Clinicians debate whether wounds should get wet after same-day surgery

CDC guidance is limited — here’s what the experts say

One of the great controversies in same-day surgery is whether sutured wounds should be allowed to get wet after surgery. Some surgeons insist that surgical wounds be kept dry for days to weeks.

"Overall, the general public as well as the general medical community still persists in believing that wound management should be carried out under dry conditions, so the wound can form a scab," says Liza G. Ovington, PhD, CWS, president of Ovington & Associates, a wound care education and consulting firm in Dania, FL. However, she says, "That may not be the case."

There’s a tendency to associate wetness with infection. "We’re so used to dry wound healing, seeing scabs; it seems intuitive that the wound should be dry to the point that it forms scab or dries out," Ovington says. Proposed guidelines on surgical site infection from the Centers for Disease Control and Prevention (CDC) say clinicians should protect a primarily closed incision site with a sterile dressing for 24 to 48 hours post-op.

Initially, the recommendation included the wording "dry sterile dressing," but "dry" was dropped due to questions surrounding the definition of a dry dressing, according to William Trick, MD, medical epidemiologist in the Hospital Infections Program at the CDC.

The proposed guidelines fall under Category 1A: Strongly recommended for all hospitals and strongly supported by well-designed scientific studies. In the proposed version, there is no recommendation on covering the incision beyond 48 hours nor on an appropriate time to shower/bathe with an uncovered incision. Therefore, the issue is unresolved. (For more information on the proposed CDC guidelines, see Same-Day Surgery, October 1998, pp. 127-131. The CDC will publish the guidelines this spring, according to Trick.)

Research supports occlusive dressings

While there has been an extensive amount of nurse research on the topic of wound healing and wetness, the physician literature is limited, says Wendelyn Valentine, RN, MSN, CNOR, CRRN, COCN, clinical nurse specialist, surgical, at the University of Washington Medical Center in Seattle.

The research supports moist wound healing and the use of occlusive or semi-occlusive dressings, say sources interviewed by SDS. Technically, occlusive dressings don’t transport liquid or gas, Ovington says. Semi-occlusive dressings won’t transmit liquids, but will transport gases such as oxygen, she says. However, the terms are often used interchangeably.

Ovington points to several human clinical trials of occlusive dressings, which don’t allow a wound to dry out, vs. conventional (gauze) dressings in surgical wounds,1-4 including a randomized controlled trial that minimizes bias.5 These studies support the use of occlusive dressings, she says.

Valentine refers to two benchmark studies: The first study demonstrated lower rates of infection for wounds, even surgical wounds, when occlusive dressings were used.6

"That’s the optimal research-based treatment for most patients," she says.

The second study gives an overview of wound healing in a moist environment.7 Sutured wounds heal faster if the environment is physiologically moist, Ovington says. Physiologically moist refers to the naturally moist state of tissue. "As natural organisms, we’re mostly composed of water. With a wound, it’s actually healthier if it’s physiologically moist."

The idea of allowing a moist healing environment has not gained full acceptance, however, Ovington says. "Often, this is new and, therefore, uncomfortable information to a clinician."

Valentine says she believes wound healing in a moist environment makes the shower/bath issue insignificant. "If you’re keeping a moist environment intentionally, that would lead you to believe that the wound getting wet makes no difference."

Semi-occlusive dressings maintain the physiologically moist state of wounds, Ovington says. "The wound is kept moist because the transparent film slows the evaporation of moisture from the tissue."

Transparent film dressings might be the most appropriate for sutured surgical wounds, she says. The transparency allows the clinician to see the wound through the dressing. Also, the wound is waterproof, so patients can bathe or shower.

Keeping the wound free of bacteria is also critical because sutures can allow bacteria to gain access to tissue, Ovington points out.

Valentine agrees. "If a fresh wound is put under an occlusive dressing, that protects it from any external bacteria," she says.

In terms of showering or bathing, patients should be able to wash the wound area after 24 to 48 hours if the cleaning is done gently, emphasizes John Fildes, MD, FACS, professor of surgery at the University of Nevada School of Medicine in Las Vegas. Fildes spoke on acute wound failure at the October Clinical Congress of the Chicago-based American College of Surgeons.

"It’s been shown that the wound forms a scab," Fildes explains. "At the level of the epidermis, it is sealed within 24 hours."

Soap and water are appropriate cleaning agents, he maintains. "I tell them after 24 to 48 hours, they can remove dressing; they can shower and wash the area very gently with soap and warm water, and then pat it dry."

It’s not uncommon medical practice for a surgeon or nurse to inspect or clean a wound the day after surgery, Fildes points out. "When they clean, they commonly use solutions like Betadine or alcohol, which are far more likely to damage the immature healing tissues than simple soap and water."

Fildes admits that his advice is an exception to what most surgeons practice. "Most will keep an occlusive dressing in place for several days or until the first office visit to inspect the wound."

References

1. Michie DD, Hugill JV. Influence of occlusive and impregnated gauze dressings on incisional healing: a prospective, randomized, controlled study. Ann Plast Surg 1994; 32(1):57-64.

2. Kleczynski S, Niedzwiecki T, Brzezinski M. The search for an "ideal" surgical dressing [W poszukiwaniu "idealnego" opatrunku chirurgicznego]. Polim Med 1986; 16(1-2):55-61.

3. Hulten L. Dressings for surgical wounds. Am J Surg 1994; 167(1A):42S-44S; discussion 44S-45S.

4. Rasmussen H, Larsen MJ, Skeie E. Surgical wound dressing in outpatient paediatric surgery. A randomised study. Dan Med Bull 1993; 40(2):252-254.

5. Holm C, Petersen JS, Gronboek F, et al. Effects of occlusive and conventional gauze dressings on incisional healing after abdominal operations. Eur J Surg 1998; 164(3):179-183.

6. Hutchinson JJ. The prevalence of wound infection under occlusive dressings: A collective survey of reported research. Wounds 1989; 1(2).

7. Field CK, Kerstein MD. Overview of wound healing in a moist environment. Am J Surg 1994; 167(1A).

Sources

For additional information on wound healing, contact:

John Fildes, MD, FACS, 2040 W. Charleston Blvd., Suite 302, Las Vegas, NV 89102.

Liza G. Ovington, PhD, CWS, President, Ovington & Associates, 429 S.E. Third Terrace, Dania, FL 33004. Telephone: (954) 929-1902. Fax: (954) 929-2308. E-mail: lizao@msn.com.

Wendelyn Valentine, RN, MSN, CNOR, CRRN, COCN, Clinical Nurse Specialist, Surgical, University of Washington Medical Center, 1959 N.E. Pacific St., Box 356090, Seattle, WA 98195-6090. Telephone: (206) 548-4532. E-mail: wendyv@u.washington.edu.