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Istrazuvanje Za Otvoreni Rani Kaj Kucinja

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   RI REF COMMUNICATIONS   \ \CMMUNICATIONS BREVES Open wound management for treatment of postoperative infections in eight dogs Michael S. Bauer, Audrey M. Remediosand Bryden J. Stanley Postoperative infections are major contributing fac- tors to increased morbidity, prolonged hospitaliza-tion, added expense, and surgical failures. Treatment options include systemic antibiotics alone, surgical debridement and primary or delayed primary closure, various drainage techniques, andopen wound manage- ment followed by secondary closure or second inten- tion healing  1,2). Management is based on clinical judgement regarding theseverity of infection, condi- tion of tissues, presence of foreign materials, and fail- ure of response toless aggressive management. Not all infected wounds require openmanagement, but when indicated, benefits include optimal drainage, and daily inspection, debridement and lavage of the tissues. The eight dogs in this case series were treated at the Western College of Veterinary Medicine  WCVM between September 1986 and April 1988  Table 1). Postoperative infections developed either while hospitalized at WCVM or while animals were under the care of a referring veterinarian. Six infections developed following orthopedic surgery, onefollowed delayed primary closure of a softtissue wound, and onefollowed jejunal resection and anastomosis. Wound management following diagnosis of infection was similar in all dogs. Dog 1 developed an infection of the left stifle joint and surrounding softtissues two months following extracapsular repair of a ruptured cranial cruciate liga- ment. Number 5 polyester fiber suture (American Cyanamid Co., PearlRiver, New York)had been used to perform a lateral retinacularimbrication.   drain- ing tract and local swelling had been unsuccessfully treated with systemic antibiotics for one monthby thereferringveterinarian. Initial management at WCVM consisted of removalof the suture material,surgical debridement, bacterial culture, antibiotic sensitiv- ity determination, and open wound management. The infection extended into the joint Dog 2 sustained a distal femoral fracture which was repairedusing a 6-hole, 3.5 mm bone plate one year prior to the development of a draining tract. Systemic antibiotics, given for one month, were unsuccessful in decreasingdrainage. The dog subsequently developed an acute nonweight bearing lameness and was referred. Can Vet J 1989; 30: 46-49 Radiography revealed amidshaftfemoral fracture at the proximal end of the plate and osteolysis around the proximal screw. The plate was removedand tissue and screws weresubmitted forbacterial culture and antibioticsensitivity determination. The fracture was repaired using a 10-hole, 3.5 mm bone plate. Cefazolin  30 mg/kg, tid, IV)  Eli Lilly Inc., Toronto, Ontario) was administered after harvesting th tissue and implant forculture. Eight days after surgery,the inci- sion site appeared grossly infected. Dog 3 sustained a 12 cm laceration in the left flank whichwas treated as anopen wound for two days followed by delayed primary closure. The wound appeared infected on the sixth postoperative day. The remaining five dogs developed infections fol- lowing routine surgical procedures (Table 1). I igure 1. Lavage of an open wound of the left lateral thigh with tap water using a sterile hand-held nozzle  case 8). The dog is in right lateral recumbency. S: Stifle. Wound management was similar in all dogs. As soon as infection was suspected,material forculture was obtained by fine needle aspiration or by swabbingof purulent discharge. Appropriate systemic antibio- tics, based on sensitivity studies, were begun (Table 1). Under general anesthesia, each wound wasopenedand lavaged usinga sterile hand-held spraynozzle that delivered warm (20-25°C) tap water at apressure of 1-2 psi  6.9-13.8 kPa) and volume of approximately 2 L/min. The procedurewasperformed in an operat- ing room equipped with asurgery tablethat drained into a sink  Figure 1). Following an initial 10-30 min lavage period, remaining debris and necrotic-appearing tissues were excised. Thewounds were bandaged with Can Vet J Volume 30, January1989 Department of Veterinary Anesthesiology, Radiology and Surgery, Western College of Veterinary Medicine, Univer- sity of Saskatchewan, Saskatoon, Saskatchewan S7N OWO. 46   j  ;D I -::::-,:::N7::: .,:..: .: .: .......... .......   d Com lecom v dqy. hea ... ........ ....... .LJOstridlum Secondary Com ely   rtgem   y hi ed   If   ::-,:: ........ .. C. h-A0--t-i .....   id i   bs.lu gens heWed- ............... wet-to-dry dressings (3) using sterile gauzes and 0.05 chiorhexidine  AyerstLaboratories, Montreal, Quebec) covered by cotton, gauze and tape. Orthopedic stockinettes, tied over the animal s back, were used to secure dressings involving the limbs. In areas not suitablefor application of secure bandages, 2-0 nylon (Cyanamid Canada Inc., Montreal, Quebec) was used to construct numerous looped eyelets around the defect. Gauze sponges were held in place with umbilical tape laced through the eyelets  Figure 2). Collars were used to prevent self mutilation. Bandages were changed daily and the wounds lavaged for 5-20 min as previously described. Intravenous oxymorphone (0.1I mg/kg, IV) (Dupont Pharmaceuticals, Dupont Canada Inc., Mississauga, Ontario) was used for analgesia and restraint forthe initial bandage changes. All wounds healed completely. Two wounds  cases 3 and 5) healed by second intention. Each woundbegan to produce granulation tissue after 3-5 days of man- agement. Thewounds allowed to heal by second inten- tion were covered with healthy granulation tissueafter six days and completely closed within 30 days. In case 3, the wound healed by second intention and the dog had decreased range of motion in the left coxofemoral joint due to wound contraction. The remaining six wounds were closed 6-9 days after the onset of open wound management. In each case, granulation tissue covered the wound and necrotic-appearing tissue was absent. There was no growth on routine  cases2,6,7) or quantitative  cases 1,8) bacterial cultures prior to closure. Four of six wounds treated by secondary closure healed without additional complication or treatments. The distal 2 cm of one wound  case 1) dehisced.Antibiotics were continued and thedefect healed by second inten- tion in 14 days. One dog  case 2) developed a small subcutaneous abscess containing Pseudomonas aeruginosa, and was successfully treated with systemic Can Vet J Volume 30, January 198947  :? Figure 2.   dressing over the open wound in case 8 held securely by use of umbilical tape laced through preplacednylon eyelets. gentamicin  2 mg/kg, tid, IM)  Schering Canada Inc., Pointe Claire, Quebec). This animal had been treated witha closed suction drain at the timeof closure. The drain was left in place for five days and gentamicin was given forten days. Successful management of wound infection is dependent on decreasing the bacterial loadwithin the wound and providing an optimal environment for hostresistance  4). Bacterial load can bedecreased with appropriate systemic antibiotics, wound lavage and continual drainage  4). Host defenses are dependent on systemic as well aslocal wound factors. Systemic host defense mechanisms canbe optimized by manag- ing such factors as hypovolemia,hypoproteinemia, malnutrition, or diabetes mellitus. Enhancement of local host resistanceconsists of removing foreigndebris, necrotic tissue and establishing drainage  1,4). The decision to use open wound management instead of drains or medical management alone in ourdogs was based on clinical judgement involving the severity of infection, presence of existing foreign material, presence of necrotic tissues, and lack of response to less aggressivetreatment. Chlorhexidine was chosen for the wet-to-dry dressing because of its bactericidal and nonirritating properties  5). Saline ortap water mighthavebeen equally effective. Wound lavage is effective in removing bacteria and infection-promoting debris  1,2,4).   multitude of lavagesolutions and delivery systems exist  1,2,4-8). An ideal lavagesolution is sterile, isotonic and isosmotic  2). Tap water does not meet these require- ments. However, we felt the potential benefits and higure 3. Healthyappearinggranulation tissue seven days following open wound management with tap water lavage  case 8). positive clinical results at our hospital, outweighed the facts that tap water is hypotonic and nonsterile. Tap water effectively reduces surface bacterial num- bers, removes debris, and is minimally irritating to tissues  7,8). The use of tap water lavage as a solution is convenient and inexpensive, and the use of large volumes is practical. High pressure  25-60 psi) versus low pressure  0.5- 10 psi) lavagehas been investigated  6,8-10). The speculation that high pressure lavage may drivebacteria into deeper tissue has been disproven (6). However, high pressure lavage may cause tissue damage resulting in infection (6). High pressure wound lavage has been shown to be more effective in decreas-ing bacterial numbers than low pressure lavage  8-10). However, these investigations involved single lavage of experimentally infected wounds with immediate closure  8,10). One advantage of open wound manage- ment was dailylavage. The effectiveness and ideal pressurefor repeated lavage has not been established. Single, low pressure lavage decreases soil material Can Vet J Volume 30, January 1989 48  capableof promoting infection by up to 48Wo  10). Thenumber of bacteria removed is proportional to lavage volume  1,1 1). We hoped to decrease bacterial load andremove exudate and debris on a dailybasis using multiple, low pressure, large-volume lavage. Low pressure lavage was selectedfor two reasons. High pressure lavage systems deliver a small stream making lavage ofmassive wounds impractical, and, becauseof the apparent pain associated with high pressurelavage, generalanesthesia is usuallyrequired. Using low pressure, we were able to lavage large wounds by initially using narcotics for analgesia, andfound that dogs tolerated lavage without any analgesic on subsequent sessions. The development of nosocomial infection during open wound management was a potential complica- tion. However by using sterile techniques during lavage and bandage changes, adequately securingthe ban- dages, andpromoting drainage and host defence mech- anisms, nosocomial infection was avoided in seven of eight cases. The only dog in our study that developed an infection following secondary closure was treated by use of a drain;the drain may have provided a route for bacteria to ascend. Open wound management is an effective method of treating selected postoperative infections Closure options following open wound management include delayed primary closure, secondary closure, and second intentionhealing  1,2). Delayedprimary closure is usually performed within five daysof wounding and precedes the development of granula- tion tissue (2). We believe this type of closure is usually inappropriate and may have led to postoperative infec- tion in case 3. Secondary closure usually is performed afterfive days, once necrotic-appearing tissue is absent and granulation tissue develops  2). Second intentionhealinginvolves formation ofgranulation tissue, epithelialization and contraction without surgical closure (2). The closure technique chosen in our dogs wasbasedon owner compliance, appearance of the wound, and bacterialcultures  five dogs). Secondary closure wasused insix of eight cases. Healthy appearing granula- tion tissue was present in each case. Bacteria were not isolated from routine  threecases) or quantitative cultures (two cases) obtained prior to closure. Quan- titative bacterialcultures are advocated prior to wound closure in people (4). Our lab requires 1 cm3 of tissue which is often impractical or impossi l to harvest from canine wounds. In our series we used bacterial cultures as an ancillary test once we felt closure was indicated. Quantitative bacterial cultures were not per- formed in all dogsbecause of insufficient amounts of tissue. Visual inspection and clinical judgement, based on the presence of healthy appearing granulation tissue and absence of necrotic-appearing tissue, appear to be accurate indications forsafeclosure. Two wounds were left to heal by second intention becauseof lack of ownercompliance  case 3) and to avoid a second generalanesthetic in a dog with a rapidly closing wound  case 5). Wound contraction may result in disfigurement or, as demonstrated in case 3, decreased limb mobility (2). In retrospect, secondary closure would have been anappropriate alternative to second intention healing. In summary, open wound management is an effec- tive method of treating selected postoperative infec- tions. We felt that wound lavage was an important aspect of treatment; however, controlled studies are needed to compare the effectiveness of multiple, low pressuretap water lavage to othertreatment modalities. Cvi References 1. Swaim SF. Surgery of Traumatized Skin: Management and Reconstruction in the Dog and Cat.Philadelphia: W Saunders Co., 1980: 70-213. 2. Daly WR. Wound infection. In: Slatter DH, ed. Textbook of Small Animal Surgery.Philadelphia: W Saunders Co., 1985: 37-51. 3. Swaim SF,WilhalfD. The physics, physiology, and chemistry of bandagingopen wounds. Compend Contin Educ Pract Vet 1985; 7: 146-156. 4. Tobin GR. Closure ofcontaminated wounds. Symposium on wound management. Surg Clin North  m 1984; 64: 639-652. 5. Amber El, Henderson RA,Swaim SF, Gray BW.   comparison of antimicrobial efficacy and tissue regeneration of four anti- septics on canine wounds. Vet Surg 1983; 12: 63-68. 6. Wheeler CB, Rodeheaver GT, ThackerJG,Edgerton MT, Edlich RF. Side effects of high pressure irrigation. Surg Gynecol Obstet 1976; 143: 775-778. 7. Branemark P, Ekholm R. Tissue injury caused by wound disinfection. J Bone Joint Surg [Am] 1967; 49-A: 48-62. 8. Gross A, Cutright DE, BhaskarSN. Effectiveness of pulsating water jet lavage on treatment of contaminated crush wounds.  m J Surg 1972; 124: 373-377. 9. Madden J, Edlich RF, Schauerhamer R, Prusak M, Borner J, Wangensteen OH. Applicationof principles of fluid dynamics to surgical wound irrigation. Curr Top Surg Res 1971; 3: 85. 10. Rodeheaver GT, Pettry D,ThackerJG,Edgerton MT, Edlich RF. Wound cleansing by high pressure irrigation. Surg Gynecol Obstet 1975; 141: 357-362. 11. Singleton AO, Julian J. An experimental evaluation of methods used to prevent infection in wounds which havebeen con- taminated with feces. Ann Surg 1960; 151: 912-916. Can Vet J Volume 30, January198949

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