Cuidados pós-sutura

AFTERCARE
Dressing and bathing — Most wounds should be covered with an antibiotic ointment and a nonadhesive dressing immediately after laceration repair. Evidence for this approach is as follows:
• A trial of 426 patients with wounds that received care within 12 hours found that treatment with topical bacitracin zinc (eg, Bacitracin®) or combination ointment containing neomycin sulfate, bacitracin zinc, and polymyxin B sulfate (eg, Neomycin®) significantly reduced the rates of wound infection when compared to a petroleum ointment control (5 to 6 percent versus 18 percent) [19].
• A crossover trial in four adults evaluated reepithelialization for wounds to the upper dermis on the inner aspect of the arm. Occluded wounds had 1.4 to 3.8 times increased new skin growth at five days. All wounds were 100 percent reepithelialized at seven days [20].
• A crossover trial in 10 adults evaluated epithelial coverage in full thickness wounds to the lower extremity between occluded and air exposed sites. Occluded wounds had significantly increased epithelial coverage than air exposed wounds at seven days (62 versus 39 percent), but there was no difference in coverage at 14 days [21].
A nonadherent sterile gauze (eg, Xeroform) from which most of the grease is wrung, followed by cloth gauze, is ideal [22]. A simple Band-Aid will suffice for many small lacerations. Scalp wounds can be left open if small, but large head wounds can be wrapped circumferentially with Kerlix.
The dressing should be left in place for 24 hours, after which time most wounds can be opened to air. Wounds closed with nonabsorbable (eg, nylon, polypropylene) suture may be gently cleaned with mild soap and water or half-strength peroxide after 24 hours to prevent crusting over the suture knots. An antibiotic ointment can be applied to the wound as well, with instructions to apply the ointment two times per day at home until suture removal. In contrast, absorbable sutures rapidly break down when exposed to water and should be kept dry.
Patients with nonabsorbable sutures (eg, nylon, polypropylene sutures) may be allowed to shower or wash the wound with soap and water without risking increased rates of infection or disruption of the wound based upon the following studies:
• A trial of 857 patients who underwent minor skin excisions found that allowing bathing more than 12 hours after suture placement without antiseptic or dressing use was not inferior to keeping the wound dry and covered (infection rate 8.4 versus 8.9 percent, respectively) [23].
• An observational study of 100 patients who underwent primary excision of a skin or soft-tissue lesion or local flap closure and began washing their wounds twice daily within 24 hours of surgery found no wounds developed infection or dehiscence [24].
Although not well studied, prolonged soaking of nonabsorbable stitches including swimming in chlorinated water should be avoided because of the theoretical risk of premature loss of suture tensile strength with wound dehiscence. Patients with sutures should also not swim in natural bodies of water because of a potential increased risk of infection.
Prophylactic antibiotics — Proper wound preparation is the essential measure for preventing wound infection after suturing simple lacerations. (See "Minor wound preparation and irrigation".)
We recommend that healthy patients with sutured nonbite wounds NOT be prescribed prophylactic antibiotics [25]. A meta-analysis of seven trials (1701 total patients) found that prophylactic antibiotics in healthy patients with nonbite wounds were associated with a 16 percent increase in infection relative to control patients (95% CI 23 percent reduction to 78 percent increase in infection) [25].
Prophylactic antibiotics may decrease the risk of infection in some animal and human bites, intraoral lacerations, open fractures, and wounds that extend into cartilage, joints or tendons [26]. In addition, some experts advocate prophylactic antibiotics in patients with excessive wound contamination (eg, soil or water contamination), vascular insufficiency (eg, devascularized wound, peripheral artery disease), or immunocompromise [26]. (See "Initial management of animal and human bites", section on 'Antibiotic prophylaxis' and "Soft tissue infections following water exposure", section on 'Empiric antibiotic treatment'.)
Suture removal — The timing of suture removal varies with the anatomic site [27]:
• Eyelids – 3 days
• Neck – 3 to 4 days
• Face – 5 days
• Scalp – 7 to 14 days
• Trunk and upper extremities – 7 days
• Lower extremities – 8 to 10 days
Follow-up visits — Most clean wounds do not need to be seen by a physician until suture removal, unless signs of infection develop. Highly contaminated wounds should be seen for follow-up in 48 to 72 hours. It is imperative that clear discharge instructions are given to every patient regarding signs of wound infection.