Surgical Wound Care

1. Pre-operative risk assessment
    1. 1.1 All patients undergoing surgery should be assessed pre-operatively to determine their risk for developing post-operative wound complications. Patients are at increased risk if they have any of the following risk factors: (Level of evidence: High)

      ● Obesity (BMI>30 kg/m2)

      ● Current smoker

      ● Diabetes

      ● Poor nutritional status

      ● Cushing's disease, chronic use of corticosteroids or other immunosuppressive agents

      ● Multiple comorbidities

      ● Presence of fistulas, contaminated or dirty wounds

      ● Currently on chemotherapy or immunotherapy (eg. Bevacizumab)

      ● History of radiation

      ● Presence of implants, mesh or hardware placements

      ● History of previous non-healing wounds

      ● Surgery is performed as an emergency or of long duration

2. Management of closed surgical incision healing by primary intention
    1. All closed surgical incisions should be appropriately dressed in the operating room.
    2. The timing of the first dressing removal is at the discretion of the surgeon. When indicated wounds may be assessed by the surgical team and/or nurse daily or more frequently. Special devices (NPWT, Supportive devices) can be considered but out of the scope of this guideline. The assessment should include the following: (Level of evidence: Moderate)

      ● Location of incision

      ● Length of incision

      ● Closure method e.g. sutures, staples, steri-strips, tissue adhesives

      ● Approximation of the skin edges

      ● Presence of the acute inflammatory response edema which should be present 1-4 days post surgery

      ● Presence of the healing ridge which should be present 5-9 days post surgery

      ● Presence of hematoma, seroma or exudate or signs of infection

    3. Clean closed surgical incisions do not require cleansing or any dressings after the initial surgical dressing is removed. (Level of evidence: High)
      1. A clean dressing can be applied to absorb discharge, and decrease wound contact with clothing.
    4. After the dressing applied in the operating room is removed, patients may shower anytime. The area should be dried well after the shower. (Level of evidence: Moderate)
3. Management of infected open surgical wounds
    1. Management of infected wounds should be initiated by the surgical team and if necessary staples or sutures should be removed and the wound should be opened and drained (Level of evidence: High)
    2. Wounds should be assessed (refer to Appendix A) subsequently by the surgical team and/or nurse when the patient is in hospital. If the wound is complex, a timely referral to a Nurse Specialized in Wound, Ostomy and Continence (NSWOCC) should be made. (Level of evidence: Moderate)
    3. Potable water is sufficient for cleansing wounds. Clean technique should be used for dressing changes. Clean technique involves meticulous handwashing, maintaining a clean environment by preparing a clean field, using clean gloves and sterile instruments, and preventing direct contamination of materials and supplies (Level of evidence: High)
      1. If the patient is immunocompromised, sterile normal saline should replace potable water for cleansing the wound
    4. Contaminated or dirty wounds should be irrigated with potable water at low pressure (4-15 psi) prior to application of new dressings. (Level of evidence: Low)
      1. If the patient is immunocompromised, sterile normal saline should be used for irrigation
    5. Antiseptic soaked gauze should be used for initial wound packing or contact layer (Level of evidence: Low)
    6. Debridement should be considered if there is necrotic tissue and antibiotics should be considered if there are systemic signs of infection (Level of evidence: Moderate)
4. Management of surgical wounds healing by secondary intention
    1. Wound care should be based on:

      ● Wound type (superficial, deep or tunneling)

      ● Infected or Non-Infected

      ● The amount of exudate/transudate (nil-low or moderate-copious) in the wound

    2. The wound care algorithm (Appendix B) and wound care product categories (Appendices C and D) should be referred to for determining the appropriate treatment. (Level of evidence: Moderate-High)
5. Discharge Planning and Care
    1. Patients and their caregivers should be involved in the care planning of their surgical wounds while in hospital and prior to discharge. (Level of evidence: Low)
      1. At discharge (including short stay, admissions <48 hrs), the patient and caregiver should be given verbal and written information on the following:

        ● When the first dressing should be changed or removed once at home (at the discretion of the surgeon)

        ● The appearance of a normal surgical incision as it heals

        ● How routine cleansing/showering of the incision should be done

        ● Dressings, creams or ointments should be avoided

        ● Surgery specific activity restrictions and support devices that are required to allow healing of the incision

        ● When staples or sutures should be removed based on the procedure, wound site and factors affecting wound healing (at the discretion of the surgeon)

        ● When drains should be removed (at the discretion of the surgeon)

        ● Information about signs and symptoms that indicate there may be a wound infection

        ● When to seek medical help, and who he/she should call and their contact information if the patient has concerns

        ● The date and time when the patient should have a planned follow-up appointment with the surgeon or other identified health care professional or contact information so he/she can make that appointment

    2. If the patient has an open wound, a consultation including a member of the hospital clinical team (patient’s nurse), patient’s surgeon, the hospital Toronto Central Local Health Integrated Network (LHIN) Care Coordinator, the patient and caregiver prior to discharge should be held to determine the community requirements and care needs. (Level of evidence: Low)
      1. The following should be considered:

        ● Care will be given at an ambulatory nursing clinic or patient’s home based on a care coordinator’s assessment and care giver availability The capacity of the patient and care giver to self-manage wounds should be assessed. To provide self-care, the patient and caregiver should be able to:

        ○ Remove and apply wound dressing using clean technique

        ○ Understand products that are available and their use

        ○ Describe changes to the wound that may require medical attention

        ○ Know the names of retail stores that carry required topical dressings and ability to purchase required topical wound care dressings or recommended substitute wound care products for the duration of treatment

    3. If the patient has an open wound, the following information should be provided by the hospital to the LHIN Care Coordinator at discharge: (Level of evidence: Moderate)

      ● Medical history including current medications and whether the patient is on antibiotics

      ● A complete wound history and wound description including type, size and type of drainage

      ● Topical therapy including preferred cleansing methods, dressing type and frequency of changes which are being used

      ● Goals of care

      ● Information about the planned follow-up with surgeon, including contact information

    4. The provision of topical wound treatment should be seamless from acute care to community care. Care of the open wound should be based on the recommendations from the Wound Care Guideline. (Level of Evidence: High)
      1. After reassessment by LHIN Care Coordinator providers and if changes are suggested, the hospital clinical team and LHIN Care Coordinator providers should agree on a plan
6. Follow-up care
    1. Post-discharge, all queries and follow up of patients of surgical wounds should be referred to the surgeon unless a designate has been identified prior to discharge.
    2. Changes to recommended care should be made in discussion or via fax with the surgeon or designate as indicated at discharge with LHIN provider.
Appendix A: Assessment of open wounds
The following items should be assessed in open wounds:
  • Wound bed
    • Granulating – healthy red tissue presents as pinkish red coloured moist tissue and bleeds easily
    • Epithelializing – tissue is pink, almost white and only occurs on top of healthy granulating tissue
    • Sloughy – tissue is yellow, should not be confused with pus
    • Necrotic – tissue may be moist or dry and black/brown (devitalized tissue)
    • Hypergranulating –granulation tissue grows above the wound margin
  • Wound measurement
    • Measure length and width of wound
    • Use a cotton tip applicator to assess depth of wound and to check for undermining, tunnelling, or sinus tracts
  • Wound Edges
    • Colour – pink edges indicate growth of new tissue; dusky edges indicate hypoxia; erythema edges indicate an inflammatory infection
    • Raised Edges – where the wound margin is elevated above the surrounding tissue may indicate pressure, trauma, or malignancy
    • Rolled Edges – where the wound edges roll down towards the wound bed, this may indicate wound stagnation or a chronic wound
    • Contraction – wound edges are coming together, signs of healing
    • Sensation – increased pain or the absence of sensation should be noted
  • Exudate/Transudate
    • Exudate/Transudate refers to:
      • Serous: clear, thin watery, straw colour - normal
      • Sero-sanguinous: clear, thin watery pink colour - normal
      • Sanguinous: thin watery red colour - trauma to blood vessels
      • Purulent exudate: thick yellow, grey, green colour
    • Amount
      • Too much exudate/transudate leads to maceration and degradation of the skin
      • Too little can result in the wound bed drying out
      • Small amount – (soaks through a foam dressing in >3-5 days)
      • Scant amount – (soaks through foam dressing in > 5-7 days)
      • Moderate-Copious amount (soaks through a foam dressing 24 – 72hrs)
  • Infection
    • Local indicators of infection include:
      • Erythema
      • Purulent exudate
      • Foul odor
      • Localized pain
      • Warm to touch
      • Wound breakdown
    • Systemic indicators include:
      • Increased temperature
      • General malaise
      • Increased leucocyte count
  • Surrounding Skin
    • Surrounding tissue may present as: healthy, macerated, dry/flaky, erythema, black/blue discolouration, induration (hardening), or cellulitis
  • Pain
    • Assessment before, during and after dressing change required
Appendix B: Management of open wounds by type

This table is intended to provide basic wound care suggestions when initiating treatment. Please refer to a Nurse Specialized in Wound, Ostomy and Continence Canada (NSWOCC)for further treatment recommendations. All open wounds should have a primary contact layer and a cover dressing Tables 1-3 Recommend wound care products for the following wound types: Superficial Wounds (table 1); Deep Wounds (table 2); Tunneling Wounds (table 3) Each wound type offers recommendations for infected/non-infected wounds and amount of exudate (nil/low or moderate/copious)
Table 1. Management of superficial wounds (only skin and subcutaneous tissue)
Wound Type Wound Product Exudate
Nil/Low Exudate Moderate**– Copious Exudate
Infected Primary Contact Layer
  • Antimicrobial gauze
  • Hydrogel
  • Antimicrobial Sheet/Mesh
  • Antimicrobial Alginate
  • Antimicrobial Hydrofibre
  • Antimicrobial Sheet/Mesh
  • Cadexomer Iodine
  • Gentian Violet/Methylene Blue
Cover Dressings
  • Antimicrobial Foam
  • Absorbent Pad
  • Non-adherent Sheet
  • Antimicrobial Foam
  • Absorbent Pad
  • Foam
Non-Infected Primary Contact Layer
  • Foam
  • Hydrogel
  • Antimicrobial Sheet/Mesh
  • Calcium Alginate
  • Hydrofibre
  • Non-Adherent Sheet/Mesh
Cover Dressings
  • Absorbent Clear Acrylic Dressing
  • Absorbent Pad
  • Foam
  • Hydrocolloid
  • Non-adherent Sheet
  • Transparent Film
  • Absorbent Pad
  • Foam
Table 2. Management of deep wound (involves deep soft tissue)
Wound Type Wound Product Exudate
Nil/Low Exudate Moderate**– Copious Exudate
Infected Primary Contact Layer
  • Antimicrobial gauze
  • Antimicrobial Moistened Gauze
  • Antimicrobial Alginate- (Manuka Honey Packing)
  • Antimicrobial Hydrogel
  • Antimicrobial Moistened Gauze
  • Antimicrobial Sheet/Mesh
  • Gentian Violet/Methylene Blue
  • Antimicrobial Alginate-with Silver
  • Antimicrobial Hydrofibre with Silver
  • Hypertonic Packing
  • Polymeric Membrane Packing
Cover Dressings
  • Antimicrobial Foam
  • Absorbent Pad
  • Foam
  • Antimicrobial Foam
  • Absorbent Pad
  • Foam
Non-Infected Primary Contact Layer
  • Hydrogel
  • Moistened Packing
  • Calcium Alginate
  • Hydrofibre
  • Hypertonic
  • Moistened Gauze
Cover Dressings
  • Absorbent Pad
  • Foam
  • Non-adherent Sheet
  • Absorbent Pad
  • Foam
Table 3. Management of tunneling wounds (narrow opening or passageway)
Wound Type Wound Product Exudate
Nil/Low Exudate Moderate**– Copious Exudate
Infected Primary Contact Layer
  • Antimicrobial Hydrogel
  • Antimicrobial Moistened Packing
  • Antimicrobial Sheet/Mesh
  • Antimicrobial Alginate
  • Antimicrobial Hydrofibre
  • Antimicrobial Moistened Gauze
  • Antimicrobial Sheet/Mesh
  • Gentian Violet/Methylene Blue
  • Hypertonic Packing
Cover Dressings
  • Antimicrobial Foam
  • Absorbent Pad
  • Foam
  • Antimicrobial Foam
  • Absorbent Pad
  • Foam
Non-Infected Primary Contact Layer
  • Hydrogel
  • Moistened Packing
  • Calcium Alginate
  • Hydrofibre
  • Moistened Gauze
  • Non-Adherent Sheet/Mesh
  • Hypertonic Packing
Cover Dressings
  • Absorbent Clear Acrylic Dressing
  • Absorbent Pad
  • Foam
  • Hydrocolloid
  • Non-adherent Sheet
  • Absorbent Pad
  • Foam