Tropical Doctor, January 1990

41

Table 1. Rate of traditional practices carried out among 853 children below 5 years of age Traditional practices

Children affected

%

Uvulectomy Milk -teeth extraction Eyelid incision Female circumcision"

731 599 164 28

85.7 70.2 19.2 6.1

"No of females = 456

teeth extraction and eyelid incision is not available. In case of milk teeth extraction because of incorrect proceduresand unhygienic conditions, complications such as ostitis and osteomylitis were observed. And among children with eyelid incision, secondary skin infections were frequently encountered. Although many children will survive the danger of such complications, the fact that it causes considerable damage among some children should be considered a serious matter. In our opinion intensive health education together with relevant health activities should be able to modify the situation. REFERENCES

1 Sircar BK, Ademe M. Uvulectomy as associated with sickness.

Trop Doct 1988:18:143 2 Adekoye EO, Ewamin F, Ofd RA. Serious complications with uvulectomy performed by a 'native doctor'. Trop Doct 1984:14:160-1

P ostoperative dressings: are they really necessary? A Longombe

C M E Nyankunde

Centre Medical Evangelique de Nyankunde, Zaire, via PO Box 21285, Nairobi, Kenya TROPICAL DOCTOR,

1990; 20: 41-42

INTRODUCTION

The surgical dressing has long been thought to be a necessary step in the surgical process. Not to dress the surgical incision was considered a sure way to court wound infections. Considering the cost of all types of hospital supplies here in Zaire, we decided to make a study on the need for postoperative surgical dressings. For years, the standard has been sterile surgical dressing for almost a week postoperatively for all surgical incisions.

MATERIAL AND METHODS

The study took place a seven-month period at the Centre Medical Evangelique, Nyankunde, and in two of the surrounding hospitals (Assa and Banda). During the first part of the study (23 October 1987 to 23 January 1988, 59 cases), all incisions were dressed in a sterile manner up to the fifth postoperative day. On the fifth postoperative day, we removed the dressing, washed the incision with a quartenary ammonium, applied a solution of iodine, then placed another sterile dressing which stayed until the seventh or tenth postoperative day. At the time, the wound was again inspected and the sutures removed. The second portion of the study was between 1 November 1988and 28 February 1989 (62 cases). During that period, the surgical dressing was removed the first postoperative day and methylene blue, an antiseptic, applied to the incision. The surgical wound was left open to the air. The sutures were removed on the seventh to tenth postoperative day as before. All the operations were performed by the same surgeon (AOL) using the same technique. The skin closure was braided nylon suture. Ninety-five of the cases were closed with a running stitch and 16 were closed with interrupted sutures (both vertical mattress). If a drain was deemed desirable, it was placed through a separate stab incision. This was dressed separately. All wounds were classified as (i) clean, (ii) clean contaminated, (iii) contaminated or (iv) dirty. We decided at the beginning of the study that only the last two categories of wounds would benefit from antibiotic therapy except for bone operations in which antibiotic coverage was the rule. A wound was designated 'infected' if pus was discharged. The two periods were chosen to include part of the dry and rainy season in each. The cases that were excluded were: (l) All patients who died before the fifth day postoperatively (the day felt to be the earliest on which an infection would be expected to be clearly evident); (2) all oral, rectal or vaginal operations; (3) circumcisions; (4) orthopaedic operations for infection (eg chronic osteomylitis); and (5) all traumatic wounds. RESULTS

There were four (3.3070) sutureline infections in this study (Table 1). No significant difference was found between the

42

Tropical Doctor, January 1990

Table 1. Wound infections Dressing Long-term dressing Dressing one day Total

Infected wounds

Wounds without infection

Total

2

57

59

2

60

62

4

117

121

wounds covered in the traditional manner and those left open to the air after one day (P > 0.1). There were two infections in the traditional dressing group or first period (3.4070). One was after a subtotal thyroidectomy and was a low grade infection. The other was frankly purulent and came after a sigmoid resection and anastomosis for sigmoid volvulus colonic obstruction. Both wounds had interruption skin sutures of braided nylon. There were also two infections in those dressed for only one day. One occurred after a caesarean section done for cephalopelvic disproportion in a patient who arrived more than 24 h after her membranes were ruptured. She appeared to already have an early amnionitis. The other wound infection was the second side of a bilateral inguinal herniorraphy. Both incisions were closed with running braided nylon.

this study was too small to draw a conclusion. We feel that leaving the surgical incision open after 24 hours has numerous advantages. The patient and his family can see the incision without an unsupervised and less than aseptic removal of the dressing. The surgeon can tell at a glance if a haematoma or wound infection is developing. Open wounds allow evaporation of sweat. Finally, the hospital can save on dressing materials. In summary, the good results obtained without dressings have made us rethink our usual method of wound care. The significant factor is a meticulous operative technique and not the fact of covering the wound. ACKNOWLEDGMENTS

I thank Dr Ted Sugimoto (Oicha), Dr Philip Fischer and Dr Carlos Somoza (CME) for their advice. REFERENCES

Panda M. Traitement des plaies en urgences et en milieu hospitalier. Techniques du platre, Syllabus, 2nd edn, Zaire: Department de Chirurgie, Faculte de Medecine de Kinshasa 1983:5-6 2 Cruse PIE, Foord R. The epidemiology of wound infection. A 10 year prospective study of 62,939 wounds. Surg Clin North Am 1980;60:27-40 3 Klefstad-Sillonville. Sutures primitives post-operatoires sans pansement. Afrique Medicate 1976;144:647 4 L'Esperance P. Infections post-operatoires, In: Pathologie Chirurgicale, 3rd edn. Paris: Masson 1978:3-6 I

DISCUSSION

Despite advances in surgical technique, antibiotic therapy, and antisepsis, infection is still a major problem. Most authors cite general infection rates between 5 and 8% of all cases", This is slightly higher than the 3.3% infection rate of this study and the 4.7% in the large Canadian study of Cruse and Foord-. The results of our study seem to agree with the theory advanced by Panda! and L'Esperance". This theory posits that wound infections are due to perioperative contamination. If this is true, placing a sterile dressing after the operation will not prevent infection. It needs to be mentioned again that meticulous surgical technique will aid in preventing wound infections with good asepsis and accurate suturing. Drains, if needed, are best placed through a separate stab incision-. If they are brought through the wound, pooling of plasma and blood could encourage infection. In this study, there were no wound infections in wounds that were drained. As far as infection differences between raining and dry seasons, the number of infections in

HIV: implications for blood transfusion and banking in Africa J W Carswell FRCS 38 Park A venue, Orpington, Kent BR6 9EH, UK TROPICAL DOCTOR,

1990,20, 42-43

Countries with an appreciable HIV problem receive assistance in screening blood for HIV antibodies as part of WHO's Global Programme on AIDS (GPA). This will be a start in ensuring a safe blood supply, and should encourage those in charge of many hospitals to improve blood transfusion services generally. The presence of HIV in a community often, illogically, makes it more difficult to persuade people to donate blood.

Postoperative dressings: are they really necessary?

Tropical Doctor, January 1990 41 Table 1. Rate of traditional practices carried out among 853 children below 5 years of age Traditional practices C...
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