Alternative management of complex wounds and fistulae

Abstract

The management of complex wounds and fistulae can often prove challenging to even the most skilled clinician. The incidence and complexity of fistulae vary considerably from centre to centre, however they often lead to prolonged hospital stays. Routine admissions for 4-5 days may lead to 4-5 months in the event of fistulae formation. Thus, many patients experience not only compromised physical health, but also complex psychological problems. This article provides a brief overview of the challenges and developments of managing a complex wound with multiple fistulae and a pictorial illustration of an innovative alternative wound management system.

An accountable fistula management treatment plan

“…From an extensive review of case studies in the literature, from 1978 to most recent case studies, the principles of nursing management for enterocutaneous fistula has changed little with the focus on maintaining skin integrity, recording accurate intake/output ensuring adequate nutrition and providing psychological support (Geels et al, 1978;Black, 1995;Benbow, 2001;Hess, 2002a;b;Burch, 2003;Renton et al, 2006). Medical management has changed little also, with the focus on complete bowel rest and adequate nutrition; Changing an appliance can take 60-90 minutes 2-3 times weekly (Cobb and Knaggs, 2003; and allow sufficient time Burch, 2003;Renton et al, 2006) Remove appliance and thoroughly cleanse the skin with warm (Hess, 2002b;Burch, 2003; tap water ensuring any residual adhesive is removed. Irrigate the wound with warmed normal saline Irrigation minimizes tissue damage.…”

“…Warm saline will prevent cooling, which reduces effective healing (Kiernan, 1999) Ensure continuous suction is available throughout Prolonged contact results in skin erosion within 3-4 hours. Suction prevents spillage the procedure of effluent onto skin and soiling to the new appliance (Black, 2000;Cobb and Knaggs, 2003) Apply absorbing powder to excoriated areas to aid healing (Hess, 2002b;Renton et al, 2006) and adhesion of pouching system Apply filler paste or cohesive seals to any creases…”

“…Ensuring an even topography facilitates a smooth surface for effective pouching and protects skin (Black, 1995;Forbes, 2001;Burch, 2003;Cobb and Knaggs, 2003) Apply strips of skin wafer or cohesive seals around the edge Promotes added security and thickness of inner edge of appliance, therefore adhesion of the wound of pouching system (Cobb and Knaggs, 2003;Burch, 2003; Apply appropriate wound management system according Appliances available for fistula management depend on size, position and output (Burch, to size of wound and effluent produced 2003;Renton et al, 2006). Use wound drainage systems when effluent > 100 ml/24 hours (Black, 1995) Apply continuous drainage for high output fistulas High output fistulas defined as > 500 ml/24 hours.…”

“…All of these factors were considered when defining the care plan for Mrs X. Renton et al (2006) suggest that skin integrity is perhaps the biggest challenge when caring for fistula patients. Effluent from the fistula must be contained at all costs.…”

“…Rolstad and Byrant (2002) provide a comprehensive guide for fistula assessment and documentation ( Table 1). Renton et at (2006) suggest several factors that require consideration when managing fistula for patients: n Extended hospital stay n Skin integrity n Compromised nutritional status n Altered body image a frightening experience (Cobb and Knaggs, 2003) and often the site of the wound can be very disturbing for the patient (Renton et al, 2006). The production of effluent through an abdominal wound is likely to have a detrimental effect on the patient's body image.…”