Thursday, April 10, 2008

Sutures and Wound Care

How do you have patients take care of their incisions? I usually tell them that it is okay to shower (no tub baths) the day after surgery. I encourage the use of soap and water. I think it helps keep the incision clean. It also encourages them to move. There are exceptions to this--skin grafts, hand surgeries, etc--where they are told to keep the dressing clean and dry.

I read an article recently regarding this basic premise of postop wound care and how it affects the sutures used for wound closure. The article was by Raghu Athre, M.D., of the Department of Otolaryngology — Head and Neck Surgery at Southwestern Medical Center, University of Texas, Dallas. The study was suggested by an observation in postsurgical patients after they had undergone surgical treatment for head and/or neck cancer.

Owing to the equivalent scar profile of absorbable suture and permanent suture, and the ability of the surgeon to conserve time and minimize patient anxiety by using absorbable suture, most surgical patients have the superficial layer of their surgical wounds closed with 5-0 fast-absorbing gut suture. The main criterion for this decision is surgeon preference. At 1-week follow-up, a subset of these patients show dehiscence of the most superficial layer of skin closure. The superficial epidermis pulls apart, and no evidence of the fast-absorbing gut sutures can be found. The separated wound closes by secondary intention over the ensuing 3 to 4 weeks without significant complications. Extensive questioning of these patients reveals that most of them used hydrogen peroxide to clean their wounds postoperatively. The question of whether hydrogen peroxide affects the tensile strength of fast-absorbing gut sutures by increasing its degradation rate became the focus of this study.

So he and his team conducted a laboratory study comparing the tensile strength of nylon, polypropylene and fast-absorbing gut sutures. In the study, each suture type was treated with either three percent hydrogen peroxide or water for a period of five days, emulating wound care following a surgery. Then an In-Spec 2200 bench-top tester was used to assess the maximum tension that the sutures could bear prior to breaking. The results:

On preliminary visual examination, nylon and polypropylene sutures did not appear to be affected by either water or hydrogen peroxide. Both groups of suture samples retained their shape, color, and general feel when handled. The fast-absorbing gut suture, however, was different. The fast-absorbing gut suture subjected to water did not appear to be affected compared with control suture. The fast-absorbing gut suture subjected to hydrogen peroxide rinses completely disintegrated during handling. It could not hold any tension at all, and in 1 case, the hydrogen peroxide–treated suture had completely degraded; the only thing left behind was the needle.

Creating a cosmetically appealing scar that does not affect form and function is one of the important endpoints of a surgical procedure. Complications such as wound infection, wound dehiscence, hypertrophic scarring and contractures may all result from improper closure techniques, improper wound-care regimens — as well as patient factors such as nutritional status and medical comorbidities.

FUNDAMENTAL CHANGE IN THOUGHT NEEDED

Many standard superficial wound-care regimens include water, soapy water, antibiotic ointments (neosporin, bacitracin, bactroban, etc), hydrogen peroxide and Dakin's solution, or any combination of these. Patients are very likely to use hydrogen peroxide unless told not to do so. We surgeons need to give specific instructions to patients for home care. [This could also be said about any physician who repairs lacerations, etc.] We may want to strongly advise them to avoid use hydrogen peroxide, and to select saline or soap and water for wound cleaning instead.

The results of this study underscore the importance of the agents used in wound care following a surgery. Hydrogen peroxide should be avoided as a superficial wound-care regimen where fast-absorbing gut sutures are used.

REFERENCE

Athre RS, Park J, Leach JL. The effect of a hydrogen peroxide wound care regimen on tensile strength of suture. Arch Facial Plast Surg. 2007;9:281-284.

Dr RS Athre interviewed by Cosmetic Surgery Times on his study; April 2008 Issue

5 comments:

Eric, AKA The Pragmatic Caregiver said...

While I'd never use H202 for wound care (Powerful oxidizer near fragile cells? Pass. I'm a CHX kind of guy.), I can see why patients would.

1) Visibly effective - the foaming action = doing something.

2) Works better than water at removing stains from skin prep, especially betadine or that weird blue-green stuff. It also cleans off the blood/serum crusties.

3) Germs are bad.

My suggestions to improve compliance:

A) Include your preferred post-op wound care instructions before the procedure, where possible, and make direct emphasis as to the consequences of deviating from the recommendations.

B) If there's prep or serous residue left after closing, make some minor attempt to blot up. I've personally witnessed people being deeply alarmed about the wide prep field and damaging the closures in the process of removing their betadine tan.

C) Send them home with a two-day supply of your preferred care method, even if it's something as simple as mild soap and water, or saline. Even if they say they already have it. At the price of procedures, a starter supply of saline or a bottle of mild liquid soap is a tiny percentage of the total fee and keeps people from having to stop and do something special, or remembering where they put the stuff they got a week before.

E

rlbates said...

Thanks, Eric. Good suggestions.

Mimi Lenox said...

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Message In a Bottle

Dreaming again said...

C .. is incredibly helpful! Even if I have it, I don't have to find it in my post op/proceedural state.

I, as a patient despise suture and wound care. I keloid something terrible. I'll never forget my poor dermatologist afte he removed my skin cancer saying "you just scar ugly. Stop it"

Chrysalis Angel said...

Great suggestions, Eric gave. Interesting post.