Wound washout

Last modified by Hussein Abdallah on 2024/03/13 19:10

Before the Case

Know what was done, when, and by whom.

Know whether there is hardware in the incision.

It is vitally important to know whether there was a CSF leak in the prior case and whether there are areas of exposed dura (e.g. prior laminectomy). This will significantly change the speed and aggression with which you debride.

Supplies

Abx irrigation with pulse evac (vanc/gent vs. Ancef)

If the wound will be left open, ask for:

White sponge
Wound vac
Black sponge x 2

Positioning

Prone on jelly rolls. The face is held in a face holder.

Prep

Every attending will have their own preferences.The safe universal option is to prep with betadine widely.

Draping

Lay towels in a wide rectangle around the wound. Be sure to leave a wide margin of skin undraped around the wound.

Ask the scrub tech to cut the Ioban into 4 pieces. Apply the ioban strips to the edges of the blue towels, allowing a thin strip to cover the skin. Leave the central part of the field bare of Ioban.

Drape with four universal block drapes.

Procedure

Open and culture

Open the incision with heavy curved Mayo scissors by spreading. Cut any remaining suture.

Inspect the incision. Collect two cultures from the superficial compartment using swabs. Ask the circulating nurse to open the swabs right when they are about to be used. Be careful not to touch the end of the swab with your fingertips. Make sure it only touches the inside of the incision and then place directly in the collection vial. Cultures can be called superficial wound culture #1 and #2.

If the fascia is intact, do not open it. Instead, call the attending and ask them if they want you to inspect below the fascia.

If the fascia is opened, collect two more cultures from the subfascial space. They can be called deep wound culture #1 and #2.

Debride

Irrigate with antibiotic irrigation. Remove any pus or loose debris. Residual bone chips must be removed.

Take special caution not to debride over areas of exposed dura.

Remove any black or white devitalized tissue with sharp dissection. Ideally, the walls of the incision should show little pinpricks of venous bleeding after debridement. Do not coagulate venous bleeders. Only use bipolar sparingly to coagulate arterial pumpers. Allow the rest to bleed freely.

After debridement, irrigate with 3 L of antibiotic irrigation with the Pulsavac. Focus on washing the walls and corners of the incision.

Never irrigate directly over exposed dura or spinal cord (this can cause hydrocontusion)

If the wound will be closed primarily, sharply debride the skin edge. Ask for a fresh 10-blade and remove the innermost strip of skin along the skin edge. This gives the wound a fresh, bleeding edge. Do not coagulate venous bleeders, only coagulate arterial pumpers.

Closure

If the wound will be primarily closed it will be either by neurosurgery alone or with plastics. If plastics is involved, ask the circulator to call for them and let them take over. If plastics is not involved, ask the neurosurgery attending how they want the wound closed.

If the wound is to be left open, lay white sponge against any areas of exposed dura. Pack the remaining cavity with black sponge. Use as many pieces of black sponge as is necessary to fill the cavity to the skin edge. Fill the cavity with black sponge to the skin edge but not beyond. Keep track of how many pieces of white and black sponge you leave in the wound and record that number in your postop note. This is important so that no foreign bodies are left behind in the wound when it is ultimately closed.

Once the wound is packed with black sponge, dry the skin of the back or neck very well with dry lap sponges. Ask for several vials of benzoin or Mastisol (they are equivalent) and apply liberally to the skin in a wide border around the open wound. The red hash marks show where you should apply Mastisol or benzoin.

Ask for a large wound vac tape and cover the entire wound. Make sure the skin is dry or the vac tape won't stick.

Ask for a smaller piece of wound vac tape and stick to the skin going off laterally. This piece of tape is placed to protect the skin from the abrasive quality of the black sponge that you are about to place over it.

Use large scissors to cut an "X" in the vac tape in the center of the wound.

Ask for the thin, coiled, spiral shaped black foam. Uncoil it and cut a length that will extend from the center of the open wound to the edge of the vac tape. Place one end against the area marked by the red "X", the other end out laterally, and cover completely with new vac tape. Cut another "X" in the vac tape overlying the lateral end of the thin sponge.

Peel the sticky backing off the proximal tubing pad and apply over the cut "X" marked in red above. Make sure the tubing is pointed out laterally so that it doesn't coil under the patient when they're laying on their backs.

Connect the proximal and distal tubing and turn on the vac. A continuous pressure of 125 mmHg is usually appropriate.

Once the vac is turned on, the black foam should suck down into the open wound and become more firm. If it doesn't, or if the vac gives an "air leak" warning, search for the area of leak and apply more vac tape to repair it. Leaks usually happen around folds in the skin. To address this, remove any tape from over the skin fold, dry well, apply Mastisol or benzoin, and pull the fold open and hold it flat before applying new tape over it.

After the case

Documenting findings in your immediate post-op note:

It is crucial that you document in your immediate post-op note the extent of infection as described below as ID will use this information heavily. There is a giant difference between a sterile superficial dehiscence and deep subfascial pus involving hardware in terms of how it will be treated. If you don't know what to specifically say exactly, ask your attending / chief "how would you like me to document the extent of infection for the purposes of ID?"

Items to address:

Depth explored: Did you open supra-fascial or sub-fascial?

Depths of infection: Was the infection supra-fascial or sub-fascial?

Hardware involvement: Was hardware grossly involved?

Infectious material: Any purulent/cloudy material (or lack thereof)?

Culture swabs: were these collected superficially (supra-fascial) or deep (subfascial)?

Number of sponges: if you don't close and a wound-vac is left in, document separately the number of white and black pieces of sponge the next person should expect to find in the next washout / closure. A whole snail is one black piece, if you cut it into pieces it's however many pieces, etc.