Drug changes are the most common thing for surgeons, yet they are also the easiest to neglect. A sterile incision can become infected due to improper dressing changes; skin flaps can become necrotic due to alcohol irritation; more painful are some necrotic skin wounds that require lengthy dressing changes to heal; and bone outgrowth often requires a skin flap to fix. There is indeed a lot to be said for changing the medication, and the right change can often turn decay into magic. Principle: Asepsis. Remove inactivated necrotic tissue. Maintain and promote the growth of granulation. Prevent exposed wounds and cover exposed wounds. Promote wound healing. Purpose: 1. Observe the wound 2. Remove necrotic tissue 3. Clean the wound 4. Drainage and patency 5. Promote tissue growth. The purpose of our surgical dressing change is two provides. Namely: ① to provide a relatively sterile environment for the trauma surface to avoid re-attack. ②Provide a relatively conducive environment for growth and healing of the wound surface so that it can heal as early as possible. Basic techniques: 1) Establishing the concept of asepsis; 2) Methods of dressing release; 3) Methods of dressing change delivery; 4) Methods of disinfection of the wound surface and surrounding skin; 5) Methods of dressing fixation; 6) Handling of dirty dressings; 1) Preparation before dressing change 1) Fully understanding the wound, the size and depth of the wound site, the amount of gauze stuffed in the wound cavity, the presence or absence of drainage and whether to remove or replace it, whether to dilate or flush it The wound should be treated with the following: 1. Check whether the required dressings, instruments and drugs are available first, and special supplies should be prepared, such as antibiotic solution for wound surface, local anesthetic blade for dilation, long vascular clamp probe for deep wounds, special drainage tube for suprapubic cystostomy replacement, etc. The patient’s mental state, general condition and the process of drug exchange may occur, should be fully prepared to understand in detail. 2, aseptic preparation: general drug exchange requirements in the morning care or drug change room cleaning work after half an hour, preferably in the drug change room change. Wear a mask and hat, invite the patient to the dressing change room, observe the wound situation (uncovering gauze should be uncovered in the direction of the wound, vertical uncovering is easy to make the wound open again), assess the number and type of instruments and dressings needed, and then go to wash your hands and then prepare the items for the dressing change. Generally need two sterile bending tray, two forceps, alcohol cotton balls, etc., clip take instruments, forceps must be head down, not cocked up, the order first clip forceps, put the middle of the bending tray, clip gauze covered on top, iodine, alcohol divided on both sides of the bending tray, first clip iodine cotton balls after clip alcohol cotton balls (if first clip alcohol, residual forceps of alcohol clip iodine cotton balls will dilute the iodine, affecting the disinfection effect). 3, operation: hand to take the outer auxiliary material, and then tweezers to take the inner layer, if stuck with saline cotton balls to moisten and uncover. Two tweezers, one touching the skin, one touching the excipient (two always do not touch). Disinfection along the wound and suture mouth gently dip, and then (clean wound) from the inside out zigzag elimination, alcohol two or more times, the scope to exceed the cover gauze. Cover gauze light side down, cover more than eight layers of gauze (generally a gauze block four layers). Sticky tape to follow the direction of the skin pattern and vertical gauze sticky, generally three, two sides of the pressure side sticky, the middle one. Finally wash your hands (to protect yourself). 4, the order: clean first after the pollution, first simple after complex. This is also true for a patient with multiple wounds. Second, the frequency of dressing change in principle auxiliary material wet that should be changed 1, general wounds: the first time within 24h, after every 2-3 days / time; 2, special wounds: after mastectomy, 3-5 days / time; 3, after implantation: 7-9 days / time; 4, gastrointestinal fistula: 2-3 days / time; 5, summer, daily change, dressing alcohol gauze; Third, how much dressing selection is appropriate? In the first few days the growth of the wound is mainly the growth of granulation tissue, it needs a more moist environment, so the dressing can be used more layers in the first few days to keep the wound relatively moist. In the later days, the growth of the wound is mainly the growth of keratin, and at this time the wound needs a relatively dry environment, so the dressing should be as thin as possible while playing a role of isolation. In addition to the role of protecting the wound from external pollution, the dressing also has a certain drainage effect, so the dressing should be closely attached to the wound during dressing change, especially when the wound is more concave than the surrounding. IV. Commonly used dressings and local care products selection 1. Alcohol: decubitus ulcer protection (50%), skin and instrument disinfection (70%). Wounds with intact epidermis can be changed with alcohol, but if the epidermis is broken, alcohol cannot be used. 2, iodophor: low irritation to mucous membrane, no need to deiodize with ethanol, no corrosive effect and low toxicity. Iodophor is better than iodine in terms of application (mucous membrane, skin, etc.) and disinfection (less allergic reactions), but it also has a range of application, which is not good for wounds that bleed a lot, and is not suitable for wounds that are too large. Iodoform is complex iodine, which is ineffective or inefficient for greasy wounds or areas with developed sebaceous glands. Alcohol or iodine, on the other hand, can degrease and better fix the bacterial proteins, which are more penetrating in areas with abundant sebaceous glands. So it will be applied around the scalp wounds. 3.Saline (0.9%): It has the function of improving the nutrition of granulation tissue and adsorbing the secretion of the planar surface, and has no adverse stimulation to the granulation tissue. Generally used in rich blood supply, more traumatic secretions, small chance of infection, and sensitive mucous membrane. The application of physiological saline is mainly for flushing and wetting, because for an extensive area of wounds or combined and uneven wounds, flushing can remove some impurities and infectious materials. 4.Hypertonic saline: used when the wound is heavily edematous. The purpose of hypertonic saline is that the local swelling of the wound is not healed, but can achieve local dehydration effect. Hypertonic saline with petroleum jelly gauze can stimulate the growth of granulation, and is often used clinically for wounds that have not been closed in one phase, or after the infected wounds have been cleared and thoroughly applied. 5, hypertonic glucose: a dehydrating drug, can enhance plasma osmolarity and produce dehydration, for infected wounds with poor local nutrition, large wounds, poor or ineffective after changing medication with other drugs, varicose veins on the lower extremities with skin erosion and ulcers, difficult healing of wounds, shallow Ⅱ to deep Ⅱ small area burns with obvious edema, slow healing of wounds, and decubitus ulcers are more effective. Hypertonic glucose can be evenly distributed on the trauma surface, causing a hypertonic environment, resulting in dehydration of bacterial cells, loss of bacterial reproduction capacity and death of the bacteria, and dehydration of the local cells of the body, reducing the edema of the trauma surface and granulation tissue, and forming a protective film to prevent the continued invasion of cells into the infection, improving local blood circulation, improving the nutrition around the trauma surface, and promoting the healing of the trauma surface. In addition, glucose also has a myogenic effect, which can reduce the pain of the wound and facilitate the healing of the wound. 6, hydrogen peroxide (3%): cleaning wounds, ulcers, pus sinus, loosening necrotic tissue, remove adherent dressings. Used for rinsing traumatic wounds, foul-smelling wounds, especially for anaerobic bacterial infections. 7.Gentamicin solution (0.2-0.5%): local flushing, used for Pseudomonas aeruginosa, staphylococcal infected wounds. 8.Furacillin (0.02%) solution: surface disinfection of ulcers, purulent wounds, etc. 9, 10% zinc oxide ointment: applied to the surface of the skin, has the effect of protecting the skin from secretion erosion, commonly used in the skin around intestinal fistula, biliary fistula, etc.; zinc oxide gelatin: long-lasting calf ulcers. 10.Insulin + hypertonic glucose + (growth promoting factor): mainly applied to non-healing wounds of diabetic patients. 11.2％ red mercury: disinfection of skin mucous membrane, skin abrasion with red mercury is best, without bandage. 12.Cod liver oil: local application, used to promote the formation of epithelium on the traumatic surface. 13.Acetic acid (0.5-2%): scalding, burn infected wounds. 14.Chlorhexidine (0.05%): traumatic surface and wound irrigation. 15.Lifanox: contraction of wounds with the best effect (direct wet cover). 16, magnesium sulfate (50%) solution: for contusions, cellulitis, dermatitis and other anti-inflammatory and swelling. Local wet and hot compresses. 17, boric acid ointment (5%): burns, abrasions, skin ulcers and bedsores. Wet cover with boric acid solution to decay until the flesh buds are fresh. The use of myogenic powder can promote the growth of flesh buds. 18.Polyvinyl pyridone iodine (PVP-I): a new type of antiseptic, effective for bacteria, fungi and budding cells. 0.05%~0.15% solution is used for mucous membrane, wounds and pus cavity rinsing; 1% solution is used for dressing sterile incision; 1%~2% solution is used for wet dressing infected wounds, most suitable for chronic lower limb ulcers and cancerous ulcers. 19, Vaseline gauze: can provide a moist environment conducive to the growth of trauma granulation, and can reduce the exudation of tissue fluid, early trauma can also stop bleeding, but for serious infected trauma should be used with caution, because it is easy because of poor drainage, often aggravate the infection. 20, 0.02% potassium permanganate solution: lasting effect, with clean, deodorant, antiseptic and bactericidal effect. Used for washing rotten and foul-smelling, infected wounds, especially for suspected anaerobic bacterial infection, anal and perineal wounds. It is often used clinically for wet dressing with 1:5000 solution. 21.0.1% Ravnol : has antibacterial and bactericidal effect. Used for cleaning and wet dressing of infected wounds. 22.1％～2% phenoxyethanol solution: has bactericidal effect on Pseudomonas aeruginosa, with the best effect, using trauma continuous wet dressing. 23.10% garlic solution: has the effect of sterilization and enhancing tissue cell phagocytosis, and has a better effect on Staphylococcus aureus infection. 24.2%～4% methyl violet (gentian violet) solution: with bactericidal and astringent effect. Used for the disinfection of superficial skin or mucous membrane ulcers, and to promote the healing of nodules. 25.Pure carbolic acid solution: with corrosion, sterilization effect. Use pure carbolic acid solution swabs to cauterize anal fissures and chronic sinus tracts, so that the unhealthy granulation tissue necrosis off to promote healing. After using it, you need to wipe with an alcohol swab to neutralize it, and then wipe with an isotonic saline swab. 26, 10%-20% silver nitrate solution: used to cauterize anal fissures, chronic sinus tracts and corrosive overgrowth of granulation tissues, after use need to wipe with isotonic saline swabs. 27.Bactroban ointment: used for infected wounds. 28.Streptomycin ointment: applied externally on gauze for tuberculous wounds. 29.Erythromycin ointment: applied to epidermal lesions without dressing. V. Treatment of common wounds 1. Clean wounds are disinfected with iodophor, which is less stimulating and more effective; for clean, nascent granulation wounds, they can also be covered with petroleum jelly gauze to reduce the pain of patients during dressing changes and to reduce tissue fluid exudation and loss. 2, rich blood supply, small chance of infection of the wound can be saline simple wetting, sterile overlay dressing can be. 3, for wounds with skin defects, the defect area is repeatedly rinsed with saline, and the surrounding area can be routinely disinfected with iodophor, and after disinfection, covered with saline gauze or petroleum jelly gauze. Saline gauze is good for keeping the wound fresh and dry, and petroleum jelly gauze is good for the growth of granulation of the wound. 4. The principle of infected or contaminated wounds is to drain the pus. If necessary, remove the sutures, expand the wound, drain thoroughly, rinse the wound repeatedly with hydrogen peroxide and saline, necrotic tissue should be given for debridement, you can also fill the wound with antibiotic gauze, the wound is best disinfected with iodine twice alcohol three times deiodination around the wound. Of course, infected wounds should be changed every day. When changing the medication for the septic incision, be sure to carefully wipe off the pus moss at the incision, and after the pus moss is removed, there should be slight blood oozing out so as to help the incision heal as soon as possible. It should be adequately drained and should not be filled too tightly, otherwise it will affect the blood supply and is not conducive to drainage; saline gauze or topical antibiotics, such as penicillin and gentamicin, can also be used. 5, decubitus ulcer, septic osteomyelitis and other infected wounds: iodophor disinfects around the wound, while the wound is flushed with hydrogen peroxide, saline, and covered with gentamicin dressing. 6.For osteomyelitis with bone outgrowth the dressing change should be diligent in the first place, because there is a lot of exudation, and the dressing should be more. During the dressing change, necrotic tissue should be removed at any time, and gauze can be placed in the medullary cavity. The empirical method is to first rinse the trauma with saline, then with 0.1% iodine, then with hydrogen peroxide, and finally with Qingda gauze wet and covered with a dressing. When the trauma surface has fresh granulation and less exudation, perform surgery to remove the dead and sclerotic bone, use a suitable musculocutaneous flap to cover the trauma surface, external fixation frame for external fixation, and then perform bone lengthening after the flap becomes viable. 7, open fracture external fixation of patients followed by the first iodophor disinfection (while cleaning the removal of necrotic tissue), followed by the use of hydrogen peroxide disinfection, then saline rinse, and finally furacilin filling to cover the wound surface. Wait for its granulation growth and perform free flap coverage. 8, fat liquefaction of the incision: fat liquefaction is prone to occur in fat-rich areas, at which time the incision is widely opened (all areas of fat liquefaction are opened), culture + drug sensitivity, and enhanced drug exchange. Such an incision should be changed for a long time, in order to shorten the time, after the initial disinfection in the local subcutaneous injection of gentamicin, place glucose powder into the incision, change the medication every day, wait for the wound to exude less after the oil gauze to stimulate the growth of granulation, fresh after the second phase of suture or butterfly tape pulling together. 9, long ulcerated wounds, to use Chinese herbal medicine change. Chinese medicine dressing change has its own unique features, but there is usually no sterile concept. For example, for refractory sinus tracts (such as after brain surgery, after heart bypass surgery or sinus tracts caused by chronic osteomyelitis, usually early with eighty-two dan or nine one dan + red oil ointment, lifting rot and removing pus, and late with raw muscle san + red oil ointment closure, the effect is very good, even if the Pseudomonas aeruginosa or drug-resistant Staphylococcus aureus infection can be well cured. 10.For contaminated oily wounds, wash away the oil stains with turpentine. 11.For old granulation wounds: such granulation tissue has poor regeneration ability (dark red color, not fresh, uneven height, sometimes old bleeding appearance), the surrounding tissue is not easy to heal, scrape or cut the surface granulation tissue with a scraping spoon to make it bleed, reveal fresh granulation, and apply rubber ointment externally (this is the Chinese medicine to decompose and regenerate the muscle, while the western medicine will flush with hydrogen peroxide to achieve the purpose of decomposition). If there is pus, attention should be paid to observe the presence of pus cavity or sinus tract, and pay attention to the change of patient’s body temperature. 12, granuloma edema wound dressing change: repeated multiple wound dressing change or irregular dressing change operation can easily lead to wound granuloma edema. Due to the unhealthy granulation high out of the skin causing wound healing difficulties. If these traumatic changes occur, routine local disinfection should be used followed by cutting off the unhealthy granulation high above the skin with sterile scissors. After the local bleeding is much, compress to stop the bleeding, use magnesium sulfate powder or chloramphenicol powder evenly sprinkled on the bleeding granulation tissue, after that the dressing is covered with oil gauze and gauze wrapping (at this time the applied drug using powder can achieve both hemostatic and anti-inflammatory effect). Later interval 3 to 4d with 33% magnesium sulfate aqueous solution gauze (at this time with aqueous solution to facilitate tissue absorption) block to give wet dressing wound. The granuloma edema wound application 33% magnesium sulfate change. The reasoning is two: one, the use of high magnesium sulfate can make edema granulation dehydration; second, magnesium ions have to promote the role of skin cell regrowth, in the process of dehydration and guarantee the supply of a large number of magnesium ions. Therefore, as long as the treatment of edematous granulation is reasonable, the healing of this wound can be accelerated. Chymotrypsin can also be used as a wet compress to promote local tissue healing. 13, for Pseudomonas aeruginosa infected wounds: characterized by light green pus with a special sweet fishy odor, if the wound surface is crusted, pus accumulates under the scab and there is necrotic tissue, the scab, pus and necrotic tissue should be removed. Burn trauma early green pus infection can be cut scab implants. Also available 1% to 2% phenoxyethanol wet dressing, or 0.1% gentamicin, 1% silver sulfadiazine, 10% methanesulfamilone and other solutions wet dressing. Trauma such as small available 3% acetic acid, 10% chloral hydrate and other solutions wet dressing. 14, reimplantation surgery or anastomosis of the flap surgery can best be changed with furacilin solution similar to the body temperature, change with alcohol can be scolded; finger dressing gauze should avoid ring wrapping, local best to fill with shredded gauze. Sixth, precautions 1, aseptic one-stage wound dressing change is generally in 24 hours, 72 hours routine observation of local swelling and oozing. 2.After open wound surgery, strive for 24, 48, 72 hours for three consecutive days of drug changes, pay special attention to the easy emergence of hematoma or drainage situation in a timely manner to exclude dangerous situations is more critical. 3, for large area trauma, first of all, pay attention to clear the wound, for the necrotic tissue including necrotic tendons and vascular tissue do not appease, strive for several times in the change of medicine, once the boundary line is obvious then decisive excision. Reluctantly left, will only delay the growth of granulation, or even cause infection. 4.For the wound that has cleared most of the necrotic tissues, pay attention to the growth of the granulation, the granulation tissue itself has the ability to resist infection, if there is no obvious exudation, then do not use antibiotics or other medication changes, only use iodophor to disinfect the skin of the trauma edge, and cover it with wet saline gauze. 5, oil gauze should not be put on the trauma, it should be on the saline gauze to prevent the saline from evaporating too quickly. 6, there is an infection of the trauma to pay attention to do a bacterial culture + drug sensitivity before changing the medicine, so as to avoid later passive. 7, the surface of the moist trauma is conducive to tissue growth, which is the main reason we usually like to use saline gauze to cover the trauma, while saline gauze also has the role of unobstructed drainage, but because the moist environment is also a breeding ground for bacterial growth, bacteria will enter the log proliferation period in 6-8 hours, so for serious infected trauma, to make diligent drug changes (preferably 3-4 times / day), many people Like trauma at the same time with gentamicin wet dressing, the first 1-2 times the effect is very good, long-term effect is not good, and easy to lead to drug-resistant bacteria produced. 8, petroleum jelly gauze can provide a moist environment conducive to the growth of trauma granulation, and can reduce the exudation of tissue fluid, early trauma can also stop bleeding, but for serious infection of the trauma to be used with caution, because it is easy because of poor drainage, often aggravate the infection. 9, open wound dressing change is best not to let alcohol seep into the wound, alcohol is not conducive to wound healing. 10, orthopedic trauma more common infected trauma is skin necrosis, decubitus ulcer trauma, hypertonic saline is generally used in a certain period of time, in heavy infection, exuding more trauma, can quickly reduce the trauma and granulation tissue edema, reduce exudation. 11. Reimplantation surgery or skin flap surgery with anastomosed vessels can best be done with furacilin solution similar to body temperature for dressing change, finger dressing gauze should avoid ring wrapping, and it is best to fill with shredded gauze locally. Other words of experience: There is also a clinical situation of eczema-like changes around the wound, where the skin is red, rash, and prone to breakout. Initially, various methods were used to change the medication, such as iodophor gauze, petroleum jelly gauze, erythromycin eye ointment, etc., how can not be changed. Finally saline cotton balls were lightly rubbed and then covered with dry gauze, and it soon improved. The cause is unknown! For some sinus tracts, the change can be done with white granulated sugar, not too concerned about aseptic operation, and usually can be changed well. However, some sinus tracts that are connected to the joints and are difficult to heal, my method is to scrape the aging meatus in the sinus tract to make it ooze blood, then use cotton balls and other liners in the area of the sinus tract pathway and apply pressure bandages to close the sinus tract, do not change the medication for a week, the point is to always maintain a certain pressure, I believe you will jump up and down with excitement when it opens. If the appearance of the wound after healing, no special requirements for aesthetics (such as the abdomen), there is no need to change the medication so complicated, my experience is with whatever the problem wound (infection, fistula, not healing), 10% hypertonic NS effect is the best, to open the infected incision for example: after conventional treatment, with 10% hypertonic NS 10-20ml wet a piece of gauze, fill (deep incision) or cover ( The entire incision is covered with dry gauze, the thickness of which is not soaked by saline, and generally no other treatment is needed. The key to this method is to be sure to use 10% hypertonic NS, the amount should be sufficient, do not dilute (generally textbooks speak of dilution into 3%), otherwise the effect is greatly reduced. The mechanism may be: (1) hypertonic NS sterilization effect is good, no bacteria can survive in 10% hypertonic environment. (2)Elimination of edema. The patient was an elderly male with a tuberculous abscess of the skin on the left chest for nearly ten years, which repeatedly ulcerated and caused pain to the patient and was not cured by using various methods. The method I used was to put the gecko (live or executed fresh) on a tile with a gentle fire slowly so that it becomes able to be crushed into powder and cannot become scorched black. Use the gecko powder sprinkled on the wound, once a day, or three times a day, depending on the powder on the wound. Dressing or no dressing. See the skin healing after the effect, not the skin healing while the pus is still in the wound. The powder can be applied after cleaning the pus. The first of these is that if the antibiotic is absorbed into the bloodstream from the wound surface, it is likely to cause side effects or toxic reactions similar to those seen with systemic medication; the latter is likely to cause antibiotic resistance. I think the use of antibiotics should still be used according to the principles of antibiotic use, emphasizing that early debridement should be as clean as possible, sutures should not leave a dead cavity, avoid or reduce the destruction of normal tissue, adequate drainage, timely dressing changes, and it is best to use antibiotics according to the culture of secretions and drug sensitivity tests. After taking the inner thigh medium-thickness skin slice for skin grafting during surgery, the donor area was not healed for a long time, and rifampin and Mepore burn cream were given to be applied externally on gauze, which was cut into about 1cm2 and covered with stacked tiles, and the medication was changed qd. The first change of medication took more than 2 hours, first remove all the scabs and blood scabs from the wound and the surrounding area with soap and water, then NS, peroxide is not used, the wound is thoroughly cleaned, the normal skin around the wound is disinfected with alcohol, and then the gauze is patiently covered with a stack of tiles around 1cm2. In short, the wound dressing change process is not a simple mechanical action, but a process of observing the condition and treating the disease. It requires both hands, brain and responsibility. In the change of medicine both to see the wound, but also to ask the condition, to be verified by scientific methods, is the whole process of wound dressing change. Only by establishing this concept can the wound achieve timely healing.