WOUND MANAGEMENT
Category Major Risk Factor
presence of 1 = high risk of surgical site complication
Moderate Risk Factor presence of 2 ≥ high risk of surgical site complication
Patient-related risk factor o BMI ≥ 40kg/m2 or ≤ 18kg/m2
o Uncontrolled insulin dependent diabetes mellitus o Renal dialysis
o ASA Physical Status >II o Age< 1 year or >75 years o BMI 30–39.9kg/m2 o Immunosuppression
Procedural-related risk factor
o Extended duration of surgery* o Emergency surgery o Hypothermia
o Anaemia / blood transfusion o High wound tension after closure o Dual antiplatelet treatment
o Suboptimal timing or omission of prophylactic antibiotics o Tissue trauma/large area of dissection / large area of undermining
(adapted from ref 6; the risk factors represented in this table are examples only and not an exhaustive list).
*Defined as >T (hours) which is dependent on the type of surgical procedure, and is the 75th centile of duration of surgery for a particular procedure, e.g. coronary artery bypass graft has a T of 5 hours and caesarean section has a T of 1 hour
Figure 1: General patient and procedural risk factors for surgical site complications
Technological advances in design of NPWT system now drives the prophylactic use to support the closure of surgical incisions by primary intention.6
The mechanism of
action is not completely understood although resultant benefits appear to be through the combined effects of reduced lateral tension at the incisional wound edges, improved lymphatic drainage and reduction in haematoma and seroma.6
Such has been the volume of high-quality evidence reporting on NPWT prophylaxis, the National Institute of Health and Care Excellence (NICE) has published guidance on using a specific device in the UK NHS to help prevent SSI following surgery,7
known
as the Pico Single-use Negative Pressure Wound Therapy System (sNPWT). Pico sNPWT is a canister-free system consisting of a sterile pump and multi- layered adhesive dressings. Each dressing has four layers: a silicone adhesive wound contact layer, which is designed to minimise pain and damage during peel- back and to reduce lateral tension; an absorbent layer to remove exudate and bacteria from the wound; and a top film layer, which acts as a physical barrier and allows moisture to evaporate. Pico sNPWT differs from conventional negative pressure
Brompton and Harefield infection score
SSI predictive score for CABG +/- additional procedures Diabetic =
1 OR HbA1c >7.5% = 3 BMI ≥35 = 2 Female = 2 Emergency = 2 LVEF <45% = 1
Group Low-risk Medium-risk High-risk Score 0-1 2-3 ≥4 % patients 66 26 8 SSI risk 2.6 6 16
wound dressings in that it has no separate canister, is portable and disposable and has a proprietary dressing layer with Airlock Technology that is designed to allow even distribution of negative pressure across the incision and zone of injury.7
NICE recommendations explicitly state
that: l Evidence supports the case for adopting Pico negative pressure wound dressings for closed surgical incisions in the NHS. They are associated with fewer surgical site infections and seromas compared with standard wound dressings.7
l Pico negative pressure wound dressings should be considered as an option for closed surgical incisions in people who are at high risk of developing surgical site infections.7
l Cost modelling suggests that Pico negative pressure wound dressings provide extra clinical benefits at a similar overall cost compared with standard wound dressings.7
However, the effectiveness of the guidance is dependent upon use being rationalised to use on people considered ‘at-risk’ of developing an SSI. This implies that standardised widespread adoption of sNPWT
prophylaxis will result in an unfavourable cost-benefit ratio.
Clear cost savings using sNPWT prophylaxis can be achieved, from earlier discharge of patients and reductions in the sometimes substantial treatment costs due to managing the consequences of SSIs.3,6 Furthermore, the prevention of SSIs becomes even more pertinent given the current health crisis due to COVID-19, where discharging patients with confidence frees up critical healthcare professional (HCP) resource and can facilitate remote patient management.8 However, the cost of the technology in the context of the estimated global volume of surgical procedures may surpass the cost burden of SSIs. Rationalising the use of sNPWT prophylaxis to patients and procedures considered at risk of developing an SSI is not standardising practice; it requires identifying the appropriate candidates based upon an individual risk assessment and prescribing the prophylactic therapy, integrating application of the therapy in theatre without comprising the surgical plan and monitoring post-operatively to ensure continuous delivery of NPWT and fluid handling is united to a patient’s rehabilitation regimen and discharge plan. By comparison, there is prescient that standardised practice within surgical care can significantly improve patient safety outcomes.5
Moreover, simply adhering to a specific protocol correlates with improved outcomes, which alone has been shown to reduce SSIs,5
sNPWT prophylaxis.9
Figure 2: pre-operative patient risk scoring process used at Hospital Bristol NHS Foundation Trust (adapted from ref 12)
72 l
WWW.CLINICALSERVICESJOURNAL.COM
Adherence to a protocol relies upon standardising clinical practice in order to embed it, which can be challenging within surgical care as the patient pathway spans multiple departments, locations and multidisciplinary teams. Information transfer and communication across the surgical continuum of care has been identified as a key component in optimising safety
OCTOBER 2020 as well as when incorporating
Page 1 |
Page 2 |
Page 3 |
Page 4 |
Page 5 |
Page 6 |
Page 7 |
Page 8 |
Page 9 |
Page 10 |
Page 11 |
Page 12 |
Page 13 |
Page 14 |
Page 15 |
Page 16 |
Page 17 |
Page 18 |
Page 19 |
Page 20 |
Page 21 |
Page 22 |
Page 23 |
Page 24 |
Page 25 |
Page 26 |
Page 27 |
Page 28 |
Page 29 |
Page 30 |
Page 31 |
Page 32 |
Page 33 |
Page 34 |
Page 35 |
Page 36 |
Page 37 |
Page 38 |
Page 39 |
Page 40 |
Page 41 |
Page 42 |
Page 43 |
Page 44 |
Page 45 |
Page 46 |
Page 47 |
Page 48 |
Page 49 |
Page 50 |
Page 51 |
Page 52 |
Page 53 |
Page 54 |
Page 55 |
Page 56 |
Page 57 |
Page 58 |
Page 59 |
Page 60 |
Page 61 |
Page 62 |
Page 63 |
Page 64 |
Page 65 |
Page 66 |
Page 67 |
Page 68 |
Page 69 |
Page 70 |
Page 71 |
Page 72 |
Page 73 |
Page 74 |
Page 75 |
Page 76 |
Page 77 |
Page 78 |
Page 79 |
Page 80 |
Page 81 |
Page 82 |
Page 83 |
Page 84 |
Page 85 |
Page 86 |
Page 87 |
Page 88 |
Page 89 |
Page 90 |
Page 91 |
Page 92
