Discussion and analysis of dressing changing skills after anorectal diseases
2016-11-08 Li Yudong Letter from Doctor Anorectal
【Abstract】Whether the technique of dressing change after anorectal disease operation is appropriate directly affects the speed of wound repair, so postoperative dressing change plays a vital role in the entire treatment process. In many textbooks, the techniques of dressing changing, especially the techniques of dressing changing after local anal surgery are extremely brief. Combining clinical practice and years of experience accumulated by Beijing Hospital of Traditional Chinese Medicine Affiliated to Capital Medical University, the author will discuss and introduce the physiological and pathological process, points and misunderstandings of postoperative dressing change, and personal experience in the work process. Physicians provide new and broader ideas in the understanding and skills of clinical dressing change.
[Keywords] anorectal diseases; postoperative; dressing skills
1. The physiology of wound repair
1.1 Inflammatory phase: The essence of the inflammatory phase is a defense response of the body against trauma. After the tissue is injured by surgery, the internal environment of the tissue is severely damaged, including bleeding, vasoconstriction, blood coagulation, necrotic tissue after injury, and purulent cell formation, etc., so that histamine, kinin, serotonin and prostate are released from the tissue Inflammatory factors such as vitamins cause the expansion of small blood vessels and increase the permeability of capillaries to produce inflammatory reactions. Then, macrophages and granulocytes enter the tissue wound area, secrete proteolytic enzymes, dissolve necrotic tissue proteins, and swallow necrotic cells and foreign bodies, play a role in cleaning up the wound, and lay the foundation for the growth of fibrous tissue in the next stage. This period will take about 3-5 days.
1.2 Fibrous proliferation phase: After the inflammatory phase, fibroblasts produced by the connective tissue of the wound and endothelial cells derived from new capillaries form naive connective tissue, which forms granulation in the wound from bottom to top, self-created margin to the center It grows and gradually fills up the defect. When the wound cavity is filled, this period ends and enters the epithelial coverage period. The fiber proliferation period plays an important role in healing wounds. This period will take about 5-20 days.
1.3 Epithelial coverage period: It is completed by the proliferation of epidermal cells at the wound edge and migration into the wound. The epidermis at the wound margin first extends downward to reach the connective tissue layer of the dermis, and then a large number of nuclear divisions and cell proliferation occur. As a result, the epithelium thickens and extends into the newly grown connective tissue, and finally covers the wound completely, allowing the wound to heal. This period will take about 3-5 days.
2. Stages of dressing change after anorectal surgery
The characteristics of wounds after anorectal disease surgery are ligation, more necrotic tissue, deep wounds, and more drainage. According to the physiological process of wound healing, dressing change after anorectal surgery can be divided into three phases.
2.1 Early stage (necrotic tissue shedding period): 3-5 days after the operation, the wound is mainly inflammatory exudation. The principle of dressing change in this period is to clean the wound, remove foreign bodies and pus, make the wound flow smoothly, and reduce bacteria Stimulation of reproduction and secretion to prevent secondary infections. In principle, the dressing change is mainly aqua drugs, covering the wound with water gauze, such as huanglian water or bactericidal gauze wet compress after rinsing with hydrogen peroxide to clean, penetrate, reduce inflammation, and absorb, and promote inflammation absorption. .
2.2 Mid-term (granulation growth period): 5-20 days after surgery, there is very little wound secretion, mainly granulation tissue hyperplasia. Since the granulation tissue is weakly resistant to external physical and chemical stimuli and is vulnerable to injury, this period should focus on protecting the granulation tissue so as not to affect the wound healing. When changing the dressing, ointment drugs should be used to cover the wound, such as Dragon Ball ointment, Kangtai ointment, etc., to protect the new granulation from external stimulation. Disinfectants should be used as little as possible during this period, because they not only have antibacterial effects, but also damage tissues, which is not conducive to wound growth.
2.3 Later period (climbing period): 8-25 days after operation. The wound cavity has been filled with granulation tissue. The epithelial cells of the wound margin migrate to the center of the wound, and finally cover the wound to heal the wound. Principles of treatment during this period: reduce stimulation to the wound, protect epithelial growth, and prevent overgrowth of granulation. Washing should be done less or not when changing dressings, and the fiber membrane on the wound surface that promotes epithelial growth should be protected. It is advisable to perform intermittent dressing changes, and the wound can be wrapped with gauze.
3. The role and points of dressing change after anorectal surgery
3.1 Guide the patient's benign psychology: Before changing the dressing, pay attention to the patient's internal condition and mental state, let the patient understand the purpose and significance of the dressing change, explain to the patient the importance of dressing change for wound healing and the operation steps of dressing change, and give Comfort and sympathy, eliminate some of the patients' misunderstandings and fear or disgust, increase the patient's confidence in the recovery of health and give full play to their subjective initiative. When changing the dressing, the attitude should be gentle and the operation should be gentle and meticulous. Don't be bored by the patient's groaning and complaining. Surprising voices and expressions should be avoided to prevent the patient from fear, doubt and increased anxiety. Practice has proved that the operation is gentle, not only can Reduce the patient's pain, and make it easier for the patient to receive treatment. If the operation is rough, the opposite result will occur.
3.2 Wound cleaning: the cleaning of the wound is generally done with normal saline. In principle, the wound should be washed from the center to the outside, and the inside and outside of the wound should be separated. The cotton ball outside the wound cannot be washed inside, and the cotton ball inside the wound should also be washed. Do not wash the outside of the wound to avoid mutual contamination inside and outside. Generally, the wound should be cleaned according to the top-down, inside-out rule. For ordinary wounds, where there is not much purulent secretion, it is not necessary to clean it. For those with deeper and larger cavities, more secretions and necrotic tissues, you Perform flushing. The rinsing fluid can be normal saline, hydrogen peroxide, metronidazole, etc., which can clean purulent secretions, reduce wound surface pollution, and continue to reduce inflammation and sterilization of drugs.
4. Treatment of special wounds
4.1 Treatment of high anal fistula thread hanging incision: high complex anal fistula usually takes part or all thread hanging treatment, and it is difficult to change dressing after operation. The purpose of the treatment of this type of wound is to promptly remove the secretions and tissue residues drained from the drainage strip or rubber band, and to prevent premature healing of the wound base and false healing of the tissue above the drainage strip. Therefore, when changing the dressing, it is necessary to expose the wound surface as much as possible, clean the upper and lower wound surfaces of the drainage strip, rotate the drainage strip to discharge the secretions as much as possible, and fill the wound base and the top of the drainage strip with oily gauze to prevent the wound from prematurely bonding. Bridge healing. For the postoperative wounds of anal fistula with severe infection and more secretions, flushing should be used to clean the wounds to make the wounds clean and unobstructed, laying a good foundation for tissue growth after the drainage strips fall off.
4.2 Treatment of complex anal fistulas with open ducts: The main mechanism is that after the primary fistula of the main duct is removed, the branch ducts will adhere and the necrotic tissue will be absorbed to achieve the purpose of healing. Therefore, for an open tube with a lighter infection, a small cavity, and less necrotic tissue, the water gauze can be pulled out after 48 hours. Just press a little bit on the open pipe. Don't stimulate the open pipe orifice too much. Don't put ointment in the pipe, otherwise it will not be conducive to the adhesion of the pipe. It is also not advisable to flush the pipeline, because the liquid medicine stays in the wound after lavage, which is not only useless, but will stimulate the cavity and affect granulation, and even penetrate into the normal tissues to cause irritation or infection. For open tubes with more infections and a lot of necrotic tissue in the cavity, after removing the open water gauze at 48 hours postoperatively, the open tubes can be continuously washed for 2-3 days to remove the necrosis
Bacteria in the tissues and cavities minimize the infection and eliminate the unfavorable factors for the healing of duct adhesion. However, after flushing, the flushing fluid should be sucked and discharged as much as possible to avoid irritating the tissue in the cavity. After changing the dressing every day, you only need to apply a little pressure on the open pipeline, don't stimulate too much, which will affect the adhesion healing.
5. Operational misunderstandings in dressing change
Put an end to the wrong operation of the "three menaces". "Three Meng" can aggravate the injury without healing for a long time, and increase the patient's discomfort, which should be eliminated in clinical dressing change.
5.1 Vigorous wiping: not only refers to excessive force during scrubbing and disinfection, but also refers to excessive wiping times. Vigorous rubbing will not only damage the new tissue, but also increase the patient's pain and make the patient feel disgusted with dressing changes. At the same time, due to excessive stimulation, it is easy to cause edema of the granulation tissue. Therefore, when cleaning the wound, the movements must be gentle and gentle, so that the wound surface is clean without damaging the new tissue.
5.2 Vigorous poke: refers to the excessive force or excessive rubbing into the anus or the wound surface when treating the wound, which stimulates and damages the new tissue in the wound, or even shed blood. Therefore, when changing the dressing, the wound should be fully exposed, and the anus should not be rubbed and stabbed, and the medicine should be gently inserted in accordance with the patient's anus contraction and contraction law to make the medicine reach the wound. When drainage of anal fissure and anal fistula after operation, the wound should be inserted along the bottom of the wound and parallel to the incision. When there is resistance to swelling, you can first avoid the incision and penetrate through the anus, and then press the dressing forceps to the bottom of the wound, and then pull it out from the inside to the outside.
5.3 Heavy plug: It refers to filling the wound cavity too deeply and tightly, resulting in poor drainage, obstructed circulation, and preventing the wound from growing up from the bottom. Therefore, the filler should be filled naturally when it reaches the bottom of the wound, and it is better not to be loose or tight. Do not use force to fill the wound, or even brace it to deform the wound and cause iatrogenic injury.
6.1 Shengji series of topical drugs are divided into Shengji Yuhong ointment (red gauze strip) gauze strips, scalded No. 1 gauze strips, and Ermu scattered gauze strips based on the differentiation of TCM syndromes and the order of their application in various stages in postoperative wound repair. . Red gauze is mainly used in the shedding period of necrotic tissue, has the effects of clearing away heat and detoxification, decaying and growing muscle. It can also be used for edema and slow growth of granulation tissues in various stages; scalded No. 1 gauze is mainly used for the granulation growth period, with convergence and hemostasis. The effect of promoting muscle healing; Ermusan gauze is mainly used in the period of granulation repair and epidermal crawling; because it is rich in rare pharmaceutical ingredients, it has a good nutritional effect on the new tissue of the wound and is the first choice for the late stage of wound repair.
6.2 Infrared and laser irradiation
In the process of dressing change and wound repair after surgery, we often use infrared radiation and semiconductor lasers.
6.2.1 Infrared radiation
The basis of infrared treatment is the warming effect. Under infrared radiation, tissue temperature rises, capillaries expand, blood flow speeds up, material metabolism increases, tissue cell vitality and regeneration ability increase. In the treatment of chronic inflammation, infrared rays can improve blood circulation, increase the phagocytic function of cells, eliminate swelling, and promote inflammation to dissipate. Infrared rays can reduce the excitability of the nervous system, have analgesic effects, relieve striated muscle and smooth muscle spasm, and promote the recovery of nerve function. At the same time, it can improve tissue nutrition, eliminate granulation edema, promote granulation growth, speed up wound healing, promote tissue swelling and hematoma dissipation, reduce postoperative adhesions, promote scar softening, and reduce scar contracture.
6.2.2 Semiconductor laser
According to the biological characteristics of the Mandison (M day C) semiconductor laser, combined with the research effect of the analgesic mechanism of low-level lasers, it can be considered that its analgesic effect is achieved through a variety of interconnections. After the biological tissue is irradiated by the semiconductor laser, the analgesic substance in the tissue, that is, morphine-like substance, is released, the content of local serotonin is reduced, and the excitability of peripheral nerves is also reduced. These factors work together to produce analgesic effects.
6.3 Fumigation and washing before dressing change
Fumigation therapy is a more common physical therapy method. Traditional Chinese medicine believes that fumigation and washing therapy has the effects of dredging the physique, detoxifying and reducing swelling, promoting blood circulation and collaterals, promoting qi and relieving pain, expelling wind and dampness, killing insects and relieving itching, and promoting the growth of granulation tissue, which is beneficial to wound healing. Modern medicine believes that the principle of fumigation and washing therapy mainly consists of three aspects: ①Therapeutic effect of drugs: in the process of fumigation and washing, the drug directly acts on the lesion, and the effective ingredients in the liquid can be absorbed through the skin or the granulation tissue of the wound. Medicinal effect. ②The effect of warming meridian: the fumigation and washing of warm steam and liquid medicine can warm the local meridians, increase local blood supply, enhance the disease resistance of local tissues, and improve and restore local tissue functions. ③The local cleansing effect can control the pathological changes, reduce the adverse irritation, and promote the healing of the wound.
Fumigation and washing before dressing change can alleviate the patient’s fear of changing dressings. According to the syndrome differentiation, self-made fumigation and washing prescriptions (mainly atractylodes, purslane, rhubarb, raw arborvitae leaves, etc.), Sanhuang decoction, and detoxification Decoctions and other topical fumigation and washing medicines can effectively reduce postoperative pain, itching, edema and other complications, and promote wound healing.
The dressing change after surgery must be scientific. It is a very important link to guide patients into a benign psychology, make them understand the significance of dressing change for healing, and obtain the cooperation of patients. Proficiency in the operation techniques of dressing change, careful observation and according to different local conditions, according to the physiological and pathological laws of wound growth and healing, take corresponding treatment methods, and divide the dressing treatment course into three phases, which can more effectively make the wound grow normally . In the early stage, cleaning, drainage, and anti-inflammation are the mainstays. The water agent is often used to change the dressing to have adsorption, drainage, penetration, and anti-inflammatory effects; in the middle stage, it is necessary to protect the new granulation tissue to prevent excessive stimulation of the granulation tissue to avoid affecting growth; Dressing change is characterized by less irritation and discontinuity, so that the wound has a good growth environment. Intermittent dressing change not only allows the wound to grow normally, but also accelerates the healing of old wounds. Therefore, it can be said that the highest level of dressing change after anorectal surgery is to provide a wound close to the physiological environment.