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Wound management in PCCS

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Routine Mediastinal and Thoracotomy wound management

  • Surgical wounds are covered with an occlusive dressing or surgical glue.
  • Surgical glue will remain in situ and lifts off as the skin heals and regenerates.
  • Instruct the parents and child they are able to shower or sponge over the glue but for the area not to be immersed under water for 2 weeks or until healed and dry (so avoid baths).
  • Where a dressing is in place; this is routinely taken down day 7 post operation (some discharge and old blood under dressing is normal and should not be disturbed). 
  • Clean wound with normal saline and reapply occlusive dressing every 7 days until day 14 post closure.
  • Occlusive dressing can be removed prior to Day 7 if:
    • excessive wound ooze
    • unable to clearly visualise the wound through the dressing
    • other clinical indicators that may indicate a wound infection

*Any concerns about the wound contact the surgical team to review - on-call surgical registrar phone 021 380548.

Sutures

  • Clear undissolved suture knot at skin level to be left intact for 3 weeks. This can be snipped at skin level if causing irritation.
    • Prolene sutures (interrupted sutures running along the length of the wound) have specific instructions depending on the patient - please check with the surgical team - via the on-call surgical registrar phone 021 380548.
  • Chest drain sutures
    • Infants > 6 months with normal saturations remove at 7-12 days post operation either in hospital or by GP
    • Infants < 6 months, all cyanosed infants and children, all Fontans (where slower to heal) leave all sutures until 14 days
    • Following removal of chest drain suture apply an airtight dressing to support wound for 24 hours.

Discharge Instructions

  • See GP for wound management and removal of drain sutures
  • Instruct parents to observe for signs of wound infection: redness, swelling/oedema, discharge, fevers. See GP or home care nurse should this occur.
  • Instruct parents to be vigilant with sun protection over the following summer
  • After 3-4 weeks if wound completely healed (no scabs or open areas on scar line) parents can be instructed to apply tape (e.g. Hyperfix/Omnifix or Micropore) over scar line as this can help with scar reduction.
    • Parents will need to observe for any undue skin irritation caused by taping, and will need to stop taping the wound should this occur.
    • Replace tape every 7 days or earlier if soiled or not adhering. Parents instructed to remove Hyperfix or Micropore using oil, and then clean well before reapplying the tape.

Chest drains

See associated Starship policy (click on link below)

http://adhbintranet/ADHB%5FPolicies%5Fand%5FProcedures/Clinical/Starship_Children's/chest_drain_management.htm

Chest drain sites need to be observed daily

  • Cover chest drain with a transparent dressing to allow easy visibility of insertion site.

  • Ensure chest drain is secure. Firmly anchor chest drain to the skin with tape using the mesenteric method (firmly anchored means less pain for the child).

  • If discharge coming from around the chest drain insertion site, apply an absorbent dressing 

Permanent pacemaker wounds

  • The pacemaker generator site will be glued post op and to remain in situ. Instruct parents the glue will degrade as the skin regenerates

  • Instruct parents if problems with wound to contact the nearest pacemaker clinic. If they are experiencing any problems accessing their local Pacemaker clinic they will need to go to the nearest Emergency Department.

  • Please instruct the parents and child not to immerse the area underwater for 14 days after surgery (can shower or sponge over glue or wound dressing. Contact Pacemaker technician on-call if any concerns phone 021 808605 or Surgical team on-call phone 021 380548

Wound infection

Wound infections tend to occur in 2nd and 3rd weeks after surgery. Suspect if:

  • Recurrent fevers, child looks unwell, child experiencing increasing or excessive pain, wound discharging, wound cellulitis > 5mm erythema out from edge of wound, WBC elevated with left shift.
  • If you are the first to view a wound that looks infected then please apply a loose dry dressing only until viewed by the surgeon.
  • Wound swab only if wound is discharging, don't let the swab touch the skin (there is no point in swabbing dry skin)
  • Ensure blood cultures drawn for any persistent or recurrent temperature greater than 38.0c
  • Call Surgical registrar or Surgeon to review Ph 021 380548. Ensure senior medical involvement before decision to start antibiotics 

Choosing an appropriate wound dressing for the infected wound:

Initial wound dressing

  • Most severely infected wounds require close inspection by surgical team and may drain profusely over first 48-72 hours. If wound discharging large amounts of exudate, apply a loose absorbent dressing to allow the wound to drain freely.
  • In wounds with large amounts of discharge the dressing should be changed as frequently as required to ensure effective absorption of exudate. 

After 48-72 hours

  • Once most of the heavy exudate has drained from the wound, select appropriate dressings that will manage the on-going discharge and promote wound healing.

Documentation

Ensure ALL children with wound infections are reviewed by the surgical team and the plan of care is documented in the notes (including products used on wound)

Colour:
- Condition of surrounding tissue (cellulitis, redness, oedema, fluctuant, maceration induration etc)
- Cellulitis depth / width out from scar line (draw on wound care plan)
- Tissue category: necrotic, sloughy, granulating, epithelialising, over exuberant granulation

Depth and Size:
- Level of tissue involvement: epidermis intact but reddened, superficial or deep, fluctuance/collection/swelling, sternum mobile
- Deep sutures visible

Exudate:
- Points where the wound is discharging
- Type of discharge (purulent, serous, haemoserous, sanguineous etc)
- Amount (nil, minimal, Moderate, heavy)

Wound Edges:
- Areas of skin edge dehiscence (draw on wound care plan)
- Note any tunnelling, sinus or undermining of wound edges.
- Degree of attachment of wound edges to wound base

Wound Measurement:
- Measure wound length and width measure tissue changes out from wound

Other: Pain, Odour, document pain relief required for dressing changes

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Document Control

  • Date last published: 08 August 2016
  • Document type: Clinical Guideline
  • Services responsible: Paediatric Cardiology
  • Author(s): Kirsten Finucane, Helen Sargent, James Rance
  • Owner: Marion Hamer
  • Editor: Marion Hamer
  • Review frequency: 2 years