Managing Surgical Site Complications

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Evaluating Patient Risk Factors

by the WoundSource Editors

Surgical site infections (SSIs) are the most prevalent surgical wound complications, comprising approximately 15% of all health care–associated infections, with more than 500,000 reported yearly.1 Preventing SSIs is perhaps the best way to prevent further surgical wound complications.

There is not a large, differentiable list of subsets of surgical wound complications that are treated with separate, discrete interventions; many complications, such as wound dehiscence, are direct results of SSIs. As such, an overview is provided with strategies to manage and prevent SSIs.

The process of identifying a developing surgical wound complication may resemble the following scenario: On post-operative day five, the patient may report increased pain and have an elevated white blood cell count. Wound assessment may reveal increased erythema beyond wound margins, cloudy exudate increasing in quantity, and exposure of subcutaneous tissue.

Creating a Plan of Care

Once a surgical wound complication has been identified, a comprehensive wound care plan should be employed. At a minimum, local management of the surgical wound should include:

  • Wound cleansing with a non-cytotoxic agent
  • Periwound skin management
  • Debridement of nonviable or necrotic tissue
  • Appropriate treatment of infection (e.g., Superficial infection may be treated with oral antibiotics, whereas a spreading, deeper infection may necessitate intravenous antibiotics)
  • Moisture balance or exudate management, including dressings to promote moist wound healing
  • Culturing for pathogens before initiation of antibiotic therapy

A classification should also be assigned to the complication; however, it is imperative to note there are no true guidelines for treatment based solely on classification. SSIs are classified as follows:

  • Superficial incisional: involving the skin or subcutaneous tissue within 30 days of the procedure
  • Deep incisional: involving deep soft tissues, such as fascia or muscle within an incision
  • Organ or space surgical wound dehiscence: occurring within 90 days if an implant is involved1

Dehiscence often occurs with SSI and is a complete or partial disruption of wound closure that occurs around five to seven days post-operatively. Dehiscence is associated with increased risk for repeat dehiscence, SSI, and incisional hernia formation.2

Advanced dressings: The plan of care will also include appropriate dressings and/or utilization of advanced therapies; emerging dressing technologies have broadened the spectrum of available options for managing surgical wounds. A study published in The Journal of Tissue Viability focused on surgical wounds healing by secondary intention, which is the mechanism by which dehisced wounds heal, and identified advanced dressings as the most common single treatment for surgical wound complications and SSI.3 Utilize dressings tailored to individual wound conditions; ideally, they will be evidence based with regard to adequate moisture management, ability to decrease pain, and management of bioburden or infection. The type of dressing and frequency of dressing change will be based on dynamic, unique wound characteristics identified through thorough wound assessment.

Cellular and/or tissue-based products (CTPs): These products are topical materials engineered to promote biological repair or regeneration of wound tissue by providing signaling, structural, or cellular elements, some with and some without systems that contain living tissue or cells.4 CTPs are utilized widely in the treatment of acute and chronic wounds, with use mostly guided by Medicare-accepted indications and reimbursement schedules. There are few CTPs with indications specifically for surgical incisions or surgical wound dehiscence, and this may limit availability. One such graft with these indications is a cryopreserved placental allograft created utilizing native components of placental tissue and providing extracellular matrix scaffolding with growth factors and living cells such as fibroblasts, which can play a significant role in the three latter phases of wound healing.4 Although these products may enhance healing, further research is needed to determine whether they should be options in the current standard of care. These products can add significant cost, and therefore utilization should be seen in terms of risk to benefit and cost containment, while keeping the individual patient’s needs in mind.

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Negative pressure wound therapy (NPWT): NPWT is an accepted treatment modality for various types of wounds, including dehisced surgical wounds. The beneficial aspects of NPWT for surgical wound complications involve management of high exudate levels, periwound skin protection, increased granulation tissue formation, reduction of tissue edema, and approximation of wound edges.5 In complete evisceration or delayed fascial closure of abdominal wounds, the use of open abdomen NPWT decreases mortality, decreases the number of dressing changes, reduces the risk of incisional hernia, and affords a higher rate of complete abdominal wall closure, thus effectively decreasing the need for additional surgical reconstructions such as component separations.6

Management of surgical wound complications such as SSIs or dehiscence should be appropriate for the individual needs of the patient and include meticulous assessment, as well as a comprehensive plan of care based on the principles of modern wound management and moist wound healing. Diagnosis of SSIs commonly occurs after discharge following inpatient surgical procedures, and because nearly 75% of surgical procedures are performed on an outpatient basis, many SSIs will be diagnosed in the community setting. Discharge planning should accordingly address the need for prompt identification of early signs and symptoms of potential complications.7

Assessment of Surgical Wound Complications

Surgical wound assessment should begin immediately after surgery. Steps for management of surgical site complications include wound assessment including diagnosis of complications, risk factor identification and minimization, and local wound care including symptom control or prevention of further sequelae.

The same literature-validated tool should be used for each assessment for best identification of changes. Subjective patient assessment is of great importance during this time because the wound is typically covered by a dressing for 48–72 hours post-operatively and can potentially stay intact for up to seven days. Patients’ pain assessment and vital signs and laboratory values such as lactate, white blood cell count, and sedimentation rate can be of particular value in determining early signs and symptoms of post-operative wound complications.

Conclusion

Management of surgical site complications begins with post-operative wound assessment, risk factor identification and minimization, prevention or treatment of SSIs, and local wound care, using evidence-based best practices.

References
1. Centers for Disease Control and Prevention (CDC). Surgical site infection (SSI). 2016. www.cdc.gov/HAI/ssi/faq_ssi.html . Accessed September 12, 2018.
2. Naga Muneiah S, Roopesh Kumar NM, Sabitha P, Prakash GV. Abdominal wound dehiscence: a look into the risk factors. IOSR J Dent Med Sci. 2015;14(10):47–54.
3. Chetter IC, Oswald AV, Fletcher M, Dumville JC, Cullum NA. A survey of patients with surgical wounds healing by secondary intention; an assessment of prevalence, aetiology, duration and management. J Tissue Viability. 2017;26(2):103–7.
4. Pourmoussa A, Gardner DJ, Johnson MB, Wong AK. An update and review of cell-based wound dressings and their integration into clinical practice. Ann Transl Med. 2016;4(23):457.
5 . Bryant RA, Nix DP. Acute & Chronic Wounds: Current Management Concepts. 5th ed. St. Louis, MO: Elsevier; 2016.
6. National Institute for Health and Clinical Excellence (NICE). Surgical site infection: evidence update June 2013. www.nice.org.uk/guidance/cg74/evidence/ evidence-update-241969645. Accessed September 11, 2018.
7. Managram AJ, Horan TC, Pearson, ML, Silver, LC, Jarvis ER. Guideline for prevention of surgical site infection, 1999. Infect Control Hosp Epidemiol 1999;20(4):247–78.

The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.

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