Thank you for joining this webinar. This is a session that has been, done in collaboration with, NBS and their select everyday range. I've been really pleased to be invited to talk about this subject.
It's actually really something that when you dig down into it, you think about post-op wound management, simple wound management, sort of the everyday surgical, elective surgery. It's just something that is just done. And actually there's a lot of depths in why things might go wrong.
I've been looking into the surgical site infections and why we, how we measure whether surgery's been successful and these kind of things. So really what I'm going to focus on in this session is how to look at post-op, wounds, the reasons why they break down, some of the things that you can think about and some of the strategies that you can use for post-op recovery. So I'm Georgie Hollis.
I, I'm a lot. I'm Georgie Hollis. I, set up the Banaging Angels probably around 2014.
I've been involved with wound management for many years, probably around 20 years now just focusing on the veterinary side. I call myself a wound technology specialist mainly because my interests are in the science and the application of technologies for wound healing, but specifically transferring some of the technologies from human healthcare to animals and exploring the regulatory and the sort of the applications of that in the veterinary world. So my feeling is that if animals can benefit from the technologies that are being developed for humans and that that should be, that should be the way forward.
So. So to crack on Covering in this session, what I'll be going through is really the physiology of wound healing as I usually do, but it's always good to go through that and comparing sort of post-operative wounds to open wounds. Some of the common wound complications, I'm gonna talk a little bit about surgical site infections and why I think that's not the main thing to aim to review, but, really what the background reason is to some of these surgical.
Site infections, some of the factors that contribute to wound complications. So I'll dig into why that happens. At some of the wound protection methods, so covering really the post-op dressing, sort of the timeline, well, how long you should leave dressings on, sort of the, for elective surgery, collars and bandaging and sort of the, the, when you use which, and a little bit of home management of post-operative wounds.
What can the client do? Introducing the word concordance instead. Compliance.
That's very much a NHS, sort of a human healthcare word, where it means a partnership as opposed to trying to convince someone to do what you want them to do. And I've just got a little bit on the, quality improvement and how you use these SSI figures if you want to really improve what you do and, and just to, motivate the team to maybe focus on some of the areas that may be causing the SSI's. So the physiology of wound healing is really the same whether it's an elective surgery or if it's open wound management.
So hemostasis, obviously good hemostasis we want when we're dealing with a surgical wound is to manage the hemostasis effectively. And when you have an open wound, hemostasis does it's, does its thing. It stops the bleeding.
It stops the patients bleeding to death hopefully, and platelet aggregation around the site of the wound will then cause a fibrine seal to block any, vessels that may have been, contributing to bleeding. It stops, it means that the patient, doesn't bleed out effectively and that platelet aggregation at the site of injury. They stick to the collagen fibres in the tissues.
We are all made up of about 80% collagen, thankfully. I probably need a bit more than I used to have, but those collagen fibres will attract the platelets. The platelets will stick to those fibres and those platelets then release their contents into the wound and that's the magic of the stimulation of inflammation.
So inflammation will only happen if your platelets start to release their contents into the wound. No platelets, you don't get the typical inflammation that you should do. And inflammation is a natural process.
It is the body's way of cleaning up the wound. It begins with neutrophils that, come to the site of injury. Their role is to help, annihilate any bacteria or any, any potential contaminants that could potentially cause infection.
They use their reactive oxygen species and lots of, their chemical warfare, if you like to help. Neutralise bacteria and then late inflammation is where you have macrophages that will come along and they will start to produce proteases that break down the dead stuff and they break down the bacteria that are left in the wound and they produce through these proteases, this protein soup, which really looks like slough and yellow stuff. And this yellow stuff is most, Visible really within about 2 to 4 days after injury, and that's when those macrophages have done a whole lot of work in breaking down dead stuff, producing these proteases.
And our job when we're managing wounds, really, if it's an open wound, is if we can help the macrophages along by debriding these wounds, lavaging these wounds, getting rid of as much dead stuff as we can. We actually reduce the amount of proteases that the macrophages need to produce and they get to a point where the wound bed is clean more quickly, which means that they then stimulate granulation tissue formation is the body's way of saying, OK, the coast is clear. We're now ready for you to bring in the vascular tissue and to start remodelling.
And remodelling is where you start to get new tissue growth, collagen deposition in the wound, fibroblasts start to lay down collagen. And those fibroblasts are really critical. They're also killed by chlorhexidine, so I get very upset when people use, hibby or scrub or chlorhexidine on granulating wounds because those poor fibroblasts are laying down collagen as a matrix.
It's for vascular tissue to grow into so that you can get your lovely healthy granulation wound beds. So I should have explained this poor cat. This is an image of a cat that, was actually in the Cayman Islands and it was in a charity practise.
The cat had been attacked by a dog and obviously it's got a pretty, considerable wound. And due to the resources that they had available there, they actually managed this wound very simply through lavage, good wound debridement, waiting for granulation tissue to form, supporting the process by keeping the wound bed moist, a tie of dressing was ideal here and because this was a young cat, the process of healing. Progressed really well and as you, as is physiologically ideal.
So when we're managing wounds, we're aiming to go with the physiology as much as possible. There's no product on the planet that will make a wound heal faster than is physiologically possible. But what we want to do is we want to make sure that each stage of healing can progress in the most efficient way possible.
So getting through inflammation efficiently, getting to about 4 days post injury, we should then start to see granulation tissue forming. We can then support that through moist wound healing, creating the optimal environment, protecting the wound from contamination. Debris, interference, everything that might disrupt those new blood vessels growing into that matrix.
So that vascular tissue growing into those collagen fibres will build and build from the base of the wound up. So if you've got a pocketing wound, it will only heal from the bottom up and the edges will only come together once that wound bed is filled with vascular, viable vascular tissue. So, We have a granulation tissue in this, in this image of this cat and you will see that it's looking quite healthy.
It's got a nice raw steak, strawberry jam look to it. Surprisingly, granulation tissue doesn't tend to have any nerve endings, so it doesn't tend to be painful at this point. And you can find that you can often, manage these wounds open with little sedation in many, many cases.
So if you've got the tie over dressings in place, you can often lavage or clean these wounds, with the patient really quite comfortable. And, so your granulation tissue will fill the wound bed, your fibroblasts are laying down collagen. Once the collagen fibres and the granulation tissue in the wound on the, in the picture on the right where it says epithelialization and wound contraction, once those fibres and the vascular tissue has grown to a flat.
And a nice level, you can see the epithelial margin. It's like a little pink margin all the way around the wound starts to create chemical messengers that stimulate the fibroblasts, some of them to turn into myofibroblasts. And these myofibroblasts stimulate wound contraction.
So they will shrink the wound from what may have been an enormous looking traumatic wound. To wounds that are on the body that may shrink by up to 70% of their original size. So the fact with this cat is that, you can see the process kind of in real time.
You're looking at, late inflammation at about 4 or 5 days, maybe a little longer. And you've got a granulation tissue formation at around 10 days, that's looking really quite healthy. And at about 2 to 3 weeks you've got a lovely epithelial wound margin and wound contraction and you can see that this is, is progressing quite well.
There's also a little dot, a white dot in the middle of that picture on the right hand side at the bottom. And that's actually a rogue epithelial cell that has somehow managed to survive in the middle of that wound. And if you look really closely and hopefully in HD maybe, but you often see this little halo of effect where you can see the epithelial margin actually switching off the granulation tissue, production.
So that's what the epithelial margin does. It kind of has a wave of inhibition. At the front of it.
And that's why when you do have grafts and you place a graft, even pinch grafts and punch grafts, they can produce this wave of inhibition of granulation tissue. So you start to have the wound contract from two points. So from the middle of the wound as well as the edges, which is, which is really quite a magical thing.
But that's not what we'll go down. Maybe that's for another time. So the main point of this, this slides just to give you that revision of how wounds heal, that it is a predictable process.
It relies on different kinds of cells stimulating different processes as healing goes on. So platelets, stimulating the inflammatory response, inflammation, aiding the cleanup process. You will end up with a fluffy wound.
More exudate because you've got a flush of lymphatic fluid full of white blood cells and all the things that are going to flush away all the dead stuff. And then you have your fibroblasts stimulating, collagen deposition and laying down collagen, the matrix of granulation starting to fill in and then epithelialization and wound contraction. And it's a beautiful thing.
So, in this case, you will see that this cat actually went on to heal beautifully, and that is actually the process in, in reality of the physiology of what makes us heal. So as Derek Nottenbelt, equine professors always said, there's no evolutionary advantage of a wound that doesn't heal. But what we do want to do is we want to try and help these wounds heal as efficiently as possible.
And with a minimal delay so that we can have an optimal outcome for that patient. So sometimes things don't go to plan. So really focusing on the subject of this session is is wound breakdown, post-operative management of wounds.
They don't always go to plan. So there are really 3 objectives of wound management that we would be aiming for in any kind of wound and even with wounds that are reconstructed or closed, by primary intention. So we're aiming for a functional cosmetic repair, relief of pain and distress and a rapid return to normal use.
So if things do go wrong, that means that potentially healing is delayed, return to normal use is delayed, and, potentially costs increase significantly because obviously the patient may need further surgery or further intervention to to resolve the problem. But things happen, things do go wrong, and there are ways to measure sort of what is a typical, complication rate and I'm sure many practises will be monitoring SSI's in practise to kind of give you a guide of how well you're doing with your post-op, with wounds post-op and what your complications rates are and exploring that. So let's focus on that.
So I thought I'd put an image here of a of a wound that has been closed surgically and you can see that it's got some redness. There are signs, potentially that the wound might break down or there's been areas that are, healing better than others maybe, but you might look at this wound and think, hm, I'm not sure. I'm not sure if this is going to break down or not.
So there are standards for measuring SSI's and surgical site infections. So you may be looking at a basic scale of early identification where you might be just looking at redness, a little bit of exudate. Is there a little bit of a discomfort?
Is the area swollen, to more profound signs of is there an obvious wound breakdown, total dehiscence, is there a deep, surgical site infection? Does it go down to muscle? Does it go down to bone?
And these are the more severe. So monitoring surgical site infections is something that you can do where you can grade those to give you an idea of how serious the complication is. And I think this is something that is caught on in quite a lot of practises and I think in on quite a few practise management systems, there are ways that you can, record post-op review and your rate of, potential complications.
So what I was going to raise here is that I would say that the surgical site infection measure is probably not the measure of the complication as such. It's the measure of the effect of a complication. So my opinion would be that a surgical site infection is usually as a result of something that may have predisposed to it.
So bacteria are opportunists. They are looking for opportunities to find A rich bed of protein, rich material that is probably not well vascularized so that they can create their colony, potentially create a biofilm, and then potentially start to seed bacteria around the wound and cause a localised infection. And then once that localised infection starts to spread even further, then it would become a systemic infection.
But these bacteria are looking for the opportunities and that's where The complications that are, lead to surgical site infections are generally, in my opinion, led by providing the opportunity for that to happen. So I'm being, careful about the way I word it because it's kind of like, If you've got a surgical site infection, an infection is a is the result, the outcome, not necessarily the problem that you need to fix, if you see what I mean. So some of the stats for typical routine veterinary procedures are that surgical site infections are reported at between 2 and 4%.
The more complex the surgery, the more invasive the surgery, the more damage to localised tissue during the surgery, then there's chances of, complication go up. And that's really due to the fact that you have larger structures involved, you have more time in theatre, but I will go onto that in a moment. And there are various reasons for that.
So the main point of this slide is to say the measure of SSI's isn't necessarily the measure of the cause of complication. So let's have a look at what those might be. So number one on the list, and I've kind of gone through in a in a trying to go in a logical manner.
I think most people would be familiar with aseptic technique. I've certainly had a lot of questions where people have asked, what is the best solution to use for skin prep? What is the best process for skin prep, but the focus is often on the, antimicrobial scrub as opposed to the rest of the, the rest of the process.
The actual, influence of, aseptic technique on the rate of surgical site infections is not just the patient, but it's also the environment. So environmental contribution to wound breakdown is around about 50%. So that's the theatre environment that is, the, you know, airflow, making sure that you've got a clean field when you are preparing the patient.
And then the other 50% is the patient preparation and the local, the local management of that wound. So skin prep is only one part of it. Clipping the wound will have an influence.
So if you, clip wounds with a dirty blade, that's going to contribute to, local flora that is increased around the wound, that is going to mean that you can't get, that you may have other microbes available that weren't there originally. The process of asepsis, aseptic technique, you're never going to get a completely clear, clean environment. So all you're doing is you're reducing the risk of the bacteria that is around the wound, that is around the environment so that the number of bacteria that To potentially contaminate that wound during surgery is below a threshold that could cause, infection or multiplication within a, within the normal healing time.
So if you inoculate a wound with enough bacteria, let's say 10 to 6, bacteria per gramme of tissue, if you manage to do that in, in surgery, let's say you get a nice bit of fluff that drops into the wound, then That bacteria in that wound may be enough to stimulate ongoing inflammation so that the wound may break down. So that will contribute to, the incident of a surgical site infection once the bacteria have proliferated. Hopefully that makes sense.
So this is just one of the, one of the factors, but it's generally the one that people think is, is the main cause, of surgical site infection is that, preparing the patient may not have been appropriate, but there's actually many, many more. So other factors that will, contribute to wound breakdown is the breeds and the species variables. So dogs and cats don't heal in the same way.
Cats will actually heal, more slowly through certain phases of healing. They will have a slower granulation tissue formation, I believe. Whereas, dogs may heal slightly differently.
So you may see different, different rates of healing and some Variables between species, but also greyhounds, sighthounds, they have potentially a thinner skin. They have, less elasticity potentially. If you compare a Shar Pei with a greyhound, there's going to be a lot more tissue available in a Shar Pei than there is in a greyhound, but then Shar Pei will also have their own, complications relating to skin disease and and other underlying factors.
Patients with coexisting, skin conditions, co-existing infections, poor nutrition, so, that goes for obese as well as, underweight patients and also temperament and stress. So stress does contribute to, delays in healing and I think there was a study done on humans where they, made incisional wounds on couples and the couples that argued more, apparently their wounds healed more slowly than couples who were, A little bit more compatible, if you like. So I've just put a note here about, greyhounds and tranexamic acid, that, the excessive bleeding and brooding, 36 to 48 hours after surgery may well contribute to wound breakdown.
And complications, in that breed. So I've certainly seen some case studies or or cases where people have asked for help where that has been a considerable factor in the potential for the wounds not to progress as they expected. So another reason why things can break down, and this is a really significant one, duration of surgery.
So for every additional 30 minutes of surgery time, you will increase the risk of surgical site infection by 14 to 17%. So that's quite a profound increase. So lengthy analgesia, prolonged surgery will make a big difference in terms of the risk of surgical site infection and that's that's purely due to The exposure of tissue to, contaminants from the environment.
So add to that that you might be, doing surgery somewhere where it's not ideal. Perhaps you just think, well, I'll just do a quick stitch up, but it doesn't turn out as quick as you hoped it would be. All of these things can, contribute to, extended risk of surgical site infections.
So I'm sure everyone's Be aware of procedures where you may have expected to be in there for 30 minutes or so and then you end up being in there for an awfully lot longer, being aware that that patient is potentially much more at risk of surgical site infections as a result. I guess recommendations would be for that if there is a complex surgery or if there is a reconstruction to be done, making sure that everything's ready beforehand, make sure that the environment is as good as it can be before the surgery, before the patient's anaesthetized so that during surgery everything is available. I know I've I've been in in clinics where you know, that bit of kit that you were looking for isn't actually in the bowl that you were hoping for.
Things aren't ready or things aren't available that you hoped would be there and it causes a delay of 10 minutes or so. It will all add up. So.
So some other causes of wound breakdown, a common one is dead space. So, dead space, should be managed really with drain placement or with a plan of surgery that makes sure that that dead space doesn't, isn't such an issue. Let's say sort of walking suit.
Which is, sort of making sure management of layers, proper sort of, sort of consideration of all of those layers and the dead space that's going to be produced. And if there is dead space, using drains, I've got a picture here of a drain that's been used, in a wound that's been reconstructed and correct use of drains, really important. So this drain is a great attempt, but it, exits, sort of between the shoulder blade.
And then exits down, at the point of gravity below the wound, which is correct, but generally we wouldn't advise that any, drains are exposed dorsally. They should actually be under the skin because potentially if there's contamination on the outside of that drain. At the dorsal aspect, it will, track bacteria and contamination through on the surface of that drain and it's consistently going to be contaminating that wound as the drain is placed.
So correct drain placement, it's surprising how many images we see where, drain placement isn't isn't always correct. And I think most of the specialists that I've spoken to, recently, would probably advocate more for an active drain. So, the, the grenade type drains where, that is a little bit more, efficient at draining, .
Dead space or seroma or exudate that builds in these areas, but you can also measure the exudate and the and the fluid that comes off if you use these active drains. So you actually know whether this wound is, increasing in production of exudate or if it's decreasing. And ideally what you should see is that these wounds after about 4 days, once the inflammatory process subsides, you should see that that exudate reduces to a point where, production.
Levels out and you stop, you should be able to get to a level where, that wound no longer requires the drain. If you do get a seroma or if you do get swelling, so a picture of this dog here in the corner, one of the ways to manage that, I've, I've certainly seen one recently where, the, clinician was draining that daily, using a syringe. It's probably better not to, puncture the outside because you, and to insert a syringe, even if you swab the tissue.
You may well introduce more contamination into that wound and you could risk, more infection, getting in an introduction of bacteria. So what I should have said earlier is most, many of the surgical site infections, many of the wound complications due to wound infection. From a surgical point of view, and elective surgery, most of the surgical site infections tend to be the patient's own flora and the local flora that has contaminated the wound.
So that comes down to aseptic technique again, minimising the amount of flora that can contaminate the wound during surgery, but also putting a needle into the seroma is going to potentially introduce bacteria that's on the surface of the skin. Even if the needle is sterile, it may, push bacteria. Staph intermedia into the wound and you risk that becoming infected.
So, general management of seroma is hot or a cold compress. So you do that alter alternating, so hot to cold, a couple of times a day. Some compression to help that, exudate kind of to give you kind of that osmotic sort of, a pressure that against the exudate so it doesn't keep filling up the hole.
And, if you've got a well fitting pet shirt, that's where a snug fit is really important. And you can also put padding underneath those, pet shirts to come and reinforce that pressure. And you should find within a few days that some gentle pressure, hot and cold compresses, it, it does help to reduce those seroma if they do happen to form.
But management of dead space initially and correct, surgical reconstruction should avoid that in the first place. One area that is a potential cause of wound breakdown that really is no fault of any bacteria is if there is a reconstruction that potentially left a, meant that the the flap or the reconstruction was never going to be viable anyway. So if you have a skin flap, so what I've tried to illustrate here is a types of flaps.
So on the, right hand side you've got a kind of a rectangle with some capillaries in it. Generally if you've got a flap of skin, that is, let's say if you can visualise an A4 piece of paper. If the flap of skin is 2 times its width, generally the capillaries and the blood flow will be enough pressure to, support viability of the tip of that flap.
So a flap that is 2 times its width. Has a good chance of survival. One that is, 3 times its width, generally will die off.
So you will find that the perfusion, the pressure that is in those capillaries just isn't enough to get to the tip of those flaps. So you, it's not unusual to see if somebody's done an advancement flap and it ends up being quite narrow and quite long. That you will see those and you'll think, I think this may well break down.
So it's good to, rather than just take the tissue and, think this will fit here or this is what I need to take from here. Bear in mind once you cut tissue, it will shrink anyway. So what you thought was a wider flap ends up being a narrower one.
So then you think, oh God, too late. It may be better to plan it in advance and if in doubt, ask for help. Certainly bandaging angels, although we're not surgeons, we do have a, a good network of surgeons that will always be willing to help plan for surgery rather than, and also happy to help if things have gone wrong and to get you, get you back on track.
So, long flaps tend to die off at the tip and flaps with pointy, so triangular flaps will also tend to die off at the tip and that's a. Again, a perfusion issue. So I think for those who are not so experienced with surgery, sometimes it's tempting to do a flap and to pull tissue from nearby to areas that maybe, maybe are problematic.
So I've got some, a little image at the bottom of some of the problematic areas in dogs and cats, so elbows, inguinal area. sort of in the axilla, it can be tempting to use tissue that's available nearby just to try and close that deficit. But sometimes that will cause you more problems than, solutions because due to movement and all, all of the, tension in the area, which I'll come on to next, and the shape of the flap potentially.
Those, that tissue cannot be perfused or cannot adhere to the wound bed effectively and you end up with a big wound breakdown. So if you have any wounds in the positions of the, the illustrations, generally it's good to get advice on axial pattern flaps and, flaps that have already got their own cutaneous artery so that that will support a bigger flap. And it means that it doesn't, doesn't work on the rules of this narrow, long and narrow, wound breakdown at the tip, you will end up with areas that can be covered much more effectively with much more tissue and, much more.
Robustness under movement and under different, different locations. So this is a typical one where tension at the wound site, so areas where edges of the wound have been pulled together and they're under enough tension that the capillaries and the blood supply that feeds the edges of that wound gets stretched so that they can't, can no longer, support the margins of the wound and you can end up with either wound breakdown because of the tension, increased inflammation because of the tension. It can be uncomfortable for the patient.
One of the main reasons patients will self-traumatize is quite often when the, area is under some tension, it becomes quite uncomfortable, if you can imagine. So tension at the wound site doesn't mean it's an infection. It just means that that area is under some tension.
It may be a mobile area, it may be stifle, it may be over a joint, doesn't mean that that's a surgical site infection. That would be, essentially, a wound breakdown due to physiology, if you like. And commonly seen are wounds that break down or just won't heal over joints.
So due to anatomical location, more than anything, if you've got shearing forces, beneath the wound, so what that happens with that is that the shearing force will break down some of those collagen matrix that the vascular tissue is trying to grow into and in doing that because that tissue has been broken down, the macrophages come along, clean it up, they basically debride the dead stuff and the collagen is laid down again by the fibroblasts, which will be again, trying to create a matrix for that vascular tissue to grow into. And if you don't overcome the movement and the shearing forces, that process just keeps going on and on and on, and you end up with this typical image of a hole in the middle, where the tissue is just not able to remodel because of the phys physics and the biomechanics with a kind of a donut or granulation, around the edge. So that's not, again, that's not wound infection.
That is just the physiology that is being held up due to movements and, and continued trauma. And that's what you'll see in patients where perhaps the client has let the patient run around a lot more than, they should have done. Perhaps in dogs and with, bony prominences and, potentially where bandaging, is pressing on the wound, use of donuts to offload these areas can help a lot, but also just restricting movement may help a massive amount.
But if you can't stop that process of, biomechanics, contributing to wound breakdown, then probably you're not going to win. So, really just to go through some of the things that might be a nice solution or what really it's what I'm concluding from some of the reasons why wounds break down, I think aseptic technique is the pre-op preparation. To get the minimum amount of bacterial colonisation in that wound or, or, contamination during surgery, planning for surgery, so getting your technique right.
If you have got a large wound, ask for help, get some advice. Most local specialist practises will be more than happy to help you, make a decision on what is the most appropriate route to closure. That is absolutely not a failure to ask for help.
I think some of the research I've done shows that most practises only see 3 or 4 challenging wounds a year. So it's nobody's, nobody is going to know exactly how to manage all of these wounds all of the time. And it can be daunting and you can look at a wound like in the picture and see all of this dead tissue and slough.
It's easy for me to say, in theory, This is a simple thing of debride, we, I talk about prepare, promote, protect, simple process of making sure you get the wound bed clean, get rid of the dead stuff, promote optimal granulation tissue formation and protect the wound against contamination and factors that delay healing like movement and everything else. That's great. It's easy for me to say because I've seen it implemented for thousands of cases, but when you've got that one case in front of you with a client that is, Short of funds that, you've got a colleague that thinks something different to you.
One person wants to use honey, one person wants to use laser. Getting back to basics is really difficult. So, from an elective surgery point of view, really pre-op prep, surgical planning, wound protection, post-op, that will help you, with the interference.
It will help you with cross contamination and reducing. The incidence of more bacteria getting to the wound, but it's a, it's a small part in terms of the, the surgical site infection risk, and obviously client education, getting them on board and trying to manage expectations from their point of view. It's great to offer radical surgery, but if they can't afford it and they don't have the facilities at home to rest the patient, then everybody's probably wasting their time.
I don't need to teach you all that. I'm sure you all know it. So I, I thought I'd, just go through the Halstead's principles.
So really the the reasons why wounds break down. So I've gone through some of the reasons that I think, the complications happen and most of them are associated with Halstead's principles. So, I found this kind of handy way of remembering what Halstead's principles are, but this goes right back to basics of surgery.
So achieving optimal hemostasis. Not limited bruise, limited bruising, not too much blood around all of this stuff that is just going to imagine more blood, more platelets, more, more volatile inflammation. Keep that tissue as, as, as free of, free of bleeding as possible.
Aseptic techniques. So that's surrounding tissue management. Skin prep, there are, there is some controversy about the different types of solutions you use on wounds, around wounds and how you effectively decontaminate wounds.
But certainly do some research on that. I'll cover that in a moment. Light touch surgery, so gentle handling, try and be nice to the tissues, don't damage too much vascular tissue.
The more, aggressive you are with tissue. The more compromise, vascular compromise there's going to be and the more inflammation, which is going to contribute to wound dehiscence. Supply of blood, you want to make sure that there's a good blood supply to that wound.
If you create a tourniquet effect around the limb with your, with your sutures because there's not enough tissue available, then chances are the blood supply isn't going to be preserved. Tension free closure, easier said than done, but considering tension free closure, I guess before surgery, certainly at this wound here is, post, tumour removal, wide excision and you've ended up with a large wound that maybe in theatre was possible to close, but actually once the patient was out and about and a little bit more boisterous than planned, things didn't go quite so well. So open wound management for those cases.
Be an option until you can decide how that wound can be closed. Negative pressure wound therapy is a is a great adjunct to helping those wounds close while you get some time to create a healthy granulating wound bed and decide on what reconstruction method you could make. Even tissue acquisition.
So getting the edges even and dead, dead space. So use of drains, appropriate drains and trying not to have too much dead space. So it kind of goes with everything I said before.
So, I just sort of put a picture here of this, stitch. Wound, and that is from a friend. So I know it's not going to get me into trouble, but essentially wide clipping, making sure that, your area is sterile, but, a good clip, before, before surgery and good, skin prep.
Hand washing priority, hand washing has been found to be one of the major factors of, contamination, in clinics. I know Dennis Bill Wigan has done an awful lot of research on infection control and surgical site infections and hand washing is generally one of the ones that is, highlighted as the main weakness. I see so many pictures of wounds where people are, showing me a picture of a wound and they're not wearing any gloves.
Gloves should be worn when managing wounds, even with skin prep, even when reviewing the wounds and it's a case of when you're prepping a wound. Gloves for prepping the wound and a different set of gloves for when you're applying dressings so you don't cross contaminate the pre-cleansed wound flora with the post clean wound flora. And I've put mobile phones because everyone's got their mobile phone with them and you might want to take pictures and definitely advocate taking pictures of wounds, so you can follow up and, mobile phones tend to be a fantastic carrier.
So you can wipe your phones down with alcohol swabs, and it really should be something that maybe you do. And then patient, aftercare, pre and post, patient care. So I've put pre-peri and post-op, so three stages of skin prep.
One of the most important things is the. Dilution and the contact time of the skin scrub. And I don't think this is always done, as is indicated on the packaging.
So if you do use hibby scrub, what is advocated on the packaging for its optimal use isn't really what's done in veterinary practise, but there's reasons for that because actually it's very hard to get a scrub to do what you need it to do in animals with lots of fur as compared to, to humans. So ideally it should be diluted. To no more than, no less than 3%.
And I think people often do 50/50 dilution, which means that it would be at 2%. The manufacturers actually advocate that the scrub hippy scrub is used neat and it's meant to be used on damp skin. Applied neat with a moistened gauze swab and you then have to apply that and let it have contact time of 2 minutes.
Then you're supposed to wash it off or I guess you wipe it off with a moistened gauze swab and then reapply for a further minute. So that's 3 minutes contact time of neat chlorhexidine scrub is what is advocated by the manufacturers. I don't think that's what tends to happen.
If you do dilute it by 50%, then the contact time needs to be increased by 50%. So that means you need 6 minutes contact time, not the 3 minutes contact time. And for anyone who has anyone who's impatient while you're waiting for that contact time, resistance has been shown to chlorhexidine at 3% for the scrubs.
So it is really important that we do those contact times because it's one of the only, it's one of the only reliable. The decontaminants for skin that we use in human healthcare for elective surgery. And if we start to get resistance, then we are going to be very, very short of options for, elective surgery across the board.
So peri-surgery, it's not the scrub. It, so this is like directly prior to surgery, you'll be using it at your choice of chlorhexidine or iodine with isopropyl alcohol, and that tends to be the, the normal, skin contact, decontaminant, that you use post pre-surgery that is then left to evaporate so you don't need to remove that. And then post-op, the recommendation for post-op dressings is ideally that they stay on for 8 to 12 hours.
If you read the packaging, they will say 24 to 48 hours. And that's mainly to account for the seal, the fibrine seal that is created between the margins of the suture margin. So once you get that fibrine and seal, the wound is going to be able to look after itself.
And that's the idea. Wounds under tension, probably not going to have such a good fibre and seals. So that's probably another good reason to close, without tension.
Dressings that are paper based, so like the Primapore dressings, once they get wet or once they strike through, then they have the potential to wick bacteria from the surface of the dressing through to the wound itself. So if you have a dressing in place and it gets soiled or it gets wet within the 1st 8 to 12 hours, it should really be changed, to avoid cross contamination from the outside to the wound bed. So, something that is, worth mentioning is that, tissue handling, the houseste's principle, careful handling of tissue, it will, contribute to a wound breakdown.
So if you've got someone who's particularly heavy handed, then that you can. Note that, but also the use of materials and instruments. So blunt instruments using blunt dissection or instruments that are potentially not designed for the purpose, undermining of tissue with, sort of forced undermining, sharper instruments will be ideally less, less damaging, I would, I would guess.
So, You may need to manage wounds open for a period of time. If you have a wound that is, contaminated and it's a wound that is needing some preparation prior to, reconstruction, wound bed preparation is the process of you helping that wound along. So there's an image of some negative pressure therapy where you can, use that to aid rapid granulation tissue formation so you can then do your reconstruction once the wound bed is ready.
And post-op interference, the picture here is of a wound that, was an excision of a lick granuloma and the wound broke down post, a few days post op and the patient was interfering with the wound. And that's more than likely due to tension at the wound site. But also it may be that there was an underlying condition that was contributing to the lick granuloma.
So it may well have been there was some arthritis that was contributing to that. So finding The source of the reason for interference is going to be key. So if a patient is interfering with a wound, chances are it's itchy, it's uncomfortable, it may be a sign of inflammation, it may be a sign of a foreign body, that is causing chronic inflammation.
So there will usually be a reason for it. So if it's not to 4 days, considered tension, it might be ischemia. So that tourniquet effect, where if you can imagine, you'll get pins and needles, it will feel really, You'll get that paresthesia, that strange feeling.
Inflammation may also mean it's red, it's, it's painful. If it's extended inflammation beyond 4 to 10 days, ask why, because that may be infection, it may be a surgical site, suture reaction. It may be foreign body, it may be something else that's going on.
If there's inflammation extending past 4 to 10 days, there's something going on, there's a problem. It may be infection, it may not be infection. It may be something totally different.
And at day 14 to 30 with the remodelling process, bear in mind that once wounds get into this maturation phase and the scar tissue starts remodelling, actually you do get a few nerve endings being kind of involved in that remodelling process and that can become quite itchy and quite annoying. And that is a typical time where the patient has been discharged, they've gone home, and everything's gone well. And then at 23 weeks afterwards they come back and they've been gnawing at the wound or they've been, having a go at it.
So there, there's medicinal ways to get through that period. So, but also massage, the client can use emollient creams that will also help keep that tissue supple. And it can help to break down those collagen fibres and help that remodelling process and reduce that, that kind of itch at that stage.
But it is, it is a normal part of healing that can be observed in in many patients. So just beware that's the time that they might start causing you issues. So, really kind of getting onto the post-op protection from collars and shirts, I've often been asked, what's better, a collar or a shirt, and actually the fact is there is a place for both.
Collars, obviously, people tend to think, well, the patient can't. If they're going around the house, they're knocking things over or they can't get to the feed bowl, it's uncomfortable for them. But actually within the 1st 24 to 48 hours, post surgery to avoid licking of the wound and that strike through of getting the dressings wet, it's totally reasonable to use a collar during hospitalisation and and and that practise.
Post-op dressings, 12 to 24 hours. So a dressing to cover the wound, keep it dry, monitor for strike through, and potentially pet shirts can be used within practise then to, just further protect the wound, maybe hold a dressing in place and provide some ongoing protection and, and, during recovery. Once it comes to the patient going home, it may be better to use a soft collar if, you have a wound that you are concerned that they might, the interference, it's vulnerable to interference.
After 4 days, once the inflammatory phase has passed, pain should reduce, any discomfort should reduce. Chances are that the wound will be less liable to be, To be interfered with or it should be, so monitoring those wounds at that point, but a soft collar for 3 to 4 days would be reasonable and then using a pet shirt to cover the area. If you can, you can get leg covers as well that are also available, that, will cover the area, for however long the client feels is appropriate to get that wound closed and so that scar tissue can form.
So a little bit about the pet shirts, they've been around for some time now. They've been around. I certainly have been aware of the medical pet shirts for over 20 years.
So, I met the manufacturer of the medical pet shirt, well, around about 20 years ago when she first brought, the medical pet shirts to the veterinary, the veterinary world and her focus was very much that she wanted a pet shirt that Covered wounds, helped with the post-op management of wounds that really overcame the issues with the cone in terms of the patient not being able to, you know, go around the house knocking things over, but more of a welfare issue for the patient so that the patient can recover comfortably. And what she'd found is that a lot of these, a lot of sort of the onesies and things that were available or the little dog coats that people did, did use sometimes weren't necessarily anatomically correct or they didn't fit perfectly or they just weren't snug enough to hold dressings in place and to be secure around the wound. And they evolved a, fabric that has a stretch in four directions.
That was, that is important purely because these pet shirts are meant to fit snugly to hold everything in place so the animal can't get their nose underneath the, the legs and get into the, the sutures. But also if it doesn't stretch in four directions, that means that, the shirts may tug or they may pull in different directions. So it means that if you have a longitudinal stretch, it may be long in the back, but it may be tight around the girth or the other way around it may be.
The back doesn't stretch and you end up with rubs under the axilla. So a lot of work went into creating the right fabric so that these shirts could be made anatomically correct, with a range of sizes that fit, cats, dogs, rabbits and that all fit with this sort of compression that will hold dressings in place, but also, support, healing. The other thing that was unique about the pet shirts is that they had this popper, these popper buttons that can be opened to allow the dog to, toilet.
So rather than having hooks or zips, the idea was that you can unpop at the, at the rear end, roll the shirt up so that the dog can have a wee, and you can do that up again, but that these poppers are not able to be opened by the patient. So that that was a secure, a secure way of holding these in place. And one of the most important things is that they are actually washable at 60 degrees.
So this might sound, OK, great. I could wash things at 60 degrees, but actually many materials and many synthetic fabrics can only be washed at 40 degrees and it's only 60 degrees that is, the level at which you can wash in a standard washing machine with standard washing powder that will actually neutralise bacteria. So there is some data, on that, but anything that is washed at 40 degrees actually needs to have a specialist, antibacterial, washing machine solution.
So it should be a specific antibacterial washing solution. So if there's any cross contamination in that wound, if there's any MRSA in the clinic or around or if there is any cross contamination, it, it isn't resolved at 40 degrees C only at 60. And many materials will actually degrade at that temperature.
So always look for the washing instructions if you do have any of these kind of things. NVS have just launched a new pet shirt in their select NVS range, and this has been developed in conjunction with medical pets. Shirts.
So it's got all the technology that you would expect from the quality of, NPS. That's the four-way stretch, anatomical fitting and the 60 degree wash capacity. So all of these great features are now available from NPS through their select range.
So I just wanted to put some data in about the collars and the versus pet shirts. There is a place for collars, but pet shirts are well, well understood to be an effective way of, helping to support animal welfare and and to support healing. So I've created a little chart that, well, I think will be available, after the event, which just gives you an idea of when to use pet shirts versus collars.
So really, I'll let you have a look at that, but I know it will be available and, really. A little guide of what to look for. So immediate management, e-collars and pet shirts, monitor for exudate and discomfort.
Early recovery, you're looking at 2 to 4 days. You've got your inflammatory peak, so that's when you're going to have your most likely signs of pain interference. So you want to be monitoring those for interference.
Tissue repair, 5 to 21 days. Start to monitor for signs of wound breakdown. Handy if you can give clients a, a little guide of what to look for.
They should be checking that wound daily for you so that, they can report back to you if there's any issue. The earlier you spot signs of surgical site infection, so redness, discomfort, the better. But, really you'll be looking for those anything up to 30 days after, after surgery.
And really, Once, wounds start to heal and they start to mature, so open wounds that maybe have closed with scar tissue formation. So that's what I've put kind of 3 down the list, is you can, the client can have the pet shirt for as long as they like to protect scar tissue. And just remember scar tissue doesn't have any melanocytes.
It doesn't necessarily have any sebum. Because of the hair follicle, lack of hair follicles. So having a pet shirt to protect from sunlight, direct sunlight, but also, tissue dehydration isn't necessarily a bad thing, but I would also advocate using, non-hypoallergenic, very basic moisturisers that will also give scar tissue some integrity.
So I've just put a little pet shirt 101 just to give you, a few tips for, selecting the right pet shirt and things to look out for. So ideally ensure the size is the correct fit for the patient. So even though the, medical pet shirt, technology has this four-way stretch and can adapt, in most, in all directions, you do need to get the correct length.
So it's a, there's a very simple ready retina with with the select range that. Helps you choose the right one for the patients size. So looking at the back length and that's where, this, this range have been made to fit the widest, widest variety of anatomical shapes and sizes.
Ideally show the client how to put the shirt on and take it off. So I have definitely seen cases where, a wound has broken down or an area has broken down on the patient because the client actually wasn't taking the shirt on and off and the patient was actually toileting through the shirt. And it was only 10 days later that they came back and the patient had some nasty excoriation due to that, but they were just weren't shown how to take it on and off.
And they actually, thought that it was meant to stay on until they came back. So demonstrate how to roll up the shirt so that, they know what to do for toileting rather than assuming it needs to stay on the whole time. Show them where to look for rubs.
So point to the, in the, check under the armpit, in the inguinal area around the neck and just get, tell them just what to look for, just to monitor those areas every day, and explain that it should really be washed. If it gets soil, so any soiling, any bacteria that's going to be on that shirt, ideally you want to be washing that 60 °C, and you can advise them that it's at 60 degrees with a normal detergent, that would be fine. And for long term management of wounds with pet shirts, ideally they should have two so that they can have one on the patient and one in the wash if you like.
So that makes kind of makes sense. So I've, put a kind of a list here of the, some of the snags that you get with some of the other shirts. So once the shirts kind of arrived on the market, and I, I certainly know that, there was an awful lot of challenges to the medical pet shirt brands sort of as they came out and everybody started to produce their own pet shirts.
Some of them have, different issues. Really just what to look out for. If you are comparing different shirts and I had a chat with someone yesterday who was saying that their clients buy their own shirts and they buy them on Amazon and then they bring them in and then it's really difficult for you to say, well, actually it doesn't necessarily fit very well or it doesn't fit so well or they may get complications with that.
So things to look for, I can't really help if the client is determined to use their own, but maybe it's a case of pre-surgery. Going through what you use and why a pet medical pet shirt is different to some of the onesies and some of the things that you can buy, sort of the glitter, glitter fabrics and the pretty, pretty outfits that you can get. Maybe it's just part of the process of the pre-surgical, discussion to explain why.
Why it's really important. So what we tend to see inconsistent sizing, there can be too big, too baggy. You can see in the picture, there's, you can see under the armpit, the dog could maybe get under the, get their nose under the, the edges, pulling, pulling out the, sutures if they need to.
There's options with, some that have a hook fastening or a zip fastening, hook fastening. I, can come undone. I mean, I'm just, I'm splitting hairs really if you like, but, I have noted that there are reports of them, snagging on the fur, and possibly being removed.
Zip fastening is, is fine, but one of the comments that, in discussion yesterday is that it's actually quite hard to put the shirts on when you have the patient stand in the shirt and then zip up the back when the patient is wiggling, but that's just really a practical thing. But I have also seen some complications where, patients have been, recumbent with a zip on a heat pad and, the, the heat has transferred through zips. So that's something to bear in mind if you have a zip fastening.
I've mentioned the material choice and the wash temperature, which is really my number one is if it can't be washed at 60 degrees, then it's probably, not going to be as protective as you, as you would expect. So we're near the end, but, the client responsibilities for managing, their patients, concordance means you're in partnership. So really they need to help you keep an eye on that wound.
And I guess quite a lot of people now. Have mobile phones. So if they, if in doubt, I'm sure one of the nurses who is helping them, if you have a wound nurse in practise, which we, I would love a wound nurse, then maybe, you know, you take responsibility for taking a text message with a photograph on it.
I love a photo every day to see how things are progressing and it's really encouraging to be able to text back and say, do you know what, that's looking really good. Or maybe we need a second opinion. But having a client check the wound every day for rubs, and taking the shirt off and putting it back on again as opposed to leaving it on, 20 until the follow up appointment.
I think most of that is, is covered. Yeah, contact the vet team if there's any sign of complication. That's, that's a priority they should too.
So don't leave it, contact someone for help. So really just, looking at rounding up in terms of what could we do better? How can we avoid post-op complications.
I think I've highlighted that there's lots of different reasons why you get post-op complications and that the surgical site infection is really your symptom of potentially something that has led you to a wound breakdown and it's exploring that that is going to give you a better understanding of where things could change or what could be done better. But it's really difficult. Everybody hates the word audit and people don't like the idea of going through notes or figuring out what complication rates are and who did the surgery and what did they do wrong.
It's not a case of doing anything wrong. It's more like, trying to discover areas and simple ways that you can fine tune. So I tend to, I, I tend to think of it more as a game than a criticism.
So, let's say you're cycling on your bike and I'm going to the village shop on my bike and I'm cycling there and I can get there in 2 minutes, say, and then I discover a technique, maybe just using a slightly different gear or breathing differently. I can make it in 50 seconds. All I'm doing is fine tuning.
It does, I still get to the shop, but it's a case of, it's not a criticism, it's just how can we make this, how can we play this game a little bit better? Where can we, where can we win? We're comparing ourselves to the surgical site infection rates that we might be looking at.
You might want to categorise those rates according to different procedures, so typically spayed, neutering. And really then get together and explore where those areas might be improved and you may not be able to improve them. You may actually find that you're absolutely brilliant and you're doing things the best way, you possibly can.
But you might also find that maybe there is a skin prep solution that is, easier to apply at the right concentration and the brand that you're using so that you can get less contact time. You can get through surgery, you can maybe apply it easier, and you still get the same outcome rates. So it's kind of identifying small areas that you can just fine tune one step at a time and don't blame the team.
If you find that there's a surgeon who maybe has had more seroma formation than others, that's not a criticism. It's a case of, well, well how do we explore this? Maybe we could use a different type of drain.
Maybe there's an alternative way to do this procedure, help each other get better and, help each other measure outcomes and celebrate together when you get, get somewhere and small improvements, make a difference because at the end of the day, it's about the team and it's about the patient outcomes and if your patient outcomes are, improving all the time, then you can be proud to do what you do every day.
