Page 1547 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

1066 PART 10: The Surgical Patient

operative incision. It is recommended to keep this dressing dry and dressing changes. Table 112-3 lists commonly used topical agents and
in place for the first 48 hours following surgery. During this initial negative wound pressure devices along with their mechanisms of action
48 hours, an epithelial barrier develops over the wound when it has and typical usages.
been closed by primary intention. After this initial period, the skin can Vacuum-assisted wound-closure devices are employed in more and
be cleansed with water, and no further dressing is necessary. Surgical more postoperative patients every day. These devices place the wound
wounds that are left open to heal by secondary intention or that have under subatmospheric pressures that increase blood flow to the affected
necrotic tissue, wound exudates, or inflammatory cells do not form this area, reduce edema and excess fluid, and increase wound contraction to
epithelial barrier. Larger, open wounds require a moist, occlusive dress- allow for enhancement of wound granulation. It is important to ensure
ing with frequent removal of exudates and necrotic tissue to allow for that wounds are not highly contaminated or do not have significant
appropriate epithelialization. The wet-to-dry dressing provides a moist amounts of necrotic tissue before the use of these devices. Many of these
environment, traps the wound exudates, has bacteriostatic properties, devices use a sponge that is placed over the wound and then covered
and does not adhere to the wounds. Dressing changes will occur at by an occlusive dressing. Reported advantages of this type of therapy
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least twice daily for clean wounds, but more frequently for wounds with include reduced frequency of dressing changes, improved patient com-
a greater amount of exudative and inflammatory material. Normal fort, improved efficiency of wound closure, and improved removal of
36
saline solution is used to soak the dressing prior to application. Meshed edema fluid. There is some evidence that this negative- pressure therapy
gauze should be used to provide a mechanical debridement action with may hasten time to grafting or secondary closure, and may help improve

TABLE 112-3 Topical Wound Management Choices
Generic Name a Brand Names a Mechanism Uses
Collagenase Santyl Active enzymatic ointment that continuously Debridement of pressure ulcers, diabetic
removes necrotic tissue from wounds to keep bed ulcers, venous leg ulcers, and severe burns
free of cellular debris
Dimethicone Proshield Protective barrier with adherence properties similar Partial- and full-thickness pressure wounds
to zinc oxide function around fluid drainage sites (ostomy, fistulas)
Double (polymyxin B/bacitracin) and tri- Bacitracin, Neosporin Polymyxin B: bactericidal and active against Minor wounds: cuts, scrapes, burns
ple (bacitracin, neomycin, and polymyxin Pseudomonas aeruginosa and other gram-negative Most minor wounds heal spontaneously with
B) antibiotic ointment bacteria topical agents, but antibiotic agents may
Bacitracin: a polypeptide antibiotic, is usually speed wound healing
bactericidal against gram-positive organisms
Neomycin: aminoglycoside, bactericidal for many
gram-positive and gram-negative organisms
Hydrocolloid Askina Hydro, Biofilm, Brulstop, Absorbs exudate and fluid at the point of contact— Partial- and full- thickness pressure sores,
DermaFlex, DuoDERM, Hycolloid reducing the risk of bacteria being transported across leg ulcers
the whole surface of the wound face, fluids are then
pulled into inner layer and absorbed by the cotton
content, treated surface reduces risk of adhesion to
the wound face
Hydrogel Aquaheal, Carrysyn, DermaGel, Nondrying hydrogel polymer that protects the Partial- and full-thickness pressure sores and
Dermagran, Flexigel, Skintegrity wound bed from foreign contaminants and hydrates leg ulcers as well as cuts, abrasions, scrapes,
to maintain a moist wound healing environment to and minor burns
encourage faster healing
Mafenide acetate Sulfamylon Reduces bacterial population in the avascular tissues Adjunctive for second/third-degree burns
of second- and third-degree burns Caution: mafenide is metabolized to a car-
bonic anhydrase inhibitor which could result
in metabolic acidosis
Papain/urea Accuzyme, AllenZyme, Ethezyme, Papain: proteolytic enzyme from papaya, digests Necrotic and sloughing tissues (acute or
Gladase, Kovia, Pap-Urea cysteine residues (present in most proteins including chronic) including pressure ulcers, varicose
growth factors, not present in collagen though) and diabetic ulcers, burns, postoperative
Urea: activates papain and denatures nonviable wounds, pilonidal cyst wounds, carbuncles
protein
Combination of two synergistic enzymes
Papain/urea/chlorophyllin copper Allanfil, Panafil, Papfyll, Ziox Papain/urea: as above Granulating wound, acute and chronic varicose,
Chlorophyllin: Denatures nonviable protein matter diabetic and decubitus ulcers, burns, postop-
(debrides, deodorizes, with hydrophilic base) erative wounds, pilonidal cyst wounds, miscel-
laneous traumatic or infected wounds
Silver impregnated dressing Acticoat, Actisorb, Arglaes, Interdry AG, Silver antimicrobial protection that acts as a barrier Placed on wound/burn beds to sustain anti-
SilverCEL to over 150 wound pathogens 125 microbialization without cytotoxicity
Silver sulfadiazine Silvadene Prevents infections, exact mechanism not known Prevention and treatment of second/third-
Bactericidal for many gram-negative and gram- degree burn infections
positive bacteria as well as yeast
a Frequently used nomenclature is in bold.

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