use of packing for surgical wounds - ram pages€¦ · use of packing for surgical wounds maggie...
TRANSCRIPT
![Page 1: Use of Packing for Surgical Wounds - Ram Pages€¦ · Use of Packing for Surgical Wounds Maggie Benson Clinical Problem Solving II . ... Examine evidence for the use of wound packing](https://reader030.vdocument.in/reader030/viewer/2022040915/5e8e257fc091e01ca04a86c8/html5/thumbnails/1.jpg)
Use of Packing for Surgical Wounds
Maggie Benson Clinical Problem Solving II
![Page 2: Use of Packing for Surgical Wounds - Ram Pages€¦ · Use of Packing for Surgical Wounds Maggie Benson Clinical Problem Solving II . ... Examine evidence for the use of wound packing](https://reader030.vdocument.in/reader030/viewer/2022040915/5e8e257fc091e01ca04a86c8/html5/thumbnails/2.jpg)
Purpose
� Present patient management s/p Incision and Drainage in an outpatient setting
� Examine evidence for the use of wound packing with a wound s/p Incision and Drainage
![Page 3: Use of Packing for Surgical Wounds - Ram Pages€¦ · Use of Packing for Surgical Wounds Maggie Benson Clinical Problem Solving II . ... Examine evidence for the use of wound packing](https://reader030.vdocument.in/reader030/viewer/2022040915/5e8e257fc091e01ca04a86c8/html5/thumbnails/3.jpg)
Patient Demographics
� 68 year-old Caucasian male
� Served in army
� Retired
� Lives with wife
![Page 4: Use of Packing for Surgical Wounds - Ram Pages€¦ · Use of Packing for Surgical Wounds Maggie Benson Clinical Problem Solving II . ... Examine evidence for the use of wound packing](https://reader030.vdocument.in/reader030/viewer/2022040915/5e8e257fc091e01ca04a86c8/html5/thumbnails/4.jpg)
Diagnosis � Dx: Incision and Drainage (I & D) s/p cellulitis
� Cellulitisà bacterial skin disease � Swollen, red, warm, tender � Life-threatening if untreated � Bacteria enter skin through recent surgery,
puncture wound, ulcer, etc � Possible causes: streptococcus or staphylococcus
(MRSA) � More common in middle-aged and elderly � Risk factors: diabetes mellitus,
immunocompromised state, alcoholism, intravenous drug use, prior cellulitis, poor circulation
� Treatment: antibiotics, elevation, immobilization
![Page 5: Use of Packing for Surgical Wounds - Ram Pages€¦ · Use of Packing for Surgical Wounds Maggie Benson Clinical Problem Solving II . ... Examine evidence for the use of wound packing](https://reader030.vdocument.in/reader030/viewer/2022040915/5e8e257fc091e01ca04a86c8/html5/thumbnails/5.jpg)
Diagnosis: Cellulitis vs. Cutaneous Abscess � Cellulitis
� Bacterial skin infection
� Inflammation and/or swelling
• Cutaneous Abscess • Bacterial infection
that causes pocket of pus
• Pain, inflammation, and/or swelling
• Can develop in areas of cellulitis
http://www.antimicrobe.org/images-Monographs/e1_Cellulitis_MRSA_1.jpg
http://www.microbiologybook.org/Infectious%20Disease/abscess1.jpg
![Page 6: Use of Packing for Surgical Wounds - Ram Pages€¦ · Use of Packing for Surgical Wounds Maggie Benson Clinical Problem Solving II . ... Examine evidence for the use of wound packing](https://reader030.vdocument.in/reader030/viewer/2022040915/5e8e257fc091e01ca04a86c8/html5/thumbnails/6.jpg)
Diagnosis � I & Dà indicated if abscess shows sign of pus
� Procedure: � Sedation
� Iodine wash
� Incise abscess
� Remove necrotic or devascularized tissue
� Pressure irrigation with saline
� Loosely pack wound with gauze
� Apply dressing for absorption
� Follow-up 24-48 hours to remove packing and evaluate healing
![Page 7: Use of Packing for Surgical Wounds - Ram Pages€¦ · Use of Packing for Surgical Wounds Maggie Benson Clinical Problem Solving II . ... Examine evidence for the use of wound packing](https://reader030.vdocument.in/reader030/viewer/2022040915/5e8e257fc091e01ca04a86c8/html5/thumbnails/7.jpg)
Patient History � Cut R hand while helping attach a trailer
� Began to get red and swelling up R armà cellulitis � Did not result in cutaneous abscess
� Possible MRSA infection
� Given Vancomycin and received I & D 4 days later
� Sent to PT clinic 2 days after I & D for whirlpool treatment
� No relevant comorbidities
http://www.nhsdirect.wales.nhs.uk/encyclopaedia/c/article/cellulitis/
![Page 8: Use of Packing for Surgical Wounds - Ram Pages€¦ · Use of Packing for Surgical Wounds Maggie Benson Clinical Problem Solving II . ... Examine evidence for the use of wound packing](https://reader030.vdocument.in/reader030/viewer/2022040915/5e8e257fc091e01ca04a86c8/html5/thumbnails/8.jpg)
Examination � Day 1
� Un-bandaged
� Whirlpool treatment � Measurements
� Re-bandaged
![Page 9: Use of Packing for Surgical Wounds - Ram Pages€¦ · Use of Packing for Surgical Wounds Maggie Benson Clinical Problem Solving II . ... Examine evidence for the use of wound packing](https://reader030.vdocument.in/reader030/viewer/2022040915/5e8e257fc091e01ca04a86c8/html5/thumbnails/9.jpg)
Wound Examination � Located in anterior metacarpal area of R hand
� Length: 3.0 cm Width: 0.5 cm Depth: 1.0 cm
� Drainage: serosanguineous
� Periwound: maceration
� ROM: unable to make fist with R hand
![Page 10: Use of Packing for Surgical Wounds - Ram Pages€¦ · Use of Packing for Surgical Wounds Maggie Benson Clinical Problem Solving II . ... Examine evidence for the use of wound packing](https://reader030.vdocument.in/reader030/viewer/2022040915/5e8e257fc091e01ca04a86c8/html5/thumbnails/10.jpg)
PT Evaluation � Impairments
� Soft tissue swelling
� Decreased ROM in R hand � Occasional throbbing sensation and numbness
� Activity limitations � Unable to write with dominant hand
� Unable to perform ADLs independently
� Participation restrictions � Unable to play golf
![Page 11: Use of Packing for Surgical Wounds - Ram Pages€¦ · Use of Packing for Surgical Wounds Maggie Benson Clinical Problem Solving II . ... Examine evidence for the use of wound packing](https://reader030.vdocument.in/reader030/viewer/2022040915/5e8e257fc091e01ca04a86c8/html5/thumbnails/11.jpg)
Prognosis � Prognosis= good
� Compliant with treatments and dressings
� No report of pain
� Active
� No comorbidities
![Page 12: Use of Packing for Surgical Wounds - Ram Pages€¦ · Use of Packing for Surgical Wounds Maggie Benson Clinical Problem Solving II . ... Examine evidence for the use of wound packing](https://reader030.vdocument.in/reader030/viewer/2022040915/5e8e257fc091e01ca04a86c8/html5/thumbnails/12.jpg)
Goals Patient goals: healing of wound, play golf
Physical therapy goals:
In 2 weeks:
1. Patient’s wound depth will decreased to ≤ 0.5 cm.
2. Patient will demonstrate compliance with wearing wound bandage.
In 4 weeks:
1. Patient’s wound will be healed.
2. Patient will be able to make full fist on R hand.
3. Patient will report no difficulty with ADLs using R hand.
![Page 13: Use of Packing for Surgical Wounds - Ram Pages€¦ · Use of Packing for Surgical Wounds Maggie Benson Clinical Problem Solving II . ... Examine evidence for the use of wound packing](https://reader030.vdocument.in/reader030/viewer/2022040915/5e8e257fc091e01ca04a86c8/html5/thumbnails/13.jpg)
PT Treatment � Will be seen 2-3 times/week for 4-8 weeks
� Intervention: � Whirlpool at 98°F with Chlorizine of R hand while
seated x 15 min � After whirlpool, bandage
� Iodoform gauze � 2- 4x4 sterile gauze � 1- ABD � 1- soft wrap � ACE bandage � Bandnet
![Page 14: Use of Packing for Surgical Wounds - Ram Pages€¦ · Use of Packing for Surgical Wounds Maggie Benson Clinical Problem Solving II . ... Examine evidence for the use of wound packing](https://reader030.vdocument.in/reader030/viewer/2022040915/5e8e257fc091e01ca04a86c8/html5/thumbnails/14.jpg)
34 days post initial evaluation= DISCHARGED Advised contrast bath and gentle exercises
27 days post initial evaluation Closed wound Thick scaring éROM but no fist
25 days post initial evaluation No depth or drainage
21 days post initial evaluation No swelling Scant drainage Depth <0.5 mm
18 days post initial evaluation Minimal serosanguineous
drainage Finger tips to palm Depth 1.5 mm
4 days post initial evaluation Yellow drainage Depth decreased to 0.5 cm
![Page 15: Use of Packing for Surgical Wounds - Ram Pages€¦ · Use of Packing for Surgical Wounds Maggie Benson Clinical Problem Solving II . ... Examine evidence for the use of wound packing](https://reader030.vdocument.in/reader030/viewer/2022040915/5e8e257fc091e01ca04a86c8/html5/thumbnails/15.jpg)
Outcome � Wound closure ✓ Goal met
� Calloused area resolved
� No erythema (cellulitis) � Minimal edema in digits
� Patient able to approximate finger tips to palm, unable to complete fist Goal partially met
� Some difficulty with ADLs Goal partially met
� Optimal Instrument: 4.5% to 3%
![Page 16: Use of Packing for Surgical Wounds - Ram Pages€¦ · Use of Packing for Surgical Wounds Maggie Benson Clinical Problem Solving II . ... Examine evidence for the use of wound packing](https://reader030.vdocument.in/reader030/viewer/2022040915/5e8e257fc091e01ca04a86c8/html5/thumbnails/16.jpg)
Intervention Question
For my 68 year-old male patient, does packing a wound s/p Incision and
Drainage promote wound healing and if so, which dressing is more effective?
![Page 17: Use of Packing for Surgical Wounds - Ram Pages€¦ · Use of Packing for Surgical Wounds Maggie Benson Clinical Problem Solving II . ... Examine evidence for the use of wound packing](https://reader030.vdocument.in/reader030/viewer/2022040915/5e8e257fc091e01ca04a86c8/html5/thumbnails/17.jpg)
• Prospective randomized control trial • Level 1b
• Purpose: Determine whether packing of simple cutaneous abscesses after I & D is beneficial when compared to I & D alone
Routine packing of simple cutaneous abscesses is painful and probably unnecessary
O’Malley et al. Academy of Emergency Medicine, 2009
![Page 18: Use of Packing for Surgical Wounds - Ram Pages€¦ · Use of Packing for Surgical Wounds Maggie Benson Clinical Problem Solving II . ... Examine evidence for the use of wound packing](https://reader030.vdocument.in/reader030/viewer/2022040915/5e8e257fc091e01ca04a86c8/html5/thumbnails/18.jpg)
O’Malley et al. Methods
� Emergency department setting
� Inclusion criteria: 18 years or older with abscesses < 5 cm largest diameter on trunk or extremities
� Exclusion criteria: abscess >5 cm, pregnancy, comorbidities, steroid use, immunosuppressive state, abscess on face, neck, hands, feet, genital or rectal areas
� 48 subjects randomized into 2 groups: packing or no packing
� All subjects received trimethoprim-sulfamethoxazole (TMP-SMX), ibuprofen, and narcotic prescription
� Pain recorded 2x/day
![Page 19: Use of Packing for Surgical Wounds - Ram Pages€¦ · Use of Packing for Surgical Wounds Maggie Benson Clinical Problem Solving II . ... Examine evidence for the use of wound packing](https://reader030.vdocument.in/reader030/viewer/2022040915/5e8e257fc091e01ca04a86c8/html5/thumbnails/19.jpg)
O’Malley et al. Methods
� Cleaned abscessà anesthetizedà incised abscessà collected cultureà irrigated with saline
� Packing group: ribbon gauze (1/4 inch non-iodophor-impregnated)
� Non-packing group: covered with sterile gauze and silk tape
� Instructed to not change dressing and returned in 48 hours
� Follow-up via phone call at 10-15 days post I&D
� Primary outcome: need for intervention
![Page 20: Use of Packing for Surgical Wounds - Ram Pages€¦ · Use of Packing for Surgical Wounds Maggie Benson Clinical Problem Solving II . ... Examine evidence for the use of wound packing](https://reader030.vdocument.in/reader030/viewer/2022040915/5e8e257fc091e01ca04a86c8/html5/thumbnails/20.jpg)
Results
� Packed group reported higher post op pain than non-packing group immediately post I&D and at 48 hour follow-up
� 34/48 subjects returned at 48 hours
O’Malley et al.
![Page 21: Use of Packing for Surgical Wounds - Ram Pages€¦ · Use of Packing for Surgical Wounds Maggie Benson Clinical Problem Solving II . ... Examine evidence for the use of wound packing](https://reader030.vdocument.in/reader030/viewer/2022040915/5e8e257fc091e01ca04a86c8/html5/thumbnails/21.jpg)
O’Malley et al. � Use of packing is painful and uncertain of benefits
Limitations
� Small pilot study
� No reports of changes in wound measurement
� Planned further investigation to determine if results can apply to a broader population at multiple centers
![Page 22: Use of Packing for Surgical Wounds - Ram Pages€¦ · Use of Packing for Surgical Wounds Maggie Benson Clinical Problem Solving II . ... Examine evidence for the use of wound packing](https://reader030.vdocument.in/reader030/viewer/2022040915/5e8e257fc091e01ca04a86c8/html5/thumbnails/22.jpg)
• Prospective randomized control trial • Level 1b
• Purpose: Investigate rate of healing and pain level when using a silver-containing hydrofiber dressing after I & D compared to other dressing
Use of silver-containing hydrofiber dressing for filling abscess cavity following incision and drainage in the emergency department: A randomized controlled trial
Alimov et al. Advanced Skin Wound Care, 2013
![Page 23: Use of Packing for Surgical Wounds - Ram Pages€¦ · Use of Packing for Surgical Wounds Maggie Benson Clinical Problem Solving II . ... Examine evidence for the use of wound packing](https://reader030.vdocument.in/reader030/viewer/2022040915/5e8e257fc091e01ca04a86c8/html5/thumbnails/23.jpg)
Alimov et al. Methods
� Inclusion criteria: 18 years and older with cutaneous abscess greater than 2 cm in diameter or cellulitis that required I&D
� Exclusion criteria: pregnancy, immunodeficiency, hypersensitivity to Aquacel Ag or components, multiple abscesses, diabetic foot, systemic manifestations, ischemic ulcer, previous abscess, facial abscess
� 92 subjects followed up 48-72 hours post I&D then 10-14 days after initial visit
![Page 24: Use of Packing for Surgical Wounds - Ram Pages€¦ · Use of Packing for Surgical Wounds Maggie Benson Clinical Problem Solving II . ... Examine evidence for the use of wound packing](https://reader030.vdocument.in/reader030/viewer/2022040915/5e8e257fc091e01ca04a86c8/html5/thumbnails/24.jpg)
Alimov et al. Methods
� Subjects randomized into 2 packing groups � Intervention: Aquacel Ag
� Standard care: Iodoform
� Primary outcome: proportion of subjects with greater than 30% reduction in surface area of abscess or cellulitis at first follow-up
� Secondary outcome: pain intensity level
![Page 25: Use of Packing for Surgical Wounds - Ram Pages€¦ · Use of Packing for Surgical Wounds Maggie Benson Clinical Problem Solving II . ... Examine evidence for the use of wound packing](https://reader030.vdocument.in/reader030/viewer/2022040915/5e8e257fc091e01ca04a86c8/html5/thumbnails/25.jpg)
Alimov et al. Results
� 68 subjects returned to 1st follow-up
� Subjects with abscess: Aquacel Ag group more likely to experience greater than 30% reduction in SA
� Subjects with cellulitis: no significant difference
� Pain ratings for Aquacel Ag vs. Iodoform
![Page 26: Use of Packing for Surgical Wounds - Ram Pages€¦ · Use of Packing for Surgical Wounds Maggie Benson Clinical Problem Solving II . ... Examine evidence for the use of wound packing](https://reader030.vdocument.in/reader030/viewer/2022040915/5e8e257fc091e01ca04a86c8/html5/thumbnails/26.jpg)
Alimov et al. � Subjects with cutaneous abscess presented with faster
wound healing and reduction in perceived pain when antimicrobial hydrofiber was used for packing in wound dressing than iodoform dressing
� Cellulitis improvement not affected by Aquacel Ag
Limitations
� Number of subjects unavailable for follow-up
� Self-reported measures of pain
� Single center w/ routine use of silver-containing dressing for burns
![Page 27: Use of Packing for Surgical Wounds - Ram Pages€¦ · Use of Packing for Surgical Wounds Maggie Benson Clinical Problem Solving II . ... Examine evidence for the use of wound packing](https://reader030.vdocument.in/reader030/viewer/2022040915/5e8e257fc091e01ca04a86c8/html5/thumbnails/27.jpg)
Conclusion � Packing may be painful and unnecessary
� No reports of wound measurements
� Aquacel Ag gauze > iodoform for healing and pain
� Patient had cellulitis, not abscess
� Wound healed within ~5 weeks with no pain
� Further investigation is needed
![Page 28: Use of Packing for Surgical Wounds - Ram Pages€¦ · Use of Packing for Surgical Wounds Maggie Benson Clinical Problem Solving II . ... Examine evidence for the use of wound packing](https://reader030.vdocument.in/reader030/viewer/2022040915/5e8e257fc091e01ca04a86c8/html5/thumbnails/28.jpg)
References 1. Alimov, V., et al. 2013. Use of a silver-containing hydrofiber dressing for filling
abscess cavity following incision and drainage in the emergency department: a randomized controlled trial. Advanced Skin Wound Care, 20-25.
2. Allison, E. Jackson, Jr. and John Gough. 1996. "Cutaneous Abscesses." Emergency Medicine-A Comprehensive Study Guide, New York: McGraw Hill.
3. Connell, Patrick and John 1. Ellis. 1992. “Cutaneous Abscesses and Gas Gangrene." Principles and Practice of EmerR-ency Medicine. 3rd ed. Philadelphia: Lea & Febiger.
4. Kessler, D. O., Krantz, A., and Mojica, M. 2012. Randomized trial comparing wound packing to no wound packing following incision and drainage of superficial skin abscesses in pediatric emergency department. Pediatric Emergency Care, 514-517.
5. Mayo Clinic. Cellulitis. Mayo Clinic. http://www.mayoclinic.org/diseases-conditions/cellulitis/basics/definition/con-20023471.
6. O’Malley, G. F., et al. 2009. Routine packing of simple cutaneous abscesses is painful and probably unnecessary. Academy of Emergency Medicine, 470-473.
![Page 29: Use of Packing for Surgical Wounds - Ram Pages€¦ · Use of Packing for Surgical Wounds Maggie Benson Clinical Problem Solving II . ... Examine evidence for the use of wound packing](https://reader030.vdocument.in/reader030/viewer/2022040915/5e8e257fc091e01ca04a86c8/html5/thumbnails/29.jpg)
Questions?