"Wound dressing pain after open heart surgery"

I have been working within R&D and on the commercial side of wound care for more than 25 years so obviously I have a keen interest in both acute and chronic wounds. I recently had the opportunity (if you can call it that) to see the wound care world from a totally different perspective, that of the patient. This was because I required an aortic valve replacement due to Bicuspid aortic valve disease (BAVD). The following treatise is a view from the patient’s side with the thought that this might be helpful to nurses and patients alike. It is noteworthy at this stage to state that before surgery I was in agreement with the widely held belief that treatment of surgical wounds in so far as choice of dressings and subsequent dressing change was largely inconsequential and secondary to the actual surgical intervention (bar that of infection) and that pain/discomfort associated with dressing removal (at for example vascular access, drain and wound sites) would be adequately controlled due to the significant amount of analgesia (morphine, paracetomol etc. , ) that was given to control pain. Subsequent first-hand experience has led me to change this view.

Medical background: My BAVD was diagnosed during a routine hospital check prior to a knee arthroscopy where a heart murmur was detected and subsequent diagnosis was confirmed by ultrasound as being bicuspid aortic valve disease where the valve has only two leaflets. In this disease calcium deposits on and around the leaflets eventually cause the valve to stiffen and narrow (stenosis) and as the disease progresses the heart must pump increasingly harder to force the blood through the valve. Additionally if the bicuspid valve does not close completely, blood can regurgitate causing strain on the heart’s lower left chamber, the left ventricle and over time, the ventricle will dilate. The main symptom of aortic valve regurgitation is shortness of breath during exertion. Although at this time I was asymptomatic as a consequence of this I was monitored for about six years until symptoms became evident and surgery then required.

Wound Focus: Treatment of my bicuspid aortic valve disease required replacement (tissue graft) of the aortic valve and an ascending aortic graft emplacement. In order to do this a sternotomy was undertaken whereby the sternum was transected to provide access to the relevant portion of the heart. After the surgical procedure was (successfully) completed the sternum was then wired together and the skin sutured with dissolving sutures.

Immediately post-op (12 – 24 hrs) I was not consciously aware of my wound site other than that of severe chest pain. However after being moved out of intensive care and onto the wards I became cognisant of the fact that I had at least three vascular access sites, neck and wrists all retained by adhesive dressings. Whilst the wound site itself was not covered the lower wound and drain site were dressed with an adhesive surgical dressing.

Post-operative rehabilitation: This phase occurred almost immediately I was able to mobilise, in the first 24 hours in ITU rehabilitation consisted of pulmonary exercises and coughing (very painful) and as soon as I was able getting out of bed for assisted short walks, until I met the criteria for transfer to the wards.

Wound Dressings: Initially the wound dressings did not generally impede rehabilitation in that the pain from the surgical procedures was an overriding factor. However as more mobility was required to aid rehabilitation, I became increasingly aware of the wound/retention dressings. This was because the dressings did to some extent pull on my skin and coupled with an increased skin sensitivity around the wound site, did, to a small extent impede movement/mobility. It was also interesting to note that the analgesia (oral morphine and paracetomol) did not appear to affect this sensation, nor did it reduce the considerable amount of acute pain associated with removal of dressings from the access sites and in particular the drain site. The nurses approach to removing the dressings varied from slowly peeling dressings back to a quick sharp pull, neither of which seemed effective at reducing dressing removal pain. Although the nurses each did their very best to buffer the impact it seemed to me that earlier intervention as to choice of which dressings might be used (eg. less adhesive) would make both the patient and nurses life easier.

Additionally and rather surprisingly to me (considering I had worked with wounds for many years) was the psychological impact that the sight of the surgical incision had on me. The incision site was not covered by a dressing therefore when I was washing etc. , it was in full sight in the mirror and it was days if not weeks before I could bring myself to look at this. I was also very aware that part of the incision site could be seen by visitors, some of whom also reacted in a distressed or embarrassed manner. My thoughts then were that even if a dressing provided no overtly clinical benefit other than cosmetically covering the wound site then this in itself would be advantageous to the patient.

Overall Impressions: Nobody can say that they enjoy a hospital stay, especially if that stay includes major treatment/surgery and it goes without saying that the nurses and doctors that treated me were extremely professional and caring. However as I indicated at the beginning, my previous impressions were that wound dressings/dressing changes had a limited impact on the patient in terms of overall treatment and clinical outcomes. However in my case this proved not to be the case, wound, vascular access or drain site dressing were very painful upon removal. The adhesion of such dressings to the surrounding skin caused discomfort and to a certain impeded movement and mobility. It is possible that in a frail patient this pain and discomfort could have a greater impact and be detrimental to rehabilitation. Perhaps the impact of post-surgical dressings on patient QoL needs to be investigated further and given the same level of regard as that given to chronic wounds.

• With this last statement in mind an e-survey of surgical patients is being undertaken in conjunction with the University of Huddersfield. This study will provide a more focussed evaluation of pain/stress in relation to wound care in this patient population after various surgical procedures.

Looking for respondents for clinical survey into psychological impact of post-surgical wounds http://svy.mk/ZvjPDN Please RT. Thank you!