Wound Care and Healing in Perioperative Practice

WOUND CARE AND HEALING IN PERIOPERATIVE PRACTICE

1972 1972 WOUND CARE AND HEALING IN PERIOPERATIVE PRACTICE

STUDY GUIDE

Disclaimer AORN and its logo are registered trademarks of AORN, Inc. AORN does not endorse any commercial company’s products or services. Although all commercial products in this course are expected to conform to professional medical/nursing standards, inclusion in this course does not constitute a guarantee or endorsement by AORN of the quality or value of such products or of the claims made by the manufacturers. No responsibility is assumed by AORN, Inc, for any injury and/or damage to persons or property as a matter of product liability, negligence or otherwise, or from any use or operation of any standards, recommended practices, methods, products, instructions, or ideas contained in the material herein. Because of rapid advances in the healthcare sciences in particular, independent verification of diagnoses, medication dosages, and individualized care and treatment should be made. The material contained herein is not intended to be a substitute for the exercise of professional medical or nursing judgment. The content in this publication is provided on an “as is” basis. TO THE FULLEST EXTENT PERMITTED BY LAW, AORN, INC, DISCLAIMS ALL WARRANTIES, EITHER EXPRESS OR IMPLIED, STATUTORY OR OTHERWISE, INCLUDING BUT NOT LIMITED TO THE IMPLIED WARRANTIES OF MERCHANTABILITY, NON-INFRINGEMENT OF THIRD PARTIES’ RIGHTS, AND FITNESS FOR A PARTICULAR PURPOSE. This publication may be photocopied for noncommercial purposes of scientific use or educational advancement. The following credit line must appear on the front page of the photocopied document:

Reprinted with permission from The Association of periOperative Registered Nurses, Inc. Copyright 2014 “WOUND CARE AND HEALING IN PERIOPERATIVE PRACTICE.” All rights reserved by AORN, Inc. 2170 South Parker Road, Suite 400, Denver, CO 80231-5711 (800) 755-2676 www.aorn.org

Video produced by Cine-Med, Inc. 127 Main Street North, Woodbury, CT 06798 Tel (203) 263-0006 Fax (203) 263-4839 www.cine-med.com

2 WOUND CAREAND HEALINGIN PERIOPERATIVE PRACTICE

Wound Care and Healing in Perioperative Practice

TABLE OF CONTENTS

PURPOSE/GOAL ...... 4 OBJECTIVES...... 4 INTRODUCTION...... 5 TYPES OF WOUND CLOSURE ...... 5 PHASES OF WOUND HEALING ...... 6 FACTORS AFFECTING WOUND HEALING...... 7 SURGICAL SITE INFECTIONS ...... 8 Wound classification...... 9 Categories of SSIs ...... 10 PERIOPERATIVE WOUND TREATMENTS...... 11 COMPLEX WOUND CARE ...... 15 PEDIATRIC WOUND CARE...... 15 COLLABORATION...... 16 SUMMARY...... 16 POST-TEST...... 22 POST-TEST ANSWERS...... 23

3 WOUND CAREAND HEALINGIN PERIOPERATIVE PRACTICE

PURPOSE/GOAL The purpose of this study guide and accompanying video is to educate perioperative registered nurses (RNs) and other interested health care personnel about the physiology of wound healing and to review key concepts and practices for providing wound care in the perioperative setting.

OBJECTIVES After viewing the video and completing the study guide, the learner will be able to: 1. Define wound healing. 2. List types of wound closure. 3. Describe the physiology of wound healing. 4. Describe how wounds are classified. 5. Discuss factors that affect wound healing. 6. Categorize surgical site infections (SSI). 7. Describe practices to prevent SSIs. 8. Describe perioperative wound management practices and treatments.

4 WOUND CAREAND HEALINGIN PERIOPERATIVE PRACTICE

INTRODUCTION reaction. The wound also heals under optimal conditions – the Wounds are caused by surgical incision or excision; by trauma skin edges are approximated with skin staples or tape soon secondary to mechanical, thermal, or chemical destruction of after wounding; there is no tissue loss or dead space; drainage tissue; and by underlying acute or chronic disease processes.1 is minimal; and the wound is handled with strict adherence to Wound healing can be defined as the body’s process of re- aseptic technique. establishing continuity in the tissues by replacing dead and missing cellular structure and tissue layers with viable tissue.2 Wound management is an essential competency area for perioperative RNs who care for patients with a wide range of wounds every day in both inpatient and ambulatory settings. To optimize wound healing, these patients need treatment that is tailored to their unique medical and surgical histories and specific wound characteristics. Patient education also is crucial for successful wound healing because by necessity, much wound care occurs outside the hospital or ambulatory surgery facility. To provide quality wound management, perioperative RNs and other clinical personnel need to fully understand the Closure by secondary intention. Typically, this type of physiology of wound healing, risk factors for impaired and closure involves chronic wounds, contaminated wounds, and 1 delayed healing, and best practices and current products that wounds characterized by marked tissue loss. The skin edges support healing. In addition, perioperative RNs should be typically cannot be approximated, and the wound is left open competent in classifying and documenting surgical wounds in and allowed to heal from the inside to the outside surface. This accordance with the Centers for Disease Control and practice enables cleaning and dressing of the healing wound. Prevention’s (CDC) Surgical Wound Classification system.3 The tissue gap gradually fills in with granulation tissue made up of fibroblasts and capillaries and subsequently contracts to The field of wound management has become increasingly reduce the size of the wound. The healing process takes longer complex as emerging research reveals new information about and involves substantially more scar tissue than closure by wound healing and as new wound care products enter the primary intention. market. This study guide and the accompanying video will review wound care and wound healing based on current research and expert clinical recommendations.

TYPES OF WOUND CLOSURE There are three main types of wound closure.1

Delayed primary closure (tertiary closure). In this type of closure, the wound is closed three or more days after injury or surgery.1 Clinicians may elect delayed primary closure for markedly contaminated wounds, such as wounds incurred in war zones, ileostomy closure, and peritonitis, or if a patient is hemodynamically or otherwise unstable.1,4 Delayed primary Closure by primary intention. This type of closure occurs closure typically requires a primary and secondary suture line, when the clinician creates an operative wound in an aseptic such as the use of retention sutures, and clinicians use delayed environment with minimal destruction of tissue and tissue primary closure surgery to reduce the risk of surgical site

5 WOUND CAREAND HEALINGIN PERIOPERATIVE PRACTICE infections (SSI). In a meta-analysis of eight randomized triggers platelet clumping to help fill the wound and slow studies of delayed primary versus primary closure, however, bleeding. Vasoconstriction is followed by histamine-induced researchers found flaws in design and outcomes assessment.4 vasodilation, which enables platelets and other blood cells to The researchers concluded that the trials included in the meta- enter the wound. Fibrinogen is cleaved into fibrin, which in analysis had failed to provide definitive evidence that delayed turn enters the wound to form an initial coagulum, or clot. primary closure prevents SSI. Additionally, in a Cochrane Thrombocytes (platelets) release growth factors, and chemo- systematic review, the researchers concluded that there was a attractants recruit neutrophils and macrophages, which release lack of robust evidence to guide clinical decision-making cytokines (extracellular signal proteins or peptides) such as regarding when to close traumatic wounds.5 In a retrospective interleukins that help direct and orchestrate the healing study of fractures, researchers identified a significantly higher process. These events induce the first phase of wound healing, rate of deep infections in delayed primary closures (17.8%) the inflammatory phase.1 compared with primary closure cases (4.1%; P = 0.0001).6 The researchers concluded that immediate closure of carefully selected grade I, II, and IIIa open fractures was safe and was associated with a lower infection rate than delayed primary closure.

PHASES OF WOUND HEALING The physiology of wound healing is highly complex and dynamic, and research continues to reveal new information about the cellular, humoral, and molecular processes involved. The literature does not concur on the number or nomenclature of stages involved in wound healing. For the purposes of this study guide, however, we will define three main phases of wound healing as: inflammation, proliferation, and 1 1 The inflammatory phase usually lasts one to four days. remodeling. During this phase, plasma, neutrophils, and macrophages leak into the wound, causing the classic signs of inflammation: redness, swelling, heat, and pain. An exudate from the wound may also be observed. Neutrophils predominate during the early inflammatory phase, while macrophages predominate later.2 Macrophages secrete numerous factors that trigger the multiplication of smooth muscle and endothelial cells.

The cellular- and tissue-level events of wound healing often overlap or occur simultaneously. The first and immediate physiologic response to wounding, however, involves the mechanism of hemostasis. Immediately after injury, blood vessels at the wound site undergo vasoconstriction to minimize blood loss. Platelets activate the intrinsic clotting (or coagulation) pathway, and injured tissue activates the Leukocytes phagocytize bacteria and dead or damaged tissue, extrinsic clotting pathway.2 Platelets adhere to the damaged helping to clean and debride the wound and prevent infection. endothelium and release adenosine diphosphate (ADP), which The proliferative (or granulation) phase is characterized by

6 WOUND CAREAND HEALINGIN PERIOPERATIVE PRACTICE the production of granulation tissue, neovascularization, and potential for complications of the wound healing re-epithelialization.1 During proliferation, granulation tissue process. composed of connective tissue and new capillaries fills the • Psychological stress increases blood glucose levels wound gap. Myofibroblasts (connective tissue cells) attach to which may negatively affect the healing process. collagen and contract, pulling the edges of the wound together • Smoking increases the risk for infections, wound to reduce scar tissue. Epidermal growth factors induce rupture, anastomotic leakage, and wound and flap epithelial cells to migrate from the edges of the wound across necrosis and decreases wound tensile strength. the bed of granulation tissue, covering and closing the defect with a thin tissue layer. This protective barrier helps prevent • Alcohol consumption increases susceptibility to fluid and electrolyte loss and reduces the risk of infection. infection and impairs angiogenesis (eg, growth of new blood vessels). • Malnutrition: impairs wound healing as a result of inadequate intake of dietary protein. • Systemic steroid medications cause wounds to heal with incomplete granulation tissue and reduced wound contraction.7 • Chemotherapeutic medication delays cell migration into the wound, decreases early wound matrix formation, lowers collagen production, impairs proliferation of fibroblasts, and inhibits wound contraction.8 • Chronic diseases and immunocompromised conditions (eg, diabetes) delay wound healing. Diabetes mellitus is one of the most prevalent patient-specific The third phase of wound healing is remodeling, which risk factors for delayed wound healing or non-healing. This begins approximately two to four weeks after the initial wound 1,7 disease affects an estimated 8.3% of the US population and and may continue for up to one year or longer. During this about 27% of US adults aged 65 years and older.9 Diabetes phase, granulation gradually stops and apoptosis mellitus is caused by insufficient levels or response to the (programmed cell death) causes the recession of existing hormone insulin and is characterized by high blood glucose granulation tissue. Wound contraction continues, and scar levels. Diabetes is associated with serious complications such tissue gradually re-organizes into an avascular, acellular as blindness, kidney failure, heart and blood vessel disease, matrix primarily composed of parallel bundles of collagen. stroke, and premature death.9,10 It is the seventh leading cause This process improves the tensile strength of the wound, of death in the United States.9 although scar tissue has only about 80% of the strength of unwounded tissue.7

FACTORS AFFECTING WOUND HEALING Numerous patient-specific and perioperative risk factors affect the rate and outcome of wound healing. Patient-specific risk factors for delayed wound healing include the following:7,8 • Aging slows the healing process, especially in males, even when they do not have comorbid conditions. • Decreased oxygen levels decrease oxygen tension to the wound and compromises its tensile strength. • Obesity places excess tension on wound edges and is Diabetic foot ulcers affect an estimated 15% of patients with associated with local hypoperfusion, contaminated diabetes mellitus and are the leading cause of non-traumatic skin folds, and pressure injuries which increase the lower limb amputation.8,11 Factors contributing to non-healing

7 WOUND CAREAND HEALINGIN PERIOPERATIVE PRACTICE foot ulcers include defective T-cell immunity; impaired SURGICAL SITE INFECTIONS leukocyte chemotaxis, phagocytosis, and bactericidal activity; diminished peripheral circulation; decreased local angiogenesis; and neuropathy. The key diagnostic test for diabetes is a fasting glucose level. A fasting glucose level of 70 to 100 mg/dL is considered normal.12 Patients with levels between 100-125 mg/dL have impaired fasting glucose, a type of prediabetes. Impaired fasting blood glucose is considered a risk factor for type 2 diabetes mellitus and its complications. Diabetes is diagnosed in persons with fasting blood glucose levels that are 126 mg/dL or higher. An impaired glucose tolerance (IGT), a 2- hour post-meal glucose level between 140 and 199 mg/dL, is also considered a risk category for diabetes mellitus. The most common cause of impaired wound healing in Patients with type 1 diabetes mellitus have an absolute surgical patients is a surgical site infection (SSI). Left deficiency of insulin because of insufficient production of this 13 untreated, SSIs can progress and cause serious complications hormone by pancreatic beta cells. In contrast, patients with including delayed healing, nonhealing, systemic infection, and type 2 diabetes mellitus have a condition known as insulin even death. Surgical site infections are also associated with resistance, which occurs when insulin no longer acts normally an increased risk for revision surgery, antibiotic therapy, and on target tissues and compensatory insulin secretory response prolonged hospital stays, which can adversely affect patients’ is inadequate. Additional causes of diabetes include pregnancy quality of life and add substantially to health care costs.23 The (ie, gestational diabetes), genetic defects, surgery, and drug- increasing prevalence in healthcare settings of antibiotic- induced hyperglycemia. resistant bacterial pathogens, such as methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Perioperative patients with diabetes mellitus are at risk for 24 numerous potential complications. Degeneration of small enterococci (VRE) have increased the need to prevent SSIs. blood vessels can occur in many organs, leading to a range of These resistant pathogens are associated with poor outcomes medical problems. Other complications of diabetes mellitus and major increases in health care costs. include delayed wound healing, hyper- or hypoglycemia, Diverse factors affect the risk of SSIs, including the:23 hypertension, surgery-related pressure ulcers, and increased risk of SSI or other infections.14-16 • patient’s underlying susceptibility to infection; • severity of the primary disease or condition and number Glucose is a major source of energy for most cells of the body, and severity of comorbid conditions; including the brain. Because stress increases blood glucose levels, both diabetic and non-diabetic patients may have very • the correct type, dose, timing, and route of antimicrobial high blood sugars in the perioperative period, and clinicians prophylaxis administered when indicated; should perform frequent blood glucose monitoring.17 • exposure of the incision to environmental contaminants or the patient’s own microflora; Perioperative factors also affect wound healing. For example, many surgical patients are at risk for unplanned • adherence to sterile technique; and hypothermia in the relatively cool environment of the OR • implemented surgical techniques that minimize tissue suite. Hypothermia causes peripheral vasoconstriction, which damage, eliminate dead space, and reduce the amount can compromise wound healing.18 Perioperative RNs should of time the operative wound is exposed to air. implement measures that assist the patient in maintaining normothermia during operative procedures.19,20 Other Prevention of SSIs examples of perioperative factors that affect wound healing Before an operative or other invasive procedure, patients may include adherence to sterile technique and limiting the be instructed to follow a series of essential practices to reduce duration of surgery and the amount of traffic and number of the risk of SSIs. Clinicians often instruct patients to shower persons in the OR.21,22 with soap or with an antiseptic solution before the procedure to cleanse the skin at the incision site. This practice helps

8 WOUND CAREAND HEALINGIN PERIOPERATIVE PRACTICE reduce the microbial load at the site, thus decreasing the risk the surgical procedure, perioperative RNs should determine of infection.25 and document the surgical wound classification according to the CDC Surgical Wound Classification system.3,30 When the Patients also may undergo a complete preoperative history and operative procedure is completed, the surgical incision should physical assessment, which may include laboratory and other be protected with sterile dressings that remain over the site for diagnostic testing. This assessment and testing can identify 24-48 hours postoperatively.32 abnormal laboratory values and other indicators of underlying conditions that could increase the risk of postoperative Wound classification infection. The CDC Surgical Wound Classification system is used to classify wounds based on the likelihood and degree of wound contamination at the time of surgery. It is important to note that if there is no wound, there is no wound classification (for example, in a closed reduction of a fracture, or examination and manipulation of a joint under anesthesia). The four wound classifications are:3,30,32 • Class 1 (Clean) • Class 2 (Clean-contaminated) • Class 3 (Contaminated) • Class 4 (Dirty or Infected) On the day of surgery, the procedure room should be prepared by perioperative personnel following AORN Class 1- Clean wounds are uninfected operative recommendations for environmental cleaning and using sterile wounds in which no inflammation is encountered, and technique when opening instrument packs, drapes, and other the respiratory, alimentary, genital, or uninfected supplies.22,26 Additionally, the perioperative team should urinary tracts are not entered. In addition, class 1 follow recommended hand hygiene protocols.27 If a surgical wounds are primarily closed, and, if necessary, are site requires hair removal, clipping is recommended, rather drained with closed drainage. Operative incisional than shaving, to reduce the risk of opening the epidermis at wounds that follow non-penetrating (blunt) trauma the surgical site and increasing susceptibility to infection.21 should be included in this category if they meet these criteria. An example of a Class 1/clean procedure is a The perioperative team’s coordinated efforts to prevent SSIs total hip replacement. should continue in the operative suite. Perioperative RNs should perform preoperative skin antisepsis of the surgical site Class 2- Clean-contaminated wounds are operative to remove soil and transient microorganisms from the skin, incisions in which the respiratory, alimentary, genital, reduce the microbial count to sub-pathogenic levels, and or urinary tracts are entered under controlled inhibit growth of microorganisms.21 All team members should conditions without evidence of infection or practice strict adherence to sterile technique, monitor for contamination. Examples of Class 2/clean- breaks in sterile technique, and be prepared to immediately contaminated procedures include operative communicate about and correct breaks if they occur.22 The procedures where the biliary tract, appendix, vagina, team should also wear correct surgical attire to reduce the bladder, and oropharynx are entered, provided that likelihood of lint and other particles contaminating the there is no evidence of infection or major break in incision.28 The RN circulator should monitor traffic and the surgical technique, such as spillage from the number of persons in the OR should be kept to a minimum to gastrointestinal tract. reduce air currents that could contaminate the surgical site.22,29 Class 3- Contaminated wounds include open, fresh, The team should monitor the patient’s physiological status accidental wounds, wounds associated with operative carefully and take steps to promote normothermia and procedures in which there was a major break in sterile sufficient oxygenation.19 Additionally, the surgeon should technique, procedures where there was gross spillage practice good surgical technique by working carefully and from the gastrointestinal tract, or incisions in which efficiently to reduce the amount of trauma to the tissues and acute, nonpurulent inflammation is encountered. An the time that the open incision is exposed to air. At the end of example of a Class 3/contaminated procedure is an

9 WOUND CAREAND HEALINGIN PERIOPERATIVE PRACTICE

operative procedure performed with unsterile Surgical Wound Classification Decision Tree is designed to instruments. enable perioperative nurses to accurately classify surgical wounds based on the CDC surgical wound classification Class 4- Dirty or infected wounds are old traumatic 33 wounds with retained devitalized tissue, existing system. The decision tree asks a series of yes or no questions clinical infection (e.g. purulence), or perforated that enable perioperative nurses to accurately classify wounds viscera. The definition suggests that the organisms based on the descriptions in the CDC classification system. causing postoperative infection were present in the When using the decision tree, it is important for the operative field before the operation. An example of a perioperative RN to keep in mind that incisions from similar Class 4-Dirty, infected procedure is a surgical incision operative procedures might be classified differently based on and drainage of an abscess. factors such as whether the genitourinary tract was entered; whether infection was encountered during the operative These surgical wound classifications reflect the likelihood that procedure; or other considerations related to surgical wound wound infection will occur. Wound classification allows for 34 classification. comparison of wound infection rates associated with different surgical techniques, surgeons, and facilities.30 This Patients, support persons, and home care providers usually are comparison is not only useful for research, but may also serve responsible for the majority of wound care after operative to alert infection prevention personnel regarding wounds at procedures. Therefore, postoperatively, patient and caregiver increased risk for infection, which could enable health care education is very important. Perioperative RNs need to providers to implement surveillance and preventative educate patients and their support person about warning signs measures.32 of infection such as redness, marked swelling, fever, and purulent discharge or foul odor at the incision site. Patients and support persons should also be instructed verbally regarding hand washing techniques, dressing changes, and patient restrictions on bathing and showering. Sending written directions home with the patient or support person helps to reinforce these important messages. Perioperative RNs are positioned to serve as leaders in SSI prevention within many health care organizations. However, studies point to the need for improved patient education efforts in this area. In a survey of surgical patients, 26% of respondents thought that education regarding SSIs could be improved, 16% could not remember discussing SSI risks and prevention with any health care worker, and only 60% recalled receiving written information about SSIs from the health care facility.35

CATEGORIES OF SSIs SSIs are categorized by the affected tissues.32,36

Each surgical wound should be evaluated and classified independently and documented by the perioperative RN in the patient record after the operative procedure. The AORN

10 WOUND CAREAND HEALINGIN PERIOPERATIVE PRACTICE

Superficial incisional SSIs occur within 30 days after the • Clinicians have cultured organisms from an operative procedure, involve only the skin and subcutaneous aseptically obtained sample of fluid or tissue in the tissue of the incision, and have at least one of the following:36 organ or organ space; • Diagnosis of superficial incisional SSI by the • Detectable abscess or other sign of infection involving physician or attending surgeon the organ or organ space is present, or • Purulent drainage from the incision site • The surgeon or attending physician has diagnosed an organ or organ space SSI. • Organisms cultured aseptically from tissue or fluid obtained from the superficial incision • Pain or tenderness, localized swelling, redness, or heat at the surgical site If a superficial incisional infection is present, the surgeon deliberately opens the superficial incision to allow drainage, unless the incision is culture-negative.

PERIOPERATIVE WOUND TREATMENTS Topical Hemostatic Products. Wound healing begins with hemostasis. Many methods are used to stop bleeding during surgery and may include applying pressure, suturing or using electrocautery on bleeding vessels or tissue, and administering blood and blood products. When traditional methods are ineffective or not feasible to attain hemostasis, surgeons may In deep incisional SSIs, infection occurs within 30 or 90 days choose to apply a topical hemostatic product to help control of the operative procedure, the infection involves deep soft bleeding.37 These products can also potentially reduce total tissues such as fascial and muscle layers of the incision, and procedure time and promote faster patient recovery.38 must meet one of the following criteria:36 Passive or mechanical hemostatic agents are applied at the • The attending surgeon or physician has diagnosed the bleeding site and rely on the normal clotting cascade to work. infection as a deep incisional SSI. They provide a barrier to stop blood flow and a surface that 39 • There is purulent drainage from deep tissues but not enables blood to clot more rapidly. Examples of passive the organ/space component of the surgical site. hemostatic agents include collagens (AviteneTM sheet and ® ® ® • A detectable abscess is present and/or the patient flour, UltrafoamTM, Helistat , Helitene , and Instat ), cellulose (Surgicel®, Surgicel Fibrillar®, and Nu-Knit®), experiences spontaneous dehiscence, or the surgeon ® deliberately opens the surgical site when the patient gelatins (porcine gelatins include Gelfoam sponge and powder, and Surgifoam® sponge and powder), and has fever, localized pain, and/or tenderness (unless the ® ® ® site is culture-negative). polysaccharide spheres (Arista , Hemostase , and Vitasure ). Organ/space SSIs are defined as infection within 30 or 90 Active hemostatic agents contain thrombin and products days of the operation.36 Additionally, the infection must mixed with thrombin. They act at the end of the coagulation 38 involve a part of the anatomy, other than the incision, that was cascade to enhance clotting at the bleeding site. Active opened or manipulated during the operation and must meet at hemostatic agents made from human and bovine sources, and least one of the following criteria: recombinant thrombins are licensed for clinical use in the United States. Specific products available in the United States • There is purulent drainage from a drain placed into the include Thrombin, Topical, Bovine Origin (Thrombin-JMI®); organ or organ space; Thrombin, Topical, Human (EvithromTM OmrixTM Bio-

11 WOUND CAREAND HEALINGIN PERIOPERATIVE PRACTICE

are central to wound healing.1 Both human and recombinant growth factors are used in wound care and management.1 Platelet-derived growth factors are extracted from 50 to 200 mL of venous blood.1 The platelets are separated out and activated with thrombin to create a gel. The gel is applied to the clean wound bed.

pharmaceuticals, Ltd); and Thrombin, Topical, Recombinant (RecothromTM ZymoGenetics, Inc). Flowables are combinations of passive and active hemostatic agents that mechanically obstruct the flow of blood and actively convert fibrinogen in blood into fibrin at the site of bleeding. Because flowables do not contain fibrinogen, they require direct contact with blood to provide the fibrinogen for Irrigation. This is an important practice for cleaning and conversion into fibrin.39 Flowables may be made of bovine hydrating wounds, preparing the wound bed for further gelatin and pooled human thrombin (Floseal®), or porcine treatment, and allowing care providers to better visualize the gelatin with or without thrombin (Surgiflo®). wound.43 Irrigating a wound through a continuous or pulsed release of fluid to the wound surface serves to flush Fibrin sealants promote blood clotting by supplementing the contaminants and nonviable tissue from the wound. Sufficient patient’s own clotting factors, speeding up local coagulation, pressure and volume of irrigation fluid are needed to achieve and catalyzing the activation and aggregation of platelets and 40 good results, but care also must be taken to minimize damage formation of fibrin. The fibrin in these products is derived to healthy tissue. One study found that excessive irrigation from pooled or individual human plasma, equine or bovine 40 pressure during acute orthopedic surgery was associated with collagen, and bovine thrombin. Synthetic sealants are also 40 visibly damaged bone, bacterial contamination of the licensed for clinical use. They are made from polyethylene medullary cavity, and delayed fracture healing.44 The volume glycol polymers and cyanoacrylates. Specific products include of irrigating solution should be adjusted based on the size of Tisseel®, Tachosil®, Vitagel®, Coseal®, Duraseal®, Bioglue®, the wound and the extent of contamination, and the edges of and OmnexTM. the wound may need to be separated to fully irrigate the tissue. It is important to keep in mind that patients can have adverse After irrigation, the wound should be examined, and reactions to topical hemostatic agents as a result of allergies additional irrigation should be performed if necessary to flush or previous sensitization.41 The most immediate risk is remaining contaminants and dead tissue from the site. Some anaphylaxis resulting from allergies or previous sensitization options for irrigation solutions include normal saline, sterile to immunogenic substances. Bloodborne pathogen infection water, and commercial wound cleansers. is also a risk when patients are exposed to products derived from blood, although this risk has decreased with improved donor screening programs.41,42 It is important to follow the manufacturer’s written directions for preparing the topical hemostatic product for patient use or delivering it to the sterile field. Growth factors. Growth factors are naturally occurring peptides and cytokines, that are sometimes used in wound care.1 These soluble proteins help initiate and direct the mitosis (cellular division) of fibroblasts, smooth muscle cells, epidermal cells, and vascular endothelial cells, all of which

12 WOUND CAREAND HEALINGIN PERIOPERATIVE PRACTICE

Incision and drainage. This is performed to release pus from an abscess.1 To perform incision and drainage, the clinician antiseptically prepares the skin and uses a sterile instrument to make a small incision. He or she deepens the incision until pus is observed, and then explores and enlarges the incision with a surgical instrument. Specimens are often taken for culture and the surgeon can use a gloved finger to break up any loculations (i.e., sealed pockets of pus). The surgeon enlarges the wound to ensure sufficient drainage, and may loosely pack it with gauze or place a drain. After treatment, the wound is often left open to heal by granulation. In some cases, incision and drainage are very painful, and may be 1 pressure wound therapy device, which is a closed, sealed performed under general anesthesia. system, promotes evacuation of excess fluid via suction tubes into a liquid waste collector.46 This therapeutic modality has been used for many types of lesions including open abdominal wounds, skin graft donor sites, open fractures, acute burns, pressure ulcers, trauma- induced wounds, diabetic foot ulcers, split-thickness skin grafts, sternal wounds, and in type 1 (i.e., clean) wounds in obese patients.46 Furthermore, indications for the use of negative pressure wound therapy are increasing as more negative pressure wound therapy systems enter the market. Negative pressure wound therapy can potentially reduce the risk of SSI and expedite healing.47,48 Potential adverse effects 49 Debridement. This is performed to remove dead and of this modality include pain and skin damage. Patients have devitalized tissue from a wound and facilitates wound healing also reported concerns about decreased mobility, sleep and closure.1,45 If nonviable tissue is not debrided and remains disturbances, and the noise created by these systems. To in the wound, it can impede healing and serve as an infection prevent and minimize adverse outcomes, negative pressure nidus (i.e., a place for infection to begin).1 wound therapy devices should be used by personnel with verified competency in their use. In addition, it is important Methods of debridement include mechanical methods such as not to cut sponges directly over the wound, to carefully pressure irrigation; surgical debridement with a scalpel or monitor the number and sizes of sponges placed in the wound, scissors; application of debriding agents with enzymatic action follow the health care organization’s protocols for patient that contain collagenase; and biologic methods such as sterile 1 assessments, and follow the manufacturer’s instructions for maggot debridement therapy. Each approach has benefits and correct pressure ranges. risks; for example, surgical debridement can result in bacteremia as bacteria at the wound site enter the bloodstream. Wounds that lack intrinsic, extrinsic, or mechanical damage may be closed immediately after debridement.45 If the debrided wound is not immediately closed and is left to heal by secondary intention, follow-up assessment is required. Debrided wounds also may require secondary debridement to optimize healing.45 Negative pressure wound therapy. This therapy, which emerged in the late 1990s, is another technique that can be used to facilitate wound healing. In negative pressure wound therapy, the wound is filled with one or more sterile sponges 1 Skin substitutes. These materials are created by placing and sealed with occlusive dressing material. The negative human cells onto matrixes of collagen or synthetic materials.1

13 WOUND CAREAND HEALINGIN PERIOPERATIVE PRACTICE

The human cells then grow and divide, secreting growth factors that trigger cellular migration into the wound field and in turn promote epithelialization and revascularization.1 Because of these characteristics, skin substitutes can be useful as a temporary bridge to permanent closure of burns and other complex wounds, such as chronic ulcers. Skin substitutes also may be used to cover skin graft donor sites. Both biological and synthetic skin substitutes are available. Examples of specific skin substitute products include Biobrane®, Dermagraft®, TransCyte®, Apligraf®, AlloDerm®, Oasis®, and Integra®. Different products are approved for different uses, such as diabetic foot ulcers or superficial burns. Skin substitutes can provide relatively long-term wound coverage and also have the advantage of being compatible with Dressings. These help protect the site of a wound from autologous tissue, readily commercially available, and infection or further injury.1 Dressings have several functions, associated with fewer risks of adverse effects involving the including absorption of drainage, providing an environment 1 donor area. that promotes healing, and provision of a mechanism to apply Drains. Drains provide an exit for serum, blood, lymph, medications. Dressings also are used to support, splint, and intestinal secretions, bile, and pus from the operative site.1 immobilize injuries, and are used in some cases for aesthetic They may also be used to prevent deep wound infections. reasons. Dressings come in many options including: Drains are most commonly made from latex, polyvinyl The surgeon places a primary dressing directly over the chloride (PVC), or silicone. It is important to ensure that wound or in the wound and these are usually made of a patients are not latex-sensitive before placing latex drains. The nonadherent material. A secondary dressing is placed over surgeon usually inserts a drain at the time of surgery through the primary dressing to absorb excessive drainage and provide a separate small incision called a stab wound near the primary hemostasis. The secondary dressing is bulkier than the incision. In some cases, he or she may suture the drain to the primary dressing and helps protect the wound. skin. Numerous types of dressing materials are available, including Simple drains permit free flow through the drain onto a • cotton mesh gauze, nonadherent dressings (e.g., dressing. An example is a Penrose drain in which fluid ® ® ® flows along the outside of the drain onto a dressing by Telfa , Adaptic , scarlet red gauze, Xeroform ); ® ® means of gravity and capillary action. A T-tube drain • transparent films (e.g., Bioclusive , Opsite , is also a simple drain.1 Tegaderm™); ® ® Closed drainage systems are airtight circuits that help • hydrocolloid dressings (e.g., Comfeel , Sorbex , ® prevent environmental contamination of the drainage DuoDERM , Tegsorb™); site. They are portable, self-contained, closed wound • hydrogel (e.g., Carrasyn®, SoloSite Gel®, NU-GEL®, suction systems, and use suction to pull drainage from Curagel™, Vigilon®); 1 the wound into a collection unit. Jackson-Pratt and ® ® ® • alginates (e.g., AlgiDerm , Algosteril , Curasorb™, Hemovac systems are closed drainage systems. SeaSorb®, Kaltostat®, Sorbsan™); Chest drainage systems are designed to drain air, blood, • foam (e.g., Lyofoam®, KendallTM Foam, Allevyn™, pus, or lymph from the pleural cavity; prevent fluid Flexzan™, BioPatch™, VigiFOAM®); and air from re-entering the pleural cavity; and enable • silicone (e.g., Cica-Care® Silicone Gel Sheeting, the patient’s lungs to re-expand and restore normal ® ® negative intrapleural pressure.1 A water-seal container Mepiform , Oleeva ); is connected to the chest tube to allow one-way • collagen (e.g., FibracolTM Plus, Promogran™, ® ® ® movement of liquid and air out of the pleural cavity. Cellerate RX™, Biostep , Catrix , ColActive , ® ® Changing or emptying the container should be Collieva , Biopad ); and accomplished according to the manufacturer’s • composites (Alldress®, Primapore®, OpSite™ Post- instructions and the health care organization’s policy Op, Dermasil™). and procedure.

14 WOUND CAREAND HEALINGIN PERIOPERATIVE PRACTICE

Despite this variety of available dressing materials, current prevent edema. research does not definitively support the use of one type of Patient education is an important aspect of nursing care for dressing over another. In a meta-analysis of 16 controlled trials patients with casts, splints, or braces. Perioperative RNs involving 2,594 patients, researchers found no evidence that should instruct patients not to remove casts or splints unless any one type of dressing significantly reduced the risk of SSIs 1 they are told to do so by a physician. Patients also need to or reduced the risk of pain or scarring compared with other understand whether and in what manner bathing or showering types.50 However, the researchers also concluded that results is permitted; and to communicate with their health care were unclear or at high risk of bias. provider if they experience signs of impaired circulation and Postoperative care for some operative procedures includes nerve compression of the affected extremity (e.g., pain, lack sterile dressing changes.1 Dressing changes that cause the of easily detectable pulse, pallor, pressure, poikilothermia55 patient substantial pain may require anesthesia. Examples [inability to maintain a constant core temperature], tingling or include dressing changes in patients who have extensive burn burning, inability to move muscles around the cast); and signs injuries or who have traumatic abdominal wounds that were and symptoms of infection (e.g., drainage or a foul odor near closed by tertiary intention with placement of a negative the cast’s edges).56 pressure wound therapy device. Such patients could require Patients should also be instructed to practice good skin care several surgeries to change the dressings as the wound heals. around the cast and not to insert objects (e.g., coat hangers), Collodion is a topical, flexible occlusive dressing for use on creams, lotions, or powder under the cast. surgical incisions.51 Before using collodion, the care provider should confirm that patients are not allergic to ether, alcohol, COMPLEX WOUND CARE or cellulose-based products. Because collodion is a mixture The term complex wound is used to refer to wounds that are of ethyl alcohol (22%) and ether (67%), it is EXTREMELY challenging and costly to treat and require individualized, FLAMMABLE. Lasers and electrosurgery devices should not coordinated approaches to wound management.57 This be activated in the presence of flammable agents such as category of wounds includes ostomies, chronic venous ulcers, collodion until the agents are dry and the vapors have ulcers associated with vasculitis or diabetic neuropathy, deep dissipated.52,53 Care providers should follow the pressure sores, traumatic or necrotizing wounds, burns, post- manufacturer’s instructions for use, be familiar with the Safety radiation wounds, and complicated surgical wounds.55 Data Sheets about the product, and follow the facility’s 54 Complex wounds may require an individualized treatment policies regarding storage and use of collodion. approach using advanced wound care therapies developed by Perioperative personnel should follow local and state fire a multidisciplinary team. Surgery is sometimes indicated for regulations regarding the storage of flammable liquids such complex wounds. Debridement may be performed to remove as alcohol-based skin antiseptic solutions, hand sanitizers, nonviable tissue, while grafts or tissue flaps may be used to alcohol, acetone, and collodion and the location of 58 29 reconstruct lost skin and subcutaneous tissue. Other dispensers. therapies for complex wounds include the use of biological Casts, splints, and braces are used to help protect and skin equivalents and negative pressure wound therapy.59 Some immobilize extremities during wound healing.1 For example, patients with complex wounds also benefit from nutritional a femoral cast brace might be placed after orthopedic surgery and behavioral counseling to help them understand and cope to repair a femoral shaft fracture, or a short arm cast might be with the need for ongoing care at home. placed to immobilize and protect a radial fracture while it heals. Splints or casts are made from plaster or fiberglass. PEDIATRIC WOUND CARE Padding is placed between the skin and the splint or cast to Many of the principles of adult wound care also apply to protect the skin and prevent skin burns or damage from plaster infants and children. However, some aspects of wound care casting materials that produce heat as they harden. must be tailored because of physiological and developmental Before and after an operative procedure in which a cast, splint, differences between children and adults. For example, infants or brace is placed, to the perioperative RN should assess and and young children may not be able to verbally express pain, which can increase the risk of pressure sores or friction document the patient’s circulation, motion, and sensation 60 (CMS check) in the affected extremity. After surgery, the blisters. Additionally, the skin of infants is more susceptible to epidermal tears and blisters, because their epidermis is only immobilized limb is usually elevated with pillows or foam 60 padding devices which promotes venous return and helps loosely attached to the underlying dermis. Children’s skin

15 WOUND CAREAND HEALINGIN PERIOPERATIVE PRACTICE

consistently follow adult guidelines for SSI prevention. Based on their findings, the researchers recommended protocol- based management of pediatric blood glucose levels and sending mediastinal wound cultures at the time of surgical closure. Personnel at some health care facilities have implemented pediatric-specific measures to prevent postoperative wound complications. For example, nurses in the cardiac and main ORs at a major children’s hospital designed and implemented a tool to assess patient risk and plan nursing interventions to prevent pressure ulcers in pediatric surgery patients.67 A also is more sensitive to certain chemicals found in topical prospective study indicated that use of the tool in conjunction products.60 Antiseptic solutions such as alcohol, povidone with increased awareness and education regarding pressure iodine, and hydrogen peroxide can be cytotoxic and can delay 60 ulcer prevention, and a hospital-wide focus on skin care wound healing, particularly in children. 67 helped to reduce pressure ulcers in pediatric surgery patients. Children also may try to pull off wound dressings; thus, topical or paint-on products may provide superior wound COLLABORATION protection. Some children experience pain during application Collaboration between health care team members can help to of tissue adhesives, and may benefit from a topical analgesic achieve optimal outcomes in wound care. Perioperative RNs applied before application of the tissue adhesive.61 One provide wound care in collaboration with a diverse range of prospective study found that amniotic membrane was superior clinical providers, such as physicians and licensed to silver sulfadiazine in children with burn wounds.62 Use of independent practitioners, infection preventionists, wound and amniotic membrane was associated with reduced hospital stay ostomy RNs, advanced practice nurses, and other health care and number of dressing changes. It is important to note that personnel. Collaboration is always important, and is especially dosages of topical wound care products intended for adults important in cases of chronic and complex wounds, such as should be carefully evaluated and reduced when necessary for venous ulcers, which require the efforts of a multidisciplinary children.59 Furthermore, perioperative personnel need to team to manage challenges and complications as they arise.68 follow product manufacturers’ written instructions for use. Collaboration is also essential for patients who have comorbid conditions such as diabetes or other risk factors for delayed Surgical site infections are an important consideration in healing or non-healing. children and adolescents as well as adults. Studies indicate surgeons and RN circulators classify pediatric wounds SUMMARY differently. In a single-center retrospective cohort study of 312 pediatric appendectomy cases, the surgeon diagnosis-based Perioperative RNs and their colleagues should understand the and RN circulator-based surgical wound classifications complex physiology of wound healing; identify patient risk differed in 92% of cases, and differed by more than one factors that negatively affect wound healing; and implement classification in 56% of cases.63 The researchers concluded evidence-based nursing practices for improved wound that such inconsistencies could significantly affect outcome healing. These practices include providing measures, which could cause misdirection of quality- • preoperative patient education and preparation; improvement efforts and incorrect inter-hospital ratings. • intraoperative care, including maintaining sterile Another small cross-sectional study reported poor consensus technique and correctly classifying surgical wounds; among pediatric surgeons on the classification of incisions on neonates.64 • postoperative assistance in the treatment and management of perioperative wounds; Guidelines for prevention of specific types of SSIs may be • collaboration and communication with clinical lacking in children even when available for adults, and the providers involved in wound management; and incidence rates of pediatric SSIs may be poorly understood or underreported.65,66 Researchers conducting an online survey • wound management education for patients . of 89 congenital heart programs recently reported that the Perioperative nurses play a key role in managing wound care incidence of pediatric sternal wound infections was 1.53%.64 and preventing SSIs in surgical patients. The researchers also found that pediatric programs did not

16 WOUND CAREAND HEALINGIN PERIOPERATIVE PRACTICE

Editor’s note: Gelfoam and Floseal, are registered trademarks, trademarks of Covidien, Mansfield, MA. SeaSorb is a and CoSeal and TISSEEL are trademarks of the Baxter registered trademark of Coloplast Corp, Minneapolis, MN. Corporation, Deerfield, IL. BioGlue is a registered trademark Kaltostat is a registered trademark of Convatec of Cryolife, Kennesaw, GA. Avitene and Ultrafoam, are Manufacturing, Bridgewater, NJ. Sorbsan is a trademark of trademarks of the Davol/Bard Company, Warwick, RI. Dow Hickam Pharmaceuticals, Houston, TX. Allevyn and EVITHROM, INSTAT, SURGIFOAM, SURGIFLO, OpSite are trademarks of Smith and Nephew, St Petersburg, DERMABOND, SURGICEL, SURGICEL Microfibrillar, FL. Flexzan is a trademark of Mylan Bertek Pharmaceuticals, SURGICEL Nu-Knit, EVICEL, and SURGICEL SNoW, are Research Triangle Park, NC. BioPatch is a registered registered trademarks and OMNEX is a trademark of Ethicon, trademark of Ethicon, Blue Ash, OH. VigiFOAM is a registered Johnson & Johnson, Inc, Somerville, NJ. Helistat is a trademark of Bard Medical, Covington, GA. Oleeva is a registered trademark of the Integra Life Sciences Corporation, registered trademark of BioMed Science, Allentown, PA. Plainsboro, NJ. Vitagel is a trademark of Vitaprep Stryker, Fibracol Plus and Promogran are trademarks of Systagenix, Malverne, PA. Progel is a registered trademark of Neomend, San Antonio, TX. Cellerate RX is a trademark of Wound Irvine, CA. Thrombin-JMI is a registered trademark of Pfizer, Management Technologies, Fort Worth, TX. Biostep and New York, NY. Arista is a trademark of Medafor, Minneapolis, Primapore and Cica-Care Silicone Gel Sheeting are registered MN. Vitasure is a registered trademark of OrthoVita, Malvern, trademarks of Smith and Nephew, St Petersburg, FL. Catrix is PA. DuraSeal is a trademark of Covidien, Boulder, CO. a registered trademark of Lescarden, New York, NY. ColActive Recothrom is a registered trademark of The Medicines is a registered trademark of Covalon Technologies, Ontario, Company, Parsippany, NJ. SurgiSeal is a registered trademark Canada. Collieva is a registered trademark of BioCentury, San of Adhezion Biomedical, Wyomissing, PA. LiquiBand is a Carlos, CA. Biopad is a registered trademark of Angelini registered trademark of Cardinal Health, Dublin, OH. Pharma, Gaithersburg, MD. Alldress and Mepiform and CryoSeal is a registered trademark of the ThermoGeneis Corp, Lyofoam are registered trademarks of Molnlyncke Healthcare, Rancho Cordova, CA. Helitene and Integra are registered Norcross, GA. Dermasil is the trademark of Innocoll, Athlone, trademarks of Integra LifeSciences Inc, Plainsboro, NJ. Ireland. Tachosil TachoSil is a registered trademark of Nycomed Pharma AS, Zurich, Switzerland. Biobrane is a registered trademark of Bertek Pharmaceuticals Inc, Morgantown, WV. Dermagraft is a registered trademark of Organogenesis Inc, La Jolla, CA. TransCyte, Opsite, and SoloSite Gel are registered trademarks of Smith & Nephew, St Petersburg, FL. Apligraf is a registered trademark of Organogenesis Inc, Canton, MA. AlloDerm is a registered trademark of LifeCell, Branchburg, NJ. Oasis is a registered trademark of Cook Biotech Inc, West Lafayette, IN. Hemovac is a registered trademark of the Zimmer Inc, Warsaw, IN. Xeroform and Telfa are registered trademarks of Covidien, Mansfield, MA. Bioclusive and Adaptic are registered trademarks of Systagenix, San Antonio, TX. Tegaderm is a trademark of 3M, St Paul, MN. Comfeel is a registered trademark of Coloplast, Minneapolis, MN. Sorbex is a registered trademark of Melrose Chemicals, Lachine, QC, Canada. DuoDERM is a registered trademark of ConvaTec, Australia. Tegsorb is a trademark of Evonik, Hopewell, VA. Carrasyn is a registered trademark of Carrington Laboratories, Irving, TX. NU-GEL is a registered trademark of Life Technologies, Grand Island, NY. Curagel is a trademark of Tyko Healthcare, Mansfield, MA. Vigilon is a registered trademark of Bard Medical, Louisville, CO. AlgiDerm is a registered trademark of OUC Medical, Tampa, FL. Algosteril is a registered trademark of Les Laboratoires Brothier, Nanterre, France. Curasorb and Kendall Foam are

17 WOUND CAREAND HEALINGIN PERIOPERATIVE PRACTICE

REFERENCES 1. Alexander’s Care of the Patient in Surgery. 14th Ed. Rothrock JC, ed. Mosby, 2011: 250-266; 735-736; 956-946. 2. Mercandetti M, Cohen AJ. Wound Healing and Repair (2013). Available at: http://emedicine.medscape.com/article/1298129-overview Accessed March 11, 2014. 3. Guideline for Surgical Site Classification, 1999. The Centers for Disease Control and Prevention. http://www.cdc.gov/hicpac/SSI/table7-8-9-10-SSI.html. Accessed August 29. 2014 4. Bhangu A, Singh P, Lundy J, Bowley DM. Systemic review and meta-analysis of randomized clinical trials comparing primary vs delayed primary skin closure in contaminated and dirty abdominal incisions. JAMA Surg. 2013;148(8):779-786. 5. Eliya MC, Banda GW. Primary closure versus delayed closure for non-bite traumatic wounds within 24 hours post injury. Cochrane Database Syst Rev. 2011;(9):CD008574. 6. Jenkinson RJ, Kiss A, Johnson S, et al. Delayed wound closure increases deep-infection rate associated with lower-grade open fractures: a propensity-matched cohort study. J Bone Joint Surg Am. 2014;96(5):380-386. 7. Rodriguez-Merchan EC. Surgical wound healing in bleeding disorders. Haemophilia. 2012;18(4):487-490. 8. Guo S, Dipietro LA. Factors affecting wound healing. J Dent Res. 2010;89(3):219-229. 9. National Diabetes Statistics, 2011. National Diabetes Information Clearinghouse. http://diabetes.niddk.nih.gov/dm/pubs/overview/#types. Accessed March 11, 2014. 10. The Facts About Diabetes: A Leading Cause of Death in the U.S. National Diabetes Education Program. http://ndep.nih.gov/diabetes-facts/. Accessed March 22, 2014. 11 Pendsey SP. Understanding diabetic foot. Int J Diabetes Dev Ctries. 2010;30(2):75-79. 12. Glucose test – blood. Medline Plus. http://www.nlm.nih.gov/medlineplus/ency/article/003482.htm. Accessed March 11, 2014. 13. American Diabetes Association. Diabetes Care. Jan 2009; 32(Suppl 1):S62–S67. 14. Wolfson TS, Hamula MJ, Jazrawi LM. Impact of diabetes mellitus on surgical outcomes in sports medicine. Phys Sportsmed. 2013;41(4):64-77. 15. Tsang ST, Gaston P. Adverse perioperative outcomes following elective total hip replacement in diabetes mellitus: a systematic review and meta-analysis of cohort studies. Bone Joint J. 2013;95-B(11):1474-1479. 16. Liu P, He W, Chen HL. Diabetes mellitus as a risk factor for surgery-related pressure ulcers: a meta-analysis. J Wound Ostomy Continence Nurs. 2012;39(5):495-499. 17. Rutan L, Sommers K. Hyperglycemia as a risk factor in the perioperative patient. AORN J. 2012;95(3):352-361. 18. Horosz B, Malec-Milewska M. Inadvertent intraoperative hypothermia. Anaesthesiol Intensive Ther. 2013;45(1):38-43. 19. Recommended practices for the prevention of unplanned perioperative hypothermia. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2014;431-442. 20. Paulikas CA. Prevention of unplanned perioperative hypothermia. AORN J. 2008;88(3):358-365. 21. Recommended practices for preoperative patient skin antisepsis. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2014;73-87. 22. Recommended practices for sterile technique. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2014;89-117. 23. Harrop JS, Styliaras JC, Ooi YC, et al. Contributing factors to surgical site infections. J Am Acad Orthop Surg. 2012;20(2):94-101. 24. Hsu V. Prevention of health care-associated infections. Am Fam Physician. 2014;90(6):377-382.

18 WOUND CAREAND HEALINGIN PERIOPERATIVE PRACTICE

25. Kamel C, McGahan L, Polisena J, et al. Preoperative skin antiseptic preparations for preventing surgical site infections: a systematic review. Infect Control Hosp Epidemiol. 2012;33(6):608-617. 26. Recommended practices for environmental cleaning. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2014;255-276. 27. Recommended practices for hand hygiene in the perioperative setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2014;61-72. 28. Recommended practices for surgical attire. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2014;49-60. 29. Recommended practices for a safe environment of care. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2014;229-254. 30. Recommended practices for prevention of transmissible infections in the perioperative practice setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2014:385-420. 32. Mangram AJ, Horan TC, Pearson ML, Hospital Infection Control Practices Advisory Committee. Guidelines for prevention of surgical site infection. 1999. Am J Infect Control. 1999;27(2):97-132. 33. Surgical wound classification decision tree. AORN, Inc. http://www.aorn.org/Clinical_Practice/Clinical_FAQs/Supporting_Documents/Wound_Classification.aspx. Accessed March 11, 2014 34. Van Wicklin SA. Venous thromboembolism prophylaxis in pediatric patients; The Centers for Disease Control and Prevention surgical wound classification system; using the Surgical Wound Decision Tree tool; using cotton surgical masks; using povidone-iodine solution for surgical skin antisepsis before thyroid procedures. [Clinical Issues]. AORN J. 2012;95(1):155-163. 35. Anderson M, Ottum A, Zerbel S, et al. A survey to examine patient awareness, knowledge, and perceptions regarding the risks and consequences of surgical site infections. Am J Infect Control. 2013;41(12):1293-1295. 36. Surgical Site Infection (SSI) Event. CDC. http://www.cdc.gov/nhsn/pdfs/pscmanual/9pscssicurrent.pdf. Accessed March 22, 2014. 37. Ozawa S. Patient blood management: use of topical hemostatic and sealant agents. AORN J. 2013;98(5):461-478. 38. Gabay M, Boucher BA. An essential primer for understanding the role of topical hemostats, surgical sealants, and adhesives for maintaining hemostasis. Pharmacotherapy. 2013;33(9):935-955. 39. Burks S, Spotnitz W. Safety and usability of hemostats, sealants, and adhesives. AORN J. 2014;100(2):160-176. 40. Gabay M, Boucher BA. An essential primer for understanding the role of topical hemostats, surgical sealants, and adhesives for maintaining hemostasis. Pharmacother. 2013;33(9):935-955. 41. Ofosu FA, Freedman J, Semple JW. Plasma-derived biological medicines used to promote haemostasis. Thromb Haemost. 2008;99(5):851-862. 42. Camp A, Hemostatic agents: a guide to safe practice for perioperative nurses. AORN J. 2014;100(2):132-144. 43. Gabriel A. Wound irrigation. Medscape. http://emedicine.medscape.com/article/1895071-overview Accessed March 11, 2014. 44. Bahrs C, Schnabel M, Frank T, et al. Lavage of contaminated surfaces: an in vitro evaluation of the effectiveness of different systems. J Surg Res. 2003;112(1):26-30. 45. Nicks BA, Ayello EA, Woo K, et al. Acute wound management: revisiting the approach to assessment, irrigation, and closure considerations. Int J Emerg Med. 2010;3(4):399-407. 46. Webster J, Scuffham P, Sherriff KL, et al. Negative pressure wound therapy for skin grafts and surgical wounds healing by primary intention. Cochrane Database Syst Rev. 2012;4:CD009261. 47. Bonds AM, Novick TK, Dietert JB, Araghizadeh FY, Olson CH. Incisional negative pressure wound therapy significantly reduces surgical site infection in open colorectal surgery. Dis Colon Rectum. 2013;56(12):1403-1408.

19 WOUND CAREAND HEALINGIN PERIOPERATIVE PRACTICE

48. Monsen C, Wann-Hansson C, Wictorsson C, et al. Vacuum-assisted wound closure versus alginate for the treatment of deep perivascular wound infections in the groin after vascular surgery. J Vasc Surg. 2014;59(1):145- 151. 49. Andrews A, Upton D. Negative pressure wound therapy: improving the patient experience part 3 of 3. J Wound Care. 2013;22(12):671-672,674,676-678. 50. Walter CJ, Dumville JC, Sharp CA, et al. Systematic review and meta-analysis of wound dressings in the prevention of surgical-site infections in surgical wounds healing by primary intention. Br J Surg. 2012;99(9):1185- 1194. 51. Rotenberg BW, Marchie A, Cusimano, MD. Skin sealants: an effective option for closing cerebrospinal fluid leakage. Can J Surg. 2004; 47(6):466-468 52. Recommended practices for laser safety in perioperative practice settings. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2014;141-154. 53. Recommended practices for electrosurgery. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2014:123-140. 54. Material Safety Data Sheet: Collodion. MVAPMed. http://www.mvapmed.com/MSDS_Forms/COLLODION%20%20USP%20EU.pdf. Accessed March 17, 2014 55. Mabvuure NT, Malahias M, Hindocha S, et al. Acute compartment syndrome of the limbs: current concepts and management. Open Orthop J. 2012;6(need issue number):536-543. 56. MacKenzie MA, Hermus AR, Wollersheim HC, et al. Poikilothermia in man: pathophysiology and clinical implications. Medicine (Baltimore). 1991;70(4):257-268. 57. Ferreira MC, Tuma P Jr, Carvalho VF, et al. Complex wounds. Clinics (Sao Paulo). 2006;61(6):571-578. 58. Coltro PS, Ferreira MC, Batista BP, et al. Role of plastic surgery on the treatment complex wounds. Rev Col Bras Cir. 2011;38(6):381-386. 59. Greer N, Foman NA, MacDonald R, et al. Advanced wound care therapies for nonhealing diabetic, venous, and arterial ulcers: a systematic review. Ann Intern Med. 2013.15;159(8):532-542. 60. McCord SS, Levy ML. Practical guide to pediatric wound care. Sem Plast Surg. 2006;20(3):192-199. 61. Harman S, Zemek R, Duncan MJ, et al. Efficacy of pain control with topical lidocaine-epinephrine-tetracaine during laceration repair with tissue adhesive in children: a randomized controlled trial. CMAJ. 2013;185(13):E629- E634. 62. Mostaque AK, Rahman KB. Comparisons of the effects of biological membrane (amnion) and silver sulfadiazine in the management of burn wounds in children. J Burn Care Res. 2011;32(2):200-209. 63. Levy SM, Holzmann-Pazgal G, Lally KP, et al. Quality check of a quality measure: surgical wound classification discrepancies impact risk-stratified surgical site infection rates in pediatric appendicitis. J Am Coll Surg. 2013;217(6):969-973. 64. Woodward CS, Son M, Calhoon J, et al. Sternal wound infections in pediatric congenital cardiac surgery: a survey of incidence and preventative practice. Ann Thorac Surg. 2011;91(3):799-804. 65. Vu LT, Nobuhara KK, Lee H, et al. Conflicts in wound classification of neonatal operations. J Pediatr Surg. 2009;44(6):1206-1211. 66. Toltzis P, O’Riordan M, Cunningham DJ, et al. A statewide collaborative to reduce pediatric surgical site infections. Pediatrics. 2014; pii: peds.2014 [Epub ahead of print] 67. Galvin PA, Curley MA. The Braden Q+P: a pediatric perioperative pressure ulcer risk assessment and intervention tool. AORN J. 2012;96(3):261-270 68. Langemo DK. Venous ulcers: etiology and care of patients treated with human skin equivalent grafts. J Vasc Nurs. 1999;17(1):6-11.

20 WOUND CAREAND HEALINGIN PERIOPERATIVE PRACTICE

69. Prevention Strategies: Core Intraoperative Measures slide 17. http://www.cdc.gov/HAI/pdfs/toolkits/SSI_toolkit021710SIBT_revised.pdf. Centers for Disease Control and Prevention. Accessed June 13, 2014.

21 WOUND CAREAND HEALINGIN PERIOPERATIVE PRACTICE

POST-TEST WOUND CARE AND HEALING IN PERIOPERATIVE PRACTICE Multiple choice. Please choose the word or phrase that best completes the following statements.

1. A shoulder examination under anesthesia is an 6. Choose the TRUE statement about topical example of what class of wound? hemostatic products. a. Class 1 a. Active hemostatic products include cellulose b. Class 2 and gelatins. c. Class 3 b. Fibrin sealants increase levels of fibrinogen and d. No wound classification thrombin at a bleeding site. c. Flowables contain fibrinogen. 2. The most common cause of impaired wound healing d. Passive or mechanical hemostatic products in surgical patients is contain thrombin. a. diabetes mellitus. b. inadequate dietary protein intake. 7. A Penrose drain is an example of a c. intraoperative hypothermia. a. chest drainage system. d. surgical site infections. b. closed drainage system. c. simple drain. 3. Which physiologic response to wounding is primarily characterized by granulation tissue, neo- 8. Choose the TRUE statement about dressings. vascularization, and re-epithelialization? a. Certain dressings are definitively associated a. Hemostasis with improved outcomes. b. Inflammatory phase b. Primary dressings are bulkier than secondary c. Proliferative phase dressings. d. Remodeling phase c. Primary dressings are usually made of adherent material. 4. An advantage of closure by secondary intention is d. Secondary dressings absorb discharge, protect a. ability to clean the wound surface. wounds, and promote hemostasis. b. faster healing. c. less scarring. 9. Ostomies, burns, chronic venous ulcers, and necrotizing wounds are examples of 5. A patient presents 10 days after hernia repair with a a. class 1 wounds with low risk of infection. fever of 101º F (38.3º C). The suture line has b. complex wounds that require individualized partially dehisced and you observe purulent treatment. discharge from the tissue underlying the incision. c. superficial surgical site infections that require What kind of surgical site infection is this most antibiotic therapy. likely to be? d. wounds that require delayed primary closure. a. Deep incisional b. Organ or space 10. Use of the Center for Disease Control and c. Superficial incisional Prevention’s Surgical Wound Classification System a. adds significant time to operative procedures. b. enables comparison of infection rates and assessment of infection risk. c. is recommended primarily for complex or high- risk wounds. d. must be performed by a surgeon.

22 WOUND CAREAND HEALINGIN PERIOPERATIVE PRACTICE

POST-TEST ANSWERS

WOUND CARE AND HEALING IN PERIOPERATIVE PRACTICE

0 b 10.

.b 9.

.d 8.

.c 7.

.b 6.

.a 5.

.a 4.

.c 3.

.d 2. .d 1.