Introduction

The presence of more than one chronic condition in an individual is often referred to as comorbidity. Various comorbidities can interfere with, or inhibit, wound healing processes. These conditions are associated with complex management, economic burden, and poor outcomes.1 Some of these obstacles to healing include nutritional abnormalities, aging, diabetes, and infection to name a few.2 The prevalence of such comorbidities in patients with complex wounds reinforces the importance of identifying these conditions and finding ways to mitigate the risks they pose to wound healing.

Inadequate Nutrition

What It Does

Because wound healing requires protein and energy, those with protein-energy malnutrition (PEM) and other nutrient deficits are at a higher risk of wound chronicity. Deficits in carbohydrates and certain vitamins and minerals can also factor in stalled wound healing.2,3 Malnourished patients may have decreased immune function, sarcopenia, reduced collagen synthesis, diminished tensile strength, loss of function, as well as higher risk of infection, hospital-acquired conditions, and mortality. Patients over the age of 65 and those within the residential and inpatient settings are at a greater risk for PEM.3

How to Identify It

With the help of dietary experts on the multidisciplinary team, clinicians can identify potential malnutrition by observing 6 key characteristics.4 Theses characteristics were developed by Academy of Nutrition and Dietetics (ASPEN) in 2012 who recommend patients demonstrating 2 or more of the following conditions may be diagnosed with malnutrition5:

Weight loss
Inadequate energy intake
Loss of muscle mass
Loss of subcutaneous fat
Fluid accumulation (may obscure extent of patient’s weight loss)
Reduced hand grip strength (identifies functional status)4,5

A more in-depth nutrition assessment by a dietician may follow to help establish a comprehensive plan of care.4

How to Help

The interdisciplinary team can improve patient nutrition through oral supplements, protein fortified or nutrient-dense foods, education, and, if necessary, enteral or parenteral nutrition.3-5 Although the recommended daily intake (RDA) for protein is the same for both young and aging adults, research suggests that those of the aging population should consume more dietary protein, accounting for several factors including changes in protein metabolism, and to support the management of acute and chronic conditions. Specifically, literature suggests that those age 65 and older with injuries should consume 1.2-1.5 grams of protein per kilogram of body weight while malnourished patients of this population need approximately 2.0 grams of protein per kilogram of body weight.3-5 It is estimated that 35% of those in residential care do not meet RDA for dietary protein intake.3 Decreases in appetite, cognitive impairment, physiological issues chewing and swallowing, sociocultural factors, and financial and access issues are potential obstacles to reaching a patient’s dietary goals.3 Despite the various reasons why a patient may not adhere to a nutrition plan, through fostering a strong patient-provider partnership, clinicians may work towards overcoming these barriers. For instance, patients who cannot afford or cannot access a diet conducive to wound healing may benefit from referral to community social service or food support agencies.

Diabetes

What It Does

Approximately 500 million people have diabetes mellitus (DM) and 25% of patients with DM who develop a wound will suffer from wound chronicity.6 Diabetes has several associated complications that pose unique challenges to wound development and healing, and patients may not be aware of the details of these risks. Hyperglycemia can lead to blood vessel narrowing and decrease the ability of red blood cells to transport nutrients to the tissues.6,7 In addition, diabetic neuropathy may cause a loss of sensation in the extremities that increases the risk of unrecognized injury, especially foot ulceration. Diabetes also causes immune cell dysfunction that can lead to infection. All these biochemical, vascular, and neuropathic factors can contribute to nonhealing or delayed healing of wounds.7

How to Identify It

Although a wound care clinician may not be the one to diagnose diabetes, having an awareness of its presenting symptoms may be helpful in discussions with the care team to make sure a patient receives the care they need. Signs of diabetes include the following8,9:

Excessive hunger, thirst, and urination
Fatigue
Numbness or tingling of the hands and feet
Blurry vision
Slow-healing wounds
More infections than is usual for the patient

Some patients may be asymptomatic and it is possible that a patient presenting with a complex wound could be unaware that they have the disease. The diagnosis of diabetes is established primarily by blood glucose testing, usually by a primary care provider or endocrinologist.8,9

How to Help

Wound care clinicians can assist patients with diabetes by encouraging them to incorporate best practices and engage with care team members such as primary care, endocrinologists, podiatrists, dietitians, diabetes educators, optometrists or ophthalmologists, and others as indicated. Since clinical encounters for complex wounds, like diabetic foot ulcers, are often at regular intervals, wound care clinicians may be uniquely suited to provide related education and referrals that could benefit the healing trajectory and overall health of the patient.

Aging

What It Does

The skin of older adults is fragile and more prone to breakdown. In addition, the aging population experiences the following risk factors that can impact wound healing8,10:

Higher infection risk
Diminished inflammatory response
Lower antibody production
Endocrine slowdown

This age group also often has cardiovascular and pulmonary diseases that impair oxygen delivery to tissues, and thereby delay wound healing.1

How to Help

Clinicians should identify any other comorbidities and ensure that these conditions are managed as effectively as possible.11 Frequent skin checks are necessary as the skin becomes older, and a clinician should check for details like skin tearing and skin trauma from adhesives or certain clothings.10 Dressing selection must take into account the potential for skin fragility.10

Infection

What It Does

Bacteria can proliferate in the wound and on the skin. If present at levels causing infection, these organisms may use oxygen and nutrients needed for wound healing and may have byproducts that pose further challenges.1 If not appropriately treated, a wound infection can spread and lead to tissue necrosis, deeper infection, need for surgical drainage or debridement, or even sepsis or amputation.

How much do you know about Complex Wound Management? Take our 10-question quiz to find out! Click here.

How to Identify It

To evaluate for wound infection, clinicians use culture techniques, imaging, and bloodwork values, although these can be inconclusive, especially in some patients with immunocompromise or diabetes. In these patients, secondary signs of infection are important, such as serous exudate with concurrent inflammation, delayed healing or wound breakdown, wound base pocketing, and malodor.11,12 The concept of biofilm and early, frequent intervention thereof, is also vital in one’s understanding of mitigating infection and the complexities it poses in wound care. In some patients with immunocompromise or diabetes, however, these tests are not diagnostic. In these patients, secondary signs of infection are used, such as serous exudate with concurrent inflammation, delayed healing or wound breakdown, wound base pocketing, and malodor.11,12

How to Help

Topical, oral, or intravenous antibiotic therapy may be applied for wound infections as indicated, and infectious disease specialists may be asked to consult. Accurate culture results can help guide proper antibiotic selection, as does the depth and extent of the infection. Surgical intervention to drain or remove infected, devitalized tissue may also occur.12

Conclusion

By understanding the effects of specific comorbidities on wound healing and identifying these comorbid conditions accurately, clinicians are well on their way to helping their patients achieve optimal wound healing outcomes, especially for complex wounds.

References

Valdera JM, Starfield B, Sibbald B, et al. Defining Comorbidity: Implications for Understanding Health and Health Services. Ann Fam Med. 2009;7(4):357-363. doi: 10.1370/afm.983
Chandan K. Human Wound and its Burden: Updated 2020 Compendium of Estimates. Adv Wound Care. 2020;10(5)281-292. https://doi.org/10.1089/wound.2021.0026
Mathewson SL, Azevedo PS, Gordon AL, et al. Overcoming protein-energy malnutrition in older adults in the residential care setting: A narrative review of causes and interventions. Aging Research Reviews. 2021;70. doi:https://doi.org/10.1016/j.arr.2021.101401
Tyler RD, Guenter P. Identifying malnutrition: from acute care to discharge and beyond. Nurse Pract. 2017;42(4):18-24. doi:10.1097/01.NPR.0000513334.61944.8e
White JV, Guenter P, Jensen G, et al. Consensus Statement: Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition. JPEN. 2021;36(3): 275-283. https://doi.org/10.1177/0148607112440285
Burgess JL, Wyant WA, Abujamra BA, et al. Diabetic Wound-Healing Science. Medicina. 2021;57(10):1072. https://doi.org/10.3390/medicina57101072
Spampinato SF, Caruso GI, De Pasquale R, Sortino MA, Merlo S. The Treatment of Impaired Wound Healing in Diabetes: Looking among Old Drugs. Pharmaceuticals (Basel). 2020;13(4):60. doi:10.3390/ph13040060
Molnar JA, Underdown MJ, Clark WA. Nutrition and Chronic Wounds. Adv Wound Care. 2014;3(11):663-681. doi:10.1089/wound.2014.0530
Centers for Disease Control and Prevention. Diabetes symptoms. 2022. Accessed January 31, 2023. https://www.cdc.gov/diabetes/basics/symptoms.html
LeBlanc K, Campbell K. Best practice recommendations for the prevention and management of skin tears in aged skin. Wounds International. 2018. www. woundsinternational.com
Patient populations: barriers to care. WoundSource. Published March 31, 2022. Accessed January 31, 2023. https://www.woundsource.com/blog/patient-populations-barriers-care
Malone M, Schultz G. Challenges in the diagnosis and management of wound infection. Br J Dermatol. 2022;187(2):159-166. doi:10.1111/bjd.21612

Introduction

Vascular ulcers are wounds on the skin that form as the result of abnormal blood circulation in the body, including arterial and venous etiologies.1 Estimates suggest 3-5% of those over 65 in the United States have a vascular ulcer.1 Of those with peripheral arterial disease, approximately 20-70% have chronic wounds, according to data up to 2018.2 Since arterial ulcers may be underdiagnosed, certain experts theorize that the number of chronic wounds developed due to arterial insufficiency is higher in reality.2 Clinicians must differentiate between arterial and venous ulcers, as they require distinctly different treatments that may prove detrimental if used to treat the other condition. Therefore, wound care professionals should familiarize themselves with the varying characteristics of all types of vascular wounds.

What Are Venous and Arterial Ulcers?

Arterial ulcers are skin injuries that develop due to tissue ischemia. Ischemia develops when there is insufficient blood perfusion to the extremities due to problems in arterial circulation. As a result, blood cells cannot deliver the necessary nutrients and oxygen to tissues, creating a higher risk for necrosis and open wounds.3 Venous ulcers occur when there is damage or a break in the leg’s skin in a person with impaired venous valves. These leg valves struggle to return blood to the heart, often resulting in fluid buildup in the lower extremities. If swelling/edema is significant, it can cause pain and fluid leakage through the skin.4

Risk Factors

Multiple factors can contribute to the development of an arterial wound. The most common cause is atherosclerosis, and, therefore, the following are risk factors for atherosclerosis which may lead to arterial ulcers3:

Smoking
Hypertension
Dyslipidemia
Diabetes
Family history

One should note that arterial insufficiency often does not act alone in causing arterial ulcers. Other contributing forces, such as trauma or neuropathy, often play a role.3 Venous ulcers occur when blood pools in the veins, causing an increase in pressure and can be caused by a variety of conditions. Risk factors include any disease that impacts the veins, including the following5:

Varicose veins
Phlebitis or Deep Vein Thrombosis (DVT)
Traumatic or past injury to the lower extremities

While not all these factors can be prevented, clinicians can recommend measures to reduce patient risk of vascular damage. These recommendations may include increasing activity, avoiding smoking, maintaining a healthy weight, reducing stress levels, and keeping blood sugars stable.6

What Are the Characteristics of Arterial Ulcers?

Clinicians often find arterial ulcers on pressure points of the foot, such as the tips of the toes and the ankles. They are usually found in these distal areas because they are the furthest distance away from the heart.1 If a patient develops an injury on their foot, it may also develop into an arterial ulcer. Assessment of the lower extremities will likely show the skin to be shiny, dry, thin, and taut with sparse or no hair and be cool to the touch.7,8 Pedal pulses may also be decreased or absent.7 Arterial ulcers appear “punched-out” and can appear round with clearly defined wound margins.6,7 They tend to be dark in color and may present as yellow, gray, brown, or black with hints of pink or red. These wounds are often rather deep, and new tissue growth is not usually readily evident. Typically, the bases of these wounds won’t bleed.7

Due to ischemia, these wounds are prone to infection because the body’s defenses cannot be delivered through the blood to the tissues effectively.1 These ulcers can be very painful, and pain may occur with moderate to heavy activity. This type of pain is known as claudication, which can also worsen with lower extremity elevation.8 Nighttime pain can be a problem if patients lay flat in bed at night because, with the legs in a horizontal position, cardiac output is decreased, and the lack of blood flow to the legs increases pain.6 To properly identify arterial insufficiency, wound care professionals should first provide the patient with a referral to a vascular specialist from the multidisciplinary team. The involvement of a vascular specialist will likely result in measurements such as the patient’s ankle-brachial index (ABI), toe-brachial index (TBI), transcutaneous oxygen levels, Doppler studies, or more advanced studies.7

What Are the Characteristics of Venous Ulcers?

Venous ulcers are generally found on the lower extremities between the ankles and knees, known as the gaiter area, and the medial malleolus. These wounds are shallow and ruddy with an irregular shape. The presence of slough or exposed subcutaneous tissue can also give wounds a yellow color, and exudate may be moderate to severe. The skin on the patient’s lower extremities may be thick and flaky with scabs and may itch or burn. Skin can become discolored and remain red, purple, maroon, or brown, even once ulcers have healed.5 Edema is a hallmark of venous insufficiency, and venous ulcer pain tends to be related more to the edema than wounds alone.6 Pain is generally dull and aching and improves with elevation.5

How much do you know about Complex Wound Management? Take our 10-question quiz to find out! Click here.

Treatment

To heal an arterial ulcer, clinicians should improve circulation. To accomplish this, there are various endovascular and open procedures for revascularization in the right candidates after full evaluation of the level and e. Experts have found other therapeutic interventions, such as structured exercise therapy (SET), increase mobility and reduce pain at rest due to arterial insufficiency.2 Amputation may be necessary if the damage to the vessels is extensive.1 Infections may need to be treated with antimicrobial dressings, cleaning solutions, and possibly oral or IV medications. Avoiding excess pressure or shear to the limbs in both arterial and venous ulcers is essential.

Conversely, compression and elevation are ideal therapy options for venous ulcers. Compression wraps or stockings help the vessels return fluid to the heart. Clinicians should elevate patients’ legs so that gravity can aid in pulling blood down. It may take several months or even years for venous ulcers to heal, depending on the patient’s ability to tolerate compression dressings and elevation. Absorbent dressings that are easy to remove will help control exudate and prevent tissue damage upon removal. Wound care professionals should continue these tactics to prevent wounds from returning even after the ulcers have healed.4

Conclusion

Although there is some crossover in risk factors for and presentation of arterial and venous ulcers, each has key features that will assist the clinician in their differentiation. A careful history and physical exam will identify essential clues to the ulcer’s etiology. The ulcer’s appearance, coloration, and depth, along with the condition and characteristics of the surrounding skin and tissue, are vital pieces of information. Additionally, a focused pain assessment, including aggravating and alleviating factors, will help distinguish the type of ulcer in question and hopefully lead to a clearer pathway for diagnosis and treatment.

References

Vascular Ulcer. Cleveland Clinic. Accessed January 18, 2023. https://my.clevelandclinic.org/health/diseases/23357-stasis-ulcer.
Bolton L. Peripheral arterial disease: Scoping review of patient-centered outcomes. Inter Wound J. 2019;16:1521-1532. https://doi.org/10.1111/iwj.13232
Hess CT. Arterial Ulcer Checklist. Adv Skin Wound Care. 2010;23(9):432. Doi: 10.1097/01.ASW.0000383218.26406.4b
Venous Ulcers – Self-Care: Medlineplus Medical Encyclopedia. MedlinePlus. Accessed January 19, 2023. https://medlineplus.gov/ency/patientinstructions/000744.htm.
Bonkemeyer Millan S, Gan R, Townsend PE. Venous Ulcers: Diagnosis and Treatment. Am Fam Physician. 2019;100(5):298-305.
Bryant RA, Nix DP. Acute & Chronic Wounds: Current Management Concepts. 5th ed. St. Louis, MO: Mosby;2015.
Arterial Ulcers. WoundSource. Accessed February 1, 2023. https://www.woundsource.com/patientcondition/arterial-ulcers
Eriksson E, Liu PY, Schultz GS, et al. Chronic wounds: Treatment consensus. J Wound Repair and Regeneration. 2022;30:156-171. https://doi.org/10.1111/wrr.12994

Introduction

Severe burn wounds are among the most debilitating injuries because they can significantly affect the entire body.1 The body’s inflammatory response to a severe burn injury can lead to fluid loss, dangerously low blood pressure, and shock.2 The risk of infection is also elevated in patients with severe burn wounds.2 Therefore, prevention of these complications is a key component of care for these patients.3

Emergency Care and Stabilization of the Patient

Emergency care for patients with severe burns begins with the Advanced Trauma Life Support guidelines (ATLS) and an initial assessment to identify other life-threatening conditions.4 Before the patient is transferred to a burn care facility, respiratory and cardiovascular support, fluid resuscitation, pain management, and initial burn wound care should be provided as needed.4 To maintain adequate urine output in the patient, clinicians should begin fluid resuscitation.5 This regimen should be adjusted as needed in response to the patient’s vital signs, urine output, and concurrent illnesses or injuries.5 Pain management is essential for patients with burns.1 Although opioids are commonly used to manage pain, long-term use of these drugs can lead to opioid-induced hyperalgesia.1Alternatives to opioids include the following1:

Ketamine (an anesthetic, analgesic, or amnestic agent)
Sedative agents
Anxiolytic agents
Anticonvulsant agents (pregabalin and gabapentin)

A patient who has a severe burn injury will need a referral to a specialized burn care facility after stabilization.3 If there is a delay in transfer to a burn care facility, interim treatment should take place in an intensive care unit.4

Burn Wound Assessment

After stabilization, a clinician may then perform a comprehensive evaluation, starting with a history and physical examination followed by an assessment of the patient’s burn wound(s), including burn depth and total body surface area (TBSA).5

Classification of Burn Depth

Clinicians may use the following classification to characterize burn depth3:

Superficial burns: affecting the epidermis, which usually stays intact
Superficial partial-thickness burns: extending through the epidermis to the upper (papillary region) dermis
Deep partial-thickness burns: extending through the epidermis and upper dermis to the lower (reticular region) dermis
Full-thickness burns: destroying the epidermis and dermis and extending subcutaneously to fat, muscle, and sometimes even bone

Total Body Surface Area Involvement

Burn severity assessment also includes determining the extent of TBSA affected. The Rule of Nines is a common method that calculates TBSA involvement in the area of partial- and full-thickness burn injuries3:

Head: ~ 9%
Torso front: ~ 18%
Torso back: ~ 18%
Each leg: ~ 18%
Each arm: ~ 9%
Genital area and perineum: ~ 1%
Palm of the hand: 1%

With the Rule of Nines, if more than 15% of the body is affected, then the patient will require at least one intravenous (IV) line for fluid resuscitation.3 Another method used for TBSA burn calculation, especially in children, is the Lund and Browder Chart.5 In this method, each arm accounts for 10%, the anterior trunk and posterior trunk each account for 13%, and head and leg calculations depend on the patient’s age. The Palmar Surface Method of TBSA calculation is often used for small burns. In this method, the palm of the hand accounts for 0.5%, and the entire hand surface, fingers included, accounts for 1%.5 A burn wound with a TBSA greater than 20% is considered severe.5

Causes of Burn Injury

The clinician should ascertain the cause of the burn injury when taking the patient’s history and assessing the wound. Although more than 80% of burns are thermal (eg, from fire, steam, or hot objects),5other causes of burn wounds include the following3:

Electrical sources
Radiation (sunlight, x-ray exposure, or radiation therapy)
Chemical contact
Friction
Inhalation injury

Early Burn Wound Care

Sometime between 24 and 72 hours after the injury, debridement, wound excision, and wound coverage will likely take place in the operating room.4 Wire mesh, temporary grafts, or skin substitutes may be used for wound coverage.4 For full-thickness burns of the extremities, patients may be at risk for neurovascular compromise, such as compartment syndrome, and escharotomy or compartment release may be necessary, sometimes urgently.4 For other wounds, an escharotomy is indicated in patients with possible respiratory or vascular compromise.4

How much do you know about Complex Wound Management? Take our 10-question quiz to find out! Click here.

Ongoing Care and Support of Patients With Severe Burns

Rehabilitation of patients with these complex injuries may take years, and optimal long-term care requires a multidisciplinary team.4Specific issues include the following:

The patient’s metabolic rate may rise with the size of the wound.4 These patients need nutritional support, often including pharmacologic agents to counter hypermetabolism.4
Although burn-related immunocompromise increases the risk of infection, systemic antimicrobial therapy is administered only when the wound is infected.4 Topical antimicrobial ointments, silver-containing agents, bismuth-impregnated petroleum gauze, chlorhexidine, and mafenide may be indicated for certain partial-thickness burns.6
In addition to grafts, surgical procedures to correct contractures may be necessary.
Patients may need psychosocial support as they heal to adjust to the burn-related changes in their lives and reenter daily living activities and the workforce.4

Challenges in Managing Patients with Severe Burns

As mentioned earlier, severe burns, or the body’s response to them, may exhibit an impact on every organ system.2,7 These effects include airway and pulmonary damage, cardiovascular dysfunction that can lead to hypovolemic shock or cardiac arrest, acute kidney injury, ileus and stress ulcer formation, and neuroendocrine disorders, including increased metabolic rate, immunosuppression, and musculoskeletal contractures.7 The often surgical nature of burn treatment can result in prolonged healing and rehabilitation needs that one must consider. Infection prevention is another challenge because the loss of the skin means loss of protection against infection.

Conclusion

Care of patients with severe burn wounds requires clinicians to think quickly and multitask. The stakes are very high for these critically ill patients. A holistic view, encompassing all aspects of the burn injury, its systemic effects, and the patient’s psychosocial milieu, is crucial to ensure the best possible outcome.

References

Wang Y, Beekman J, Hew J, et al. Burn injury: challenges and advances in burn wound healing, infection, pain and scarring. Adv Drug Deliv Rev. 2018;123:3-17. doi:10.1016/j.addr.2017.09.018
National Institute of General Medical Sciences. Burns. Accessed January 31, 2023. https://www.nigms.nih.gov/education/fact-sheets/Pages/burns.aspx
WoundSource Editors. An overview of burns: symptoms, causes, and treatments. WoundSource. Published December 31, 2010. Accessed January 31, 2023. https://www.woundsource.com/blog/overview-burns-symptoms-causes-and-tre…
Gauglitz GG, Willliams FN. Overview of the management of the severely burned patient. Up to Date. Updated April 6, 2022. Accessed January 31, 2023. https://www.uptodate.com/contents/overview-of-the-management-of-the-sev…
Schaefer TJ, Szymanski KD. Burn Evaluation and Management. StatPearls Publishing; Published August 6, 2022. Accessed January 31, 2023. https://www.ncbi.nlm.nih.gov/books/NBK430741/
Tenenhaus M, Jeschke MG, Collins KA. Topical agents and dressings for local burn wound care. Up to Date. Updated August 6, 2022. Accessed January 31, 2023. https://www.uptodate.com/contents/topical-agents-and-dressings-for-loca…
Culleiton AL, Simko LM. Caring for patients with burn injuries. Nurs Crit Care. 2013;8(1):14-22. doi:10.1097/01.CCN.0000423824.70370.fa

Introduction

Surgical wounds originate when a surgeon cuts into tissue with a surgical tool, such as a scalpel.1 The size and placement of a surgical wound will depend entirely on the procedure performed due to varying incision requirements. Regardless, most surgical interventions aim for wound closure with primary repair. Tissue edges are typically brought together and held in place by various modalities, such as sutures or staples.2 However, this result isn’t always the case, as some wounds may be left open to heal secondarily or may fail to heal primarily.1 This piece will discuss the surgical wound timeline, various complications of a surgical wound, signs/symptoms of infection, along with the recovery process for patients. More specifically, the Centers for Disease Control and Prevention (CDC) outlines a classification that applies to surgical wounds to preemptively identify those that might be at risk for surgical site infection. This classification includes the following3:

Class I – clean, uninfected, primarily closed, and in lower-risk anatomic areas
Class II – clean-contaminated, without the appearance of infection, but possibly in a higher-risk anatomic area
Class III – contaminated, possibly when an object comes into contact with the wound that increases risk, such as with a gunshot wound
Class IV – dirty-contaminated or dirty-infected, have devitalized tissue, possibly exposed to things like fecal material

Surgical wounds

Much like other types of wounds, there is an anticipated timeline for surgical wound healing. Generally, a wound heals within 4 to 6 weeks.4 Some wounds can take longer, though, possibly up to a few months.1 However, clinicians can consider any surgical wound that deviates from this projected wound healing process complicated or even chronic.4 Simply, this delay in healing can continue to be a problem when a wound significantly interferes with the quality of one’s life or causes sequelae or further complications.

What Types of Complications Occur?

Surgical wound complications may take several forms. In general, wounds become complicated when they become infected, inflamed, when tissue edges separate, and/or fluid builds up under the surface (discussed in further detail below). If present, these conditions will delay the physiological healing process. Most complications, such as a surgical site infection (SSI), tend to occur within the first 30 days after surgery.1,5,6 Estimates cite that about 2-4% of all patients who have surgical procedures will have an SSI.5 This type of complication can not only cause mortality and morbidity but can also lead to hospital readmissions. 5 Therefore, prompt identification of early signs and symptoms of infection is critical.7Signs of SSI may include the following:

Erythema
Incision is hot to the touch
Delayed healing
Malodor
Purulent drainage
Localized pain
Fever

There are other more specific types of complications that can happen when it comes to surgical wounds, though, including the following:

Dehiscence is the partial or total separation of previously approximated wound edges, estimated to usually take place at 5-8 days post-op.8 Sutures placed too tightly may increase risk. Excessive drainage or bleeding can be early signs of dehiscence, whereas the most worrisome sequela is exposure of underlying tissues, organs, or bone.8
A fistula is an abnormal connection between the wound bed and a nearby organ structure or blood vessel. Cutaneous fistulae can be thought of as abnormal “tubes” connecting tubular structures (ie, intestine, artery, vein, etc) to the external skin. They often result originally from trauma and/or surgical procedures and are driven by lingering inflammation/infection. For example, an “enterocutaneous” fistula refers to a pathological tubular connection between an intestine and the skin.9
A seroma is a collection of serous fluid in the wound bed (thought to be due to poor lymphatic drainage and the presence of a physiological “dead space”). Seromas may present as swelling localized to the surgical site, fluctuant, and exhibiting clear drainage from the wound. Depending on severity, they may require aspiration or surgical revision to be drained. The presence of a seroma also increases the risk of infection.10
A hematoma is a collection of blood in the wound bed. Hematomas are more concerning than seromas because they may be caused by incomplete hemostasis and active bleeding, requiring urgent surgical revision. They may also require evacuation.

How much do you know about Complex Wound Management? Take our 10-question quiz to find out! Click here.

Which Patients Are Most at Risk for Surgical Wounds?

Certain patient demographics, comorbidities, and peri-procedural variables can place an individual patient at higher risk for postoperative wound complications. Some of these risk factors can be minimized or optimized, whereas others cannot. Patients with one or more of the following risk factors should be monitored closely after surgery for the development of complications11,12:

Elderly patients
Surgical procedure lasting more than 2 hours
Surgical drain removed too early in postoperative course
Oncology patients (history of radiation therapy and/or glucocorticoid use)13
Obesity
Uncontrolled diabetes (hyperglycemia leading to infection; poor tissue perfusion secondary to microvascular disease)
Smoking (vasoconstriction and immunosuppression)
Malnutrition/hypoalbuminemia (insufficient protein to support the proliferative stage of wound healing)
Ischemia (vascular disease, venous insufficiency, and/or “too tight” sutures)

General Management Principles to Prevent/Treat Surgical Wound Complications

At the time of discharge and transfer to post-acute care, it is critical to identify and document the location of all wounds. Clinicians should perform a thorough physical examination and communicate the results with the multidisciplinary team and patient to ensure they are aware of these wounds.14 In addition to examining wounds, the operating clinician should also remove nonabsorbable sutures and/or staples at an interval appropriate to the individual case. This process typically takes place around 7-21 days post-procedure, depending on location.15 If not removed, they can become a nidus for infection and prevent proper wound healing. Clinicians should consider these other general principles when discharging or transferring a patient:

Daily wound assessment, dressing changes, and local wound care is imperative.
If a clinician suspects infection, prompt microbiological swabs for culture can help to identify the causative organism and antibiotic sensitivities.7
Early (and frequent) mobilization appropriate to the case promotes lymphatic drainage. This mobilization can help prevent the accumulation of seromas and maximize outcomes.16,17

Conclusion

While the majority of postoperative wounds will heal within weeks, many can take longer. Surgical wound complications—such as infection, dehiscence, seroma, and fistula—most often occur within the first month after surgery. Optimizing modifiable risk factors, early mobilization, daily assessment, and regular wound care can minimize complications, much like in the care of other complex wounds.

References

DePietro M, Luo EK. Surgical Wound. Healthline. Published July 26, 2017. Accessed February 6, 2023. https://www.healthline.com/health/surgical-wound
Misteli H, Kalbermatten D, Settelen C. Simple and complicated surgical wounds. Ther Umsch. 2012;69(1):23-27.
Surgical Site Infection Event (SSI). National Healthcare Safety Network. Published January 2023. Accessed February 7, 2023. https://www.cdc.gov/nhsn/pdfs/pscmanual/9pscssicurrent.pdf
Wallace HA, Basehore BM, Zito PM. Wound healing phases. In: StatPearls. StatPearls Publishing;2022.
Surgical Site Infections. In: Patient Safety Network (PSNET). Agency for Healthcare Research and Quality (AHRQ). Published online September 7, 2019; https://psnet.ahrq.gov/primer/surgical-site-infections
Frequently Asked Questions About Surgical Site Infections. CDC. Published May 9, 2019. Accessed February 6, 2023. https://www.cdc.gov/hai/ssi/faq_ssi.html.
Zabaglo M, Sharman T. Postoperative wound infection. In: StatPearls. StatPearls Publishing. Updated September 19, 2022. Accessed February 6, 2023. https://www.ncbi.nlm.nih.gov/books/NBK560533/
Rosen R, Manna B. Wound dehiscence. StatPearls. Published online May 8, 2022. Accessed February 6, 2023. https://www.statpearls.com/ArticleLibrary/viewarticle/31401.
Phillips M. Gastrointestinal fistula. Mount Sinai Health Library. Published May 4, 2022. Accessed February 6, 2023. https://www.mountsinai.org/health-library/diseases-conditions/gastroint…
Kazzam ME, Ng P. Postoperative seroma management. In: StatPearls. StatPearls Publishing; 2022. https://www.ncbi.nlm.nih.gov/books/NBK585101/
Surgical Site Infections. Hopkins Medicine. Accessed on February 5, 2022. https://www.hopkinsmedicine.org/health/conditions-and-diseases/surgical…
Armstrong DG, Meyr AJ. Risk factors for impaired wound healing and wound complications. UpToDate. Published June 24, 2021. Accessed February 6, 2023. https://www.uptodate.com/contents/risk-factors-for-impaired-wound-heali…
González CVS, de Carvalho VF, Park Kim SH, et al. Complicated surgical wounds and associated factors in oncology patients. Plastic and Aesthetic Nursing. 2020;40(2):91. doi:10.1097/PSN.0000000000000307
Nagle SM, Stevens KA, Wilbraham SC. Wound assessment. In: StatPearls. StatPearls Publishing; 2022. https://www.ncbi.nlm.nih.gov/books/NBK482198/
Jewell T. Surgical staples: what you need to know. In: Healthline. Published January 11, 2019. Accessed February 6, 2023. https://www.healthline.com/health/surgical-staples#how-long-do-you-need…
Tazreean R, Nelson G, Twomey R. Early mobilization in enhanced recovery after surgery pathways: current evidence and recent advancements. J Comp Eff Res. 2022;11(2):121-129.
Shakil-Ur-Rehman S, Sheikh S, Danish K. The Role of Early Mobilization in the Prevention of Post Operative Wound Infection after Lower Extremity Orthopedic Surgeries. J Islam Int Med. 2012;7:63-66.