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Surgery Exam 2 > Postoperative care - Wound healing and Management > Flashcards

Postoperative care - Wound healing and Management Flashcards

1
Q

Wound:

A

“a disruption of the normal structure and function of the skin and underlying soft tissue.”
● May arise through traumatic injury (including surgery) or from the breakdown of previously intact skin
● Are generally classified as acute or chronic

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2
Q

Acute Wounds

A
  • Often acute wounds have an easily
    identifiable mechanism of injury, often due
    to trauma or surgery
  • Normally heal in a linear process through
    the stages of wound healing.
  • Have a predictable time frame (Around a 6-12 week duration)
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3
Q

Chronic Wounds

A
  • Chronic wounds can develop from acute
    traumatic or surgical skin injury or result from
    breakdown of previously intact skin.
  • Wound healing has failed.
  • Does not progress linearly through the stages
    of healing, chronic wounds are often stuck in
    the inflammation stage.
  • No specific orderly sequence
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4
Q

Primary wound closure

A

reapproximation of the edges, then closed

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5
Q

Secondary wound closure

A

Left open, heal through granulation development, reepithelialization, scarring is an issue
○ “Healing by secondary intention”
○ Infected tissue and burns; or lack of tissue

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6
Q

Delayed primary closure

A

left open for short time (in a controlled, moist
environment), then closed primarily

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7
Q

Which wounds typically are closed by secondary intention?

A

Infected tissue and burns; or lack of tissue

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8
Q

Which wounds typically are closed by delayed primary closure?

A

Contaminated wounds, perhaps crush or blast injuries, or avulsion injuries, with attempt to avoid infection

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9
Q

Which wound closure technique is preferred?

A

Primary wound closure is preferable because of faster healing, less scarring,
improved hemostasis, and better
aesthetic and functional results.

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10
Q

Stages of wound healing:

A

Hemostasis/Coagulation
Inflammation
Migratory/Proliferation
Maturation/Remodeling

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11
Q

Coagulation/Inflammation (Days 0-4 to 6)

A

● Begins immediately after an acute injury
● The clot provides hemostasis/coagulation and also provides a matrix for cell migration, formation of extracellular matrix, and a
reservoir for cytokines and growth factors
● Coagulation products (i.e. fibrin, fibrinopeptides, thrombin split
products, complement components) are produced immediately after
injury to attract inflammatory cells
● Platelets are the primary component here; directs clotting via intrinsic and extrinsic pathways

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12
Q

Interleukins and other inflammatory components (histamine,
serotonin, and bradykinin) cause vessels to _____

A

constrict for hemostasis, then dilate, so that blood plasma and leukocytes can
migrate into the injured area.

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13
Q

● Macrophages (stimulated by fibrin) release ____, it builds up. Its level is
tightly regulated by tissue oxygen levels

A

lactate

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14
Q

Lactate function

A

Signals acute wound healing → stimulates angiogenesis
and collagen deposition

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15
Q

Oxygen function in coagulation/inflammation

A

Tissue O2 falls due to metabolic demand of the inflammatory cells, causing oxidative stress and moderate hypoxia which is an important signal for tissue repair and angiogenesis

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16
Q

Fibroblasts function

A

● Fibroblasts organize and begin to contribute to healing
○ Circulating stem cells contribute fibroblasts (connective tissue) to
the healing wound but the exact process is unknown

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17
Q

Fibroplasia

A

(replication of fibroblasts)- foundation of wound
It is stimulated throughout the wound healing process by many mechanisms including
various growth factors released by platelets, also by the continual release of peptide
growth factors from macrophages

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18
Q

Proliferation (Days 4 to 6-14)

A
  • Fibroplasia (replication of fibroblasts)- foundation of wound
  • Matrix Synthesis- fibroblasts secrete collagen and proteoglycans
  • Angiogenesis- required for wound healing.
  • Epithelialization- several growth factors regulate epithelial cell replication.
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19
Q

Matrix Synthesis

A
  • fibroblasts secrete collagen and proteoglycans of the connective tissue matrix that holds the wound edges together and embeds cells of the healing wound matrix.
  • These extracellular molecules polymerize, form a scaffold, and become the physical basis
    of wound strength.
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20
Q

Angiogenesis

A
  • required for wound healing. New capillaries sprout from preexisting venules and grow toward the injury in response to chemoattractants released by platelets and macrophages.
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21
Q

Epithelialization

A
  • several growth factors regulate epithelial cell
    replication.
  • During wound healing, maximal cell proliferation occurs in the epithelium a few cells away from the wound end. New cells migrate over the cells at the edge and into the unhealed area and anchor to the first non epithelialized matrix area encountered.
  • Process repeats until wound is closed.
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22
Q

Most effective when surface
wounds are kept moist (even short periods of drying impair this process)

A

Epithelialization-

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23
Q

Maturation/Remodeling (Day 8 to two years)

A

● The very early provisional extracellular matrix is replaced with a more mature
one by forming larger, better organized, stronger, and more durable collagen
fibers.
● Fibroblasts and leukocytes secrete collagenases that cause lysis which is part
of reorganizing the new matrix.
● Healing is successful when a net excess of matrix is deposited despite
concomitant lysis.

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24
Q

Common causes of delayed healing- local vs systemic

A

● Tissue hypoxia
● Inflammation
● Malnutrition
● Proliferative scarring
● Infection
● Smoking
● Aging
● Immobilization
● Diabetes
● Vascular diseases
● Immunosuppressive therapy

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25
Q

Tissue hypoxia

A

● Oxygen is required for successful inflammation, bactericidal activity,
angiogenesis, epithelialization, and matrix (collagen) deposition.
● Human healing is profoundly influenced by local blood supply, vasoconstriction, and all other factors that govern perfusion and blood
oxygenation.
● Hypoxia → higher wound infection rates, collagen deposition impairment

26
Q

_____ causes microvascular ischemic changes.

A

Diabetes

27
Q

Failure to heal is common in patients taking these medications:

A

○ Corticosteroids/anti inflammatories
○ Immunosuppressants
○ Chemotherapeutic agents that inhibit inflammatory cells.

28
Q

_____ is a main fuel for wound repair

A

Glucose

29
Q

How Malnutrition impairs healing?

A

○ Associated with prolonged inflammation and
disruption of matrix deposition, cellular
proliferation, and angiogenesis
○ Monitor overall nutrition status → albumin and prealbumin

30
Q

Proliferative Scarring

A

● An excessive tissue response characterized by local fibroblast proliferation and overproduction of collagen
● Unable to find a balance of collagen deposition or lysis
● It is unknown why some wounds continue in the dysregulated repair process
○ So no good treatment options exist

31
Q

Hypertrophic scars:

A

generally raised, self-limited (not outside wound
borders), are related to residual inflammation, and may regress after a year
or so

32
Q

Keloid scars:

A

extend beyond the borders of the wound and are most common in pigmented skin; don’t regress
Treatment: intralesional corticosteroids, excision, radiation, laser,
anti-mitotic meds

33
Q

Steps to prevent scarring

A

● Keeping the wound moist in early phase healing
● Avoid stretching the area
● Limit sun exposure by covering or > 50 spf sunblock

34
Q

Local Impediments of Wound Healing

A

● Infection
● Foreign bodies (e.g. sutures)
● Smoking
● Radiation
● Trauma
● Cancer
● Arterial/venous
insufficiency
● Hypothermia

35
Q

Systemic Impediments of Wound Healing

A

● Nutritional deficiencies (e.g. malnutrition = worst case)
● Aging
● Diabetes
● Liver disease
● Alcoholism
● Medications (rheumatoid drugs, chemo, etc)
● Inherited disorders (connective tissue disorders such as
Ehler Danlos syndrome)

36
Q

Infection of a wound

A

● Bacteria- inhibit the inflammatory phase and prevent epithelialization
● Results in cellular death and necrotic tissue which increases local inflammation and new cell growth
● New tissue growth cannot occur in the
presence of necrotic tissue

37
Q

Surgical site infection

A

an infection related to an operative
procedure that occurs at or near the surgical incision within 30 days of the procedure or within 90 days if implants are placed

38
Q

*An important risk factor of surgical site infections

A

The degree of contamination of a surgical wound at the time of operation. (Clean, clean-contaminated, contaminated, dirty/infected)

39
Q

Acute vs Chronic Wounds

A

Acute wounds:
● Normal timing and linear progression of healing
● Expect to heal with steady improvement
○ 6-12 weeks
Chronic wounds:
● Complex, multifactorial process that slows or halts
healing in any phase
● Duration of healing? Unknown (if at all)
● Less than ~15% reduction weekly or ~50% of the surface
area over a 1 month period

40
Q

Venous Stasis Ulcers

A

○ Usually lower extremities
○ Due to venous hypertension
○ Reflects stasis of perivascular
leakage of plasma into tissue
which stimulates chronic
inflammation
○ Contact dermatitis is common
○ Tx: elevation, compression, phlebectomies, if
needed. And treat the underlying venous reflux

41
Q

Arterial/Ischemic Wounds

A

○ Due to poor perfusion; are painful
○ Treatment:
■ Needs vascular reconstruction
■ Wound care (possibly hyperbaric oxygen)

42
Q

Diabetic Foot Wounds

A

○ Major contributing factors
include:
■ Neuropathy
■ Foot deformity
■ Ischemia
○ Once ulceration occurs,
chances of healing are poor
○ Most diabetic wounds are
infected
○ Tx: achieve good BS control
and eradicate infection

43
Q

Major contributing factors of Diabetic Foot Wounds

A

■ Neuropathy
■ Foot deformity
■ Ischemia

44
Q

Decubitus (pressure) ulcers, also known as “pressure injuries”

A

A localized area of tissue necrosis that develops when soft tissue is compressed between a bony prominence and an
external surface
■ Multifactorial, most result from
prolonged pressure or shear force
injury
■ “Most” are preventable with proper patient
turning/hygiene
■ Symptom of the underlying problem

45
Q

Wounds kept moist _____ faster

A

re-epithelialize

46
Q

Types of wound dressings:

A

● Transparent films- Tegaderm
● Hydrocolloids- Duoderm
● Foams
● Gels
● Alginates
● Relatively new collagen products
● Petroleum based gauze- Xeroform

47
Q

Wound Debridement types:

A

● Irrigation
● Surgical
● Enzymatic
● Biologic

48
Q

Irrigation derbidement

A

Important to decrease the bacterial load and remove loose material. Should be part of routine management.

49
Q

Surgical debridement

A

uses a scalpel or other sharp instrument to remove devitalized tissue and debris

50
Q

Enzymatic debridement

A

apply exogenous enzymatic agents (eg, collagenase) to the wound

51
Q

Biologic debridement

A
  • uses the larvae of the Australian sheep blow fly or green bottle fly.
    Also maggot therapy → used to treat pressure ulcers, chronic venous
    ulceration, diabetic ulcers, etc.
    ○ Excreted enzymes liquefy necrotic tissue which is then ingested
52
Q

Which wound debridement type uses maggot therapy?

A

Biologic debridement

53
Q

Wound Packing

A

● Wounds with large soft-tissue defects may have an area of dead space between the surface of intact healthy skin and the wound base. May be considered tunneled or undermined. Measure!!
● Gauze is often moistened and placed in the wound and covered with dry gauze

54
Q

Topical Therapy for wounds (antiseptics and antimicrobial agents)

A

● Iodine-based - an antimicrobial that reduces bacterial load within the
wound and stimulates healing by providing a moist wound environment
● Silver-based - silver is toxic to bacteria. Dressings have not demonstrated
significant benefits.
● Honey - has broad-spectrum antimicrobial
activity due to its high osmolarity and high
concentration of hydrogen peroxide

55
Q

Suture types

A

■ Silk- long track record, good choice, loses its strength over time
■ Synthetic non absorbable- retain strength, does not handle as
well as silk- requires multiple knots
■ Synthetic absorbable- strong, incite minimal inflammation;
useful in GI, GU, gyn operations that are contaminated
■ Other options- catgut (bovine), stainless steel wire

56
Q

alternative to suturing;
minimizes errors in technique

A

Staples

57
Q

____ are More prone to scarring

A

Staples

58
Q

Surgical glue use

A

typically used
on smaller incisions with
minimal depth; often less
painful

59
Q

Implantable materials

A

○ Soft tissues prostheses (e.g.
hernia repair) - mesh
■ Has reduced recurrence
rates
■ Related to a tension free
closure
○ Skin grafting

60
Q

Negative Pressure Wound Therapy
(NPWT)

A

○ Stabilizes distractive forces of an
open wound (helps wound contract)
○ Promotes granulation tissue
formation
○ Reduces edema and improves wound
perfusion
○ Removes exudate
○ Provides clean, moist environment

61
Q

Management of chronic wounds - TIME

A

● Tissue (debridement if necessary)
● Infection/Inflammation
● Moisture
● Edge- undermine wound edges
○ Periwound skin (about 4 cm around the wound)
■ Protect the good skin

Surgery Exam 2 (3 decks)

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