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Bedside emergency: Wound dehiscence


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CE credit is no longer available for this article. (Expired June 2009)


Originally Posted June 2007

By Sally Beattie, RN, MS, CNS, GNP

SALLY BEATTIE is clinic manager at University of Missouri Hospital and Clinics in Columbia, MO, and a member of the RN editorial board. The author has no financial relationships to disclose.

Most surgical patients heal uneventfully, but some will experience a complication that could be deadly. Are you ready for this bedside emergency?

As nurses, we frequently take care of postoperative patients who present with a broad range of medical histories and who usually heal without incident. A small but significant percentage of patients, however, experience one of the most dreaded complications of surgery: wound dehiscence, the partial or complete separation of the outer layers of the joined incision.

Certain procedures, especially abdominal surgeries, are associated with a higher incidence of wound dehiscence. Up to 3% of abdominal surgery patients experience this complication, which has associated mortality rates between 14% and 50%.

Separation of all the wound layers may lead to an even more serious and emergent complication: evisceration. In this type of situation, internal organs, usually the bowel, protrude through the open wound—a complication that can lead to peritonitis and septic shock. Here, we'll review the quick action required to prevent a potentially fatal outcome for your patient.

Know how wounds normally heal

Familiarity with normal wound healing will assist you in your postop assessment and help you predict the occurrence of dehiscence.

In the first few days after surgery, incised tissue begins to bind together, a process accomplished through the deposition of fibrin and epithelial cells, as well as strands of collagen that fill in the gaps and seal the incision. You'll observe the start of this process soon after the initial dressing is removed, which is usually within 48 hours after surgery.

Thereafter, you'll assess the wound at least every eight hours. You may observe some scabbing on the incision and slight swelling around the sutures or staples and the wound edges. The incision itself may appear erythematous and feel slightly warm to the touch. All this is part of the normal inflammatory reaction triggered by the surgical procedure.

Drainage from the wound during the early postop period is expected, too. In the first one to five days after surgery, it should change from a small or moderate, but consistent, amount of sanguineous (bloody) drainage to serosanguineous (a watery mixture of serum and blood) to serous (mostly serum and yellowish).

By day 5, you should be able to palpate a "healing ridge" of granulation tissue directly under the incision and extending approximately 1 cm on both sides of the wound.5 Any deviations from this normal healing process—especially between postop days 5 and 10—could spell trouble. Most dehiscences occur 4 – 14 days after surgery.

Certain signs point to greater risk

Both systemic and local factors can contribute to wound dehiscence, but a common cause is surgical error. Sutures or staples placed too far apart, under too much tension, or too close to the incision edges may prevent the tissue from meeting and binding together properly. Unduly tight sutures can result in strangulation of the wound edges, causing necrosis. On the other hand, if you observe any separation in the incision, notify the surgeon, who may fill in the gaps with more sutures or apply sterile adhesive strips.

Dehiscence may also occur when sutures are removed too early, especially in wounds that don't have adequate buried absorbable sutures to provide tensile strength. Sutures shouldn't be removed until the healing ridge has developed.

Deep wound infection is yet another cause of dehiscence, so it's imperative that you report the presence of any of the following, whether all or just a part of the incision is affected: redness or swelling, excessive pain or tenderness on palpation, or purulent or malodorous drainage. Also report increasing amounts of serosanguineous drainage beyond the fifth postop day.

Other risk factors for dehiscence are listed in the box on page 37. The presence of any of these circumstances mandates extreme vigilance in your postop wound assessment. Even your healthiest patients may have risk factors for wound dehiscence—forceful coughing, vomiting, or straining to have a bowel movement, for instance. Make sure the surgical site is properly splinted when the patient is doing any of these things. When possible, administer stool softeners and antiemetics before constipation and vomiting become problems.

If your patient tells you, "I feel like I've split open," take heed. A remark like this may be the first indication that his wound has dehisced—or worse, eviscerated.

Act quickly if dehiscence occurs

Wound dehiscence usually happens suddenly and is accompanied by a sharp rise in serosanguineous drainage. If you observe wound separation or excessive drainage, notify the physician immediately, and reassure the patient. Also, make sure the following sterile supplies are at the bedside: cotton-tipped applicators, disposable towels, normal saline (NS), 50 cc catheter-tip syringe, basin, large abdominal dressings, suture-removal kit, waterproof drape, gloves, mask, and gown.6 If necessary, have someone else gather these supplies while you remain with the patient.

A physician can usually diagnose dehiscence based on the clinical presentation and wound inspection. Imaging studies, such as ultrasound, CT, or MRI, may be used to evaluate for pus and pockets of fluid.

If the dehiscence involves only a portion of the incision, as is frequently the case, be prepared to assist the surgeon as he opens the sutures and probes the wound with a sterile, cotton-tipped applicator. Should this exploration reveal a large segment of open wound that extends deep into the gut, or if the entire incision has split open, your patient may need to go to the OR right away. Visibly eviscerated organs constitute a surgical emergency, as their exposure can lead to sepsis from bacterial contamination.

While your patient waits to be transported to the OR, keep the wound and organs covered with wet dressings. Either soak the dressings in a basin of NS or lay the dressings over the wound and irrigate them using the sterile syringe. Each time you moisten the dressings, inspect exposed viscera for signs of ischemia or necrosis, which may develop if blood supply has been interrupted. Don't try to push protruding viscera back into the abdomen. Instead, report your findings immediately to the attending physician.

In the meantime, keep the patient in bed in a low Fowler's position—about 15 – 45 degrees. Flex the knees to reduce tension in the wound area. In anticipation of surgery, change the patient's intake status to NPO. Make sure he has a patent IV line, and administer fluids and antibiotics as ordered. You may also need to insert a nasogastric (NG) tube and attach it to suction to prevent further stress inside the abdomen. Monitor vital signs every 15 minutes and assess for signs of sepsis. Since dehiscence can be a frightening experience for the patient, continue to calmly reassure him.

Be sure to document thoroughly. Note the time the dehiscence was identified and reported to the physician, the activity the patient was engaged in immediately preceding the incident, and the patient's condition. Document the appearance of the open wound and, if indicated, the eviscerated organs, and note the amount, color, consistency, and odor of the drainage. Record your nursing actions, as well as your continuing assessment of the patient's vital signs.

What to do when surgery is delayed

If surgery isn't needed, or it's delayed because of the size of the wound, the quality of the adjacent tissue, or the general condition of the patient, management will be essentially the same as that for any other open wound: You'll assess and manage your patient's pain, and you'll encourage wound healing by preventing infection and maintaining a moist wound environment. Other interventions that may be needed include debridement of necrotic tissue, control of local infection, resolution of bowel edema, and treatment of associated intra-abdominal conditions.

Explain to the patient that it may take some time before the incision closes. Note that frequent dressing changes may be necessary, particularly if there's continuous or excessive wound drainage.

If you're keeping the wound bed moist with saline-soaked gauze, be aware that your patient may develop enterocutaneous fistulae and adjacent soft tissue maceration. Should the gauze dry out, it will stick to the skin, making dressing removal painful.

Instead of gauze dressings, some hospitals use negative pressure wound therapy to treat abdominal dehiscence. It induces healing by mechanically drawing wound tissue together, decreasing the wound size, and encouraging granulation tissue formation. It increases local perfusion, reduces bacterial colonization, and removes interstitial fluid, which reduces tissue edema and promotes the absorption of intra-abdominal fluid. This type of therapy enables the quantification and replacement of lost fluids as well.

Being proactive and prepared

Wound dehiscence is an unwelcome complication of abdominal and other surgeries. With or without evisceration, it can be potentially fatal. Knowledge of the normal wound healing process, the factors contributing to wound dehiscence, and the actions needed to keep a bad situation from getting worse will ensure the best outcome for your patient.

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REFERENCES

1. Dayton, M.T. (2004). Surgical complications. In C. M. Townsend, R. D. Beauchamp, et al. (Eds.). Sabiston textbook of surgery (17th ed.), (p. 297). Philadelphia: Elsevier Saunders.

2. Agency for Healthcare Research and Quality. "National healthcare quality report, 2006." 2007. www.ahrq.gov/qual/nhqr06/safety/T2-14A.htm (30 Mar. 2007).

3. Hahler, B. (2006). Surgical wound dehiscence. Medsurg Nurs, 15(5), 296.

4. Heller, L., Levin, S. L., & Butler, C. E. (2006). Management of abdominal wound dehiscence using vacuum assisted closure in patients with compromised healing. Am J Surg, 191(2), 165.

5. Patton, R. M. (2006). Interventions for postoperative clients. In D. D. Ignatavicius & M. L. Workman (Eds.). Medical-surgical nursing (5th ed.), (p. 340). Philadelphia: Elsevier Saunders.

6. McGovern, K., & Tscheschlog, B. A. (Eds). (2001). Handbook of nursing procedures. Springhouse, PA: Springhouse.

7. Doughty, O. B. (2004). Wound care strategies. Home Healthc Nurse, 22(6), 364.

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Watch for these risk factors

Some patients are at higher risk for wound dehiscence following abdominal surgery. Be especially vigilant when assessing the wound of a patient with one or more of the following factors:

  • Advanced age (65 years or older)
  • Chronic disease (diabetes, hypertension, renal ure, pulmonary or liver disease, immune deficiency, cancer)
  • History of chemotherapy or radiation
  • Malnutrition
  • Hypoalbuminemia
  • Increased intra-abdominal pressure or tension (ileus or distended bowel, n.ghing, straining, vomiting)
  • Obesity
  • Tobacco use
  • Use of certain medications (anticoagulants, aspirin, colchicines, systemic corticosteroids, penicillamine, cyclosporine, metronidazole, cytotoxic chemotherapeutics)
  • Wound complication (incisional infection, hematoma, inadequate incisional closure).

Sources: 1. Heller, L., Levin, S. L., & Butler, C. E. (2006). Management of abdominal wound dehiscence using vacuum assisted closure in patients with compromised healing. Am J Surg, 191(2), 165. 2. Semchyshyn, N. "Surgical complications." 2006. www.emedicine.com/derm/topic829.htm (21 Mar. 2007).

 

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