was not stained by the antiseptic).
4. Scissors are used to cut specifically this unstained section.
5. The thread is completely extracted with forceps.

Such a strict algorithm has an important rationale: it eliminates the pulling of the outer, potentially contaminated part of the thread through sterile tissues, thereby preventing infection of the suture canal. Finally, the forming scar is treated again with an antiseptic solution and covered with an aseptic dressing.

Maceration prevention and skin care

Special attention is required for the skin around the wound when there is a risk of its contact with aggressive biological fluids: intestinal contents, pancreatic juice, bile, urine, or pus (which is often encountered in fistulas, paraproctitis, or osteomyelitis). The pathogenesis of complications in this case is predictable: exposure to the discharge leads to maceration, followed by inflammation, ulcer formation, which become the entry gates for secondary infection.

Several strategies are used to protect the skin:

• Mechanical protection. Prevents fluid from directly contacting the skin. Obturators, pelotes, intestinal prostheses, and special obturating dressings are used.
• Enzyme inactivation. Maceration is frequently caused by aggressive enzymes (trypsin, chymotrypsin, pepsin). To neutralize them, dressings are moistened with meat broth, acidophilus milk, or minced meat is used, as well as irrigation via microirrigators.
• Creation of a barrier film. Ointments (zinc ointment, Lassar's paste), powders (calcined gypsum, talc, chalk), or film-forming agents (BF-6 glue, cerigel) are applied to the skin.

If the skin has already undergone maceration, tanning and drying solutions are used for its treatment: 5–10% tannin solution, 3–5% potassium permanganate solution, or 1% alcohol solution of methylthioninium chloride (methylene blue). In case of severe skin changes, an open (dressing-free) wound management method is adopted.

Class and exam questions

What else to study on this topic

• Specifics of primary and secondary suture placement
• Signs of suture cutting-through and cutting-in
• Mechanism of action of film-forming agents (cerigel, BF-6 glue)
• Technique of placement and use of microirrigators for wound irrigation

Other topics in "CHAPTER 10. GENERAL ISSUES IN TRAUMATOLOGY"

Prepared by WhiteCoat Pro faculty in accordance with the medical school curriculum. For educational purposes only.