Wound Ooze Research Articles

Flowtron foot-pumps for prevention of venous thromboembolism in total hip and knee replacement

IntroductionMechanical prophylaxis with foot-pumps provides an interesting alternative to chemical agents in the prevention of venous thomboembolism following major orthopaedic surgery procedures. The aim of this prospective study was to assess efficacy and safety of the Flowtron® foot-pumps system following total hip and knee replacement. The foot pumps were used as main tool for prevention of thromboembolic events, in most cases in association with a variety of chemicals. MethodsThe primary endpoint of the study was to assess the incidence of deep vein thrombosis and pulmonary embolism after total hip and knee replacement. The secondary endpoints included postoperative bleeding, swelling, bruising and wound ooze. Results424 consecutive patients were included in the study. Symptomatic deep vein thrombosis was detected in 7 patients (1.6%). All symptomatic deep vein thromboses were detected after discharge before the six week follow-up clinic. Five non-fatal pulmonary embolisms occurred (1.2%). Only one patient presented a major wound bleeding (0.2%). The mean difference of swelling of thigh pre-versus postoperatively was only 22.8 mm. DiscussionIn conclusion, thromboembolism prophylaxis after total hip and knee replacement using Flowtron® foot-pumps as main prevention tool of an individualised protocol appears effective and safe. This is the first clinical report related to this popular brand of foot pumps.

Safety of Desirudin in Thrombosis Prevention After Total Knee Arthroplasty

Desirudin, administered 30 minutes before total hip arthroplasty is superior to enoxaparin in preventing proximal deep vein thrombosis (DVT) and pulmonary embolism (PE) with similar bleeding. The purpose of this study was to determine the safety of desirudin in patients undergoing elective total knee arthroplasty (TKA) when the first dose of desirudin was administered the evening after surgery. This is a case series of patients undergoing TKA who received desirudin 15 mg every 12 hours subcutaneously for an average of 5 days with the first dose administered postoperatively. The primary endpoint was major bleeding; secondary endpoints included wound outcomes (oozing and infection) and new symptomatic DVT or PE. Desirudin has a favorable safety profile when administered postoperatively in patients undergoing TKA with no reports of major bleeding, wound ooze, or infection. No patients experienced symptomatic DVT, but 2 patients had PE detected by computed tomography after experiencing atypical symptoms. The safety profile of desirudin is improved when administered postoperatively. Bleeding and wound outcomes seem to occur less frequently than historical desirudin and enoxaparin controls.

The use of a biodegradable antibiotic-loaded calcium sulphate carrier containing tobramycin for the treatment of chronic osteomyelitis

We report our experience using a biodegradable calcium sulphate antibiotic carrier containing tobramycin in the surgical management of patients with chronic osteomyelitis. The patients were reviewed to determine the rate of recurrent infection, the filling of bony defects, and any problems with wound healing. A total of 193 patients (195 cases) with a mean age of 46.1 years (16.1 to 82.0) underwent surgery. According to the Cierny-Mader classification of osteomyelitis there were 12 type I, 1 type II, 144 type III and 38 type IV cases. The mean follow-up was 3.7 years (1.3 to 7.1) with recurrent infection occurring in 18 cases (9.2%) at a mean of 10.3 months post-operatively (1 to 25.0). After further treatment the infection resolved in 191 cases (97.9%). Prolonged wound ooze (longer than two weeks post-operatively) occurred in 30 cases (15.4%) in which there were no recurrent infection. Radiographic assessment at final follow-up showed no filling of the defect with bone in 67 (36.6%), partial filling in 108 (59.0%) and complete filling in eight (4.4%). A fracture occurred in nine (4.6%) of the treated osteomyelitic segments at a mean of 1.9 years (0.4 to 4.9) after operation. We conclude that Osteoset T is helpful in the management of patients with chronic osteomyelitis, but the filling of the defect in bone is variable. Prolonged wound ooze is usually self-limiting and not associated with recurrent infection.

Alcoholic Chlorhexidine or Alcoholic Iodine Skin Antisepsis (ACAISA): protocol for cluster randomised controlled trial of surgical skin preparation for the prevention of superficial wound complications in prosthetic hip and knee replacement surgery

IntroductionWound complications following arthroplasty are associated with significant impact on the patient and healthcare system. Skin cleansing prior to surgical incision is a simple and effective method to prevent wound...

The necessity of pharmacological prophylaxis against venous thromboembolism in major joint arthroplasty

Venous thromboembolism (VTE) is a recognised post-operative complication of major lower limb joint arthroplasty. Current National Institute for Health and Clinical Excellence (NICE) guidelines suggest the use of both mechanical and pharmacological prophylaxis following hip and knee replacement. Since the introduction of enhanced recovery programmes following hip and knee arthroplasty the requirement for routine pharmacological VTE prophylaxis has been questioned. The purpose of this study was to assess the efficacy of pharmacological prophylaxis against symptomatic VTE in patients undergoing hip and knee arthroplasty under an enhanced recovery programme. Symptomatic VTE incidence was audited in 1,100 patients undergoing primary or revision total hip or knee arthroplasty at the same hospital with only mechanical prophylaxis from 2007 to 2009. Following addition of chemical prophylaxis (enoxaparin) symptomatic VTE incidence in 522 patients undergoing primary or revision total hip or knee arthroplasty from 2011 to 2012 was re-audited. In the mechanical prophylaxis group incidence of DVT was 0.73 % [95 % confidence interval (CI) 0.37-1.43 %] and incidence of pulmonary embolism (PE) 0.91 % (95 % CI 0.49-1.67 %). Following addition of pharmacological prophylaxis incidence of DVT was 0.57 % (95 % CI 0.20-1.68 %) and incidence of PE 1.15 % (95 % CI 0.53-2.48 %). We found no statistically significant difference in symptomatic VTE incidence following the addition of enoxaparin. We question whether routine pharmacological prophylaxis still has a role following total hip and knee arthroplasty. Peri-operative optimisation, including post-operative analgesia and mobility, with current enhanced recovery programmes may be sufficient. As anticoagulants carry increased risk of post-operative bleeding and wound ooze, in addition to significant cost implications, their role remains controversial.

Direct Thrombin Inhibitor (Dti) vs. Aspirin in Primary Total Hip and Knee Replacement Using Wound Ooze as the Primary Outcome Measure. A Prospective Cohort Study

The latest NICE guidance dictates that all patients undergoing lower-limb arthroplasty should be prescribed potent venous thromboembolic (VTE) prophylaxis. However, use of potent anti-thrombotics is likely to lead to increased post-operative wound ooze. Postoperative wound ooze is associated with increased risk of infection. This study used a prospective, consecutive, multi-surgeon sample of 110 patients undergoing primary total hip replacement (THR) and total knee replacement (TKR) prescribed either direct thrombin inhibitor (DTI) (n=51, 26 males: 25 females, age 69 ±18) or aspirin (n=59, 25 males: 34 females, age 69 ± 19). Hospital stay, body mass index (BMI), wound length and patient demographics were documented along with a daily assessment of wound ooze. The use of DTI's was associated with a significant increase in mean days to dryness in both THR (6.2 ± 0.98, 95% C.I. 5.2-7.1) and TKR (6.6 ± 1.89, 95% C.I. 4.7-8.5) compared to aspirin in THR (3.0 ± 1.03, 95% C.I 1.9-4.0) and TKR (3.4 ± 1.21, 95% C.I 2.2-4.6) with p-values of <0.0001 and 0.0024 for THR and TKR respectively. Age, gender and wound length were not found to be significant confounding variables. DTI's proven benefit in lowering venous thromboembolism when compared with aspirin needs to be balanced with their increased cost and increased duration of wound ooze.

Unplanned overnight admissions in day-case arthroscopic shoulder surgery

The majority of arthroscopic shoulder procedures can be safely performed as day-case surgery. However, despite better pain control and preoperative assessment; some patients end with unplanned overnight admission. The aim of this study was to investigate the reasons behind unplanned admissions of patients undergoing day-case arthroscopic shoulder surgery. A retrospective review of 242 consecutive cases of arthroscopic shoulder surgery performed by the senior author over a period of two years (2007–2008) was carried out. Twenty cases were planned admissions and were therefore excluded. 222 cases were included, of which 40 (18%) were unplanned overnight admissions. Documented causes for overnight stay included abnormal post-operative observations, pain and wound ooze. The age of patients who stayed overnight was significantly higher ( p = 0.006). The difference in ASA grade between both groups was less marked but still statistically significant ( p = 0.031). More complex procedures, such as rotator cuff repair, were more likely to result in unplanned overnight admission ( p < 0.001). The experience of the anaesthetist and administration of interscalene nerve block were not significantly different between the two groups. However, patients anesthetised by less experienced anaesthetists were less likely to receive an interscalene nerve block ( p = 0.016). In conclusion; higher patient age, higher ASA grade and more complex arthroscopic procedures are significant risk factors for unplanned overnight admissions in day-case arthroscopic shoulder surgery.

A comparison of a direct thrombin inhibitor against aspirin as venous thromboemoblism prophylaxis in primary total hip replacement using wound ooze as the primary outcome measure

A comparison of a direct thrombin inhibitor against aspirin as venous thromboemoblism prophylaxis in primary total hip replacement using wound ooze as the primary outcome measure

A Retrospective Study on the Long-term Placement of Peripherally Inserted Central Catheters and the Importance of Nursing Care and Education

Peripherally inserted central catheters (PICCs) have been used for years in Taiwan, but their broad usage has been restricted by their short durability and complications. The aim of this study was to evaluate the most important factors causing failure of PICCs by comparing 2 periods of retrospectively studied cases before and after we implemented nursing care improvements. We analyzed possible factors affecting the length of the insertion period, according to the reasons for catheter withdrawal after insertion, self-care ability, coagulation status, and other factors. We reviewed 2 different periods of PICC insertions at our hospital (133 and 143 cases, respectively) before and after an announcement of nursing educational comprehensive guidelines for post-PICC care. In the first period, the most common complication due to PICC placement was wound oozing (24.7%), followed by infection/phlebitis (9.7%), occlusion (6.7%), and leaking (3.8%). In the second period, comprehensive educational guidelines for post-PICC manipulation were provided. The outcomes of PICC insertions significantly improved from 33.8% in the first period to 64.3% in the second period (odds ratio, 3.53), and the complication rates of persistent oozing (7%), infection (4.2%), and occlusion (2.8%) significantly decreased. Changes in nursing care provided in the period 2 contributed to improvements in the success rate of PICC. This is the first study suggesting that cancer nursing practice for PICC could benefit from professional guidelines that reinforce in-service education, strict control of PICC candidates without risk of coagulopathies, and a special nursing care system for patients with poor self-care ability.

Factors affecting wound ooze in total knee replacement

Wound ooze is common following total knee arthroplasty (TKA) and persistent wound infection is a risk factor for infection, and increased length and cost of hospitalisation. We undertook a prospective study to assess the effect of tourniquet time, peri-articular local anaesthesia and surgical approach on wound oozing after TKA. The medial parapatellar approach was used in 59 patients (77%) and subvastus in 18 patients (23%). Peri-articular local anaesthesia (0.25% Bupivacaine with 1:1,000,000 adrenalin) was used in 34 patients (44%). The mean tourniquet time was 83 min (range, 38-125 min). We found a significant association between cessation of oozing and peri-articular local anaesthesia (P = 0.003), length of the tourniquet time (P = 0.03) and the subvastus approach (P = 0.01). Peri-articular local anaesthesia, the subvastus approach and shorter tourniquet time were all associated with less wound oozing after total knee arthroplasty.

The art and rationale of applying a compression dressing

Compression dressings are commonly used by medical and nursing staff to arrest bleeding in a trauma or first aid situation. Their use on surgical wounds may reduce blood loss, wound ooze and infection risk. We have seen variation in the techniques used by staff in our Orthopaedic department, often resulting in no compression being achieved. In this article we explore the mechanical rationale underlying a compression dressing, in order to facilitate the technique of its application. We believe better practice will improve wound management, reduce rates of haematomas and persistent wound ooze, and lower infection rate following surgery.

Novel STSG Donor Site for Forearm Flaps: Radial Skin Paddle

Objective Split thickness skin grafts (STSG) harvested from the thigh are often utilized to provide coverage for radial forearm donor sites. To eliminate the morbidity of the thigh STSG donor site, we assessed the feasibility of harvesting the STSG from the radial. Methods Prospective data was collected from patients undergoing forearm free flap reconstruction at a tertiary medical center in a 6-month period. The radial forearm free flap (RFFF) harvesting procedure was modified to incorporate STSG harvest from the paddle site as the first step after arm tourniquet activation. Results There were 27 patients in this cohort, with mean age of 68.2. There were 24 fasciocutaneous RFFF, 2 osteocutaneous RFFF, and 1 ulnar flap. The indications for free tissue transfer were as follows: intraoral defects (n=13), pharyngeal patch repair (n=8), total laryngopharyngectomy (n=1), external skin coverage (n=5). The mean forearm defect was 41.2 cm2 (24–77 cm2). 22 out of 27 skin grafts were non-meshed. Harvesting from the forearm skin paddle was successful in 25 patients (93%). Two patients required a thigh STSG; both patients were octagenerians with frail skin. All the forearm donor sites healed well, except one patient required a later revision procedure for exposed tendon. Conclusions Based on this study, the thigh STSG donor site can be eliminated in 9 out of 10 patients undergoing radial forearm free flaps. This translates to decreased risk of pain, infection, and wound oozing. Older patients with frail skin and atrophied forearm muscles were likely to require a thigh donor site.

Wound Oozing After Total Hip Arthroplasty

Total hip arthroplasty is a commonly performed operation and yet little information exists about the duration of wound oozing, the factors associated with this and the implications. The aim of this work was to identify factors influencing wound oozing by establishing their effect on the time taken for wounds to cease oozing after total hip arthroplasty. Sixty-two consecutive patients undergoing total hip arthroplasty were included. Wounds were examined for wound oozing on a daily basis by the same observer and were then re-dressed. The time taken for each wound to become dry was recorded. Data were analysed to determine if the time-to-dryness was influenced by wound length, body mass index, estimated volume of blood in the dissected tissues, duration of surgery and ASA grade. Time to dryness was associated with wound length (P = 0.01), body mass index (BMI, P = 0.05), estimated volume of blood in dissected tissues (P = 0.05) and length of hospital stay (P = 0.02). No association was found with duration of surgery or ASA grade. A small-incision, meticulous haemostasis at surgery and a reduction in pre-operative obesity reduce the time taken for hip arthroplasty wounds to become dry. Prolonged wound oozing delays hospital discharge.

A Pilot Study of the Effects of Vivostat Patient-derived Fibrin Sealant in Reducing Blood Loss in Primary Hip Arthroplasty

A pilot study evaluated the effectiveness of Vivostat patient-derived fibrin sealant in reducing blood loss in patients who underwent primary hip arthroplasty. Eighty adult patients undergoing elective surgery were randomized to receive either Vivostat sealant or control (no additional hemostatic treatment). Patients allocated Vivostat sealant donated 120 mL of blood, which was then processed perioperatively to produce a fibrin sealant that was applied to the bleeding wound surfaces just before closure. Transfusion requirements, blood loss during surgery, drain volumes, and daily hematocrit and hemoglobin levels were measured. Hospitalization times, adverse events, and postoperative wound complications were also monitored. Blood loss during surgery and wound drainage volume was lower in the Vivostat group than in the control group, although the differences were not significantly different. Transfusion requirements (median, 270 mL of packed red blood cells) and hospitalization times (both median 7 days) were the same for both groups. No adverse events related to the use of Vivostat occurred. There were indications of a possible reduction in the incidence of postoperative wound oozing (15% vs 25%) and hematomas (6% vs 11%) with the use of Vivostat compared with the control group, although differences were not statistically significant. In conclusion, in this pilot study, use of Vivostat patient-derived fibrin in hip arthroplasty was not associated with a significant reduction in blood loss. Further studies, with larger numbers of patients, may be warranted to investigate a possible benefit of Vivostat in reducing postoperative wound complications.

Occasional-operator percutaneous brachial coronary angiography: first, do no arm.

The percutaneous brachial approach to coronary angiography is perceived, rightly or wrongly, to be the easiest of the arm approaches. Predominantly femoral operators may therefore be encouraged to use the percutaneous brachial approach as an occasional procedure. We decided to investigate prospectively whether this was a reasonable strategy by examining outcome in patients who underwent percutaneous brachial cardiac catheterization by occasional brachial operators. Between October 1997 and 2000, 55 patients underwent percutaneous brachial coronary angiography (0.6% of coronary angiographies), aged 66 +/- 10 years, of whom 40 (73%) were male. Chief indications for a brachial approach were peripheral vascular disease in 35 (64%), failed femoral approach in 10 (18%), and orthopnoea in 5 (9%). The procedure was completed successfully in 46 patients (84%). Reasons for failure were failure of access (two), brachial artery spasm (one), inability to negotiate brachial/subclavian tortuosity (two), dissection of the brachial artery (two), and inability to intubate a vein graft (two). Six patients required catheterization from an alternative site (brachial arteriotomy in two, percutaneous transradial in two, femoral in two), with success in all. There were complications of varying severity in 20 patients (36%). Major complications were false aneurysm requiring surgical repair (one), large brachial hematoma requiring surgical exploration and arterial repair (one), and hematoma with clinical median nerve dysfunction for one month. Minor complications included need for repeat coronary angiography via alternative approach (six), weakness of radial pulse < 24 hr (two), brachial artery dissection without clinical sequelae (two), brachial artery spasm terminating procedure (one), and wound oozing (three). Percutaneous brachial coronary angiography is a hazardous procedure when undertaken by occasional brachial operators. Complications are unacceptably frequent. As with all practical procedures, complication rates are likely to be inversely proportional to operator volumes. Patients requiring an arm approach should be referred to operators with high-volume brachial or radial experience.

The use of wound drains in total hip replacement surgery

For virtually three decades wound drains were used almost routinely in total joint replacement without question and were considered essential. On reviewing the literature, however, the scientific evidence for their use is scanty. More recently, a number of relatively small studies have questioned their value. It was therefore decided to carry out a large, definitive study to determine whether or not the use of a wound drain affected the outcome in primary total hip replacement. In July 1994, a prospective, randomized control trial began in Musgrave Park Hospital. A total of 872 primary total hip replacements were included (440 with a drain and 432 without). A number of different parameters were measured in thepostoperative period including blood loss, wound and drain site ooze, haematoma formation and wound infection. The study found no evidence to suggest that drains are actually harmful to patients, but they do not appear to be necessary. Consequently, it is proposed that postoperative drainage systems offer little advantage in the outcome of primary total hip replacements. A saving of £ 12 508 could be made over the course of a year if no drains at all were used for patients undergoing total hip replacement surgery in the study hospital (drain per unit cost £7. 16×1747, 1995/96).

BALSAM OF PERU IN MASTOID SURGERY

The use of Peruvian balsam is certainly not new, but judging from inquiries that I have made, this valuable drug has not the general acceptance that its merit warrants. At the completion of the mastoid operation and after the middle ear has been flushed through the aditus, the wound is tightly packed with a gauze pad saturated with a mixture of equal parts of balsam and alcohol. This is removed one or two minutes later and serves the double purpose of sterilizing the wound and checking oozing. The wound is then lightly packed with one-half inch strip gauze moistened in 1:5,000 solution of mercuric chloride and the balsam-alcohol mixture. Over this, plain gauze pads moistened in mercuric chloride solution are placed with rubber tissue over all and bandaged as usual. The first dressing is made forty-eight hours later, and this interval is observed for the first three dressings, at the