Week 9 Flashcards
Name the six goals of wound care
reduce ecchymoses reduce “dead space” prevent hematoma and seroma formation prevent infection preserve function preserve appearance
What are the seven complications of wound healing?
ecchymoses hematomas seromas infection wound dehiscence bad scarring loss of function
What are the causes of ecchymoses? How can we reduce their severity?
Cause – blood leaks into the skin and often into the subcutaneous fat
Reduction techniques–
careful handling of tissues during surgery and repair
avoid use of excessive volume of local anesthesia
Proper pressure bandaging (tight enough to prevent oozing of blood in the tissue but not to cut off normal circulation) for 24 hours
intermittent ice packs for 2-3 days
What causes hematomas?
Causes – post-op sustained capillary bed leakage or venous/arterial bleeding from the raw surface of the surgical site or within a traumatic lesion
What pre-operative steps can be taken to reduce the occurrence of hematomas?
Pre-op Prevention:
- Assess each patient’s general health status and history of coagulopathies
- Identify any history of significant bleeding during prior low-risk surgical or dental procedures.
- Identify common medical problems - renal dysfunction, hypertension, liver disease, and abnormal coagulation which may affect healing.
- Screen for alcohol abuse, which impairs coagulation of platelets and decreases vasoconstriction.
- Identify all medications that patient takes both daily and prn and the last date taken.
T or F: aspirin, Alka-Seltzer, ibuprofen, and clopidogrel (Plavix) have been shown to increase risk of hemorrhage more than warfarin!
TRUE
(NOTE: Gingko biloba, garlic, ginseng, ginger, feverfew, vitamin E and saw palmetto have all been implicated in increased operative and post-operative bleeding)
T or F: all prescribed and non-prescribed anticoagulants must be stopped 1 week prior to dermatologic surgery
False
continue warfarin or clopidogrel (Plavix) to avoid thrombotic events. Avoid use of non-medically necessary supplements and anticoagulants for 1 week. j
What intraoperative steps can be taken to reduce bleeding and hematomas?
- Produce careful surgical hemostasis
- Use “quilting” (figure-of-8) sutures to tie off “bleeders”
- Place drains when needed
- Choose Quikclot or Surgicel gels: help reduce surgical time, lessen the necessity for drains, overall decrease in operative complications and increased quality of care for patients
What post-op management steps can reduce bleeding and hematomas?
Pressure bandaging:
- For 24 hours post-op excisional surgery use hypoallergenic paper tape or elastic wrap such as Coban to hold in place 2 twice-folded 4x4s
- Apply ice packs over the dressing for 20 minutes every hour for six hours for patients on anticoagulant medications or who have excessive bleeding during surgery
- Consider prolonged use of drains and “suction” drains
Contrast the treatments for expanding or clotted hematomas compared to fluctuant ones
Hematoma expanding or clotted:
1. Partially or completely re-open the surgical wound
2. Identify any oozing vessels
3. Stop bleeding by suture ligation or electrosurgery
4. Do a full-layer re-closure
5. Insert a drain if indicated
6. If there is a high risk of more bleeding or the wound is contaminated let the wound heal by secondary intention!
Hematoma is a fluctuant (liquefied) mass:
1. Aspirate – use large needle directly through the wound
2. Repeat daily until hematoma stops forming
3. Continue using pressure bandaging
Does prophylaxis with antibiotics for routine or elective MS generally lower the risk of infection?
No- it increases the risk of infection (kills off good bugs too)
What are current guidelines for withholding antiplatelet drugs and other anticoagulants?
Delay surgery for three days after the last dose of aspirin.
Continue warfarin or clopidogrel (Plavix) to avoid thrombotic events.
Avoid use of non-medically necessary supplements and anticoagulants for 1 week
BOTTOM LINE: IN EACH CASE weigh the real and increased risk of bleeding with the lower but potentially life-threatening risk of a thrombotic event if an anticoagulant is temporarily discontinued.
Prophylactic antibiotics are indicated in patients with traumatic wounds in what three situations?
- prosthetic cardiac valve
- hx of infective endocarditis
- congenital heart disease
What are the arguments against using antibiotics in traumatic wounds?
- There are limited indications for the routine use of antibiotics in lacerations.
- There is a single reliable study showing an advantage to prophylactic oral antibiotic use of penicillin for intraoral wounds.
- Clean, properly debrided early traumatic wounds in patients that are not immune compromised do not require prophylactic antibiotics.
T or F: wounds can not dehisce as long as sutures are in place.
False
dehiscence (wound edges splitting open) can occur with the sutures in place or following their removal
