Hemorrhaging & dehiscence

EricJRN, MSN, RN · Aug 29, 2007

Yes. Keep in mind that most cases of wound dehiscence occur several days after the wound closure.

Daytonite, BSN, RN · Aug 29, 2007

The crux of this is understanding what the definition of dehiscence is. Dehiscence is when the edges of a surgical wound fail to join, or they just separate. Dehiscence, according to the reference I am looking at, occurs 6 or 7 days postop, usually after sutures have been removed. (page 458, Nurse's 5-Minute Clinical Consult: Treatments from Lippincott Williams & Wilkins, 2007) Hemorrhage does not occur. However, there may be drainage of fluids with fluid volume loss and infection as potential complications. Hemorrhage will only occur if there is a blood vessel that was cut and was not sutured or the sutures for some reason came out and the vessel opened. This would be a rare occurrence as well as a surgical emergency.

FYI. . .I had abdominal surgery at the end of June. My wound started to dehisce about a week and a half later. It was already draining through the incision even though there were metal staples in place. The minute the staples were removed--twang--a two inch section of the incision opened. A month later I was hospitalized with a septic infection and a 4 inch deep crater into the wound--no visceral organs were visible, it was all adipose tissue that was open and exposed. A CT scan confirmed a deep wound abscess and a wound culture was positive for enterococcus (not VRE, thank god). And, boy, did it drain. The drainage always has been serous (pale yellow) with maybe a tinge of blood here or there. Two months later, it is still open, only about 2 inches deep and an inch long, so it is making some progress healing, drainage is lessened but still present, and the infection was finally cleared after 18 days of IV and oral antibiotics. I am continuing to pack the crater with wet (sterile normal saline) to dry dressings. You won't see these in hospitalized patients unless, like me, they come back in with a septic infection. They are treated at home or with home health nursing care.

Jedi of Zen · Aug 29, 2007

The crux of this is understanding what the definition of dehiscence is. Dehiscence is when the edges of a surgical wound fail to join, or they just separate. Dehiscence, according to the reference I am looking at, occurs 6 or 7 days postop, usually after sutures have been removed. (page 458, Nurse's 5-Minute Clinical Consult: Treatments from Lippincott Williams & Wilkins, 2007) Hemorrhage does not occur. However, there may be drainage of fluids with fluid volume loss and infection as potential complications. Hemorrhage will only occur if there is a blood vessel that was cut and was not sutured or the sutures for some reason came out and the vessel opened. This would be a rare occurrence as well as a surgical emergency.
FYI. . .I had abdominal surgery at the end of June. My wound started to dehisce about a week and a half later. It was already draining through the incision even though there were metal staples in place. The minute the staples were removed--twang--a two inch section of the incision opened. A month later I was hospitalized with a septic infection and a 4 inch deep crater into the wound--no visceral organs were visible, it was all adipose tissue that was open and exposed. A CT scan confirmed a deep wound abscess and a wound culture was positive for enterococcus (not VRE, thank god). And, boy, did it drain. The drainage always has been serous (pale yellow) with maybe a tinge of blood here or there. Two months later, it is still open, only about 2 inches deep and an inch long, so it is making some progress healing, drainage is lessened but still present, and the infection was finally cleared after 18 days of IV and oral antibiotics. I am continuing to pack the crater with wet (sterile normal saline) to dry dressings. You won't see these in hospitalized patients unless, like me, they come back in with a septic infection. They are treated at home or with home health nursing care.

I'm still trying to wrap my mind around the concept. I guess it should be pretty simple, but I'm wondering how or why a wound would come apart like that if epidermal proliferation has already progressed enough to stop any bleeding. Is dehiscence primarily something that occurs in obese patients? (ie, large abdominal mass, skin stretched tight...that sort of thing?) And is it painful? (or was it in your case?)

Sorry if this sounds like a very stupid question; but I just want to make sure I clearly understand the concept. I'm a first year student, obviously. (So feel free to dump me in the garbage bin of academic loserdom anytime now..)

Kiringat · Aug 29, 2007

Risk factors for the condition include diabetes and increased age (slow healing), obesity (lots of extra pressure), wound infection, poor wound closing and injury to the wound following the operation. Good web article here: http://findarticles.com/p/articles/mi_m0FSS/is_5_15/ai_n17215449

I saw it happen to the patient of a fellow student. The patient refused to splint (support) his incision when coughing. He more or less blew out his staples, had to go back to surgery, and ended up with an infection. Not pretty.

Daytonite, BSN, RN · Aug 30, 2007

I think the answer to your question, Jedi of Zen, lies in the principles of medicine and surgery, rather than with nursing principles. It's a good question though because I think it's important to know the underlying pathophysiology of what is going on with things. So, A+ for asking the question; and, A+ if you can understand the explanation I found and posted below which I found on the e-Medicine web site. It is specifically pointing to suturing technique as the reason for dehiscense. This is why I said above that the underlying reason of this may be medical in nature. I also am a medical coder and now that I'm thinking about it, a wound dehiscence is always coded as a mechanical complication of surgery (meaning that its reason for occurring can be traced back to the actual episode of surgery, not an underlying problem in the patient). No doubt, once the dehiscence takes place, obesity, diabetes, infection, and immunosuppression are just opportunistic conditions ready to step up to the plate to get into the fracas.

This text is from the e-Medicine article, "Surgical Complications" (http://www.emedicine.com/derm/topic829.htm) and gives you the medical explanation of why dehiscence occurs. You might need to sit with a medical dictionary while you read through this:

"

Dehiscence

Dehiscence results when a wound fails to heal in apposition. The healing wound has minimal tensile strength, and, although reepithelialization occurs rapidly within 2 days, fibroplasia and subsequent collagen production are initiated after a delay of approximately 5 days. The deposition and remodeling of collagen gradually increase the tensile strength of the wound. The wound regains 3-5% of its original strength at 2 weeks; 15%, at 3 weeks; 35%, at 1 month; and increases to a final strength of 80%, after several months.

Both systemic and local factors can cause wound dehiscence; however, the most common cause involves surgical error. Excessive tension on the wound resulting from inadequate undermining or poor planning of the repair causes the wound to split apart because of sheer mechanical force. Unduly tight sutures also strangulate the wound edges, causing necrosis and decreased strength. The use of electrocautery coagulation decreases the tensile strength of wounds by increasing inflammation in response to necrotic tissue.

Dehiscence may result when sutures are removed too early, especially in wounds that do not have adequate buried absorbable sutures to provide tensile strength (see Image 12). Superficial sutures serve to approximate wound edges, but they do little to fortify the wound against tearing apart. Dehiscence may become apparent immediately upon suture removal. The surgical dictum of "without inflammation, there is no healing" provides a clue to the readiness of the wound for suture removal. One should note a pink, raised healing ridge (which usually appears at days 5-8) prior to suture removal. Complications, such as hematoma, infection, and trauma, can also result in wound dehiscence.

Systemic factors increase a patient's risk of wound dehiscence. Age older than 65 years, hypoalbuminemia, obesity, uremia, malignancy, systemic infection, hypertension, Cushing disease, thyroid disease, liver disease, and congestive heart failure can predispose to wound dehiscence. Additionally, tobacco use and certain medications (eg, anticoagulants, aspirin, colchicines, systemic corticosteroids, penicillamine, cyclosporine, metronidazole, cytotoxic chemotherapeutics) have adverse effects on wound healing and increase the risk of dehiscence.

Prevention of wound dehiscence by proper surgical technique is ideal. Avoiding crushing of tissue, excessive electrocautery, ineffective hemostasis, dead space in the wound, excessive wound tension, and overly tight sutures is important, because they not only increase the risk of dehiscence but also contribute to the development of other complications.

Buried absorbable sutures should be adequately used to provide tensile strength. Consideration should be given to the tensile strength retention properties of suture material when suturing high-tension areas, such as the back. For example, polydioxanone (PDS II) is a synthetic absorbable monofilament suture with low reactivity and prolonged retention of tensile strength. The suture retains 70% of its strength at 2 weeks; 50%, at 4 weeks; and 25%, at 6 weeks, providing extended wound support. This suture has been associated with significantly less scar spreading in high-tension areas when compared with a polyglycolic acid (Dexon) suture. Patients should be instructed to avoid stretching or trauma to the wound area. Wound immobilization with Steri-Strips and a dressing provides some protection for the area and serves as a reminder to the patient.

Wounds may be resutured in cases of dehiscence due to premature suture removal or trauma without evidence of infection. Devitalized tissue may need to be removed; however, routine freshening of the wound edges should be avoided to prevent removal of active fibroblasts, which are present in the wound edges. Retention of these fibroblasts allows the already initiated healing process to continue. Dehiscence due to hematoma may be resutured in uncomplicated cases after complete removal of the hematoma. In cases of delayed hematoma or infection, the wound is best treated by allowing it to heal by second intention granulation. Scar revision is best planned after adequate healing has occurred, usually no sooner than 8 weeks."

http://www.emedicine.com/med/topic2422.htm#targetC - Wound Infection (Surgical Site Infection-SSI)

http://www.fpnotebook.com/SUR10.htm - Wound

Jedi of Zen · Aug 30, 2007

Daytonite,

Ookay...I think I see what you mean about the surgical side of this problem. I guess even surgeons make mistakes, huh...

In any event, thank you for the A! lol. and btw, how painful was this when it happened to you, if you don't mind me asking?

Daytonite, BSN, RN · Aug 31, 2007

Daytonite,
Ookay...I think I see what you mean about the surgical side of this problem. I guess even surgeons make mistakes, huh...
In any event, thank you for the A! lol. and btw, how painful was this when it happened to you, if you don't mind me asking?

Hey! I was perfectly ready to take the blame for being overweight and diabetic. But, when I read the article on eMedicine I'm feeling better and reached for a piece of candy (not really! I've had gastric bypass surgery and can't eat too much of that kind of stuff anymore.) I had another wound dehiscence when I had a hysterectomy 17 years ago as well. I suspect that it was expected though because they put 3 large stay sutures in. The incision was much lower and in the pelvic area. The incision was already coming apart on the third post op day. Without the stay sutures that were kept in for 6 weeks until the wound started closing I think I would have had a big pothole that would have taken months and months to fill in.

Surprisingly, I have no pain at all. I never had any pain with the hysterectomy wound either. The first time I saw the doctor push the sterile cotton-tipped applicator down into the wound and it kept going down, down, down, I kind of made a silent gasp and waited to feel something, but I felt absolutely nothing. I think the reason is because it is primarily adipose tissue and there are no nerves in it. Even when I had the surgery, I had very little incisional pain and went home on the 4th postop day without any pain medication. When I was hospitalized a month later with the septic infection, the nurses had to change the dressing twice a day and I was always asked and my face was being watched to see if it hurt. It didn't. It's just a case of it looks bad and looks like it should hurt, but doesn't.