Clinical practice Ten top tips: management of surgical wound dehiscence he worldwide volume of surgery is al, 2004). In North America, the fiscal estimate considerable, with an estimated 234.2 of SSI is reportedly USD10bn annually in direct T million major surgical procedures carried and indirect medical costs (Urban, 2006). The out every year across the globe (Weiser et al, estimated costs attributable to SSI in Europe 2008). In Australia during 2010-11, 2.4 million range from EUR1.47bn to EUR19.1bn (Leaper et admissions involved a surgical procedure al, 2004). In Australia, estimated costs associated (Australian Institute of Health and Welfare, with SSI are AUD268 mn per year (Mclaws et 2012). Wound healing by primary intention al, 1988; Mclaws andTaylor, 2003) as reported following surgery is assisted by the use of in the acute care setting. The cost of SWD sutures, staples, glue, adhesive tape wound not only impacts the acute care setting; the dressings or negative pressure wound therapy burden is also borne by district and community (NPWT), and healing commences within hours nursing settings. Recent studies have yielded of closure (Rodero and Khosrotehrani, 2010). data regarding the cost of managing SWD Authors: Failure of the wound to heal may be due to (Tanner et al, 2009; Sandy-Hodgetts et al, Kylie Sandy-Hodgetts, Karen Ousey, Elizabeth Howse a number of reasons: patient-related factors, 2016). Further additional costs associated with for example age, cardiovascular disease delays in healing and reduced quality of life for (Webster et al, 2003; van Ramshorst G et al, the patient, family, and the wider community 2010), mechanical reasons of suture breakage may be difficult to ascertain from a financial or knots slipping (Baronski and Ayello, 2012), point of view. More importantly, the use of an infection or dehiscence (Riou et al, 1992; optimal therapy to improve wound healing Ridderstolpe et al, 2001; Webster et al, 2003; outcomes following surgery and prevent wound van Ramshorst G et al, 2010), radiotherapy complications remains to be determined. or chemotherapy (Spiliotis et al, 2009). Surgical wound dehiscence (SWD) is defined Identify risk factors: Patients may be more as the rupturing of opposed or sutured margins 1 at risk of wound dehiscence if they are following a surgical procedure (Mosby, 2009). over 65 years old, have signs of systemic and Dehiscence can occur up to and including local wound infection, are obese, or have had day 30 postoperatively, with some reports a previous surgery in the same anatomical of dehiscence occurring between day 7 and region (Australian Wound Management 9, and day 13 (Spiliotis et al, 2009). Further Association, 2011). Most dehiscence occurs definition of wound dehiscence according to 4–14 days following surgery (Riou J et al, the Centers for Disease Control and Prevention 1992; Ridderstolpe et al, 2001; Webster C et definition classifies dehiscence as a deep al, 2003; Spiliotis et al, 2009; van Ramshorst G surgical site infection (deep or organ space SSI) et al, 2010; Sandy-Hodgetts et al, 2015). The Kylie Sandy-Hodgetts is Research (Horan et al, 2013) and, as such, is classified as patient assessment should be undertaken and Associate, Curtin University, an SSI, regardless of whether the dehiscence results documented following every visit to Western Australia; Adjunct Research is confirmed as microbial or of a non-microbial the patient with any changes reported to the Fellow, University of Western nature. Consequently, determining prevalence nurse in charge and medical staff.Intraoperative Australia and incidence of dehiscence is sometimes risk factors, such as emergency admission Karen Ousey is Professor of Skin thwarted due to the very nature of the medical (Sakamoto H et al, 2003; Watanabe A et al, Integrity, Director Institute of Skin reporting and clinical coding within the acute 2008), classification of surgery (Culver et al, Integrity and Infection Prevention; care setting as it is often lumped under the 1991); clean, clean-contaminated or dirty, Clinical Associate Professor, SSI definition with little or no clarity recorded duration of procedure and intraoperative Australian Catholic University Adjunct Clinical Professor, between superficial or deep SSI. This reporting warming (Leaper, 2006; Wong et al, 2007), are Queensland University of conundrum is also faced in post discharge known factors that may contribute to delayed Technology, Australia surveillance in the community nursing setting postoperative healing. Postoperative factors, where it most likely when the dehiscence such as intra-abdominal pressure, e.g. excessive Elizabeth Howse is Nurse may occur. coughing, recurrent vomiting and constipation, Practitioner Wound/Ostomy Management Silver Chain In the UK, SSI constitutes 20% of all may also lead to dehiscence following surgery, Community Nursing Service, Perth, healthcare-related infections, and at least 5% of according to anecdotal evidence. Knowledge Western Australia admitted patients will develop an SSI (Leaper et of these risk factors during the patient’s 16 Wounds Asia 2018 | Vol 1 Issue 1 | ©Wounds International 2018 | www.woundsasia.com journey is key to postoperative management. Association, 2011; International Wound In-depth pre-operative assessment of the Infection Institute, 2016; Australian Wound patient to identify and record any risk factors to Management Association, 2016; National inform preventative measures to reduce risks Institute for Health and Care Excellence, should be adhered to and clinicians should 2017); clinicians should check with their local follow their local guidelines. This may include clinical guidelines as to the management of health education regarding weight loss and postoperative wound infection. Any of the nutritional advice. following indicators should be documented in the patient’s notes/care plan and reported Identify signs and symptoms of wound to the nurse in charge and medical staff. 2 dehiscence: Surgical wounds may often A plan of care to manage these indicators present with specific visual signs that may should be developed and clearly documented indicate a disruption to the normal healing with clear, achievable evaluation dates. Local process and possibly the presence of infection. guidelines must also be checked as to the Top Tip 4 discusses infection in more detail, clinical indicators of wound infection. The however, visible signs of healing disruption may indicators are: include, but are not limited to: ■ Dull wound tissue ■ Opposed sutured margins open or separated ■ Slough at any point along the incision site ■ Failure of wound to decrease in size ■ Broken sutures (non-healed opposing ■ Hypergranulation margins) ■ Increased exudate ■ Redness at the incision site ■ Erythema ■ Patient experiencing pain at the incision site. ■ Increased pain or unexplained pain ■ Malodour Further indication of disruption to the normal ■ confirmed presence of infection healing process, which include, but are not (microbiology) limited to: ■ Increased temperature of periwound tissue. ■ Swelling, oedema, seroma ■ Bleeding Determine goal of care (e.g. surgical ■ Exudate from the incision site. 5 debridement/closure versus healing by secondary intention): The goal of care may be Accurately assess and categorise type of different to healing by primary intention and, 3wound dehiscence including ongoing as such, clear and achievable goals should be assessment of the patient: Complete accurate documented. This should be discussed with the wound assessment (anatomical location, patient and all planned interventions explained. size, tissue involvement/characteristics, The goal of care is to prepare the wound bed exudate type/amount, presence of odour, and for future closure. Interventions will include pain assessment) in the patient notes and assessment of the wound bed to identify any wound care plan is paramount; treatment signs necrotic tissue and infection. If infection should be documented in the notes after is suspected, there should be appropriate use every assessment. Determining the type of antibiotics, removal of drains, sutures or of dehiscence and recording the correct staples and surgical debridement. Following classification provides clinical coders and the removal of necrotic tissue, superficial researchers with much-needed information in dehiscence can be closed by secondary regards to the patient’s dehiscence. There are intention. For large and deep wound two types of dehiscence: dehiscence, NPWT and a return to theatre for ■ Partial dehiscence closure may be indicated (Avila et al, 2012). ■ Full-thickness dehiscence. Referral to tissue viability services and the medical team should be made for advice and Assess for clinical indicators of infection: care following all wound dehiscence. The goal 4 The early identification of clinical indicators of care and planned interventions should be of infection is important in the management discussed and explained to the patient, and of the patient’s surgical wound. There are recorded in the notes with clear and achievable several published guidelines for the detection, evaluation dates. diagnosis and management of wound infection The article has been published (European Wound Management Association, Correct wound bed preparation: in Wounds International 2006; Australian Wound Management 6 Effective wound bed preparation is Wounds Asia 2018 | Vol 1 Issue 1 | ©Wounds International 2018 | www.woundsasia.com 17 Clinical practice essential to the wound healing process. should